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The History of Mental Health Services in Modern England: Practitioner Memories and the Direction of Future Research

  • John Turner (a1), Rhodri Hayward (a2), Katherine Angel (a3), Bill Fulford (a4), John Hall (a5), Chris Millard (a2) and Mathew Thomson (a6)...

Abstract

Writing the recent history of mental health services requires a conscious departure from the historiographical tropes of the nineteenth and twentieth centuries which have emphasised the experience of those identified (and legally defined) as lunatics and the social, cultural, political, medical and institutional context of their treatment. A historical narrative structured around rights (to health and liberty) is now complicated by the rise of new organising categories such as ‘costs’, ‘risks’, ‘needs’ and ‘values’. This paper, drawing on insights from a series of witness seminars attended by historians, clinicians and policymakers, proposes a programme of research to place modern mental health services in England and Wales in a richer historical context. Historians should recognise the fragmentation of the concepts of mental illness and mental health need, acknowledge the relationship between critiques of psychiatry and developments in other intellectual spheres, place the experience of the service user in the context of wider socio-economic and political change, understand the impacts of the social perception of ‘risk’ and of moral panic on mental health policy, relate the politics of mental health policy and resources to the general determinants of institutional change in British central and local government, and explore the sociological and institutional complexity of the evolving mental health professions and their relationships with each other and with their clients. While this is no small challenge, it is perhaps the only way to avoid the perpetuation of ‘single-issue mythologies’ in describing and accounting for change.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

* Email address for correspondence: j.a.turner@surrey.ac.uk

References

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1. Volker Hess and Benoît Majerus, ‘Writing the History of Psychiatry in the 20th Century’, History of Psychiatry, 22, 2 (2011), 139–45; see also Greg Eghigian, ‘Deinstitutionalizing the History of Contemporary Psychiatry’, idem, 201–14; Eric Engstrom, ‘History of Psychiatry and its Institutions’, Current Opinion in Psychiatry, 25, 6 (2012), 486–91.

2. Paul Hoff, ‘Die psychopathologische Perspektive’, in M. Bormuth and U. Wiesing (eds), Ethische Aspekte der Forschung in Psychiatrie und Psychotherapie (Cologne: Deutscher Ärzte-Verlag, 2005), 71–9.

3. Contributors were drawn exclusively from England, and the cultural and institutional differences of Scotland, Wales and Northern Ireland are consequently not addressed in this paper.

4. See Appendix for a list of speakers.

5. See A. Seldon and J. Papworth, By Word of Mouth – ‘Elite’ Oral History (London: Methuen, 1983) and Lynn Abrams, Oral History Theory (London: Routledge, 2010). Most methodological discussion of elite oral history concentrates rightly on the limitations of memory, the need for triangulation between witnesses and with contemporary documents, and the pitfalls of a narrative co-constructed as a conversation between historian and witness (on which see in particular E.M. McMahan, Elite Oral History Discourse: a Study of Cooperation and Coherence (Tuscaloosa: University of Alabama Press, 1989)). These issues are of particular salience when the objective is to produce the most accurate possible account of a sequence of events. Our project was to generate themes for enquiry, and in this case the challenge was more to situate the interpretations of contributors in existing literature. A more forensic and less discursive approach will be necessary if, in a subsequent study, contributors are to be asked to provide evidence for answers to the questions which might be posed in such enquiries.

6. Cf. J.K. Wing and J.M. Hailey, Evaluating a Community Psychiatric Service: The Camberwell Register 1964–71 (Oxford: OUP, 1972); D.H. Bennett and H.L. Freeman, Community Psychiatry (London: Churchill Livingstone, 1991).

7. Policy aspirations are encapsulated in two documents: Department of Health and Social Security, Hospital Services for the Mentally Ill (London: HMSO, 1971); Better Services for the Mentally Ill, Cmnd 6233 (London: HMSO, 1975).

8. The disclosures of ill-treatment and malpractice in Report of the Committee of Inquiry into Allegations of Ill-Treatment of Patients and other irregularities at the Ely Hospital, Cardiff, Cmnd 3975 (London: HMSO, 1969) were followed by 17 further enquiries in the subsequent decade of which the most notable related to Whittingham Hospital (1972), Napsbury Hospital (1973), South Ockendon Hospital (1974) and Normansfield Hospital (1978).

9. Rose, Nikolas, ‘Psychiatry as Political Science: Advanced Liberalism and the Administration of Risk’, History of the Human Sciences, 9, 2 (1996), 123.

10. Healy, David et al. , ‘Service Utilization in 1896 and 1996: Morbidity and Mortality Data from North Wales’, History of Psychiatry, 16, 27 (2005), 2741.

11. Burns, Tom, Community Mental Health Teams: A Guide to Current Practices (Oxford: Oxford University Press, 2004).

12. Department of Health Circular HC(90)23/LASSL(90)11 (London, 1990). The CPA was simplified in 1999 as part of the Labour government’s reforms: Department of Health, Effective Care Co-ordination in Mental Health Services (London, 1999).

13. Clark, D. et al. , ‘Improving Access to Psychological Therapy: Initial Evaluation of Two UK Demonstration Sites’, Behaviour Research and Therapy, 47, 8 (2009), 637728.

14. M. Shepherd et al., ‘Minor Mental Illness in London: Some Aspects of a General Practice Survey’, BMJ (1964), 2, 1359–63, amplified in Michael Shepherd et al., Psychiatric Illness in General Practice (London: Oxford University Press, 1966).

15. David Goldberg, ‘Epidemiology of Mental Disorders in Primary Care Settings’, Epidemiologic Reviews, 17, 1 (1995), 182–90. The three-nation survey was built upon a model set out in David Goldberg and Peter Huxley, Mental Illness in the Community: The Pathway to Psychiatric Care (London: Tavistock, 1980).

16. T. O’Sullivan et al., ‘Goldberg and Huxley’s Model Revisited’, Psychiatric Bulletin, 29 (2005), 116; T. O’Sullivan et al., ‘Goldberg and Huxley’s Model 27 Years On’, Psychiatric Bulletin, 31 (2007), 316.

17. David Goldberg, Transcript, 17 December 2010, 30.

18. Hugh Freeman, Transcript, 17 December 2010, 9.

19. Goldberg, op. cit. (note 17), 3.

20. John Hall, Transcript, 17 January 2011, 3.

21. Elaine Murphy, Transcript, 7 April 2011, 2.

22. Diana Rose, Transcript, 3 December 2010, 3.

23. Trevor Turner, Transcript, 31 January 2011, 9.

24. Hall, op. cit. (note 20), 26, citing in particular the work of Wolfensberger. See W. Wolfensberger, ‘Social Role Valorization: A Proposed New Term For the Principle of Normalization’, Mental Retardation, 21, 6 (1983), 234–9.

25. Freeman, op. cit. (note 18), 8.

26. Goldberg, op. cit. (note 17), 5.

27. Roy Griffiths, ‘NHS Management Inquiry’, Letter to the Secretary of State (London: DHSS, October 1983), reprinted in BMJ, 287, 6402 (1983), 1391–4; Martin Gorsky (ed.), The Griffiths NHS Management Inquiry: Its Origins, Nature and Impact (London: LSHTM, 2010).

28. Roy Griffiths, Community Care Agenda for Action: A Report to the Secretary of State for Social Services (London: HMSO, 1988).

29. Goldberg, op. cit. (note 17), 4.

30. Hugh Freeman, Transcript, 31 January 2011, 17. On the role of front-line workers in policy making see, e.g., Michael Lipsky, Street Level Bureaucracy (New York: Russell Sage, 1980) as re-interpreted in Catherine Durose, ‘Revisiting Lipsky: Front-Line Work in UK Local Governance’, Political Studies, 59, 4 (2011), 978–95.

31. Freeman, op. cit. (note 18), 9.

32. Goldberg, op. cit. (note 17), 6.

33. Turner, op. cit. (note 23), 11–12. In fact the Care Programme Approach, a set of management procedures for assessment, co-ordination and review, was developed by the Department of Health well before the Zito episode, as part of the implementation of the National Health and Community Care Act.

34. Murphy, op. cit. (note 21), 3. On the other hand, the report by the National Confidential Inquiry into Suicide by People with Mental Illness (NCISH), Patient Suicide: the Impact of Service Changes (Manchester: University of Manchester, 2013) notes on page 10 that by 2011 ‘Trusts that had retained their specialist teams saw a larger fall in patient suicide than trusts that merged them [into generalist Community Mental Health teams]’.

35. Hall, op. cit. (note 20), 4.

36. Jim Symington, Transcript, 31 January 2011, 13. The phrase ‘ordinary life’ resonates with the title of a seminal King’s Fund paper, and its use, like the reference to Wolfensberger’s work above, illustrates the extent to which approaches originating in the care of people with learning disabilities generalised to other mental health services. King’s Fund, An Ordinary Life: Comprehensive Locally-based Residential Services for Mentally-handicapped People (London: King’s Fund, 1980).

37. Symington, ibid., 13.

38. Hall, op. cit. (note 20), 4–5.

39. Murphy, op. cit. (note 21), 2.

40. Peter Bartlett, Transcript, 31 January 2011, 6.

41. Peter Barham, Transcript, 3 December 2010, 8, quoting the words of a user group in 1990.

42. Symington, op. cit. (note 36), 14.

43. Department of Health, The Mental Health Policy Implementation Guide (London: HMSO, 2001).

44. Louis Appleby, Transcript, 21 June 2011, 11.

45. The evolution of the NSF is described by the chairman of the External Reference Group in G. Thornicroft, ‘National Service Framework for Mental Health’, The Psychiatrist, 24 (2000), 203–6.

46. Rose, op. cit. (note 22), 15, in respect of the Recovery movement.

47. Appleby, op. cit. (note 44), 11. The deployment of an economic case for treating mild mental illness can be traced back at least as far as 1957, in Sir Frederick Armer [Chairman of the Board of Control], ‘The Magnitude and Cost of Mental Illness’, The Lancet, 269, 1977 (1957), 1031.

48. Rose, op. cit. (note 22), 9; Victor Adebowale, Transcript, 9 May 2011, 13–14.

49. Goldberg, op. cit. (note 17), 5.

50. David Pilgrim, Transcript, 17 January 2011, 8.

51. Bartlett, op. cit. (note 40), 5.

52. It is significant, at least culturally, that the first reports of the Ministry of Health after the establishment of the NHS were proud to report that over 97% of mental patients were being treated in hospitals accountable to the Ministry.

53. See, eg., Roy Porter, Madmen: A Social History of Madhouses, Mad-Doctors and Lunatics (Stroud: NPI Media Group, 2004); Dale Peterson (ed.), A Mad People’s History of Madness (Pittsburgh: University of Pittsburgh Press, 1982); Nick Hervey, ‘Advocacy or Folly: The Alleged Lunatics Friend Society, 1845–63’, Medical History, 30, 3 (1986), 245–75.

54. On the links to the 1980s see Peter Campbell, ‘From little acorns: the mental health service user movement’, in Sainsbury Centre for Mental Health, Beyond the Water Towers: The Unfinished Revolution in Mental Health (London: Sainsbury Centre for Mental Health, 2005), 73–82. On these groups, see also Nick Crossley, Contesting Psychiatry: Social Movements in Mental Health (Abingdon: Routledge, 2006). Crossley contrasts these movements to an earlier generation of mental health movements led by clinicians, social workers and philanthropists which aimed to extend the reach of services in the interests of ‘mental hygiene’. See also Helen Spandler, Asylum to Action: Paddington Day Hospital, Therapeutic Communities and Beyond (London: Jessica Kingsley, 2006).

55. Campbell, ibid., 76.

56. On present-centredness in historical interpretation, see Adrian Wilson and T.G. Ashplant, ‘Whig History and Present-Centred History’, The Historical Journal, 31, 1 (1988), 1–16.

57. Rose, op. cit. (note 22), 5.

58. Rose, op. cit. (note 22); Glenn Roberts and Paul Wolfson, ‘The Rediscovery of Recovery: Open to All’, Advances in Psychiatric Treatment, 10 (2004), 37–48, and from another perspective, Deborah Mountain and Premal J. Shah, ‘Recovery and the Medical Model’, Advances in Psychiatric Treatment, 14 (2008), 241–4; Joel Braslow, ‘The Manufacture of Recovery’, Annual Review of Clinical Psychology, 9 (March, 2013), 781–809; Nikolas Rose, ‘“Screen and Intervene”: Governing Risky Brains’, History of the Human Sciences, 23, 1 (2010), 79–105.

59. Ulrich Beck, World Risk Society (Cambridge: Polity Press, 1990); Robert Castel ‘From dangerousness to risk’ in G. Burchell, C. Gordon and P. Miller (eds), The Foucault Effect: Studies in Governmentality (Hemel Hempstead: Harvester Wheatsheaf, 1991); Niklas Luhmann, Risk: a Sociological Theory (New York: De Gruyter, 1993); Nikolas Rose, ‘Governing Risky Individuals: The Role of Psychiatry in New Regimes of Control’, Psychiatry, Psychology and Law 5, 1 (1998), 177–95.

60. Rose, op. cit. (note 22), 4.

61. Murphy, op. cit. (note 21), 16.

62. Murphy, op. cit. (note 21), 4, 6.

63. See, eg., HC Deb., 10 July 1961, 644, 26–7; HC Deb., 23 October 1961, 646, 548; ‘Medico-Legal – Detention for Forty Years’ BMJ, 2, 5250 (August 1961), 527; The Times, 30 July 1961.

64. Report of the Committee on Mentally Abnormal Offenders, Cmnd 6244 (London: HMSO, 1975).

65. Turner, op. cit. (note 23), 11, 12.

66. Rose, op. cit. (note 59), 190; Castel op. cit. (note 59), 293, 288.

67. Turner, op. cit. (note 23), 24.

68. Nicola Glover-Thomas, ‘The Age of Risk: Risk Perception and Determination Following the Mental Health Act 2007’, Medical Law Review, 19, 4 (2011), 604.

69. We are obliged to Dr Tony Black for discussions of Victorian attitudes to risk.

70. See, eg., Joseph Melling, Bill Forsythe and Richard Adair, ‘Families, communities and the legal regulation of lunacy in Victorian England: assessments of crime, violence and welfare in admissions to the Devon Asylum, 1845–1914’, in Peter Bartlett and David Wright, Outside The Walls of the Asylum: The History of Care in the Community, 1750–2000 (London: Athlone Press, 1999), 153–80.

71. Sarah Hayley York, ‘Suicide, Lunacy and the Asylum in Nineteenth Century England’, University of Birmingham PhD thesis, 2009, esp. 180–294.

72. Åsa Jansson, ‘From Statistics to Diagnostics: Medical Certificates, Melancholia, and “Suicidal Propensities” in Victorian Psychiatry’, Journal of Social History 46, 3 (Spring 2013), 716–31.

73. Harvey Gordon, Broadmoor (London: Psychology News Press, 2012), esp. chap. 2.

74. Charles Mercier, reporting on recent medico-legal cases in Journal of Mental Science, 42 (1896), 230. Mercier was commenting breezily on reports which included a double murder, two other murders, a suicide and a number of assaults.

75. Freeman, op. cit. (note 30), 18.

76. David M. Clark, Transcript, 17 December 2010, 14.

77. Department of Health, ‘The Findings of the Financial Mapping Exercise 2002’ http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4123379 accessed 12 September 2012.

78. Gavin Thompson, NHS Expenditure in England (London: House of Commons Library, 2009), SN/SG/724, 7.

79. Martin Knapp and Martin Prince, Dementia UK: The Full Report (London: Alzheimer’s Society, 2007), esp. chap. 6. On public expenditure share, see, eg., Richard Humphries, Social Care Funding and the NHS (London: King’s Fund, 2011). On principles, see Commission on Funding of Care and Support, Fairer Care Funding (Dilnot Commission Report) July 2011.

80. Cooper, David, Psychiatry and Anti-Psychiatry (London: Paladin, 1971).

81. Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (New York: Harper & Row, 1974) and 34 other books on similar themes.

82. Goffman, Erving, Asylums (New York: Doubleday Anchor, 1961).

83. Barton, Russell, Institutional Neurosis (Bristol: Wright & Sons, 1959).

84. Colin Jones, ‘Raising the Anti: Jan Foudraine, Ronald Laing and Anti-Psychiatry’, in Marijke Gijswijt-Hofstra and Roy Porter (eds), Cultures of Psychiatry and Mental Health Care in Postwar Britain and the Netherlands (Amsterdam: Rodopi, 1999), 283–94.

85. Wing, J.K., ‘Laing and Goffman: Self and Others’, British Journal of Psychiatry, 118 (1971), 360361.

86. Jones, Kathleen, ‘Society Looks at the Psychiatrist’, British Journal of Psychiatry, 132 (1978), 321332.

87. Anthony David, ‘In Memory of RD Laing’, Psychiatric Bulletin, 13 (1989), 696–8; A.W. Clare, ‘R.D. Laing 1927–89: An Appreciation’, Psychiatric Bulletin, 14 (1990), 87–8.

88. M. Roth, ‘Schizophrenia and the Theories of Thomas Szasz’, British Journal of Psychiatry, 129 (1976), 323 & 325, responding to Szasz, Schizophrenia: The Sacred Symbol of Psychiatry (Syracuse: Syracuse University Press, 1976).

89. Kendell, R.E., ‘The Concept of Disease and Its Implications for Psychiatry’, British Journal of Psychiatry, 127 (1975), 305315.

90. Wing, op. cit. (note 85), 361.

91. Freeman and Goldberg, Transcript, 17 December 2010, 27.

92. Turner, op. cit. (note 23), 9.

93. Barbara Taylor, Transcript, 17 December 2010, 28.

94. Barham, op. cit. (note 41), 6, citing Foucault.

95. Pilgrim, op. cit. (note 50), 9; Division of Clinical Psychology, Clinical Psychology: The Core Purpose and Philosophy of the Profession (Leicester: British Psychological Society, 2010), defines formulation as ‘…the summation and integration of the knowledge that is acquired by th[e] assessment process that may involve psychological, biological and systemic factors and procedures. The formulation will draw on psychological theory and research to provide a framework for describing a client’s problem or needs, how it developed and is being maintained…. This provides the foundation from which actions may derive… Psychological intervention, if considered appropriate, is based upon the formulation.’.

96. Barham, op. cit. (note 41), 23.

97. Andrew Roberts, a service user who has taken a leading role in developing a service user perspective on the history of the movement, is one who has criticised this line of argument. For insight on the service user perspective on their own history and for a timeline of developments and a wealth of material on this history: http://studymore.org.uk/mpu.htm.

98. Barham, op. cit. (note 41), 23. Mervat Nasser, ‘The Rise and Fall of Anti-Psychiatry’, Psychiatric Bulletin, 19 (1995), 743–6, sees MIND, transmuted from the World Federation for Mental Health in the UK in 1970, as embracing an anti-psychiatric philosophy (745–6).

99. Bracken, P. and Thomas, P., Postpsychiatry: Mental Health in a Postmodern World (Oxford: Oxford University Press, 2006).

100. Fulford, K.W.M, Moral Theory and Medical Practice (Cambridge: Cambridge University Press, 1989).

101. Moncrieff, Joanna, The Myth of the Chemical Cure (London: Palgrave, 2009).

102. Richard Bentall, Madness Explained (London: Allen Lane, 2003); Richard Bentall, Doctoring the Mind: Why Psychiatric Treatments Fail (Harmondsworth: Penguin, 2010).

103. Nick Craddock et al., ‘Wake-up Call for British Psychiatry’, British Journal of Psychiatry, 193 (2008), 6–9. This was signed by 35 senior psychiatrists.

104. Pat Bracken, et al., ‘Psychiatry beyond the current paradigm’, British Journal of Psychiatry, 201 (2012), 430–4. This was signed by 29 senior psychiatrists.

105. On the inapplicability of RCT, Margaret Rustin, Transcript, 17 January 2011, 12.

106. Clark, op. cit. (note 76), 13.

107. And see Benjamin Vicente et al., ‘Attitudes of Professional Mental Health Workers to Psychiatry’, International Journal of Social Psychiatry’, 39, 2 (1993), 131–41.

108. National Institute for Mental Health in England, New Ways of Working for Everyone: Progress Report, April 2007 (London: Department of Health, 2007).

109. Thornicroft, Graham and Tansella, Michele, ‘Components of a modern mental health service: a pragmatic balance of community and hospital care’, British Journal of Psychiatry, 185 (2004), 283290.

110. See for example the second (1981) edition of Shepherd et al., Psychiatric Illness in General Practice and D. Tantam and D. Goldberg, ‘Primary medical care’ in Douglas H. Bennett and Hugh L. Freeman, Community Psychiatry: The Principles (London: Churchill Livingstone, 1991), 361–85.

111. See a good description in M.P. Bender, Community Psychology (London: Methuen, 1976), 38–45.

112. See J.W. Rawlinson and A.C. Brown, ‘Community psychiatric nursing in Britain’, in Bennett and Freeman, Community Psychiatry, 463–87.

113. Notably child psychotherapy at the Tavistock Clinic: Rustin, op. cit. (note 105), 10–11. This is still true for counselling psychology.

114. Applications for clinical psychology training have been heavily skewed towards women, with an under-representation of ethnic minorities.

115. See, eg., Pamela Austin et al. (34 signatories), ‘Regulation: Refusing to Participate’, Therapy Today 20, 6 (July 2009); Andrew Samuels, ‘HPC Regulation: More Harm Than Good’, Therapy Today 20, 5 (June 2009).

116. For a partial exception, see Cathy Smith, ‘Family, Community and the Victorian Asylum: A Case Study of Northampton General Lunatic Asylum and its Pauper Lunatics’, Family and Community History, 9, 2 (2006), 109–24.

117. Huxley, Peter and Thornicroft, Graham, ‘Social Inclusion, Social Quality and Mental Illness’, British Journal of Psychiatry, 182 (2003), 289290.

118. See, eg., Peter Bartlett and David Wright, Outside The Walls of the Asylum: The History of Care in the Community, 1750–2000 (London: Athlone Press, 1999), which largely concentrates on the 19th century.

119. The phrase was used by Kathleen Jones as a chapter heading in Asylums and After, and has provoked legal and medical historians ever since.

This investigation was generously supported by the Wellcome Trust [grant number 093390Z/10/Z].

Keywords

The History of Mental Health Services in Modern England: Practitioner Memories and the Direction of Future Research

  • John Turner (a1), Rhodri Hayward (a2), Katherine Angel (a3), Bill Fulford (a4), John Hall (a5), Chris Millard (a2) and Mathew Thomson (a6)...

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