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Outside the Walls of the Asylum: The History of Care in the Community, 1750–2000
Am J Psychiatry 2000;157:1028-1029. doi:10.1176/appi.ajp.157.6.1028
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Sheffield, U.K.

Edited by Peter Bartlett and David Wright. Atlantic Highlands, N.J., Athlone Press, 1999, 260 pp., $90.00; $33.95 (paper).

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Samuel Taylor Coleridge wrote, "If men could learn from history, what lessons it might teach us! But passion and party blind our eyes, and the light which experience gives us is a lantern on the stern, which shines only on the waves behind us!"

In the British National Health Service, the number of asylum beds have more than halved since the mid 1950s. At its inception in 1948, the British National Health Service inherited 154,000 psychiatric beds. There are now fewer than 40,000. Most of the 130 large hospitals of that time have already closed. Most of the remainder will be closed by 2005. The closure of the asylum has occurred in parallel with the development of extramural or, as it is more usually known, community care. Bartlett and Wright open the preface to their book with the observation that this momentous change has "constituted one of the most contested programmes in contemporary social policy."

Outside the Walls of the Asylum is the report of two workshops held at Oxford University and the University of Nottingham under the auspices of the Wellcome Trust. The subtitle describes its ambition: The History of Care in the Community, 1750–2000. The geographical territory is Britain and Ireland. It is edited and written by social scientists and one psychiatrist.

The editors comment that the history of psychiatry thus far has largely been an asylum history. They suggest this is for two reasons. The first is that many of the histories were written by practicing physicians whose locus of work was the asylum. Second, there are archival factors that have shaped this tradition.

Broadly speaking, there are two strands in psychiatric historiography. One is a meliorist view of the history, exemplified by Kathleen Jones: a tradition of presenting medical practice as progressive, humane, and liberating mankind from error, celebrating the construction of the substantial and often ornate "museums of madness" as the acme of Victorian philanthropy. The alternative, "revisionist" history of the 1970s is exemplified by Andrew Scull. The revisionist discourse talks about the restrictive incarceration of the insane and the rounding up of delinquent and indigent individuals for "societal convenience." Societal and medical motivation is described as venal rather than humane.

In their introduction, the editors suggest that we will find the reality somewhere between these extremes. They want to demonstrate and exemplify that there was a great deal of community care (i.e., care between the asylum and the larger society) in Britain in the early modern period.

There follow 12 chapters that examine this theme in finer focus. The sources of information are voluminous. They include documentary records within the hospitals, national and local government records, and newspaper reports. A fifth of the book is references, the great majority of which are to primary sources. The contributors mix statistical information with illuminating individual stories and case histories.

Inevitably, there is interpretation by the authors of a large amount of information. This is the so-called frame problem in cognitive psychology, currently more widely known in public/political life as "spin." However, the "authorial frames" seem to me to be largely dispassionate.

To highlight only one particularly illustrative chapter, Dr. Harriet Sturdy and Prof. William Parry-Jones describe the policy pursued in late nineteenth-century Scotland of the "boarding out" of insane patients. This involved up to four patients being placed in private dwellings with relatives or unrelated individuals. These guardians were paid a weekly sum for the patients’ maintenance. This was supervised, with some vigor, by the General Board of Lunacy based in Edinburgh. By 1890, the commissioners are quoted as stating the system was no longer a novelty, "its successful working is best shown by its unobtrusiveness and by routine performance of its functions." Its decline was not precipitated by any tangible dissatisfaction but by larger changes in society after World War I.

All the chapters are written in a clear and readable way. The last three contributions, reviewing the postwar era, are less compelling—perhaps because British society has become more complex and plural.

I think that the chapters support the assertion made by the editors in their introduction. The subject has many resonances for the present. This is a book, pace Coleridge, which I have learned from.




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