Instincts of the herd in peace and war 1916–1919

PHIL BROWN, The transfer of care. Psychiatric deinstitutionalization and its afiermath, London, Routledge & Kegan Paul, 1985, 8vo, pp. xvi, 275, £19.95. This sociological overview of the impact ofdeinstitutionalization on America's mental health services is written from a perspective which is informed by debates within the history of psychiatry as well as medical sociology. In his description of the growth of a federal mental health policy after World War II, and the shift towards community care, Brown documents the complex interweaving of political and economic factors, institutional and professional inertia, and the impact of psychoactive drugs in the processes of change. He endorses Andrew Scull's argument that psychoactive drugs were taken up with uncritical enthusiasm by a mental health administration which already felt grossly overburdened by its in-patient policy; and he emphasizes that the location of psychiatric in-patient care in general, rather than specialist, hospitals has further entrenched a biomedical approach to mental disorders. The way in which the retraction of state hospital provision for the insane has been shadowed by an expansion of the number of psychiatric beds in voluntary-aided, private general and private psychiatric hospitals is clearly demonstrated. Chilling statistics, such as the 18,000 former state mental hospital inmates estimated to be homeless in New York, portray a stark impression of the colossal inadequacies of "community care" as it is currently practised; statistics beside which complaints that, for example, "the New York City public library system has had to endure troublesome patients hanging out in branch libraries, and to spend scarce funds on extra security" sound carping. However, one of the strengths of Brown's study is the care he takes to document diverse points of view, seeing the mental health services America now has as the outcome of a dynamic interaction between government policies, professional and institutional interests, and public opinion. The chapter on 'Antipsychiatry and mental patients' rights' offers a subtle reassessment of the patients' rights movement, arguing that even if, as Scull has suggested, its growth was precipitated by the economic crisis within institutional psychiatry, it has heightened public and professional awareness of the importance of respecting patients' civil liberties. In addition, Brown wants to salvage the antipsychiatric idea of "symptoms-as-protest" against unacceptable social conditions, insisting that genuine mental health reform, operating through a range of institutional and community-based facilities, could only be effective if it were part of a more widespread expansion ofinvestment in social and welfare services, most notably the creation ofa national health care system. An awkward anachronism in the programmatic conclusion of this otherwise well-informed book is Brown's suggestion, after criticizing the extent to which some states in America rely on contractors to perform essential health care services, that "Britain's National Health Service is a likely model" for the more directly-controlled kind of health service he would like to see in America. Charlotte MacKenzie Wellcome Institute