Originally published by Penguin in 1992, this book by the psychologist and historian Peter Barham provided a searching and, at times, discomforting analysis of the project to close asylums in Britain in the latter part of the twentieth century. At the core of the book was the fate of patients relocated to the community. Shining through the account was Barham's passionate concern for their plight and for their right to be full citizens of the society to which they had returned. Barham traces a historical arc, beginning with the Victorian asylum. Although these institutions were inspired by the York Retreat, a small, homely facility, they quickly became large, overcrowded ‘warehouses’. Barham writes that the Victorian asylum staff often showed compassion to their charges; nevertheless, in his view, the patient was treated as ‘other’ and not as an equal. They were perceived to lack self-agency and to require the asylum to protect them from themselves. Barham views this as the beginning of seeing the patient as somehow permanently ‘flawed’ and inferior to their sane counterparts. The prevailing psychiatric discourse of the time served to reinforce such thinking. He then looks at the mid-twentieth century when the move to close the asylums was gaining momentum. He contends that the impetus came from two disparate sources: the anti-psychiatric movement and the introduction of new antipsychotic drugs that gave psychiatrists the hope that they could successfully treat their patients, thus rendering the need for asylums redundant. Barham finds it ironic that the first group wanted to overturn psychiatric conformity, whereas the second wanted the patient to conform to society.
He then examines the move to the community, and states that, although he staunchly supported the move, some of the officials pushing for it were not necessarily motivated by humanitarian reasons, but by financial ones, and that the way the policy was implemented was often shockingly inadequate. Patients were left isolated, impoverished and with patchy support from psychiatric and welfare services. More fundamentally, Barham argues, the process of rendering the mentally ill person a second class member of society, which began with the Victorian asylum, continued with the move to the community. Very little thought had been given to the psychological and social needs of the newly returning patient and their status in the outside world.
The most compelling part of the book is that devoted to the voice of the patient, a chapter that was largely based on interviews that Barham and his colleagues conducted with people with schizophrenia. We hear about the impact of a psychiatric diagnosis on an individual: how it affects their identity and self-worth. Are they still the same person? Are they a ‘schizophrenic’? If so, are they irreversibly changed and permanently damaged, or is there hope of a return to their previous mode of being? Further, the diagnosis profoundly affects their relation with others, and they tell sad tales of failed job interviews after potential employers learn of their psychiatric illness, and of relatives being uneasy about letting them babysit. Although most of the patients often find the world unsympathetic, unsupportive and sometimes hostile, all are agreed that living in the community is preferable to being in a psychiatric hospital.
Barham concedes that the choice between treatment in hospital or in the community is not a straight forward one of always choosing the latter. He refers to David Copperfield by Charles Dickens, in which Betsey Trotwood proudly proclaims that she has saved the mad Mr Dick from being locked in an asylum, as his brother had advocated, by arranging for him to live in her home. Barham admits that if the mentally ill person is not as gentle and charming as Mr Dick, the request of relatives for their admission to hospital should be honoured.
Barham's writing is fired by his fervent belief in the potential of the mentally ill person and their right to full membership of society. His book has just been re-issued with a preface by the mental health campaigner, Peter Campbell and a new prologue in which Barham reflects on the continuing relevance of the questions raised in his book to today.