Mental Health Care and Social Policy

Phil Brown

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000574043
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Originally published in 1985, at a time when the previous 2 decades had witnessed dramatic changes in the US mental health system. These included the decline of the state mental hospital, the birth of the community mental health center and the expansion of psychiatric services in general hospitals. The inevitable results of the changes were the creation of a huge nursing home population of the chronically mentally ill, and the multiplication of urban 'street people'. Mental health care is uncoordinated and underfunded. The historical roots of these problems are examined in this book which is designed both as a professional reference volume and as a text for students in the sociology of mental health and illness. The contributors are drawn from diverse fields, including sociology, psychiatry, psychology, epidemiology and social history.

Part I Historical and conceptual concerns

INTRODUCTION

In this first part of the book, we are concerned with the social historical background of mental health care, and with a conceptual framework for studying mental health institutions and policy. The three selections here cover a long period of history, and the reader may wonder what can be learned about the present from eighteenth-and nineteenth-century concerns. Unfortunately, most examination of mental health policy has been flawed by ahistoricism. As these readings demonstrate, there is much to learn from the historical record, and these authors have pioneered in extrapolating current methods of examination from the past.

Andrew Scull’s ‘Madness and segregative control: The rise of the insane asylum’ grounds the origins of the asylum in the political and economic system of its environment. Scull shows how emerging capitalist market relations required a more precise identification of able-bodied and non-able-bodied deviants. Relief and other social welfare programs would then be able to prevent the able-bodied from freeloading, and could attempt to inculcate work habits and social discipline into the recipients of relief. Further, these institutions were intended as punitive, restrictive locations where the able-bodied would work for their keep. Yet they became centers for the very non-able-bodied misfits.

The workhouse or almshouse was difficult to run with mentally ill residents, and an increasing differentiation of deviants was necessary. A growing state centralization made possible the centralization of deviant-processing institutions, so that the asylum became a highly structured phenomenon run by a more bureaucratic authority. The huge new madhouses, however, did not in fact operate very rationally in terms of patient care, since their size and changing social composition made moral treatment impossible. Whatever rationality existed was that which could maintain the bare minimum of survival in the easiest, most bureaucratic and most inexpensive way.

Still, rationalist, scientific beliefs held by dominant classes and groups led those social leaders to seek the advice and practices of an expert group of psychiatrists, thus providing a framework for professional development. This demand for a professional group, Scull argues, was a search for scientific legitimation of the developing institutional social control practices. It was also an attempt to classify existing mores and value systems as normal or abnormal. Scull goes beyond a conspiracy approach to labor-force control, however, in demonstrating that institutionalization in the custodial hospitals served the interests of various classes and the psychiatric profession.

The United States of the early nineteenth century saw the declineof informal, local care for the insane as a result of urbanization, industrialization and immigration. Some reformers responded with a naturalistic, optimistic attitude toward mental illness and a crusading theology concerned with mainstream social reform. In such an environment the state hospital boom began.

The first state mental hospitals employed ‘moral treatment,’ based on Tuke’s English approach. This involved much interaction between provider and patient, in an attempt to restore the person’s normal social involvement and sense of reality. Early successes of moral treatment were due to a small patient population of persons similar in background to the psychiatrist/superintendent, allowing for intensive therapy grounded in shared values. But within a decade there were more lower-class patients, which, combined with a growing inpatient census, led to a decline of personalized treatment in favor of an administrative psychiatry typified by its main text, Kirkbride’s manual of asylum construction and maintenance. At midcentury, hospital directors and boards were openly nativist, alarmed at the many immigrant patients. An increase in the number of patients, and overworked staff led to an increased use of restraints, and a working-class and peasant immigrant clientele contributed to public support for protection and social control since such patients were considered unlikely to adjust to social norms. Psychiatry veered toward a somatic approach and a nihilistic prognosis that replaced the earlier ‘cult of curability.’ Thus a state hospital system was stripped of its original goals of short-term therapy for a small clientele. Those goals were to be carried out in smaller, elite private asylums, while public facilities faced financial constraints and growing prejudice.

David Rothman’s book, Conscience and Convenience: The Asylum and its Alternatives in Progressive America, picks up the matter in the late nineteenth and early twentieth centuries. Scull’s discussion of Rothman’s earlier book, The Discovery of the Asylum: Social Order and Disorder in the New Republic, pointed out that Rothman focused too much on value systems and avoided discussion of the state and the economic factors. In ‘The enduring asylum,’ excerpted from Rothman’s Conscience and Convenience, we observe greater attention to those factors. Rothman seeks to go beyond the recording of specific reforms, in order to examine the problematic elements of social service reform in general. He emphasizes the increasing power of the state, as well as the erroneous view of Progressive era reformers that the state was solely a benevolent actor.

Mental health reformers failed to consider realistic obstacles to their ideal notions. Failure, therefore, was viewed as due to faulty implementation; underlying assumptions and structures were not to be questioned. Thus the conscience of the reformers lost out to the various forms of convenience. For example, the new alternative facility, the psychopathic hospital, shortly came to function simply as a processing station along the path to the state hospital. The new hospitals themselves became overcrowded, and a new custodialism developed in the supposed alternative to custodialism.

Institutional self-preservation remained important. For instance, state hospitals did not want to board out or parole those patients who were most suitable for family care in the community, since the labor of those patients would be lost. Professionalist practices played their part too — psychiatrists largely opposed the development of outpatient care by hospitals for fear of incursions on private practice.

Joseph Morrissey, Howard Goldman and Lorraine Klerman’s ‘Cycles of institutional reform’ provides an excellent synthesis of the last two centuries of mental health care, showing the continuity of problems. The authors show how the same issues constantly arose. Both the nineteenth-century project and the current community mental health and deinstitutionalization programs were flawed, since ‘each movement was launched with little or nor appreciation of the practical limits to which the core ideas could be pushed.’ For example, the cult of the asylum perpetuated faith in the state hospitals even when they were clearly unable to deal with a growing and more chronic population. In this century new techniques such as milieu therapy and psychoactive drugs were applauded, but there was sparse research on their use in chronic care or on the need for community support systems.

Both nineteenth- and twentieth-century mental health reforms were ‘initially stimulated by therapeutic innovation but were ultimately accelerated by political-economic considerations.’ In the former case, according to Morrissey et al., concern shifted from moral treatment to custodial care at the cheapest cost. In the present, fiscal conservatism was joined to the ideals of community mental health advocates and civil libertarian reformers, but with little documentation of the cost-benefit virtues of deinstitutionalization and no analysis of the social costs of dumping patients. Even now, as deinstitutionalization is being reversed, there is still a paucity of clear research knowledge.

Theoretically and analytically, Morrissey et al.’s sophisticated effort builds on three themes. First, a social institutional perspective examines manifest and latent functions of state hospitals. Second, an organizational perspective explores changes in the institutional arrangements of mental health care. Third, a social policy analysis points to the scope of necessary changes. Throughout their work, Morrissey et al. point to how a two-class system of care was developed and perpetuated. Like Rothman, these authors show how professionalist and economic concerns defeated many fine ideas. Thus, despite many changes within the mental health system, the overall framework remained very much the same.

CHAPTER 1 Madness and Segregative Control: The Rise of the Insane Asylum^{* †}

Andrew T. Scull

In recent years sociologists have rightly come to see deviance and control as essentially symbiotic rather than antagonistic phenomena. Unfortunately much of the work done pursuant to this basic insight has been marred by its narrow, ahistorical and non-structural focus. While the immediate interaction between deviants and control agencies and the etiological significance of deviance-processing have received considerable attention, the historical and structural contexts within which this processing occurs have been largely ignored. We have thus been forced to make do with ‘an analysis which lacks a sense of history, a sensitivity to institutional patterns, and a range which is wider than a narrow focus upon encounters between deviants and officials’ (Rock 1974: 145). Adequate theoretical work in this area clearly demands that we develop an historically informed, macro-sociological perspective on the inter-relationships between deviance, control structures, and the wider social systems of which they are a part. More specifically, we need to clarify the developing relationships between the nature of deviance and its control, and the increasing rationalization of the social order which has been the dominant feature of Western social development since the Middle Ages.

^* Revised version of a paper presented at the 70th Annual Meeting of the American Sociological Association, August 25-29, 1975. I am very grateful indeed to Steven Spitzer for his advice and criticism. I should also like to thank Magali Sarfatti Larson and two anonymous Social Problems readers for their comments on an earlier draft. ^† Reprinted from Social Problems, vol. 24, pp. 337-51, 1977, with permission of the Society for the Study of Social Problems and the author.

I

Three key features distinguish deviance and its control in modern society from the shapes such phenomena assume elsewhere: (1) the substantial involvement of the state, and the emergence of a highly rationalized, centrally administered and directed social control apparatus; (2) the treatment of many types of deviance in institutions providing a large measure of segregation from the surrounding community; and (3) the careful differentiation of different sorts of deviance, and the subsequent consignment of each variety to the ministrations of experts — which last development entails, as an important corollary, the emergence of professional and semiprofessional ‘helping occupations.’ Throughout much of Europe, England, and the United States, all these features of the modern social control apparatus are a comparatively recent development.

Prior to the eighteenth century, and in many places as late as the early nineteenth century, the control of deviants of all sorts had been an essentially communal and family affair. The amorphous class of the morally disreputable, the indigent and the powerless — including such elements as vagrants, minor criminals, the insane, and the physically handicapped — was managed in essentially similar ways. Characteristically, little effort was made to segregate such ‘problem populations’ into separate receptacles designed to keep them apart from the rest of society. Instead, they were dealt with in ways which left them at large in the community. Most of the time families were held liable to provide for their own, if necessary with the aid of temporary assistance or a more permanent subsidy from the community. Lunatics were generally treated no differently from other deviants: only a few of the most violent or troublesome cases might find themselves confined — in a specially constructed cell or as part of the heterogeneous population of the local gaol (Fessler 1956).

The transformation of traditional arrangements into what we know today as systems of social control is clearly a subject with a profound sociological significance. I shall comment on some aspects of this transition with respect to one major variety of deviance, by examining nineteenth century efforts to ‘reform’ the treatment of the mentally ill. More specifically, I shall try to provide an account of the reasons for the emergence of the asylum as the primary, almost the sole, response to the problems posed by insanity.

This explanation will radically challenge David Rothman’s (1971) provocative account of the American ‘discovery of the asylum,’ probably the study of the history of mental institutions most familiar to American sociologists working in the field of deviance. The account Rothman provides in his book is essentially, despite occasional backsliding, an idealistic one. The rise of the asylum is pictured as the product of a peculiarly Jacksonian angst about the stability of the social order — anxiety mixed with a naive and uniquely American utopianism about the value of the well-ordered asylum. This was to be an institution which would at one and the same time eliminate the scourge of insanity, and by correcting ‘within its restricted domain the faults of the community . . . through the power of example spark a general reform movement’ (Rot...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Dedication
• Table of Contents
• Preface
• Introduction
• Part I Historical and conceptual concerns
• Part II The changing mental health system
• Part III Providers and treatments
• Part IV Alternatives to traditional mental health services
• About the authors