Who Cares about the Mad These Days? Some Reflections on the Post-Asylum Landscape*

I first embarked upon Closing The Asylums almost thirty years ago, though the second edition appeared in the late 1990s. I am pleased that a decision has been made to reissue it, mainly because I feel that while much has changed, both in British society and in mental health, in the intervening period, many of the paradoxes, dilemmas, uncertainties, and ironies of the post-asylum landscape that I identify in the book are still very much alive and relevant to current debates. It may be helpful if, in this introduction, I try briefly to set the book in the context of its emergence and also draw attention to some features of the current scene, notably the dramatic increase in the recourse to coercion and constraint in the delivery of mental health care in the community, that are less prominent in the book.

On page 123, referring to the proposals for Community Treatment Orders that were already being debated in the 1990s, I say that it ‘appears unlikely that they will be implemented’. Well, I obviously made the wrong call there for they were indeed introduced in England and Wales in 2008. And yet, ten years later, the controversy around them, far from abating, has if anything increased, and research has now questioned their effectiveness and value. So, as I shall discuss, having taken off with determination in one direction, the debate has now circled back to re-engage with some of the same questions and concerns, practical and ethical, that I try to identify here.

Starting in the early 1990s already community care was being widely derided as an idealistic, foolhardy, ill-judged, irresponsible, and even cynical, endeavour, a deceitful foil for cost-cutting measures that involved the ‘release’ (as though the penitentiary and the psychiatric hospital were indistinguishable) of mental patients into the community whose propensity for violence was, apparently, perfectly obvious to everyone apart from the misguided elite (politicians and doctors mostly