Tag: mental health

Review: Outrageous Reason

Peter Barham, Outrageous Reason: Madness and Race in Britain and Empire, 1780-2020  (Monmouth: PCCS Books, 2023), 248pp, £21.50, softcover.

by Michael Romyn

In July 1981, Winston Rose, a 27-year-old father of two was choked to death by police officers in a neighbour’s back garden in Leyton, east London. Concerned for her husband during a period of poor mental health, Rose’s wife, Thora, had sought the advice of the social services, setting in motion a series of destructive actions by a range of state agents, including his GP, psychiatrists, and finally the police: 11 officers in total, some carrying riot shields, were sent to apprehend a visibly fearful Rose for psychiatric detention. Like the murder of George Floyd by a police officer in Minneapolis almost 40 years later, Rose’s fate was abetted by the spectre of violence his blackness supposedly portended. Rose, to be sure, stood little chance of being treated by the authorities with the care his situation necessitated. Rather, he was seen and dealt with as someone whose humanity was obscured by the myth and presumption of black dangerousness.

As Peter Barham shows, Rose’s life and death are a window onto the enduring entanglements of race-making and madness under the hegemony of white reason: mapped onto racialised bodies in broad swathes, madness and the dysfunction, deviancy, and dangerousness it signifies has made up a key dimension of the constitutive outside against which white liberal ‘rationality’ constructs and defends itself. This is a story Barham traces from the hold of the transatlantic slave ship to the hold of the police in contemporary Britain, demonstrating the way in which ideas about race and madness continue to flow along channels created by and for empire. The concept of the ‘hold’ certainly appears frequently across Outrageous Reason’s 14 chapters. For Barham, it can mean the deadly grasp applied by police officers and hospital wardens to black people like Rose and George Floyd, as well as Sean Rigg, Jimmy Mubenga, and numerous others, but also a ‘physical, ideological or, sometimes, figurative space, one of traumatic memory, in which persons, or the traces of persons such as records, are sheltered or stored, or, more commonly, held captive.’ (5).

Here, Barham’s objective is to retrieve a number of these subaltern persons or their traces through case studies and vignettes, some of which utilise personal narratives and other testimonial sources that place us squarely in the historical terrain. For example, we are plunged into the miserable depths of Kingston Lunatic Asylum in post emancipation Jamaica via the observations of Henrietta Dawson. Admitted to the asylum in the late 1850s, Dawson, who, like every patient at Kingston, was a woman of colour, was subjected to and witness of all manner of arbitrary violence, humiliation, and routinised punishment at the hands of staff, including the sometimes lethal practice of ‘tanking’, whereby patients were dunked and held underwater. Drawing on works by an array of scholars of slavery and postcolonialism, Barham argues that the conditions Dawson described were not a localised aberration in the hinterlands of British Empire, but that the asylum was an ‘engine room of colonial modernity’ (61); while cloaked in principles of benevolent governance, the Kingston asylum ‘scandal’ exposed the constitutive violence and racist differentiation at the heart of the imperial project. With the case of Orville Blackwood, who died in appalling circumstances at Broadmoor high-security psychiatric hospital in August 1991, Barham illustrates the disturbing continuities between Dawson’s experience and the treatment of black patients in contemporary spaces of ‘care’. As is made so clear in the book’s final chapters, the systematic negation of the colonial subject – to the status of ‘savages’, ‘beasts’, ‘barbarians’ and so on – continues to seep into and pollute our institutional cultures in both quotidian and cataclysmic ways.

The question of what care has looked like for the poor and racialised is posed at the outset of the book through the episode of the Zong slave ship massacre of 1781, where more than 130 captive Africans were thrown overboard by the crew in a chilling piece of financial calculus. While likely a simple error of re-painting, Barham argues that the earlier renaming of the ship, from the Dutch Zorg, meaning ‘care’, to Zong, augured the horrific events on the vessel to come. But he also sees it as a symbol of the way in which care has been routinely ‘abjected’ or ‘transformed into something else’ (57) when it comes to those deemed ‘mad’ or ‘damaged’ by the arbiters of white reason. The case of Alice Rebecca Triggs, a white domestic servant who spent the last four decades of her life in a mental institution after receiving a diagnosis of ‘moral imbecility’ in 1919, makes a wider point about how such delimitations of care and understanding not only imperilled black lives, but also the lives of the ‘lower or inferior orders’ in Britain who posed ‘a threat to the vitality and stability, and hence to the future, of the white race’ (102).              

There is another aspect of care to consider here: early on in the book Barham writes that he is ‘trying to feel my way, challenging and exploring diverse forms of “knowing” and drawing as much as I can on the exercise of…“negative capability”’ (6). Certainly, he treads the complex and multiple intertwining pasts of race, class, and madness and their troubling resonances in the present with considerable care and empathy, and in a way that forces us to think about and contend with our own cultural assumptions. In doing so, Outrageous Reason marks an important step in what Barham describes as a ‘gathering discourse, or convergence of voices’ (213) that enjoins a revaluation of conceptions of pathology and dysfunction, as well as the hegemony of whiteness that upholds them.

*

Michael Romyn’s first book, London’s Aylesbury Estate: An Oral History of the ‘Concrete Jungle’, was published by Palgrave Macmillan in 2020.

Review: Closing the Asylum

Peter Barham, Closing the Asylum: The Mental Patient in Modern Society (London: Process Press, 2020)

Steffan Blayney, University of Sheffield

When the first edition of Peter Barham’s Closing the Asylum was published in 1992, it attempted to describe the historical underpinnings of a protracted upheaval in mental health provision which was still very much ongoing. While the dismantling of the Victorian asylum system had been the professed aim of successive British governments dating back at least to the 1959 Mental Health Act – and while the overall asylum population had been declining steadily since its peak in 1954 – still in the early 1990s deinstitutionalisation remained an unfinished project. By the time of the book’s second edition in 1997, with the majority of hospitals open a decade previously now closed, this seemed harder to argue, yet by this point characterisations of ‘care in the community’ as a failure were already becoming mainstream. This new edition, published in 2020, arrives in the wake of the 2018 Independent Review of the Mental Health Act amidst ongoing debates about the extent of coercion and legal compulsion within the mental health system.

Barham’s original text, reissued here with a new prologue and preface, situated twentieth-century debates over deinstitutionalisation within the longer history of how modern societies have dealt with the ‘problem of insanity’. This has always been a social question at least as much as it has been a medical one. In nineteenth-century Britain, and particularly after the New Poor Law of 1834, the public asylum emerged – alongside the workhouse and the prison – as a means to deal with surplus populations produced by industrialisation. Idealistically imagined by their founders as spaces of care and rehabilitation, the Victorian asylums quickly became little more than overcrowded repositories for incurables and undesirables. The segregation of the mad was given legitimacy by an emerging psychiatric profession whose own optimism about the possibility of cure quickly ceded to essentialising views of mental patients as inherently ‘broken’ or ‘flawed’ individuals, who for the most part would remain incapable of participating in society and undeserving of recognition as fully human. While such conceptualisations were never without their critics, Barham argued, the eventual movement towards asylum closure that emerged in the twentieth century failed to seriously challenge the underlying ideological structures which continued to produce madness as a social problem and the mental patient as a second-class citizen.

The resulting story of deinstitutionalisation was one in which the hopes held by many for the full liberation of hospital inmates would always be secondary to more cynical policy motives. Focusing primarily on mental health law and policy in England and Wales, and weaving historical and sociological analysis with the views of service users and campaigners, Closing the Asylum described how hopes entertained by reformers from the mid-twentieth century for progressive alternatives to the authoritarian psychiatric hospital were repeatedly frustrated or co-opted. Too often, talk of patient freedoms or more enlightened approaches to care functioned as little more than ideological cover for governments eager to cut expenditure by avoiding the costs associated with long-term custodial care. Hospitals emptied, but the services which would allow former inmates to live meaningfully independent lives fail to materialise, with new developments in psychopharmacology enabling the management of symptoms without the need for costly social or psychological therapies. For some who would formerly have been hospitalised, the institutions of the criminal justice system expanded to fill the vacuum (a growing prison population since the 1990s includes an increasing proportion of inmates identified as suffering from a mental health condition). For many more, especially those already from deprived backgrounds, newfound freedoms were undermined by persistent poverty, insufficient welfare support, and the stigma of illness leading to discrimination in housing and employment. Where the mental patient is still viewed by society as a problem to be solved rather than a full political subject, Barham demonstrated, ‘community care’ can function just as effectively as the asylum as a technology of social exclusion and marginalisation.

Another aspect of the old regime which failed to disappear along with its physical architecture was its use of force and legal compulsion. While it might have been expected that the move away from the rigid hierarchy of the asylum would lead to greater liberty for patients, evidence from the last three decades, which Barham details in the prologue to the new edition, shows that the opposite is true. The use of constraint and coercion, justified by the supposed risk posed by patients to themselves or others, has not only persisted through deinstitutionalisation but is increasing. Despite falling numbers of long-stay patients, the total number of people being detained involuntarily almost tripled between 1988 and 2015. This combined with drastic reductions in the overall number of psychiatric beds through years of austerity means that half of all psychiatric inpatients are now detained under the Mental Health Act  – compared to around 10% in the 1970s. Moreover, with the arrival of Community Treatment Orders (CTOs) in 2008, mandating compulsory outpatient treatment under threat of detention, formal coercion is now no longer limited to the hospital setting. The violence of the system, it might be added, is not evenly applied: black patients are more than four times more likely to be involuntarily detained than their white counterparts, and more than ten times more likely to be subject to a CTO. Nor is the ‘shadow of coercion’ (8) which extends over the mental health system limited to those against whom the provisions of the Mental Health Act are directly mobilised. As service user activists (and some psychiatrists) have argued, in a system where patients and doctors know that the threat of compulsion is always available, it becomes difficult to see any treatment as fully voluntary.

While sharply critical of the way deinstitutionalisation has played out in practice, Barham has remained neither nostalgic for the asylum nor pessimistic about the prospects for more progressive services in the future. As he makes clear in the prologue to the new edition, ‘though the book is consistently critical and questioning of the way in which policies of community care have been implemented, it nonetheless holds steadfast to a positive view of the capabilities of the diverse range of people who are assembled under the banner of the “mentally ill”, and to the promise of community-led, above asylum-led lives for enhancing their life prospects.’ Deinstitutionalisation in this context should be seen not as an irrecoverable failure but as an unfinished ‘emancipatory project’ (28).

The ‘real questions’ that societies need to answer, as Barham maintained in 1992, have never been ‘about dismantling the mental hospitals as such, but about the prospects for manufacturing the social and political will adequate to the task of bringing back and reassimilating into society what had been thrust into the mental hospital’ (151). For Barham this means reaching a point where individuals are treated not primarily as ‘patients’, defined in law by their diagnosis, but as ‘persons’ entitled to full rights as citizens. Drawing on ideas advanced by the psychiatric survivor movement (the new edition includes a preface from the veteran campaigner Peter Campbell) he advocates a shift from managerial or paternalistic conceptions of care, underpinned by coercion, towards a focus on empowerment and autonomy for service users. This will not be achieved through legal or medical fixes, but only by reckoning with the centuries-old legacies of a system which has created the ‘mentally ill’ as a class apart.

Review: On the Heels of Ignorance

Owen Whooley, On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing (Chicago, IL: University of Chicago Press, 2019), ISBN: 9780226616384


Ahlam Rahal, McGill University, Montreal

Positioning himself in psychiatric knowledge as a researcher, Owen Whooley starts On the Heels of Ignorance by describing memories from his childhood, which planted the seeds that grew into his writing about psychiatric ignorance. As the son of a man with a mental illness, young Whooley had daily experienced questions related to his father’s mental health problems. His attempts to understand his father’s depression and drug addiction had always been surrounded by ignorance, uncertainty, and inscrutability. As the author explains, both he and mental health professionals failed to grasp his father’s inner world or to define clearly the characteristics of his mental illness. This experience impacted Whooley’s thoughts and provided the impetus to study historical ignorance within psychiatric knowledge. 

Unlike earlier scholars, who critically investigated the profession of psychiatry and the sociopolitical interests that underlie health professions (e.g., Foucault, 1976; Fromm, 1955), Whooley investigates both challenges in psychiatric knowledge and power interests that proliferate within the psychiatric field. The biggest challenge, according to Whooley, is ignorance, which hampers our grasp of mental illness. 

Ignorance, Whooley argues, is related to two self-reinforcing dimensions: ontology and epistemology. The ontological dimension refers to descriptions, causes, and the nature of “insanity”; whereas epistemology involves the assumptions, investigations, and inquiry approaches that grasp the essence of the mental illness. Whooley argues that the multiple definitions of the nature of the mental illness that psychiatry has offered throughout history have influenced the investigation of mental illness, and therefore, created incoherent psychiatric knowledge. Explaining these attempts to redefine and reinvent psychiatric identity, Whooley suggests that psychiatry has aimed to maintain its prestigious position, professional authority, and social control over the population and other health fields through the recreation of its discourse. Through writing this book, the author attempts to answer the following question: How has psychiatry dealt with its knowledge’s challenges, securing itself as a prestigious profession, and restoring professional power? 

To answer these questions, Whooley traces the historical development of psychiatric discourses. The author uses qualitative methods of inquiry, collects data from multiple sources, including the American Journal of Psychiatry over its entire run, professional journal articles such as the American Journal of Psychoanalysis, institutional documents, and interviews with thirty mental health professionals. Through this data, Whooley reconstructs the knowledge of psychiatry, illuminating both crises that have emerged within its body of knowledge and the strategies psychiatry has used to deal with unknown fields (i.e., ignorance). 

The book is divided into five chapters. In each chapter, the author discusses the reinvention of psychiatric knowledge in a specific period, ontological assumptions regarding mental illness, dominant therapeutic modes, and psychiatric institutional infrastructure. Each chapter ends with a remaining unknown field in psychiatry, which threatens psychiatric authority, and therefore motivates policymakers and practitioners to reinvent the body of psychiatric knowledge.

Considering the multiple transformations that psychiatry has undergone and the wide range of literature the book embraces, readers might get frustrated by seeing the incohesive forms of knowledge and different tactics that psychiatry has used in an attempt to overcome ignorance. After reading about psychiatric knowledge in each period, I pause for a breath, thinking of the varied tactics that policymakers, directors and regulators in psychiatry have used to restore psychiatric authority in each era. As the book details, these tactics mainly include cultural and institutional strategies. Culturally, officials have redefined the nature of the mental illness, starting with adopting religious morals in early times, continuing through embracing biological and psychoanalytical principles, and ending with borrowing knowledge from medicine and neuroscience. Institutionally, psychiatry has concealed its ignorance by attaching itself to a secured and prestigious doctrine that dominates the science of each period. In current times, psychiatry has attached itself to the fields of medicine and neuroscience. 

This book not only provides mental health professionals with rich information about the historical development of psychiatric knowledge, but also stimulates readers’ thoughts about psychiatrists’ interests in changing their professional knowledge. Readers who might have been diagnosed with mental illnesses might also benefit from reading this book to rethink the appropriateness of the treatments they receive. Do those treatments meet their needs? Do psychologists understand their clients’ inner worlds? Should clients be hesitant to trust mental health professionals? 

Whooley devotes a great deal of effort to exploring challenges and debates within psychiatry but pays less attention to external social events that played a role in reshaping psychiatric knowledge. An example of that is the economy. In the last chapter, Whooley shows that, when psychiatry has turned to diagnosis and medications, pharmacological companies have benefited from this transformation. But it remains unclear how the financial benefits of such companies have motivated changes in psychiatric knowledge, supporting its scientific power in turn. But incomplete answers in this book might provide readers with opportunities to study the political-economic forces that have reshaped psychiatric discourse. Such studies might grasp the understanding of how psychiatry has dealt with its ignorance in light of internal and external power relations.