estate – Getting By – focuses not only on the economic and social pressures facing the residents but also the ways in which they overcome them.
Wacquant (2007) terms this ‘territorial stigmatization’ – the processes whereby areas are characterised by:
… forms of poverty that are neither residual, nor cyclical or transitional, but inscribed in the future of contemporary societies insofar as they are fed by the ongoing fragmentation of the wage labour relationship, the functional disconnection of dispossessed neighbourhoods from the national and global economies, and the reconfiguration of the welfare state in the polarizing city. (Wacquant, 2007: 66–7)
Media representations of community care as a failing policy focused on either the neglect of patients or an increased risk to the public. The longer the policy was in the public eye, the more the media focus was on the alleged increased risk that former psychiatric patients posed to their fellow citizens. There is a similar arc here to the asylum narratives outlined earlier. The failings of the policy in its later iterations acts as a prism through which the whole prism is viewed. This obscures not only positive aspects of earlier periods but also means that the narratives of those who might have spent their lives in institutions but did not are never examined or are lost. By 1984, there were 71,000 inpatients, roughly half the number when Powell made his Water Tower speech in 1961. Leff and Triemann (2000) argue that the first wave of community care was largely seen as a positive move. This period saw the resettlement of long-stay patients. These patients were, on the whole, better supported by mental health services. One key aspect of this was the fact that resettlement often involved the use of specific funding for that purpose. Later, community care services had to compete with others for access to increasingly squeezed funds.
As with deinstitutionalisation in the US, community care rather rapidly became associated with street homelessness or people living in very poor accommodation. Scull (1986), in criticising the impact of deinstitutionalisation, identifies what he terms a modern trade in lunacy. He notes that the irony of a policy developed to deal with the abuses of the asylum regime leading to concerns about vulnerable people being exploited by unscrupulous private landlords. Similar concerns in the early 19th century had been a driving force in the establishment of the original asylums. In 1976, John Pilger, then a campaigning journalist for the Daily Mirror, wrote an expose of the way that psychiatric patients were being discharged to bed and breakfast (B&B) accommodation with no support or follow up. Pilger report is based in Birmingham, which he describes as a ‘city of lost souls’. The article reports that former patients are living in crowded, often insanitary conditions. They are often not allowed in the accommodation during the day so spend their time wandering about the city centre as there is little in the way of constructive activity. The social workers that Pilger interviewed for the article suggest that Birmingham, possibly because of its size and the number of B&Bs acts as something of a magnet. They give accounts of psychiatric institutions outside of the city discharging patients with a one-way ticket to Birmingham. When reading the Ritchie Inquiry (Ritchie et al, 1994) and its account of Christopher Clunis’s contact with mental health services, which took place 15 years after Pilger’s article, one is struck by how often Clunis is living in homeless accommodation – a clearly totally unsuitable environment and one that could not possibly hope to meet his needs.
The asylum was thus not replaced by a well-resourced system of community mental centres, crisis accommodation, supported and independent living schemes and employment, which would enable people with mental health problems to complete the journey from ‘patient to citizen’ (Sayce, 2000) As the asylum closed, a fragmented, dislocated informal network of bedsits, housing projects, day centres or, increasingly, prisons and the criminal justice system replaced it (Moon, 2000; and Wolff, 2005). For many, as Parr et al (2003) demonstrated the friendship and communal living aspects that existed in asylums were lost. Knowles (2000) in her study of the way that former patients negotiated the public spaces, shopping malls and urban environment of Montreal shows that rather becoming integrated into the wider community, this group was isolated and shunned in similar ways to asylum patients. A series of powerful black and white photographs captures the ways that the ‘mad’ exist alongside but are ignored by the wider society. Knowles (2000) highlights the ways in which the responsibility for the care of the ‘mad’ has moved from public to private institutions. She goes on to suggest that the restructuring of mental health services acted as a model for other ‘problematic populations’. As Cross (2010) suggests, pre-existing social representations of the ‘other’ are very powerful in their ability to create a new identity for social categories. In this case, the representation of the mad from the asylum era has followed those people into the community. The homeless mentally ill (black) man became a TV and film drama cliché of gritty urban realism. The representation has changed – the mad are not now dishevelled creatures chained to walls – they are the homeless of the modern city living on the streets with all their belongings in shopping carts. Their presence on the margins is accepted as a feature of modern urban life. In his discussion of asylum seekers, Bauman (2007) argues that in a world of ‘imagined communities’ they are the ‘unimaginable’. Similar processes can be identified here; the mad became one of the constituents of what Bauman termed ‘internally excluded’. The media debates about community care led not to calls for investment in community mental health services but changes to legislation and a demand for the return of institutionalised care (Cummins, 2010b).
Conclusion
Mental health and responses to it take place within specific locations – temporal and spatial. The geographical locus of treatment provides an insight into the theoretical underpinnings of treatment but also wider social attitudes. Two idealised notions or representations of the asylum and the community came to play a dominant role in broader understandings of mental health policy. The asylum/community binary contains within it a series of other binaries: past/future; rural/urban; inclusion/exclusion; abuse/dignity; institutionalisation/independence; tradition/modernity; and deterioration/progress. The development of asylums involved the institutionalisation of populations who were regarded in some way as deviant (Castel, 1988, 1989). Asylums were located on the outskirts of cities or in rural settings, partly for therapeutic reasons but also as acts of exclusion. The asylum dominated the landscape in a physical but also a metaphorical sense. The closure of the asylums represented not just the transfer of the location of services but a switch in the modality of service provision (Joseph and Kearns, 1996). The seclusion of the asylum setting and their architecture ironically made them attractive to property developers in the 1980s. Those sites that were abandoned became part of the Gothic myth of the asylum.
Community care was seen as an antithesis to the dehumanising regime of the total institution that Goffman (2014) and others outlined. Community was used in a very problematic way that overlooked some of the philosophical difficulties with the concept. The community was assumed to be an entity rather than an abstraction but also a welcoming one. This proved to be naive, perhaps even wildly optimistic. As community care was being introduced, a series of economic and social policies placed tremendous pressure on the poorest
