that are generated by societal responses to mental illness. The response clearly involves social control, but we also need to see it as something more than that. There are many aspects to it because mental illness is such a diverse and complex phenomenon. Finally, the focus in Foucault’s account is on essentially state responses. This overlooks the other ways that families, wider social attitudes and public sanctions – formal and otherwise –combine to produce social order (Ignatieff, 1985).
Foucault (2003) and Goffman (2017) challenge established notions of progress. They also question the role of psychiatry, viewing it as a disciplinary process. The focus is often on the impact of the asylum regime on the incarcerated. There is a danger of overstating this. For example, the voice of the service user/patient is largely if not totally absent from Goffman (2017). The influence of these writers has led to an explosion in research and literature that explores all aspects of the asylum. The history of the asylum from below is, perhaps, more attractive than a narrative of the struggle of psychiatrists to humanise an inhumane system. However, it is important to examine all aspects of the asylum regime. The fundamental difficulty with these hugely influential accounts is that they are based on a discourse of subordination and domination. In challenging the notion of progress, there seems to be a denial of its possible existence whatsoever. Unfairly in my view, Foucault seems to be held personally responsible by many for the failings of community care. Stone (1982), for example, argues Foucault had a destructive impact on the development of mental health services, arguing the attacks on institutional care led to a collapse in the belief in care itself.
Conclusion
As noted, the progressive proponents of community care saw the abuses of the asylum system as a fundamental human rights issue. Institutionalised forms of treatment were inherently abusive as they denied people the full rights of citizenship and subjected them to inhumane and degrading treatment. For fiscal conservatives, the asylums were part of an increasingly unaffordable welfare state. In later chapters, I explore how the progressive vision of community care disappeared. By 1998, and the arrival of the first New Labour administration, community care had officially ‘failed’. One is tempted to respond that it had never really been tried. The sweeping statement that it had failed ignores the fact that there were and are people who would previously been institutionalised, who have not been and are living independently. However, the grander vision of a series of community mental health and crisis centres that would replace the large glooming presence of the asylum has never materialised.
The assumption that there is a binary of the asylum/community and that they are always in opposition is something of an illusion. The idea that all the problems raised by the asylum regime could be solved by a return to the community ignored more fundamental questions about the nature of mental health services. The impulse behind community care was to improve the standards of mental health provision. The overwhelming majority of writers accept that there will be a need for a period of recovery that involves a therapeutic setting of one sort or another. The York Retreat and others like it were just that – a retreat from the pressures of the world. Even a writer as radical as Laing accepted this and set up therapeutic communities as a result. This is not to deny that is that prolonged periods of hospital care can in themselves be damaging and that services need to exist to intervene at an early stage to provide support to those suffering from any form of mental distress. This is a public health model of service provision that ideally develops tiers that will meet individual and community need. Community care from the late 1980s onwards appears as a policy with few vocal supporters. This is partly due to the media coverage of high-profile cases (Cummins, 2010, 2012). One should, perhaps, not be too shocked that the tabloid media, which did so much to contribute to the stigma that users of mental health services face, reported these cases in such a lurid fashion. These reports undermined wider support for the policy. The response has been a call for more coercive legislation, one which ultimately led to the introduction of Community Treatment Orders.
Moon (2000) highlights the geographical paradox at the heart of the development of community care services: the closure of the asylums has not resolved the marginalisation of those experiencing mental health problems. The asylums were distant institutions geographically and metaphorically (Philo 1987; Scull 1989). The notion of community care was based on an inclusive vision. In tracing the history of community care, this volume seeks to examine why that vision never materialised. Far from being a welcoming, supportive environment, communities, particularly in urban areas, have reproduced the worst aspects of the asylum (Wolff, 2005). Those with the most complex needs are often found living in the poorest neighbourhoods, in poor quality residential care homes, on the streets or increasingly in the prison system (Moon, 2000; Singleton et al, 1998). The overall picture is a very bleak one, so bleak in fact that the asylum system appears to have some advantages in that it was, at least, a community. For a variety of reasons – economic, social and political – the community has not proved up to the task of providing humane and effective services for those with the most complex needs.
Mental health services have always struggled to gain an appropriate level of funding – particularly in comparison with other areas of medicine. This is partly a reflection of the stigma attached to the area. The period that is mostly examined in this volume (1983–97) was one that saw a broader restructuring of the welfare state. These pressures meant community care was never properly funded (Scull, 1986). One of the main conclusions of a series of inquiries into failures in community care services (Ritchie, 1994; Blom-Cooper et al, 1995) was that resources were stretched to breaking point. It is interesting to note that these inquiries called for more investment in mental health services but focused on the need for more secure provision. In addition, there were calls for changes in mental health legislation. When examining these issues, it is impossible to separate mental health services from the wider discourses of risk and risk management that came to dominate social work, in particular, as well as other public services (Cummins, 2018a).
The critics of the asylum regime from a human rights perspective were clearly not arguing that they should be replaced by prisons, police custody, homelessness and poor quality bed and breakfast accommodation. The treatment of mental illness is fundamentally a moral issue that involves questions about the rights of the individual and the wider society (Eastman and Starling, 2006). Such questions did not disappear because of the advent of community care. The powers of compulsory admission have remained largely unchanged. The reform of the Mental Health Act (MHA) in 2007 saw the introduction of Community Treatment Orders legislation. This could be taken as the symbolic ending of a policy commitment to community care. These debates are the result of the nature and impact of mental illness. It is only, perhaps, on the more extreme wings of libertarian thought (Szasz 1963, 1971) that there is a total rejection of the therapeutic state having powers to intervene when individuals, because of their mental health, are seen as putting themselves or others at risk in some way. One of the many paradoxes of community care is that the rights of the mentally ill are on a much stronger footing than they have ever been. In the US, challenges to the legal processes of detention were one of the key drivers of deinstitutionalisation (Harcourt, 2005). In the UK, greater legal protections exist that mean people can challenge,
