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About this book

The second edition of this acclaimed book offers a critical analysis of the transition from institutional to community care for people with mental health problems. Despite the almost complete abandonment of the old Victorian asylum system, the powerful cultural legacy of segregation remains potent in modern thought
Rogers and Pilgrim analyse the impact of new policies introduced by the Labour government since it came to power in 1997, identifying both the processes and causes of policy change and assessing its value in the context of longer term debates about madness and distress.

Table of Contents

Understanding Policy Formation


1. Policy Formation and Mental Health Services

An understanding of mental health policy requires reference to a range of interpretative frameworks. When discussing health policy in general, Palmer and Short (1989) draw attention to four major policy perspectives:
  • economic
  • political science
  • sociological
  • epidemiological and public health
Anne Rogers, David Pilgrim

2. Interest Groups and their Perspectives

The mental health care policy arena, like other areas of health and social care, involves a number of social groups which at times hold different sets of interests. They also subscribe to varying perspectives of mental health. A‘medicalised’ view of ‘mental illness’ dominates mental health policy and practice both in the UK and in most other countries. However, there is none the less a diversity of conceptualisations of mental health and illness which influence the making and development of mental health policy and the nature of practice.
Anne Rogers, David Pilgrim

Historical Considerations


3. The Dominance of the Victorian Asylum

This chapter, the first of two with a historical emphasis, summarises the factors which led to the emergence of the large asylum system in the nineteenth century. It then outlines the enduring impact this system had on developments up to and including the twentieth century. The next chapter will continue the account, continuing the story from the Second World War to the present.
Anne Rogers, David Pilgrim

4. After the Second World War

The previous chapter focused on the growth and dominance of the Victorian asylum system. This chapter summarises how, after the Second World War, the asylum went into a period of crisis for a variety of reasons, before declining. However, as we will note in Chapters 9 and 10, the professional routines of asylum-based psychiatry still remain powerful. Whilst the large hospitals have now been physically demolished or recommissioned for other purposes, the cultural impact of the asylum is still evident today. The story of the rise and fall of the asylum provides clues about the nature of this cultural inertia.
Anne Rogers, David Pilgrim

Post-Institutional Developments


5. The Mental Health Professions

Mental health professionals are stakeholders in policy development at a national level and in its implementation in particular localities. Policy determines professional activity, but professional values and views shape policy. Most of this chapter is about the dialectical relationship between professionals and their policy context. Eleven case studies are provided to illustrate this point about embodied mental health policy. We will cover the following:
the importance of expertise: the case of professional power/ knowledge
professional adaptation to policy shifts: the case of marketisation and its demise
agents of the State: the case of mental health law
the limits to professional autonomy: the case of self-regulation
the inertia of the asylum: the case of psychiatrists
in the wake of 1948: the case of clinical psychologists
breaking with the asylum tradition: the case of community mental health nurses
occupational substitution: the case of approved social workers
the threat to professional dominance: the case of the police and mental health work
inter-disciplinary work in flux: the case of primary and community care
the workforce as a mirror of wider society: the case of gender and class
Anne Rogers, David Pilgrim

6. Patients and their Significant Others

This chapter will address the constraints and opportunities for psychiatric patients and their significant others, which have emerged within mental health policy recently under the following headings:
  • ‘anti-psychiatry’ and patients’ rights
  • the rise of the mental health service users’ movement in Britain
  • the professional response to users’ views
  • Old and New Labour on mental health
  • the problem of need definition
  • identifying the needs and interests of ‘carers’
Anne Rogers, David Pilgrim

7. From Mental Illness to Mental Health?

Most of what are called mental health services actually respond to people with a diagnosis of mental illness. In this chapter, we consider the issues of mental health promotion and prevention in its broader social context. As institutions recede not only as a means of incarceration but also from the public eye, influences on mental health and well-being from within broader social life take on greater salience. This includes the social and personal factors that make people vulnerable to mental distress, and aspects of the environment that promote or inhibit psychological well-being. It includes the way in which the public, government and community agencies include or exclude those with mental health problems and accept or reject them as ‘citizens’.
Anne Rogers, David Pilgrim

8. Primary Care

In the past, primary health care has been favoured by central government as the site for the secondary prevention of mental health problems. (In the last chapter we noted that secondary prevention entails early screeening and ‘nipping problems in the bud’.) The rationale for this is that GPs are the designated gatekeepers of health services, and the first port of call for patients. Because of their ready accessibility, GPs are likely to have contact with most of their patients on an annual basis. Goldberg and Huxley (1980) suggested that over a period of a year, over 90 per cent of patients considered to be suffering from a mental health problem made contact with their GP. Recent estimates suggest that between 10.5 and 13.5 per cent of those considered to have severe and enduring mental health problems are managed at the primary care level (Callanan et al., 1997).
Anne Rogers, David Pilgrim

9. Community Mental Health Care

As we noted in Chapters 3 and 4, mental health care over the last two centuries has been dominated by the rise and fall of the asylum. Moving from institutional to community settings has triggered a whole new mental health enterprise called ‘community care’ or ‘care in the community’. In some ways, the idea of community care in mental health ran counter to the dominant trend within the NHS after 1948, which, until recently, was centralised and hospital-dominated. Latterly, ‘community care’ has been an emotive term within a policy context. It has tended to draw venom and passion in equal amounts from both policy-makers and commentators. On the positive side community care has held out the promise of a humanitarian solution to oppressive institutions. On the negative side, ‘the community’ has been seen as a dustbin into which all but the most dramatically dangerous, and hence politically embarrassing for society, problems can be dropped. Such strong contrary views have been influential in both driving and retarding full de-institutionalisation and an enlargement of citizenship for people with mental health problems.
Anne Rogers, David Pilgrim

10. The Disappearing Institution?

This chapter returns to the enduring legacy of the old asylum system. Whether the focus has been on the purported impact of pharmacological innovations, the fiscal crisis of the state or a shift in psychiatric discourse, most of the arguments of policy analysts suggest a demise of institutional arrangements, and their predominant displacement by community mental health work which we discussed in the preceding chapter. The re-orientation toward community management has been accompanied by changes in the way in which mental health has as a topic been treated by sociology and social policy. Not only has the relevance of inpatient work faded from view in theoretical analyses, compared to past work on the total institution as exemplified by Asylums (Goffiman, 1961), but a ‘post-modern’ trend has demoted the political, economic and experiential importance of coercive bio-medical regimes.
Anne Rogers, David Pilgrim

11. Questions of Effectiveness

In Chapter 3 we noted that, during Victorian period, mad-doctors and lay administrators of asylums generated a rhetoric of therapeutic optimism in which they made inflated claims of cure. Since then, a dilemma which has dogged those professionally responsible for madness and psychological distress relates to their credibility. Put simply, what can be reasonably expected of mental health professionals? This is a global question for governments, since they all need to contain expenditure on health and social services. Cost minimisation or cost-effectiveness have become hallmarks of health service management throughout the world.
Anne Rogers, David Pilgrim

12. Past, Present and Future

In Chapter 4 a number of factors were considered about British mental health policy in the late twentieth century. This chapter moves to an appraisal of the implications of these factors for the coming years. To start this process we return to the three-tier analytical framework, introduced at the start of the book (Pilgrim and Rogers, 1999). Macro, meso and micro factors will be sub-headings for the appraisal and tentative predictions.
Anne Rogers, David Pilgrim
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