Outside the Walls of the Asylum: The History of Care in the Community, 1750-2000 (review)

This anthology of twelve essays edited and introduced by Peter Bartlett and David Wright attempts to submit a novel historiographic position regarding the experience of the mentally ill and retarded in Britain and Ireland in the modern era. In contrast to earlier, prevailing efforts focused chiefly on the asylum and its role in controlling unsanctioned behaviors, this work proposes that historians have neglected the complex array of extramural, family, and community-based care that considerably influenced the lives of people with mental disorders during this period. In addition, the book aspires to add historical insight to current policy debates in Britain on the "universally supported in principle, and universally condemned in practice" (p. 16) programs for "Care in the Community"—the amorphous outpatient policies in the era of deinstitutionalization.

The collection draws on papers originally presented at workshops held at Oxford and the University of Nottingham. There is much to be commended here, including the readiness of various authors to challenge the predominant analyses through new primary research. As in any compilation, the individual contributions range in quality, style, and emphasis. The two chapters on the unique experience in Scotland are particularly compelling and balanced. In examining eighteenth-century Scottish practices, R. A. Houston demonstrates skillfully not only the large proportion of the mentally ill and retarded who were cared for outside the asylum setting, but also the array of lay individuals willing to provide respectable domiciliary and domestic care. Harriet Sturdy and William Parry-Jones illustrate the Scottish system of "boarding-out" that flourished over a century ago for relatively stable, but chronic, mentally ill and retarded persons. Although this system garnered international attention at the time, they suggest that it has been overlooked as an obvious, and successful, forerunner to present efforts to integrate people with mental illness and retardation into the larger community. Jim Campbell provides an instructive review of the recent history of Northern Ireland's uniquely "integrated" system of social welfare and community-based mental health initiatives, and its complex relationship with those most affected by "the Troubles." An entry on "puerperal mania" in Britain exposes the torturous history of approaches to postpartum psychoses and depressions, casting a recent high-profile American case in broader perspective.

Bartlett and Wright frame the work within a larger historiographic context reasonably well, particularly in contrasting their emphasis on care outside the asylum with the anti-institutional works of Michel Foucault, Erving Goffman, David Rothman, and Thomas Szasz. Nonetheless, a general bias that emerges in a number of the essays suggests that the work, as a whole, is not nearly as original as it claims. Although the volume is distinctive in its emphasis on interactions outside and intertwined with the asylums, various authors reveal a persistent tendency to view all actors within the same Foucauldian and antipsychiatry framework that typifies previous histories. The level of suspicion can be nearly paranoid, and the familiar two-dimensional landscape of social construct and social control reemerges, simply having shifted to arenas outside the asylum. In a number of essays, family, caregivers, neighbors, administrators, and, of course, physicians continue to be interpreted more or less exclusively as motivated by power relations, turf wars, and attempts at control and surveillance. Often, there is little consideration of the possibility that beneficence or necessity could have motivated such figures in their approach to mental ills. Furthermore, as in much social history, those suffering from mental illness or retardation rarely come alive on these pages, appearing as mainly voiceless manikins in a political endgame.

Notwithstanding the foregoing criticism, the book is helpful in its endeavor, if incompletely successful, to broaden the scope of historical works...