Despo Kritsotaki, Vicky Long, Matthew Smith, eds. Deinstitutionalisation and After: Post-War Psychiatry in the Western World. Houndmills, Basingstoke, Hampshire: Palgrave Macmillan, 2016. 323 pp. $99.99 (cloth), ISBN 978-3-319-45359-0.
Reviewed by Andrea Zittlau (Universität Rostock)
Published on H-Disability (July, 2017)
Commissioned by Iain C. Hutchison
Deinstitutionalization is defined as the process that occurred when, particularly in the second half of the twentieth century, mental health care shifted from being based in residential asylums to becoming primarily an outpatient, community-based service. While the asylum has inspired a tremendous body of research, most prominently by Michel Foucault and by Erving Goffman, the forms of care that followed its deconstruction have not been studied substantially. This collection of essays is an attempt to fill the void and begin a debate about the consequences of deinstitutionalization. The introduction sketches the history of the process, particularly focusing on the post-World War Two years and the antipsychiatry movement that conceptualized the institution as a depersonalized, cruel entity. However, why the called-for change in treatment and the introduction of medication inevitably led to a reduction of hospital beds is not explored further in the book. It seems that the institution, as Michel Foucault conceptualized it, cannot be changed, only destroyed.
The first series of essays deals loosely with the history of deinstitutionalization. The American historian John Burnham, for example, argues that deinstitutionalization coincided with a shift from a producer to consumer society. He focuses on the asylum’s history as a workhouse creating valuable producers that became obsolete the moment patients had to be consumers. He exhibits a pessimistic view, stating that “in the United States, at least, free market extremism as a part of consumer culture brought many terrible things to deinstitutionalized mental patients—isolation, homelessness, exploitation and imprisonment” (p. 54). This is also the tenor of the editors, who speak of a “transinstitutionalization” (p. 5), stating that “for those who were truly institutionalized, leaving institutions to live in the community, support has most often been inadequate” (p. 30). Many essays share this attitude, pointing at administrative and financial difficulties or mocking the antipsychiatry movement. but hardly any contribution provides substantial case studies or the necessary patients' and caretakers' voices. Rather, the book tries to present deinstitutionalization as a phenomenon (and problem) of many countries in the Western world. Articles cover (West) Germany, France, Greece, Italy, Australia, the United States, and Great Britain, but all of them either look exclusively at the administrative policies of deinstitutionalization or take a positivistic, biographical approach to medical professionals who advocated deinstitutionalization. The voices of families who were now expected to replace the care of asylum are rare, although not absent from the book; patients’ voices are even rarer.
The only exception is the contribution, by a Canadian research collective, called “After the Asylum in Canada: Surviving Deinstitutionalization and Revising History.” A team consisting of a historian, psychologists, health policy scholars, and sociologists was awarded a grant by the Canadian Institute for Health Research to examine the history of deinstitutionalization. The team was multidisciplinary and multinational and set out to understand the reduction of hospital beds in chosen locations. However, soon it became very clear to them that “the motivations for this evolution were a complex blend of new therapeutics, professional change and fiscal planning … [with far-reaching] impacts on the Canadian economy and on human rights discourses, particularly those that hinged upon questions of ability, disability, health and illness” (pp. 78-79). Their chapter describes the journey of their research into these complexities and highlights the contribution of an ex-patient who happened to be part of the team: Jayne Melville Whyte. The article stresses how having her on the team significantly changed not only the focus of the research group, but also its methods: “Whyte encouraged some of us to set aside our academic scaffolding, and instead to stop and listen to different voices both in the archives and in the interpretation of those historical texts” (p. 83). The work resulted in, among other things, a documentary movie called The Inmates Are Running the Asylum: Stories from MPA (2015) and a website. While the article only focuses on the process of research, the “After the Asylum” website provides lesson plans that allow for classes on peer support and activism or community initiatives, among others. The page is clearly aimed at researchers as well as general-interest audiences and vividly illustrates how the process of deinstitutionalization could have been investigated.
Deinstitutionalization and After shows the difficulties of academic research within the field of disability studies. While administrative processes, especially in the area of law-making, have been documented and are easily accessible, individual cases can be more difficult to trace. This does not only involve patients, but also families and employees. Their voices are important in order to understand how the discourse about mental illness changed—a contribution made by the antipsychiatry movement—and thus the idea and methods of cure. The asylum changed, not in isolation, but together with other institutions like the hospital and the school. It is necessary to acknowledge the complexity of the issue to be able to question what happened to former patients and what happens to people in need of care right now. The book does not raise these questions, but creates the space for others to do so.
. The "After the Asylum" website is accessible at http://aftertheasylum.apps01.yorku.ca/en.
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Andrea Zittlau. Review of Kritsotaki, Despo; Long, Vicky; Smith, Matthew, eds., Deinstitutionalisation and After: Post-War Psychiatry in the Western World.
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