Perspectives in Biology and Medicine

COMMUNITY PSYCHIATRY—A CHANGING LOCUS OF REJECTION? TIMOTHYJ. O'GRADY* The postwar period has seen a massive reduction in the number of psychiatric in-patients. In England, for instance, the asylum occupation rate fell from 344 to 161 per 100,000 between the years 1954 and 1980 [I]. This achievement is usually attributed not to the introduction of effective psychopharmacology but to a change in attitudes, a general enlightenment characterised by the "open door" movement among psychiatrists . Prins [2] has suggested that five main influences contributed to this trend. 1.Interest in the effects of the social environment upon the individual. 2.Effective physical treatments. 3.Improved psychiatric education for doctors. 4.Knowledge of the harmful effects of institutional care. 5.Developing awareness on the part of the general public of the problems of mental disorder as evidenced by the formation of associations for mental health. Prins made little mention of political and economic factors in the development of the "community care" concept. Nor does he mention the extension of community care to geriatric, mental handicap, neurological , and other services for chronic illness. Seemingly erroneous predictions made in the early postwar years about the future demand for services for the "ambulant sick" are attributed by Prins to statistical errors and a general naivety and optimism such as that associated with the formation of the NHS. Predictions were based on an extrapolation of the trend from 1954 to 1959, so that, in 1961, Enoch Powell, then U.K. health minister, proposed a 10-year plan for the closure of the large mental hospitals. Government publications [3, 4] outlined the blueprint for community * Consultant Psychiatrist, Lincoln County Hospital, Lincoln LN2 5QY, England.© 1988 by The University of Chicago. All rights reserved. 003 1-5982/88/3 103-0584$0 1 .00 324 I TimothyJ. O'Grady ¦ Community Psychiatry developments: the running down of large institutions and their replacement by local government facilities comprising social work services, homes for the elderly, hostels, group homes, day centres, and supervised lodging schemes. The transfer of funding responsibility from central to local government has been one of the main themes of the community care movement. Under such a process the burden of budgetary restraint is devolved to a large number ofincreasinglyjunior managers, although by far the greater part of the budget is still supplied from the central exchequer. Such devolution has been the major mechanism of cost constraint in health and social services. Although Prins feels that public awareness of mental illness problems has increased, he gives little evidence for this belief. In concentrating on changes in mental health legislation he ignores the wealth of fieldwork outlining popular attitudes toward the mentally ill. Nevertheless, Prins's overview of developments—the "enlightenment" theme—is widely shared. It runs something as follows: there has been a liberalisation of popular attitudes toward mental illness; the mental patient is consequently more welcome in the community; such a welcome has improved the lot of the mental patient by increasing his personal freedom, alleviating his actual illness, and normalising his life-style. In evaluating community care, one must examine, therefore, the degree of welcome there has actually been by the community and whether the well-being of the mental patient has altered. If the level of resource provision for the mentally ill is related to the general level of concern in the community, one may begin to suspect that in material terms there has been little evidence of improving attitudes. Perhaps three clusters of ideas can be distinguished within the nebulous concept "community psychiatry," namely, topographic, sociotherapeutic , and political. The term topographic relates to the physical replacement of large mental hospitals because they are antiquated, uncomfortable , and expensive institutions that are usually isolated from the urban areas that they serve and occupy very large sites on prime building land. New facilities in general hospitals were proposed to deal with acute cases. Aftercare in hostels and the like would replace "long stay" beds. Clinics would infiltrate the community from health centres and "mental health shops." The sociotherapeutic model of treating mental illness concentrates on the relationship between the patient and his family, neighbours, workmates , and employers. Since mental illness is manifest in behaviour...