Recovery From Schizophrenia: Psychiatry And Political Economy

THE POLITICAL ECONOMY OF SCHIZOPHRENIA 93POLITICS AND INSTITUTIONSBroadly speaking one can set down four possible political motives for adeinstitutional trend:• cost savings;• a humanitarian concern for the welfare, liberty and human rights of theinstitutional inmates that outweighs the fear of their liability to thecommunity;• a need to put the buildings to a new purpose;• a need to put the inmates to a new purpose.Which elements are applicable to postwar psychiatric deinstitutionalization?Cost saving, as discussed above, has clearly been an important factor behind theemptying of psychiatric institutions, but it does not explain the differences in thecharacteristics of the process between countries.Humanitarian concerns, while usually part of the rhetoric associated with changesin institutional use, are probably never sufficient cause for such changes. Thewelfare of the mentally ill was the espoused reason for the nineteenth-centurymovement to institutionalize massive numbers of the insane and of the reversetrend after the Second World War. The humanitarian concerns of the advocatesof deinstitutionalization during the late nineteenth and early twentieth centuries,however, were never sufficient to halt the expansion of hospital care. Why didtheir views suddenly become effective after the Second World War?Furthermore, humanitarian considerations scarcely account for the widespreadpractice in the US, after deinstitutionalization, of maintaining people withpsychosis in poverty and in degrading housing or institutional environments inthe community, largely without proper care and treatment. On the contrary, itseems more probable that the philosophy of care is a secondary phenomenon,itself shaped by the contemporary patterns of institutional use.The conversion of old institutions to new purposes historically has been verycommon. Seventeenth-century French leper hospitals became houses ofcorrection, 61 a nineteenth-century British jail was converted into an insaneasylum 62 and Victorian infirmaries and workhouses in the twentieth centurybecame general hospitals or reception centers for the destitute. There is noindication, though, that the mentally ill were discharged from mental hospitalsafter the Second World War to make way for some urgent new function for thebuildings. Many of the old hospital wards were closed and left vacant. Moreurgent, perhaps, was the need to avoid the capital outlay required to keep the old,Victorian institutions functional.We must look, then to a change in the perceived value of the institutional inmatesthemselves to find the stimulus for deinstitutionalization.