From asylums to deinstitutionalization and after: an analytic review

Preamble

From time immemorial, humankind has attempted to understand the puzzle and challenges involved in so-called mental illness. Historically, a variety of procedures have been attempted, including psychosurgery, mechanical contention, institutionalization, ECT, and prescription of medication, in a serious attempt to alleviate and/or cure mental illness. However, in the recent literature we find that these therapeutic measures, applied singly or jointly, have had limited efficacy. Admittedly, this invites us to be prudent, to continue researching with renewed vigour, and to avoid being seduced by the illusion of curability. On the other hand, as can be inferred, a survey of all the above-mentioned procedures is an impossible task, beyond my area of expertise. Hence in this paper I will analyse solely the creation of the asylum as the preferred method of care for the insane, its ultimate dismantlement, and the advent of care in the community. In doing so, I also identify continuing issues of institutionalization, containment and segregation. Simultaneously, controversial issues such as the incarceration and homelessness of the mentally ill are also discussed. The paper ends with an expression of my own conclusions on the topic under examination here.

My overall argument is that if psychiatry is going to have a future, it has to start recognizing the environmental, that is the psychosocial, dimensions of all mental illness as well as continuing to consider what, if anything, brain research and neuroscience can contribute to the understanding and treatment of mental illness.

In short, this paper aspires to be a sort of “brainstorming exercise” that stimulates debate on what mental illness is, and how best to confront the many problems involved. Such a dialogue can be found in the paper itself, where my ideas are confronted by Andrew Scull, an internationally renowned contemporary expert in the history of psychiatry, to whom I am indebted for causing me to seriously rethink the domain of what we call mental illness.

Historical background

From the mid- to late 20th century the conceptual pillars of the psychiatric establishment experienced a seismic shift, or, as other experts termed it, a tectonic sociocultural change.

In practical terms, it implied a drastic transformation from a producer culture (by which the institutionalized patients of asylums, if not curable, could be trained to carry out some productive activity, which later enable them to re-enter the workforce) to a consumer culture. In this view, the patient became a ‘consumer’ to the psychiatrist’s ‘provider’ within the mental health care system (Burnham, 2016). However, before considering this change, which I will explore in depth later, specifically in the penultimate section of this paper, it seems necessary to take a look back at the old days of asylums and explain why it is important to revisit deinstitutionalization today.

Founded on institutional psychiatry and the coercive treatment of individuals often designated ‘pauper lunatics’ (Hilton, 2020), the old asylum of the last century was transformed into a new model erected on the concept of deinstitutionalization. In most countries this process began in the years following the Second World War and reached its height between the 1960s and the 1990s, the latter decade marking the case of Japan. It is also worth noting that the process has continued apace in many jurisdictions. The roots of deinstitutionalization can be traced back to the novel community-based services that emerged in the early 20th century, such as the movement for mental hygiene and child guidance clinics (Kritsotaki et al., 2016, p. 7).

It is striking that the main focus of research has been on the history of asylums, and in particular the prevalent systems prior to deinstitutionalization, rather than the many difficulties involved in its implementation, an aspect I will examine in the next section. With this in mind the purpose of this paper is to contribute to fill a gap in the history of psychiatry, since, as Kritsotaki et al. (2016, p. 3) note:

Unlike the history of asylums, which dominated the historiography of mental illness and psychiatry until the 1990s and continues to attract the attention of both scholars and students, the history of deinstitutionalisation is only beginning to be told.

These assertions, however, are not entirely accurate. As Andrew Scull pointed out to me in an email dated 18 May 2024, he had already written on this topic in a paper and book two decades before the 90s (Scull, 1976, 1977).

Before reviewing recent literature explaining the reasons for this oblivion and disinterest, it is worth noting that as result of deinstitutionalization the mental patient was empowered, and thus achieved a significant degree of real liberty and personal autonomy over his or her recovery and reinsertion into society. This, naturally, depends on which patients we are talking about. It is worth noting here, as Scull pointed out to me, via email on 18 May 2024, that some patients, victims of over-hospitalization, reintegrated fairly successfully and benefited from the change. However, many of the most seriously disturbed did not. In any case, as with every unstoppable change in the history of contemporary psychiatry, the shift was preceded by fierce resistance from the more traditional, conservative psychiatric circles, who vehemently opposed the implementation of the planned reforms. So, while those who embraced the idea of serious changes in psychiatry received them in laudatory terms, the advocates of maintaining the psychiatric status quo, expressed their deep reticence and hostility. This, at least, is my personal perception. In Scull’s opinion, however, there was surprisingly little overt resistance from psychiatry, most of whose practitioners already worked outside institutions (Scull, personal communication, May 18, 2024).

In the face of this supposed resistance to change in mainstream psychiatry, the psychiatric establishment had already paved the way for irreversible transformation. This seemed like a breath of fresh air, that with renovated interests and aspirations aimed to become the dominant model in psychiatry in the years ahead. However, as I will show in detail below, in retrospect all promised changes always deliver an array of lights but also shadows of different intensity. In other words, no organizational-institutional change, albeit hoped for and cherished by a good many psychiatrists, is ever definitive. At best, they last for a considerable time.

But, so as not to anticipate the end of our analysis, let me follow up these introductory remarks with a reflection on the idea of asylum, a place where many patients dwelled within the walls of a closed institution with no other company beyond other inmates and the medical staff. Their world, thus, was limited to the physical barriers and psychic confines of, in many instances, an inhospitable territory of human misery and affliction. In doing so, I will give a more accurate picture of the asylum for those not familiar with it, that is to say, the most recent generations of psychiatrists educated in a biomedical model dominated by drug therapy and advances in neurosciences.

In pursuit of truth and intellectual honesty, however, it should be also said to today’s novice psychiatrists, that, in their beginnings, when asylums were devised, there was no discriminative or punitive purpose in secluding and isolating patients. The medical superintendents in the asylums were, at their best, focused on the welfare and custodial care of those confined there (Dain, 1971; Laws, 2011; Scull, 1993; Smith, 1999). The great achievement of the asylums was to house the mentally ill so that they would simultaneously be protected and would not interfere with the normal (I would prefer to say adequate, to avoid the pejorative connotations regarding what is considered within normalcy) functioning of society. The asylum thus became a humanitarian alternative to the poorhouse of that day, where the point was that inmates were expected to work (Burnham, 2016). The reasons for incorporating labour into the daily routine of mental hospitals, beyond a general belief that the maxim ‘no work is a dangerous occupation’ was as true for the insane as it was for the sane, is provided in great detail in a recent book by the historian of medicine, Freebody (2023, pp. 62, 66, 93) in these terms:

The introduction of work in asylums may have been linked to the beginnings of important and far-reaching changes to the economy associated with the transition from pre-industrial to industrial economic organization. These changes began in the mid-eighteenth century in England, and the mid-nineteenth century in France, prompting the emergence of new attitudes towards work and workers. (. . .) Work was considered a particularly effective means of instilling self-control; it distracted the patient from their troubles, focused their attention on the fulfilment of a task and provided opportunities for social interaction and cooperation with staff and other patients. A patient’s day was scheduled to include regular hours for work, balanced with periods for recreation and amusements. (. . .) The benefit of work as a method of disciplining large numbers of patients and of offsetting institutional running costs was given equal or greater priority than its role as a means of therapy. While patient work featured prominently in the early asylum annual reports, it had become almost a footnote in reports at the end of the nineteenth century, with little evidence of work being found to suit patient’s aptitudes or previous occupations.

On this basis, perhaps inmates’ work, occupation and recreational activities served, to an extent difficult to measure and know today, as healing factors in their lives and the day-to-day routines of the institution, but, in tandem with these charitable intentions, the major problems faced by managers were overcrowding, physical disease and the least degree of mechanical restraint they could employ for control (McCandless, 1979; Taylor & Brumby, 2020). For all these reasons, as I will explain in the next section, over time at the institutional level, the asylum became the quintessential example of what commentators such as Goffman termed a total institution. The asylum was seen as a place where individuals were cut off from wider society for an appreciable period of time, together leading an enclosed, and formally administrated round of life (Stephenson & Hilton, 2021). Before moving on to the next section, in which I will reflect upon on the idea of asylum as a total institution, let me pay homage to the charismatic figure of Dr. Russell Barton (1923–2002), the maverick Anglo-American psychiatrist, who acted as Physician Superintendent at Severalls Hospital in Colchester, Essex, England for over a decade. This apparent digression is motivated by the strong criticism that Barton, like Goffman, addressed to the old asylum system. It is worth saying here that Severalls Hospital was built in May 1913 and was shut down in the early 1990s, before a separate section for the elderly closed in March 1997 (Gittins, 1998). Dr. Barton’s tenure was between 1960 and 1971, working in the service of those most disfavoured and in most need. He regarded the institution itself as pathogenic, and advocated that psychiatric hospitals must provide humane, dignified and rehabilitative treatment. For me, this advocacy undoubtedly evokes the moral treatment of mental patients postulated by the Englishman W. Tuke (1732–1822) and his French contemporary Ph. Pinel (1745–1826). In Barton’s view, patients suffered from two conditions (Hide, 2021, pp. 61–62): one for which they were initially admitted and a second caused by the stultifying environment of the hospital, resulting in a condition that was ‘characterized by apathy, lack of initiative, loss of interest and submissiveness’. These were the principal features of the concept or construct labelled by him as ‘institutional neurosis’, a term which provided the title for his book Institutional Neurosis (Barton, 1959). With respect to how Barton conceived of writing this book, the issues it tackled and its international recognition, Hilton (2018, p. 308) says:

Barton wrote Institutional Neurosis in the late 1950s while working as a psychiatrist at Shenley Hospital, Hertfordshire. The book explained the harm which custodial hospital regimes caused to patients, and described how to remedy the situation. It was translated into Greek, French, Spanish and German. In 1960, he was appointed medical superintendent (chief psychiatrist, with additional administrative responsibilities) at the 2000-bed Severalls Hospital, Colchester. He implemented innovative practices, giving patients greater autonomy and enabling staff to provide better care, ultimately improving outcomes for patients and job satisfaction for staff. His writing, reputation and work at Severalls was associated with him advising about psychiatric care in Europe, the United States of America (USA) and China.

Despite the indisputable fame and professional boost that it implied for Barton’s career, the term ‘institutional neurosis’, coined at the end of 1950s, provoked controversy from the outset. Defending his use of the term in the British Medical Journal 13 years later, Barton wrote:

While not wishing to promote the use of a term ascribed to me (but I suspect widely used before I heard it), I feel I must defend its adoption by a recapitulating the reasons I prefer it. The term ‘institutional’ does not imply that institutions are the only cause of the disorder, but that it was first generally recognized in institutions – as the use of Bornholm in Bornholm disease. The term neurosis is used rather than psychosis since the syndrome itself does not interfere with the patient’s ability to distinguish between reality and phantasy-indeed, the passivity adjusts the individual to the demands of the institution but at the same time hamper adjustment to the world outside (Barton, 1972, p. 505).

In my view, two important lessons can be extracted from these comments. First, the key role that institutions can have in the chronification of the diseases suffered by those under confinement. Second, they should not lead us to erroneously think that Barton encouraged the closure of asylums; rather his criticisms were directed towards the substantial improvement of inmates’ living conditions and the good functioning of staff-patient relations. In this respect, Barton roundly affirmed:

Until the art of running them [psychiatric hospitals] is appreciated and implemented they are probably better closed, the public inconvenienced, and the taxpayer obliged to pay three or four times as much for a less effective service fragmented into units in general hospitals, day care centres, and hostels, run by an administrative miasma in which committees, quarrels, and professional self indulgence command more time than patients (Barton, 1972, p. 505).

It is also easy to see how Barton’s ideas could be misinterpreted by those in the highest political spheres with responsibility for mental health policy, as clearly noted by Dr. Rollin (1911–2014), Barton’s colleague in his well-informed and very intimate obituary of Barton (Rollin, 2003, p. 35):

What is beyond doubt, however, is that Barton’s views were sweet music to the ears of politicians of both major parties and must have provided ammunition for those who advocated closure of the mental hospitals in favour of ‘community care’.

The wisdom of the decision is still being debated and one wonders if it ever came to a vote, how Barton would cast his in the light of today’s experience, both here [Britain] and in the USA.

With these reflections, we are now in a position to turn to Goffman and his provocative ideas on the asylum as a total institution.

The Asylum as a total institution

In the process of re-defining psychiatry as a medical discipline and its professional competencies, the progressive dismantlement and demise of the old asylum system was inevitable. At the historical level, possibly the most documented and informative examination of the asylum system is that of the influential Canadian-born American sociologist and writer Erving Goffman (1922–1982) in his classic text Asylums (Goffman, 1961). In his magna opus, subtitled Essays on the Social Situation of Mental Patients and Other Inmates, Goffman defines the total institution, of which the asylum is the paradigm, as a site for a kind of dreadful experimentation, a site which is cut off from the rest of society, enclosed behind physical barriers such as locked doors, high walls, and barbed wire. In other words, a ‘dead world’ governed by a routine, administrated life marked by a separation between a small supervisory group and a large ‘managed group’ of inmates (Morgan, 2022). From this perspective, people in asylums were dehumanized and considered as objects and non-persons (‘hollow men’), namely, people were ‘annihilated by the asylum’ and objectified.

In this process of apparently orchestrated and minded-deliberate dehumanization of the inmates, the asylum itself played a key role for Goffman, as Woods (2011, p. 135) eloquently explains:

In Asylums, (. . .) Erving Goffman produced compelling sociological evidence that the asylum itself was deeply implicated in the development of its inmates’ symptomatologies. The ritualized, dehumanizing practices of the ‘total institution’ induce self-defensive responses, which are then interpreted as symptoms of an underlying psychopathology, whereas they are better understood within the complex social context of the closed asylum community. Like Szasz, Goffman cast doubt over psychiatry’s scientific and moral legitimacy, and confines himself to a strictly sociological model of mental illness in which ‘the psychiatric view of a person becomes significant only in so far as this view itself alters his social fate’ (. . .).

Extending these criticisms to the old asylum model, and paraphrasing Franco Basaglia (1924–1980), the well-known Italian psychiatrist who became a critical voice and conscience of psychiatry, institutional psychiatrists continued to analyse the various forms of patients’ objectification instead of questioning the fact that they were objectified (Basaglia, 1987, p. 64). Against this conception, strongly consolidated in conventional psychiatry, Basaglia found inspiration for his project to transform psychiatry in both Goffman, mentioned above, and Primo Levi (1919–1987), the Italian chemist, partisan, writer and Jewish Holocaust survivor, who, in his essay Se questo è un uomo (If This Is a Man) (Levi, 1958), offers a first-person account of his experience in the concentration camps. Giving an explanation of how both Levi and Goffman left an indelible mark on Basaglia’s theoretical-clinical conceptualization, Morgan (2022, p. 384) writes:

Goffman’s account of the asylum as a total institution was central to the critique of psychiatric power in this period. His concept of the mortification of subjectivity and the production of a new form of embodiment within total institutions informed Basaglia’s critique at every point. This horror at the degradation and mortification of subjectivity within institutions was also a product of a closeness to the experiences of the Second World War and the experience of occupation in Italy. Basaglia’s own experience of imprisonment during the war and his reading of the literature on concentration camps (particularly Primo Levi’s work) informed a visceral reaction when he first entered a psychiatric institution, and an increasing commitment to the destruction of the institution.

From another perspective, the internationally acclaimed British psychiatrist, Ronald D. Laing (1927–1989), invited us to rethink the semantic and clinical implications of the term asylum and its abolition in the field of psychiatry. His aim, he said, was to ponder in the most profound, the widest sense, the idea of asylum (Laing, 1985). In initiating this task, he alerts us to whether the means taken to abolish the worst features of the old mental hospital system may not usher in other, new abuses. So, in relation to the Italian experience of changing psychiatry, in the short interval from 1978 to 1985, in a clear reference to the Basaglia project, Laing (1985, p. 36) expresses his thoughts in highly critical terms as follows:

The Italians decided that their asylums, by and large, did not in fact offer asylum – that is, a place of safety, security, and refuge – and they therefore abolished them as far as they could. But they did not substitute real asylums for the false asylums they abolished. They made virtually no attempt at all to provide places of safety and refuge. They now realise that there are thousands of people at any one time who cannot get it together to provide a roof over their heads. They are homeless. We need not wrangle over how many people were unnecessarily locked up in the old style of psychiatric institutions: the fact is that there are thousands of people in Italy, in this country, in every country, who would fall into complete dilapidation if others did not care for them, whether with cruelty or kindness, brutality or respect. Italian-style crisis intervention teams, short-term admission to general psychiatric units, day centres, depot injections of tranquillizers or what not, still leave over, unaddressed, those thousands of people whom no one wants to have sleep under the same roof, and who cannot find for themselves any place to be.

In relation to these incisive comments on the closure of asylums in Italy between 1978 and 1985, I will say nothing, since it is not my purpose here to analyse the many merits and demerits implicit in the reform of Italian psychiatry during those years, but only offer some of the intricacies, the nitty-gritty, involved in the process of closing asylums. Thus, among the hurdles for the institutional psychiatrist to overcome in this enterprise was becoming aware of how dehumanization of the patient resulted more from the violence of the asylum than the disease itself. In this respect, Basaglia (1985, pp. 46–47) observes:

The psychiatrist has to bracket the illness, the diagnosis, and the syndrome with which the patient has been labelled if he wishes to understand him, and above all else, succeed in helping him, since the patient has been destroyed more by what the illness has been held to be and by the ‘protective measures’ imposed by such an interpretation than by the illness itself.

Thus, in Basaglia’s eyes, the symptoms and diagnosis should not be taken to be proxies for the person’s own experiences and actions (Basaglia, 1987). Formulated in another way, the symptoms and associated diagnoses might very well have been accurate, but taken together these facts tell us very little about the nature of the ‘illness’ or the person, his or her life story, subjective experiences, social context and present needs (Davidson et al., 2010). By not bearing in mind all these aspects encompassing the life of an individual and concentrating only on the clinical aspects, the psychiatrist takes the risk of no longer viewing the patient him- or herself as a person, but of transforming them into nothing more than an object of scrutiny and manipulation by others. In attempting to avoid this undesirable situation, Basaglia warns us to the great dangers inherent in asylums, comparing these circumstances with those in the prison system (Basaglia, 1980, p. 20):

The asylum is also an extraordinary observatory of behaviour patterns and the huge experimental laboratory where the lack of individual life (i.e., lack of productive and rational life) is the excuse for the failure to apply ethical principles to the same extent as in medicine and, moreover, justifies the withholding, temporary or permanent, of individual rights to a greater extent than in the prison system.

Under these considerations, in my view, rather than being regarded as sick people, patients in mental institutions became the purest expression of the destructive action of an institution whose primary objective was to protect healthy people against madness. Hence, it is a truism to note that the task of changing this vision of psychiatric care required a profound change in the prevailing mentality of both the psychiatric establishment and society at large. The clearest sign of this resistance to change is that the definitive closure of asylums in Italy envisioned in the 60s and 70s by Basaglia, its main architect, would take at least 20 years to come into effect (Balbuena Rivera, 2023).

In looking back to psychiatry on these issues, the ideas of the American-Hungarian psychiatrist T. S. Szasz (1920–2012) on involuntary psychiatry and the role played by psychiatrists in residential asylums also merit attention. In this respect, Szasz (2009) attacks the medicalization of human distress and the coercive nature of psychiatry. In similar fashion, he opposes the use of coercive psychiatric practices. In place of the existing ‘institutional psychiatry’, with its custodial approach to persons experiencing ‘problems in living’, Szasz (1961, 1976) advocated for ‘contractual psychiatry’. By this he meant that those suffering from problems in living should be legally empowered to seek help as they saw fit, without the intervention of the state or any other collective organization (Kotowicz, 1997). In marked contraposition, for Szasz, the institutional psychiatrist was someone who imposed themselves on patients who did not pay them, did not want to be their patients and were not free to reject their help. The contractual psychiatrist, by contrast, offered their services to patients who must pay them, must want to be their patients and were free to reject their help (Clare, 1976). In differentiating the contrasting roles of the institutional and contractual psychiatrist in terms of their interaction with patients, I only wish to express the therapeutic bond created according to whether it is established freely, by mutual consent, or imposed as happens in institutional psychiatry.

With these ideas on asylums outlined above, it now seems appropriate to explain the process of transition from asylums to deinstitutionalization, starting with its definition and the complex ramifications linked to it.

The many faceted complexities involved in deinstitutionalization

The first of these complexities has to do with the very definition of deinstitutionalization. Habitually, deinstitutionalization is defined as the process that happened when mental health care shifted from being based in residential asylums to becoming primarily an outpatient service during the second half of the 20th century (Kritsotaki et al., 2016, p. 4). For others, the process also involved the integration of remaining psychiatric institutions and their functions with those of other health services.

As a result, those who before had lived for possibly long periods of time in asylums, were now expected to live in their home communities, receiving psychiatric care and treatment in clinics and general hospitals. Thus, the mentally ill were now seen as individuals who were no longer required to be set apart from society, whether it be for their protection, society’s protection (or convenience) or because secluded, secure institutions were deemed to be the most therapeutically valuable spaces for recovery. At this point, it should also be remembered that mentally ill people generally consisted of those who were developmentally disabled, brain damaged or mad (later ‘psychotic’) as measured by local standards (Burnham, 2016, p. 40).

Under these premises, deinstitutionalization was more than merely a process of transitioning care and support from residential institutions to the community. It undoubtedly implied a significant philosophical sea change (Kritsotaki et al., 2016, p. 4). Changing this mentality and, by extension, the mode of functioning in psychiatric care, it is easy to understand it was not an easy task, as it involved measures like the improvement of conditions for patients, ending restraints, reducing electro-shock treatment, opening up the wards and knocking down walls and fences. This, in my view, represented a serious questioning of the old asylum system, which was thus put under scrutiny. Amplifying this examination, one could include the serious survey of the idea of mental illness, its misrepresentation and/or misconception (Skott-Myhre, 2021), bringing into focus here ideas formulated many decades back, such as that mental illness was a metaphor, an empty social construction (Szasz, 1961, 1976). These ideas, in my view, are still prevalent nowadays in the open debate about psychiatry, whereby mental illness is conceived only as an organic condition scarcely permeable to environmental influences.

Second, there was the increasing need for planning and thinking carefully about how to counteract and demolish the stigmatization of being patient in mental care. In practical terms, this serious effort has only been partially achieved, as evidenced by the many ambiguities and inadequacies of health policy towards people suffering from mental illness, which has failed to secure their social and economic equality (Whitaker, 2009). In support of this disappointing assessment, the literature today provides credence and evidence-based arguments for those who are interested in reading further about this important topic (Barham, 1997; Long, 2014).

Third, deinstitutionalization generated pernicious effects in former mental patients who were not so much deinstitutionalized as they were ‘transinstitutionalized’ into the criminal justice system. For their part, thousands of others found themselves homeless, living in the streets or in temporary accommodation. Paradoxically, however, although the incarceration and homelessness of the mentally ill are issues of contemporary relevance, both have been recognized as consequences of deinstitutionalization since the 1970s (Arboleda-Florez & Holley, 1988; Stelovich, 1978; Timms, 2021; Whitmer, 1980).

From deinstitutionalization to community

For all the panoply of reasons cited above, deinstitutionalization has been a project for the transformation of psychiatry and social policy, which has generated undesirable effects. So, as was the case in the pre-institutional era – that is before of development of asylums – so after deinstitutionalization, families in many countries have been left to fill in the cracks left by an inadequate mental health system, providing much of the care formerly supplied by the state or private hospitals (Kritsotaki et al., 2016, p. 6).

By requiring families to shoulder these subtle matters, mental health problems have, in my view, been magnified, and the key role which families could perform in prevention and care if they were adequately informed and/or trained has been forgotten. In this difficult context, outpatient services have been needed more than ever, such as day hospitals, occupational mental health centres, community mental health centres, therapeutic communities, specialized services for children and the elderly, follow-up services and transitional living facilities. However, community mental health care was meant first to replace institutionalization, and after deinstitutionalization, in terms of providing care in the community, via prevention, it was soon seen that the task was not to be easily achieved. Thus, although demonstrating preventive psychiatry in practice was more difficult than describing it in theory, it was compelling enough to convince many psychiatrists, politics and activists that institutions could become a thing of the past (Torrey, 2013).

In this difficult task of reshaping psychiatry, psychopharmacological research also proved to be of great utility, as has been substantiated by the introduction of antipsychotic drugs in the 1950s and after. However, drug therapy has not resolved all problems inherent to each mental disorder as initially hoped. A well-informed and documented analysis can be found in a recently published book (Scull, 2022). As such, although psychiatric medication contributed to the shift to the community, it was not its sole or main cause, and had to be complemented with social treatments in order to lead to the reintegration of patients in their social environment and to a deinstitutionalized mental health system (Kritsotaki et al., 2016, p. 18; Long, 2012). For that reason, more than competing, both the biomedical model and the psychosocial approaches to mental illnesses should work collaboratively in benefit of patients and their families.

In considering the effects caused by drugs, Patel (2021, pp. 33–39) makes a useful distinction between the terms efficacy, efficiency and effectiveness: efficacy refers to getting things done (Is it working?), efficiency means doing things right (Is it working within the most economical way?) and effectiveness concerns doing the proper things (Is it actually working well?). Despite the increasing confidence of psychiatrists in the use of these new drugs, they have been questioned for the unequal therapeutic effects produced according to the group of patients they are used with. So, in the case of outpatients with mild or moderate symptoms, these have responded well to drugs and/or psychotherapy. However, in the case of patients diagnosed with severe, chronic mental illness, who had previously been institutionalized, such hopes of improvement and recovery did not last. In this respect, if we peruse the literature today we will not find a satisfactory explanation for these poor results. In attempting to shed light on the intricacies that encompasses the prescription of drugs, Scull (2022, pp. 358–359) notes:

Yet it must also be pointed out that, for many patients, the therapeutic interventions the profession relies on have only limited efficacy. Accumulating evidence published during the last quarter century indicates that large fractions of those diagnosed with schizophrenia, bipolar disorders, and depression are not helped by the available medications, and it is difficult to know in advance who will respond positively to drug treatments. For many patients, a further major problem is that such relief as the pills provide must be set against the serious, debilitating, and sometimes life-threatening side effects that often accompany the ingestion of these medications. In this connection, academic psychiatry’s close ties to the pharmaceutical industry and clinicians’ overreliance on drugs as their primary treatment modality have created another profound set of concerns for the future of the profession.

Irrespective of whatever preoccupations have been created nowadays in the psychiatric profession for its close ties to the pharmaceutical industry, it has not prevented drug treatments being recommended for alleviating the symptoms associated with every mental illness. Even though, it is true that the major corporations have largely abandoned the field, the problem of drug prescription as the preferred option for treating mental illness remains the same (Herzberg, 2009; Scull, 2022; Tone, 2009).

Bearing this in mind, it is also important to emphasize that deinstitutionalization represented a shift in social control styles and practices, which were closely associated with deep-seated changes in the socio-political organization of advanced capitalist societies (Scull, 1977, p. 152). This debatable idea seems to be reinforced, although with different gradations, in a set of works subsequently published on this matter (Busfield, 1986; Murphy & Datel, 1976; Roberts & Kurtz, 1987; Warner, 2004). Scull himself sets out his views on this important matter in a recent chapter he contributed to a collection of essays on the social history of psychiatry and mental health in Britain 1960–2010 (Ikkos & Bouras, 2021). He describes how the era of institutionalization was coming to a close in the early 1960s, when Enoch Powell (1912–1998), then Minister of Health in Harold Macmillan’s Tory government, gave a speech at the annual conference of the National Association for Mental Health in 1961. The kernel of this speech was the idea that implied a radical shift in mental health policy, whereby Britain, like the rest of the Western world, should shift its primary emphasis on institutionalization as the preferred solution to the problems posed by serious mental illness to community care. Under these tenets, the bureaucratic machinery commenced to operate in the following year, 1962, when the NHS Hospital Plan began the process of enacting the elimination of by far the greatest part of mental hospitals. Paradoxically, however, in UK, the asylums did not begin to vanish from the scene until the 1980s under Margaret Thatcher, though their population did shrink significantly throughout the 1960s and 1970s (Scull, 2021). In parallel, within the psychiatric establishment, psychiatrists embraced the myth that the mass discharges of mental patients reflected advances in therapeutics, most especially the psychopharmacological revolution that began in 1954, with the marketing of Largactil (chlorpromazine) 7 years before Powell’s speech. With both initiatives on the table, the definitive closure of asylums and the drastic reduction of expenditure on welfare and particularly on mental health care, the politician’s concerns were attenuated. The argument forcefully put forward for this radical shift in social policies was the need for citizens deemed to be too dependent on the state (those labelled as mental patients) to gain a greater sense of responsibility for their own lives. These ideas, however, in Scull’s view, contradict, or at best, cast a veil of doubt, on the true reasons behind deinstitutionalization, as he himself recognizes:

The record demonstrates that it was policy choices, not drugs, that fundamentally underpinned deinstitutionalisation, whose impetus did not come from the ranks of psychiatry. Indeed, the shift from the hospital to the community occurred largely behind the backs of the profession and independent of its predilections and actions. Political preferences ruled and, by and large, the profession followed along (Scull, 2021, pp. 307–308).

Deinstitutionalization, in Scull’s view, was thus no accident. It was a consciously chosen neoliberal policy, pursued relentlessly over many decades. From this perspective, those suffering from serious forms of mental illness must live in need, in a hostile world, a world characterized by a shrinking welfare state, doubly stigmatized for their illness and because they show no signs of reform or recovery (Scull, 2021). If we accept these ideas as valid, it would be undeniable that the consideration that community services would be inexpensive in comparison to residential care provided an important motive to administrations for moving mental health care to the community (Kritsotaki et al., 2016, p. 19). As I will note below in the final section of my paper, with which I will finish my analytical review, this assertion has been seriously questioned in the literature.

Concluding remarks

As has been shown here, the dismantlement, closure and abolition of asylums substantially changed the lives of mental patients previously confined in those psychiatric institutions. It was a difficult process of transition, for many reasons, as I have expounded here, but finally led to a transformation in psychiatry, in which fortunate patients would be treated in a range of smaller and more community-oriented facilities, ranging from therapeutic communities and half-way houses to community mental health clinics and in private and public medical practices. As a consequence, deinstitutionalization has resulted in a decentralized, pluralistic mental health sector funded by a diversity of public and private programmes, although it has not meant the end of the mental hospital. Supporting this last assertion is the idea that residential units and hospitals had specific functions which could not easily be replaced or removed. In clear accordance with this latter idea, Craig (2021, p. 301) says:

Closing the asylum did not guarantee the elimination of institutional care, which remained in the longer-stay rehabilitation units and group homes that replaced the asylum. If added to residential forensic care and mentally ill people in prison, it has been argued that there are now as many people in some form of incarceration as there were in the old hospitals. Changes are also seen in the use of acute inpatient care where the rates of involuntary admissions have steadily risen since the mid-1980s, possibly due to reductions in acute beds or to changes in tolerance of risk among community teams.

To complicate matters still further, families and communities also opposed deinstitutionalization, arguing that at least some of the mentally ill were unable to live outside the institutions and/or posed a threat to the community. This latter, in my view, however, gives cause to think carefully about the possibility that, although a return to a reliance on the old asylum system seems inviable and unwelcome, there may be a place for such facilities were they reimagined, thus giving a new opportunity and meaning to asylum within the contemporary history of psychiatry. In this respect, Kritsotaki et al. (2016, p. 35) wisely tell us:

The term ‘asylum’ may seem archaic and pejorative, but, during a time when discussion of ‘asylum-seekers’ dominates the new agenda in many Western countries, perhaps we should reconsider what the word can also convey – a place of refuge. Community care might be preferable in the long term, but it is possible that people facing intractable psychiatric problems still need what asylums offer at difficult times in their life.

From another angle, the shape and extent of deinstitutionalization has varied in different countries and even within countries. Despite the differences in deinstitutionalization observed across geographical locations, common factors characterizing community care today are also evident. Among some of these improvable similitudes would be enumerated a lack of trained personnel, extensive bureaucracy and more recently, with the worldwide economic crisis, the decrease in public funding for mental health care. In this respect, Kritsotaki et al. (2016, pp. 30–31) alert us to the dangers which began a long time back and still remain present today in mental health care:

Exacerbated by cuts to the social welfare programmes in many countries that began with the rise of neo-liberal governments during the 1980s in North America, the UK and elsewhere, community care was increasing perceived not as professional care delivered in the community but as informal, voluntary and unpaid care by the community, namely by relatives, friends and neighbours, care that was not always possible or optimal. As a result, the mentally ill were at greater risk of lacking the specialised treatment they needed, of losing genuine opportunities for kinship, friendship, and neighbourhood networks and of facing the prospect of homelessness or incarceration.

If we, experts and lay people, really want to change things, now is the time for making this a reality. Consolidating this reality, in my view, requires us to create a collective conscience which mobilizes and truly transforms social policies and the welfare state. By this means, we will get to minimize the stigma of mental illness and achieve a tolerant and inclusive society receptive to those mentally ill in most need.