with service user rights but was introduced at a time of welfare retrenchment. In the UK and the US, this major shift to a community oriented vision of mental health service provision was introduced by governments committed to a small state and convinced of the supremacy of the market.
Community care is a phrase that does not appear in many, if any, contemporary mental health policy documents. It has either been discarded or is so deeply embedded that it is not worth commenting on. One of the aims of this volume is to examine the reasons behind the disappearance of community care from official discourse. The closure of the large psychiatric hospitals that had been built in the 19th century is one of the most significant social policies of the last 50 years. The process of asylum closure is usually referred to as deinstitutionalisation. Estroff (1981) identified four groups of patients who were affected by the process of deinstitutionalisation:
•long-term hospital patients who were discharged;
•patients who experienced potentially multiple psychotic episodes and hospital admissions – this group was treated as outpatients or with short, crisis-oriented admissions;
•patients who were treated on an outpatient basis;
•those patients who experienced a first serious episode of mental distress and were not admitted to hospital or who were in hospital for a relatively brief period compared to asylum admissions.
The first two groups were the focus of the first stage of the process of deinstitutionalisation. In theory, the second two groups would benefit from the establishment of community mental health centres and other changes to the provision of mental health care. Community care represents what now might seem the idealistic belief that the closure of the asylums would represent a hugely progressive shift in the care and treatment of the mentally ill. There are several narratives of community care that are examined in this volume. One of the most powerful is that community care was an inherently progressive idea based on inclusive notions of citizenship. This narrative is based on a view that sees asylums as Gothic sites of seclusion and terror. As Scull (1986) noted, this modern view of the asylum is a betrayal of its origins and would have shocked the founders of these institutions. Figures such as Tuke at the York Retreat established them as progressive and a humanitarian response to suffering. The debates about the causal factors and influence on the development of community care are explored here. What emerges is a complex, messy and often contradictory picture. Progressive idealism, fiscal conservatism and new pharmaceutical developments combined to render the asylum obsolete. The progressive drive for community care was based on the idea that the discredited asylum would be replaced with a range of properly resourced community-based resources to support citizens in acute distress. I think it is clear that this ambitious goal was never achieved. Turner and Columbo (2008) argued risk assessment has replaced an ethic of care as the main focus of service user contact. An understanding of the rise and fall of the asylums, the radical challenge to psychiatry and the subsequent failings of community care is important if we are to appreciate how to build new models of service provision.
The rise of the asylum
One way of understanding the development of community care is to see it as a response to the failings of the asylum regime. The asylum is situated physically apart from the wider community (Pilgrim and Rogers, 2014). This physical distancing, subsequently, became a metaphor for the social and civic isolation of the patients. These institutions were built on sites away from the main centres of population thus physically separating the mad from the rest of the population. Scull (1977) sees the rise of asylums as part of the Victorian response to the problems of urbanisation. In tracing the rise of the asylum, Scull (1977,1986) outlines the way that the institution was linked to and played a role in the new status of psychiatry as a distinct branch of the medical profession. Scull (1986) was particularly critical of Foucault and those who viewed asylums simply as forms of social control. He notes that there was an optimism in this period that contrasts strongly with the end of the asylum period. The new asylums were established to rescue the mad from the kinds of maltreatment and neglect with which they became synonymous. The hospital was a rational, technical response to mental illness.
Michel Foucault is one of the most influential and widely cited writers in the humanities and social sciences. His work and the responses to it have opened new areas of debate. Foucault’s work is complex and often appears contradictory. The key themes that he explored include: the nature of power; the development of modern institutions, such as prisons and psychiatric hospitals; and modern modes of social regulation. Foucault argues that these shifts in what he terms ‘technologies of power’ cannot be necessarily seen as progressive. They reflect changes in the dynamics of societal power. His work on two key institutions of modernity – the asylum and the prison – has at its core a concern with the exercise of power (Foucault, 2003). His work is a challenge to the traditional notion that the development of these institutions can be read as a process of reform. Foucault sees these institutions as new technologies of power. The task is to examine the shifts in social, cultural and political beliefs that underpin these reforms.
Foucault’s work is, unlike that of other critics of the asylum regime, historical. He explores the birth of these modern institutions. His influence was and is such that it was taken to be a criticism of contemporary systems (Cummins, 2017). Foucault outlines the way that the focus of punishment and treatment moves from the body of prisoners or patients to their minds. He argues that this is a more pervasive form of social control. In this analysis, power and the power to punish are much more dispersed throughout the social system. It therefore operates on several levels. Foucault terms this ideology of discipline ‘savior’. Expressions of this ideology can be found among all groups including those termed deviants and it operates as a mechanism of repression both of the self and others. A subject is created by a series of what he terms ‘dividing practices’ (Foucault, 1982). These ‘dividing practices’ are the application of a branch of knowledge such as psychiatry or criminology. The application of such knowledge, for Foucault creates new groups or cases or in as he puts it ‘specifications of individuals’. The implications of being placed in such a category are potentially profound. These include being institutionalised and being denied the rights of citizenship. Foucault argues that the ‘Great Confinement’ saw the development of institutionalisation as the response to the poor, mad or offenders. In Discipline and Punish (2012), Foucault outlines the development of the ‘disciplinary gaze’. This is the process by which individuals become cases subject to a system of classification and control. In his writings, Foucault draws attention to the symbolism of the institutions. Bentham’s panoptican becomes not just an architectural design but an embodiment of new society, whose institutions form a ‘carceral archipelago’ for the management of deviant populations, be they criminals or the insane (Foucault, 2003).
It would be a mistake to assume that there were not attempts to respond to the radical perspectives of Foucault and others. The liberal view of the asylum highlights that they represent progress on the previous system. The motives of reformers are fundamentally humanitarian and focusing on the relief of the pain and suffering of their fellow citizens (Jones, 1960). This is an approach that does not see these institutions solely in terms of exercising functions of social control. Individuals such as Tuke, the founder of the York Retreat, are represented as challenging the more hostile views of wider society. By contrast, Foucault
