Historical analysis of mental health care wedded to an almost unbearably painful warts and warts memoir.
Historian and writer Barbara Taylor’s The Last Asylum is partly an objective analysis of mental healthcare provision from the early provision of ‘places of asylum’ and/or places of incarceration, to the more recent dismantling of long stay psychiatric hospitals in favour of ‘Care In The Community’ . Asylum provision itself, which, at its best can provide a place of safety and community for the vulnerable, can at its worst also be a dumping ground for all kinds of people with mental, emotional or behavioural ‘difficulties’ which are perceived as outside society norms. And moreover can be a place where the lost, confused, furious, terrified or despairing can be treated brutally and abusively
History’s verdict has yet to be delivered, and it is possible that the judgment will be more favourable to the old asylums, at least in some respects, than psychiatric modernizers would like us to believe
Closing asylums, however, has been far from an unalloyed blessing. The change in the way psychological dis-ease has been dealt with was not a move done with completely pure, outcome driven intent. Cost was a huge driver. Like asylums themselves, and how patients fared within them, ‘Care In The Community’ as a concept is hugely variable on the ground, as Taylor, explains. At its best, people are supported back into community by skilled case workers, with provision for sheltered housing, day centres, and a wealth of trainings. Unfortunately the ‘at its best’ is a rare beast in times of austerity, and in the aftermath of Thatcher’s ‘There is no such thing as Society’ ethos, the vulnerable may find themselves with little care, and outside any community.
Anthony Bateman summarized the situation to me : “The relational, pastoral component of mental health care has been eliminated. All that is left now is a mechanistic, formulaic, depersonalised substitute for quality care”
The Last Asylum is not only objective and historical analysis. Taylor herself is/has been one of the vulnerable, from very young. She came from a high-achieving and materially successful Canadian background. Material well-being, as she acknowledges, was certainly helpful to her in one of her chosen routes towards recovery, but material well-being is not of course any guarantee that parents will be able to provide good, supportive, loving and unexploitative grounding for their children. Taylor suffered abuse as a child, the sexual dynamics in her family were disturbing, and the relational messages from both parents, remarkably creepy. Early signs of Taylor’s anxiety, depression and instability were ignored, and it seems there was a fair degree of undermining of her, as well as exploitation.
The lived past is never really past; it endures in us in more ways than we understand
More than half the book is about Taylor’s long experience of breakdown, rage, terror, despair, self abuse and alcoholism, and details her personal experience as a ‘service user’ of mental healthcare provision – including 3 spells as an inmate in ‘The Last Asylum’ –Colney Hatch Lunatic Asylum, which on its opening in 1851 represented progressive, enlightened treatment of mental health, but very quickly became associated with some of the worst excesses of institutions where the fragile were dumped, forgotten and incarcerated. At the time of Taylor’s 3 admissions there, in the late 1980s, the final one lasting 5 months, the now renamed ‘Friern Hospital’ was already scheduled for closure, under those changed ‘Care In The Community’ drives. But, as Taylor explains, the Hospital provided a place of safety, support and containment for many, and proper provisions for community care outside were often non-existent
As well as support through hospitalisation, Taylor was also lucky in her NHS psychiatrist. She also took the decision to embark on psychoanalysis, privately paid for. Soon, she was seeing her analyst (including during her spells in Friern) 5 times a week. This went on for 21 years.
I know………it gave me pause for thought too.
And a large part of this book recounts the circular conversations between Taylor and her analyst – she kept journals recording what she said, what he said, what she felt, what her dreams were. This makes for pretty depressing reading to be honest. And, it must be said at times extremely wearing. Taylor is, I think, very honest: there is little attempt to charm the reader, to get the reader to like her – she presents herself as grandiose, self-obsessed, manipulative and without empathy, compassion and understanding for others around her. Indeed these aspects of her nature and behaviour formed a major strand in her analysis However…….though all this meant that her personal story at times became utterly wearing, there had to be far more to her than that, as she also had a group of incredibly supportive friends over the decades, who clearly loved and cherished her, and did not wash their hands of someone who, on the face of it, in her account in this book, does not reveal just why those friends so clearly were and remain her loyal friends.
Poverty is a psychological catastrophe. Anyone who thinks that madness is down to defective brain chemistry needs to look harder at the overwhelming correlation between economic deprivation and mental illness
I value this book for the honesty and clarity which Taylor sometimes expresses about herself – she is well aware that the ‘luxury’ – in terms of how it helped her – of that 21 year journey of analysis was only available because of family funds – for a long, long, time she was too ill, too self-destructive, too drunk to work. And she also answers the questions which I think any reader must have about whether that 21 years was a waste of time and money, whether she could/would have got better without it, and faster, whether some of the ‘fast result’ approaches like CBT would have been a better option, whether, if long term stay in Friern had not been available, could she/would she have got better – or might she have killed herself without any or all of these supports. Indeed did some of the support (those 21 years) actually make her WORSE. As she shows, going into deep analysis is not some wonderfully self-indulgent place, it’s at times excruciatingly abrading, an endless delving for suppurating boils. Most of us find ways to plaster over and avoid our deepest pains, if at all possible.
Homeless feelings are boundless; they sweep all before them. Their violence is as all-engulfing as the primeval experiences – aloneness, helplessness, total vulnerability – that power them. Some memories never lose their potency; they live on in the heartbeat, the muscles, the breath
She is honest enough, in effect, to say she can’t really answer any of that – who knows? Nor is she crassly suggesting that any one approach is ‘the’ approach for the treatment of mental and emotional illness. What she cogently argues against is the taking away of choice. Some people needed the support of asylum; some people needed a longer, more relational safer space afforded by a psychotherapist – or even a psychiatrist who was more than just a quick dispenser of pills on a ten or twenty minute appointment. What we have now is, often, doing no more than placing a plaster over an infected wound, dispensing pills which cosh the symptoms of dis-ease, and create dependency. It’s a one size fits all.
A disturbing, thought provoking book, and a powerful one