Issues in mental health

16.1 · Free notes

Mental health in historical context: asylums, deinstitutionalisation and care in the community

Key points

• Early asylums such as Bethlem Royal Hospital (London, founded 1247, source of the word 'bedlam') were custodial. They used restraint, isolation and sometimes public viewing, with little treatment.
• The Lunacy Act 1845 and County Asylums Act made it compulsory for each county to build an asylum. The 1808 Act had only permitted it. Victorian asylums became huge, isolated, overcrowded institutions.
• Moral treatment, as at Tuke's York Retreat (1796), promoted kindness, work and no chains. It was a humane reform, but later asylums drifted back to containment.
• Early 20th-century physical treatments included insulin coma therapy, lobotomy (Moniz, 1935) and ECT (Cerletti and Bini, 1938). These were often used without informed consent.
• Goffman (1961) described asylums as total institutions that control every aspect of life and strip away identity. Barton (1959) called the resulting passivity institutional neurosis, now called institutionalisation.
• The Mental Treatment Act 1930 allowed voluntary admission and outpatient clinics. The Mental Health Act 1959 ended most legal certification, allowed informal admission and promoted community care.
• Chlorpromazine (1950s, the first antipsychotic) controlled symptoms such as hallucinations. Along with Powell's 1961 'water tower' speech and the 1962 Hospital Plan, it enabled deinstitutionalisation, the closure of large psychiatric hospitals and discharge of patients.
• Other drivers of deinstitutionalisation were scandals (e.g. Ely Hospital inquiry, 1969), Goffman's critique, human-rights concerns and cost savings. Costs are a political as well as a humanitarian motive.
• Care in the community: the NHS and Community Care Act 1990 made local authorities assess needs and arrange care packages. The Care Programme Approach (1991) added a key worker and care plan, delivered through CPNs, day centres, group homes and crisis teams.
• The Mental Health Act 1983 (amended 2007) governs compulsory admission, or 'sectioning'. Section 2 allows up to 28 days for assessment and Section 3 up to 6 months for treatment, renewable. Community Treatment Orders (2007) allow recall to hospital if conditions are breached.
• Strengths of community care: it is less restrictive and reduces institutionalisation. The TAPS study (Leff et al.) followed long-stay patients from Friern and Claybury hospitals. It found most coped well, with wider social networks and no overall worsening of symptoms.
• Weaknesses: under-funding, the revolving door of repeated readmission, homelessness, and trans-institutionalisation into prisons. Public fear after high-profile cases (e.g. Christopher Clunis, 1992) and carer burden are also problems.

In more detail

• Timeline to learn: 1247 Bethlem founded → 1796 York Retreat → 1845 Lunacy Act → 1930 Mental Treatment Act → 1950s chlorpromazine → 1961 Enoch Powell's 'water tower' speech → 1990 NHS and Community Care Act.
• Peak numbers: the number of patients in psychiatric hospitals in England and Wales peaked at around 150,000 in the mid-1950s, then fell sharply as hospitals closed.
• Rosenhan's influence: Rosenhan's (1973) finding that hospital staff failed to spot sane pseudo-patients added to criticism of large psychiatric institutions.
• Exam tip: explain deinstitutionalisation with three drivers: new drugs (chlorpromazine), critiques of institutions (Goffman, scandals) and changes in cost and policy.