In addition to the emergence of medication, histories of community care also highlight the role of anti-institutional knowledge (e.g. Coppock & Hopton, 2000). A key
proponent of anti-institutional views was the American sociologist Erving Goffman, who had spent around eighteen months undertaking an in-depth ethnographic study of institutional life in a Californian hospital, prior to writing his influential book
2.4.1 Goffman
For Jones (1993), Goffman’s strength was in his ability to draw out common threads in institutional life, which readers took as professing general patterns in institutional care. Goffman’s critique was eloquent and wide ranging. From the moment patients enter institutions the ‘mortification of the self’ (Goffman, 1968a) began. He argued people were stripped of their identities, through the removal of all aspects of personal
identification. They wore standardised clothes and personal belongings were removed. Goffman reported that conditions for patients in institutional life could be quite
horrific. Although, his book focused on what he referred to as ‘total institutions’, he was, in part, talking about mental institutions. Goffman argued that life was harsh for mental patients, indeed, that it was in essence abnormal, with a two-tier social world, with the staff and their social activity (numerous games, groups and other events) on one hand, and the patients’ limited existence of menial work, exclusion from staff activity and very limited space, on the other. Goffman was scathing about physical treatments, such as Insulin Coma Treatment, Electro-Convulsive Therapy and Psychosurgery. He observed administration of treatments (one of which detailed in Chapter One) and argued that they constituted a form of abuse. The social world of patients also came under Goffman’s wrath, as he stated that group activities such as games, art lessons, dances etc, formed another attack on patient privacy as they contributed to the controlled nature of patients’ time and space.
According to Goffman’s argument mental disorders are vulnerable to the effects of individuals’ immediate environments. If conditions are poor, patients are exposed to practices producing negative experiences, resulting in exacerbation, rather than improvement, in mental health. Individual bodies are presented as susceptible to the workings of social practices, meaning mental distress operates as impacted upon by external forces. This was a move away from the mainstay prescription of individual neurology as the basis of distress. Goffman’s work, amongst other anti-institutional research, introduced the notion of social practices as contributing to mental distress, which was no longer within the sole remit of neurological activity. Biological psychiatry drawing support from drug therapy was not the sole determinant in the continued move into community care. Despite differences in concepts of mental distress, these contrasting approaches became part of the same relational forces to move mental health care from institutions to community settings.
2.4.2 Laing
Laing (1969), himself a trained psychiatrist, argued that the focus should not be on the practices associated with ‘schizophrenia’, but on individuals’ experience of their own world. This is drawn from existentialism, and involves understanding people’s own individual subjective experiences; the ways people consciously encounter the outside world. The medical approach that constructs people as machine-like, in terms of their susceptibility to their own physiological make-up, fails to adequately account for their overall ‘illness’ experience (Laing, 1969). From this, Laing did not attempt his own theory of schizophrenia, but believed that an insight into individuals’ perception of their world (Laing defines this as the space and time from which a person experiences and acts) could help understand their so-called abnormal behaviour. The focus of much of Laing’s work was individuals’ perceptions of their own family environment. This had led to childhood, and particularly the relationship with parents or caregivers, to be seen as a key factor in the development of mental disorders. Laing and Esterson (1964) sought to gain insight into how individuals who had been diagnosed and consequently treated as ‘schizophrenic’ perceived their own worlds, both as an individual, and as a part of the ‘family nexus’ (p.21), in which the person may be a brother, sister, or father etc. From this perspective, Laing provided therapy to individuals and published certain case studies of his work. He believed that the realms of psychiatry and
psychopathology were not the correct places to attempt an understanding of the meaning and significance of mental disorders contained under the umbrella of ‘schizophrenia’ (Laing, 1969).
The move Laing is making is summed up well in the following extract:
‘No one has schizophrenia, like having a cold. The patient has not ‘got’ schizophrenia. He is schizophrenic.’ (1969: 34)
Laing sought to re-conceptualise schizophrenia as a way of being, an existential state that people are. Although he was careful to state he was not coming up with a new theory of schizophrenia as a whole, he clearly was to an extent, in terms of offering a new system of thought regarding people’s experiences labelled as schizophrenic. Namely, that it is not something that people have, but a way people live. He did not believe that schizophrenia was an illness as such, in the same way that people may
have a virus. Rather the schizophrenic experience was a way of living, of being, that is predominantly constituted in the network of relations that form people’s family
environment.
2.4.3 Szasz
Another key anti-psychiatry proponent was Szasz, who argued from a very different position than Laing. For Szasz (1974), mental illness as defined by psychiatry is very much influenced by social, cultural, and particularly political factors. He believed that mental illness is an invention of psychiatry, akin to the invention of ‘witches’ in
medieval times, which can then account for certain social and moral difficulties. Rather than admit that particular problems exist, the people who are involved can be
diagnosed mentally ill, through no fault of their own, and then ‘treated’ through
psychiatric intervention. In addition to this, mental illness can also camouflage and blur the borders surrounding certain socially outcast subgroups. Bowers (1998), in drawing on the writings of Szasz, describes how certain societal issues, such as poverty,
domestic violence, low employment, can become medicalised through diagnosing those within such situations as mentally ill, thus covering up the real difficulties members of such groups suffer. Bowers (1998) critiques the work of Szasz by stating that it is too generalistic, as social and morality factors associated with illnesses are always ignored or glossed over. Additionally, the crux of Szasz’s argument really concerns a category error, namely that he disagrees that experiences labelled as mental illnesses are any different to those labelled physical illnesses. With this he offers his definition that for an illness to exist a physical lesion should be present. He uses this to suggest that diagnoses for which no aetiological nature has been identified (e.g.
schizophrenia), should not be treated as illnesses, with subsequent pressure to engage in current dominant treatment practices (e.g. taking medication). Rather people should be free to choose what kind of treatment they desire, if, that is, they make the decision to seek treatment. In this way Szasz adopts a liberalist humanist position, a very different one to a lot of the other so called ‘anti-psychiatrists’. This is another example of an ambiguity regarding political viewpoints, in that radical liberatarianism (that of Szasz) end up desiring the same thing as left-wing socialists (such as Laing and Cooper), namely, a move away from an ‘illness’ model of mental health.
2.4.4 Basaglia
Approaches critical of psychiatry that had an impact on ‘anti-psychiatry’ also emerged from work taking place in Italian psychiatry, primarily under the helm of Franco Basaglia (1981; Basaglia, Scheper-Hughes, & Lovell, 1987). The political thrust that drove Basaglia was an anti-psychiatric one, but with a distinct flavour from that of Szasz and Laing. Basaglia had been very influenced by phenomenological writings in his early years as a psychiatrist, and believed that to develop an understanding of mental illness one had to directly address the subjective experiences of those who suffered with such disorders. His beliefs though began to change when he became psychiatrist in chief at the Gorizia psychiatric hospital, where he came to realise that his commitment to a phenomenological philosophy failed to account for the range of social and political factors that constructed cultural understandings, and the actual experiences, of living with mental health difficulties in mental hospitals. This is the stage at which Basaglia became more overtly political in his approach. He sought to strip away the layers of social and political forces, and concentrate directly on what people had to say about their experiences. This involved moving away from the vocabulary and material infrastructure of psychiatry, such as diagnostic classifications and psychiatric treatments. He was accused in some corners of denying that mental illness existed (Basaglia et al., 1987), but this was not an accurate representation of what he was trying to do. He actually believed that one could only know the reality of mental illness if one stripped away all the political and social factors that construct it to such an extent. He believed in it, but not in the ‘reality’ created by the psychiatric vocabulary that was the dominant knowledge framework through which mental health was understood.
Basaglia’s was a practical philosophy in a sense. He sought to translate his beliefs into a material existence through transforming the psychiatric hospital at Gorizia. He was not solely interested in developing a new theory of mental health, but was driven by a desire to practically improve the lives of those treated by psychiatry. He fully believed that they had mental illnesses, but did not agree that institutional psychiatry was a beneficial, or appropriate, treatment and care paradigm. While Basaglia was the driving force behind reform at Gorizia, it was the move from a hierarchical power structure, with psychiatric power (i.e. Basaglia) at the top, to a collective shared form of power and responsibility. The creation of a weekly forum (assemblea) occurred, in which no
formal power structures were present. It had no set directive, aside from being a space in which patient and staff concerns could be raised and discussed. This often led to disagreements and fierce debates, but this was welcomed, as there were no right and wrong answers, in a psychiatric sense, to be produced by the assemblea. Rather it was a forum for all voices making up the institution to be heard. Chaired variously by staff and patients, it helped create a shared responsibility. If decisions made turned out to be incorrect or not appropriate, it was not the staff that were held responsible, but all members. This shared responsibility was galvanised when one particular decision did turn out to be incorrect. This was the case in which a patient was released back to his family but proceeded to murder his wife (Basaglia et al., 1987). Despite the authority’s attempts to lay the blame for this firmly at Basaglia’s feet, all members of the
assemblea protested, on the basis of it being the result of an incorrect decision made collectively.
A range of factors meant that Basaglia was not able to truly experiment with his own version of anti-psychiatry until the early 1970s when he became asylum director of the Trieste Institution. Basaglia set up a pioneering centre for the treatment of people with mental health difficulties in the town of Trieste in Northern Italy. The premise behind the centre was a move away from large asylum based care, to smaller (e.g. 15 bed) centres, something he performed through persuading people (e.g. left wing groups) that ‘patients’ should be released from mental institutions in the name of liberty and
freedom (Jones & Poletti, 1985). Basaglia was clearly influenced by Marxist ideas, in that he focused on the social forces at work in the cultural ways of thinking about mental illness. The large institutions were taken as the physical workings of institutional power designating what should be seen as mentally ill. In this way, Basaglia believed that radical changes were needed, as the lives and experiences of those housed in asylums were the product of political forces. Lives could be re-claimed through integration into smaller, community-based programmes of mental health care. Basaglia argued people would benefit from a more socially integrative framework, with small units set up in general hospitals for those in need of in-patient care.