The demise of the asylum and the rise of care in the community

The treatment of the mentally ill measures the health of any society

Jack Nicholson in One Flew Over the Cuckoo’s Nest. The film reflected worries about brutal psychiatric institutions

Henry Cockburn was diagnosed with schizophrenia in 2002. Before that he was a heavy cannabis user.

His father, Patrick Cockburn, The Independent’s award-winning foreign correspondent, has seen – at first hand – the dramatic changes in the way we treat the mentally ill over recent decades. Today, in the second of his groundbreaking four-part series, he explains how psychiatric care in Britain went wrong – while Henry reveals his experiences as a schizophrenic marooned in the system.

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The treatment of the mentally ill measures the health of any society because they are the most vulnerable and the least able to defend themselves against cruelty and neglect. It is an issue that affects the lives of a large part of the population. At any one time some seven million people in England and Wales over the age of 16 – one in six of the adult population – are suffering from a significant psychiatric problem. At least one-third of all families have a member who will at some stage be mentally ill.

Mental illness may be pervasive but it remains a largely hidden plague. Despite significant progress over the past decade, knowledge of psychiatric disorders lags far behind that of physical illnesses. Neat-sounding categories such as schizophrenia, bi-polar depression and schizoid-affective are not distinct diseases like TB or polio, but names given to a psychosis on the basis of symptoms evident when a patient sees a psychiatrist. As these symptoms change – as they often do – so does the diagnosis.

In the 1950s medications were discovered that could control, but not cure, mental disorders, and it is still not known exactly how they work. Only last month it was revealed that big pharmaceutical companies have largely stopped the search for new drugs to treat mental illnesses after spending billions of dollars in the search. They had found that not enough was known about the human brain and its ills for them to have a reasonable prospect of success.

Given the uncertainty about the nature of mental illness, it is extraordinary that governments in Britain and across the world should have revolutionised the treatment of those suffering from it. In the years since the mental asylums created by the Victorians were first denounced in the UK as relics of a past era – by Enoch Powell as Minister of Health in 1962 – the great majority of them have been closed. Between the 1950s and today the number of beds available for psychiatric patients in Britain has declined spectacularly from 150,000 to 27,000.

The asylums were supposed to be replaced by “Care in the Community”, a cuddly-sounding approach that one Labour minister derided as “couldn’t care less in the community”. The crime novelist P D James, who worked as an administrator in the NHS and whose husband was a long-term patient in a mental hospital, commented bitterly that community care “could be described more accurately as the absence of care in a community still largely resentful or frightened of mental illness”.

Half a century ago every British city had at least one mental asylum on its outskirts, but these were rapidly closed down and sold off, often to become luxury flats or the site of a supermarket. It was one of the most radical changes in the British institutional landscape since the dissolution of the monasteries in the 16th century. As with the monasteries, the motives leading to the demise of the asylums combined a genuine belief that the system was wrong with an ideological hostility to their existence and a keen sense of the financial advantages stemming from their demise.

The psychiatric hospitals were caught in a pincer movement from right and left. The left saw the asylums as being like prisons, whose inhabitants were primarily the victims of an authoritarian system. Films like One Flew Over the Cuckoo’s Nest propagated this attitude. On the right, such views were welcome because they provided respectable reasons for spending less money on the mentally ill and reduced the role of public welfare.

What followed this revolutionary change is still a subject of angry dispute among doctors and former patients. Many things were wrong with the old asylums, which could be brutal and uncaring, but they were also a place of refuge for people who desperately needed one and had nowhere else to go. Barbara Taylor, a historian who spent time as a patient in the late 1980s in the Friern mental hospital in north-east London, formerly known as Colney Hatch, recalls in an essay that “for me Friern was truly an asylum. I entered it on my knees: I could no longer do ordinary life, and giving up the struggle was an incalculable relief. My home in the hospital was a locked acute ward with a deservedly violent reputation: a Dickensian barrack of crumbled brickwork and peeling walls, reeking of fag smoke and teeming with ghosts; but for me it was sanctuary.”

The end of the asylums came not just in Britain but across the world and is still going on. In the United States the number of beds available for psychiatric patients fell from 558,000 in 1955 to 53,000 in 2005.

Some of the slogans of the anti-asylum movement in Britain and the US are chilling in their covert or unintentional cruelty. One of them was “de-institutionalisation”, as if healthy people, and not just the mentally ill, are not themselves dependent on institutions where they work, such as a school or an office. The institutional needs of the mentally ill are often very simple, described by one social worker as being “a place where you can go and sit and chat and have a cuppa, and lunch”.

But even this is sometimes denied them on the grounds that it makes them part of a “dependency culture”. A carer, lamenting the closure of a day centre in Wales, says “often people are very withdrawn, lonely or low, or in another world, others have lost most of their personality and are referred to as being burnt out. These people don’t want or need anything very demanding, just coming to the centre and getting out of the house is enough, and a blessing for carers.”

The disastrous impact of “care in the community” was being recognised in the 1990s and more sophisticated community care became available such as the Early Intervention in Psychosis units that aim to help young people suffering their first psychosis by detecting and treating it in its early stages. But the closure of so many mental asylums in the past continues to have a negative impact because almost all those now inside are there by compulsion. Psychiatrists say they are becoming increasingly like an 18th-century Bedlam, with locked rooms like cells and an emphasis on preventing escape. Dr Humphrey Needham-Bennet, a consultant psychiatrist, says “they are more like a prison than a hospital”.

Paradoxically, mental health care in Britain since the closure of the asylums has moved in two different and contradictory directions. One, motivated by media and public fears, is to treat mentally ill people as potential axe murderers to be closely incarcerated. The other approach, equally exaggerated, is to understate the gravity of a chronic mental illness and pretend sufferers can live “in the community” as if they were not ill.

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