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The Last Asylum: A Memoir of Madness in Our Times, by Barbara Taylor, Hamish Hamilton, RRP£18.99, 320 pages
In closing down the vast mental hospitals of the Victorian era, did we unintentionally jettison some things of value for the psychologically ill? This question is an undertow throughout Barbara Taylor’s The Last Asylum – a hybrid of memoir, history and exploration of the present state of mental-health provision in the UK.
Taylor’s own breakdown occurred in 1981, just two years before the Mental Health Act that introduced to the wider public the concept of “care in the community”. Thus, Taylor (a Canadian-born academic who had arrived in London in the early 1970s) entered the UK’s mental health system at a period of cataclysmic change. She was to spend 21 years in privately funded psychotherapy and, concurrently, four years in the public mental health system as both outpatient and inpatient. In 1988 Taylor entered the colossal Friern Hospital (originally called the Second Middlesex County Pauper Lunatic Asylum), which would be taken out of service less than five years later.
Friern had been constructed on a wave of what certain historians have dubbed mid-Victorian “therapeutic optimism”. But the hopefulness evaporated and Friern itself came to typify all that was rotten, wrong-headed and even sinister in the treatment of lunacy. In 1961, Conservative health minister Enoch Powell attacked the “isolated, majestic, imperious ... asylums, which our forefathers built ... For the great majority of these establishments there is no appropriate future use.” Powell had read the obsequies early, and it would be the mid-1980s that saw the dismantling of the network of free-at-the-point-of-use asylums created by the 1845 Lunacy Act.
Taylor recalls acts of violence between Friern patients, occasional abuse and neglect by staff, and the overuse of medication for long-stay patients. Yet she also enumerates the positive aspects of detention in Friern. The hospital could function as “a refuge from unmanageable suffering”. What’s more, the elderly long-stay patients often built up strong friendships, which were brutally truncated when the hospital was shut down and its inmates speedily dispersed. Some were sent off to therapeutic communities, but far too many were shunted into hostels, bedsits or other isolating environments.
This “decarceration” had nominally been undertaken to replace coercion and dependency with self-reliance. What the reformers had failed to appreciate was that, as Taylor writes: “For people with severe mental disorders, just being around other people is sometimes all that is desired or tolerable.”
For Taylor, psychoanalysis provided the means to explore her breakdown and discover the nature of “the Laughing Woman” – the vile internal critic who would regularly hoot derision at her. Psychoanalysis has been under fire from many quarters for years: “People imagine it as self-indulgent,” Taylor writes – “all that delicious chit-chat about oneself!” They are unlikely to think so after reading her account of the gruelling sessions at her analyst’s practice. “Accurately remembered madness is oxymoronic; if you can really remember it, you are still mad,” Taylor writes. So she has reconstructed her experiences as best she can, and these sections of her book make for a deeply moving, often harrowing, read. Her bravery in digging into her “deep memory” is considerable.
The real triumph of the book, though, is its concise, dispassionate, nuanced examination of how the UK’s mental health services are run right now. Taylor points out that the emphasis on abolishing patient “dependency” upon institutions and staff has created a patchwork of services that overlooks continuity of care. It is an approach that has not just shut down the Victorian “bins” but has closed the day-care centres and rehabilitation programmes that provided invaluable companionship and a place of retreat – of “asylum”, as the Victorians understood it. It is cheaper, and chimes better with market forces and the cult of the individual, to spend the health budget on sticking-plaster quick-fixes; to encourage people to “own” their illness, get “well” and return to work as quickly as possible. Ironically, this “independence imperative” is all very Victorian – a Samuel Smiles Self-Help system that is wholly unsuited to people who really do need to interconnect with others.
Even more ironically, we have started locking people up again. Introduced in the 2007 Mental Health Act, Community Treatment Orders facilitate the compulsory detention of patients who refuse to take their medication. It was envisaged that they would rarely be enforced: in reality, the first three years saw some 14,295 people forcibly detained in special units that had neither the space nor staffing levels to cope. The asylums, you see, have been shut down.
Taylor avoids presenting simplistic solutions to this, the most complex of socio-medical problems; but she is surely correct to identify that the most long-lasting recoveries will be brought about by patients being allowed to be part of a therapeutic community and establishing continuity of care with their health workers. “Service-users” are now beginning to write psychiatric history from the patient’s perspective, Taylor notes. Her book is a invaluable contribution to this burgeoning genre.
Sarah Wise is author of ‘Inconvenient People: Lunacy, Liberty and the Mad-Doctors in Victorian England’ (Bodley Head)