Feature

Life on the outside

Has the policy of closing the big psychiatric institutions led to poverty, homelessness and misery for former patients? Dylan Tomlinson sifts the myth from the reality

A ‘great and silent tradegy’ was highlighted by the National Schizophrenia Fellowship last year. Thousands of seriously mentally ill people were being ‘put out’ of mental hospitals and left on the streets, in bedsits or ‘with their often aged and beleaguered parents’.

This is the haunting and emotive judgment of mental hospital closures which is becoming accepted. The string of scandals about the conditions in mental hospitals which regularly shocked Britain in the 1960s and 1970s seem to be forgotten. But in one sense there has been no change in thinking. The closure of institutions and integration of mentally ill people into the community has always been fundamentally unpopular. It matters little how many times psychiatric workers point to the dependent state of their elderly charges: fondly held myths about their unpredictability and dangerousness do not lose any of their power over the public imagination.

The unlocking of the asylums in the 1940s was a sensational act. New regimes such as that at Belmont Hospital were based on ‘permissiveness, communalism and democracy’. Therapeutic communities were set up to prevent patients from becoming regimented and losing their autonomy. In the future inpatient admissions were to be a last resort for treating mental illness.

But just as community alternatives and psychiatric units in general hospitals have been slowly established, public concern about the plight of lonely, neglected dischargees has begun to show itself. Conditions within the rundown asylums, for all their faults, are now being seen as preferable to the isolation of the bedsit or the desolation of Cardboard City. There is nostalgia for the security of the mental hospital. Anti-institutional thinking no longer appears valid when the communityless conditions of life outside are bleak. In effect we are coming full circle to the point where the psychiatrists are being lobbies to ‘take back their own’ and provide long term care.

The health authorities responsible for running down the hospitals have never been popular. Many studies have suggested that their lay members have been able to exert little influence where key government policies have been handed down for local implementation. The recent history of general management reform, competitive tendering and district mergers tends to confirm such a view. There is apparently well founded suspicion that strategies for mental hospital closure are being received from above and do not derive from ground level desire for change.

NHS spending on mental illness has held up reasonably well within the general constraints on the service. At the same time, it has not achieved the improved levels against other care groups which were envisaged by the ‘priority’ status it was given in the 1970s.

Two recent independent studies, carried out in Worcester and London, show that the conditions of patients moved out of the asylums are at least no worse than those they left behind. But more importantly, interviews with more than 400 patients and their carers found a fairly high degree of satisfaction with the new arrangements.

Only one possible suicide occurred among 278 patients placed in the community as part of the rundown of Friern and Claybury hospitals in London. Seven people could not be traced after discharge and may have drifted into vagrancy. The analysis carried out by the clinical members of the Team for Assessment of Psychiatric Services found no significant change in the psychiatric problem count of the residents … is, the severity of their delusory or paranoid beliefs … as a result of the move into the community. Perhaps most importantly their physical health did not deteriorate and thus there was no evidence to support the thesis of large scale health authority ‘putting out’.

Asked how they felt about being outside hospital, patients expressed a strong preference for the new settings, citing particularly the increase in freedom, privacy and better quality food.

In Worcester, where the local asylum was completely closed, a Medical Research Council team interviewed more than 150 long term clients of the new services. They were also generally satisfied with facilities on offer.

There is no new magic ingredient in the health authority plans which have led to this apparently scandal-less conclusion. On the whole they are rather old fashioned, being based on the model of ‘group homes’ and hostels. There is a greater degree of care being given within the new homes than in the past but the basic model for resettlement is unchanged. Why then is there this apparent discrepancy between the researched outcome of closures and the plight of mentally ill people amongst the homeless?

Of course it is an administrative fantasy to believe that the move out of the asylums has made all those dreams of home life come true. There is one sense in which the image of health authority dumping may be appropriate. With the closures the authorities are able to cast off a number of responsibilities, They can share housing, employment and social security responsibilities with other agencies, such as local councils and voluntary organisation. Closer inspection of changes across the whole range of HA services, including district general hospitals, reveals that there are really two stories to be told about hospital closures.

The first concerns elderly patients who make up the majority still resident in asylums. Many were first admitted before the arrival of modern treatment regimes and subsequently became institutionalised. They have been gradually resettled in various forms of community care fairly successfully for many years. It is these patients who are now subject to transfer to new community units as the big hospitals reach the nadir of their viability. Here research can show good results: while no cure is being offered, the patients show a clear preference for living in the community.

The other story concerns the younger generation of patients who become ill in the years after the vigorous attempts to keep people out of hospital. They have been treated more and more from the general hospital departments of psychiatry, where lengths of stay are for weeks rather than months. Thus whilst there have been steadily increasing numbers of admission to the new units. It is often the same people who come in several times a year. A sequence of admission, readmission, discharge, relapse and readmission has been established for patients with fairly intractable problems who would previously have remained permanently in the hospitals. It is the distress felt by others about the conditions faced by those who are discharged in this way, and who are perhaps never wholly well, that solidifies the image of dumping. Closures are then scapegoated.

Other social policies have accentuated the crisis for people with long term mental health problems in the community. The squeeze on private rented housing, lack of investment in public housing and high interest rates facing would-be homeowners make it difficult for most to acquire adequate accommodation. Britain has always had a much higher proportion of people in temporary or part-time employment than other European countries, giving some scope for exploiting people with few skills.

The euphoria of the united Britain of the post-war era, in which therapeutic communities underpinned by communalism could be established, now belongs to a scarcely credible bygone age. There could be no greater contrast than a divided Britain sold on individualism. Is it right in these circumstances to retreat back into the institutions.

The beneficial effects of asylum closures should not be clouded by the negative impact of NHS cuts. However well funded community care may be it is no more of a miracle cure for entrenched problems of mental illness than the care of the therapeutic communities. Since social problems associated with homelessness and poverty have always been significant in mental illness, need seems bound to increase. The current reaction to change manifests panic at the increased visibility of mentally ill people outside institutions. Timely reminders of the horrors of the Poor Law institutions should keep that panic at bay.