The asylum casts a long shadow over
psychiatry. Broad picture policy debates are frequently framed in terms of
whether deinstitutionalization has ‘worked’, whether ‘community care’ is
working, and whether, with the loss of the physical locus for the activities of
psychiatry, the psychiatric professions have become merely another means of
social control. Pilgrim and Rogers ask these questions (and others) of British
psychiatry, and their answers are far from reassuring to the psychiatric
professions, or to consumers of mental health services. Mental Health Policy
in Britain is the second edition of this work. The first was published in
1996. I have not read the first edition, so I am not in a position to compare
the two. The authors have worked in the area of psychiatry for many years,
publishing a number of research papers, critiques, and books. Rogers is a
sociologist, Pilgrim is a psychologist, so neither represent the mainstream of
psychiatric professionals, providing an opportunity for a more critical view of
the area than that found in most psychiatry journals.

The book begins with an overview of
the process of policy formation. These two chapters are a useful reminder to
take a broad view of mental health policy, and in particular, to note that
mental health policy serves a range of interests and interest groups, and
attempts to meet what are sometimes conflicting aims. The second chapter on the
history of psychiatry is necessarily brief, but still a useful summary of a
history that is still very much alive in the practice of psychiatry. A theme
introduced in this section, and returned to throughout the book is the
chameleon-like nature of ‘institutionalism’, and how inpatient services
continue to dominate psychiatry both economically and philosophically. At
least, that is Pilgrim and Rogers’ argument. The extent that it holds true
requires closer examination. The third section covers developments in the post
institutional era. Given that in Britain, as in the US (but not in all western
countries), some of the old hospitals continue to operate, albeit reduced in
size and status, the term ‘post-institutional’ is necessarily provisional. This
final section provides some useful discussion of new developments, such as
mental health in primary care, and the reconceptualization of psychiatric
services as ‘mental health services.’ Mental Health Policy in Britain
provides a useful overview of policy development in Britain over almost two
centuries. While readers would do well to respond to this book with the same
critical eye the authors bring to their work, they will find much to ponder in
Pilgrim and Rogers’ analysis.

Mental Health Policy in Britain
covers important issues that are unique to Britain as well as some that are
easily generalizable to other contexts. The Care Programme Approach (CPA) is
peculiar to Britain, even if some of the issues it attempts to address are
encountered elsewhere. Originally designed to ensure minimum standard of care,
Pilgrim and Rogers argue that the CPA soon became administrative rather than
clinical. So inclusive is this policy that according to Pilgrim and Rogers 1% of
Britons have care programs. The English mental health legislation also has some
peculiarities not found in other jurisdictions, such as specific reference to
‘psychopathic disorder’ and powers of police to refer individuals, under
compulsion, to mental health services. Issues which are more closely shared
with other countries are integration of secondary and primary care, and
questions of compulsion in the community.           

A major strength of the book is
that Pilgrim and Rogers take a critical view of the institutional interests of
psychiatry, in particular its claims to authority and its right to dominate the
discourse of mental health policy. They provide many examples of how the
interests of psychiatry have come to influence policy, even when clear
alternatives have been articulated. This discussion is not confined to the
relatively recent past. Pilgrim and Rogers cite describe how debate in the
1930s around nascent idea of community care was effectively silenced by the
consortium of political interests of politicians and psychiatrists. The
supposed legalism of the 1983 Act is also shown to have been subsumed by
clinical interests, something that has been noted in mental health law reform
internationally. A commonly held view that institutions were downsized for
economic reasons is questioned, with Pilgrim and Rogers showing how that
explanation applied to a later period of deinstitutionalization, but was not an
initial factor. Neither were the new psychotropic drugs decisive in reducing
bed numbers, as is sometimes argued. Reviewing more recent developments, Rogers
and Pilgrim comment on the difficulty of having an effective consumer lobby in
policy development, in particular given the divergent views and interests of
consumer lobbyists.

On the issue of language, the
authors take issue with the use of the term ‘consumer’, principally because
many psychiatric patients are treated under mental health legislation, and
therefore have limited choice. However this is a rather doctrinaire
interpretation, and a surprising one for a sociologist. In a highly contested
area such mental health, language is used less literally than Pilgrim and Rogers
analysis implies. "Consumer" is a term that recognizes the market
model imposed on healthcare in the 1990s, and which seeks to appropriate the
power of the market discourse. The term highlights important rights obscured by
the more paternalistic term "patient", and thus serves an important
rhetorical function. That said, Pilgrim and Rogers’ critique shows up the
limitations to such rhetoric. 

A theme throughout the book is that
of citizenship. This continues the evaluation of post institutional psychiatry,
but broadens its focus from a narrow clinical view, to one based on a broader
entitlement to the rights of citizens. I felt that this was a theme that could
have been developed further, although Pilgrim and Rogers’ task was to describe
the process of policy development, rather than to outline a model for it. But
as more mental health care is provided in the primary care sector, especially
by non-specialists, the notion of ‘mental health consumer’ (or ‘patient’)
becomes more problematic. Also, as much of Pilgrim and Rogers’ discussion
shows, provision of clinical services cannot be divorced from meeting the
social needs of patients for housing, support, access to medical care, and
employment, needs that are consistently rated higher by patients than by
professionals.  

At times Pilgrim and Rogers adopt
an almost cynical view of health professionals as self interested, subverting
concepts such as "need" to supplant the interests of patients with
their own professional self interest. The authors talk of a professional
assertion of "right to treat" although it is not clear that that
right has been specifically asserted by any professional groups, except under
conditions of compulsion. While there is no doubt that patients are at times
persuaded, even coerced, into accepting professionals’ views, in practice there
are limits to professionals’ powers of persuasion, even within the framework of
legislation. Pilgrim and Rogers are convinced that use of legislation is
inherently "repressive", and take every opportunity to present what
they call "therapeutic law" in this light. Their view of
professionals (especially doctors and nurses) allows them to construct the
introduction, in the 1983 Mental Health Act of a nurses’ holding power, as an
extension of professionals’ repressive powers, rather than a legal check on
such powers through statutory accountability. Again, there is a sense that this
view results from the authors’ preferred philosophical approach to mental
health law, rather than consideration of the possible consequence of their
approach. As Elyn Saks noted in her book Refusing Care,
solutions to the ethical issues of mental health law are unlikely to be found
simply by appeal to principle. When Pilgrim and Rogers state that "mental
health [legislation] glibly allows others to pass judgement and take action
about the control of risky behaviour" (p. 197) they are surely guilty of
talking up the powers of psychiatrists and diminishing the significance of
legal accountability.

Pilgrim and Rogers contrast care in
the community with that provided in inpatient services. Inpatients are offered
less talking therapies, they are increasingly likely to be held under legal
powers, drugs are used as a first option, and inpatient clinicians are less
willing to negotiate alternatives than their community counterparts. In a
somewhat depressing conclusion, Pilgrim and Rogers state that little has
changed in inpatient care since the Victorian era. This combined with their
assertions of continued medical dominance in British psychiatry might lead one
to conclude, after Baudrillard, that deinstituionalisation did not take place.
The authors succeed in their aim of showing how mental health policy, while it
may be set centrally, is ultimately determined by a range of stakeholders with
central policy makers having less influence than might be supposed. Whether
professionals are quite as self interested as is argued here is open to debate.
The recent campaign against the English government’s draft mental health bill
was resisted by an alliance of professional and consumer groups, with broad
agreement that proposed powers such as anticipatory containment were a police,
rather than a health matter.

Mental Health Policy in Britain
will be of interest to British readers for its coverage of the mental health
policy issues that impact on their work. Readers in the old Commonwealth will
find it interesting to compare developments in their own countries with those
of a country with broad similarities in its health system. For US readers, I
suspect the book will provide a study in contrasts. Any US equivalent
publication would have large sections on State vs. Federal funding, cost
shifting, and insurance cover, not to mention the complexities of multiple
mental health laws. But there will be enough of common interest to make the
book useful reading. This is useful contribution to literature on mental health
care, especially for those concerned to develop a critical view of the process
of policy formation. It has broad appeal, to clinicians, policy makers,
academics and researchers.  

©
2006 Tony O’Brien

Tony O’Brien RN, M.Phil, Senior
Lecturer, Mental Health Nursing, University of Auckland, a.obrien@auckland.ac.nz

Categories: MentalHealth