Neoliberalism, advanced marginality and mental health

This chapter will discuss the broader impact of neoliberal social and welfare policy. In particular, it explores the impacts of increased inequality and the spatial concentration of poverty. These processes are referred to as “advanced marginality”. This concept captures the ways, in which, areas of poverty are surrounded by areas of affluence. In addition, advanced marginality symbolises the processes whereby groups and individuals are effectively excluded in a literal and metaphorical sense from major areas of modern society. This section is influenced by the work of Loic Wacquant (2008a, 2008b, 2009a and 2009b) and his notion of territorial stigmatisation. This is the modern context of community. It then goes on to examine the impact of austerity policies that have been followed since 2010 on both mental health service users and wider mental health provision. The links between poverty and poor mental health are examined below.

Introduction

When Theresa May became Prime Minister in July 2016, she made a speech on the steps of Downing Street in which she outlined a series of ‘burning injustices’ her administration would seek to tackle. Many were struck by the irony of this commitment to tackling inequality and disadvantages coming, as it did, from a senior member of the coalition and Conservative governments that since 2010 had introduced a series of policies which had targeted those living in poverty and the most vulnerable. The scandals of the revelation of the real impact of the ‘hostile environment’ created by May’s Home Office and the appalling treatment of the Windrush generation lay ahead. In May 2017, May announced that a review would be undertaken of the ‘flawed’ Mental Health Act (MHA). In making the announcement she stated:...

International perspectives

This chapter will examine deinstitutionalisation in Italy, the United States, and post-apartheid South Africa. In examining the different drivers and outcomes of policies in these areas, similar themes to the UK experience emerge. These include: the role of scandals in the pressure for change, the role of fiscal considerations in the development of policy, an initial period of optimism and the impact of scandals. In Italy, the work of the psychiatrist, Franco Basaglia was seen as a possible blueprint for wider reforms. Basaglia’s work became very influential amongst radicals and the anti-psychiatry movement. The USA was at the forefront of the deinstitutionalisation policy. The links between the closure of psychiatric facilities and the expansion of the use of imprisonment have been most closely examined in this context. Finally, the chapter examines the total policy failure that led to the deaths of one hundred and forty-four patients in Gauteng Province, South Africa in 2014

The asylum and the community

This chapter will argue that the development of mental health policy was hugely influenced by conceptions of space and place. By the middle of the 20th century the asylum had become, in the public and sociological imagination a Gothic institution of seclusion and abuse. The chapter will explore the development of this representation of the asylum. The final representations of the asylum contrast dramatically with the original ones that saw the new institutions as a modern, progressive deinstitutionalisation was to present the community in binary opposition to the asylum. Community based services would, almost by reason of their location, lead to the creation of a new form of inclusive mental health provision. This is based on an idealised notion of community. As the pressures on mental health services grew, a range of social policies that were introduced that meant that urban communities, in particular, became exclusionary rather than inclusionary.

Community care: a brief overview

This short chapter provides a brief overview of the development of community care. It examines the way that the asylum became an obsolete institution - certainly one that few defenders in the early 1980s. In giving a brief overview of the intellectual underpinnings of community care, the chapter introduces a series of issues such as: deinstitutionalisation and the penal state, community care inquiries and the asylum/community binary that are examined in depth in subsequent chapters. Community care is a complex and highly influential shift in mental health services. As with all policies, there were a series of drivers behind the policy - a combination of progressive idealism that attacked the whole notion that institutions could ever provide humane, dignified care and fiscal conservatism

Inquiries

This chapter will explore a number of mental health inquiries that took place in the early and mid-1990s. It will argue that the media reporting – particularly that which appeared in tabloid newspapers – had a key role in undermining support for the progressive elements of community care. This is not to diminish the nature of some of the cases that led to the Inquiries. It is, rather, to consider the way that this media reporting helped to construct a particular discourse around, risk and mental health. This reporting played on a series of long standing, often racialised tropes about the nature of mental illness. One of the most important of these was the notion that there is a clear, identifiable and causal link between mental illness and violence. These are complex issues. However, complexity was drown out by the dominant narrative was that the community faced new dangers in the form of “psychokillers”. Alongside this, a theme in the reporting of such cases was that liberal mental health professionals were refusing to use their powers to intervene

Reform or revolution? Mental health legislation and the development of community care

This chapter will explore the development of mental health legislation from the introduction of the 1983 MHA to the introduction of Community Treatment Orders (CTOs) in the reforms of 2007. The chapter ends with a brief discussion of the Wessely review of the MHA that was completed in 2018. Reform of mental health legislation reflects two potentially conflicting strands. One is the state’s power to incarcerate the “mad”, the other is the move to protect the civil rights of those who are subject to such legislation. The development of legislation reflects the broader pattern of community care as a policy. The initial optimism and progressive reforms of the early 1980s are overtaken by a more managerialist, pragmatic approach which focuses on risk and risk management

Deinstitutionalisation and the penal state

This chapter will explore the relationship between deinstitutionalisation and the increase in the use of imprisonment. The chapter begins with a consideration of the problem of how do we define “mentally disordered offenders” and a brief outline of the Penrose Hypothesis (Penrose, 1939 and 1943) which sought to explain the links between the use of imprisonment and institutionalised psychiatric care. This approach will be used as critical lens to examine policy developments in this area. Broader issues regarding the treatment of mentally disordered offenders will then be discussed. This section will highlight the pressures on the CJS and the way that it has become, in many cases, a de facto provider of mental health care. The argument that deinstitutionalisation has led to the “criminalisation of the mentally ill” will be discussed. The legacy of deinstitutionalisation and the expansion of the penal state will be discussed focusing on contemporary issues in the CJS.

Conclusion

This chapter brings together the main themes of the volume. It argues that deinstitutionalisation and community care should be understood as distinct policies – one should follow on from the other, but this has not happened. These policies which have been adopted across the globe were driven by a combination of fiscal conservatism and progressive idealism. Fiscal conservatism was, for most of the period, the dominant force. Community care has become discredited, but it can be reinvigorated by a call to the progressive idealism that underpinned it.