Risk and Confinement: Geographies of Mental Illness

Author Hubbard, Andrew

Published 2009

Thesis Type Thesis (PhD Doctorate)

School Griffith School of Environment

DOI https://doi.org/10.25904/1912/499

Downloaded from http://hdl.handle.net/10072/367560

Griffith Research Online https://research-repository.griffith.edu.au

Risk and Confinement: Geographies of Mental Illness

Andrew Hubbard BA (Hons). MA.

Griffith School of Environment Science, Environment, Engineering and Technology Group Griffith University

Submitted in Fulfilment of the Requirements of the Degree of Doctor of Philosophy

October 2008

Abstract

This thesis examines the role of risk in framing confinement and spatial control in contemporary mental health policy. It argues that geographers’ focus on ‘post- asylum’ geographies has meant that the continued role of confinement in mental health has not been sufficiently examined. While deinstitutionalisation resulted in a change to the spatial configuration of care for people with mental illness it did not mean that confinement of people with mental illness ceased. Indeed, as the thesis shows, there has been a renewed emphasis on confinement in a number of jurisdictions. The thesis argues that the concept and language of risk has been used in mental health policy to support this renewed focus on confinement.

The thesis a) provides evidence for the continued and/or resurgent significance of confinement, b) explains how this resurgence relates to the increasing framing of mental health policy by risk and c) explains what this means in relation to the spatiality of social control of people with mental illness.

The methodological approach is shaped by an emphasis on understanding the historical context of the use of risk in public policy. There are two key aspects of the methodology. First, the importance of ‘the history of the present’; this is a concern to understand the historical conditions of existence upon which contemporary practices exist. Second, a discursive analysis of public policy broadly framed around critical discourse analysis.

The continued role of confinement and how it relates to risk in contemporary mental health systems is examined in two case studies, one England and Wales, the other Queensland, Australia. The thesis demonstrates that there has been a renewed focus on confinement in these jurisdictions, driven by a policy concern to exert greater control over risk and uncertainty. It rejects the argument proposed by Castel (1991), and other governmentality theorists, including Deleuze (1992) and Rose (2002), that moves towards decentralised control have been shaped by governance through the abstract factors of risk.

In both of the case studies risk was used largely in an individualised sense, in which risk was identified as being embodied in particular individuals, rather than in an aggregative sense. The thesis concludes that the concept of risk has primarily been

i used to support the continuation of spatially fixed modes of control over people with mental illness, rather than to facilitate decentred forms of control of people with mental illness.

ii Declaration

This work has not previously been submitted for a degree or diploma in any university. To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made in the thesis itself.

Andrew Hubbard October 2008

iii Table of Contents

Abstract ...... i

Declaration ...... iii

List of Tables ...... ix

List of Figures ...... ix

List of Acronyms and Abbreviations ...... x

Acknowledgements ...... xi

Chapter 1. Introduction ...... 1 1.1 Research Questions ...... 2 1.1.1 Research Aim: ...... 2 1.1.2 Research questions: ...... 2 1.2 Post-asylum Geographies ...... 2 1.3 Contemporary Confinement ...... 5 1.3.1 Institutionalisation ...... 6 1.3.2 Forensic mental health care ...... 8 1.3.3 Criminalisation ...... 9 1.3.4 The revival of confinement ...... 10 1.4 Risk and Confinement ...... 12 1.5 Methodological Approach ...... 13 1.6 Terminology in this Thesis ...... 14 1.7 Organisation of Thesis ...... 15 1.8 Conclusion ...... 17 Chapter 2. Mental Illness and Social Control ...... 18 2.1 Introduction ...... 18 2.2 Social Construction of Mental Illness ...... 19 2.3 The Relation between Mental Illness and Social Control ...... 20 2.3.1 Deviance, mental illness and social control ...... 21 2.3.2 Non-functionalist accounts of social control ...... 24 2.4 Social Control and Spatial Control ...... 26 2.4.1 Space as materiality and representation ...... 27 2.4.2 Historical evolution of confinement of people with mental illness ...... 28 2.4.3 The emergence of the carceral society ...... 29 2.4.4 The disciplinary society ...... 32 2.4.5 Deleuze and the decentring of social control ...... 33 2.5 Social Control and Deinstitutionalisation ...... 34 2.5.1 Deinstitutionalisation and the spatiality of social control ...... 34 2.6 Conclusion ...... 36 Chapter 3. Risk and Safety ...... 38 3.1 Introduction ...... 38 3.2 The Social Construction of Risk ...... 39 3.3 The Growth of the Risk Society ...... 40 3.3.1 Actuarial notions of risk ...... 42 3.4 Beck and the Risk Society ...... 44

iv 3.4.1 Reflexive modernisation ...... 45 3.4.2 Individualisation ...... 47 3.4.3 The politics of risk society ...... 48 3.4.4 The significance of risk ...... 49 3.4.5 Giddens and public policy ...... 50 3.5 Risk and Safety ...... 51 3.6 Risk Society in Context ...... 54 3.7 Conclusion ...... 56 Chapter 4. Governmentality, Risk and Mental Health ...... 58 4.1 Introduction ...... 58 4.2 Governmentality and Risk ...... 59 4.2.1 Biopower and neoliberalism...... 61 4.2.2 Neoliberalism and risk ...... 62 4.2.3 Governmentality, criminology and risk ...... 63 4.2.4 Aggregation, crime and risk ...... 65 4.2.5 From risk management to risk control ...... 66 4.3 Health and Risk ...... 67 4.3.1 Public health and risk ...... 68 4.3.2 From dangerousness to risk ...... 69 4.3.3 Risk and mental health ...... 70 4.3.4 Assemblages of risk ...... 71 4.4 Conclusion ...... 72 Chapter 5. Methodology ...... 74 5.1 Introduction ...... 74 5.2 Methodological Design ...... 74 5.2.1 The importance of ideas: A discursive approach ...... 74 5.2.2 The importance of context: A material approach...... 76 5.2.3 Historical context ...... 76 5.3 Research Design ...... 78 5.3.1 Case studies ...... 79 5.3.2 Quantitative research ...... 79 5.3.3 Historical policy analysis ...... 81 5.3.4 England/Wales historical analysis ...... 83 5.3.5 Queensland historical analysis ...... 84 5.3.6 Contemporary policy analysis ...... 84 5.3.7 Critical discourse analysis ...... 85 5.3.8 Methods of analysis ...... 87 5.3.9 Ethics ...... 88 5.4 Conclusion ...... 88 Chapter 6. The Use of Confinement in England and Wales ...... 90 6.1 Introduction ...... 90 6.2 Confinement: The Contemporary Context ...... 91 6.2.1 Deinstitutionalisation ...... 91 6.3 Compulsory Admissions ...... 92 6.3.1 Psychiatric beds ...... 92 6.3.2 Psychiatric admissions ...... 95 6.3.3 Length of stay ...... 97 6.3.4 Increased staff use of compulsory admissions ...... 98 6.3.5 Readmissions ...... 99 6.3.6 Forensic mental health system ...... 100 6.3.7 Growth in forensic mental health bed numbers ...... 101 6.4 Trends in Confinement ...... 103

v 6.4.1 Demographics ...... 103 6.4.2 Private mental health system ...... 104 6.4.3 Criminalisation ...... 105 6.4.4 Compulsory care in the community...... 107 6.5 Conclusion ...... 108 Chapter 7. Historical Analysis of Risk and Confinement in England and Wales ...... 110 7.1 Introduction ...... 110 7.2 Uses of Risk...... 111 7.3 Origins and a Focus on Cure 1845-1885 ...... 112 7.3.1 Establishment of the asylum system ...... 113 7.3.2 Confinement for cure ...... 114 7.3.3 The role of medicalisation in confinement ...... 116 7.3.4 Role of danger in confinement ...... 117 7.4 Individual Liberty and Public Safety 1885-1920 ...... 119 7.4.1 Safeguards against confinement ...... 119 7.4.2 Public safety ...... 122 7.4.3 Consolidation and control ...... 123 7.4.4 Rise of safety as a rationale for confinement ...... 124 7.5 Resurgent Medicalism 1920-1950 ...... 124 7.5.1 Facilitating early treatment ...... 125 7.5.2 Control and confinement ...... 128 7.6 Community Care and Deinstitutionalisation 1950-1975 ...... 128 7.6.1 Voluntary treatment ...... 129 7.6.2 Community care and dangerousness ...... 131 7.6.3 Origins of the forensic system ...... 132 7.6.4 Bifurcation of policy ...... 133 7.6.5 Danger and the decentring of care ...... 134 7.7 Renewed Legalism 1975-1992 ...... 136 7.8 Historical Uses of Risk ...... 138 7.8.1 How confinement has been justified ...... 138 7.8.2 Uses of danger, safety and risk ...... 140 7.9 Conclusion ...... 140 Chapter 8. Risk as Policy Object, England and Wales ...... 142 8.1 Introduction ...... 142 8.2 The Extent of the Framing of Risk ...... 143 8.2.1 Risk as response to safety ...... 144 8.2.2 Failure of community care ...... 149 8.2.3 Safety and security ...... 151 8.2.4 The use of risk as a policy object ...... 152 8.3 Meanings of Risk ...... 152 8.3.1 Risk factors ...... 153 8.3.2 Risk and bifurcation ...... 155 8.3.3 Risk level ...... 156 8.3.4 Balancing risk ...... 157 8.3.5 Contradictions of risk ...... 159 8.4 The Object of Risk: The Mental Health Act 2007 ...... 159 8.4.1 A risk centred approach ...... 161 8.4.2 Compulsory treatment ...... 163 8.4.3 The definition of mental illness ...... 164 8.4.4 Personality disorders ...... 165 8.4.5 Compulsion in the community ...... 169 8.4.6 Outcome of reforms ...... 170

vi 8.5 Risk as a Policy Object ...... 170 8.6 Conclusion ...... 174 Chapter 9. The Use of Confinement, Queensland ...... 176 9.1 Introduction ...... 176 9.2 Deinstitutionalisation ...... 177 9.3 Contemporary Context ...... 182 9.4 Mental Health Services in Queensland ...... 183 9.4.1 Compulsory admissions ...... 183 9.4.2 Confinement ...... 184 9.4.3 Private care ...... 186 9.4.4 Forensic care ...... 187 9.4.5 Criminalisation ...... 188 9.5 Community Care ...... 190 9.6 Conclusion ...... 191 Chapter 10. Historical Analysis of Risk and Confinement in Queensland ...... 193 10.1 Introduction ...... 193 10.2 Policy in Queensland: Neglect, Crisis, Action ...... 194 10.3 Prevention of Crime: 1843-1858 ...... 195 10.4 A Growing Emphasis on Care: 1859-1884 ...... 197 10.4.1 Formalisation of a medicalised approach ...... 199 10.4.2 Dangerousness and medicalisation ...... 200 10.5 A Broadening of the Net: 1884-1935 ...... 202 10.6 Individual Liberty: 1935-1962 ...... 204 10.7 Community Care and its Rejection: 1962-1992 ...... 206 10.7.1 The introduction of community care ...... 206 10.7.2 ‘Dangerous patients’ ...... 208 10.7.3 Paternalism ...... 211 10.7.4 Bifurcation ...... 213 10.7.5 Continued rejection of community care ...... 214 10.8 Historical Uses of Risk ...... 215 10.8.1 How confinement has been justified ...... 216 10.8.2 Uses of danger, safety and risk ...... 217 10.9 Conclusion ...... 217 Chapter 11. Risk and Confinement in Contemporary Queensland ...... 218 11.1 Introduction ...... 218 11.2 Risk in Legislation ...... 219 11.2.1 Central role for risk ...... 220 11.2.2 Risk management as the goal of confinement ...... 220 11.3 How Risk is Utilised in Policy ...... 222 11.3.1 At risk ...... 222 11.3.2 Public health ...... 224 11.3.3 Risk factors ...... 225 11.3.4 ‘Risk of’...... 227 11.3.5 ‘Risk to’...... 228 11.3.6 Actuarial notions of risk ...... 229 11.3.7 Risk management ...... 231 11.3.8 Risk assessment ...... 233 11.4 Risk and Confinement ...... 235 11.4.1 Safety and forensic services ...... 236 11.4.2 Community care ...... 238 11.4.3 Danger ...... 239

vii 11.5 Risk as a Policy Object ...... 240 11.5.1 The extent to which risk is used in policies of confinement ...... 241 11.5.2 How risk has been used in policies of confinement ...... 242 11.6 Conclusion ...... 244 Chapter 12. Conclusion: Risk and the Spatiality of Control of Mental Illness ...... 245 12.1 Introduction ...... 245 12.2 Research Question One...... 247 12.3 Research Question Two...... 249 12.4 Research Question Three ...... 251 12.5 Research Aim ...... 254 12.5.1 Risk and spatial control ...... 255 12.6 Critical Reflections and Future research ...... 257 12.7 Conclusions ...... 259 Appendix One: Sources Analysed for Historical Analysis England and Wales ...... 262 Legislation ...... 262 Government and Select Committee Reports ...... 262 National Archives of The United Kingdom ...... 263 Additional Sources ...... 266 Appendix Two: Sources Analysed for Historical Analysis Queensland267 Legislation ...... 267 Government and Royal Commission Reports ...... 267 Cabinet Minutes ...... 268 Queensland Archives ...... 268 Other Sources ...... 268 Appendix Three: Sources Analysed for Contemporary Analysis England and Wales ...... 269 Policy Documents ...... 269 Legislation ...... 270 Parliamentary Sources ...... 270 Appendix Four: Sources Analysed for Contemporary Analysis Queensland ...... 271 Queensland Government Policy Documents ...... 271 Commonwealth Government Policy Documents ...... 272 Legislation ...... 272 Parliamentary Sources ...... 272 Appendix Five: Legislation ...... 273 English and Welsh Legislation ...... 273 Queensland Legislation ...... 273 References...... 274

viii List of Tables

Table 1: Number of Forensic Beds per 100,000 Population EU Countries ...... 9 Table 2: Psychiatric Bed Numbers England and Wales ...... 93 Table 3: Total Number of Psychiatric Admissions England and Wales ...... 95 Table 4: Hospital Occupied Bed Days Commissioned for People with a Mental Illness (Millions) England and Wales ...... 97 Table 5: Secure Beds (Excluding Special Hospitals) England and Wales ...... 102 Table 6: Key Mental Health Policy Developments England And Wales ...... 144

List of Figures

Figure 1: Total Number of Involuntary Placements Germany and France 1992-2000 7 Figure 2: Total Number of Involuntary Placements EU Countries 1992-2000 ...... 7 Figure 3: Forensic Admissions per Year Europe ...... 8 Figure 4: Compulsory Admissions in England And Wales ...... 96 Figure 5: Mean Length of Stay by Category England and Wales ...... 97 Figure 6: Percentage of Hospital Psychiatric Patients Compulsorily Admitted England and Wales ...... 99 Figure 7: Patients in High and Medium Security Care England and Wales ...... 103 Figure 8: Compulsory Admissions in Private Hospitals England and Wales ...... 105 Figure 9: Timeline of Mental Health Law Reform England and Wales ...... 160 Figure 10: Expenditure on Mental Health Services in Queensland ...... 180 Figure 11: Total Inpatient Psychiatric Beds Queensland ...... 181 Figure 12: Total Compulsory Psychiatric Admissions Queensland 1975 –1990 ..... 184 Figure 13: Psychiatric Admissions Queensland ...... 185 Figure 14: Private Sector Separations- Australia ...... 186 Figure 15: Number of Forensic Beds Queensland ...... 188 Figure 16: Rates of Imprisonment Queensland and Australia ...... 189

ix List of Acronyms and Abbreviations

CDA Critical Discourse Analysis DSM The Diagnostic and Statistical Manual of Mental Disorders HES Hospital Episode Statistics ITO Involuntary Treatment Order MMHS Modernising Mental Health Services Safe, Sound and Supportive NHS National Health Service NMDS National Minimum Data Set NMHS National Mental Health Strategy NSF The National Service Framework for Mental Health PBS Pharmaceutical Benefits Scheme SAPHS South Australia Prisons Health System

x Acknowledgements

This thesis, like most, has had its share of ups and downs. There are a number of people I would like to thank for sharing the ups and helping me persevere through the downs.

Firstly I would like to thank my supervisors. Brendan Gleeson provided a constant challenging eye, and as head of the Urban Research Program nurtured a positive environment for the PhD students. My associate supervisor, Jago Dodson, gave me consistently thoughtful and insightful advice and feedback. In addition I would also like to thank Jenny Cameron who was incredibly welcoming and did so much to encourage a supportive environment among all the PhD students.

Thanks also to my fellow PhD students who have shared this journey with me. I feel very lucky to have shared an environment with so many great colleagues. I would particularly like to say thanks to Jodi, Michael, Peter, Rowan, Sarah, Toby and Wendy.

Finally thanks to Anna, who not only supported me through this journey but also provided me with invaluable assistance with the thesis.

xi Chapter 1. Introduction

Since the advent of large-scale asylums in 17th and 18th century Europe the care and treatment of people with mental illness1 has been strongly connected with the social control of deviance. In particular care and treatment of mental illness has been, at least in the Western World, characterised by spatial confinement or separation of the ‘mentally ill’ from the ‘mentally healthy’, the ‘abnormal’ from the ‘normal’, the ‘dangerous’ from the ‘safe’. This emphasis on the spatial control of people with mental illness changed with the process of deinstitutionalisation, which began in the 1960s and 1970s. Deinstitutionalisation involved the release of people from long-stay psychiatric institutions into the community. This has been the most significant feature affecting systems of mental health care over the last half century. It has resulted in a profound shift in the care of people with mental illness away from confinement towards decentralised forms of community care. Part of the rationale for deinstitutionalisation was the idea that care of people with mental illness should be undertaken in the least restrictive way possible (Bartlett and Wright 1999, Hazelton 2005).2

This shift towards the predominance of deinstitutionalisation and community care has been so significant that a number of geographers have referred to the contemporary period as a ‘post-asylum’ era (see for example Philo 2000b). The phrase ‘post- asylum’ implies that institutionalisation and confinement are no longer significant features of the mental health system. In this thesis I argue that this implication is wrong- that there has been a significant renewed emphasis on confinement and compulsion of people with mental illness within a number of Western jurisdictions. I further argue that this shift is part of a return to spatially centred forms of social control of deviance, driven by a desire to exert greater control over hazard and uncertainty.

In this thesis I will a) provide evidence for the continued and/or resurgent significance of confinement, b) explain how this resurgence relates to the increasing framing of mental health policy by risk and c) highlight what this means in relation to the

1 The use of terminology used to describe ‘people with mental illness’ is discussed at the end of this chapter. 2 There are a number of factors that have been attributed to helping lead to deinstitutionalisation including new drug therapies, a growing emphasis of individual freedom and economic factors (see Scull 1977, Hoult 1986, Prior 1993 for discussion of these various factors).

1 spatiality of social control of people with mental illness in two case studies of England and Wales, and Queensland, Australia. I will address these issues through the following research questions.

1.1 Research Questions

This thesis addresses the following research aim and associated research questions:

1.1.1 Research Aim:

To understand the role of risk in framing confinement and spatial control in contemporary mental health policy.

1.1.2 Research questions:

1. How significant is the role of confinement within contemporary mental health systems? Purpose: • To see how much and in what ways confinement and compulsion of people with mental illness is occurring in particular jurisdictions.

2. How have ideas of risk been utilised in past mental health policies and how has this related to the use of confinement? Purpose: • To see if there has been a shift in the use of ideas of risk by examining how risk has been used in the past, and how these uses have been related to the rationale for confining forms of care.

3. To what extent, and how, are ideas of risk used in contemporary policies of confinement of people with mental illness? Purpose: • To show how ideas of risk are used in the contemporary period and how these differ from previous uses, and to understand the extent to which risk underlies contemporary policies and practices of confinement.

1.2 Post-asylum Geographies

Geographers, at least in the Anglo-American world, have demonstrated a strong interest in the care and treatment of mental illness over the last thirty years. This

2 interest has been stimulated by an increasing recognition of the socio-spatial nature of the care and treatment of people with mental illness. Most research by geographers largely coincided with, and followed, deinstitutionalisation, which had tremendous geographic implications as it changed the established places of care and created new loci of care (see Wolpert and Wolpert 1974, Dear and Taylor 1982, Laws and Dear 1988, Philo 1997). Deinstitutionalisation resulted in a new spatiality of care and treatment for people with mental illness constituting them as new forms of geographic subjects, and resulting in much more decentred forms of care and treatment.

Initial geographic concern with deinstitutionalisation (particularly in the United States) focused on the continued isolation of people who had been deinstitutionalised. Many geographers have looked at how forms of spatial separation and exclusion persisted despite the removal of people from institutions, a phenomenon sometimes referred to as ‘institutions without walls’. This has included research on the spatiality of care and residence, which is often a key site of struggle in arguments about community care facilities (see for example Gleeson and Memon 1997). It also included work on the phenomenon of the ‘service dependent ghetto’, first identified by Dear and Wolch (1987) in Los Angeles, which referred to the way that people with mental illness had become concentrated in low income inner city areas (also see Law and Gleeson 1998). Dear and Wolch argued that people with mental illness were being marginalised in service dependent ghettos by both the pull of the location of community services in the inner city and simultaneous push away from suburban areas due to negative influences such as community attitudes.

As deinstitutionalisation unfolded the attention of geographers shifted to focus on the concomitant processes of community care, and the creation of a diverse range of spaces and places resulting in a complex network described as ‘post-asylum geographies’ (Philo 2000b). These post-asylum geographies have largely focused on the way that mental health services are structured and experienced for those people who are not, and have seldom, if ever, been institutionalised. This category of research encompasses a range of themes including the experiences of community based services, the externalities of community based mental health care, the political economy of service provision (particularly the relationship between neoliberalism and community care) and the increased importance of embodiment in mental health care (see for example Parr 1997, 1999, 2008, Kearns and Joseph 2000, Milligan 2000).

3 Although there has been a strong focus on these post-asylum geographies it is inaccurate to suggest that there is now a landscape of care devoid of confinement. As Wolch and Philo argue:

Despite much of the world supposedly having entered a post-asylum era, marked by new spaces and places for people suffering mental ill-health, the ‘post-asylum geographies' being created … also contain signs that people are being returned to sites of confinement akin to the asylums of old (2000: 138).

Moon (2000) suggests that the vast majority of this work on post-asylum geographies has unproblematically seen the asylum as old and community care as new. He argues, with particular reference to the United Kingdom, that it is inaccurate to speak of a post-asylum period with the assumption that asylums and support for them has disappeared. Parr (2008) also notes that there is evidence for reinstitutionalisation in England, which problematises the notion of a decisive shift to landscapes of community care.

Despite this recognition of, and the mounting evidence for, the ongoing importance of compulsion and confinement in mental health care and treatment, most geographers have paid scant attention to the continuing role and practice of confinement. There has been little focus on trends of confinement and its implications for the spatiality of the care and treatment of people with mental illness. One partial exception to this is the work by Moon, Joseph and Kearns (2005, 2006) which examines the persistence of the private asylum in the UK, Canada and New Zealand. This work is, however, primarily framed around understanding the continued role of the private asylum as an exception to ‘the dominant modality of community care’ (Moon et al. 2006: 145). It thus implies an acceptance of the notion that confinement is rare in contemporary mental health services.

The vast majority of recent mental health research by geographers has focused on the non-confining aspects of mental health care. Most of the geographical work on confinement is historical. One key example of this is Philo’s (2004) examination of the geography of mental health care in England and Wales from medieval times to 1860 (also see Driver 1993, Edginton 1997, Park and Radford 1997 for other examples of geographical work focusing on institutions). Philo’s historical research focuses on the importance that location and place had on the development of the care of madness and the spaces reserved for insanity. He argues that the places in which sites of care and confinement for people with mental illness were located

4 strongly related to conceptualisations of madness; through this argument he presents a compelling case for the socio-spatial nature of madness.

I argue that with an emerging body of evidence pointing to a renewed focus on confining forms of care, in at least some Western jurisdictions, geographers need to renew their focus on institutionalisation and on the relationship between spatial control and people with mental illness. There is increasing evidence that suggests that the status quo of community care and deinstitutionalisation is being challenged with an increase in compulsory confinement. This indicates a change in the spatiality of the care and control of people with mental illness. This is a shift that appears to be at odds with most current theoretical conceptions of the relationship between spatiality and social control, which primarily emphasise the importance of increasingly decentred forms of control in the contemporary world (as discussed in Chapters Two and Four).

I present and discuss evidence of a renewed focus on confinement below and then in more depth in both of my case studies, one in England and Wales, and the other in Queensland, Australia. In arguing for more research and focus on confinement of people with mental illness I do not mean to suggest that this should replace research around community care, nor to suggest that community care is no longer the dominant form of care. Rather I argue that additional research exploring confinement can provide new insights into the care and treatment of people with mental illness and particularly into the relationship between spatiality and social control in the contemporary era. In addition any shift towards greater use of confinement has implications for the rights and freedoms of people with mental illness that deserve serious examination.

1.3 Contemporary Confinement

Confinement has been the primary form of control exerted over people with mental illness since at least the 19th century.3 Part of the rationale of spatial confinement has been to exert and maintain social control in response to deviant behaviours. The dominance of confinement changed with the process of deinstitutionalisation, but

3 This has varied considerably between jurisdictions, even within the West. Foucault, for instance, dates ‘the great confinement’ in Europe to the mid 17th century. However it is clear that confinement specifically of people with mental illness was not widespread in England and Wales until at least the 1840s (Scull 1979, Porter 2002).

5 confinement continues to be a significant form of control exerted over people with mental illness. There is a growing body of evidence that there has been a resurgence in the use and importance of confining forms of treatment of people with mental illness, which includes increases in institutionalisation, forensic care, and confinement within the criminal justice system.

1.3.1 Institutionalisation

There has been little comprehensive research on the extent to which people have continued to be compulsorily treated in psychiatric facilities. In particular there has been scant scholarly examination of the similarities and differences between contemporary patterns of institutionalisation and prior forms of institutionalisation, with few in-depth examinations of confinement in particular jurisdictions.4 What research has been done has focused on the Western European context and has shown that there have been trends towards the increased use of confinement and compulsory treatment since the 1990s. One of the first pieces of research to conceptualise these trends as reinstitutionalisation was by a community psychiatrist Priebe, and his colleagues (Priebe and Turner 2003, Priebe 2004, Priebe, Badesconyi, Fioritti, Hansson, Kilian, Torres-Gonzales, Turner and Wiersma 2005). Priebe argues that a period of ‘reinstitutionalisation’ is emerging, where there is greater use of controlling mechanisms for treating mental illness.

There have been clear increases in the number of compulsory admissions to psychiatric facilities between the early 1990s and 2000 in a number of jurisdictions in Europe, including Germany, France, Austria, the Netherlands, Finland, Sweden and Denmark (Zinkler and Priebe 2002, Salize and Dressing 2004, Mulder, Broer, Uitenbroek, van Marle, van Hemert and Wierdsma 2006), as demonstrated by Figure 1 and Figure 2 below.

4 By jurisdiction I mean the geographical area over which a government body has the power to exert authority.

6 180k

160k

140k

120k

100k

80k

60k

Number of placements 40k

20k

0k 1992 1993 1994 1995 1996 1997 1998 1999 2000 Year

Germany France

Figure 1: Total Number of Involuntary Placements Germany and France 1992-2000 Source: (Salize and Dressing 2004: 164)

16,000

14,000

12,000

10,000 Austria Sweden 8,000 Finland Ireland 6,000 Denmark Number of placements 4,000

2,000

0 1992 1993 1994 1995 1996 1997 1998 1999 2000 Year

Figure 2: Total Number of Involuntary Placements EU Countries 1992-2000 Source: (Salize and Dressing 2004: 216)

As the trends in Figure 1 and Figure 2 illustrate there have been steady increases in the number of compulsory admissions across parts of Europe. This represents broad data from a small number of jurisdictions making discernment of influences difficult. It is hard to judge the significance of these changes without more detailed consideration of the contexts in which they occur. There are a range of factors that could help to explain these trends, such as changes in data collection, changes in the formality of admissions (which might, for example, lead to increased turnover) or

7 changes in legislative frameworks. In Italy and parts of Germany, for example, these trends have been accompanied by legislative changes aimed at making involuntary admissions easier (Priebe and Turner 2003). In other jurisdictions, such as Austria and the Netherlands, the increases in involuntary admissions occurred despite legislative changes that emphasised the rights of people with mental illness including greater legal representation (Salize and Dressing 2004). There are inevitably a range of contextual particularities that need to be considered in more detail, as I do in the later chapters on my case studies of England/Wales and Queensland, before conclusions can be drawn about these trends.

1.3.2 Forensic mental health care

The strongest evidence pointing towards a renewed focus on confinement is the growth in the forensic mental health sector. This is the sector that provides specialist secure care for mentally disordered offenders and other people with mental illness who have been identified as needing secure care. The exact nature of forensic mental health systems varies by jurisdiction, but despite these differences the forensic mental heath sector has grown rapidly in many different jurisdictions since the 1990s (Figure 3). The number of forensic admissions has more than tripled in Austria, doubled in Germany and the Netherlands with smaller increases elsewhere.

1,200

1,000

Austria 800 Belgium Denmark Finland 600 Germany Ireland Netherlands 400 Sweden Number of addmisions England & Wales

200

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Figure 3: Forensic Admissions per Year Europe Source: (Salize and Dressing 2007)

8 Growth in the number of new forensic admissions has been accompanied by an increase in the number of forensic mental health beds across Europe, as shown in Table 1. This growth has contrasted with the decline in the number of general psychiatric beds across the regions (Salize and Dressing 2007).

Table 1: Number of Forensic Beds per 100,000 Population EU Countries England Germany Italy Holland Spain Sweden 1990 1.3 4.6 2 4.7 1.2 9.8 2002 1.8 7.8 2.2 11 1.5 14.3 Change +38% +70% +10% +143% +25% +46% Source: (Priebe et al. 2005)

The trend towards the greater provision of forensic services is the clearest of those Priebe et al. (2005) identify.

1.3.3 Criminalisation

An increasing number of people with mental illness have been jailed for crimes instead of being treated within the mental health system. Geographers have long suggested that a concomitant process of transinstitutionalisation, where people with mental illness are increasingly institutionalised in the criminal justice system, has accompanied the process of deinstitutionalisation (see for example Wolch, Nelson and Rubalcaba 1988). Despite this long-standing concern there has been little in- depth research by geographers into this process, especially outside of the United States. As Wolch and Philo’s review article of the state of post-asylum geographies notes ‘the fact is that the trend toward the prison-as-asylum has yet to be documented at any length by geographers’ (2000: 138).

There is limited agreement on the number of prisoners who suffer from mental illness, due to the very different methodological approaches used in trying to arrive at such figures (Henderson 2003). These methodological differences include: the degree to which a study relies on self reporting, what sort of diagnostic tools are used, whether the emphasis of the study is on severity or prevalence, who administered the tools, and how mental illness is defined, for instance whether personality disorders are included (see for example Hoffman 1990, Davis 1992, Konrad 2002). Despite these problems there is a significant body of evidence that demonstrates that there are a large number of people with mental illness in criminal justice systems throughout the Western world. The findings of the most substantial

9 review of mental disorder in prisoners worldwide concluded that 14% of prisoners in Western countries have a major psychotic illness or major depression (Fazel and Danesh 2002).

Findings from a wide range of country specific studies support this worldwide study. Research in Australia, for instance, indicates that there are a high number of people with mental illness in the criminal justice system across Australia. An estimated 20% of Western Australian prisoners have a mental illness (Attorney General 2005). A South Australia Prisons Health System (SAPHS) report to the State Government’s Generational Health Review said prisons and remand centres were becoming populated with mentally ill and homeless people who had ‘fallen through the chasms in the mental health system’ (The South Australian Prisons Health System 2002: 2). SAPHS said the problem was a direct result of government "truth in sentencing" and "get tough on crime" policies, which had resulted in much higher levels of imprisonment than previous policies. A major survey of mental illness among New South Wales (NSW) prisoners found that there is a high prevalence of mental illness, almost 10% of inmates had experienced symptoms of psychosis in the previous 12 months (Butler and Allnutt 2003). Similar research in the United States indicates that 20% of prisoners suffer a serious mental illness, with up to 5% actively psychotic (American Psychiatric Association 2000).

The evidence is compelling that a large, and possibly increasing, number of people with mental illness are currently incarcerated in the criminal justice systems of many Western jurisdictions. This high degree of criminalisation has undoubtedly had an impact on the way mental health policy has been shaped. The nature and extent of confinement of people with mental illness in the criminal justice system is a pressing problem, as is the relationship between criminalisation and the wider mental health system. The relationship between the criminal justice system and the mental health system is an area that warrants new and ongoing social scientific examination. Despite its significance the impact of criminalisation only forms a peripheral part of my thesis, in order to retain a manageable focus.

1.3.4 The revival of confinement

While there has been a range of research that is alert to a revival of institutionalisation and confinement little research has focused on why the trend towards institutionalisation and confinement has occurred, or why these trends seem

10 more apparent in some jurisdictions than others. One exception is the work by Moon, Joseph and Kearns (2005, 2006), referred to earlier, which looks at the continued existence of the private asylum. One of the most compelling features of this work is the attempt to understand and conceptualise the blurring of boundaries between the public and private and between the community and asylum. In particular they argue that these boundaries have been treated too simplistically in the literature. They reject a stark contrast between the ideas of public/private and community/asylum in favour of a reflexive approach that focuses on the reality of policy implementation. While they argue that the boundaries between these zones have become fuzzy they focus primarily on the fuzziness of how individual institutions (in particular private institutions) have negotiated their ongoing existence. They identify some significant changes relating particularly to the private asylum but largely do not attempt to locate these trends within the wider trends occurring within the public sector. The main focus, especially in Moon et al. (2006), is on explaining the private asylum primarily as a form of exceptionalism rather than identifying how it operates as part of wider changes in mental health policy.

Earlier work by Moon (2000) does address some of the wider issues. He argues that it is inappropriate to speak of a post-asylum period, with the assumption that asylums and support for them has disappeared. Moon’s argument resonates with the common suggestion that deinstitutionalisation has effectively resulted in an ‘asylum without walls’, reflecting the social isolation and exclusion faced by many people with mental illness as they struggle to get by in the ‘community’. Moon goes on to explore the beginnings of a move towards reconfinement in public policy discourse in the United Kingdom and the potential reasons behind this move. He argues that one of the key reasons for the success of critiques of community care is the very visibility of the urban population of people with mental illness. Deinstitutionalisation replaced the "concealed other" with the "visible other". This, he asserts, has made the 'risk' associated with people with mental illness more visible:

With deinstitutionalisation, the objects of this lack of understanding were released into the everyday gaze of a population for whom mental ill-health was a matter of dread incomprehension a visible `other' from which the public had once been shielded (Moon 2000: 241).

Moon concludes that the discourses of protection, safety, risk and dangerousness are crucial in understanding the turn to confinement.

11 1.4 Risk and Confinement

The research aim of my thesis derives from Moon’s (2000) argument that understanding the role of risk is essential to understand the role of confinement in contemporary mental health policy. I expand on Moon’s argument to provide a more in-depth examination of the relationship between risk and confinement. I argue that ultimately the shift towards greater levels of confinement of people with mental illness is related to attempts to control uncertainties made more apparent by the contemporary focus on risk. I suggest that examining the relationship between risk and confinement can help to explain the relationship between social and spatial control in mental health care.

Understanding the significance and role of risk has become an increasingly important socio-theoretical concern over the last two decades. Attempts to explain why and how risk has assumed such significance in the contemporary world are best exemplified by Beck’s Risk Society theory (1992, 1994, 1995). Beck argues that the ‘risk society’ characterises the period of late modernity which we are now in. This, he argues, is a period that is characterised by increasing uncertainties and risks and also by attempts to formulate responses to address these risks and uncertainties.

Risk society theory suggests that the current era is a new period of reflexive modernity, where the traditional certainties of industrial modernity no longer hold sway and risks are much more readily apparent. Past traditions and certainties have been undermined resulting in lives characterised by fluidity and uncertainty. In this period of reflexive modernity ‘risk’ assumes a new importance for ‘the less we can rely on traditional certainties, the more risks we have to negotiate’ (Beck 1995: 10). The increase in uncertainty means that government and society is increasingly organised around dealing with those risks, the ‘risk society’. As a result of the increase in uncertainty safety and security become increasingly important features of governance.

The attempt to govern through this uncertainty is where risk becomes central, as risk can be defined in the risk society as a systematic way of dealing with hazards and insecurities (Beck 1992: 21). The idea of risk is a way of attempting to normalise and control the world of uncertainties. Beck and Giddens argue that in this new risk society much political decision making is now about managing risks (Giddens 1999). Because contemporary mental health policy deals extensively with hazards and

12 uncertainties, the identification of risk is a core element of mental health treatment. The increasing centrality of risk in contemporary mental health practice makes it important to explain how risk operates in mental health policy, an explanation that has so far only been explored patchily.

I argue that much of the existing research on social policy and risk has suffered from a lack of context, which I attempt to remedy in my research. Risk has largely been treated as a homogenous process or explanation rather than being understood as operating differently in different places depending on its historical evolution and spatial context. I argue that the way that risk operates needs to be understood within both a spatial and historical context. Through the use of two case studies of England and Wales and Queensland, Australia I analyse the role risk plays in framing confinement and spatial control in contemporary mental health policy and how this has been shaped by historical contingencies.

1.5 Methodological Approach

My methodological approach is shaped by my emphasis on understanding the historical context of the use of risk in public policy. There are two key features of the methodology. First, I stress the importance of ‘the history of the present’, which is a concern to understand the historical conditions of existence upon which contemporary practices exists. Second, I focus on public policy and particularly on the discursive basis of public policy.

Understanding how risk is used in relation to confinement in the contemporary era implies understanding similarities and variances with the way this has occurred in the past. I draw particularly on Foucault’s idea of ‘the history of the present’. This does not focus on traditional ‘narrative history’ with the expectations of a comprehensive history of past events, but argues that it is essential to recognise the historical way we think, what we take for granted. As Foucault put it:

We have to know the historical conditions which motivate our conceptualization. We need a historical awareness of our present circumstance (Foucault 1982: 209).

Foucault’s work attempts to show the historical contingencies of present situations. A goal of this thesis is to understand the contingencies and interconnections that

13 compose the present without falling into a teleological understanding of history, which assumes a natural progression from the past.

This thesis is also guided by a social constructionist approach towards language that rejects the idea that policy language is a neutral medium in which objective policy objects are dealt with (Burr 1995, Travers 2004). Rather it takes the approach that policy acts to create the subject with which it is concerned. It is:

A constant discursive struggle over the criteria of social classification.... that guide the ways people create the shared meanings which motivate them to act (Fischer and Forester 1993: 2).

A social constructionist approach holds that the way in which a policy object is discussed helps to create the object in that very way. Mental illness is, at least to some extent, socially constructed. The way that mental illness is viewed and discussed in policy helps to create an understanding of what mental illness is.5 Discourses shape practices in particular ways and can determine whether a given person is deemed mentally ill and subjected to the very material practice of confinement. Although I focus on policy discourse I recognise that material practices are also significant and that there is always a need to see how policy is implemented, negotiated and resisted.

1.6 Terminology in this Thesis

The terminology with which mental illness is discussed can help to construct certain views of what mental illness is and what it means to be ‘mentally ill’. The very act of labelling can help to constitute a particular understanding of mental illness. I have adopted the terminology of ‘people with mental illness’ throughout my thesis as being the most appropriate for the context of this thesis. There are two main concerns with this form of terminology, first, as Gleeson (1999) argues (with reference to disability), this terminology may depoliticise the social discrimination that people suffer by glossing over the reality of people’s experiences and the suffering they face. It can be seen as playing down the 'very real' mental and emotional distress that people experience by placing a secondary emphasis on their illness. Second, this form of terminology can suggest a false homogeneity of people as though all individuals with mental illness are the same, a concern which none of the terminological choices

5 The way in which mental illness is socially constructed, and the implications of this, is discussed in more depth in Chapter Two.

14 easily avoids. However the use of the terminology of people with mental illness helps to stress the humanity of people, that their ‘mental distress’ is not the sum of their identity. This is also the most widely used terminology within the Australian policy context in which my work is primarily embedded. It is widely used across the mental health sector, including by advocacy groups and service providers in Australia. Thus the phrase ‘people with mental illness’ is the primary terminology I utilise. However in some discussions of historical treatment of people with mental illness I use terms contemporaneous with those times, such as ‘mad’ or ‘lunatic’, where the context suits contemporaneous language use.

1.7 Organisation of Thesis

Chapter Two outlines the essential role spatial relations play in how mental illness is understood. I argue that confinement acts as a form of social border maintenance and has strongly influenced how society has conceived of mental illness. I show how the socio-spatial exclusion of people with mental illness occurred at particular times in particular contexts rather than being an inevitable response to mental illness. I illustrate how deinstitutionalisation has destabilised the relationship between social and spatial control which has dominated mental health policy over the last 200 years in the Western world. Finally I argue that the relationship between confinement and social control has not been adequately theorised in relation to the renewal of confinement.

In Chapter Three I illustrate how risk has become an increasingly important component of the contemporary world including in social policy. I examine how risk became something new and important when it transformed from something subject to fate, towards something under human control. In this way risk has became used as a way of trying to cope with the uncertainties of contemporary society. This, I argue, means that safety and the avoidance of danger, lies at the heart of risk society. In making these arguments I critically examine the main sociological approaches used to understand risk, including the risk society theory of Beck and Giddens and the cultural theories of Douglas. I argue that much of the previous scholarship on risk in the contemporary world has been profoundly aspatial and atemporal and that this needs to be remedied by an approach sympathetic to historical and spatial context.

15 Chapter Four extends the discussion of risk to show how other research has attempted to explain relationships between risk and mental health. In particular I draw on governmentality theory, which suggests that risk has been used as a strategy of neoliberal governance to encourage self government resulting in increasingly decentred forms of social control. One implication of this has been a new tension in the management or control of social deviance, between deregulation at the macro-level and the continued requirement of a micro-politics of control and surveillance. I conclude that moves towards a renewed emphasis on confinement pose a challenge for governmentality explanations of the role of risk.

Chapter Five outlines the methodological approach of the thesis, which draws on Foucault’s ‘history of the present’ and policy analysis. I explain and justify my primary focus on the discursive realm of public policy and explain how my approach has been influenced by critical discourse analysis. I then discuss my case study research and my methods of analysis.

Chapters Six, Seven and Eight discuss the case study of England and Wales. Each of these chapters specifically addresses one of my three research questions. In Chapter Six I present evidence showing that confinement plays a strong and increasingly important role in mental health services. In particular there have been increases in both compulsory admissions and rapid growth in the forensic mental health system. In Chapter Seven I analyse the history of mental health policy from 1845 to the 1970s, showing how risk has been related to the rationalisation of the spatial confinement of people with mental illness in policy. In Chapter Eight I present the analysis of the relation between risk and confinement in contemporary policy.

Chapters Nine, Ten and Eleven present the findings of the case study of Queensland, Australia. Again each of these chapters specifically addresses one of my three research questions. Chapter Nine presents empirical evidence showing the continued role of confinement in Queensland mental health services. Chapters Ten and Eleven provide the historical and contemporary analysis of the way confinement is rationalised in policy and the relationship between risk and confinement. Finally Chapter Twelve draws together the key elements of the case study findings to address the research questions posed in this introduction and to provide some conclusions.

16 1.8 Conclusion

This thesis aims to understand the role of risk in framing confinement and spatial control in contemporary mental health policy. It is concerned with public policy and how the mental health system operates at the policy level. Both practice and people are largely absent from the overt text of the thesis, but both played a role in its conception and its ambition. I derived the research aim from experience with prior academic work involving people with mental illness and with experience working in a policy position in the non-governmental social services sector. The ongoing injustices and difficulties faced by many people with mental illness across a range of areas served as an impetus for this research.

Processes of confinement can impact people in profound and significant ways. Compulsory treatment and institutionalisation are intrinsically about the restriction of liberties and freedoms of people who differ from the ‘healthy’ norm. Institutionalisation, as the often grim history of the institutional period shows, has commonly been characterised by harsh and oppressive conditions and significant human suffering. This history means that any move towards increasing the number of people who are confined and making it easier to control and confine people has to be viewed with great care. However it would be a mistake to view confinement as an inherent wrong. As Gleeson and Kearns (2001) and Finnane (2003) point out in some circumstances institutions have provided a more caring and positive environment than the virtual abandonment which characterised deinstitutionalisation for so many. Thus the changing extent and nature of confinement needs to be viewed with a sceptical, but open mind.

17 Chapter 2. Mental Illness and Social Control

2.1 Introduction

In this chapter I argue that there is, and has been, a strong element of spatial control in the care of people with mental illness. The spatial differentiation and demarcation of the insane from the sane, the abnormal from the normal, which is the raison d'être of confinement has historically played an essential role in how the very idea of mental illness is understood. The spatial isolation and confinement of institutional forms of care acts as a type of border maintenance. It acts to demarcate the unhealthy from the healthy reinforcing the exclusion associated with mental illness. The relationship between confinement and mental illness is, however, not an inevitable relationship but an historically constructed one. In this chapter I explain the historical evolution of this relationship from the confining trend of earlier centuries to deinstitutionalisation that occurred in the later part of the twentieth century.

The chapter shows the socially constructed and socio-spatial nature of mental illness. I argue that understanding this is a precondition for understanding contemporary confinement. I argue that there is, and has been, a strong social control element to mental illness which has not been adequately theorised in relation to the renewal of confinement. In particular I address the relationship between social control and confinement, drawing upon Foucault’s idea of the carceral society. I argue that the spatiality inherent in the carceral society has been an important part of the differentiation of the normal from the abnormal, thus illustrating the importance confinement has played in our understanding of mental illness. Finally I address the way that the deinstitutionalisation of mental health care, in Western jurisdictions, appeared to destabilise the relationship between social control and spatial control. Deinstitutionalisation resulted in the dispersion and decentralisation of care and initiated a shift away from centralised forms of social control which had characterised mental health systems for at least the previous hundred and fifty years. I outline the way that two key theorists, Deleuze and Castel, have explained deinstitutionalisation in terms of changing forms of social control. This establishes the framework for my argument, later in the thesis, that current thinking about the care and treatment of mental illness has not adequately taken account of the continued emphasis on and role of spatial control of people with mental illness.

18 2.2 Social Construction of Mental Illness

Mental illness is a socially constructed concept. The corollary of this is that the care and treatment of people with mental illness is inherently a social, and as I will argue, a spatial process. The way that mental illness is conceived helps to shape the mental health system and vice-versa. Although the term ‘mental illness’ and its various synonyms, such as ‘psychiatric disorder’, are widely used exactly what they mean is contested, both within the psychiatric profession and more broadly in society. The very existence of ‘mental illness’ is contested, with views on mental illness ranging from outright rejection of the concept to total acceptance of mental illness as an objective scientifically understood reality. One extreme is the contention by the anti- psychiatric movement that ‘mental illness is a myth’ (Szasz 1973:23). Szasz argues that the concept of mental illness is inexplicably tied to the social and ethical context and that it functions as a social tranquilliser. As he puts it:

We call people physically ill when their bodily functioning violates certain norms; similarly we call people mentally ill when their personal conduct violates certain ethical, political and social norms (Szasz 1973: 23).

Critics of psychiatric medicine argue that mental illness is a function of a belief system rather than a medical fact. They argue that because some people act in different, and possibly disturbed, ways does not mean they have an illness in the scientific sense of the term (see for example Laing 1960).

Within social science there is relatively widespread acceptance that mental illness is a social construct in so far as it changes from place to place and time to time and that how it is understood changes according to its social role (Miles 1987, Prior 1993). This social science understanding of mental illness has its origins in Durkheimian functionalism, which claims that the rules and standards which define what is pathological reinforce standards of normality; they help to define what is normal by highlighting the abnormal (Giddens 1971). The concept of mental illness serves a social purpose in helping to draw a boundary around what is considered normal behaviour and what is outside the boundaries of the norm.

Although there is substantial agreement, among social scientists, that definitions of mental illness are socially constructed there are two quite different understandings of what this entails. The first is the recognition that mental illness is a social category and what is categorised as mental illness can, and does, vary over time and space.

19 This view accepts that some people face substantial mental suffering. The second, ‘stronger’, understanding is that mental illness is only a social category. This view holds that the categorisation does not refer to any underlying reality; rather it serves an entirely social role in reinforcing standards of normality and acceptable behaviour.

Even the scientific psychiatric viewpoint gives credence to the changing nature and understanding of mental illness. The Diagnostic and Statistical Manual of Mental Disorders (DSM), a primary tool of diagnosis and categorisation prepared by the American Psychiatric Association, amply illustrates the contested nature of mental illness. This is most famously illustrated by the inclusion of homosexuality as a psychiatric illness until 1973, when it was removed from the DSM after a series of bitter and contentious debates (Busfield 1986). Although homosexuality is the most famous example there are many others, indeed the entire scientific and medical basis on which diagnosis is made has changed through various editions of the DSM. The first (1950) edition emphasised the significance of psychodynamics in understanding mental illness, while the latest, fourth, edition (1994) is based on bio- medical understanding (Wilson 1993). Each edition has seen the addition and removal of numerous disorders, illustrating a constantly changing understanding of mental illness even within the scientific approach.

If it is accepted that care and treatment of people with mental illness is inherently a social process then it follows that the way that society organises care and treatment helps to constitute what psychiatric disorders are. Goffman’s (1961) classic symbolic interactionist study of asylums provides one example of this. Goffman examined how the asylum as a micro society shaped people into acting in the (disturbed and disordered) ways that were expected of them. Others have shown how understandings of mental disorders have changed in conjunction with the organisation of mental health policies and practices (see for example Finnane 2003). Thus an analysis of the current role of confinement in mental health systems may help to shed light on how mental illness is understood in contemporary society.

2.3 The Relation between Mental Illness and Social Control

The social scientific understanding of mental illness as socially constructed is an essential part of the argument that mental health policy, and mental illness itself, is inherently linked to social and spatial control. The original insight that the rules that

20 determine pathology help to reinforce what is ‘normal’ suggests that there is always some element of social control in the application of these rules about what is normal and what is disordered. The classification and confinement of particular people and/or behaviours always fulfils a social role. The physical spatial separation, or confinement, of the abnormal from the normal reinforces social control in a material way, which makes it something more than purely abstract. This has been repeatedly illustrated by numerous historians who show how the treatment of mental illness, particularly spatial separation, has served various social, economic and political purposes (see Scull 1979, Hoult 1986, Castel 1988). The work of these historians, and others, illustrates the importance that social, political and economic contexts play in shaping how mental illness is understood and how mental health systems operate. As Scull (1977) notes changes in the character of social control apparatuses are closely linked to changes in the character of the social system within which they are embedded.

Over the last few centuries, in Western countries at least, there has been a strong relationship between the care and treatment of people with mental illness and social control. The idea that the way mental health systems are organised and operated is influenced by the desire to exert and encourage control over people with mental illness is widespread. Scull (2006: 7) maintains that to suggest that society’s response to mental illness is inevitably related to social control is simply to take note of a truism. This argument, however, goes too far in positing the inevitability of the relationship between mental illness and social control. It assumes that social control an inherent response to mental illness. Over the last several hundred years there has been a relationship between social control and mental illness, but this is an historical rather than inevitable relationship. In this section I stress that social control has been a major imperative in the historical constitution of care. I also argue that care and control are relational social constructions, and that using a spatial approach can help to avoid the functionalism that can pervade theories of social control. I conclude by considering what a non-functionalist understanding of social control looks like.

2.3.1 Deviance, mental illness and social control

The degree to which social control approaches can be applied to mental illness is contested. Cohen (1985: 1), one of the main exponents of the idea of social control, defines it as being:

21 The organised ways in which society responds to behaviour and people it regards as deviant, problematic, worrying, threatening, or undesirable in some way or other.

This traditional sociological understanding of social control holds that it is about regulating the behaviour of people (as individuals or groups) so that they conform to the norms of society.

Traditional sociological approaches to understanding responses to deviance have argued that deviance is often managed through institutions that help maintain the social order by confining and controlling the deviant. However part of these understandings is that institutional control of deviance can vary according to whether that deviance is understood as being intentional or unintentional (Dallaire, McCubbin, Morin and Cohen 2001: 133). A form of moral responsibility for deviance is ascribed to intentional deviance. For example in the case of the justice system punishment and control is the response. By contrast in the case of unintentional deviance, such as physical illness, treatment and care is the response. Mental illness falls uneasily between these opposites; it is neither entirely (intentional) badness, nor entirely (unintentional) illness. This results in a situation where both control and treatment impulses are at work in the management of mental illness.

The uncertain positioning of mental illness as requiring both control and treatment has stimulated debate about the degree to which a social control perspective can be used to understand mental illness. Cohen (1985: 9) argues that although there has been considerable focus on the role of social control in relation to psychiatry it is one of the least visible modes of social control and perhaps one of the least appropriate to characterise as such. In particular Cohen (1985) and Scull (1985) reject the simplistic social control understanding of the anti-psychiatric movement of the 1960s and 1970s, which understood psychiatry as purely social control. These anti- psychiatric views adopted an approach which saw psychiatry largely in functionalist terms as existing entirely in order to manage social deviance. It is however possible to understand that psychiatry and institutions play a social control role without claiming that this is their only role.

The history of the regulation of madness in Western Europe gives credence to the significance of state provided institutional care as a form of social control of deviance. Castel’s (1988) study of the origins of incarceration of the insane in France reflects this approach. Castel, like Dallaire et al. (2001), argues that mental illness posed a

22 particular political and social problem for the state because of its uneasy position between badness and illness. Unlike other forms of social deviance, such as criminality, it could not be argued that people with mental illness had broken the social contract and therefore punishment was not appropriate. This, Castel argues, meant that confinement of the insane needed to be justified by the rationalisation of care as well as control.

Castel concludes that the fundamental aim of the mental health movement was to obliterate from the social landscape the disorder that madness represents. He argues that psychiatry is fundamentally and essentially a political science as it came into existence to answer a problem of government. It provided the means, the tools and the technology which enabled madness to be administered. It also worked to displace the political impact of the problem of madness by turning the solution from a political one into a technical one (Castel 1988: 11). In Castel’s view mental illness comes to be governed primarily for the purposes of social control. He argues that the mad were subject to specific legislation, in France, because they posed a fundamental threat to the emergence of the new contractual society. Because they were unreasonable, they were not amenable to law, because they did not bear responsibility for their state they could not be subjected to punishment, because they were unproductive they could not sell their labour. Thus the mad were a ‘site’ of disorder that needed to be removed from society. Psychiatry literally aimed to remove the deviance of mental disorder from society through the imposition of spatial isolation. Confinement and removal from society was essential to controlling this challenge posed by people with mental illness. This illustrates the historical connection between social control and spatial removal of people with mental illness. It shows the significance of social control by the state and the historical evolution of a relationship between confinement and social control (see Foucault 1967 and Scull 1979 for two other influential explorations of this relationship).

The other compelling feature of Castel’s argument is that it recognises that confinement may have been partially driven by social control, but that does not mean that the only role of confinement is a controlling role. There is an inherent tension that exists in the way people with mental illness have been confined. This is a tension between the classification of confined populations as 'different' and the attempt to rehabilitate, integrate and correct- to normalise. Practices of confinement operate as a way of removing the deviant, the abnormal, from the body of society, as psychiatric institutions largely did in the first half of the twentieth century. But confinement can

23 also be seen as a place of respite, somewhere the troubled can escape from the pressures of society and can learn to reintegrate into the norms of society. This was the basis of the thinking behind moral treatment (see for example Tukes 1813) which was a significant factor in initiating the widespread growth of psychiatric facilities in the UK (Porter 2002). The isolationary practices of traditional psychiatric facilities means that they provide the flexibility to fulfil these two very different roles. They can operate as both controlling and/or caring. It is the very flexibility of such exclusionary practices, which makes institutionalisation such an effective technique of social control. Psychiatric institutions can act as a form of direct physical control but also as a way of facilitating and teaching internalised control, a way of normalising.

2.3.2 Non-functionalist accounts of social control

Both Castel’s arguments, and others like Scull (1979) illustrate the ease with which social control arguments can slip into a strongly functionalist view, which explains individual institutions and events based on the imputed social function of that institution or event. Critics of the functionalist nature of the social control argument claim that this functionalism is unable to explain social changes and leaves little room for individual agency or for recognising the way things differ in different contexts (Rothman 1985). I argue, however, that adopting a viewpoint influenced by social control theory can help to explain mental health policy and that it is possible to do so without adopting a functionalist approach. This argument accepts that the mental health system, and particularly psychiatric institutions, is not only about the exercise of control over others, but nor are they only incidentally connected.

In a similar vein Porter (2002) argues that it is simplistic to see the rise of the psychiatric institution in functionalist, or conspiratorial terms, such as being a tool of social control designed to smooth the functioning of emerging industrial society, which was the basis of Scull’s (1979) understanding of the rise of confinement in the UK. Porter argues that the asylum should be viewed less as a central policy and more as a combination of a range of wants, rights and responsibilities between diverse parties. Confinement of particular people was thus less a product of central policy and more of bargaining between families, communities and local officials.

The argument that individuals play a role in the systems that exert power over them does not substantially weaken the importance of being open to a social control perspective. Social control should not be dismissed as simple functionalism or seen

24 as only understanding a top down imposition of power. While these elements are part of the social control perspective they are not necessarily dominant. This is most apparent in the growth of relational Foucauldian influenced perspectives, which have become increasingly influential among social theorists. These views see power, including the power relations of social control, as always being relational (Allen 2003). Much of Foucault’s early work, and much of the work inspired by him, does contain an element of social control thinking. This is particularly the case for those who have drawn upon Foucault’s notion of governmentality (an idea explained in more depth in Chapter Four). Foucault is an important part of a tradition which emphasises the importance of regulation and administration as key features of 'modern society' (Turner 1997).

The social control aspects of Foucault’s work need to be taken seriously, albeit needing to be viewed through the prism of his views on power. This means recognising power as something that is relational and that is not ‘negative’, as Foucault puts it:

Power must be understood in the first instance as the multiplicity of force relations immanent in the sphere in which they operate and which constitute their own organization: as the process which, through ceaseless struggle and confrontations, transforms, strengthens, or even reverses them (Foucault 1998: 92-93).

This explanation shows the way in which Foucault recognises power as not being merely the hierarchical imposition of force but something that is constantly created, negotiated and resisted. The major implication of understanding Foucault’s work on social control through the prism of how he views power is that the way which institutions operate as controlling mechanisms is never static and never uncontested. With Foucault’s work in mind it becomes useful to draw on Castel’s (1988) understanding of mental health policy not as elements of a structure, but rather the crystallisation of practices worked out in particular historical contexts.

The idea of mental health policy as a crystallisation of practices points towards one of the most significant lessons from Foucault’s own work namely that one should not rely on an abstract predetermined theory of social control. As Rothman (1985) argues investigations into changes in the treatment of deviance, and particularly reforms, always need to be understood within their context. The past is essential to understanding the contemporary nature of social control as modes of social control exerted in the past become part of the moral and definitional context of the present.

25 In sum, a non-functionalist approach of understanding the relationship between mental illness and social control is one that takes the meaning of relation seriously. This means understanding social control as a relationship that needs to be understood within particular contexts, including historical contexts. It means recognising that there can be elements of social control in response to mental illness, but that this is not an inevitable relationship.

2.4 Social Control and Spatial Control

As the discussion on the social construction of mental illness implied there is a strong socio-spatiality to both the concept of mental illness itself and to the care and treatment of mental illness. There is both an ontological and epistemological aspect to this socio-spatiality. The ontological is that spatiality actually defines and constitutes care and treatment; this is the socio-spatial phenomenon of care and treatment. The epistemological is a spatialised understanding of care and treatment that recognises the mutual constitution of space and society.

This epistemological idea of the socio-spatial nature of mental illness draws on a geographical construct that sees space and social relations as mutually constitutive. In this conception space is not a passive container within which things happen; rather, as Lefebvre (1991) emphasised, space is produced by social relations, which it also reproduces, mediates and transforms. In Lefebvre’s view neutral or abstract space cannot exist, as the moment it is occupied by social activity it becomes historicised and relativised.

More recent work in geography has drawn on post-structuralism to go beyond Lefebvrian ideas of space to argue that that subjects achieve and resist their systems of identification in and through social space (see for example Natter and Paul Jones III 1997). This understanding moves beyond the more structural conceptions of Lefebvre to suggest that individual identity and meaning is constructed and deconstructed through space. Space needs to be considered as both a product of society and a factor of social production. It exists and operates as both a materiality and as a representation.

26 2.4.1 Space as materiality and representation

This dual nature of space accords with how Philo (2004: 6) conceptualises two main meanings and uses of space. The first and weaker meaning is areal differentiation, how things differ between places and spaces. This sense is useful in that it shows how differences in places inevitably fragment any big theoretical or historical claims. The second, stronger meaning is that of ‘spatial relations', which focuses on how spatial configurations of all sorts enter into the very constitution of whatever events, phenomena or processes are under investigation, not just complicating them but contributing to the very making of them.

Space, in both its material and representational aspects, has played a role in how the care and treatment of mental illness is viewed and organised. The materiality is present in the physical separation that is inherent in, and the reason for, confinement. The materiality of spatial confinement of people with mental illness is used to physically delimit the ‘normal’ from the ‘abnormal’. Researchers such as Castel (1988), Foucault (1967) and Philo (2004) have shown how physical spatial separation and isolation have produced and reproduced particular structures and representations in society.

Perhaps the most thorough empirical example of this is Philo’s (2004) geographical history of the provision of treatment for people with mental illness in England and Wales from medieval times to the 1860s. It traces the way that society in England and Wales began to split into two groups, the sane and the insane. Philo argues that this split was simultaneously a social split and a spatial split. He draws on Foucault to show how ‘the space reserved for insanity’ came into being. He does this by contrasting the relatively chaotic spaces of madness in the medieval period with the increasingly rigidly undifferentiated spaces of institutionalisation created with the emerging domination of enlightenment ideas of reason.

In addition Philo also examines the spaces into which the insane were confined, and highlights the geographical implications of this. He argues that there needs to be more attention to the areal differentiation of the places and spaces within which mental health care occurred. This, he argues, can act as an antidote to the teleological nature of many histories of mental illness, which assume an inevitable progressivism. He uses his close examination of the spaces and places of madness to argue that the places in which sites of care and confinement for people with mental

27 illness were located strongly related to conceptualisations of madness, illustrating the socio-spatial dynamic in place. Philo examines how location, architecture and social environment influenced the way that madness was managed and how this in turn influenced the way madness was understood. This research emphasises the historically contingent nature of the relationship of the spatial control of people with mental illness.

2.4.2 Historical evolution of confinement of people with mental illness

Over the last two hundred years there has been a strong tendency for the care and treatment of people with mental illness to be linked to spatial control, namely confinement and isolation. Despite the apparent strength of this relationship it is a relatively recent phenomenon historically speaking. For most of human existence the care and treatment of people with mental illness has been largely a haphazard and domestic affair. Porter’s (2002) history argues that something approaching mental illness has been understood since at least 5000BC and that for almost all of this time it has been managed within the family. This accords with the general history of medicine, which has also been primarily a domestic affair. Until the mid 18th century the firm belief was that homecare was best for any kind of illness, including mental illness (Tomes 1988: 4). Thus it was not until the mid 19th century, in England and other Commonwealth countries, that isolation and spatial separation became a key part of the governance of people with mental illness.

The relationship between people with mental illness and spatial control is a fairly new concept, at least at the large scale. Foucault, controversially, dates the ‘great confinement’ in Europe to the mid 17th century. This, he suggests, was when the confining impulse of the enlightenment came to the fore, when reason sought to silence madness by removing it from the body of society. There was no similar impulse of confinement of madness in England until the 19th century (Porter 1990). Prior to this there were scattered private institutions, but little state provided care.6 Indeed as Porter (2002) notes it was not legal to use state funds for commitment until 1808 and there was no mandatory provision of asylums until 1845. As Philo’s (2004) history suggests before the 19th century care and control of people with mental illness, in England and Wales, occurred in a chaotic range of spaces including homes and a limited number of charitable establishments.

6 There were, however, workhouses, which confined a large number of people, including people with mental illness (Driver 1993).

Scull (1979) argues that the transformation to state governed institutionalisation was linked to the growth of the capitalist market system and its impact on social relations. He argues that the emergence of the capitalist wage system destroyed traditional family ties and thus weakened the ability of home-based systems of care to persist. It also weakened the customary sense of noblesse oblige, which had previously created a social obligation for the wealthy to look after their charges, as wages came to be seen as replacing social obligations. These changes occurred when bourgeoisie power was least inclined to tolerate a growing number of people in receipt of relief, therefore an institutional approach was attractive.

One of the key elements of Scull’s argument is that there was a strong correlation between the growth of an emphasis on confinement as a mechanism of control and treatment and the growth of industrial capitalism and, more broadly, the growth of modernism. Bashford and Strange (2003) justify this by arguing that practices of exclusion have proliferated under industrial modernism because of the very nature of its emphasis on liberty and freedom and because modernism is characterised by an expectation and will to order everything. The invocation of 'liberty' as an inalienable right created the very possibility of its denial as a form of punishment. Confinement became not only spatially exclusionary but simultaneously a deprivation of the newly enshrined freedoms associated with modernism. Exclusion and isolation become something that is not an aberration from liberal governance but central to its internal logic. The exclusion of those who exhibit a lack of reason reinforces the freedom of others and thus becomes more significant with the growth of modernisation.

2.4.3 The emergence of the carceral society

Foucault also links the growth of a confining tendency to the growth of modernisation and the desire to remove unreason from the body of society. Much of Philo’s work demonstrating the socio-spatial nature of the care and treatment of mental illness has built on Foucault’s approach to space and institutions, as Foucault is undoubtedly one of the most influential theorists to take space seriously (Crampton and Elden 2007). However Foucault is far from consistent in the importance to which he accords space. His research in Madness and Civilization (1967) has a strong spatial component, which illustrates the interconnected relationship between social control and spatiality. He places specific emphasis on the significance of the spatiality of confining tendencies that began to emerge in the 17th century. Foucault’s writing

29 draws upon spatial metaphors to redress what he sees as the mistaken privileging of time over space (Smith and Katz 1993: 73). Foucault insists that the role of space, place and geography in history needs to be taken seriously, which effectively sees Foucault embrace a spatialised perspective on what history itself is (Philo 2000a). This is because Foucault is wary of abstract histories and favours an emphasis on the local, on the particularities of places. He recognises that things are not homogenous, that they turn out differently in different places. Despite this one of the major problems with Foucault’s own work (and in particular Madness and Civilization) is that it does not attend enough to those very particularities of place. It draws together things which were occurring in different places as though they were unitary phenomena.7

Foucault’s conception of the ‘great confinement’ is arguably the most influential exemplar of a socio-spatial view of mental health care. Foucault argues that from the mid 1600s madness became linked to confinement (1967: 36). This, he contends, led to "unreasonable" members of the population being locked away and confined in institutions. Foucault’s ambition in writing Madness and Civilisation was not to write ‘a history of madness’, with the totality that would represent.8 His project is more accurately conceptualised as a study of the historic circumstances, or ensembles, which held captive madness at a particular time (Rose 1992). He was concerned with what was happening in particular times and places and this interest in particularities meant that he was alert to the significance of changes to the spatiality of the care of the mad. There are two key aspects to Foucault’s spatial sense (in much of his early work not just Madness and Civilization) (Philo 2004). The first is the charting of the emergence of an intent to segregate and isolate the abnormal from the normal. The second is to explore the spatiality of those spaces of confinement, to see how they have been used.

The first sense is an essential part of the argument in Discipline and Punish (Foucault 1977a). Foucault contrasts the public torture and execution of Robert- François Damiens in the late 18th century with the regimented imprisonment of prisoners by the mid 19th century. This, he argues, is indicative of a trend away from

7 In particular the historiography of Foucault’s work in relation to the central thesis of the great confinement has been heavily critiqued (see for example Porter 1990, Scull 1990, Still and Velody 1992). 8 Foucault was a strong critique of the notion of ‘total history’, instead arguing for a concept of ‘general history’ which is more concerned with the interaction of processes than with presenting an overall explanation of an historical event or time (Foucault 1972).

30 the excessive force of the sovereign where violence enforced order, including over those deemed mad, towards the more controlling mechanisms of confinement by the state. This is what Foucault refers to as the emergence of the ‘carceral society’. The appearance of these new forms of social and governmental control allowed a shift towards the ‘norm’ as a new form of law. This shift has a strongly spatial component, as the change away from the violence of the sovereign towards imprisonment relied on the enforcement of spatial control over people by the state.

The second sense, of the spatiality of places of confinement, is apparent in much of Foucault’s early work. That research demonstrates the way in which space becomes part of the desire and need to control and surveil individuals, and how this operates as both a material and representational process. This idea reaches its ultimate form in the shape of the panopticon, an idea of the British philosopher Bentham, which was a concept for a prison that allowed an observer to observe all prisoners without them being able to tell when they were being observed. The idea of the panopticon was that it would result in prisoners constantly regulating their own behaviour as they were never sure when they were being watched. Foucault saw this as the zenith of the disciplinary society, which creates docile bodies through surveillance. The theory was that the need to constantly control behaviour because of the fear of surveillance results in the internalisation of discipline. It is thus, Foucault suggests, through control of physical space that internalised discipline is created.

Foucault’s research demonstrates both the degree to which confinement has become associated with control but also the contingent nature of the link between confinement and mental illness. His work demonstrates that over the last several hundred years there has been a strong relationship between confinement and control, but that this is an historically created link, not an inevitable one. He demonstrates that there is no inherent relationship between confinement and mental illness, that ideas of exclusion and isolation are not universal phenomenon which emerge whenever madness meets non-madness (Philo 1997: 79). To assume this would imply that there is something that is inherently natural about the spatial segregation of madness. This assumption ignores that such segregation is a social phenomenon, carried out as a way of differentiating the normal from the abnormal, operating as a form of social control of difference and heavily contingent on the norms prevalent at the time. Thus the resurgence of confinement as a way of managing mental illness needs to be understood in relation to its social role not as the reassertion of some inevitable natural relationship. Of particular relevance in

31 explaining how ideas and practices of confinement and exclusion became widespread is Foucault’s notion of the disciplinary society explored in Discipline and Punish (Foucault 1977a).

2.4.4 The disciplinary society

Discipline, to Foucault, is a way of regulating the operation of individual bodies. It regulates and divides up the individual’s movement and activities; it controls the time and space through which bodies move. Prisons are an exemplar of such practices (as in the panopticon discussed above) but these practices also exist in other institutions that regulate individual and thus societal behaviour such as schools, factories and hospitals. These institutions act to identify the abnormal, to punish it and to remedy it. These disciplinary apparatuses work together to produce docile and productive individuals (Hannah 1997). Foucault argues that the purpose of these practices is to inculcate internal discipline:

What one is trying to restore in this technique of correction is… the obedient subject, the individual subjected to habits, rules, orders an authority that is exercised continually around him and upon him, and which he must allow to function automatically in him (Foucault 1977a: 128-129).

Deviance is managed through institutions that both discipline and punish through surveillance and control. Spatiality is a key element of these disciplinary institutions. By their very nature these institutions require a clear and distinct separation of spaces to differentiate the deviant from the normal, the corrected from the uncorrected. The layouts and movements within such institutions are essential to how they operate as carceral places (Philo 2001: 480). As Foucault notes: ‘in the first instance, discipline proceeds from the distribution of individuals in space’ (1977a: 141). This effect is what Foucault (1977a: 218) refers to as an ‘anti-nomadic technique’ in that it seeks to spatially control through fixing in space. By this he means that one of the key roles of discipline is to regulate movement and to create the possibility of calculable distributions through defining the spaces in which people can operate, as compared to the randomness of individuals of sovereign societies. Institutions of enclosure create a stable space within which people operate. The idea of anti-nomadicism illustrates how significant the spatiality of control is, for Foucault, in understanding the disciplinary mode of governance.

Discipline and Punish can sometimes appear to suggest that the disciplinary society is all embracing, that there was a carceral society which encompassed everything,

32 but Foucault later clarified that he did not mean for the disciplinary society to be taken for a totality, as he explains:

In reality one has a triangle, sovereignty-discipline-government, which has as its primary target the population and as its essential mechanism the apparatus of security (Foucault 1991: 102).

Foucault did not mean his analysis of the carceral society to exist as a complete explanation of an entire social form but rather to highlight a particular project of government. The idea of disciplinary societies is a model referring to the past, and should not be unilaterally and blindly projected into the present (Lianos 2003: 413). This creates the possibilities for exploring how the disciplinary society operates today in conjunction with other projects of government, a possibility taken up by Deleuze.

2.4.5 Deleuze and the decentring of social control

Deleuze (1992) argues that the Western world has been shifting away from the disciplinary society that Foucault identified towards ‘societies of control’. This is part of a continuous change, which saw, for instance, disciplinary societies replace sovereign ones. Deleuze says that these disciplinary societies are reaching a crisis, which has been growing since after World War Two, as social and economic conditions have changed. One of the key changes has been that the logic of capitalist production, originally based in the factory, has come to dominate all forms of social production. In this way the control of the enclosure (the disciplinary society) has given way to societies of control (characterised by transformation). Control is exerted through non-spatially centred means, such as the spread of surveillance across society. Thus Deleuze argues the power of closed institutions such as schools and psychiatric hospitals has become increasingly less important as control has become more diffuse in the way it operates.

For Deleuze discipline was characterised by power that was concentrated in, but not wholly encompassed by, sites of confinement. Deleuze describes the shift from discipline towards societies of control as one from centralised hierarchical forms of control to more diffuse or dispersed modes of control. In societies of control the defined boundaries of the disciplinary society have given way to smooth social space. There is a shift from the centralised power of institutions towards decentered (rhizomatic) networks of control. Power and control is both more fluid and more decentred than in disciplinary societies. No longer, Deleuze argues, is control exercised in a centred and homogenous way.

Social control emerges, according to Deleuze, as a set of assemblages, where surveillance becomes dispersed and individualised. Social control is still occurring, but in a different way from before. For Deleuze the panoptical model of domination is being dismantled and giving way to self-surveillance and self monitoring by the dominated. One of the implications of the erosion of disciplinary institutions is that there are no longer clear boundaries. People no longer enter or leave places of control but are constantly moving around a larger space of control. Control diffuses across space rather than being concentrated in particular locations. The smoothing of social space is not about the total disappearance of disciplinary institutions, but about control spreading across social space. Control, to Deleuze, operates continuously rather than discretely, inclusion and exclusion occur through continuous forms of surveillance.

As Hannah (2007) suggests these arguments of Deleuze should be of great interest to geographers as they have strong spatial implications which assumes that mechanisms of normalising control will become entirely portable. Yet, as Hannah points out, there has been little empirical work by geographers to help evaluate Deleuze’s claim that Western societies are becoming societies of control. This include little research in the field of mental health despite the fact that deinstitutionalisation appears to closely fit with Deleuze’s overall argument.

2.5 Social Control and Deinstitutionalisation

Deinstitutionalisation appears to epitomise the smoothing of social space that Deleuze refers to. The historically strong relationship between social control and confinement has been challenged by deinstitutionalisation, which has seen a shift away from an emphasis on compulsion and confinement. Deinstitutionalisation saw the release of people from long-stay institutions into the community and a shift in the care and treatment of people from spatially concentrated institutions to decentred community care.

2.5.1 Deinstitutionalisation and the spatiality of social control

The emergence of deinstitutionalisation saw a shift and destabilisation in social control and the care and treatment of mental illness (Carpenter 2001). Attempts to understand this shift, in relation to social control, have largely drawn on

34 governmentality theories (explained in Chapter 4) to argue (a la Deleuze) that there has been a fundamental change in the mode of governmentality of people with mental illness. One of the most influential and significant arguments to explain this has been made by Castel (1991). Castel, as we have already seen, was interested in how and why confinement emerged as the main form of administration of madness in France. He was, however, also interested in how and why the administration of mental illness has changed to operate through deinstitutionalisation in the present era. In his earlier historical work on institutionalisation in France (Castel 1988) he raised the question of whether policies of control over people with mental illness would always utilise the instrument of enclosed space and argued that they would not. He suggests that this has become increasingly apparent in the contemporary world, as there is a shift towards decentred forms of control, which Castel argues are characterised by a shift in governance: from dangerousness to risk.

The crux of Castel’s argument is that new forms of governance based on risk have been replacing old forms of governance. That the administration of mental illness has been moving away from the strict control of dangerous individuals via physical controls such as institutionalisation and replacing it with risk management systems. This shift, he argues, reflects the dissolution of the subject (or concrete individual), who is dangerous, replacing it with risk which does not arise from a precise danger embodied in a particular individual, but rather a combination of abstract factors, risk factors (Castel 1991: 281). Previous forms of care which relied on one on one relationships between the carer and the patient, or the custodian and inmate, and the direct exertion of control have been displaced by the governance of people through risk. The identification of dangerousness relied on information relating to the particular individual, with the shift towards risk the subject disappears to be replaced by predictive factors which allow the anticipation of danger.

This means that control, Castel argues, is now exerted through a diverse range of mechanisms that offer as much control as the asylum ever did. Control operates as a new form of surveillance, that of systematic predetection, which relies on the factors of risk to anticipate and prevent undesirable events. With this form of surveillance in place it becomes possible to dispense with actual presence and deinstitutionalisation becomes possible, as it is no longer necessary to exert physical control. This reflects an emerging framework appropriate to post-industrial society, an argument that has resonance with Deleuze’s argument about societies of control, in that both suggest that control has become more decentred. As Moon’s (2000) analysis of mental health

35 policy in the UK illustrates this is not a wholly satisfactory argument, as it does not explain the resurgence of institutionalisation which is part of the subject of this thesis. The resurgence of institutionalisation, in some Western jurisdictions, problematises the apparent decentralisation of control, which both Deleuze and Castel argue is a feature of the contemporary era.

2.6 Conclusion

This chapter has focused on the socio-spatial nature of mental illness and how it relates to social control. I argued that the link between social control and spatial control (confinement) of people with mental illness has been strong, but this is not an inevitable link, but rather an historically created one. I also argued that social control needs to be viewed through a relational view of social power that is alert to context in order to avoid the functionalism that so easily dominates social control theory.

As Foucault and Philo’s historical analyses have demonstrated the mutually constitutive relationship between space and social relations means that looking at how and why contemporary confinement occurs can tell us something significant about how mental illness is understood today. These historical analyses have shown the degree to which confinement and spatial separation have been an essential element of modern mental health systems. Under industrial modernism spatial confinement has acted as a form of demarcation of the normal from the abnormal, an argument most cogently made by Foucault with the concept of disciplinary societies. However, as Philo (2004: 46) emphasises, this is an historical creation, there is nothing inherent about the segregation of people with mental illness. The spatial exclusion of people with mental illness is a process that occurred at a particular time, in a particular context. It is something that occurs for different reasons with different impacts in different societies.

Recognising the historically contextual and socially constructed nature of socio- spatial segregation leaves open the ability to provide various answers for how and why this has occurred in particular places and times. It also means that the turn towards deinstitutionalisation was significant, as it appeared to signify a shift away from the management of mental illness through spatial segregation and towards diffuse control and management, the smooth space of Deleuze. As both Deleuze and Castel argue this shift has been part of a significant change in social organisation in

36 late modernity. This has involved a move away from concentrated forms of control and power, towards more diffuse and decentred forms of power. Castel (1991) argues that this shift, towards decentred forms of care of people with mental illness, has largely been driven by a policy focus on risk, a concept which has provided the means to shift towards decentred forms of care.

37 Chapter 3. Risk and Safety

3.1 Introduction

Risk has become a leitmotif in contemporary society; it appears in all aspects of life and society and increasingly dominates our worldview. There are global risks, like the risk of climate change; health risks, like the risks of eating fatty foods; and personal risks, like the risks of violent crime, which increasingly shape how we live our lives. Risk, and its assessment and management, has increasingly become a central administrative and bureaucratic concern of government agencies, including health agencies. As Castel (1991) and Moon (2000) have argued the contemporary focus on risk is profoundly linked to changes in the way society attempts to manage mental illness.

I argue in this and the following chapter that control, including over people with mental illness, has been increasingly reshaped around the notion of risk. Risk, I argue, is inextricably linked to control, indeed what characterises the risk society is a change in how control operates. Risk has become a significant part of reflexive modernity as a result of attempts to try and exert control over an increasingly uncertain and unstable world. My argument is that risk is about the aspiration to control future events. This desire for control is where risk intersects so strongly with mental health and confinement. It is why some theorists have attempted to draw on concepts of risk to try and explain how control is exerted in a mental health system reshaped by deinstitutionalisation (as I discuss in more depth in Chapter Four).

In the first part of this chapter I explain the way in which risk has become such a key concept used to explain changes in the contemporary world. I trace the way that understandings of risk have shifted from being an objective measure of hazard, towards being something controllable by humans. In this explanation I draw particularly on the work of Douglas. I then discuss the way that Beck and Giddens conceptualise the risk society, placing particular emphasis on understanding risk within what is termed ‘reflexive modernity’. It is by understanding risk within this framework that it becomes clear how essential the concepts of continuity and discontinuity are to understanding the risk society, and consequently the importance of an historical approach to understanding the role of risk.

38 This initial discussion about the way risk has become such a central part of explanations in contemporary social theory frames the second part of the chapter. This examines how central notions of control are to understanding risk, and consequently how ideas of control have been impacted by risk. This latter relationship forms the core of Chapter Four.

3.2 The Social Construction of Risk

That risk is not merely, or even centrally, an objective statistically based measure of the likelihood of danger or a negative event occurring is central to understanding the way risk is now used. The socially constructed nature of risk in the contemporary world was first explored in depth by the anthropologist Douglas, who applied a cultural lens to risk to identify the concept of risk as something which is culturally determined (Douglas and Wildavsky 1982, Douglas 1992). Her theories have impacted on subsequent understandings of risk and have been influential in cementing the idea that risk is (at least partially) socially constructed. There are two main elements that differentiate Douglas’ understanding of risk from those that preceded her. The first is the recognition that what we come to understand as risks are socially constructed and that this construction has a self-reinforcing aspect to it. The second is that risk plays a social role, which is also an inherently political role.

Douglas’ main focus is on why some ‘dangers’ are identified as ‘risks’ and others are not. She is particularly critical of individualistic conceptions of risk. She adopts a functionalist structuralist approach, which sees risk as primarily a cultural rather than individual concern. She argues that it is impossible to make sense of the concept of risk in a compartmentalised individualistic frame of analysis (Douglas 1992). This view was a reaction to the rational actor and psychometric economic and psychological approaches that dominated risk analysis up until the early 1990s and focused primarily on analysing individual behaviour in trying to understand risk decisions (Draper 1993).

Douglas argues that it is only by understanding the cultural role that risk plays that this phenomenon can be understood. She also argues that underlying assumptions about society are related to understandings of risk. This is because risks have a recursive effect on social practices: once people acquire an awareness of certain kinds of risk they then adhere to different forms of social organisation which are tied

39 to particular forms of risk (Douglas and Wildavsky 1982: 8-9). This relationship forms a self-reinforcing circuit; whereby particular kinds of risk are continually reinforced, thus certain risks come to be stressed because of the social role they play in particular societies. Other risks are largely ignored and become irrelevant to that society.

Risk, in Douglas’ view, has come to take on the role that taboo and pollution played in earlier societies. She argues that it is very rare for a society to be able to exist without having a mechanism that enables blame to be cast and boundaries between the self and the other reinforced. Risk serves as a common vocabulary to hold people accountable in today’s global society; it acts as a cultural response to transgression, the outcome of breaking a taboo. At the heart of these ‘risks’ are emotional dimensions of anxiety, frustration, hatred and fear. However there is a difference between the purity and taboo of early identity reinforcement and risk in contemporary society. The concept of risk is about protecting individuals against others, whereas taboo protects the community against others, often individuals (Douglas 1992: 28). Douglas argues that in effect the new concentration on risk does not protect the collective good (as it does in the case of sin and taboo). There is, therefore, in Douglas’ view, a shift in identity boundary and maintenance with the growing importance of risk.

The work of Douglas problematised the notion of risk and highlighted how risk plays a social and political role. However Douglas’ way of looking at risk is very static and does not sufficiently address how and why risks would change, or for that matter how and why risk came to replace ideas of pollution and taboo. Douglas notes that risk plays an increasingly significant role in contemporary society, but does not offer a sufficient explanation for how this state of affairs came to be. This question of how risk has come to assume significance in contemporary society lies at the heart of understanding risk theory.

3.3 The Growth of the Risk Society

The failure of Douglas to explain why the role of risk appears to have changed points to one of the central issues at the heart of debates about risk, namely how and why has risk become such a seemingly central aspect of contemporary society. Most social theorists agree that risk has come to signify something new and unique about

40 contemporary society, although not all agree. In particular some critics, such as Alexander (1996) and Scott (2000), argue that the claim that there is something either qualitatively or quantitatively different about risk in the contemporary era cannot be sustained. They argue that risk does not encompass something new, but has existed with its current meaning for centuries. This claim, as I will show, does not live up to scrutiny, but assessing it is helpful in highlighting exactly what is new about risk and the role it plays in contemporary society.

The debate about the current meaning and role of risk begins with a simple etymological question, what does risk mean and how long has it meant it. Rigakos and Hadden (2001) argue that etymologically speaking risk is a historical continuity. They claim that the role of risk as a type of panoptic project, or impulse, characterised by risk management and accounting, can be traced back to the 17th century. They argue that risk calculation and monitoring emerged as a response to the economic needs of the emerging English mercantile class. It is certainly accurate to point out that the language of risk has a relatively long history, being traceable in English to at least 1661 (where it entered from either French or Italian) (OED Online 2007). At this time it was mostly associated with the concept of the sorts of dangers which could ruin maritime commerce (Ewald 1993, Giddens 1999: 21-22). In this meaning risk existed as something outside of human control and external force, pure luck or the will of God. It was this sense of risk as being outside of control that differentiates it from our current understanding of risk. Hacking (1990) claims that risk did not emerge as a distinctive object until the 19th century when it became a central concept. He argues that this change occurred because of the influence of the way probability was thought of. Probability became a way of trying to understand the world as at once being regular, but also not being subject to immutable laws.

Hacking’s argument identifies a qualitative shift in risk, this is that the change in the meaning of ‘risk’ occurs when it is transformed from something subject to fate to something over which humans have control. Both Hacking (1990) and Bernstein (1996), in two of the major scholarly histories of risk, argue that risk increasingly became a way of transforming fate. It allowed the concept of fate, which depended on divine intervention, to be replaced by human governance of uncertainty through the use of probability and statistics. This change of meaning towards a sense of

41 control is closely linked to the rise of the modern industrial world.9 Hacking (1990) argues that states entering the modern industrialising world used the science of probability and statistics to calculate norms of behaviour and identify deviations from this norm in the belief that they could control and improve the deviant population by enumeration and classification.10 This technical use of risk furthered the idea that uncertainty could be managed by humanity. As Reddy (1996) argues modernity attempted to replace ‘uncertainty’ with ‘risk’. This modernist use of risk heralded a new way of viewing the world, which transformed uncertainty. Risk, as being calculable, became a key component of technical means to bring the world under the control of modernity. Risk, in modernity, becomes:

A grandiose technocratic rationalizing dream of absolute control of the accidental, understood as the irruption of the unpredictable…a vast hygienist utopia plays on the alternate registers of fear and security (Castel 1991: 289).

It is when the idea of risk becomes a way of bringing the world of uncertainty under management or control that it becomes something new and different. The management of uncertainty marks out risk as different from danger or hazard. This shift also introduces a tension that forms a central part of the exploration of risk and mental health policy in this thesis. This tension is that risk is about trying to control uncertainty, yet inherently uncertainty can never be totally controlled. Risk emerged with modernity as a way of trying to exert rational control over the ‘accidental’, yet this is a project which is doomed by its very nature to never be entirely successful.

3.3.1 Actuarial notions of risk

Along with the question of whether the meaning, and role, of risk has changed is the question of whether risks have become more materially prevalent (or more serious) in contemporary society, or whether there is simply more focus on risks. Douglas (1992) and to a lesser extent Giddens (1994c) argue that there has been a greater emphasis on risk. In contrast Beck (1992) argues that there has been both a qualitative and quantitative change in risk; that risks have emerged as more materially prevalent, and that it is now a time of unprecedented globally significant risks.

9 This is an argument that has similarities with Beck’s argument (discussed in section 3.4.1) about the link between the shift to reflexive modernity and the emphasis on risk. 10 A concept very similar to the Foucauldian notion of biopower explained in the Chapter Four.

42 Beck (1992) emphasised the material prevalence and increased significance of risks in his seminal book, Risk Society, where the notions of apocalyptic risks loom large. While Marx described the spectre of Communism haunting Europe, for Beck it is the spectre of environmental devastation that haunts Europe. Risk Society is written and conceptualised in the shadow of the 1986 Chernobyl disaster and its aftermath, a Europe haunted by radiation and acid rain. It is within this context that Beck appears to suggest that there has been an almost epochal increase in risk, both in number and scale as a consequence of modernity itself. This suggestion has been one of the main areas for critique of Beck’s theories. The criticism is that Beck overemphasises the influence of risk in the contemporary society (see for example Scott 2000, Elliott 2002). Beck himself is sometimes equivocal about the degree to which risks have become more intense, as he notes in Risk Society: ‘it is not clear whether it is the risks that have intensified, or our view of them’ (1992: 55).

As Beck’s theory developed it became clear that the socially constructed nature of risk is an essential element of risk society, so that our view of risks is part of what makes risk society significant. As Beck states hazards are never merely statements of facts, but they inherently contain both a theoretical and normative component (Beck 1992: 27). This, Beck argues, is one of the central elements of conflict in risk society. In his later work Beck clarifies this argument, noting that ‘the definition of danger is always a cognitive and social construct’ (Beck 1994: 6). Nonetheless there is clearly an important element of Beck’s conception that holds that there are new risks that are quantitatively and qualitatively different from previous risks. They are typically globalised risks that no one can escape from, and this idea of inescapability is crucial to Beck’s theory. It is the global reach and the inability to escape risks, which make them such a potent concept to Beck.

In contrast other theorists, particularly Giddens (1994a), are much clearer that the growing influence of risk is primarily a social construction. It is this socially constructed nature that lies at the heart of Giddens’ interest in risk, as exploring the way that ideas of risk are used and understood can help to explain changes in the way society operates. Giddens, who otherwise holds similar views to Beck in relation to risk, is very clear that he sees risk as having nothing to do with ‘real’ danger; that risk ‘in modern life has nothing directly to do with the actual prevalence of life- threatening dangers’ (Giddens 1999: 115). This is the very essence of what makes risk significant, that risk is something essentially different from hazard or danger. The crux of what makes risk meaningful, for Giddens, is the exploration of why risk has

43 assumed such importance to social life when there has been no material increase in danger.

Beck himself eventually concludes that the best way to understand risk is as neither entirely material, nor entirely social. He argues that it is cultural perception and definition that constitutes risk, however it is only by thinking of risk in terms of reality that its social materialisation can be understood (2000a: 213). This conclusion suggests that risk stands as neither fully factual claims nor exclusively value claims.

3.4 Beck and the Risk Society

Beck’s theory of risk society is one of the most influential attempts to explain the significance of risk and risk thinking (Beck 1992, 1994, 1995, Beck and Beck- Gernsheim 1996, Beck 1998). He has been a particularly influential thinker about risk primarily because he locates the contemporary focus on risk to wider changes in society. Beck uses the idea of risk to help to explain changes in contemporary society as it shifts away from industrial modernity. He sees that it is the role of risk in the changes in society that helps to mark risk as something different from ideas of ‘hazard’ and ‘danger’. Beck (1992) argues that concepts of risk have emerged as a way of trying to cope with the increasing uncertainties of contemporary times, what Beck refers to as ‘reflexive modernity’. Risk needs, as Luhmann (1993) argues, to be understood in relation to a theory of modern society and shaped by that conceptual apparatus; Beck provides that apparatus.

Beck, and to some extent Giddens (Giddens 1994c, 1999), strongly link the contemporary emphasis on risk to changes in modernity. As Culpitt (1999: 110) notes Beck ‘has made understanding the concept of risk fundamental to an assessment of modernity’. Beck and Giddens argue that risk has become more central to our society as the uncertainties associated with life increase. They argue that risk society begins when traditional certainties can no longer be taken for granted, because the less traditional certainties can be taken for granted the more risks have to be negotiated. The relationship between modernity and security lies at the heart of Beck’s definition of risk, which is that risk is: ‘a systematic way of dealing with hazards and insecurities induced and introduced by modernization itself’ (Beck 1992:21). This definition points to the way that practices of risk assessment and management have emerged as ways of attempting to normalise and control the world of uncertainties. Control is the

44 core of Beck’s understanding of risk; that risk emerges as society struggles with how to exert control over a world that appears ever more uncertain and changeable. It is through attempts to create a world of predictability and security that risk becomes central.

There are two key elements to the theory of risk society, first reflexive modernisation and second individualisation. Reflexive modernisation is an attempt to theorise changes that have occurred as modernisation has begun to modernise itself. The effect of this modernisation has been that the growth in knowledge has created ‘manufactured uncertainty’. As knowledge has grown with modernisation so has the realisation of what we do not know, and may never know. Thus a growth in knowledge leads to a growth in uncertainty. In this sense reflexive modernisation encompasses the increasing disorientation of the contemporary age. One particularly pertinent aspect of this disorientation is the impact of individualisation; this refers to the way that individual choices become both more available, and simultaneously more unavoidable.

3.4.1 Reflexive modernisation

The idea of reflexive modernisation is central to Beck’s conception of risk society. The importance of reflexive modernisation to Beck’s understanding of risk is all too often ignored by his critics, who argue that Beck privileges ‘risk’ too much in explaining changes in contemporary society (see for example criticism by Alexander 1996, Culpitt 1999, Scott 2000, Elliott 2002, Burgess 2006). Understanding risk in relation to reflexive modernisation helps to explain Beck’s insistence on risk as a key concept in explaining changes in contemporary society. In particular the idea of reflexive modernisation is useful in showing how there has been a change in how risk is thought of, and how there has been a change towards manufactured risk. Both Beck (1995: 12) and Giddens (1999: 4) conceptualise risk as having two key stages, first external and second manufactured. In the first case risk is simply a way of calculating the future, for instance the use of risk as a way of calculating insurance; this treats risk as a given. In the second case of manufactured risks these emerge reflexively out of the very processes of modernity; they are risks that are bound up in knowledge and interpretation of knowledge.

These manufactured risks are central to understanding what Beck refers to as ‘reflexive modernity’. Beck argues that there are multiple modernities and that the

45 contemporary age is a new form of modernity. Contrary to other attempts to understand the contemporary situation he does not see modernity as having been replaced by another social form, such as ‘post-modernity’. He rejects the concepts of ‘posts’ as suggesting too fundamental a break with previous modernities and thus losing sight of the continuities with industrial modernity. At the same time Beck recognises that the contemporary world is significantly different, with a range of implications for individuals and societies, as he puts it in Risk Society:

The thesis of this book is: we are witnessing not the end but the beginning of modernity – that is of a modernity beyond its classical industrial design (Beck 1992: 10).

Reflexive modernisation is not about finding a mid-point between ideas of modernity and post-modernity, but has emerged dialectically from the encounter between entrenched modernist thinking and postmodern critiques (Gleeson 2000). It identifies something distinct from either modernity or post-modernity.

Beck (2000a) recognises that there is a problem distinguishing between reflexive modernity and modernity, but he cautions that using the frames of reference of the 18th and 19th century leaves us trapped in those categories. Reflexive modernity is different from traditional industrial society, but still retains elements of modernity; it involves an intermingling of continuity and discontinuity. As I will later show this is an important insight into how contemporary mental health policy and practice can be conceived. This helps to explain how it is no longer sufficient to conceive of mental health care as existing in a dichotomous state of either community or institutional care.

The central element of reflexive modernisation is the recognition that the contradictions of modernity are of its own making- that is they are reflexive. This idea holds that reflexive modernisation arises from autonomised modernisation processes which are blind and deaf to their own effects and threats (Beck 1996: 28). Thus the transition from the industrial period to reflexive modernity arises unseen from the latent side-effects of modernisation. Manufactured uncertainty is central to this argument, this is the idea that risks are produced as a consequence of scientific and political efforts to control or minimise them; manufactured uncertainty thus arises in some senses from our expanded knowledge.

46 Reflexive modernisation suggests that the modernist foundations of risk calculation are undermined. As risks become larger in scale, more removed from their local contexts and more reflexive, then rational scientific modernist techniques of risk calculation become less reliable. The reflexivity of modernity therefore begins to subvert the emphasis on reason. No knowledge under the conditions of modernity is knowledge in the old fashioned sense of knowing as being certain (Giddens 1990). Effectively our world becomes more contingent, more open because of the knowledge that we have acquired about ourselves. Reflexive modernisation reintroduces the idea of doubt, what Gleeson (2000: 123) refers to as ‘the great emancipatory legacy of the enlightenment’. Doubt becomes essential in the risk society, as expert knowledge is central to how doubt is created since critique and doubt is how experts accumulate knowledge. The increased importance of doubt leads to the contemporary emphasis on safety and security discussed below.

3.4.2 Individualisation

The corollary of reflexive modernisation is individualisation, which suggests that risks and the activities associated with the management of risk are central to the ordering and functioning of individual and collective identity. Individualisation involves the collapse of previously collective social forms, so that the individual becomes the primary social agent. Instead of large social forces directing the experience of collectives, individual choice and agency become more significant in people’s lives (Beck and Beck-Gernsheim 1996).

As the process of reflexive modernisation occurs the hold of traditional certainties in determining social practices is weakened and individual choices become both more prevalent and less avoidable. An example of this effect is the residualisation of traditional, lifelong, single employer careers of the industrial modern world. As these increasingly disappear and work becomes more unstable people are forced to make constant, deliberative planned decisions about their work lives (Beck 2000b). Individualisation results in a proliferation of new demands on people. As choices become more complex life becomes simultaneously less certain and more under individual control. Individualisation thus has the twin effects of both emancipation and feelings of anomie (Beck and Beck-Gernsheim 1996: 42). It results in both the freedom to choose and the pressure to conform to internalised demands combined with greater uncertainty over personal security.

47 The culmination of the process of individualisation is that agency becomes more important, whether we like it or not. Reflexive modernisation emerges as a form of individualised, and privatised modernity (Bauman 2000: 7). In this world of individualisation there is greater importance placed on the individual maintenance of good mental health, such as by public health campaigns, and the importance placed on fulfilling treatment regimes. Responsibility is ascribed to the individual for their health, so those who fail to maintain their health are responsible for their own failings. It becomes acceptable to circumscribe those people’s rights, as their own failings have meant that they forego protections. So the ‘freedoms’ of the contemporary age are mixed freedoms. As Beck (1998: 3) puts it freedom’s children need to struggle with the new problems which are raised by internalised freedom, including the question of how longing for self determination can be brought into harmony with a longing for community. These struggles have implications for the politics of society with an inevitable effect on public policy, including mental health policy.

3.4.3 The politics of risk society

For Beck, and others such as Giddens (1998) and Hudson (2003), interest in the risk society is linked to questions about how social distribution has changed under the influence of reflexive modernisation and individualisation. In the risk society distributional conflicts over ‘goods’ (in the sense of things of benefit such as income or jobs, rather than the sense of commodities), which formed the basis of conflict in classical modernity during the industrial era have been covered over, or replaced by, distributional conflicts over ‘bads’ (such as pollution). These conflicts over ‘bads’ are fundamentally conflicts over how risks accompanying facets of modern-life can be distributed, controlled or prevented (Beck 1994: 6). Thus in risk society social imperatives change from eliminating scarcity towards eliminating risks. As Beck (1992: 49) puts it:

The driving force of the class society can be summarized in the phrase: I am hungry! The movement set in motion by the risk society, on the other hand, is expressed in the statement: I am afraid! The commonality of anxiety takes the place of the commonality of need.

This is not to suggest that there are no longer material inequalities, but rather that collective responses to these have been rendered less significant by the process of individualisation. Concerns over material deprivation have given way to less definite, more amorphous fears over the presence of less tangible ‘bads’.

48 3.4.4 The significance of risk

One of the major critiques of Beck’s theory is that it overemphasises the role of ‘bads’, and that there is no convincing reason to place risk at the centre of changes to modernity. These critiques hold that Beck’s theory is too sweeping, with too little reference to the people’s experience of everyday life. For instance Beck has been criticised for suggesting that the only previous political action was around distributive and material issues (Alexander 1996, Elliott 2002, Mythen 2005). This critique is unconvincing, as it relies on too broad a reading of Beck thus ignoring the nuances of Beck’s argument. Beck clearly does not suggest that previous political action was only around distributive material issues nor does he suggest that current political action is only around the distribution of ‘bads’. This critique misses one of the central elements of Beck’s theory, that of continuity. Beck sees contemporary trends as having both discontinuities and continuities with previous trends; he is interested in changes of emphasis not total change.

Similarly a second set of critiques suggest that Beck effectively removes attention from the everyday risks that threaten the lives of ordinary people, such as poverty and unemployment by emphasising broad global risks (Rose 2000a). This critique holds that Beck and others focus too much on ‘trendy’ risks associated with technology, neglecting the mundane risks especially those that afflict populations beyond advanced Western nations, and Western Europe in particular. A key element of this critique concerning the importance of everyday risks is that Beck draws too much on a limited number of empirical examples, primarily large scale environmental risks, and does not test his theory with enough rigour on a range of empirical examples (Draper 1993, Scott 2000), as Mythen puts it:

The theory of distributional logic is fundamentally reliant on the replication of a well-worn set of examples. Of course, utilising the most catastrophic of risks as a basis for constructing a general argument is an unsound sociological strategy (2005: 4.2).

Certainly Beck’s earlier work was specifically located within a particular European context of environmental risk. This foundation has influenced the way that risk society theory has been utilised and the way that Beck himself understands risk. In his early work there was a strong focus on the apocalyptic nature of hazards in contemporary society, particularly on the hazards of nuclear destruction and environmental catastrophe. Beck’s attention has been on the extent to which hazards in the contemporary world have become larger and an order of magnitude more significant

49 than in earlier times. As a result risk society theory has tended to concentrate on larger social and technological changes such as individualisation and globalisation, which it sees as deeply implicated in reflexive modernisation. This is reflected in the geographic and social policy literature that has embraced Beck's theory. There is a heavy reliance on this framework to understand environmental change (see for example Baxter, Eyles and Elliott 1999, Bennett 1999, Bulkeley 2001). However as Lash and Wynne (1992) argue, in their introduction to Risk Society, Beck's theory is widely applicable as modernisation involves not just structural change but a changing relationship between social structures and social agents.

Beck’s later studies of work (2000b) and love (Beck and Beck-Gernsheim 1995) shows that the core of the risk society thesis is a helpful lens through which to understand a range of contemporary issues, from the global to the intimate. This wider focus has also been adopted by one of the other key theorists of risk society, Giddens who utilises ideas from risk society theory to explain changing public policy.

3.4.5 Giddens and public policy

Giddens’ work parallels much of Beck’s thought in emphasising that the increasing importance of risk has been driven by changes in modernity, particularly the growth of the significance of uncertainty. Giddens has similar views to Beck in that he sees reflexive modernity as being characterised by transformations in traditional habits and customs (Giddens 1990, 1994b). He is clearer, however, in seeing that people are not more exposed to risk, or even more anxious about them, but argues that risk is closely linked to things over which humans are seen as having potential control. For Giddens the idea of risk is bound up with the aspiration to control and in particular with controlling the future. Risk becomes important in a society that is preoccupied by the future. This is an elucidation of one of the main aspects of risk society theory and provides a marker of the difference between the ‘risk’ in the risk society thesis and concepts of uncertainty, or danger. It is this attempt to exert control that marks out the significance of risk in contemporary society.

It is these attempts to exert control over risk through the social management of risk that has transformed public policy. Giddens’ (1999) emphasis on the changing role of trust in reflexive modernity is a particularly useful way of understanding this. He emphasises the importance of trust in face of the uncertainties of the contemporary world and focuses on the link between ideas of risk and responsibility. Giddens

50 argues that responsibility is associated with modernity and that the transition from external to manufactured risk is bringing about a crisis in responsibility. This crisis is occurring because of the ambiguous nature of situations of manufactured risk, which means that responsibility cannot be easily attributed or assumed (Giddens 1994c, 1999).

One impact of this is it changes the spatial relations of reflexive modernity. This is characterised by what Giddens refers to as ‘an emptying of time’ and disembedding of social systems (1990). Disembedding refers to the way that social relations are no longer part of their local context and expert systems, such as bureaucracies, come to replace them. This shift has created a situation where individuals have no choice but to place increased trust in abstract institutions, which results in a greater emphasis on the importance of trust. As a result there is greater shared risk than ever before and thus one of the major tasks entrusted to these institutions becomes that of risk management. There is a high degree of reflexivity implied in the position of Giddens. Trust is invested in institutions in order that such institutions may use their ‘expert’ knowledge to manage risk, but in turn those institutions themselves become new sources of risk.

Giddens has exercised significant influence over contemporary political debates, being an especially influential figure in relation to Tony Blair’s ‘New Labour’ policy approaches of the 1997 Labour Government in the United Kingdom (see particularly Giddens 1994a, 1998, 2001). The Labour Government was influenced by Giddens ‘third way’ theory, which is derived from his understanding of reflexive modernity (Randall 2004). Giddens argued, among other things, that given the impact of individualisation one of the main tasks of government should be to equip people with the tools to be able to make their own biographies. This saw him stress education and enterprise as a way for people to be empowered to deal with risks. Giddens is most concerned with how society should address the growing prevalence of risk and what the implications of this focus of risk are.

3.5 Risk and Safety

One of the main implications of the growing pervasiveness of risk on the lives of individuals and society has been a growing political and policy emphasis on safety and security. It is this emphasis on safety and security that makes understanding the

51 role of risk in mental health policy so pertinent. As I showed in Chapter Two Castel (1991) argues that risk has provided the technology to allow more decentred forms of care and control of people with mental illness to operate. Castel, however, largely ignores the way the new emphasis on risk has resulted in a renewed societal emphasis on trying to achieve safety and security.

Indeed I argue, drawing on Beck (1992), that effectively the normative project of the risk society is safety. The discourse, and dominance, of risk begins where trust in security and belief in progress end (Beck 2000a). Risk comes to the fore as traditional certainties crumble under the pressure of reflexive modernity, thus safety and security emerge as ways of trying to regain control over these new uncertainties. They are driven by a loss of control and the desire to reassert control. This, though, is a very particular form of control. It is an attempt to control future events, as in the risk society it is the future where uncertainty resides most strongly. It is events which do not yet, and may never, exist which influence actions (Beck 1995: 11). As a result the social impetus for addressing risk lies in the future.

While control is central to the risk society there is an ambiguity about that control, as by its very nature risk can never be entirely controlled. Risk management never tells us what should be done, but merely what should not be done, as Beck (1994: 9) puts it ‘with risks, avoidance imperatives dominate’. Under the impact of modern risks and new forms of uncertainty the traditional ways of determining and assessing risks become less potent, leading to a questioning of the legitimacy of bureaucracy (Beck 1995: 16). The recognition of the unpredictability of threats produced in the risk society results in self-reflection on the cohesion of society and the return of uncertainty to society. Risk problems are increasingly characterised by having no clear solutions, they are ‘distinguished by fundamental ambivalence’ (Beck 1995: 8). This is the case with mental illness where there is widespread disagreement even about what mental illness is, let alone about how to exert appropriate care and control of people with mental illness. The ability of mental health professionals to predict the likelihood of a violent act being carried out by a particular person diagnosed with a mental illness is very poor (Dallaire et al. 2001). Thus attempts to exert care and control over people with mental illness are themselves uncertain.

One attempt to address the ambivalence that characterises the risk society has been to see uncertainty as driven by a decline in traditional values and institutions and to seek to revitalise these, one example of this being the rise of neo-conservatism in the

52 United States (Bauman 2000). Another approach has been the growing influence of communitarianism over the last decade. Communitarian philosophies have exerted increasing influence over politics in a number of Western countries, most notably the UK (Driver and Martell 1997). Bauman (2000) argues that this is an expected reaction to the ‘liquidification’ of modern life. In other words it is a reaction to the declining certainties about the way that life should be lived, and what the norms of life are, as well as to a changing balance of freedom and security in everyday life. Communitarianism has become more prominent because communitarians realise that to obtain safety and security individual freedom may need to be limited (Bauman 1996). They have recognised the continued and continual tension between risk and security.

The continued tension between risk and security is part of the individualisation of society where the focus on risk has increasingly reinforced the primacy of the individual within contemporary modernity. Risk has been used to reinforce and generate the power of an all-pervasive colonising of our self-consciousness such that the ‘solitary’ individual is the dominating symbol of our times (Culpitt 1999). As people focus on their own performances and are thus diverted from the social space where contradictions of individual existence are collectively produced they are tempted to render the causes of misery intelligible and so tractable and amenable to remedial action (Bauman 2000). There is thus a demand for individual causes to which individuals can attribute their common fears. This relates to the ongoing embodiment of risk, where risk has increasingly moved away from something that is exerted on people towards something that is embodied in particular people, such as people with mental illness.

This desire to assess individual causes of risks to which people can attribute and assuage their fears has resulted in concern that due process and individual rights are increasingly being subjugated by concern for community safety and political decision making driven by the desire to exert control over risk. Hudson (2003: xi) examines this process in relation to criminal justice, concluding that there has been a risk oriented, ‘justice-careless’ policy shift, where adherence to principles of justice has been weakened by excessive concern with safety and with fear of crime. She argues that risk thinking has become so routinised and pervasive that it has become an accepted status quo. In this shift the individual rights of those people who are identified as being, or being associated with, a ‘risky group’ are undermined, regardless of whether they as individuals pose any actual threat. Hudson gives the

53 example of the way that offenders in the UK are given risk scores in relation to the possibility of early release, or for the intensity of community supervision. These risk strategies are not being driven by clinical judgements that a particular individual will reoffend, but because they possess characteristics associated with reoffending. This is also characteristic of how people with mental illness have increasingly been assessed with less focus on the particular individuals and more on risk factors which might be applicable to individuals (Doylan and Doyle 2000).

Hudson’s argument has been reiterated by a number of other theorists (such as Petersen and Lupton 1996, Greig 1997) who show that as governments have increasingly adopted risk avoidance as a primary concern of governance there is an increasing emphasis on the task of identifying and containing risky people, groups and situations. These concerns have been most clearly seen in relation to examination of the ‘get tough on crime’ policies increasingly adopted by most Western Governments (Stenson 2001b). These critics argue that the normative shift towards security and focus on management and control of risk has led to increased incarceration of marginalised people, including people with mental illness.

The difficulty in balancing freedom and security highlights one of the key questions to arise from thinking about risk. This is whether the uncertainty and incalculability which is inherent in the risk society will be managed through the traditional patterns of instrumental control, such as more technology and government or will they be replaced by new ways of thinking and acting which affirm ambivalence and accept uncertainty as inevitable (Beck 1994: 10-11). This is a question that my thesis attempts to address, namely the degree to which risk is associated with a return to the more traditional spatial control of people with mental illness or to which it is associated with new spatially decentred forms of control.

3.6 Risk Society in Context

The incalculability of risk society is central to Beck’s theory, yet too often this incalculability has been ignored by social scientists who use risk as an explanation as though it is a uniform phenomenon acting across a neutral space. Rose (1998) lays the blame for this firmly at Beck’s door. Rose argues that the terminology ‘risk society’ implies 'something homogenous and all embracing, an array of effects that are amenable to an epochal sociological explanation’ (2002: 213). Whereas Rose

54 suggests that risk society is more accurately a motley array of thinking and action that has come to reformulate itself in vocabularies of risk. The implication of Rose’s argument is that risk society theory should not be baldly applied to try and explain societal transitions, but rather used to grapple with the difficulties and challenges arising in disparate places.

Rose’s argument is a mischaracterization of Beck’s position as Beck has always recognised that many modernities, accompanied by highly differentiated practices of risk, are possible under reflexive modernisation. Indeed he argues that one of the characteristics of reflexive modernisation is the continuities and discontinuities with previous periods of modernity (Beck 1994: see especially 24-26). However much of the research which draws on Beck’s theory does treat risk society as a homogenous explanation.

I argue that space matters in terms of the conceptualisation of the influence of risk on mental health policy. It matters in both senses of space previously discussed, namely areal differentiation as well as spatial relations. Attention to areal differentiation or how things differ between places and spaces helps to challenge the homogeneity associated with theories of risk society. Much of the work that draws upon concepts of risk society has been profoundly aspatial and atemporal, it has little regard for how risk has emerged differently in different times and places. Beck himself shows awareness of a sense of geography as areal differentiation. In particular he is alert to the emergence of a range of modernities. If risk society emerges reflexively from the processes of industrial modernity, then it inevitably emerges differently in different places depending on the context from which it emerges. As Philo (2000a) argues, in relation to Foucault’s use of geography, phenomena, events, processes and structures are always fragmented by geography. Yet within the literature of risk society there has been very little attention to the way that risk society may be operating differently in different places, rather it has been treated as a phenomenon that applies uniformly across the Western world. In one of the few works to acknowledge this Burgess (2006: 329) notes that:

While risk related developments are now commonplace and appear diffuse … risk perceptions are constructed and continually modified by historical, economic, social, political, and institutional forces.

If there has been relatively little focus on the areal differentiation aspects of risk theory then there has been even less on the spatial relations of risk. Giddens,

55 however, is alert to the significance of spatial relations, which he identifies as a crucial constitutive aspect of risk society. Giddens (1990, 1994b) argues that the separation of time and space and their recombination is an essential element of risk society. This forms a key foundation of his argument that trust plays an increasingly important role in reflexive modernisation, in that it acts as a form of guarantor across increasingly distanciated time and space (Giddens 1990: 33). As time and space are reorganised in non-local ways then new mechanisms develop to restructure social relations across time and space. These are primarily symbolic tokens and expert systems; trust is essential to both of these mechanisms. This argument draws on an understanding of spatial relations that recognises how spatial configurations of all sorts enter into the very constitution of whatever events, phenomena or processes are under investigation. There has been little research drawing on ideas of risk society that recognises that space is not simply a socially produced materiality, but also a socially produced object/sign system. This does not deny materiality, but rather argues that any materiality is attached to the representations through which that materiality both embeds and conveys social meaning.

Thus instead of being treated as a universal explanation risk needs to be examined, as Rose (2002) argues, with diagnostic thinking, seeking specific answers about how risk has emerged in particular contexts and with particular consequences. This view has informed my decision to include an historical element to the analysis in this thesis. Understanding the spatial relations of risk and social control forms a core ambition of my thesis. My research aims to assess claims by Castel that risk has allowed a decentring of control over people with mental illness by looking at how contemporary policies of confinement relate to ideas of risk.

3.7 Conclusion

As I illustrated at the end of Chapter Two theorists such as Castel (1991) and Moon (2000) have argued (in different ways) that the contemporary focus on risk has reshaped the way that society manages mental illness. The aim of this chapter has been to establish the framework from which to assess such claims.

I have established this framework in three key ways. First I have demonstrated the extent to which risk has become a central social issue of our time. In doing this I have shown how use and understanding of risk has shifted from the idea of an objective

56 measurement of hazard towards understanding risk as social constructed. In particular I have illustrated how risk starts to perform a new social role when it shifts from something over which humans have no control towards something people can attempt to control.

Second I have argued that it is precisely this relationship between risk and control which is why risk is such a central concern in investigating mental health systems and policies. The question of how uncertainties are addressed and managed has become a central political question. Risk is crucial to this question because practices associated with risk constitute an attempt to exert control over and govern the future and counter uncertainties. As Reddy (1996:224) notes:

It is this historical transformation (to the risk society), which reflects a new phase in the “modernization of modernity”, that makes the question of how we will conceive of uncertainty a central political question of our times, and not only a matter for arid intellectual debate.

It is when risk became a way of trying to exert control over uncertainty that it came to play a political role. Here I have drawn on Giddens to argue that attempts to exert control over risk through the social management of risk have increasingly transformed public policy. There is a central tension that practices based on risk can inherently never completely succeed in eradicating uncertainty. This is central to the tension that forms a key part of the exploration of risk and mental health policy in this thesis, namely how does governance of mental illness attempt to manage uncertainty in this era of reflexive modernisation. This is a question addressed in the following chapter, which focuses on the role of risk in the governance of society, particularly in relation to mental illness.

Third I have demonstrated the extent to which too many social theorists have treated risk as though it was a uniform phenomenon acting across neutral space. There has been little regard for how space and historical context inevitably fragments such explanations. This failure of attention to the context of the adoption of risk in public policy is a failure my thesis tries to avoid through its detailed historical examination and its alertness to geographical context.

57 Chapter 4. Governmentality, Risk and Mental Health

4.1 Introduction

As I have shown in the previous chapter a central political question has become how the uncertainties and ambivalences that characterise risk society are managed. This is a question that I argue can be fruitfully addressed using governmentality theory. The aim of this chapter is to illustrate how governmentality theory has conceptualised risk and the intersection between risk and health. In particular I show how both governmentality and risk theorists have argued that the notion of risk has been used to facilitate a move towards spatially decentred forms of social control.

The governmentality approach is initially drawn from the work of Foucault and has been used to try and explain and understand the increased role of risk in the government of society. Therefore governmentality theory sits in an uneasy relationship with the risk society theory discussed in the previous chapter. On the one hand it acts as an alternative way of explaining changes to the style and substance of contemporary governance. On the other hand governmentality theorists have increasingly drawn on the insights of risk theory to explicate their views. This chapter explores the relationship and tensions between governmentality theory and risk society and what these tensions reveal about the role of risk in relation to mental health.

Governmentality theorists have been particularly interested in the relationship between risk and neoliberalism (or what Rose (1999) refers to as ‘advanced liberalism’). Many governmentality theorists see neoliberalism as a particular form of governance that uses risk as a way of managing the population. This is a form of political rule that champions individual freedom and rights against the intervention of the state. Risk is seen as a governmentality strategy of regulatory power by which populations and individuals are monitored and managed in accordance with the approach of neoliberalism.

This chapter begins by explaining the way that governmentality theory has been used to think about the role of risk in contemporary society, drawing particularly on the relationship between neoliberalism and biopower. The governmentality perspective has been utilised by criminologists who are trying to explain the relationship between

58 risk and crime control. I explore this research with a focus on what insights this might provide for understanding the relationship between risk and the governance of people with mental illness. In particular I draw on governmentality theory to further explore the shift, which was discussed in Chapter Two, of the increasing decentralisation of control over individuals. I argue that moves towards a renewed emphasis on confinement, as identified in Chapter One and in later in my case studies, pose a challenge for governmentality explanations of the role of risk.

4.2 Governmentality and Risk

Governmentality theory derives primarily from the work of Foucault and particularly his writing in the late 1970s and early 1980s. The idea of governmentality acts as a bridge joining together two key aspects of Foucault’s work. It bridges his earlier work, such as Discipline and Punish (1977a) and Madness and Civilization (1967), which has a more traditional social control perspective, and his later work, most notably his History of Sexuality (1985, 1998), which focuses on technologies of the self and subjectivity. His concern with questions of governmentality arose from criticisms that his earlier work did not adequately conceptualise the relationship between the state and society (Gordon 1991: 4). Foucault developed his ideas around governmentality based on his concern that other theories of government focused too much on the institutions of the state and not enough on the practices of the state. Foucault argues that practices of governance are as important as intentions. Governmentality theory thus seeks to elucidate the relationship between the government of ourselves, the government of others and the government of the state (Dean 1999). Governmentality exists, as Foucault puts it, as a relationship between sovereignty, discipline and government (Foucault 1991: 87).

One of the reasons that governmentality has increasingly been adopted and utilised by social theorists (such as Dean 1999, Rose 1999, O'Malley 2001) is that it offers a useful theoretical approach to understanding how society and power operates in an increasingly decentred world; a world where there is more individual freedom and power than ever before. Governmentality theory recognises that traditional ways of analysing power and politics that focus on who holds or wields power appear to be increasingly obsolete. The crucial insight of the governmentality approach is that individuals are increasingly encouraged to regulate themselves and their own

59 behaviour. Governmentality tries to look at how this happens, what Foucault refers to as ‘the conduct of conduct’ (Gordon 1991: 2).

The emphasis on trying to understand self regulation is apparent in Rose’s definition of governmentality, which encompasses both control over others and self-regulation. More precisely he defines governmentality as:

All endeavours to shape, guide, direct the conduct of others, whether these be the crew of a ship, the members of a household, the employees of a boss, the children of a family or the inhabitants of a territory. And it also embraces the ways in which one might be urged and educated to bridle one's own passions, to control one's own instincts, to govern oneself (Rose 1999: 3).

As this definition implies the governmentality perspective views power as more than just the top down imposition of force. Instead it focuses on how individuals are governed at the micro-level and how behaviours are facilitated which produce and reproduce a particular social and political order; on how thought becomes linked to and embedded in technical means for the shaping of conduct. The analytics of governmentality seeks to show that what is taken as self evident is not. That there are multiple processes whereby realities are assembled into relatively stable forms of organisation and of institutional practice (Dean 1999: 21). In the governmentality perspective the activity of government is bound up with the activity of thought - government is both made possible and constrained by what can be thought (Rose 1999: 8). Governmentality recognises that knowledge, and the way it is shaped, is fundamental to how existence is rendered calculable.

The governmentalisation of the state is an essential element of understanding the link between governmentality and risk. Governmentality understandings of risk suggest that risk has emerged as a technology of governance which helps to connect the power of the state with the ability to regulate economic life and the habits of the population. Thus the state has become much more deeply involved in the lives of its subjects. Foucault (1998) suggests that the emergence of liberal forms of governmentality over the past 300 years is linked to the increased power of experts and expertise in the state, particularly in relation to demographics. As Hacking (1990) outlines, in his history of risk and calculation, the state significantly increased its emphasis on measuring and quantifying the population and its characteristics during this period. This is what Foucault refers to as ‘biopower’, a concept that other theorists have taken up as biopolitics.

60 4.2.1 Biopower and neoliberalism

Biopower is the administration of the processes of life of the population, ‘an explosion of numerous and diverse techniques for achieving the subjugations of bodies and the control of populations’ (Foucault 1998: 140). This is a crucial technology of power of the modern state, which is aimed at enhancing the lives of the population through the application of the concept of norms. Biopower contrasts with earlier forms of power that were based on the power of violence, such as the threat of death. It serves to make the population ‘governable’, a process which Rose (1999) refers to as making government intelligible. In order for the ‘conduct of conduct’ to occur that which is to be governed must be made concrete and knowable. Through the use of these demographic methods norms and deviances become knowable. These norms become the focus of self-governance, what the individual is encouraged and internalises the desire to aspire to.

Governmentality, or more precisely what Dean refers to as the ‘analytics of government’ (1999: 9), is concerned with the analysis of the specific conditions under which particular regimes of government emerge. This analysis suggests that there is no single reason that constitutes particular regimes of power. Rather there are a range of processes which assemble different objects and subjects into stable forms of organisational and institutional practices (Dean 1999: 21). Governmentality provides insights into how we govern and are governed under different regimes of power and how such regimes emerge, operate and are superseded. This focus on changing regimes of power has influenced theorists such as Culpitt (1999), Rose (1998, 2000b), and O’Malley (1998, 2004), who have drawn on Foucault’s work and on governmentality theory, to try and understand the way that risk operates as a key process in constituting neoliberal government. These theorists have linked the rise of neoliberalism and the emergence of new forms of governmentality, which serve to reproduce the social and political relations of neoliberalism, with the increasingly central role that risk plays in society

Rose (1999), in particular, has developed the notion that neoliberal governmentality can be characterised by what he refers to as a mode of governance based on ‘the power of freedom’. This form of governance operates not through oppression and direct coercion, but instead through using freedom as a technology of government. This practice of government is aimed at establishing the sphere within which action occurs. Effectively neoliberalism employs the notion of choice as the fundamental

61 human faculty that overrides social determination. Neoliberal government uses freedom as a technical means of securing the ends of government. Freedom forms a key foundation of the politics of the present. It increasingly shapes both how we should be governed and how we govern ourselves. This argument relies on the notion that society cannot simply be freed, but has to made free. As such neoliberal governments have sought to create a series of ways through which subjects manage their own conduct. This produces individuals who do not need to be governed by others, as they govern themselves. In this understanding “to govern” does not mean the diminishment of people’s capacity to act, but rather presupposes their freedom and attempts to develop knowledge of people capacities to act and use it for the purposes of government. The aim of this is to develop subjects into individuals who are capable of making autonomous decisions.

4.2.2 Neoliberalism and risk

Neoliberal government not only governs through freedom, but it employs indirect means for the surveillance and regulation of that freedom. Risk, Rose (1999) argues, is one of the techniques that makes it possible to indirectly regulate conduct, as a form of regulation that becomes internalised within the individual subject. Risk becomes an essential technology of government that helps to make its subjects governable: ‘It is a way of representing events in a certain form so that they might be made governable in particular ways, with particular techniques and for particular goals’ (Dean 1999: 177).

One of the most important ideas linking neoliberalism, governmentality and risk is the retreat (or death) of the social (Pavlich 2001). As I have shown one key element of the risk society thesis is the increased role of individualisation. Governmentality theory similarly holds that there has been a shift from social forms of protection against danger towards individualised, or insuriantial, modes of protection. Under neoliberalism the causes of risk are no longer social nor are the protections. Instead insuriantial technologies of risk have emerged that have replaced social modes of protection, which were previously embodied by schemes such as social security. Protections against the dangers and hazards of the world have increasingly become an individualised responsibility, particularly in the Anglo-American world.

The shift to a focus on individualised risks is part of a shift to neoliberal governmentalities. Risk has been used to reinforce and generate the power of the

62 individual as the emergence of risk causes the focus of politics to shift to the security and protection of individual autonomy. This develops a self-reinforcing circuit, in that the growth of insuriantial notions of risk allows the management of governance to be devolved to the market. The establishment of individual responsibility for security, implied by risk, means that we cannot easily talk about the needs of society, which in turn reinforces the notion that security is an individual need.

The emphasis on individual responsibility for responses to danger reinforces a government focus on the lessening of risk, not the meeting of need. This reinforces the neoliberal degradation of the welfare state and its re-emergence as residual welfare states (Culpitt 1999). Under neoliberalism the attention of governance turns towards individual citizens as active subjects who are expected to police themselves as normalised subjects in pursuit of their own self-interest (Lupton 1999). Individuals are increasingly expected to be personally responsible for the risks and uncertainties that emerge in their own lives. In a sense neoliberalism both seeks to individualise and totalise simultaneously.

It is this tension between individualising and totalising which lies at the heart of the affinity of theories of risk and of governmentality. Both the literature on risk and on governmentality recognises that there is a new tension in the management or control of social deviance. While there has been a deregulation of the macro-level global society under late modernity, there has simultaneously been a requirement for a micro-level politics of surveillance and control. There has been a need to continue to exert control at an individualised level. How these macro and micro-level processes operate in conjunction with each other is a key concern for governmentality theory. This also gets to the heart of my research concerns about the spatiality of control of people with mental illness and how this operates in a society that appears increasingly deregulated.

4.2.3 Governmentality, criminology and risk

The tension between macro-level deregulation and the need for a micro-politics of surveillance has been a particularly significant issue in criminological research and theory. Criminologists have struggled to explain the apparent macro-level broadening and deregulation of responses to crime, particularly in the Anglo-American world, such as the expansion of parole, diversion and community service, and the simultaneous harshness of the micro-level of the prison system. One of the ways that

63 criminologists have attempted to explain the tension between deregulation and social control is through drawing on theories of risk.

The criminological literature that attempts to understand this tension reveals insights that are relevant to understanding the role of risk and confinement in mental health policy. Policy responses to both criminal activity and mental illness share some similarities, namely they both rely on a spatial component of control and are focused on managing and controlling social deviance. There are, of course, some significant differences, particularly in that confinement has played a more explicit and important role as a form of punishment in criminal justice than it has in relation to mental illness. Nonetheless this criminological literature illustrates the way risk has been understood in attempts to come to grips with this deregulation and control tension.

Risk began emerging as a central focus of criminological research in the mid 1980s, as it became increasingly apparent that risk was being used by the state to explain and justify policy changes in criminal justice. Early theorists focusing on risk, such as Reichman (1986) and Simon (1987), were interested in the ways in which risk management techniques such as aggregation were increasingly utilised as a way of addressing crime. Later theorists such as O’Malley (1992, 1998), Stenson (2001a) and Hudson (2003) built on this work to argue that a new penology was emerging in concert with the rise of the risk society. In this view risk has increasingly become the key mechanism through which governments try to understand and address crime. This involves a shift away from the rehabilitative and social context models of understanding and addressing crime, that were more common in the 1960s and early 1970s in many Western jurisdictions (Garland 2001), towards more punitive models of crime control.

The early focus of the criminological literature on risk was on the increasing utilisation of insurance concepts and techniques to manage the uncertainties of losses due to crimes that have or might occur (Reichman 1986: 151). Criminological theorists argued that there was a growing emphasis and reliance on probability (and risk) as part of a trend towards more insuriantial models of social control (Garland 2001). This argument was based on the idea that such models had become necessary to cope with the increasingly decentred world. As a result direct control by governments was no longer as viable as it once was, and insuriantial models of social control were necessary as ‘capital can no longer depend on the direct coercive action of the state and must search for additional forms of legitimation and regulation’ (Reichman 1986:

64 167). Simon (1987) argued that risk emerged from a confluence of two different historical processes first the growth of techniques for aggregating people and second a set of political and economic strategies that have made security a pervasive task for the state. Thus risk was entering public policy as a way of coping with the increasing macro-level deregulation.

4.2.4 Aggregation, crime and risk

The role and understanding of aggregation is a crucial one, which dominated criminological understandings of risk and has been fundamental in work on mental health and risk society. This is the argument that the growth in techniques of aggregation has been central to the application of risk as a tool for control, as it allows control to be spread and decentred. The identification of risk factors allows control to be exerted over population groups exhibiting certain behaviours or characteristics. This allows a shift away from the embodied individual who had to be spatially controlled through confinement. It suggests that in:

Crime control, as elsewhere in risk society, problems are being governed in terms of statistical aggregates, populations and distributions rather than individuals. The governance of crime is becoming actuarial in its form (O'Malley 1998: xii).

This shift led to risk management, including aggregation, being increasingly utilised as a method to deal with crime (Reichman 1986). With aggregation there is no longer a need to deal with and rehabilitate individual criminals. Instead techniques of risk management, such as criminal profiling, are applied to aggregate populations. This is a system of crime control that is aimed at minimising possible threats. It is no longer focused on specific individuals but on the distribution of behaviours in the population as a whole. This is the culmination and application of the Foucauldian concept of biopower, which allows for the administration of the population through the application of norms and the identification of deviance from these norms through risk factors.

O’Malley (1992) argues that these regulatory measures of crime control have become dominant because they function to increase the effectiveness of power. Such risk-based techniques are more effective means of control because they do not have to resort to inefficient methods of direct coercion. It is, however, too simplistic to suggest that there has been a wholesale shift from discourses of control to discourses of security. It does, however, signify an important trend, which has

65 implications for the way criminals are dealt with, namely a new emphasis on risk rather than guilt.

The change to risk management in crime signalled a move away from an emphasis on individual morality and guilt towards an emphasis on risk and safety (Hudson 2003, Mythen and Walklate 2006). This occurred as the focus of the state shifted away from individual pathologies and hence away from guilt and fault. Instead it focused on understanding and controlling aggregated behaviour as a way of facilitating increased security. This is a system of crime control that is aimed at minimising possible threats, the aggregation into populations effectively minimises individual subjectivity.

The shift away from individual subjectivity has implications for political and policy decision making in the fields of criminal justice and mental health. As Beck (1994) notes risk problems are characterised by having no unambiguous solutions. Risk tells us what should not be done, but not what should be done. Hudson (2003) explores the implications of this in relation to criminal justice and argues that due process and individual rights are increasingly being subjugated by concern for community safety. A change that undermines the fundamental rights of those who are associated with ‘risky groups’, whether or not they, as individuals, pose any actual threat. Mythen and Walklate (2006) argue that an undue emphasis on risk, which largely ignores empirical analysis of danger, has resulted in a politics of fear and vengeance. This, Hudson (2003) argues is part of a wider shift from a focus on risk management towards risk control.

4.2.5 From risk management to risk control

Hudson’s (2003) theorisation of risk and criminal justice is a rare example of work which takes seriously the need to break down and explore the heterogeneous nature of the risk society. Hudson’s analysis explores the role that risk has historically played in the field of criminal justice and argues that the provision of justice has increasingly shifted from a ‘risk management’ approach towards a ‘risk control’ approach. This represents a swing away from an emphasis on liberty towards a greater concern with security, an analysis that has strong affinities with what has occurred in the governance of mental illness.

66 Hudson’s characterisation of the difference between risk management and risk control is drawn from Clear and Cadora (2001). In this conceptualisation the aim of criminal justice systems under risk management is on keeping risks within reasonable levels, where they can be reduced and anticipated. Risk management involves the recognition of the inherent uncertainty of risk situations, and therefore the intent is not to try and eliminate or completely remove risks, but to minimise them. This approach accepts the inevitability of error when relying on techniques of risk.

In contrast risk control is about trying to prevent risk. It is about exerting external controls on risk, such as restriction of movement, to prevent the occurrence or recurrence of crime. This has an incapacitative aim that typically takes two forms: restriction of movement and psychotropic mechanisms. The purpose is to take power over situations of risk in an offender’s life such that the offender may not engage in crimes. This involves the privileging of public security over the rights of individuals. Hudson (2003) draws on these distinctions between management and control to argue that contemporary penology can be characterised by an increasing shift towards risk control and an attempt to exert complete control over the uncertainties of crime through containment.

This work by criminologists helps to highlight the way that risk can fulfil different roles in different contexts. Although criminologists have increasingly come to grips with the contradictory and sophisticated way that risk relates to criminal justice policy there has been less thorough examination of the way risk relates to mental health policy.

4.3 Health and Risk

The role that risk plays in relation to health care policy has been most apparent in the rise of the public health approach over the last few decades. Public health is concerned with addressing the health of the overall population through health promotion and prevention. It is about ways of promoting good health and preventing ill health across the population. The role of public health has become increasingly significant over the last twenty years, to the extent that it now forms a key part of government approaches to health around the world (Tulchinsky and Varavikova 2000). A typical definition of public health is provided by the Government of Australia, which defines it as:

67 The organised response by society to protect and promote health, and to prevent illness, injury and disability. The starting point for identifying public health issues, problems and priorities, and for designing and implementing interventions, is the population as a whole, or population sub-groups (Commonwealth of Australia 2003: np).

As this definition illustrates public health is a perfect example of the sort of aggregation that criminologists identified as a central feature of shifts towards a key role for risk in criminological policy. Public health also encapsulates much of the notion of biopower, with a shift towards the management of the population rather than an emphasis on individualised pathology.

4.3.1 Public health and risk

Risk has increasingly played an integral role in how ideas of public health are thought about and operationalised. The role that risk plays further illustrates the tensions between the management of the individual and society. As Peterson and Lupton (1996) argue public health effectively straddles this divide. It acts as a regime of power and knowledge that is oriented to the regulation and surveillance of both individuals and society.

Although public health is ostensibly about the health of the community as a whole it actually emphasises individuals as being responsible for their own well-being. In public health regimes individuals are increasingly expected to manage their own relationships with the world around them, and to manage their relationships with potential negative health impacts in the environment. This echoes the importance of individualisation in the risk society. In the risk society individuals are increasingly responsible for managing their own biographies, in public health they are responsible for managing their own activities based on the potential health impacts. The concept of citizen becomes a key feature of public health, as the very concept of public implies. In the 20th century citizenship has become more individualistic, rather than being construed in relation to solidarity and welfare (Petersen and Lupton 1996). Those whose behaviour is seen as risky are expected to engage in self-regulation for the sake of others. The ‘risky’ persona is placed in the position of being the source of contamination. When the risks identified by public health are viewed as amenable to change by the individual it is the individual who is given the responsibility for making that change.

68 The significance which public health places on individual responsibility for managing risks seems at odds with the notion that public health is focused on the health of the community as a whole. This, Petersen (1997) argues, following Castel (1991), is indicative of the shift of surveillance and control away from face-to-face relationships towards surveillance based on the abstract factors of risk. To Petersen public health epitomises the shift that Castel (1991) initially identified. By focusing on the health of the overall community and environment public health is about creating the context within which individuals constitute themselves as subjects in their own self-regulation of risk. This self-regulation of risk is fundamental to public health, but is less apparent in the management of mental illness, where state regulation of risk comes to the fore.

4.3.2 From dangerousness to risk

If self-regulation of risk characterises the rise of a public health approach, then state regulation of risk increasingly characterises the approach towards mental illness in Western jurisdictions over the last twenty years. As Rose (2002) argues throughout the 1990s mental illness increasingly became linked to risk. This, like Castel, he links to a shift away from individual dangerousness and individualised pathology. Rose argues that dangerousness has had a long association with madness, but that that the displacement of the language of dangerousness by that of risk indicates a change in mental health systems (also see Greig 1997). Rose suggests that this shift has occurred as dangerousness mutates from something embodied in the individual towards factors, situations and statistical probabilities. This shift indicates a change in the very way that mental health problems are understood.

The crux of the argument about the shift towards the predominance of risk in mental health policy has been (mainly following Castel (1991)) that there has been a shift from the management of people with mental illness as dangerous individuals towards the management of abstract risks across the population (Rose 2000b, 2002). This argument derives from the logic that holds that risks do not arise from the presence of a particular precise danger embodied in concrete individuals. Instead they arise from the combination of abstract factors, which render more or less probable undesirable modes of behaviour. The result of this shift is that an individual no longer needs to be individually observed for signs of dangerousness; it becomes enough that he or she is identified as a member of a 'risky population' (Lupton 1999). A shift occurs where danger, a matter of judgement or opinion, has transformed into risk, an objective quantifiable concept (Yannouldis 2002).

This argument about a shift away from dangerousness suggests that in the 1950s and 1960s dangerousness was understood as located in a few individuals, a small minority of patients. Throughout the 1970s and 1980s this mutated, dangerousness became less a quality of an individual and more a matter of factors, situations, and statistical probabilities (Pratt 1995). This increased actuarialism led to mental health being increasingly understood in terms of risk. Rose (1998) argues that this shift was partially influenced by the deliberate decisions of psychiatric professionals. They were concerned that assessments of dangerousness were too unreliable and that clinical predictions of violence were too difficult. As a result psychiatrists saw the probabilities inherent in the notion of risk as a way of attempting to address the problems of dangerousness.

Yet there is a paradox in this supposed transition from dangerousness to risk in that the very idea of dangerousness is not solely predicated on individual embodiment, a point which Castel himself recognised (1991: 283). Dangerousness implies both the confirmation of something inherent in the subject, as well as probability. The idea of a transition from dangerousness to risk also assumes that risk is not something that is, or can be embodied, which is problematic in that risk (as I will show) is increasingly being used in an embodied sense, particularly in mental health.

4.3.3 Risk and mental health

Rose (1998) argues that by the 1990s risk had become an increasingly prevalent terminology within mental health systems. He links the rise in significance of risk to the shift to community care as the site of care, an argument which Moon (2000) also makes. Confinement becomes primarily a way of securing the most risky until their riskiness can be fully assessed and controlled (Rose 2002: 218).

Rose (2002) illustrates how psychiatric professionals have differentiated risk from dangerousness in their thinking and practice. He sees three main characteristics that differentiate risk thinking from the dangerousness focus of previous mental health policy; first that it is not about legal categorisation, but administrative decision- making. Second that it is not about binary distinctions, but about location on a continuum. Third that it does not identify something fixed and inherent, but something changeable and flexible. Thus the shift towards risk indicates a change in the way that society understands and responds to mental illness.

One concern associated with this shift towards risk is that it has become increasingly unquestioned within psychiatric services. Hudson (2003) holds that this is one of the key characteristics of the use of risk in public policy. Risk has become not only pervasive, but also routinised to the extent that it becomes largely unquestioned. In one example of this Wolff (2002) shows how this idea of risk as a guiding principle has become completely ingrained in the practice of mental health professionals (also see Sawyer 2005 for an Australian example). The perverse outcome of this is that as risk culture becomes more engrained in services actuarial evidence becomes less significant. Thus the politics of risk society creates what Rothstein (2006) calls ‘institutional risk’, where those who are responsible for risk are increasingly conservative in managing it (also see Greig 1997). Institutional threats are those threats that are posed to the institutions that are responsible for the governance of societal risks. The inevitable difficulty of managing threats to society creates threats to organisations managing those risks. Thus, Rothstein argues, contemporary preoccupations with risk are driven as much by the changing distribution of ills in governance as by the distribution of ills in society.

4.3.4 Assemblages of risk

Rose (1998) suggests that viewing the shift towards risk in terms of Beck’s theory of ‘risk society’ would be a mistake as this assumes a homogeneity which does not exist. He argues that there is no move towards a particular approach towards risk, but more of what O’Malley (2004) terms ‘assemblages of risk’ which operate in conjunction with other changes in particular contexts. As Rose argues the vocabulary of risk operates differently in different circumstances, with no common mode of operation or of consequences. Further Rose suggests that actuarial styles of thought have supplemented and reshaped clinical and legal thinking, but have not replaced them. The clinical gaze of psychiatry on the individual has not been replaced by regulatory strategies targeting groups. There is not a fixed division of groups of the population into the dangerous and the risky and the non-dangerous, but rather an arrangement dependent on the idea that different types of control are appropriate for different circumstances.

This idea of different types of control relates to a theory that both Rose (2000b) and O’Malley (2004) propose, namely that shifts in contemporary governance should not be considered in terms of risk. Instead they suggest that risk strategies can be

71 divided into two categories. The first seeks to operate through inclusion, the second seeks to operate through exclusion. The first set of strategies seek to include people in the networks of society, this is analogous to Deleuze’s concept of ‘societies of control’, where control is decentralised, non-hierarchical, but constant. There is no specific surveillance, but rather surveillance is constant through practices immanent to society. The second set of strategies operate through exclusion. Exclusion refers not just to the failure to include people, but also to the very act of subjecting people to specific strategies of control. These seek to manage individuals outside the norms of society in a way to neutralise their behaviour. Confinement forms a central element of these exclusionary strategies. The notion of inclusionary and exclusionary models of risk goes to the heart of the central question of this thesis, namely how does a reassertion of confinement relate to the increased role of risk in framing mental health policy.

4.4 Conclusion

Governmentality theorists share the view that there is a shift occurring in social relationships in the contemporary era. The modes of governance of people, including people with mental illness, appear to be shifting towards a post-disciplinary actuarial mode of governance. In this new era the identification and management of risk assumes an increasingly central role. Both governmentality and risk theorists have argued that the rise of risk and associated forms of actuarial control has facilitated a move towards a post-disciplinary order where control is no longer spatially concentrated. In this new order control can be exerted through networks immanent to society. Deleuze and Castel argue that spatial concentration and exclusion are no longer necessary in order to exert control, an assessment that needs to be more thoroughly assessed, as I do in my case studies.

Where governmentality theory differs from risk society theory is in arguing that there appears to be little cohesion to these changes, either in their rationalities, or how changes are occurring (their technologies). This recognition results in governmentality theorists emphasising specifics rather than treating particular practices of government as ideal types. As a result practices of government cannot be understood as expressions of a particular principle. One of the best descriptions of governmentality theory (used by both Dean 1999, Rose 1999) is of being diagnostic. This means an emphasis on understanding specific situations; on

72 understanding the present as a set of possibilities operating within certain limits rather than prescribed certainties.

Utilising this diagnostic approach to understanding changes to the governance and control of people with mental illness means being sceptical of any claims of an epochal shift towards a post-disciplinary order. It means being alert to the complexity and contextual nature of possible strategies of controlling people with mental illness. It is from this diagnostic point that my research begins. My case studies are an attempt to examine the relationship between risk and confinement in the particular circumstances of the jurisdictions of England and Wales and Queensland.

73 Chapter 5. Methodology

5.1 Introduction

The methodology for my research is based on two key frameworks. First, historical analysis based on Foucault’s concept of archaeology. Second, policy analysis based around the critical discourse analysis (CDA) approach developed by Fairclough (1992, 1995). In the first instance my research draws on Foucault’s concept of the history of the present. This uses an understanding of history to try and comprehend the contingencies of the present without adopting a teleological approach, which sees the past as inevitably leading to the present. Second, my research focuses on the way that concepts of risk are used in policy using a CDA influenced analysis. My research aim focuses primarily on the policy frameworks that shape mental health systems and services. Accordingly the main focus of my research is on the discursive realm of policy rather than, for instance, on people’s experiences of mental health services. Although the research is focused on the way that risk is presented and rationalised in public policy, it is also concerned with the materiality of changes in the use of confinement and compulsion in mental heath treatment. These changes are traced through quantitative research looking at changes in the number of people being confined and involuntarily treated.

5.2 Methodological Design

5.2.1 The importance of ideas: A discursive approach

My research looks at the role of risk in framing the use of confinement in mental health policy. This is a research aim that is focused on the importance of the way that ideas are thought about and expressed. Therefore the research is grounded in a social constructionist perspective, which holds that our access to the world is mediated through discourse and language. It argues that all knowledge is historically and culturally specific and is a product of that culture and history and is thus reliant on the social and economic arrangements that prevailed at that time (Burr 1995, Travers 2004).

With the increasing influence of post-structuralist theory language is no longer understood as a mere reflection of meaning. Rather it is conceived as having real

74 influence in the way that meanings and concepts are understood. Language is constantly used in conjunction with actions, symbols, tools and technologies to rebuild and create understandings of the world; it has a performative role. This view is, at least partially, derived from the philosophy of Heidegger who argued that language is a means of understanding what it means to be. In Heidegger’s view language is not about representation, but rather ‘language tells us about the nature of things’ (Heidegger 1971: 146). This understanding of language as performing real actions in the world heavily influenced the work of later theorists such as Derrida and Foucault, as well as the whole school of social constructionist thought. It provides an anti-essentialist view of the world and the subject as continually constructed and reconstructed in an overdetermined and dynamic manner.

The way that we think, talk about and imagine the world effects our perceptions of it. Thus the way that confinement is expressed and justified in policy is an important part of the mental health system. Similarly the way that risk is used and understood has material implications for how mental health systems and services operate.

The idea that language and actions interact in an overdetermined manner has implications for the study of public policy, as policy is all about the interface between language and actions. There has been an increasing use of the approach of discourse analysis on public policy (see for example Jacobs and Manzi 1996, Hastings 1999, Marston 2002, Lees 2004, Jacobs 2006). Traditionally policy language has too often been accepted at face value as a form of objective medium. It has, however, increasingly been understood as a process of argumentation (Fischer and Forester 1993), where what needs to be examined is how particular versions of ‘reality’ are promoted during the policy process. This derives from the social constructionist view that when one gives an account of an event it is both a description and a part of the event itself.

A discursive approach is particularly pertinent in policy analysis, as the position of public policy means that it performs a powerful role in constructing particular issues or approaches as legitimate. Policy represents the view of truth of a dominant discourse of ‘experts’ and government agents (Iannantuono and Eyles 1997). The way that the regulation of mental illness is expressed in policy and how spatial confinement of people with mental illness is rationalised and justified is both shaped by, and helps shape, what mental illness is understood to be. What and how policy

75 refers to particular issues is important in establishing what issues and practices are legitimate.

5.2.2 The importance of context: A material approach

Critics of discourse analysis approaches sometimes suggest that proponents of these approaches have forsaken the material and empirical for the purely immaterial world of language (see for example Palmer 1990). Palmer quotes Derrida’s famous claim ‘there is nothing outside the text’ (1976: 159), as an example of the retreat to a merely discursive realm. Derrida’s comment reflects the view that nothing can be described outside of language, not that there is no material world. Indeed critical discourse analysis, the basis of the approach used here, posits an important interrelationship between language and materiality. This interrelationship means that attention to the material world is a vital component to CDA, although this aspect has often been missed by work claiming to use CDA (as discussed in section 5.3.7).

The importance of materiality reflects the general importance of context to social scientific approaches to knowledge. As Flyvbjerg (2001) so cogently argues context and example are the keys to good social science. The ability of case studies to address the complexities of context is one of the major reasons that Flyvbjerg (2001) holds up the case study as one of the key features of successful social science. He suggests that unsuccessful social science is often characterised by a lack of good examples. This is a reflection of his view that human skills and experiences are context dependent and therefore cannot be reduced to rules, whereas theory must be free of context and have rules. Context therefore is what is essential to a social scientific view of the world, as in the study of human affairs there is only context dependent knowledge. This accords with one of the main focuses of geographic research. A geographical approach requires attention to both spatial relations (as discussed in Chapter Two) and also areal differentiation. This means being aware of how things differ in different places and spaces and recognising that inevitably the differences between places help to problematise universal theoretical claims.

5.2.3 Historical context

Much of the research which has used discourse analysis approaches to public policy has been largely ahistoric, which misses one key aspect of context; the temporal.

76 Historicising discourse is a particularly important aspect of Foucauldian approaches, as archival work is crucial for conducting a history of the present.

Following Foucault (1972: 72) an historical approach does not need to be a teleological approach which assumes an inevitability of progress.11 The non- teleological aspect recognises that history never stops. It implies that we should not look at the past in order to understand how a particular endpoint has been reached now, but rather historical research allows us to see that the present is just as arbitrary and insensible as any time. An historical approach based on Foucault is fundamentally about the problematisation of concepts, which is why most Foucauldian scholarship is based around a ‘problem’, rather than a time period (Kendall and Wickham 1999). This recognises that history is ‘one way in which a society recognises and develops a mass of documents with which it is inextricably linked’ (Foucault 1972: 7). One of Foucault’s key insights is that we need to rethink historical evidence and recognise that its utility lies in what it tells us about the organisation of knowledge. Foucault’s approach recognises how history helps impose an intellectual order on the generation and use of knowledge.

This is the history of the present, which looms so large in Foucault’s approach to history, where the historical processes through which subjects and discourses are constituted need to be examined and historicised. The aim is to problematise the imagined inevitability of the present. This history of the present is apparent in the way that Foucault’s own works are constructed. As he notes in the conclusion of The Birth of the Clinic (2003: 246):

In the last years of the eighteenth century, European culture outlined a structure that has not yet been unraveled; we are only just beginning to disentangle a few threads, which are still so unknown to us that we immediately assume them to be either marvellously new or absolutely archaic, whereas for two hundred years (not less, yet not much more) they have constituted the dark, but firm web of our experience.

This conclusion reflects his concern with how our present understandings of medicine are structured. This understanding of history provides a crucial aspect of context that is often missing from discourse analysis.

11 Foucault was himself drawing on the annales tradition of historical research (Dean 1994).

77 5.3 Research Design

My research design was based around answering each of my research questions in a manner that allowed for flexibility and adjustment. This involved adopting multiple approaches with an overall framework influenced by critical discourse analysis. This section briefly outlines the main aspects of the research design with each component of the design explained in more depth in the rest of the chapter.

1. How significant is the role of confinement within contemporary mental health systems? This question is concerned with trends in the levels of confinement and with assessing how significant confinement is in contemporary care of people with mental illness. The research for answering this question drew on secondary literature and official data to assess levels of confinement and the use of mechanisms of involuntary treatment and confinement.

In addition to this quantitative work a qualitative approach was used to address this question. This involved analysis of policy documents and laws to look at how policies and practices of confinement, including community control and surveillance, have been established and carried out.

2. How have ideas of risk been utilised in past mental health policies and how has this related to the use of confinement? In order to address the second research question I analysed policy documents, legislation, and internal government documents from the 1840s to the contemporary period. This was a broad analysis of the use of concepts of risk in relation to policies and practices of confinement or deconfinement.

3. To what extent, and how, are ideas of risk used in contemporary policies of confinement of people with mental illness? In answer the third research question I used a discursive analysis of policy documents, legislation, and parliamentary papers to examine how ideas of risk were used in relation to ideas of confinement and spatial control. This analysis drew broadly on Fairclough’s CDA framework.

78 5.3.1 Case studies

My research design operates within the context of two case studies. Criteria for selection of case studies can be complex, with Yin (2003) outlining a detailed framework of validation. Stake (1994) acknowledges that balance and variety should form part of the selection criteria, but suggests that these should be subsidiary to the question of which cases are likely to lead to better understanding. Stake argues that because case studies cannot be chosen based on representativeness we should ‘take the case from which we feel we can learn the most’ (1994: 243).

These arguments about the importance of the good example and of choosing the cases from which the most can be learnt guided the selection of my case studies. I selected two case studies, with each ‘case’ being a jurisdiction. These cases were first England and Wales and second Queensland, Australia. The English and Welsh case is an example from which there is much to be learnt. It is a jurisdiction where there have been very clear and explicit moves towards increasing confinement over the last decade. The Queensland example provides a contrasting case, where deinstitutionalisation was much slower and (re)confinement is a lot less clear. The use of contrasting cases is not primarily for direct comparison, but rather to provide two cases that can both be analytically generalised to theory.

Case studies have historically been criticised as lacking in rigour and thus being inadequate sources for generalisation. This type of criticism reflects a positivistic approach to case studies which misunderstands the role of the case study. Nonetheless it is important that case study work is done in a rigorous way, which in my research involved:

1. Adopting an ethic of caution: this involved being consciously aware of the limitations of the research and being careful not too over claim or over generalise.

2. Being reflexive: this involved being reflexive about my own position and bias.

5.3.2 Quantitative research

In both of the case studies I was interested in looking at the current use of mechanisms of confinement and compulsion, as well as looking at trends over time. This involved utilising existing official data sources, some in published form and some raw data. In both cases no new data was collected and only basic statistical

79 work conducted, such as calculating rates of compulsion per capita and the proportion of psychiatric patients detained.

In addition to contemporary analysis the case studies report, in a limited manner, on historical levels of psychiatric admissions. Some of this data was sourced from secondary sources, which are cited in the relevant cases, and others directly from the government publications, which again are cited in the relevant cases. The available historical data was generally limited to some very basic statistics relating to patient numbers and admissions and is largely reported without additional statistical analysis.

England/Wales In the England and Wales case study there were two main sources of quantitative data. The most recent data about hospital admissions is collected in the Hospital Episode Statistics (HES) database (available online at http://www.hesonline.org.uk). The HES database collects details of all admissions to National Health Service (NHS) hospitals as well as admissions of NHS patients elsewhere. It contains data from 1989 onward. The most recent data was accessed in processed tabular form online, with older data from the 1990s accessed in hardcopy tables. Prior to 1987 only a ten per cent sample of admitted patient records, across all admissions, were collected nationally. For data on compulsory admissions prior to 1987 I used a combination of secondary sources (which are cited where used) and data collected from the Health and Personal Social Services Statistics data series. Basic information about levels of psychiatric admissions was published as part of this series from 1973.

Queensland In the case of Queensland there is one main source of data about the use of psychiatric services, namely the National Minimum Data Set (NMDS). This data is collected at the Queensland level, and validated and prepared at the Commonwealth level. There are two main components to this:

1. The National Minimum Data Set for Public Hospital Establishments, which collects public hospital data and includes information such as activity data and expenditure. 2. National Minimum Data Set for Admitted Patient Mental Health Care, which collects patient level data such as demographics and diagnosis.

80 This data is available in two primary forms, both of which were utilised in my work. First, this data, and its predecessor forms, have been complied into reports at the Commonwealth level and published as a series of reports, primarily as the Mental Health Services in Australia series. This series of reports releases analysis of the data as well as data in tabular form, which was used in my analysis. Second, limited data relating to hospital separations is available in an online database, available at http://www.aihw.gov.au/mentalhealth/datacubes/index.cfm.

There were two main problems collecting contemporary data for Queensland. The first is that nationally collected data in the NMDS has only been collected recently (only since 1997 for the Admitted Patient Mental Health Care), which makes getting reliable time series data more difficult. Prior to this data was collected at a state-wide level, but this data is not as detailed as that contained in the NMDS, nonetheless it did contain sufficient detail for my analysis. Second Queensland dramatically amended the Mental Health Act in 2000 (coming into force 2002). The new Act significantly changed the definition of mental illness and the process for compulsory treatment. This makes it hard to distinguish recent trends from artefacts relating to system changes.

5.3.3 Historical policy analysis

Historical policy analysis forms part of the contextual framework of the research. This involved the analysis of historical documents and examining how (and if) they conceptualised and utilised concepts of risk in relation to mental health and confinement. For heuristic purposes I have used broad historical periods in framing my analysis (Chapters Seven and Ten). The division of history into such periodisations for the sake of analysis is a useful, albeit problematic, tool of historians. It allows useful generalisations and comparisons to be made between different times. There are a number of taxonomic schemes that can be used to divide up histories, such as century, style of government, ruler, key events and metaphors (Jordanova 2000).

Although these types of heuristic devices are necessary if generalisations about historical events are to be made (see Scull (1985: 126) for a discussion on the importance of making generalisations in history using heuristic tools), it is important to recognise that these tools influence our understandings of these periods. They help to create a sense of unity, which may mask differences. Because of the way in

81 which these periodisations serve to shape our understanding of the past it is essential that ‘careful forms of periodisation are made appropriate to the research task in hand’ (Jordanova 2000: 120). In this case I’ve used a metaphoric periodisation of based around key events. In using this approach I have attempted to retain sympathy for the differences and nuances within each period.

The concept of being alert to the nuances of each period draws on the non- teleological approach utilised in Foucault’s concepts of archaeology and genealogy. Foucault and other deconstructionist approaches to history problematise linearity and causality, arguing that uncertainty needs to be turned into an advantage. Uncertainty allows a look beyond the obvious, to see the histories of exclusion or what does not fit neatly into progressivist ideas of history. It rejects the search for total history and instead concentrates on differences and transformations. Foucault’s approach to history has some lessons for being aware of difference within the historical archive. His own historical research, embodied in works such as Madness and Civilization (1967) and Discipline and Punish (1977a), is intimately connected with such a focus.

Despite the overwhelming importance of history in Foucault’s own work he provided little in the way of clear methodological statements. This means that one cannot talk about following ‘Foucault’s methods’, but rather draw on some of his insights in formulating a methodological approach (Elden 2001). More accurately Foucault does not conceive as history as a ‘method’, but rather as a ‘practice’. A practice which is always intimately related to the reasons for undertaking that practice at that particular point (Dean 1994).

The Archaeology of Knowledge (1972) and Nietzsche, Genealogy, History (1977a) provide some insights. The archaeological approach focuses on, and explores, what is said without attempting to interpret it in light of contemporary worldviews, or as Foucault puts it archaeology is ‘a pure description of discursive events’ (1972: 27). Although Foucault’s early archaeological work is sometimes seen as having been superseded by his later genealogical approach it is better to see them as acting in concert. The archaeological approach is a necessary element of a genealogical approach. Genealogy brings a new focus on the history of the present; it links the archaeological approach to our current concerns. It brings power to the foreground of analysis, or as Foucault puts it:

82 If we were to characterise it in two terms, then ‘archaeology’ would be the appropriate methodology of this analysis of local discursivities, and ‘genealogy’ would be the tactics whereby, on the basis of the descriptions of these local discursivities, the subjected knowledges which were thus released would be brought into play (Foucault 1980: 85).

While the genealogical approach brings the archaeological frame into the present it simultaneously refuses to assure us of the necessity of the present, rather it reminds us of the contingency of the present. Both the archaeological and genealogical stress the importance of taking the archive seriously and approaching it with attention to detail, but rejecting pedantry of method. Foucault characterises genealogy as ‘grey, meticulous and patiently documentary’ (1977b: 139).

My historical analysis draws on Foucault’s framework to use an archaeological approach of analysis of documents, to highlight the contingencies, interconnections and potentialities that compose present policies. The history of each case study needs to be considered on its own merits, for its own uniqueness. Drawing on a comparative approach can help achieve this, as one key approach to comparative history is premised on locating historical phenomena in their own context (Black and MacRaild 2000). Drawing on comparisons with another jurisdiction shows what is essential and particular to the case in hand. In addition no history occurs in isolation, especially the history of a public policy issue, this is particularly apparent here with the English and Welsh case and Queensland case drawing on the same jurisdictional background and foundation.

5.3.4 England/Wales historical analysis

I begin my historical analysis in the England and Wales case study in 1844 with the publication of the Report of the Metropolitan Commissioners in Lunacy to Lord Chancellor. This report established the groundwork for the Lunacy Laws of 1845, which in turn established the framework for the national mental health system. This marked the beginning of a state run and regulated mental health system. Prior to this there was only patchy state provided mental health care (Melling and Forsythe 1999, Porter 2002).

My historical analysis involved analysis of all relevant policy documents, legislation, parliamentary debates, commissions of inquiry and royal commissions between 1844 and 1993. A list of documents for analysis was initially identified through the secondary literature. This list was supplemented through database searches of the

83 National Archives of the United Kingdom, the British Library, the House of Commons Library and the House of Lords Library. All papers relating mental health policy were accessed either through the British Library, the National Archives of the United Kingdom or through online databases, most notably the House of Commons Parliamentary Papers Database.12 In addition internal government documents relating to some of these primary papers were examined in the National Archives of the United Kingdom. A complete list of documents analysed for the historical research is listed in Appendix One. This research was conducted from May 2007 until September 2007.

5.3.5 Queensland historical analysis

I begin my historical analysis in Queensland with the Insanity Act 1843 passed when Queensland was still officially part of New South Wales. This law remained in place even after the constitution of Queensland as a separate colony from New South Wales in 1859. The 1843 Act established the basis of the Queensland mental health system. I analysed all relevant documents from 1843 until 1992, when a new National Mental Health Strategy was developed.

The historical analysis in Queensland involved the same types of documents as the England/Wales case study. The same pattern of identification of relevant documents was used, namely initial identification through the secondary literature, followed by detailed searches. This included searches at the Queensland State Library, the Queensland Parliamentary Library and the Queensland State Archives. Relevant documents were then sourced through these same channels. A complete list of documents analysed for the historical analysis in Queensland is listed in Appendix Two. This research was conducted from January 2007 until May 2007.

5.3.6 Contemporary policy analysis

The contemporary policy analysis for each case study begins from the early 1990s and includes a full range of policy documents. Identifying and choosing the corpus of data is an important aspect of critical discourse analysis:

One can only make a sensible decision about the content and structure of a corpus in the light of adequate information about the archive… this is partly a practical matter of knowing what is available, and how to get access to it, but is

12 (http://parlipapers.chadwyck.co.uk/marketing/index.jsp

84 partly a matter of having a mental map of the order of discourse of the institution or domain one is researching (Fairclough 1992: 226-227).

The lists of documents analysed (which are listed in Appendices Three and Four for England/Wales and Queensland respectively) were complied through secondary sources and searches of government databases. The primary types of documents analysed were official policy documents, legislation and parliamentary debates.

My primary focus of research has been published policy documents, although I have also looked at parliamentary debates. The focus on published documents is appropriate for my research aim, as I am interested in how public policy uses the idea of risk in relation to confinement. However this approach does have the weakness that it can assume that policy is a unified, consistent whole; which it seldom is. To some extent this can be remedied, as I have tried to do, by being aware of the contradictions and nuances in finalised policy. However this inevitably misses the way that the process of policy formation is internally contested. There are always a variety of interests at work in the policy formation and these are missed when analysing published policy documents.

5.3.7 Critical discourse analysis

The analysis of documents was influenced by the critical discourse analysis approach. However it was not an explicitly CDA analysis in that I do not present the analysis through Fairclough’s model of CDA. Fairclough’s work, as one of the key theorists of CDA (Fairclough 1992, 1995, Chouliaraki and Fairclough 1999), has been some of the most significant and important in developing a framework which brings together the strengths of Marxist oriented traditional linguistically based discourse analysis with the insights of Foucault. Traditional discourse analysis was based primarily on close linguistic analysis of the text as an isolated subject of analysis. CDA broadens this analysis by also focusing on the processes of text production, distribution and consumption. This means siting the analysis in an understanding of the social, economic, political and institutional settings within which meanings are generated. This view aims to ensure that CDA is a dynamic approach, one that does not isolate language, but addresses the practices within which language operates. But it does not ignore language for a primary focus on wider context, as much broad brush Foucauldian analysis does. Instead it recognises that particular points of view can be (re)produced and normalised through the use of

85 specific grammatical deployments and that this needs to be taken into account in analysis.

This view of discourse is very similar to that utilised by Harvey (1996), a link that Fairclough draws on in his later work (Chouliaraki and Fairclough 1999). Harvey proposes a view which sees discourse as one ‘moment’ of practice among others which internalises other moments of practice, without being reducible to them. Within the broad ambit of CDA Fairclough takes a moderate position based on the Marxist tradition of social conflict (Meyer 2001), where he focuses on the role of ideology and attempts to unmask the linguistic manifestations of particular ideologies within textual contexts (see for example Fairclough 2000, 2002).

My analysis draws heavily on Fairclough’s framework and on the wider body of CDA work, but utilises more of a Foucauldian genealogical approach in analysing the third dimension of Fairclough’s framework, namely social practices. Rather than adopting a Marxist understanding of ideology to reveal the underlying purpose of discourses of risk, I adopt the Foucauldian approach of revealing the way concepts are used in constructing subjectivities. This adaptation to CDA can help overcome several of the main criticisms of CDA, namely its political bias overwhelming its analysis and its tendency to simply read ideology off texts unproblematically.

Although CDA has been adopted by many social scientists, it has also been subject of much critique, most notably in a series of exchanges between Widdowson (1995, 1996, 1998) and Fairclough (1996). One of the main criticisms has been that too much of the work done under the CDA rubric has placed the key emphasis on the ‘critical’ aspect, to the extent that political commitment has overwhelmed any sense of analysis. This view argues that too often analysis using CDA starts out knowing what it wants to find and then, not surprisingly, finds that (Tyrwhitt-Drake 1999, Antaki, Billig, Edwards and Potter 2003). Widdowson suggests that a circularity of argument can slip into the CDA approach:

CDA aims at explaining not how social inequalities are reflected or created in language itself, as social semiotic, but in the use of language as social action. You cannot explain how people express their ideology by assuming in advance that ideology is fixed in the language (1995:168).

But as even a trenchant critic like Widdowson (1995) admits it is possible to utilise the framework without falling into this error. This is the case of my research, as it is

86 looking at the use of a particular concept, ‘risk’, with no preconceptions of how it might be being constructed and used and with no explicit preset political agenda.

5.3.8 Methods of analysis

Over the last decade there has been a shift in the understanding of CDA from a particular method, using the three dimensional framework provided by Fairclough. Instead CDA is conceptualised as being a methodological approach or practice. In this view CDA provides a theoretical frame, but no specific guidelines for how to operationalise this in research. This is a view that is explicitly adopted in Fairclough’s later work, which emphasises the positive aspects of a diversity of approaches to CDA (Chouliaraki and Fairclough 1999). As Fairclough (1992: 225) makes clear, ‘there is no set procedure for doing discourse analysis’.

My research uses Fairclough as a guide, but differs in that it is not focused on examining a body of work to identify what discourses emerge in that work, but rather it involves examining how a particular concept, risk, was used and rationalised within the wider body of mental health policy discourse. References to the social and discursive practices are included in the relevant chapters (primarily Chapters Eight and Eleven). The textual analysis drew upon both theoretical work (Fairclough 1992, Halliday 1994, Fairclough 1995, Chouliaraki and Fairclough 1999, Martin 2000) and empirical examples of CDA (Darcy 1999, Hastings 1999, Hajer 2002).

As I stated above, my concern is with how the concept and language of ‘risk’ is utilised. This is distinct from an interest in risk as a practice or as a material object. I am interested in how the language of ‘risk’ came to be, and is used, as an object in policy and what meanings are associated with that language of ‘risk’.

Every document was analysed in its entirety to establish the main purposes and features of the particular document. Following this a more in-depth textual analysis was used. Every use of ‘risk’ was recorded, with each use examined in context to determine the particular meaning associated with that use, this was recorded and coded using an NVIVO database. Similarly a list of synonyms of risk was complied and analysed in the same manner. Once all of these terms had been examined they were grouped to examine patterns of use. This included looking at how the use of synonyms compared to explicit use of risk, to examine patterns of usage and the meanings contained in these patterns. I also analysed hierarchies of use to see when

87 particular terms and meanings were used. Following the examination of risk another NVIVO database was compiled which recorded how uses of risk related to ideas of confinement and compulsion.

This textual analysis, which drew from functional linguistics (Halliday 1994), was then considered within what Fairclough (1992, 1995) refers to as discursive practices. This includes consideration of who produced the document, what the aim of the document was and who the intended audience of the document was. It also implies an understanding of the context within which the text is to be read. In this case that meant a focus on the wider context of social policy in both of the case studies. The CDA form of analysis requires a high degree of attention to detail. Unfortunately the space constraints mean that in reporting on this analysis in the case studies much of the specific details of the analysis had to be sacrificed to the reporting of the wider analysis.

5.3.9 Ethics

This research fully complied with Griffith University’s ethical requirements. These traditional ethics requirements were only one aspect of the ethical considerations of my research, the other aspect being the importance of socially just research. Socially just research needs to involve considerations which extend well beyond traditional ethical procedures such as informed consent and privacy to exercise what Hay and Foley (1998) refer to as ‘moral imagination’. This means being cognisant of the wider context of research and recognising that considerations of social justice, responsibility and honesty should be regarded as integral to what constitutes ethical research.

5.4 Conclusion

My research is primarily a study of discursive formations; it is concerned with what policy means and how this influences how mental illness is understood, particularly in relation to confinement. As such my research approach is focused on the discursive realm. But as I have outlined in this chapter discourse is always merely a moment in an overdetermined world. Thus my research approach also looks at the patterns of compulsory treatment and confinement in the material world.

88 My research draws inspiration from the work of Foucault, in particular his idea of the history of the present. The key influence of Foucault’s work on my approach has been to ensure that there is an historic element to my analysis that is missing from so much contemporary discourse analysis. Foucault’s approach of the history of the present also has some clear ethical implications. Writing a history of the present is fundamentally about writing a history in the present, writing in an awareness of current power relations and struggle. This is illustrated in Discipline and Punish (Foucault 1977a) where the genealogy of the prison is explicitly a critique of present forms of the prison. That work undermines the idea of the prison as being an inevitable solution to always existing problems. Foucault’s aim in all his works around history is to make the history of the present the past. My own research aims to open up the way that risk is associated with mental illness and unsettle the rationales for the spatial confinement of people with mental illness.

89 Chapter 6. The Use of Confinement in England and Wales

6.1 Introduction

This chapter begins my answers to my research questions in relation to the case study of England and Wales. For both of the case studies there are three chapters, each of which specifically addresses one of my three research questions. In this first chapter I address the first of my research questions in the context of England and Wales, namely: How significant is the role of confinement within contemporary mental health systems?

The aim of this chapter is to provide the evidentiary basis for my discussion of policy and the use of risk in relation to confinement in the following two chapters. To this end I present evidence that suggests that the last 15 years has seen a renewed use of confinement in England and Wales. I approach this question of confinement primarily through the use of ‘overnight’13 compulsory admissions. I show that there are a range of indicators that some people are being returned to sites of confinement and that there has been an increased use of confinement as a response to mental illness. These indicators include high levels of compulsory psychiatric admissions and the rapid growth of forensic mental health services. I outline the evidence for these trends, and also argue that there are some other important issues concerning the use of confinement in England and Wales. These include: changing demographics of those being compulsorily treated; the increased role of the private sector in compulsory admissions; high levels of mental illness within the criminal justice system; and the introduction of compulsory care mechanisms which do not involve spatial confinement. I outline evidence for these trends and discuss why they are significant.

Ultimately this chapter outlines the use of compulsion and confinement in England and Wales, which then serves as the empirical basis for the analysis of the following two chapters.

13 The term ‘overnight’ is used to denote any admission longer than a day.

90 6.2 Confinement: The Contemporary Context

I have framed my discussion in this thesis so far around the concept of ‘confinement’. In this section I briefly discuss why I am using compulsory care as a proxy for confinement in both this chapter and Chapter Nine (the equivalent chapter for the Queensland case study). I have framed the language of my research aim and questions in terms of ‘confinement’ because as a geographer I am particularly interested in the spatiality of care. As I argued in Chapter Two the spatiality of care associated with isolation and removal from society is not merely incidental, but is a fundamental feature of institutionalisation. The use of the term confinement is a deliberate choice to continually emphasise the spatiality that is integral to particular types of care. However, in this chapter I mainly refer to ‘compulsory care’ or ‘compulsory admissions’ as a proxy for confinement. I have used this language here to be consistent with the language of public policy that is my primary data source.

The equation of compulsory admissions with confinement is suitable for the purposes of this thesis. In the case of England and Wales all the discussion based around compulsory admissions relates to overnight admissions where people are compulsorily held in specialised care. While using compulsory admissions as a proxy for confinement is necessary and appropriate for the context of my thesis it highlights some interesting questions of how institutionalisation and confinement should be conceived. As Moon, Joseph and Kearns (2005, 2006) have argued there is an increasingly apparent blurring of the boundaries between the community and the asylum. This is a point that I discuss towards the end of this chapter when talking about the use of compulsory care in the community.

6.2.1 Deinstitutionalisation

The answer to my first research question needs to be understood in light of the recognition of the substantial impact that deinstitutionalisation and community care has had in England and Wales. Community care increasingly came to dominate mental health policy and practice during the second half of the twentieth century in England and Wales (Peck and Parker 1998, Boardman 2005, Lester and Glasby 2006). However despite the increasing emphasis on deinstitutionalisation it has never, and was never meant to, completely replace confinement. As such confinement has continued to be a significant part of policy responses to mental illness.

Changes made in the Mental Health Act 1959 encouraged a shift towards increasing emphasis on voluntary admission to psychiatric institutions and strengthened the safeguards and protections regarding compulsory treatment.14 These moves were codified in the Hospital Plan for England and Wales (Minister of Health 1962), which called for the closure of large state hospitals and the accompanying development of community care facilities. It also established the goal of halving the number of hospital beds by 1975. This marked the beginning of the dominance of community care as public policy. From the late 1950s there was a long term shift towards deinstitutionalisation and community care. However large-scale closures of psychiatric institutions did not occur until the late 1970s and 1980s (Porter 2002, Lester and Glasby 2006). Various forms of community care began to be established in the 1970s, such as out-patient departments, day hospitals and limited community psychiatric nursing. However, there has been a turn away from this focus, particularly during the 1990s. This is most evident in a renewed emphasis on compulsory treatment and the growth of forensic services.

6.3 Compulsory Admissions

Since 1983 compulsory admissions for mental health treatment have been governed by the Mental Health Act of that year. Substantial amendments to the Mental Health Act were passed in 2007, which have changed the mechanisms governing compulsory treatment. This will in turn affect some of the trends discussed in this chapter. The details and implications of the amended Act are discussed in Chapter Eight. However the 2007 amendments did not come into force until October 200815 thus the mechanisms of compulsion and statistical data discussed in this chapter relate to the 1983 Act.16

6.3.1 Psychiatric beds

Policies of deinstitutionalisation and community care have resulted in a significant decrease in the number of available specialist psychiatric beds. This decrease in psychiatric bed numbers is part of a trend towards a general decrease in bed

14 This Act followed a 1954-57 Royal Commission on the Law Relating to Mental Illness and Mental Deficiency, (the Percy Report), which emphasised that the law should be based around the principle of least restriction of liberty. 15 Some limited provisions came into force in October 2007. 16 Data prior to 1983 refers to the 1959 Act

92 numbers across the entire health system. The total number of beds in the National Health Service (NHS) has fallen from 480,000 in 1948, when the NHS was established, to 167,019 in 2006/07, a fall of over 60% (Department of Health 2007a). This fall in bed numbers illustrates a general decline in the importance of hospital beds and hospital based treatment, which is not unique to the mental health system. However psychiatric bed numbers have fallen faster than general NHS bed numbers and have become a much less significant part of the NHS bed system. In 1954 psychiatric beds accounted for around 32% of all NHS beds (Boardman 2005, Warner 2005). This has nearly halved, falling to 18% today (Department of Health 2007a).

The number of psychiatric beds peaked in the mid 1950s and declined steadily since, falling to a new low of 27,914 in 2007, as seen in Table 2. This reflects a rapid fall in the number of large psychiatric hospitals. Between 1972 and 1982 the number of psychiatric hospitals with more than 100 beds fell from 65 to 23 (Goodwin 1997a). Specialist psychiatric hospitals have all but vanished since then, except for specialist forensic care, resulting in a decrease in the total number of psychiatric beds.

Table 2: Psychiatric Bed Numbers England and Wales Year Bed Numbers 1954 154,000 1988 63,012 1992 47,308 1996 39,477 2000 34,214 2004 32,252 2007 27,914 Source: (Boardman 2005, Department of Health 2007b)

Although the figures show a large and continuing decline in bed numbers this is less significant than it initially appears. Many of the beds which were removed, particularly in the early years, were beds which were frequently used by long-stay elderly dementia patients. As the Department of Health states many of these beds have been replaced outside of the psychiatric system. They argue that much of the loss in psychiatric beds has:

been matched by an increase in the available places in private nursing homes and private, voluntary and Local Authority residential care homes (Department of Health 2000a: 17).

93 This means that the decline in psychiatric beds has not been as large as it first appears, given that many of the early bed losses were effectively a ‘reshuffling’ of the location of beds. However despite the reshuffling it is clear that there has been a steady reduction in the number of specialist psychiatric beds in England and Wales.

The decline in psychiatric beds led to increasing concern, by the late 1990s, that there were now insufficient acute beds to meet the demand for them. These concerns were borne out by the very high occupancy rates that were being recorded for psychiatric beds by the early 2000s. The Mental Health Act Commission’s national visit (where it inspects a large number of mental health units) reported an overall occupancy rate of 98% in 2005 (Commission for Healthcare Audit and Inspection 2005: 109). Department of Health (2004b) figures reported an occupancy rate of 91% in 2004. Overcrowding has been particularly bad in parts of London where occupancy rates of over 120% have been recorded (Department of Health 2000a, Warner 2005).17 These reports, and public and medical concern about overcrowding, helped to instigate a comprehensive investigation and report into bed numbers in the entire NHS system, Shaping the Future NHS: Long Term Planning for Hospitals and Related Services Consultation Document on the Findings of The National Beds Inquiry (National Bed Inquiry) (Department of Health 2000b). That report concluded that hospital beds were an essential feature of the mental health system and should not be further reduced.

The National Bed Inquiry concentrated on reviewing the ways in which hospital beds were being used and assumptions about likely bed needs across the health system in the future. The main focus of the final report was on ensuring efficient use of acute beds, including the need to avoid premature discharge. In relation to mental health the Inquiry emphasised the need to try and avoid admissions to beds as the first priority. But the Inquiry also argued that there was an increasing need for secure accommodation, particularly medium secure level accommodation. The results of this Inquiry demonstrate the commitment to the continuing use of significant levels of confinement as part of mental health services in England and Wales.

17 Bed occupancy is calculated by comparing the official number of patients with the number of beds. Patient numbers can include those on leave and those who have been temporarily transferred to other wards, which explains how bed occupancies can be so far over 100%.

94 6.3.2 Psychiatric admissions

Although the number of psychiatric beds has declined steadily since the late 1950s psychiatric admissions18 have not followed this trend. The number of admissions rose steadily between the 1960s and the mid-1990s, as seen in Table 3. This included an increase in the raw number of admissions as well as the rate per 100,000. The number of total admissions rose until they reached a peak in the mid 1990s, from which point they have fallen again and are now plateauing. The number of total admissions fell by 63% between 1994 and 2006, while rates of admission fell 64% in the same period. Despite these recent falls in total admissions the current rate of admissions is not that much lower than in the mid 1960s, before deinstitutionalisation became a significant factor.

Table 3: Total Number of Psychiatric Admissions England and Wales Year Number of Admissions Rate of Admissions 1964 155,000 347/100,000 1982 192,000 407/100,000 1994 224,000 462/100,000 1998 201,352 412/100,000 2001 186,440 378/100,000 2004 164,849 329/100,000 2006 140,601 294/100,000 Source: (Payne 1999, The Information Centre 2006a, d, f, Office for National Statistics 2007, The Information Centre 2008c)

The increase in the number of admissions between the 1960s and 1990s illustrates that despite the closure of specialist psychiatric facilities there continued to be a high level of demand for hospital based psychiatric care. The large majority of these admissions were voluntary, but a substantial number were compulsory. This increase in admissions is thought to be the result of both the greater accessibility of mental health care and a decrease in stigma associated with care (Lester and Glasby 2006).

Unlike total admissions, compulsory admissions did fall following the shift towards community care. The Mental Health Act 1959 placed a greater emphasis on the idea of least restrictive treatment and on encouraging psychiatrists to attempt to convince people to undertake voluntary treatment. This resulted in a reduction in the number of compulsory admissions during the 1960s and 1970s. Compulsory admissions

18 Admissions refer to admissions to a psychiatric speciality as defined in the International Classification of Diseases and measured by the Hospital Episode Statistics (HES). This includes all admissions to the hospital system, including both voluntary and compulsory admissions.

95 reached a low point of a total of 13 488 formal admissions19 in 1984 (Wall, Hotopf, Wessely and Churchill 1999). Levels of formal admissions rose again in the early to mid 1990s20 before levelling off in the late 1990s and early 2000s. The total number of formal admissions increased gradually between 1984 and 1991 by an average of 500 new formal admissions per year (Department of Health 1999a, c, The Information Centre 2006g, h). From 1992 to 1996 the number of formal admissions accelerated to 1500 new admissions per year. This meant there was a 48% increase in formal admissions between 1988 and 1996. Between 1996 and 2006 there was a 12% increase in the level of formal admissions. This trend has largely been mirrored by the growth in the number of people compulsorily detained after initially being admitted as voluntary patients, as seen in Figure 4, meaning that total compulsory admissions21 have followed this trend.

50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 Number of Admissions 5,000 0

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year

Formal Admissions Changes in Status Total Compulsory Admissions

Figure 4: Compulsory Admissions in England And Wales Source: (Department of Health 1999a, c, The Information Centre 2006g, h, 2008c)

There are a number of different factors that may have affected the increased use of compulsory admissions in England and Wales. The three most significant factors are likely to be: first, a decrease in the length of stay of admissions; second, increased staff use of compulsory admissions to ensure care; and third, an increased number of

19 Formal admissions refer to compulsory admissions made under the requirements of The Mental Health Act 1983. This includes transfers made under court order from the prison system (under part III of the Act) but does not include people who have changed status from voluntary to involuntary patients, that is who enter the hospital system as voluntary patients and are later compulsorily detained. 20 This rise is almost certainly more linear than it appears in Figure 4. as data is thought to be over counted prior to 1995 (due to a change in data collection forms), which accounts for the dip which appears in the data in 1996 (Department of Health 1999: 2). 21 Total compulsory admissions includes compulsory admissions made under the requirements of the Mental Health Act, and people who have changed status from voluntary to involuntary patients.

96 readmissions. However there has been little research that weighs up the relative impact of these factors on contemporary rates of admission.

6.3.3 Length of stay

First, and almost certainly most significant, is a reduction of length of stay associated with an admission. The number of hospital bed days has declined steadily (see Table 4) and faster than the number of beds has declined. This implies that the length of stay has reduced.

Table 4: Hospital Occupied Bed Days Commissioned for People with a Mental Illness (Millions) England and Wales

Year 92-93 93-94 94-95 95-96 96-97 97-98 98-99 Hospital occupied bed 14.0 12.7 12.4 12.1 11.8 11.5 11.2 days Source: (Department of Health 2006)

There are, however, a substantial number of stays which remain long, with 9.2% of admissions exceeding 90 days and 0.9% exceeding a year (Thompson, Shaw, Harrison, Ho, Gunnell and Verne 2004). These long admissions are primarily those in forensic care, as shown in Figure 5. Over the eight years prior to 2006 the average length of stay for forensic patients has increased substantially, with only mild variations for other categories of patients.

600

500

400

300 Days

200

100

0 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year

Mental illness Child & adolescent psychiatry Forensic psychiatry Psychotherapy Old age psychiatry

Figure 5: Mean Length of Stay by Category England and Wales Source: (The Information Centre 2006a, b, c, d, e, f, 2008a, b, c)

97 The average length of stay is around seven years for high security admissions and two years for medium security admissions and there is evidence that the length of stay is increasing for medium security admissions (Forensic Faculty of the Royal College of Psychiatrists 2003: 3).

A reduction in overall length of stay, across all categories, during the early to mid 1990s is reflected in the more than doubling of throughput22 in mental health beds between 1988 and 1998 (The Sainsbury Centre for Mental Health 1998, McCulloch, Muijen and Harper 2000).23 A decline in lengths of admissions helps to explain how compulsory admissions have increased despite the decline in bed numbers.

6.3.4 Increased staff use of compulsory admissions

The second factor which is likely to have impacted on the rise in total compulsory admissions is that a shortage of psychiatric beds has encouraged staff to compulsorily admit patients in order to facilitate treatment. Occupancy rates for beds have been extremely high, as discussed above. This leads to a situation where voluntarily admitted patents are unlikely to be prioritised enough to receive a specialist psychiatric bed. As a result, Warner (2005) argues, staff are more likely to compulsorily admit a patient in order to maximise the likelihood of that patient receiving a bed.

This argument is supported by my analysis showing a steady increase in the proportion of mental health patients in hospital who were compulsorily admitted to care, as seen in Figure 6.

22 Bed throughput refers to the number of patients treated per bed. 23 Despite the decline in the overall bed numbers and the increase in throughput there is evidence that current lengths of admission are not short by historical standards. Recent research, which compared length of hospital stays in North Wales from 1886 to 1996, found that people with schizophrenia are likely to spend more time in hospital in 1996 than they would have in 1886 (Healy, Harris, Michael, Cattell, Savage, Chalasani and Hirst 2005). This showed that although first admissions were longer in 1886 today’s patients will spend longer in hospital overall.

98 35

15 Percentage

0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year

Figure 6: Percentage of Hospital Psychiatric Patients Compulsorily Admitted England and Wales Source: (Department of Health 1999a, c, Wall et al. 1999, The Information Centre 2006a, b, c, d, e, f, g, h, 2007b, 2008b, c)

As Figure 6 shows there has been a steady increase in the proportion of all HES24 psychiatric admissions that are institutionalised; increasing from 18.7% in 1994 to 32% in 2006. This indicates that an increasing percentage of psychiatric patients who have contact with the hospital system are compulsorily admitted.

6.3.5 Readmissions

The third potential explanatory factor for an increase in total compulsory admissions is a possible increase in readmissions. There is concern that a ‘revolving door’ phenomenon has emerged since the mid 1990s, which has seen a much higher level of readmissions (Laurence 2003). This suggests that the increased pressure on the mental health system, and particularly the high occupancy rates of psychiatric beds, has led to a pattern of early discharges as staff seek to free beds for urgent patients (Lester and Glasby 2006). This could result in premature discharge thus increasing the likelihood that a patient will be readmitted later. However there is no available consistent national data on rates of readmission over time. The main statistics on admissions, the HES, does not routinely calculate readmissions, because of the difficulty in defining what counts as a readmission. In addition HES data specifically excludes mental health when calculating readmissions across the entire health

24 HES admissions refer to Hospital Episode Statistics admissions, these measure all admissions to hospitals in the United Kingdom.

99 sector. Mental health is excluded on the basis that emergency readmissions are often a necessary part of patient care (The Information Centre 2008d). One of the few official records of readmissions shows that the ‘emergency psychiatric readmission rate’ actually decreased from 14.3% in 1997–98 to 12.7% by the last quarter of 2001–02 (Parliamentary Debates 8 Jul 2002).

Thus there are at least three key factors which may have contributed in some way to an increased rate of compulsory admissions. There is however insufficient evidence to weigh up the impact of these factors on the increasing use of confining mechanisms of care and control. It is therefore difficult to come to any firm conclusions about the increase in the use of confinement. This points to the need for more research on contemporary use of confining mechanisms within the mental health system.

6.3.6 Forensic mental health system

The renewal of the use of compulsion in the English and Welsh mental health system is most apparent in the rapid and sustained growth of the forensic component of the mental health system, particularly since the mid 1990s. Forensic mental health services are services that provide care for people who have been assessed as requiring close attention and/or increased physical security. These can be people with challenging behaviours, which may or may not be associated with violence, that are beyond the scope of more general psychiatric services. Some will have broken the law, others may have been assessed as likely to do so (McFadyen 1999: 1436). Such people can enter the forensic mental health system either through being identified in the general mental health system as needing special care, or through being referred from the criminal justice system.

The concept of a specialist ‘forensic’ health system is relatively new, and was established following the recommendations of the Report of the Committee on Mentally Abnormal Offenders (1974) (Butler Report).25 This report marked a key change in forensic services and called for, among other things, the establishment of a network of forensic psychiatric services based on secure hospital units and for improvements in prison psychiatric services. It recommended the urgent establishment of approximately 2000 secure beds.

25 The ‘special hospital’ system existed before this, and provided secure forms of care. It was largely administered separately from other mental health services

100

There are three main components to the current forensic mental health system (Lester and Glasby 2006):26 1. Low security services based in, or near, general psychiatric services, with higher levels of staffing than general services.

2. Medium security services consisting of locked wards, with high staff to patient ratios.

3. High security services, provided by three ‘high security hospitals’. These have much higher levels of security and deal with people who pose a serious hazard to others. The high security hospitals are Ashworth, Broadmoor and Rampton, which together have around 800 beds (Rutherford and Duggan 2007).

6.3.7 Growth in forensic mental health bed numbers

Although the Butler Report recommended the speedy establishment of 2000 secure beds these beds were slow to be created. By 1991 there were only 600 secure beds (Farrar 1996). However there was a rapid expansion of secure bed numbers in the 1990s and 2000s. By December 1998 there were 29 NHS and 8 independent sector units with medium security beds for adults in England and Wales (excluding units solely for learning disability); a total of 1,663 beds in all units. (Melzer, Tom, Brugha, Fryers, Gatward, Grounds, Johnson and Meltzer 2004).27 There was an even more rapid expansion of secure bed numbers in the late 1990s with 1,952 beds by 2000 and 2,596 by 2004, as seen in Table 5.

26 There has been little attempt to officially define security levels, see Kennedy (2002) and Forensic Mental Health Services Managed Care Network (2004) for discussions of this. 27 As Melzer et al (2004) note the lack of an agreed definition makes it difficult to report exact bed numbers, especially changes over time. Even a House of Commons Select Committee reported that they were ‘unable to obtain a precise figure for the number of medium secure beds currently in the system’ (House of Commons Health Committee 2000 para. 178).

101

Table 5: Secure Beds (Excluding Special Hospitals) England and Wales Date Available secure beds 1996–97 1,575

1997–98 1,621

1998–99 1,747

1999–2000 1,882

2000–01 1,952

2001–02 1,848

2002–03 2,064

2003–04 2,569

2004-05 2,696

2005-06 2,807

2006-07 2,993 Source: (Parliamentary Debates 2002, Department of Health 2007b)

Part of the reason for the increase in low and medium secure beds was concern that there had been too many high secure beds and not enough medium secure beds (Farrar 1996, Forensic Faculty of the Royal College of Psychiatrists 2003, Thomas, Dolan and Thornicraft 2004). This resulted in some people unnecessarily being placed in high secure beds, and others not being able to access medium secure beds. An additional concern with forensic services was that there were insufficient long stay beds resulting in a constant shuffle of secure patients (Reed 1997).28 These two concerns resulted in a reduction of high secure beds from 1750 in 1985 to 1300 in 2005 (The Sainsbury Centre for Mental Health 2005) and the increase in medium secure beds discussed above.

The rise in the number of secure forensic beds has been matched by a steady increase in the number of patients detained in medium and high secure care, as shown Figure 7.

28 See Jamieson and Taylor (2002) for an opposing view. They argue that developing long-term medium security care has little merit as only a very small number of patients, even of those who were consistently institutionalised, returned to high security once they were released to general psychiatric care.

102

3,600

3,400

3,200

3,000

2,800

2,600 Patients Detained

2,400

2,200

2,000 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year

Figure 7: Patients in High and Medium Security Care England and Wales Source: (Home Office 2007)

The growth in the number of specialist forensic beds looks unlikely to change in the near future. The National Bed Inquiry concluded that the initial impetus of bed provision should continue to be on secure beds (including medium secure, long term medium secure and intensive care) (Department of Health 2000a: 63).

6.4 Trends in Confinement

As I have shown there has been a renewed focus on compulsory care within England and Wales. This includes higher rates of compulsory treatment and the rapid growth of forensic mental health services. In addition there are four other issues that are important to consider in relation to my research question. These are: the changing demographics of those subject to confinement; the increased role of the private system; criminalisation; and the growth in compulsory care in the community.

6.4.1 Demographics

One important change which has mirrored the rise in the use of compulsion is the changing demographics of those subject to compulsion. Historically women have been the group most likely to be compulsorily treated (Payne 1999). However this has changed since the late 1980s when men overtook women in levels of formal admissions. By 1994 almost 1500 more men were being formally admitted per year

103 than women, a difference which has remained fairly steady since then. Overall the formal admission rates are higher for males (3.3 per 1000) than for females (3.0 per 1000) (Thompson et al. 2004). The rates of admission have been peaking younger for men than women. The rates of admission for men peak in the 25 and 44 age group, whereas they do not peak until the 35-44 age group for women (Thompson et al. 2004). In addition, men have on average a longer stay in detention. A Mental Health Commission census found that on the day of the census almost twice as many males (9,615) as females (5,066) were detained in both NHS facilities and independent hospitals (Commission for Healthcare Audit and Inspection 2005). This gender difference is proportionately much greater than the gender difference in admission rates, which indicates a longer average period of detention for men; however this data is not specifically collected. Thus the increase in confinement has occurred alongside a shift in who is being confined, with more young men being confined than has historically been the case.

6.4.2 Private mental health system

In addition to the increase in compulsory admissions there has also been a change in where these admissions are occurring, with an increase in compulsory admissions being made in the private sector. While the private sector still remains a relatively minor component of the overall mental health system it has expanded to provide more beds as the number of public beds has contracted. This expansion has not only been to meet growing demand from those willing and able to pay for private care, but also to meet the overflow from a stretched NHS psychiatric system. In 2000 it was estimated that around half of private services were purchased by the NHS (McCulloch et al. 2000). This includes an increasing number of compulsory admissions, as seen in Figure 8. The percentage of total compulsory admissions cared for in the private sector has increased from less than 1% in 1988 to 4.7% by 2004 (Department of Health 1999c, The Information Centre 2005). This change means that it is now easier for the public health system to increase the use of compulsion without having to create additional specialist psychiatric beds within the public system.

104 2,500

2,000

1,500

1,000 Formal Admissions

500

0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year

Figure 8: Compulsory Admissions in Private Hospitals England and Wales Source: (Department of Health 1999a, c, The Information Centre 2006g, h, 2007b)

The private sector is also responsible for an increasing number of secure beds (that is those which are part of the forensic mental health system). Approximately 35% of secure beds are now located in the private sector (Rutherford and Duggan 2007), up from 25% of secure beds provided in 2001 (Coid, Kahtan, Gault, Cook and Jarman 2001).

6.4.3 Criminalisation

In addition to the use of specialist forensic care there are also a large number of people with mental illness being held in the criminal justice system. The most comprehensive data in England and Wales comes from an assessment of the incidence of metal illness in prison conducted in 1997 (Singleton, Meltzer and Gatward 1998). This assessment found that rates of all forms of mental illness were much higher for prisoners than the rates for the general population. Prisoners suffered from high rates of neurotic problems with 58% of the male and 75% of the female remand prisoners suffering from such problems. This is much higher than for the general population where 12% of men and 18% of women suffer from neurotic problems. There was also a particularly high rate of psychosis with 7% for male prisoners and 14% for female prisoners, which compares with a rate of 0.4% for the general population (Singleton et al. 1998).

The UK government has responded to the concerns about criminalisation through a variety of strategies and policies. In theory these policies are based on the principle

105 that offenders with a serious mental illness should be diverted from the criminal justice system to receive necessary care (All-Party Parliamentary Group on Prison Health 2006). However these policies have been criticised as largely unsuccessful, to the extent that in the mid 1990s several judges threatened to require the Secretary of State for Health to appear to explain the difficulties in placing offenders within the health care system (Farrar 1996).

One result of government action to try and address criminalisation has been that there has been an increase in the number of patients in the forensic system who have been transferred from the prison system. Since 1993 there has been an increase in the number of admissions to high and medium secure services coming from prison transfers. Over the same time the number of people being civilly admitted has decreased (Forensic Faculty of the Royal College of Psychiatrists 2003: 3). There has also been a fall in general admissions to the NHS from the prison system, meaning that a high proportion of people transferred to the mental health system are now going to forensic beds. Transfers from the prison system accounted for almost 8% of formal admissions to the mental health system in 1994-95, but that has fallen to only 5% ten years later in 2004-05 (The Information Centre 2006).

Overall there are many people with mental illness currently being detained in the criminal justice system. This raises a number of highly relevant questions, some of which are being addressed in current research, and some of which are not. These questions include whether there has been an increase in the number of people with mental illness in the prison system, or whether this is a factor of improved diagnosis of the prison population (Herrman, McGorry, Mills and Singh 1991, Butler and Allnutt 2003, Henderson 2003). Second whether deinstitutionalisation has resulted in an increase in the number of people with mental illness being confined in the criminal justice system (Aderibigbe 1997, Fuller Torrey 2000, Mullen, Burgess, Cameron, Palmer and Rushena 2000, Honberg and Gruttadaro 2005). Third, and finally, whether the increased awareness of criminalisation has resulted in policy and/or service responses that have increased the use of confinement and compulsion within mental health services (Fry, Riordan and Geanellos 2002). These questions are important avenues for continued research.

106 6.4.4 Compulsory care in the community

The fourth important trend in considering the use of confinement in the English and Welsh mental health system is the rise in the use of mechanisms of compulsory treatment in the community. These involve creating powers to enforce and follow-up treatments that do not rely on spatial confinement or enforced residence in government owned or regulated accommodation. The use of such powers points to the blurring of the boundaries of community and institution. They allow compulsion to occur in a way that is not (substantially) spatially controlling.29

In England and Wales these powers have been relatively non-restrictive compared to other jurisdictions (Lawton-Smith 2005). Following concern about the lack of aftercare treatment among some patients The Mental Health (Patients in the Community) Act 1995 was passed, which amended The Mental Health Act 1983, introducing new powers including supervised discharge. There are currently three key mechanisms for compulsory community treatment, namely guardianship orders, leave of absence from hospital and supervised discharge orders. None of these powers have been widely used (Shaw, Hatfield and Evans 2000, The Information Centre 2006g, 2007a).

The relative weakness of compulsory powers governing release within the community has been debated within England and Wales (Davies 2002). The lack of use of the powers under the 1995 Act led the 1997 Blair Labour Government to argue for stronger powers of compulsion in the community. When that Government provided a brief to an expert committee on the reform of mental health legislation, they specifically asked the committee to advise on introducing compulsory treatment for patients not formally detained in hospital (House of Commons Health Committee 2000: para 19). The introduction of such powers was subsequently a key part of recommendations for new legislation, as discussed in Chapter Eight. The introduction of powers of compulsion within community settings poses the question of whether this can be considered a move towards a more controlling and confining approach, or whether this is the provision of a new, less confining, approach than conventional institutional care. This is a question which has been controversial in the English and Welsh context (Fennell 1992, Atkinson 1996, Brophy and McDermott 2003, Dawson,

29 In fact for some of these powers there do remain limited elements of spatial control. Guardianship powers, for instance, can require a person to live at a particular location.

107 Romans, Gibbs and Ratter 2003). This is a question that I discuss in more depth in Chapter Eight.

6.5 Conclusion

In Chapter One I presented evidence of a renewed emphasis on ‘institutionalisation’ and confinement in a number of European jurisdictions. I argued that much of this evidence was too broad-brush and that there needed to be more in-depth examination of these trends in particular jurisdictions. In this chapter I have presented evidence which shows that there has been a renewed emphasis on confinement in England and Wales, particularly since the early 1990s. This is not a simple trend, but is complicated by a range of factors that would benefit from further research.

The evidence I presented shows a rapid decline in the number of psychiatric beds following a policy of deinstitutionalisation, albeit a decline partially offset by a shift to beds in allied and associated sectors. This decline in psychiatric beds has continued into the 2000s. Despite this decline in beds psychiatric admissions to hospitals continued to rise until they peaked in the 1990s. This growth in psychiatric admissions reflects both a growing destigmatisation of receiving mental health care, and a broadening of the sorts of problems treated under the auspices of mental illness. The decline in admissions since the mid 1990s reflects the growing options for treatment outside the hospital system, particularly in private care. Compulsory admissions followed a different pattern, falling steadily until the late 1980s and then increasing until the late 1990s. One important new feature of this rise has been the rapid growth of the forensic sector. This resulted in a doubling of secure beds between 1996 and 2006 and a 72% increase in patients between 1995 and 2005.

Thus the answer to my first research question, in the context of England and Wales, is that confinement of people with mental illness is still playing an important part of mental health services and has increased in importance within the system since the 1980s. This renewal of confinement has occurred both in terms of compulsory admissions to the general hospital system, but more particularly through an increase in secure beds as part of the forensic mental health system. In addition there are signs that the private sector is increasingly involved in the confinement of people with mental illness. The evidence that I have presented in this chapter points to the need

108 to conduct further research. More research is needed on both what has impacted on the increased rates of admissions, such as the role of readmissions and overcrowding. There is also a need for much more research on both the phenomenon of criminalisation and particularly a teasing out of the relationship between criminalisation and the renewed focus on confinement within the mental health system.

This chapter has answered my first research question in the context of England and Wales and has provided the evidentiary basis for the following two chapters. These chapters address research questions two and three, namely how have ideas of risk been utilised in past mental health policies and to what extent, and how, are ideas of risk used in contemporary policies of confinement of people with mental illness.

109 Chapter 7. Historical Analysis of Risk and Confinement in England and Wales

7.1 Introduction

In this chapter I address my second research question in the context of England and Wales, namely: How have ideas of risk been utilised in past mental health policies and how has this related to the use of confinement?

This research question is predicated on the idea that an historical investigation of how risk has been used, and how confinement has been justified, can help to assess whether there is something new and unique about the role of risk in contemporary mental health policy and how that use of risk relates to spatial control. As I established in Chapters Three and Four there is disagreement about the degree to which the use of risk is something new that is a reaction to changes associated with reflexive modernity. The primary aim of this chapter is to lay the foundations for addressing this issue. The secondary aim of the chapter is to show how spatial confinement has been rationalised historically. Addressing these aims will establish the basis through which to understand how the use of risk in contemporary policy is linked to the use of spatial control and/or the spatial decentring of control.

The chapter draws on my analysis of historical sources and primary archives to trace the use of risk and the rationalisation of confinement in England and Wales from 1845 to 1992.30 My research begins with the establishment of the county asylum system in 1845 and the creation of a unified legal approach to the care of lunatics. This analysis continues until 1992. The following chapter examines the use of risk in more depth from 1922 onwards. Due to the nature of the research question, which is interested in historical changes, the chapter utilises a broadly chronological approach in showing how the use of risk and the justification for confinement has changed. Within this chronological approach I draw out the relevant themes over broad time periods: origins and focus on care 1845-1885; individual liberty and public safety 1885-1920; resurgent medicalism 1920-150; community care and deinstitutionalisation 1950-1975; and renewed legalism 1975-1990. In the final

30 A list of the sources analysed is contained in Appendix One.

110 section I draw the strands of this historical analysis together to specifically address both how confinement has been justified historically and how notions of danger, safety and risk have been utilised.

I use my analysis to argue that danger and safety began to replace cure as a key rationale for confinement as a reflexive reaction to the growing prominence of deinstitutionalisation and community care from the 1960s. As community care grew in importance this undermined the notion that confinement of people with mental illness could be justified on the grounds of necessity of treatment. Public safety and protection from danger came to fulfil the role of providing a continued justification of disciplinary modes of control over mental illness. This, I argue, points to the continued focus on utilising spatial confinement as a way to physically delimit the normal from the abnormal.

7.2 Uses of Risk

One of the key findings of my analysis is that the idea of ‘risk’ was largely absent from policy until the 1980s. As a result, much of my analysis in this chapter focuses on the following two questions. First, how much has confinement of people with mental illness historically been justified, in legislation and policy, by ideas of dangerousness and the protection of the safety of the public? Second, in what ways have ideas of danger and safety been conceptualised? Answering these two questions establishes the basis on which to make judgements about the degree to which the later framing of confinement around risk is substantively different from those based on danger.

Focusing on these two areas also provides the foundation for assessing the claims of both Castel (1991) and Rose (2002) that there has been a shift in governance from dangerousness to risk. As I have already illustrated in Chapters Two and Four, respectively, both Castel and Rose’s arguments about changes to the governance of mental illness have distinct chronological aspects to them. Neither is, however, entirely convincing in providing historical evidence to support these arguments. The analysis that I present in this chapter provides evidence to better examine these claims.

111 7.3 Origins and a Focus on Cure 1845-1885

Prior to 1845 the provision of mental health care in England and Wales occurred in diverse ways, with relatively little centralised control and regulation. Care and control of people with mental illness occurred across a range of places and spaces, such as homes, private hospitals, and charitable hospitals (Philo 2004). These diverse spaces were gradually superseded by a county run mental health system established in the period following 1845.31

The passage of the Lunacy Act 1845 and the County Asylums Act 1845 created a unified legal approach for the care of lunatics and established a comprehensive system of county asylums mandated by the government. Although this period created the groundwork for the next 100 or so years of mental health policy, there was little direct discussion of the rationalities for the system either in parliament or in departmental archives. Most government effort was instead focused on the administrative details of the new system.

The 1840s to 1880s was characterised by a medical triumphalism. The county asylum was envisaged as a giant step forward, which would result in a large increase in the rates of cures of people who were previously left languishing untreated. Throughout this period there was little reference in public policy to control and confinement and none to risk; even the concept of dangerousness barely appears. The adequacy of the care provided by the new system and the degree to which it was curing mental illness formed the centre of policy debates. This question of cure became the core question of debate and administration. It was this, and cost, by which the emerging mental health system was judged. In particular there was concern about whether the system was effective enough in providing early care, which it was believed was essential for curing patients (Scull 1979: 111).

The focus on cure formed the primary rationalisation for spatial separation. Confinement was predicated on the assumption that it would provide a cure for patients to the benefit of both the patient and society. If, as Dallaire et al. (2001) have argued, mental illness poses a particular problem for the state because of its uneasy positioning between badness and illness, then illness was much more the rationale for confinement than badness during this time. The lunatic subject was identified and

31 This is not to claim that these prior forms of care ceased to exist, only that they became a less significant part of the overall mental health system.

112 confined primarily on the basis of illness rather than badness. The avowed purpose of spatial segregation was to remedy this illness so that the subject could be cured and returned to society.

7.3.1 Establishment of the asylum system

The two main effects of the 1845 Acts were first to establish the Lunacy Commission, with responsibility for overseeing the regulation and care of lunatics and second, to require all counties and boroughs to provide a state operated and funded asylum. The Lunacy Act 1845 was introduced partly in response to a lack of safeguards in the previous laws against abuses within existing forms of mental health care (Parliamentary Debates 1845). The main aims of the Act were to clarify the law and provide better safeguards against abuse. Lord Ashley, a Metropolitan Commissioner of Lunacy, claimed that ‘it provided an additional security against the improper detention of pauper patients’ (Parliamentary Debates 1845: 405). These safeguards were provided in the form of the roles and functions of the Lunacy Commission, which was given national authority over all asylums.32 One of the roles of the Commission was to ensure the transfer of pauper lunatics in workhouses to asylums and to regulate their treatment in both private and public asylums.33 The transfer of patients from workhouses to asylums was an example of the focus on confinement for the purpose of cure. These transfers were predicated on the belief that lunatics who were confined in workhouses would remain mad, whereas those who were sent to asylums early were seen as having a good chance of being cured.

The Lunacy Act 1845 introduced a regime for certification, which meant that no one could be received as a lunatic without proper authorisation. The primary considerations in allowing certification were whether the person was a) a lunatic and b) failing to receive adequate care elsewhere. There was little focus on dangerousness. The statement of particulars (Schedule B) contained a tick box question as to whether a patient was dangerous, but this was a secondary consideration. It was just one of numerous particulars sought, such as marital status. The lack of focus on dangerousness as a criterion for confinement was reflected in a clause in the 1845 Act (s.87), which held that if a patient escaped then their reception

32 This is with the exception of Bethlehem Hospital, over which the Commission gained authority in 1853 after an acrimonious debate with the Bethlehem governors (The National Archives of the UK HO 45/4186). 33 They directly regulated and visited private asylums, but managed county asylums via a system of Justices of the Peace.

113 order only remained in force for fourteen days. If they managed to remain free for longer, their certification lapsed. The rationale for this clause was that if the lunatic was able to successfully evade authorities and operate in society for two weeks then their illness could not be severe enough to require confinement. This illustrates the degree to which the focus was on cure of illness not dangerousness.

The rationale for confinement was most explicitly related to whether a lunatic was receiving adequate care elsewhere. There were two major reasons for this. The first was an emerging concern that the incidence of madness was growing and would continue to grow unless more was done to ensure the cure of lunatics. Thus cure was seen as essential to prevent the growth of madness. The second reason was simply that there was no reason for counties to take on the financial burden of care if a lunatic was being cared for elsewhere (such as by the family). If a lunatic was receiving appropriate care this satisfied the main aim of the system, regardless of where this care was occurring.

Occasional references to dangerousness did occur. For example, under the Lunacy Act 1845 (s.75) no patient was to be discharged from a licensed house (private asylum) or hospital if the medical superintendent (or attendant) objected on the grounds that the patient was dangerous or unfit to be at large. However the Commissioners of Lunacy were given the power to overrule this in order to prevent dangerousness from being an excuse for unjustified committal. The absence of a focus on dangerousness is reflected in the practice that lunatics could be compulsorily certified only if they were not receiving adequate care elsewhere. Dangerousness, or lack thereof, was thus largely irrelevant to whether certification occurred.

7.3.2 Confinement for cure

The significance of the focus on cure in justifying confinement needs to be recognised in the light of the workhouse system already in place in England and Wales. The poor law provided a system of workhouses within which many lunatics were already confined (Driver 1993). These workhouses provided a place where people who could not support themselves could work to get food and shelter. Thus the asylum system was initially conceived as a way of providing a better chance of cure for the many people already confined by the state. There was therefore little need for a separate rationalisation for confinement of lunatics.

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The existence of workhouses, and the incarceration of large numbers of lunatics in them, freed the state from having to balance and address the positioning of lunatics between illness and badness. Castel (1988) argues that psychiatry in France arose as a way of removing the social disorder of madness from the social landscape. It answered a political problem of government. In England and Wales the effect of the workhouse system meant that much of the social disorder of madness had already been removed. In effect the role of workhouses left the state free to concentrate on the reformation of social deviance as spatial control was already being exerted over that deviance.

The focus on reformation meant that the idea of cure formed an essential part of how mental health policy was framed and understood. The emphasis on cure also reflected the impact that modern medical ideas had on the establishment of the mental health system in England and Wales. State initiated confinement was influenced by the idea that new medical (and moral) techniques would result in the cure of the insane (Metropolitan Commissioners in Lunacy 1844: 7). In this sense modern notions that the state had a role in the improvement of the individual, and that mental illness was something amenable to treatment drove confinement in psychiatric institutions.

The notion that madness was amenable to treatment was heavily influenced by the ideas of moral treatment. The rulebooks for various institutions illustrate the influence of moral treatment on county asylums. One example is the 1852 rulebook for attendants at Liverpool Royal Asylum, in which attendants are instructed to act in ways which accorded with the teachings of moral treatment. They are, for example, implored to ‘always work quietly’, and to ‘remonstrate kindly, but on no account speak harshly’ (The National Archives of the UK MH 51/44B). Moral treatment was a particular form of treatment that was conceptualised as a reaction to the supposedly brutal and animal like confinement of previous eras. The casting off of the chains of lunatics by Pinel, at Asylum de Bicêtre in France, in 1795 was symbolic of moral treatment. Pinel (1806: 3-4) argued for replacing harsh treatment with sympathy and kindness.

The York Retreat asylum of the Tukes, opened in 1786, exemplified the tenets of moral treatment. Care in the Retreat was focused on the concept that patients could attempt to overcome their own propensities for madness and exhibit self control

115 given the right encouragement (Tukes 1813). There were many aspects of moral treatment that did not apply to the new county asylums, such as the high staff ratio relied upon at the Retreat, where the conduct of staff in treating patients humanely was paramount. However the policy framework established around the county asylums drew on the importance the concept of cure played in moral treatment. This is illustrative of the increasing medicalisation of lunacy in the post 1845 period.

7.3.3 The role of medicalisation in confinement

The establishment of the county asylum system and the justification of its role was heavily influenced by the medicalised perspective on mental illness. The Report of the Metropolitan Commissioners in Lunacy to Lord Chancellor in 1844 (the Metropolitan Commissioners were a forerunner of the Lunacy Commission) is evidence of the influence and importance of the medicalised approach. That report both set the agenda for the Lunacy Commission, which replaced it, and was influential in the drafting of the 1845 Act (Busfield 1986: 245). One of the overriding concerns of the Metropolitan Commissioners was the incarceration of pauper lunatics in workhouses, as they stated:

It has been the practice, in numerous instances, to detain the insane pauper at the workhouse or elsewhere, until he becomes dangerous or unmanageable; and then, when his disease is beyond all medical relief, to send him to a Lunatic Asylum where he may remain during the rest of his life, a pensioner on the public (Metropolitan Commissioners in Lunacy 1844: 6).

The concern was that lunatic asylums were only receiving cases once they were incurable, which meant that asylums became filled with the incurable and thus incapable of ‘receiving those whose malady might still admit of cure’ (Metropolitan Commissioners in Lunacy 1844: 7). This desire to improve the likelihood of early treatment, and thus cure, became one of the key policy occupations until the early 20th century. From the 1840s until the early 20th century there was a belief in the curability of many mental diseases, provided that they were treated in the early stages. Both the Commissioners of Lunacy and the Ministers responsible for lunacy repeatedly claimed a high cure rate for people within their first year of suffering a mental disease. Their claims reflected a widely held professional view that people who had suffered from lunacy for over a year were likely to be incurable (Scull 1979: 111). Lord Ashley, for example, asserted this in one of his parliamentary speeches advocating for lunacy reform in 1844, where he stated:

116 If taken in time, insanity was susceptible to cure, but that if permitted to grow, it became … confirmed, and, in time, a permanent affliction (Parliamentary Debates 1844: 744-745).

He later claimed, while introducing the 1845 Act, that ‘the system we propose to substitute for the present one will effect a cure in seventy cases out of every hundred’ (Parliamentary Debates 1845: 193).

The Metropolitan Commissioners made clear that ‘the professed and indeed the main object of a County Asylum is, or ought to be, the cure of insanity’ (Metropolitan Commissioners in Lunacy 1844: 88). They were aware that asylums could be considered a place to lock up the strange and wanted to emphasise that the county asylum system was not focused on this:

A County Asylum is erected for the benefit of the whole county, and is to be considered not merely as a place of seclusion or safe custody, but as a Public Hospital for cure (Metropolitan Commissioners in Lunacy 1844: 89).

The period from 1845 until the mid 1880s was influenced by a medicalised approach to care, which resulted in a focus on confinement for the purpose of cure. It was belief in medical treatment that helped to make cure such a central element in how confinement was justified. If, as Lord Ashley claimed, 70% of cases could be cured then confinement for the purpose of control did not need to be a high priority.

7.3.4 Role of danger in confinement

The direct use of ideas of dangerousness and safety to justify confinement was rare. In one of the few direct references to ideas of dangerousness a 1859 letter to the Commissioners in Lunacy, from the Medical Office of the Somerset Asylum, recommended that counties be encouraged to develop special institutions for ‘troublesome and dangerous epileptic patients, idiotic patients insusceptible of education, and patients subject to what is called moral insanity’ (The National Archives of the UK HO 45/6686). In response the Commissioners expressed their concern that this would be an additional expense for counties, and thus undermine support for the asylum system as a whole (The National Archives of the UK HO 45/6686). Their response illustrated the low priority on confinement for the purpose of safety. The Commission wanted counties to invest their money in curable cases, not to provide lifelong care for the incurable.

117 Despite the primary focus on rationalising confinement in terms of the cure of lunacy, dangerousness was apparent as part of the justification for confinement. Although the main focus of the Metropolitan Commissioners was on shifting lunatics into asylums for cure they also claimed that workhouses held ‘not only incurable harmless idiots, but numerous maniacal and dangerous lunatics of every class’ (1844: 98), with the implication that such people were too dangerous to remain in workhouses. Lord Ashley used this line of reasoning in arguing for lunacy reform (see Parliamentary Debates 1844: 744-745). The Metropolitan Commissioners also noted concern about the ease of escape from private asylums which presented the ‘hazard to others of permitting dangerous Lunatics to be at large’ (1844: 72). The context in which these explicit references to danger were used suggests that these arguments were made primarily to buttress the importance of establishing the county asylum system, rather than being a key rationale for confinement within the new system.

In summary the period from 1845 to 1885 saw the establishment of the foundations of the state mental health system. It resulted in a new system whereby state confinement of people with mental illness was made easier. This system was justified primarily in terms of the benefit to the patient and the community of the cure that would result from confinement. There was very little direct, or indirect, framing of public policy around the prevention of danger.

The relative lack of importance of notions of danger and safety needs to be seen in light of the workhouse system, which was already confining large numbers of people with mental illness and thus already performing the role of providing protection from deviance. Policy makers and other proponents of the county asylum system envisaged that a large proportion of those admitted to asylums would either come from workhouses, or would be people who would otherwise be destined for the workhouse if asylums did not exist.

Asylums were a shift in confinement for a particular group of people rather than an entirely new system of confinement. This helps explain the focus on the rationale of cure and the lack of justification for the confining nature of asylums. Asylums were viewed as a method for distinguishing and physically separating lunatics from paupers, thus making the former available to curative medical practice. Confinement was a secondary imperative intended for only the most problematic lunatics. Due to the pre-existing workhouse system spatial confinement of the mad was part of a historical continuity of the separation of the deviant from the normal and required no

118 express justification. The establishment of the county asylum system was thus not the beginning of a disciplinary approach to control of people with mental illness, but rather was a move towards confinement justified by the reformation of illness. This is a demonstration of Castel’s (1998) notion that psychiatry helped justify confinement of people with mental illness by providing a rationale for confinement which was justified on the grounds of illness rather than purely on the grounds of control of badness. This is not to claim, as Scull (2006) warns against, that the role of psychiatry was all about social control, but to recognise that psychiatry did relate closely to the exercise of control.

The fact that dangerousness was so relatively unimportant in framing policy during this period also foreshadows my argument that dangerousness became more important as a justification for confinement as other rationales for confinement became less accepted. There was no need for explicit reference to dangerousness during this period, as the faith placed in medical treatment meant that cure alone was a sufficient rationale for confinement within the psychiatric system.

7.4 Individual Liberty and Public Safety 1885-1920

By 1885 the lunacy laws had been in place for forty years and there was pressure to introduce reforms to address some of the problems that had emerged over this period. Between 1885 and 1900 a range of amending and consolidating legislation was passed. These reforms largely focused on increasing legal protection against confinement, but did not substantially change how confinement was rationalised. Rather they continued to emphasise the focus on cure as the rationale for confinement. By the early 1900s a change started to occur as the failure of asylums to cure large numbers of people became more apparent. At this point the protection of public safety became a more significant part of how confinement was justified.

7.4.1 Safeguards against confinement

Pressure for reform of the lunacy system came from two main sources, which are evident in a departmental memorandum from 1885 (The National Archives of the UK MH 80/1). This memorandum records that the primary purpose of the amending legislation of that year was ‘to furnish safeguards against the improper confinement of persons as lunatics’, with particular emphasis on ‘provision … to prevent the improper confinement of lunatics in workhouses’.

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One pressure for reform was from the Lunacy Commission. The Commission was concerned that too many lunatics were being held in workhouses inappropriately by county authorities in order to save costs, as workhouses were much cheaper than asylums (The National Archives of the UK MH 80/1). The Commission argued that this undermined both public support for the asylum system and the curative aim of asylums. The number of lunatics being held in workhouses meant that asylums were often receiving cases once they had been held for years, rendering them likely to be incurable as far as the Lunacy Commission was concerned. The pressure from the Lunacy Commission for reform reflected the continuing importance of ideas of cure as the rationale for confinement.

The second pressure for reform of the lunacy laws was public concern about inappropriate confinement. This public concern was exacerbated by the well publicised case of Georgina Weldon (in 1878), who was certified by two doctors on her husband Harry Weldon’s request. He wanted to avoid paying the £1000 a year divorce settlement he had agreed with her, by using her spiritualist beliefs to have her confined in an asylum. She managed to avoid capture for the time that the certification order remained valid, but was unable to instigate any action against her husband or the doctors involved. This generated widespread public uproar about the lack of protection against confinement (Porter, Nicholson and Bennett 2003).

Internal departmental archives show that public concern about widespread use of confinement was part of the reason for government action regarding the way confinement was managed under the existing legislation. A letter from a secretary to the Lord Chancellor, in relation to an early 1882 Bill to reform mental health legislation, noted the need to address public concern about inadequate safeguards around committal:

I am afraid that the principal question on which the public takes the deepest interest… is not disposed of satisfactorily that is, the conditions under which lunatics are placed in Asylums (The National Archives of the UK LCO 1/64).

The Government proposed to introduce much stronger legal safeguards against confinement, a proposal opposed by the Commissioners in Lunacy, who were fundamentally opposed to the trend encompassed in the 1882 Bill of more legal safeguards and processes. The Commissioners felt that this could impinge on medical knowledge and expertise, and thus undermine the curative focus of the

120 asylum system. In a letter regarding legal safeguards the Commissioners noted that they were opposed to an order of reception for a private patient having to be made by a County Court Judge or Justice. They gave a variety of grounds, including delay and expense, but their main objection was that committal was not, and should not be, primarily a legal issue:

It could very rarely happen that a Judge or Justice would bring to bear any such skill in Lunacy as would justify him in revising the whole case, and going against the evidence or opinion of the Medical men and the patients’ friends (The National Archives of the UK LCO 1/64).

Lord Shaftesbury,34 the long-time, and influential, head of the Commission, personally wrote to the Lord Chancellor expressing in firm terms, ‘a repugnance so strong that it will be quite impossible for me to support that part of it’ [the increased role of the magistrate in assessing claims for admission] (The National Archives of the UK LCO 1/65). Lord Shaftsbury claimed that ‘it will tend to the extinction of early treatment; to clandestine confinement with all its many abuses’.

The opposition of the Commissioners in Lunacy resulted in an initial watering down of judicial oversight of involuntary treatment in reforming legislation in the House of Lords. The House of Commons, however, repeatedly knocked back the Lunacy Act Amendment Bills proposed in the 1880s because of concerns about the lack of judicial oversight. Eventually a new Bill with a stronger judicial oversight was introduced. 35 This was explained as being necessary in order to:

Provide a security against any possible abuse of the anomalous privilege which medical men have so long enjoyed, it is provided that a judicial inquiry shall be held and a judicial decision obtained before a person can be permanently confined as a lunatic (Parliamentary Debates 1889: 1793).

Debate and decision making was thus influenced by the recognition that confinement in an asylum was effectively a form of incarceration, and that the serious nature of this meant that there had to be increased oversight to prevent abuses.

The amending legislation passed between 1885 and 1889 was consolidated in the Lunacy Act 1890, which served as the framework for mental health law until 1959. This 1890 Act was far more comprehensive than prior Acts and had a much greater

34 Previously known as Lord Ashley, who introduced the 1845 legislation. 35 Jones (1960) argues that the death of Lord Shaftsbury in 1885 substantially weakened the position of the Lunacy Commission in their struggle against legalism. Lord Shaftsbury had been able to stifle moves towards a more legalistic model. He was, for example, influential in convincing the Select Committee Inquiries of 1857 and 1877 against a legalistic approach.

121 focus on the protection of the rights of alleged lunatics. The strength of the focus on administrative details led Jones (1960: 35) to describe the Lunacy Act 1890, which epitomised this approach, as:

An extremely long and intricate document, which expresses few general principles, and provides in detail for almost every known contingency. Nothing was left to chance, and very little to future development.

In particular the 1890 Act required that a judicial authority consider the statements of particulars and the evidence of lunacy before a person could be certified. In this way the 1890 Act performed the exact role that the Lunacy Commissioners had been concerned about. It transformed decisions about confinement from being primarily medical to primarily judicial. This signalled a shift from confinement being justifiable on purely medical grounds towards there being a necessity for social and/or legal grounds for the deprivation of liberty associated with confinement. As medical grounds for confinement became less compelling than notions of danger and the protection of the public started to become explicit rationales for confinement. This demonstrates the ongoing significance of spatially centred responses to mental illness, as disciplinary modes of control remained central, despite changing rationales for confinement. There was a continued focus on the use of spatial separation to separate the ‘normal’ from the ‘abnormal’ which has been an essential element of the disciplinary society (Philo 2004).

7.4.2 Public safety

The introduction of judicial oversight in the 1890 Act signified greater overt concern about public safety. Once confinement became more difficult the concern with protection from danger became more explicit. In the case of the 1890 Act the Government did not want to be seen to be placing individual rights ahead of safety and as a result the Act contained provision for emergency confinement if necessary for public safety (The National Archives of the UK MH 51/834). These provisions were to assuage concerns that judicial oversight would lead to delays in confinement, which could present a danger to the public.

The new mechanisms (s.20) provided that if a constable (or others) decided that it was necessary for public safety or the welfare of an alleged lunatic that the alleged lunatic should be placed under care and control, the constable could remove the alleged lunatic to a workhouse for up to three days. It also provided that in urgent cases either for the welfare of a person (not a pauper) alleged to be a lunatic, or for

122 public safety a person could be detained in a lunacy institution on application by a husband or wife, accompanied by only one medical certificate. These changes introduced the first real move towards a clear and explicit concern with the protection of public safety as a rationale for confinement. Safety thus became a more important rationale for confinement once decisions about confinement started to include a legal as well as medical component.

7.4.3 Consolidation and control

By the early 1900s the failure of the asylum system to cure large numbers of people was becoming increasingly apparent. The growth in the size of asylums and the number of people confined in them fed apprehension about the number of mad and “feeble-minded” people (people with intellectual disabilities) in society. This was an anxiety which was linked to the growth of the eugenics movement in England and Wales (Lees 1998). These concerns were influential in the establishment of The Royal Commission on the Care and Control of the Feeble-Minded in 1904. The Commission was tasked to investigate ways that the care of the feeble-minded operated and how the feeble-minded could be controlled more effectively in order to stop an increase in their numbers. The terms of the Commission were expanded in 1906 to include how to manage lunatics as well (Royal Commission on the Care and Control of the Feeble-Minded 1908: 206).

Although the Commission had their warrant extended to include lunatics their major focus remained on the feeble-minded. The interests of the Commission were expressive of a change in the focus of mental health policy and treatment away from cure towards care and control. By the early 1900s there was growing disillusionment with the medical approach to mental health policy (Porter 2002). It had become increasingly clear that asylums were not resulting in the high rates of cure that their advocates had claimed they would. As a result there was a distinct shift in the rationalisation of confinement towards control from this period. This shift towards control is illustrated in the terms of reference of the Royal Commission. One of the Commission’s key tasks was to identify the danger resulting from failing to confine the feeble-minded and lunatics. Among other matters they were required to report on:

Dangers resulting to such persons and the community from insufficient provision for their care, training and control (The National Archives of the UK HO 45/101/B29752).

123 The role of the Royal Commission, and the way its remit was expressed, highlights the degree to which cure became a much less important rationale for confinement from this point. This is not to claim that cure became of no importance, rather that it was no longer the dominant rationale for confinement. Protection of the public became a much more explicit rationale, signalling a more controlling approach to madness.

7.4.4 Rise of safety as a rationale for confinement

The emerging emphasis on safety as a rationale for confinement was linked to both the decline in the belief that cure was a likely outcome of confinement and the decline of other forms of confinement. As other forms of confinement of deviance, such as workhouses (Lees 1998), began to decline in importance and become less acceptable to the public it became necessary to provide a more specific rationale for continued confinement of people with mental illness. The prevention of danger and the protection of public safety started to fulfil this role.

Ideas of danger and safety were framed in a very individualistic way. Physical danger was seen as being embodied in particular individuals and to be managed at an individualistic level. This approach to understanding danger is precisely how Castel identifies the notion of danger operating in mental health policy. In Castel’s (1991: 281) view one of the major implications of an individualistic view of danger is that effective intervention to manage danger has to occur in the form of direct, face-to- face relationships between the carer and the cared. This notion of individual dangerousness implies a quality of unpredictability which is immanent in the individual. The idea of dangerousness here implies that in the future the individual may commit some dangerous act, but there is no sense of how or when this might occur. Faced with this unpredictability prevention through spatial segregation of the individual became the ideal intervention and thus confinement became justifiable. This use of individualised danger is different from the modern notion of risk which is premised on probability and actuarialism (Giddens 1999).

7.5 Resurgent Medicalism 1920-1950

During the 1920s the medical profession embarked on a determined campaign to make certification primarily a medical concern and overturn the legalism of the 1890 Act. The early 1900s was characterised by debate between legalistic and medical

124 approaches to regulating the care of mental illness. The medical model gradually gained the upper hand among policy makers and the Ministers, although the House of Commons remained committed to a legalistic approach. The medical model held that judgements about who should be confined should be primarily a matter of clinical decision making, as this would ensure that those who needed medical attention would get it. The influence of these medical ideas culminated in a push for enabling voluntary treatment both in state institutions and in community settings. As the idea grew that adequate treatment for mental illness could be received outside of confinement, rationales for confinement begin to shift much more explicitly towards control of danger.

7.5.1 Facilitating early treatment

The Lunacy Commission had strongly opposed the move towards legal oversight that was included in the 1890 Act. In 1922 a conference was held, supported by the Department of Health, to (as the subtitle of the proceedings said) ‘consider in what directions lunacy administration and the treatment of persons suffering from mental disease may be improved’ (Willis 1922). This conference was indicative of the renewed emphasis on the medical approach, following the dominance of the legalistic approach in the previous decades. The Minister of Health announced at the conference that ‘we want to introduce into our asylums, as much as possible, the hospital spirit and all that is implied by that term’ (Willis 1922: 4). The medical profession dominated the conference and one of the main aims of the conference was to develop a joint position from which to advocate for legislative change to facilitate early treatment without legal certification.

This campaign was successful to the extent that a Bill (the Mental Treatment Bill) was passed in the House of Lords in 1923, which would have amended the law to provide for voluntary treatment. As the 1890 Act stood it was difficult to get treatment in a hospital for mental illness on a voluntary basis.36 The aim of the Bill was stated as being to ensure speedy medical treatment for mental illness, as:

There is a very strong prejudice against certification, and in consequence many persons who are mentally ill delay obtaining expert advice and treatment at an early stage of their illness, with the result that some cases reach the incurable

36 In fact there was no legal basis for such treatment. It was, however, widely acknowledged that some wealthy people were able to receive treatment without certification. This point became one of the main arguments used to drive the contentious 1930 Bill though the Commons. Proponents of the Bill argued that it was effectively making possible for the lower classes what was already the case for the upper classes (Parliamentary Debates 1930).

125 stage who could have been cured had they come for treatment earlier (The National Archives of the UK MH 58/91).

The rationale for changes to the legislation was once again discussed and framed in terms of the benefit to the patient of easier treatment, leading to a greater chance of cure.

Despite support in the House of Lords and a campaign by leading medical practitioners the House of Commons did not pass the Bill, even after repeated attempts. As the Secretary to the Minister of Health later stated this was because the Commons was unwilling to weaken legal safeguards around commitment:

The experience of the Mental Treatment Bill and the corresponding clause in the Miscellaneous Provisions Bill shows how reluctant the House of Commons is to assent to any weakening of the legal safeguard against improper detention (The National Archives of the UK MH 58/216).

The debates over the Bill were indicative of the tension between legalistic and medical approaches to compulsory and voluntary treatment. These tensions were evident in a Royal Commission on Lunacy and Mental Disorder established in 1926, and were the subject of intense debate within and between the Ministry of Health and the Board of Control in the following period. Eventually the medical perspective gradually gained the upper hand. The 1926 Royal Commission was appointed following the legal case of Harnett v. Bond, in which Mr Harnett successfully sued Dr Bond for false imprisonment after having been confined for nine years (The National Archives of the UK LCO 2/052). The Harnett case raised public concern about the degree to which false imprisonment might be occurring in the mental health system.

The 1926 Commission argued that previously the mental health system had focused on detention, whereas modern medical knowledge meant that it was now appropriate to focus on cure:

A survey of the early history of the treatment of the insane in this country thus discloses, as might be expected, predominance of the idea of detention… With the advance of medical science and the growth of more enlightened views insanity is coming to be regarded from an entirely different standpoint (Royal Commission on Lunacy and Mental Disorder 1926: 16).

The key focus of the recommendations of the Commission was that health services should focus more on prevention and treatment, including encouraging voluntary treatment. The Commission called for a community service based on the treatment of patients in their own homes wherever possible with a preventive element. They also

126 argued that mental illness should be approached in a similar way to physical illness and expressed concern about the lack of safeguards against abuses.

Yet ironically, despite the Commission’s claims about previous systems focusing on detention not cure, their report was the strongest statements throughout my analysis about the need to exert social control over people with mental illness. This is further evidence that as confinement became more difficult, because of additional safeguards, notions of protection against danger became more important. The Commission was aware that its recommendations might make confinement more difficult and lead to less confinement. As a result the Commission went to some lengths to argue that confinement was necessary in many cases.

The Commission argued that medical treatment could, and should, occur without legal certification. Therefore their argument for why confinement was still necessary focused much more explicitly on confinement for the purpose of control:

It is around this problem of compulsion that the main controversies of our subject have centred… If he insists on exercising his liberty so as to cause danger to others he must suffer restraint. The price of liberty is conformity to the social conduct of order (Royal Commission on Lunacy and Mental Disorder 1926: 17).

In effect they argued that confinement should occur either where there was a danger to the individual themselves, or their neighbours or where the patient was incapable of looking after themselves. Thus danger became a more significant rationale for confinement once cure was seen as being able to be achieved outside of institutions.

Following the Commission the Mental Treatment Bill (1929) was developed to legislate its recommendations. There was considerable internal debate within the Ministry of Health about the view of the Board of Control37 that there should be no judicial oversight of the making of provisional treatment orders. As one official noted:

From the political point of view I do not believe that public opinion is prepared to allow the liberty of the subject to be infringed on the strength of medical certificates unsupported by any judicial authority (The National Archives of the UK MH 58/216).

Lord Russell, who introduced the Bill in the Lords, argued that the system needed to move away from a framework of detention:

37 This was the body which replaced the Lunacy Commission in 1913.

127 What I think is absolutely necessary, if we are to deal with this serious question in the light of modern medical knowledge, is that we should get out of our minds the idea that lunatics as a class are violent and dangerous people for whom the primary treatment is detention (Parliamentary Debates 1927: 234).

The Ministers and their officers had great difficulty trying to get the Lords to agree to allowing hospital treatment without judicial oversight, as evidenced by departmental minutes (The National Archives of the UK MH 79/421). The Lords felt that such moves would infringe too much on the liberty of the subject. Eventually, however, the Bill was passed as the Mental Treatment Act 1930.

7.5.2 Control and confinement

Developments from the 1920s illustrate how the rationale of confinement for control became stronger as prior rationales for confinement declined. Throughout the 1920s and 1930s there was much more open discussion about the need to control mental illness through confinement. This was a direct result of the growth of the view that effective treatment of mental illness could, and maybe should, occur outside of institutional settings. Thus as control over people with mental illness became more dispersed there was more attention to the idea that people with mental illness posed some sort of hazard to society, whether that be violence or more general disorder. This occurs as what Beck (1992) refers to as a reflexive response to modernisation. It was through this reflexive response to new forms of care that confinement, justified through the prevention of danger, became more prominent in public policy. This reflexive relationship is particularly clear from the 1950s and 1960s, as the next section demonstrates.

7.6 Community Care and Deinstitutionalisation 1950-1975

Although the Mental Treatment Act 1930 contained provisions facilitating voluntary treatment these were not utilised very much in the following decades (Jones 1960, Boardman 2005). However voluntary treatment became more prominent with the consolidation of the Welfare State during the 1950s and 1960s, which included a commitment to universal and accessible health care (Jones 1993). For mental health it signified the beginning of a trend away from asylums as the dominating form of care towards an increased emphasis on voluntary treatment and care outside of compulsion. It also signified a further shift towards confinement on the basis of the prevention of danger.

128

7.6.1 Voluntary treatment

The work and report of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency (The Percy Commission) (1954-57) brought into the public eye a change that had been occurring within the Ministry of Health since the end of World War Two. In their internal discussions and policy development the Ministry of Health had reached a conclusion that mental health care should shift away from an emphasis on confinement (see The National Archives of the UK MH 51/610). Their work presaged many of the same conclusions that the Percy Commission would reach. A 1949 working committee within the Ministry recorded that policy development was based on the idea that mental health treatment should more closely approximate the treatment of physical illness, with less focus on compulsion (The National Archives of the UK MH 51/610). The Ministry argued that a greater focus on voluntary treatment would both encourage more people to seek treatment and would also save money. These two arguments are indicative of the way in which deinstitutionalisation was driven by a range of, often contradictory, processes and arguments (Prior 1993).

The Ministry of Health proposed a new focus on voluntary treatment and drafted a Bill with this intent. Cabinet, however, demanded a Royal Commission before making any legislative changes (The National Archives of the UK MH 79/640). The establishment of the Percy Commission was also partially driven by media concern about the validity of commitment processes (The National Archives of the UK MH 79/640).

The Percy Commission developed recommendations similar to the policies being promulgated by the Ministry, namely emphasising the need to make mental health treatment as easy as possible by encouraging voluntary treatment. The Percy Commission held that the ability to cure mental illness depended heavily on early treatment, which they argued meant that the mental health system should shift away from compulsion as its primary mechanism of care and treatment. The notion of ‘community care’ was proposed for the first time as a mechanism for providing mental health services.

The Percy Commission was, however, careful to stress that coercion and compulsion would still have to remain a key part of the system. They argued that the expansion

129 of voluntary treatment should be in addition to compulsory treatment, not instead of it. Recognising that their own arguments for voluntary treatment could potentially be used to undermine the need for compulsion they devoted considerable attention to explaining why compulsion was necessary. The Percy Commission argued that compulsion:

On grounds of the patient’s mental disorder is justifiable when: -

(a) there is reasonable certainty that the patient is suffering from a pathological mental disorder and requires hospital or community care; and

(b) suitable care cannot be provided without the use of compulsory powers; and

(c) if the patient himself is unwilling to receive the form of care which is considered necessary, there is at least a strong likelihood that his unwillingness is due to a lack of appreciation of his own condition deriving from the mental disorder itself; and

(d) there is also either

(i) good prospect of benefit to the patient from the treatment proposed- an expectation that it will either cure or alleviate his mental disorder or strengthen his ability to regulate his social behaviour in spite of the underlying disorder, or bring him substantial benefit in the form of protection from neglect or exploitation by others;

or (ii) a strong need to protect others from anti-social behaviour (Royal Commission on the Law Relating to Mental Illness and Mental Deficiency 1957: 111).

The careful defence and justification of compulsory treatment by the Percy Commission illustrates the way in which arguments about compulsion became more explicit as alternatives to compulsion began to be used. The Percy Commission laid the groundwork for these arguments, listing a number of circumstances where compulsion should be used. The Percy Commission (1957: 114) summarised this as being ‘when the use of compulsion is necessary for the patient’s own welfare or for the protection of others’. This framing of when compulsion should be used was indicative of the increasing move away from confinement for the purpose of cure of the patient. The lengths to which the Commission went to justify why some confinement should continue points to the strength of commitment to the spatial control of mental illness. As Philo (1997: 79) has pointed out confinement and isolation is not an inevitable response to madness but, as the view of the Commission demonstrates, it is a very strong response.

130 7.6.2 Community care and dangerousness

Public policy and debate became more focused on safety and danger with the passage of the Mental Health Act 1959 and greater moves towards non-confining forms of care. Two years after the passage of the 1959 Act the Minister of Health, Enoch Powell, made his famous ‘Water Tower’ speech. There he announced his plan to reduce the number of mental health hospital beds by 50% in 15 years, a plan that would see 75,000 hospital beds removed. He noted that this implied ‘nothing less than the elimination of by far the greater part of this country's mental hospitals as they exist today’ (Powell 1961). This speech is now widely recognised as the beginning of the government’s commitment to deinstitutionalisation (Lester and Glasby 2006).

In addition the legislative changes of 1959 also occurred at a time in which legislative and policy debates were becoming increasingly open to public comment and critique. This openness began to have an influence on the types of advice offered by government agencies- an early example of this being responses to public correspondence. In one example a Dr Nelson wrote to MPs arguing that the 1959 Bill should not be passed because of the possible link between increases in crime and the liberalisation of the management of mental disorder (The National Archives of the UK HO 291/16).

This correspondence resulted in the Home Office formulating an official response to MPs which was much more explicit about the role of safety in their thinking:

In considering this whole matter the Government has had very much in mind not only the desirability of ensuring that mentally disordered persons can obtain treatment for their mental condition wherever possible without resort to compulsory powers of detention, but also the need to provide sufficient safeguards to protect the public against persons who are not only suffering from mental disorder but may be dangerous to others, or who having been convicted of offences, are likely to repeat them (The National Archives of the UK HO 291/16).

This view was reiterated in parliamentary debates, where the Minister introducing the Bill to the Commons noted that provision for non-voluntary cases:

Involves applying appropriate safeguards for the liberty of the subject, on the one hand, and for the protection of the public, where necessary, on the other (Parliamentary Debates 1959: 707).

131 The increasingly public nature of policy debates led to both more openness about rationales for decisions and more awareness of the possibility of public reaction to particular decisions and approaches. Departmental archives from the 1960s are much more alert to possible public reaction towards changes in the mental health system and are more proactive in seeking to forestall any negative reactions. One crucial way that potential negative public reaction to deinstitutionalisation and community care was addressed was through a much greater focus on the provision of forensic mental health services. The focus on these services was a way of demonstrating to the public that the dangerousness associated with mental illness was being treated seriously and being contained.

7.6.3 Origins of the forensic system

The origins of the forensic system are not straightforward. In particular there was a strong debate between the Ministry of Health and the Home Office about the degree of control which should be exerted over patients in forensic services. This tension was apparent in debates over what the role for secure mental hospitals should be and who should administer them (The National Archives of the UK HO 291/15). Secure hospitals, which primarily dealt with the criminally insane, had emerged in a de facto manner. The impetus of the 1957 Percy Commission led to consideration of how people with mental illness convicted of criminal offences should be managed. This marked the beginning of policy focused particularly on the ‘criminally insane’, what is now referred to as forensic mental health care.

The degree to which forensic patients should be treated within the standard mental health system was strongly debated. There was a series of correspondence between the Ministry of Health and the Home Office over the status of mentally ill criminals during 1958 and 1959 (The National Archives of the UK HO 291/15). The Ministry started from the position that given that mentally ill offenders were suffering from an illness they should be treated as much like other people with mental illness as possible. In contrast the Home Office focused more on forensic patients as embodied danger which needed to be controlled as closely as possible. In particular the Home Office wanted strong powers for the Secretary of State to recall offenders with mental disorders back to the criminal justice system:

We take the view that if a person has previously committed a serious offence and there is some reason to fear he may repeat the offence or another serious offence if left at large it is not right to expose the public to this risk (The National Archives of the UK HO 291/15).

132 Similarly the Home Office was critical of Ministry plans to abolish specific powers for the police to be able to apprehend people with mental illness under certain circumstances. In both of these cases the view of the Home Office prevailed, with the Ministry of Health agreeing to a greater security focus, for instance they agreed that:

The police should have a power to apprehend for his own protection or the protection of the public a person found in a public place who appeared to be suffering from a mental illness and in immediate need of care and control (The National Archives of the UK HO 291/15).

The Home Office used two key arguments, which have continued to be utilised today in justifying why a security focus was necessary. First, they argued that the safety of the community needed to be a primary objective of mental health policy. Second, they argued that a security focus would encourage greater public support for community care; that the community would support community care only if they felt that their safety would not be undermined. The approach of the Home Office became the dominant one, and forensic services increasingly became a way to demarcate the dangerous from the safe, an argument I illustrate below. In effect the bifurcation of policy inherent in the forensic system started to act as a way of identifying those who embodied danger and those who did not.

7.6.4 Bifurcation of policy

The question of how to shape forensic policy and cope with other potentially dangerous people with mental illness continued to be the area that received the most policy development into the 1970s. By the 1970s there was increasing public and policy concern about the care and treatment of people with mental illness who had committed, or been charged with, criminal offences. This concern stimulated the 1975 Report of the Committee on Mentally Abnormal Offenders (Butler Report). The Butler Report largely embraced the principles of the 1959 Act and recognised that the Act had allowed many mentally ill offenders to be treated in hospitals or in the community like any other patients. They argued that the moves towards community care needed to be accompanied by sufficient provision of secure care, as there were inevitably a number of people who could never be dealt with adequately in the community, even under close surveillance.

The Butler Report recommended the urgent establishment of a series of secure hospital units in each Regional Health Authority Area, to supplement the existing special hospitals. This was premised on the rationale that:

133 The mentally disordered offender should be placed in the treatment situation which is best for him, consistent with the requirements of public safety (Committee on Mentally Abnormal Offenders, Home Office and Department of Health and Social Security 1975: 9).

The report argued that the current arrangements of providing either highly secure special hospitals or general mental health beds left some patients insufficiently secure and others in far too restrictive an environment.

The Butler Report was influential in developing the modern forensic mental health system, which was organised around managing risk. It also marked the beginning of a clear split in policy where people with mental illness were increasingly divided into two groups, the risky and the non-risky, with policy specifically tailored towards each group. This bifurcation split people with mental illness into those over whom direct control was necessary and those over whom surveillance was sufficient control.

As I argued in Chapter Two the treatment of people with mental illness, and particularly spatial separation, has served various social, economic and political purposes. In this case the classification of some people as ‘dangerous’ allowed others to avoid this classification. By specifically classifying and separating the dangerous community care became a more palatable policy position for governments to adopt, as they could argue that the dangerous were being controlled through the forensic mental health system. The forensic system effectively bypassed the inbetweeness which has characterised the positioning of people with mental illness. Where madness once existed in an uneasy state between ‘badness’ and ‘illness’, forensic policy was a way of separating out those whose deviance was closer to ‘badness’. Thus the growth of specialist forensic care was a way of justifying community care by clearly separating those who required strict spatial segregation. It served to identify those over whom spatial control could be justified primarily on the basis of badness rather than illness. It also served to identify those who could thus be controlled through more abstract decentred forms of control in the community.

7.6.5 Danger and the decentring of care

Deinstitutionalisation and the rise of community care as a significant part of the mental health system began a breakdown of spatial confinement as the primary means to cope with the social deviance of mental illness. I argue that the rise of danger as a rationale for confinement was ultimately linked to this spatial decentring of care. As I have already shown in earlier periods spatial confinement was largely

134 rationalised on the basis of curing the patient involved. Thus as cure became accessible outside of special institutions cure was no longer as compelling a rationale for confinement of people with mental illness. As I have also shown the notion that (at least some) people with mental illness pose a danger to the community has been an undercurrent in English and Welsh policy since at least the origins of the asylum system. This undercurrent became increasingly explicit as notions of community care became stronger.

The main way in which danger was used was in the sense of its being embodied in individuals based on assessment of that individual, their history, and their behaviour. The way that danger was used was thus still a very individualistic notion which was susceptible to individual control. However during this period ideas that corresponded more closely to the idea of judging danger based on abstract factors became apparent. This idea of assigning dangerousness according to more abstract factors was the beginning of an approach that was similar to how ideas of risk operate.

The 1975 Butler Report, on forensic policy, marks the first example of risk thinking in the contemporary sense of the rejection of a static fixed category of ‘dangerous’. It was the first piece of public policy that explicitly recognised that people’s situation changes and that people do not embody a fixed level of dangerousness. The report argued that dangerousness is not a fixed, static category or state of being. As a result they argued it was therefore virtually impossible to predict individual dangerousness, although people could be assigned to various risk groups.

This was an explicit recognition of the inherent paradox in the notion of dangerousness. It recognised that there can only ever be an attribution of dangerousness to an individual that is based on a likelihood of some future act, but that there is always uncertainty about that act. The label of dangerousness thus always relates to uncertain future acts, but is applied to individuals as though it is a fixed attribute of that individual. Risk is a way to try and avoid this, as it does not carry as strong a notion of being a fixed attribute, but rather something that is variable.

The Butler Report recognised that categorising people into risk groups would inevitably lead to situations where people were subject to greater control than they needed to be. However the report concluded that this was a price that needed to be paid to order to achieve an acceptable level of security:

135 It is sometimes argued that even if there are good grounds- clinical or actuarial- for assigning the individual to a high risk group, he might be one of the minority in that group who in the event will not behave in accordance with probability. But this dilemma is inescapably involved in every decision which is based on probability. All that can be done is to weigh the unpleasantness of the consequences for the individual against the harm which he may do to others. If the harm is likely to be slight the decision should be in his favour: if great and highly probable- for example, if a sexual offence is accompanied by serious violence- the best we can do is make sure that the precautions are as humane as possible (Committee on Mentally Abnormal Offenders et al. 1975: 60).

This framing of the rationale for the division of patients into risk groups reflects the way that risk was used at this point, namely as a way of exerting greater control than the use of danger allowed. If dangerousness was about the fixed attribute of the individual then it was inherently a narrow way of exerting control, as it required making specific decisions about each individual. Risk on the other hand allowed a widening of control through including entire groups within the ambit of a ‘risk group’. The way that risk was framed in this report was by far the closest to the argument that Castel (1991) made that risk allowed the spread of control through aggregation. However this particular framing, as I will show in the following chapter, did not become a dominant framing of the use of the concept of risk.

7.7 Renewed Legalism 1975-1992

From the mid 1970s to the early 1980s there was a flurry of mental health policy development, culminating in new mental health legislation being passed in 1983. This legislation, the Mental Health Act 1983, was a return to the dominance of a legalistic model. It resulted partially from concern about the extent of power which medical professionals were able to exert under the 1959 Act (Peck and Parker 1998). In the period preceding the passage of the 1983 Act there were several policy documents which established the basic framework of the legislation.

A review of the 1959 Act conducted in 1976, A Review of the Mental Health Act 1959, held that safety should become a central element in decisions about whether or not compulsory powers should be applied:

The central concept of the Act is that a patient should only be treated under compulsory powers if it is necessary in the interests of his own health or safety or for the protection of others. Its main concern is with the balance between the protection of the public and the patient (Department of Health and Social Security 1976: 32)

136 This was effectively a formalisation of the trends that I have identified above whereby safety and security became the primary focus of mental health legislation. However this focus on safety was circumscribed in the final Act by the inclusion of the treatability test discussed below.

One of the other key issues raised in the 1976 review of mental health legislation was whether or not psychopathic disorder should be excluded from the new legislation. The review concluded that the balance of medical opinion was that most psychopaths were not likely to benefit from treatment but that there were some people suffering from psychopathic disorder who might be helped by detention in hospital. This conclusion foreshadows discussions that later took place around legislative change during the 2000s when the Blair Labour Government tried to include psychopathy part of the definition of mental illness. The question of how to manage psychopathy also prefigures the growing question of whether the idea of cure should play any part in determining whether confinement of people with mental illness should occur.

Ultimately psychopathy was not specifically included in the definition of mental illness in the Mental Health Act 1983. This decision was a reassertion of the importance of cure in justifying confinement. The inclusion of the ‘treatability test’ in the 1983 Act meant that people with psychopathic disorders could only be compulsorily treated if it could reasonably be shown that they themselves would derive some benefit from that treatment. This was effectively a repudiation of confinement purely for the purpose of prevention of danger.

The legislative reform was preceded by a 1981 white paper Reform of Mental Health Legislation (Department of Health and Social Security, Home Office, Welsh Office and Lord Chancellor's Department 1981). Both the white paper and subsequent legislation had the effect of firmly embedding the bifurcation between the safe and the dangerous in policy. This formalised the way that the forensic system operated to separate those who required strict spatial segregation. It created two distinct categories of people with mental illness. On the one hand the safe could be treated in a manner not dissimilar from those suffering physical illness and on the other the dangerous needed to be subject to firm control. This bifurcation appears to be an early example of Rose (2000b) and O’Malley’s (2004) conceptualisation of risk as operating through either inclusion or exclusion. Here the forensic system operated to

137 categorise and separate those people who embodied danger of violence and those who did not, and thus those who needed spatial control and those who did not.

The Mental Health Act 1983 was primarily a return to the dominance of a legalistic model. The 1959 Act had been passed at a time when there was still faith in psychiatrists. This was undermined by the growth of the anti-psychiatric movement during the 1960s and 1970s (Busfield 1986), so by the time the Act was revised in 1983 there was an emphasis on introducing safeguards to prevent unreasonable detention. The 1983 Act was primarily concerned with the grounds for detaining patients and the means by which their detention could be regulated. As the treatability test demonstrated the Act resulted in a slight lessening of the focus on safety and security and also in a renewed focus on cure.

After the passage of the 1983 Act there was relatively little policy development. This was a result of the small government focus of the Conservative Thatcher Government elected in 1979 (Mohan 1995). Mental health was a relatively low priority during this period and policy was primarily the sum of practice (Peck and Parker 1998, Lester and Glasby 2006).

7.8 Historical Uses of Risk

As I have shown the use of risk within policy and legislation was rare until the 1970s. However even during this later period risk was not a significant feature of policy. In this section I return to the two key questions that I identified in the early part (section 7.2) of the chapter. First, how much has confinement of people with mental illness historically been justified in legislation and policy by ideas of dangerousness and the protection of the safety of the public? Second, in what ways have ideas of danger and safety been conceptualised?

7.8.1 How confinement has been justified

My analysis suggests that the role of notions of dangerousness and the protection of public safety in justifying confinement in England and Wales has not historically been strong. This runs counter to progressivist histories of mental illness. Such histories characteristically identify 19th century mental health care as being primarily about the control of dangerousness and suggest that this was gradually displaced by a greater focus on medical treatment and cure (Scull 1999). This progressivist understanding

138 of history was the official narrative, as illustrated by the 1926 Royal Commission on Lunacy and Mental Disorder discussed above.

Contrary to these progressivist histories my research demonstrates that the notion of confinement for the purpose of cure was a much stronger explicit rationale for the establishment of the mental health system in England and Wales than confinement for the prevention of danger. This focus on cure continued to dominate the way that the government justified confinement until the early twentieth century.

However the relative lack of the use of danger to justify confinement of people with mental illness within asylums needs to be understood in light of the workhouse system which was in place in England and Wales during the 19th and early 20th century. The workhouse system meant that a large number of people with mental illness were already being detained by the state. It was necessary, then, for proponents of the asylum system to clearly differentiate asylums from workhouses. This was undoubtedly a factor in why cure formed such a strong part of the rationale for confinement of people with mental illness during the 19th century.

It was not until the 1960s that ideas of mitigating danger became a prominent aspect in the framing of policy on the confinement of people with mental illness. As I have argued, this appears to be a reflexive response to the growing influence of community care. In this way danger began to feature in the post 1960s period as what Beck (1995: 12) and Giddens (1999: 4) refer to as ‘manufactured risk’, which has arisen from the very processes of modernisation, in this case deinstitutionalisation. Once confinement was no longer the status quo, but merely one option for care, the abrogation of individual rights associated with confinement became harder to justify. It then became necessary to provide a rationale for the continued necessity of spatial confinement.

The historical analysis that I have presented in this chapter points to the continuing strong role for spatial control of people with mental illness throughout this period. As Philo (1997: 79) has argued the spatial control of people with mental illness is not a universal phenomenon, which occurs whenever madness meets non-madness. However, as I illustrated in Chapter Two, and this case study demonstrates there has been a strong focus on spatial control of madness over the last century and a half, in England and Wales at least. The justification for the spatial separation of the insane from the sane may have shifted, but the impulse has remained strong.

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7.8.2 Uses of danger, safety and risk

Ideas of danger and protection of public safety became more prominent as rationales for confinement as the rationale of cure declined. However the meaning associated with the idea of danger remained the same. This was danger as something embodied in particular individuals. This accords with the role that Castel (1991) argues that dangerousness has traditionally played, i.e. dangerousness as existing within an individual subject and thus able to be controlled through physical management of the subject.

However by the mid 1970s there were signs of a move away from a purely individualised notion of danger, towards an aggregative concept of danger where people could be grouped into categories of dangerousness based on abstract factors. This was particularly apparent as part of the growth of forensic policy. It was with the Butler Report in 1975 that the idea of dividing people into risk groups based on their characteristics was first raised. The division of people into risk groups was centred on their belonging to particular groups rather than a decision made based on an individualised assessment of propensity for dangerous behaviour. This division marks a distinct bifurcation of policy, which divided people with mental illness into the safe and the risky, a trend which (as I show in the next chapter) has some important implications for how justification of confinement occurs.

7.9 Conclusion

As I argued in Chapter Five most of the research that has used a discursive approach to policy analysis has been largely ahistoric. Despite the central importance of the changing meanings of risk there has been surprisingly little research which focuses on the historical changes of the role and usage of risk in particular contexts (Burgess 2006). Although there has been widespread acceptance that risk is socially constructed, this has seldom led to serious consideration of how and why notions of risk have changed over time. Thus a key part of the contribution of this chapter has been to properly historicise notions of risk in relation to mental illness and confinement.

This historicisation of risk and confinement provides the empirical grounding for the following chapter and provides an essential element for addressing my overall

140 research aim. The historical analysis makes it possible to assess whether the way that risk operates in the contemporary period is substantially different from how danger and safety have influenced the rationalisation of confinement. It also makes it possible to assess whether the way risk is used in relation to concepts of spatial control is part of a shift in how spatial control is justified and how it operates.

The aim of this chapter has primarily been to answer my second research question in the context of England and Wales. In this chapter I analysed public policy and legislation from the origins of the county asylum system in the 1840s to the mid 1980s. My analysis found that risk was only a minor element in the rationale of confinement over this time. Risk did not become an explicit part of the framing of mental health policy until the 1970s. Thus, at least in the case of England and Wales, the increasing use of risk in policy since the 1980s does appear to be a new phenomenon worthy of further examination: an examination that is the subject of the following chapter.

141 Chapter 8. Risk as Policy Object, England and Wales

8.1 Introduction

In Chapter Seven I demonstrated that risk was not a significant feature of the framing of confinement in mental health policy from the 1840s to the 1980s. In this chapter I show how, since the 1980s, rationales for confinement have increasingly been framed through the notion of risk. In this third chapter of my England and Wales case study I answer my third research question, namely: To what extent, and how, are ideas of risk are used in contemporary policies of confinement of people with mental illness?

I draw on my conclusions from the previous chapter, and my discourse analysis of contemporary policy to examine the two key elements of this question.38 First, I address the extent to which risk is used in framing policies of confinement in England and Wales. This is the first part of the chapter and continues where the previous chapter left off. As I demonstrated in Chapter Seven, risk was very infrequently used in the framing of mental health policy up until the 1980s. In this chapter I show how this has changed with risk becoming an increasingly important way of justifying confinement. I begin this section by describing the shift towards a risk-based approach beginning in the 1990s and the strengthening of this approach under the policy direction of the Labour Government from 1997. The chapter then focuses on the policy shift away from ‘community care’ during the 1990s and how this is an example of the impact of manufactured, or reflexive, risk. I show how this shift away from community care was indicative of a change towards the dominance of ‘safety and security’ in shaping policy.

Second, I address how ideas of risk are used in contemporary policies of confinement. In this second part of the chapter I examine how ideas of risk are used and constructed. In particular I look at how the use of the concepts of risk factors and risk levels accords with the risk literature. I draw on my analysis from the previous chapter to examine the extent to which risk operates differently from prior ideas of danger and safety.

38 A list of the sources analysed for this chapter is contained in Appendix Three.

142 In the third section of this chapter I draw the analysis of the chapter together to examine how risk has been used in reshaping the legislative framework of the mental health system in England and Wales. In this section I examine the way that risk has formed a central object in the legislative reform which occurred from 1997 to 2007. In the fourth and final section I bring together the previous strands of the chapter to look at how risk has become utilised as an object in mental health policy.

As I explained in Chapter Five (section 5.3.8) the primary focus of my analysis is on how the terminology of ‘risk’ is utilised in policy. Thus I am concerned with how the language of risk came to be used, and what meanings are associated with this language. I am not explicitly trying to understand practices associated with risk, nor with risk as an empirical effect.

My analysis concludes that risk has become a significant rationale for mental health policy as a reflexive effect of the growth of policies of community care. I argue that risk has become more significant as a way of trying to exert control over growing uncertainty resulting from spatially dispersed forms of community care. Ultimately I conclude that risk acts as a way of facilitating the continuation and renewal of spatial control over people with mental illness.

8.2 The Extent of the Framing of Risk

In this section I show how risk became a much more important part of the framing of mental health policy from the early 1990s. I demonstrate that this was, at least partially, in response to a series of inquiries during the 1990s, which emphasised the need for mental health services to prioritise safety. I argue that risk has become a central element of policy as an attempt to control the uncertainty associated with mental illness and thereby create a more secure environment for the community. Key policy documents from this period are listed in Table 6.

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Table 6: Key Mental Health Policy Developments England And Wales Date Policy Document 1993 The 10 Point Plan for Developing Successful and Safe Community Care 1994 Introduction of Supervision Registers for Mentally Ill People (HSG(94)5) A Preliminary Report on Homicide: Confidential Inquiry into Homicides & 1994 Suicides by Mentally Ill People (Confidential Inquiry) Report of the Inquiry into the Care and Treatment of Christopher Clunis 1994 (Ritchie Report) 1997 The New NHS: Modern, Dependable 1998 Modernising Mental Health Services, Safe, Sound and Supportive (MMHS) The National Service Framework for Mental Health: Modern Standards and 1999 Service Models (NSF) Managing Dangerous People with Severe Personality Disorder: Proposals 1999 for Policy Development 1999 Reform of the Mental Health Act 1983: Proposals for Consultation Safer Services: National Confidential Inquiry into Suicide and Homicide by 1999 People with Mental Illness 2000 Reform of the Mental Health Act 1983: part I the Legislative Framework 2000 Reform of the Mental Health Act 1983: part II Managing Risky Patients 2000 The NHS Plan: A Plan for Investment, a Plan for Reform The Governments Response to the Health Select Committee’s Report into 2000 Mental Health Services Safety First: Five-year Report of the National Confidential Inquiry into 2001 Suicide and Homicide by People with Mental Illness 2001 The Journey to Recovery: the Government's Vision for Mental Health Care 2002 Consultation on Draft Mental Health Bill Personality Disorder: No Longer a Diagnosis of Exclusion - Policy 2003 Implementation Guidance for the Development of Services for People with Personality Disorder 2004 Improving Mental Health Law - Towards a New Mental Health Act Government Response to the Report of the Joint Committee on the Draft 2005 Mental Health Bill 2004 Best Practice in Managing Risk: Principles and Guidance for Best Practice 2007 in the Assessment and Management of Risk to Self and Others in Mental Health Services 2007 Mental Health Ten Years On: Progress on Mental Health Care Reform Mental Health Bill - the Government's response to the Report of the Joint 2007 Committee on Human Rights 2007

8.2.1 Risk as response to safety

The killing of social worker Isabel Schwarz by a former client, in a psychiatric hospital in 1984, marked a turning point in mental health policy in England and Wales. It resulted in an inquiry in 1988, Report of the Committee of Inquiry into the Care and

144 After-care of Miss Sharon Campbell (the Spokes Report), into the care of the killer. That Inquiry made a number of recommendations about after-care for people with mental illness upon their release from psychiatric institutions (Department of Health and Social Security 1988). The recommendations of the Spokes Report became part of the foundation of the Care Programme Approach, which dominated the policy agenda of the Conservative Government until that Government’s defeat in 1997. The Care Programme Approach was an attempt to provide a more coordinated system of after-care for people released from institutions.

Inquiries into traumatic events involving people with mental illness were key influences on policy during the 1990s. These inquiries followed high profile events, such as homicides, and were instrumental in proposing recommendations that emphasised the management of risk within mental health systems. The two key inquiries of the 1990s related to two events which occurred in 1992. The first was the case of Ben Silcock, who was receiving community care when he climbed into a lion enclosure at a zoo and was mauled. The second was that of Christopher Clunis who, having repeatedly received mental health treatment in the preceding period, stabbed and killed a stranger at a tube stop.

These inquiries, particularly the Report of the Inquiry into the Care and Treatment of Christopher Clunis (the Ritchie Report), pushed safety to the top of the policy agenda, and did so in a very public way. Both of these cases generated media attention, as did the subsequent reports and recommendations. This was particularly true in the case of Clunis, as the family of the victim, Jonathan Zito, were vigorous in pursuing the shortcomings of the mental health system. This included setting up the Zito Trust to support the families of victims of mental health offenders and to highlight problems within the mental health system.

The growth of a focus on public safety from violence perpetrated by people with mental illness occurred despite the growing evidence showing that there is not a strong link between violence and people with mental illness. There is an emerging view that there is a small, but distinct, link between mental illness and violence for specific groups of people with mental illness (Krieg 2001, Mullen 2001). In particular there is a correlation between mental illness and violence for people with mental illness who are receiving no treatment and also have a dual diagnosis (a mental illness and a drug or alcohol problem) (Monahan 1992, Mouzos 1999, Soyka 2000, Mullen 2006). This link is stronger for some particular diagnoses than others, and in

145 particular is stronger for schizophrenia (Räsänen, Tiihonen, Isohanni, Rantakallio, Lehtonen and Moring 1998, Mullen et al. 2000).

The limited link between violence and mental illness is neither new, nor increasing. Mullen et al. (2000) offer a statistical analysis of offending of the seriously mentally ill since deinstitutionalisation in Victoria, Australia. They conclude that increasing rates of conviction for people with schizophrenia are consistent with general increases in rates of conviction and that ‘turning the clock back on community care is unlikely to contribute towards any positive outcome’ (Mullen et al. 2000: 614). One of the clearest findings in this research was that having a co-existing substance abuse problem was strongly related to a greatly increased chance of conviction over a lifetime. They finally conclude that:

The increasing attention now paid to offending and violent behaviours in those with schizophrenia may be more to do with an increased awareness of those phenomena that have long been present than to any recent increase in such behaviours (Mullen et al. 2000: 616).

Similarly a major study of homicides in England and Wales from 1957 to 1995 found that the number of homicides committed by people with mental illness had remained steady over that time, which amounted to an average fall of 3% per year in percentage of homicides committed by people with mental illness (Taylor and Gunn 1999).

By contrast the Ritchie Report argued that inadequacies in the existing mental health system posed dangers to the public. It called for safety to be the core concern of the mental health system. The report concluded that the Christopher Clunis case was not an aberration but a relatively common occurrence:

We have heard time and time again throughout the Inquiry, that Christopher Clunis is not alone, that there are many more like him living in the community who are a risk either to themselves or others (Ritchie, Dick. and Lingham 1994: 105).

They argued that failing to control the most dangerous group of people with mental illness would undermine the mental health system as a whole, and that such failures would begin to undermine public faith in, and support for, community care in its entirety:

We consider that if the needs of that small group are not properly meet, care in the community will be discredited and maybe perceived as a policy which has failed. We do not think that as a society we can afford to let that happen. We are

146 convinced, as we felt was every witness from whom we received evidence, that care in the community is the right approach for caring for the mentally ill and we have no wish to return to the days of locked, impersonal, dehumanising and undignified institutional care (Ritchie et al. 1994: 115).

The Ritchie Report claimed that the potential for the undermining of support for community care meant that it was not only justifiable, but necessary to use stronger measures to ensure such failures did not occur, even if this meant stricter exertion of control on all people with mental illness.

The same year that the Ritchie Report was released the first report of an ongoing inquiry into homicides and suicides by ‘mentally ill people’ was also released, A Preliminary Report on Homicide (1994) (the Confidential Inquiry). This Inquiry began in 1991, but the first preliminary report was not released until 1994, with a full report, Report of the Confidential Inquiry into Homicides and Suicides by Mentally Ill People, completed in 1996. The Confidential Inquiry located its own origins in ‘the wake of widespread concern about the care of mentally ill people and their potential for violence’ (Steering Committee of the Confidential Inquiry into Homicides and Suicides by Mentally Ill People 1994: 5). This was another in a series of reports that were explicitly trying to pre-empt a moral panic among the public on mental illness.

The preliminary report of the Confidential Inquiry outlined a strategy that became integrated into the government policy approach. This strategy was to downplay the lack of evidence for a link between violence and mental illness and instead argue for more control over people with mental illness in order to prevent further high profile incidents. The Confidential Inquiry argued that there needed to be a policy focus on ensuring that the small minority of potentially dangerous patients were effectively controlled and monitored. It made explicit the increasing policy bifurcation of people with mental illness between the severely ill (and, by implication, dangerous) and others. It identified concerns:

About a small minority of people with a severe mental illness and the ability of the mental health services to ensure that they receive adequate and consistent care once they are discharged from hospital (Steering Committee of the Confidential Inquiry into Homicides and Suicides by Mentally Ill People 1994: 5).

The Confidential Inquiry acknowledged that there is at best a modest relationship between psychiatric illness and violence (less than other attributes such as age and alcohol abuse) while simultaneously arguing that there was the need for close supervision (or confinement) of some patients. The 1994 report concluded that there

147 needed to be new systems in place to ensure that potentially dangerous patients were properly managed. The Confidential Inquiry emphasised the need for a risk reduction approach.

The reports of these inquiries, and particularly the Confidential Inquiry, (which became an ongoing inquiry producing regular reports from 1992) were aimed at pre- empting and preventing public fears. However these reports are likely to have had the opposite effect by creating a link in the public consciousness between violence and mental illness. Some carer groups have used these reports to keep (what they see as) the plight of people with mental illness in the public gaze. This has helped to reinforce a link between mental illness and violence in the public’s mind (Laurence 2003).

The election of the Blair Labour Government in 1997 heralded an increased focus on mental health policy, but did not signify a substantial change in approach. Indeed the Labour Government largely, albeit more vigorously, followed the policy path that the previous Conservative Government had initiated of framing policy around risks and the problems with community care. One of the first acts of the Labour Government, relating to mental health, was to announce a review of deinstitutionalisation, a review heavily dominated by the psychiatric profession (Pilgrim and Rogers 1997). Within two years the Labour Government had released two major policy papers indicative of their approach to mental health. The first, Modernising Mental Health Services Safe, Sound and Supportive (1998) (MMHS) outlined the policy approach. The second, The National Service Framework for Mental Health (1999) (NSF) outlined changes to services. These papers were effectively a formalisation of the more ad hoc policy arrangements of the previous administration.

MMHS was the first major mental health policy document for over ten years. It embraced the policy directions that had begun to be used over that time and made them more explicit. This is most strikingly apparent in the bold claim in MMHS that ‘care in the community has failed’ (Department of Health 1998: i). This claim is not justified as the failure of services or the failure of funding for community care; it is justified as a failure of control. The Government argued in MMHS that community care had failed because:

It left far too many walking the streets, often at risk to themselves and a nuisance to others. A small but significant minority have been a threat to others or themselves (Department of Health 1998: i).

148 This statement is indicative of the argument mounted by the Labour Government that community care had resulted in an increase in risk posed to the community and that consequently community care could only be made successful through the closer control of danger.

Evidence that community care has resulted in an increased focus on risk gives weight to Moon’s (2000) conjecture that the newly visible urban population of mental health service users is fundamental to the critique of community care. Moon argues that deinstitutionalisation resulted in a juxtaposition of threat and vulnerability that provided the essential challenge to community care. In essence deinstitutionalisation replaced the 'concealed other' with 'visible other'. Moon links this emergence of the visible other to a renewed public policy focus on risk. While Moon raises a crucial issue, what is most striking is the degree to which the trend that Moon highlights is an example of the Beck’s (1995: 12) notion that risks emerge reflexively out of the very processes of modernity. In this case the ‘risks’ of people with mental illness can be seen to have emerged out of the very process of deinstitutionalisation. The ‘manufactured’ (in Beck's sense) nature of this risk helps to explain why safety became such a central element of public policy during the 1990s and 2000s. I am arguing that in effect risk became utilised as a policy tool as a way of addressing concerns about safety. This accords with Beck’s (2000a) notion that the discourse of risk becomes prominent as trust in security ends. Beck argues that one of the major reasons that risk has become important in society is as a way of ensuring safety and security over uncertainties. This appears to be the case in England and Wales where, as I will show, risk ultimately acts as a way of justifying spatially controlled forms of care.

8.2.2 Failure of community care

The claim of the failure of community care in MMHS is illustrative of a change away from a focus on spatially dispersed forms of care and a move towards more controlling mechanisms of care and treatment in the mid to late 1990s. This shift involved both a renewed emphasis on confining forms of care, but also an attempt to provide more controlling forms of care in the community, through compulsory community care.

This move towards new, but still decentred, forms of control was apparent in the introduction of supervision registers in 1994 in the wake of the inquiries discussed

149 above. One of the aims of the registers was to ‘identify those people with a severe mental illness who may be a significant risk to themselves or others’ (NHS Executive 1994b: np). The key aim of these registers was identification; they were designed to operate similarly to the assertive outreach teams then in use in the USA. This involved identifying people with particular needs and difficulties and ensuring that they had close supervision in their care so that they would get the support and services they needed (NHS Executive 1994a). The registers contained no real mechanism of control, with no way to enforce compliance or return people to more controlling forms of care. Identification in this case is premised on risk. This is one of the early explicit markers of risk as a particular focus of care and control. This reference to risk, as a cause for surveillance, is also representative of future uses of risk in that what is meant by risk is left to clinical interpretation.

When supervision registers were created in 1994 advice was released to mental health services about the discharge of patients. This advice placed risk, or more precisely the absence of risk, at the heart of decision making about the release of patients. It stated that: ‘risk is a prime consideration in discharge decisions’ (NHS Executive 1994a: 3). This illustrated a growing focus on the containment of risk through the confinement of those thought to pose risks.

The introduction of supervision registers in 1994, which were a regulatory mechanism, was quickly followed by new legislation, the Mental Health (Patients in the Community) Act 1995. This Act aimed to improve after-care of people with mental illness by providing new powers regarding the after-care of people discharged from hospital. It allowed an application to supervise a person, ‘with a view to ensuring that he receives the after-care services provided for him’ (s.25a(1)).

These two measures, supervision registers and the 1995 Act, together placed risk at the centre of the rationale for confinement. This was based on the understanding that the absence of risk was essential for the success of community care. Together these reforms marked the beginning of a shift towards risk centred policy thinking and a shift away from the assumption that community care was inherently the best system for treatment and control of people with mental illness. The supervision advice provided that every case needed to be assessed for the risk associated with moving a patient out of care. There was a change in attitude towards community care, with a move from a focus on the positive aspects of community care towards addressing the supposed weaknesses of community care.

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8.2.3 Safety and security

As I argued in Chapter Three one of the main implications of the new concern with risk is a growing desire for safety and security. As the literature on risk showed safety has become more significant as trust in security has declined. As trust in community care became stretched,39 as evidenced by the inquiries discussed above, the emphasis on safety and security became more apparent. As the state increasingly utilised community care, the perceived failings of this approach in terms of a few high profile cases produced a countervailing response of reconfinement now justified on the grounds of risk.

If the ‘failure’ of community care involved people who posed a threat to others walking the streets then the corollary of this was that safety became a preoccupation of policy. This is signalled in the very subtitle of MMHS, Safe, Sound and Supportive. Safety was a discernible feature of policy during the 1990s, but it gradually became more and more significant. This accords with Giddens’ (1999) view that safety and security become key features of society as it attempts to exert new forms of control over increasing uncertainties.

In an attempt to exert more direct control over people with mental illness the Government put in place new systems aimed at ensuring safety and the proper management of these newly identified risky groups. In particular the Government emphasised a risk reduction approach, as advocated by the 1996 report of the Confidential Inquiry.

The Confidential Inquiry called for greater use of mechanisms for control and confinement, which they argued would lead to greater safety:

Those responsible for the patient have to use their own experience, their own personal attitudes to paternalism and coercion and their awareness of the effect on the patient of admission as they “give serious consideration” to the application of the Act. If they err on the side of compulsion, then the appeal mechanism will ensure that inappropriately prolonged detention does not occur (Steering Committee of the Confidential Inquiry into Homicides and Suicides by Mentally Ill People 1996: 61).

39 The question of why trust in community care became stretched, for instance the role of underfunding, is beyond the scope of this thesis.

151 Part of their rationale for this call for greater use of confinement was that the Confidential Inquiry recognised that risk management is an imperfect mechanism of control. They recognised that assessment of risk is difficult because there is often little to distinguish individuals posing risks from the many other people being treated. This recognises the fundamental paradox of trying to exert control through risk, namely that risk can never be entirely controlled. It also explicitly recognises that the closest that risk can come to being controlled is through spatial management, i.e. confinement.

These arguments that community care had failed and the resulting intensification of concern with safety eventually culminated in the Government deciding that the only way to deal with these problems was to overhaul the entire framework of mental health care by revising the legislation with a new emphasis on risk. The way in which legislation was changed to be framed around risk is discussed in the third part of this chapter

8.2.4 The use of risk as a policy object

In this first section of the chapter I have shown how risk emerged as a policy object primarily through a series of inquiries which focused on issues of safety and security. Through this focus on security risk became more prominent in the framing of mental health policy. Risk became a policy object that could be used to try and deal with the issues of safety and uncertainty raised by the inquiries of the 1990s.

The growing use of the language of risk in English and Welsh policy was particularly related to the identification of the ‘failure’ of community care. The major policy prescription advanced to remedy this failure was a risk reduction approach. Risk became used as a way of justifying a return to spatially controlled forms of care, or what Beck (1994: 9) refers to as instrumental forms of control. The way that risk is used as a justification for more confining forms of care lends weight to the argument made in Chapter Three that the normative project of the risk society has become that of safety.

8.3 Meanings of Risk

In this second part of the chapter I show in greater depth how ideas of risk have been framed and the meanings associated with them. Despite the central role of risk in the

152 framing of policy and legislation there is little discussion at the policy level of exactly what is meant by risk. In this section I examine how risk has been used. I focus on the concepts of risk factors, levels of risk, and what it means to be ‘at risk’. I use this analysis to frame a discussion of how, if at all, risk differs in meaning from earlier uses of dangerousness in policy. In particular I focus on the use of aggregative and individualised notions of risk.

8.3.1 Risk factors

Castel (1991) holds that the move towards risk occurs as governance shifts from a focus on individual characteristics towards a combination of factors of risk. This, he argues, allows surveillance based on risk. In this conception, and Deleuze’s (1992) ‘societies of control’, identification of abstract factors is an essential element of how these theories explain a shift towards spatially decentred forms of control. The ability to shift from centralised, individualised modes of control is dependent on being able to categorise individuals abstractly based on the risk factors they exhibit. The identification and use of risk factors plays an essential role in Castel’s explanation of the shift to risk in mental health policy. Risk factors do not, however, play a prominent role in public policy in England and Wales.

The lack of discussion of specific risk factors is not surprising, as specific risk factors are more likely to be significant at the level of clinical judgement and this is implied in discussion on risk management. However there is relatively little reference even to the abstract notion of risk factors, with little discussion of how to identify what characterises ‘risk’ and how to assess what risks are acceptable.

Within this limited policy discussion of risk there are two major contexts in which risk factors are identified, first, for a preventative public health approach and second, for purpose of risk assessment. The public health approach is not a major element of the framing of mental health policy in England and Wales (this is in contrast with Queensland, where the public health approach is more prominent, as I show in Chapter Eleven). There are, however, some risk factors that are specifically identified in terms of a public health approach in England and Wales. These risk factors are identified in order to ensure that special attention is given to attempt to prevent mental illness among those possessing or exhibiting the risk factors. A focus on the notion of risk factors is particularly apparent in relation to the development of specific strategies for various population groups, such as women or ethnic minorities (see for

153 example Department of Health 2001, Department of Health 2002b). Some of the risk factors identified include stress, loss and social isolation, and a variety of social and economic pressures (Department of Health 1999b: 46). These are typical risk factors of the type Castel identifies which can operate at an aggregative level.

However the major risk factor identified is lack of treatment. The idea that not receiving treatment is a significant risk factor for having mental illness is utilised to support the argument for greater use of compulsion and confinement. This is a key focus of NSF, which suggests that the most important risk factor in both preventing mental illness and in preventing risks to the population is ensuring that people do not become estranged from mental health services and thus that they receive the care they need:

If personal and public safety and well-being are to be assured, it is essential that mental health services stay in contact with people with severe and enduring mental illness, especially individuals who are assessed as at risk of harming themselves or of posing a risk to others (Department of Health 1999b: 47).

In this use the very notion of a risk factor is turned on its head from Castel’s conception. Rather than acting as a way of facilitating spatially decentred forms of care, this use of risk factors acts to reinforce the need for greater individualised control operating in specific circumstances. The focus on lack of treatment as a risk factor and the broader focus on individualised risk factors is indicative of neoliberal influence, where the focus on identification of risk is on individual responsibility for managing one’s own risk (Culpitt 1999).

Ultimately this use of risk comes to be used both to identify groups posing a risk as well as groups who are at risk. The concept of being 'at risk' ruptures the traditional relationship between individual action and the probability of some hazard. To be at risk is no longer about what you do, but who you are, it becomes a fixed attribute of the individual (Furedi 1998). In this way the abstract feature of governance that Castel talks about become attributed as concrete elements of individuals who are part of the larger collectivity.

The limited role that risk factors play is also emphasised by the way that risk factors become part of the discussion of risk assessment. There is an increasing emphasis on trying to develop ways of assessing risk to indicate the likelihood violence. Risk factors become synonymous with risk assessment and are much more of an individualised and embodied identification of risk than Castel’s notion of risk factors.

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The individualised focus on risk is at odds with the importance of aggregation in how risk has been seen to operate in criminal justice policies. Within the criminal justice system risk has been understood to govern crime control through statistical aggregates and populations rather than individuals (O'Malley 1998). Although the primary focus of risk in English and Welsh policy is individualised there is some sense of aggregation in the bifurcation that has occurred in mental health policy in England and Wales.

8.3.2 Risk and bifurcation

The significance of this bifurcation is apparent in the shift away from community care laid out in MMHS. The failure of community care is linked to the problems related to a small group:

A group of service users has begun to emerge with severe mental illnesses - typically schizophrenia - who are socially isolated, difficult to engage and obviously in need of care in the long term: care in the community has often failed to deliver the treatment and support they need (Department of Health 1998: 3.2).

The explicit identification of a subset of people with mental illness as causing problems for, and across, the entire mental health system is an example of an increasing bifurcation in approach. This bifurcation involves a division of people with mental illness into two groups. The first being the compliant low risk mass of people with mental illness, the second being those who are seen as difficult or in some way dangerous; particularly people with personality disorders, young men with schizophrenia and people with dual diagnoses. The danger associated with this second group is identified in MMHS. It gives official credence to these dangers by explicitly linking violence and mental illness and clearly stating that the public have a reasonable fear of the violence associated with people with mental illness:

There is a relationship between active mental illness and violence. The risk is significantly greater if the individual loses contact with services, or receives inadequate care. The public is understandably concerned about the risks of violence (Department of Health 1998: np).

In this way the meaning associated with risk is more akin to danger than the understanding of risk implied by governmentality theories of risk. The notion of risk as danger indicates that the language of risk is not associated with a shift from embodied dangerousness towards abstract factors of risk, but rather a new language for the old concept of embodied danger.

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Policy has become increasingly framed around this bifurcation, in a way that seems at odds with the concept of risk, which implies a continuum of behaviour and flexibility of change (Dean 1999, Rose 2002). Instead the bifurcated approach involves a rigid separation, effectively being a separation of the non-dangerous from the dangerous. The large-scale aggregation into these two groups allows a particular segment of the population of people with mental illness to be dealt with very differently from the rest. This is, however, a very crude binary split rather than the finer scale ‘risk factor’ aggregations identified in the criminological literature (Reichman 1986, Simon 1987). It is certainly not the case that this aggregation, through bifurcation, means that there is no longer a need to manage and rehabilitate individuals, as Reichman (1986) once suggested was the case in the criminal justice field. In summary risk factors, in relation to mental health policy in England and Wales, operate primarily to identify those specific individuals over whom control needs to be individually exerted.

8.3.3 Risk level

Although there has been some identification of aggregate groups for surveillance the primary way that risk is framed in policy is as a binary, as indicated by the policy bifurcation discussed above. This use of risk is largely synonymous with earlier ideas of danger, which were generally presented as binaries as well, the dangerous or the safe. The presentation of risk in this binary form is indicative of the way that risk has been used to facilitate a focus on safety. The implication of this binary is that if risk can be removed, through treatment, or through spatial removal, then safety can prevail.

By contrast in social theory risk has been understood as being something that is on a continuum. This was the second of three criteria which Rose (2002) argued differentiated risk thinking from thinking about danger. He argued that one of the distinct features about risk thinking is that it recognises that risk is not an ‘either or’ quality, but rather something which is always partial and uncertain. This is, however, largely not the case in policy in England and Wales. There are some exceptions where risk is understood as immanent in all people with mental illness, which then means that the question at the core of policy and practice is how to identify risks that pose a significant concern. The idea of ‘levels’ of risk is an attempt to address this concern, albeit one that once again appears inherently opposed to the idea of a continuum.

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Even within the approach of using risk levels another binary emerges, namely between risks which are reasonable or acceptable, and those which are unreasonable or unacceptable (Department of Health 1998: 27, Secretary of State for Health 2000b: 1). The division of risks as either reasonable, or unreasonable no longer pivots upon decisions between risk and no risk, where risk is used synonymously with danger. Instead it recognises that there is always risk and focuses on identifying which risks pose concern.

The division of risks as either reasonable, or unreasonable suggests an acknowledgement that ‘risk’ alone is insufficient cause for confinement, but that there are levels of risk that can trigger further action. Risk levels are used to help justify powers that might otherwise be considered oppressive, such as the case in this example:

In either case, the Tribunal’s discretionary power will be limited in regulations so that it will only be available in those cases where the patient poses a significant risk of serious harm to others. Also, except in emergencies, patients will only be transferred against their will with the Tribunal’s approval (Department of Health 2004a: 17).

The language of ‘high’ or ‘serious’ risk is repeatedly used to justify policy decisions, which might be seen as infringing on individual rights, particularly in justifying confinement of people with personality disorders (Home Office and Department of Health 1999: 7). While this use of risk may appear to be taking account of the notion that both mental illness and risk are a continuum, it is actually replacing a binary of dangerous and safe with another binary of low and high risk; or acceptable and unacceptable risk. This binary both reinforces the idea of risk as immanent in all people with mental illness and is used to justify spatial control over those who pose high or unacceptable risks.

8.3.4 Balancing risk

Inherent in the concept of risk is uncertainty; risk describes something that is not certain. Thus the use of risk within a policy context inevitably involves making judgements about levels of uncertainty and which ‘risks’ are acceptable. One of the ways that this emerges in English/Welsh policy is through the balancing of risk against other considerations, for instance balancing risk against individual rights. The judgment involved in balancing the degree of uncertainty about a supposed danger

157 with the potential harm involved in trying to limit that danger can help reveal the significance of risk in policy.

The balancing of risk against other considerations, such as individual liberty, was not a prominent aspect of public policy in the 1990s, and only emerged as more prominent in the face of explicit criticism that the Government was placing risk above all other considerations. As the Government laid out their programme for legislative reform it came under attack from a number of quarters including people with mental illness, carers, mental health professionals, and even a Select Committee (Szmukler and Holloway 2000, Chan 2002, Morgan 2004, Joint Committee on the Draft Mental Health Bill 2005). One of the major criticisms of the proposed reforms was that the Government was too focused on risk and danger and not enough on the rights of individuals (see for example Chan 2002, Laurence 2003). One of the Government’s responses to these criticisms was to introduce a more explicit emphasis on balance in approaching mental heath:

Mental health legislation is concerned with providing a balance between the rights of the individual and the need to protect that individual and society from the harm that may arise as a result of the individual’s mental disorder (Secretary of State for Health 2005: 7).

While the Government acknowledged that there had to be a balance they also held that the balance had previously been too far on the side of individual rights, at the expense of community safety. The Government reinforced the idea that there needed to be a two-way balance; that the rights of the individual could not inherently trump the potential risks that they might pose:

However, legislation that balances those rights against the necessity to act to prevent harm must be capable of proportionate application. Where the risks of not acting outweigh the harm caused by infringement of individual rights, the law must enable compulsion sometimes to prevail (Department of Health 2004a: 23).

In this way the Government framed the concept of risk as inherently opposed to the safety of the community. Through a discourse of balance risk is positioned as opposed to safety rather than as a way of assessing safety. Risk becomes an attribute of individuals which needs to be addressed at that level. In this case risk has, as Douglas (1992: 40) suggests changed from a complex attempt to reduce uncertainty to a decorative flourish on the word danger.

158 8.3.5 Contradictions of risk

As this section has illustrated the use of risk in mental health policy in England and Wales is messy and contradictory. There is no single framing of the concept of risk; instead it is used in a variety of different ways depending on the context. In some cases it is used in a way which is synonymous with embodied individualised danger, in others it is used as a way of addressing hazard in an aggregative way. However the meaning which predominates is risk as a technology of control. Within the policy developments in England and Wales over the past 20 years there has been a recognition of the uncertainties associated with the management of people with mental illness. Risk has become a significant way to address these ambiguities. In the majority of cases risk has been used to justify a reliance on old instrumental forms of control and exercise control over ambiguity through spatial control. This reflects Beck’s (1994: 9) claim that ‘with risks, avoidance imperatives dominate’. Risk thus becomes a way of controlling and avoiding hazard, rather than a way to manage it. The use of risk to exert control over uncertainty through justifying spatial control is apparent in the way in which risk has been used in legislative reform, the subject of the following section.

8.4 The Object of Risk: The Mental Health Act 2007

This third section of the chapter brings together the analysis of the first two sections to examine to what extent and how risk has played a role in legislative reform in England and Wales. The incoming 1997 Labour Government initiated a review of the Mental Health Act 1983 to assess how well the law was working and to recommend changes to the legislation. This process of reforming mental health legislation dominated the policy landscape in England and Wales from the publication of the independent review of the 1983 Act, in 1999, until the passage of an amended Act in 2007. Government attempts to frame the new legislation, and reactions against these attempts highlight some of the most contentious policy issues related to the role of control and risk. In particular four key areas are relevant: • First the risk centred nature of the amendments, • Second changes to the definition of mental illness, • Third the attempt to introduce compulsion in community care, • Fourth the attempt to specifically include people with personality disorders within the proposed legislation.

159 I discuss these four areas below with a focus on what they reveal both about the increasing importance of risk and about how risk has been framed and understood.

The process of amending the legislation began with an expert review of the 1983 Act in 1998, Review of the Mental Health Act 1983 (the Richardson Report) (1999). This report called for new legislation based on the principles of patient autonomy and non- discrimination. The Government then produced a green paper Reform of the Mental Health Act 1983: Proposals for Consultation in late 1999, followed by a two part white paper Reforming the Mental Health Act: Part I The new legal framework and Reforming The Mental Health Act: Part II High Risk Patients in late 2000. This resulted in a draft Mental Health Bill in June 2002, which was widely criticised by consumers and psychiatric professionals (Chan 2002, Akuffo 2004, Morgan 2004). The Government reacted with a series of stakeholder meetings, followed by another draft Bill in 2004. This continued to be met by severe criticism from across the spectrum including a highly critical report by a Joint Parliamentary Committee (2005). In 2006 the Government abandoned plans to create a new Act, instead announcing a series of amendments to the existing Act. The amendments were eventually passed in July 2007 and came into force in October 2008.40

Figure 9: Timeline of Mental Health Law Reform England and Wales

40 Some minor elements of the Act came into force in October 2007.

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The Government based the need for new legislation on the argument that the previous legislation was written for an era when the vast majority of care occurred within in-patient settings. They argued that new legislation was needed to deal specifically with new risks posed by the extent of deinstitutionalisation and community care. In doing so they were explicitly concerned with the reflexive nature of risks associated with modernity. The Government claimed that for community care to work it needed to be accompanied by stronger powers of compulsion and control. In particular they argued in the green paper that there was a need to recognise that there will always be a sub-section of patients who will pose a risk to the safety community:

But for some patients care and treatment outside hospital will not be a safe or practicable option if there is a significant risk that they will not keep to the care plan (Secretary of State for Health 1999: 37).

The way that the Government framed their argument for legislative reform is one that lends further weight to understanding the moves towards more confining forms of care as an explicit reaction to the reflexively arising risks of modernity (i.e. deinstitutionalisation and community care). It also lends weight to the notion that the Government’s response to the risk society was to prioritise safety as the normative project of mental health care.

8.4.1 A risk centred approach

The Richardson Report was grounded on the twin principles of non-discrimination (so that people with mental illness would be treated like any other patients) and patient autonomy. It recommended restructuring legislation with the question of capacity as the central rationale for compulsory treatment. The principle was that compulsion could only be justified where it could be shown that the person in question did not have the capacity to make appropriate decisions about their own care. The Government rejected this, and much of the Richardson Report.

The green paper, Reform of the Mental Health Act 1983: Proposals for Consultation, released by the Government in response to the Richardson Report rejected the idea of capacity and was instead centred on a risk reduction principle. It held that risk should be the centre of decision making around compulsion:

161 It is the degree of risk that patients with mental disorder pose, to themselves or others, that is crucial to this decision [whether to make someone subject to a compulsion order] (Secretary of State for Health 1999: 32).

Indeed the initial recommendations for reforms included risk assessment as part of the compulsory admission process:

Formal assessment should be carried out according to the general criteria laid down in the Mental Health National Service Framework. These include not only attention to the patient’s psychiatric, psychological and social functioning and the risk posed to self and others, but also an assessment of physical health needs and personal circumstances (Secretary of State for Health 1999: 23).

The focus on risk assessment was embedded in the assertion of the Government that safety was the primary purpose of all mental health legislation:

A small minority of people with serious mental disorders are, however, unwilling or unable to seek the care and treatment they need voluntarily and as a result may pose a risk to their own health and safety or to the safety of the public or those caring for them....This was the prime purpose of the 1959 and 1983 Mental Health Acts and remains the prime purpose of the proposals in this paper (Secretary of State for Health 1999: 9).

This assertion is apparent in Reforming The Mental Health Act: Part II High Risk Patients. The white paper argued that not only should decisions about compulsion be centred on risk, but so should decisions about who should receive community care. The Government made it clear that community care should be seen primarily as a companion to more confining and controlling forms of care, not as an alternative to such:

The new provisions will mean that compulsory care and treatment can, if appropriate, take place in the community rather than through detention in hospital. This would not be contemplated at a time when a patient was assessed as posing a significant risk of serious harm to him or herself or to other people – in these cases detention for treatment in hospital will be required (Secretary of State for Health 2000a: 17).

Ultimately the Government justified the focus on risk as being an essential element of restoring and strengthening public confidence in the mental health system:

We think these powers are necessary for the difficult cases, so that decisions on the discharge of a patient who has posed a significant risk of causing serious harm to others are made by an independent Tribunal, taking into account all the issues and circumstances of the case, rather than an individual clinical supervisor. This requirement should increase public confidence in the discharge procedure (Department of Health 2004a: 42).

These explanations and justifications built upon the policy approaches that had emerged during the 1990s and were a logical extension of those approaches and

162 arguments. The proposal for new legislation was a way of embedding and formalising the new focus on risk and safety. The way that risk prevention gains such prominence in the legislative agenda supports Beck’s notion that in risk society the social imperative has shifted towards eliminating risks. As Beck (1992: 49) suggests ‘The movement set in motion by the risk society … is expressed in the statement: I am afraid!’. This notion of the desire to exert control over risk is central to how various aspects of the legislation were framed.

8.4.2 Compulsory treatment

The thrust of the Labour Government’s legislative and policy programme during the late 1990s and 2000s was to make compulsory treatment of people with mental illness easier. In particular the Government advocated the removal of the treatability criterion from decisions about compulsory treatment. This criterion held that a person could not be compulsorily admitted unless they would benefit from the treatment in some respect. The Government argued that this criterion effectively prevented people who posed a risk to the community from being adequately treated and controlled, as they explained in the second part of the white paper, Reforming The Mental Health Act: Part II High Risk Patients:

A narrow interpretation of the definition of the ‘treatability’ provision in the 1983 Act, together with a lack of dedicated provision within existing services, means that current arrangements for this group [patients who pose a significant risk of serious harm to others] are inadequate both to protect the public and to provide the individuals themselves with the high quality services they need (Secretary of State for Health 2000b: 1).

The proposed amendments to the legislation placed risk as a central rationale for compulsion. In the 1983 Act compulsion was justified in relation to the need to provide treatment for people’s own best interests when they were not able to recognise their need for treatment. The Government argued in the second green paper, Government Response To The Report Of The Joint Committee On The Draft Mental Health Bill 2004, that this rationale should be replaced by one shaped around the control of risk:

In particular, the conditions need to be seen in terms of the overarching principle that the degree of compulsion must be proportionate to the risk that someone presents, and clinicians will use their judgement as to whether or not a person meets the conditions for compulsion, including whether appropriate treatment is available (Secretary of State for Health 2005: 5).

163 Risk is identified, repeatedly and strongly as being the key criterion that should be used to decide whether a person should be admitted for compulsory treatment:

It is the degree of risk that patients with mental disorder pose, to themselves or others, that is crucial to this decision. In the presence of such risk, questions of capacity – while still relevant to the plan of care and treatment – may be largely irrelevant to the question of whether or not a compulsory order should be made (Secretary of State for Health 1999: 32).

As this quote demonstrates the Government argued for a complete shift away from the notion of capacity towards a risk based approach. The degree to which management of risk is stressed is equally apparent in the first part of the white paper, which baldly states that risk has to take precedence over any other concern:

Concerns of risk will always take precedence, but care and treatment provided under formal powers should otherwise reflect the best interests of the patient (Secretary of State for Health 2000a: 16).

These moves to place risk at the centre of decision making about compulsion is illustrative of the degree to which safety became a key part of the policy agenda, at the expense of notions of cure or treatment. This is further illustrated in one of the key principles that the Government suggested for the new Act, namely that safety was the key criterion for deciding on the use of compulsory powers:

The safety of both the individual patient and the public are of key importance in determining the question of whether compulsory powers should be imposed (Secretary of State for Health 1999: 15).

As this principle illustrates there was a shift away from the notion that mental health legislation should be about the cure and treatment of people with mental illness towards the notion that it was about the management of the safety of the community.

8.4.3 The definition of mental illness

The risk centred approach used in the green paper, Reform of the Mental Health Act 1983: Proposals for Consultation, was further illustrated in the proposals for a new definition of mental illness. There were two particularly pertinent aspects of the definition. First was the explicit inclusion of people with personality disorders within the definition (which is discussed in more depth below). Second was the refusal to include specific exclusions in the definition of metal illness in the legislation.

The 1983 Act included a broad category of ‘mental disorder’ under which there were four subcategories: severe mental impairment, mental impairment, psychopathic

164 disorder and mental illness. Each of these categories was defined, except for mental illness, which was left to clinical judgement. There was, however, the explicit exception that a person could not be considered mentally ill solely because of ‘promiscuity or other immoral conduct, sexual deviancy or dependence on alcohol or drugs’ (s.1(3)). The white paper and subsequent Bill in 2004 provided a much broader definition of mental disorder and did not include specific exclusions.

In response to criticism for not including specific exclusions in the definition, the Government responded that exclusions were unnecessary and potentially damaging. The Government argued that exclusions would result in the failure to treat some people because psychiatrists would not always be certain that a particular patient fell under the jurisdiction of the legislation:

We believe that the exclusions should not appear in the new Bill. We intend it to focus more clearly on mental disorder and on risk to patients and to others (Department of Health 2002a: 12).

This explanation points at the central role that risk played in how the Government understood the very notion of mental health. In effect the Government was arguing that including exclusions, and thus possibly not treating some people with mental illness, was more harmful than the possibility of compulsorily treating people who did not actually have a mental illness. This places risk at the heart of mental health legislation, more important even than ‘mental disorder’ itself. The centrality of risk in the definition of mental illness supports Rose’s (2002: 218) contention that confinement has increasingly became about the securing the most risky until their riskiness can be fully assessed and controlled.

8.4.4 Personality disorders

The Labour Government’s attempts to argue for the specific inclusion of personality disorder within the definition of ‘mental illness’ in the proposed legislation is further evidence of the centrality of risk in the way that the Government conceived mental health legislation. The question of whether ‘personality disorders’ should be included under mental health legislation has had a long and controversial history in England and Wales, with this question being discussed both in the 1904 and 1957 Royal Commissions.

The Government argued that because of the way the 1983 Act was framed people with personality disorders were not being compulsorily treated, which was putting the

165 public at risk (Home Office and Department of Health 1999). They argued that the 1983 Act left psychiatrists uncertain as to whether people with personality disorders were included in the Act. This, they claimed, was the result of two features of the 1983 Act: first, uncertainty regarding whether people with personality disorders came under the definition of mental disorder, and second, whether they could be admitted for care under the treatability test. This test held that a person could only be compulsorily admitted if they would receive treatment that would benefit them.

In 1999 the Government released a consultation paper, Managing Dangerous People With Severe Personality Disorder: Proposals For Policy Development, addressing policies for managing people with personality disorders. That paper was based on the premise that people with personality disorders posed a significant danger to the public, and that current laws could not adequately manage this danger. The aim of the new policies was to:

Put in place a co-ordinated package of arrangements that offer better protection to the public in a way which strikes the right balance between the interests of the individual and society (Home Office and Department of Health 1999: 2).

What was less clear in this discussion paper was whether people with personality disorders could be considered ‘mentally ill’. This has been an ongoing controversy within the psychiatric profession. There have been widely differing views about first whether personality disorder is a mental illness, and second if there is any form of treatment which benefits people with personality disorders (Manning 2001, McCallum 2001). As a result of these uncertainties the Government carefully constructed a narrative to support the claim that personality disorder was a type of mental illness. They claimed that in the past people with personality disorders had come within the ambit of mental health legislation and what they were proposing was effectively a return to the status quo. The Government went to great lengths to trace the history of the care and treatment of people with personality disorders. They pointed to over two hundred years of history relating to what: ‘we might now see as severely personality disordered’ (Home Office and Department of Health 1999: 26), going right back to Pinel in 1801 and tracing a history of various terms towards psychopathy, as identified in 1891.

The attempt by the Government to locate their decision to include personality disorders within the Act in an historical narrative was an attempt to overcome criticism that this decision was purely about social control, and not to do with mental

166 health. In effect the Government were arguing that personality disorders are a phenomenon that has been the subject of repeated government intervention on health grounds:

The challenge to public safety presented by the minority of people with severe personality disorder, who because of their disorder pose a risk of serious offending, has been recognised by successive administrations (Home Office and Department of Health 1999: 3).

The way that the Government framed their proposals was, however, very firmly around the notion of risk rather than illness. The key aim of the proposals presented by the Government (which later became part of the legislative reform agenda) was to ensure that people were kept confined if they posed a high risk. As they stated their priorities were:

First, ensuring that dangerous severely personality disordered people are kept in detention for as long as they pose a high risk (Home Office and Department of Health 1999: 3).

The basic claim for these policy developments was that there is a small and dangerous group of people with personality disorders who pose a risk to public safety:

There is also a small group of people with severe personality disorder who come to the attention of mental health or social services practitioners, or to the police, as presenting a genuine risk but who have not been involved in any criminal offence. People in this group may benefit from a range of interventions intended to reduce risk, but not all are suitable for treatment as patients in hospital settings. These people fall outside the scope of the Mental Health Act and cannot be detained or required to comply with supervision (Department of Health 1998: 4.32).

As this quote illustrates it is risk that forms the very core of the definition of personality disorders:

the risk presented appears to be functionally linked to the personality disorder (Secretary of State for Health 2000b: 13).

Risk becomes the primary basis on which people are detained and the entire justification for that detention. Here risk is not about behaviour but rather something that is intrinsic to the embodied individual. Risk becomes functionally linked to the very notion of personality disorder. This accords with McCallum’s (2001) claim that the modern concept of personality disorder comes into existence as an index of risk management. The claim McCallum makes is broadly that the idea of personality

167 disorders entered public policy as a way to regulate dangerous individuals when other forms of regulation and prediction failed.

McCallum’s arguments (developed in the context of Victoria, Australia) have resonance in the case of England and Wales. The notion of personality disorder enters mental health policy with a firm emphasis on the regulation of dangerous individuals. The policy is framed so that risk becomes the primary criterion for confinement, overriding issues of cure and treatment. The focus becomes solely on the existence of risk in an individual, not what is the cause of that risk.

But for the relatively small number of severely personality disordered people who represent an unacceptable degree of danger to the public, detention on the basis of the risk they present, and for as long as that risk remains, can be justified (Home Office and Department of Health 1999: 7).

The focus on risk rather than diagnosis is an effective abrogation of the very rationale of mental health legislation and regulation. Thus confinement becomes the primary response to this group of people, with community care presented as posing too many risks to the community. Confinement becomes an essential strategy in managing personality disorder: There are two key elements to these proposals: • to ensure that dangerous people with severe personality disorder are kept in detention for as long as they pose a high risk to others; and, • to provide high quality services to enable them to deal with the consequences of their disorder, reduce their risk to others and so work towards successful reintegration into the community (Secretary of State for Health 2000b: 9).

These discussions about how society and the government should cope with, and/or treat, people with personality disorders illustrates the degree to which the Government in England and Wales came to the conclusion that control over deviance can only be exerted through spatial fixing. The process of decision making in reaching this conclusion is almost the exact opposite of what Castel (1991) argued made risk become so prominent. Castel argued that policy in the contemporary era was symptomatic of a shift from a focus on individual dangerousness towards control over risk at an aggregate level. Here the opposite has occurred; a more aggregative response has been rejected for one that would allow a more individualised exertion of control through confinement. The use of risk in relation to the control of dangerousness accords much more with Foucault’s (1978) conclusion that risk ultimately acts to bring the dangerous individual to the fore. It is through utilising the ‘objective’ process of risk assessment that the state can justify the abrogation of the rights of the dangerous individual. Risk assessment is ‘effective’ in Foucault’s

168 terminology because it produces a new object with definite social effects. This allows the state to exert a control that it was not previously able to justify in relation to the best interests of the people involved.

8.4.5 Compulsion in the community

Although the primary focus of amendments to mental health legislation was safety through a renewed emphasis on confinement there was also the development of new mechanisms of control. These were aimed at the middle ground between confinement and community care, namely compulsory care in the community. The Government moved to introduce stronger powers to compel people living in community settings to comply with their treatment. There had been previous developments towards this end, primarily through the Mental Health (Patients in the Community) Act 1995 (discussed section 8.2.2). The powers introduced in that legislation were not widely used and were criticised as not being strong enough to compel compliance with treatment plans (Lawton-Smith 2005).

The Government argued that the introduction of new powers of compulsion applying to people in the community would create a new middle ground between the compulsion implied by confinement and allowing people to drop out of the system, thereby posing a risk to the public:

We want the new Mental Health Act to bridge the gulf between the full compulsory treatment and detention powers, that are provided under the 1983 Act, and the comparatively weak and ineffective powers that it provides for care and supervision outside hospital (Secretary of State for Health 1999: 37).

The 2004 Bill contained a relatively simple mechanism allowing compulsory treatment orders to work in either residential or non-residential situations with little difference to how the orders were to be granted. The Government argued that this would create a less restrictive system (Secretary of State for Health 1999: 39).

The development of these mechanisms of compulsion in the community illustrates that the argument that I have been making, namely that risk has been used primarily as a justification for a renewed focus on safety through spatial fixing, is not a total explanation of the use of risk. The development of these new mechanisms of control shows that, alongside a renewed focus on confinement, the Government in England and Wales has been attempting to find new practices that cope more flexibly with the ambiguities of the risk society. It has attempted to find new mechanisms of care that

169 place safety at the centre of decision making, but which are not simple returns to instrumental notions of confinement. However these attempts have been limited compared to the use of risk as a justification for spatial control.

8.4.6 Outcome of reforms

The attempts by the Government to introduce expansive new mental health legislation including the elements discussed above were highly controversial. These proposals provoked widespread opposition from a large variety of groups including people with mental illness, mental health advocacy groups and mental health professionals (Szmukler and Holloway 2000, Chan 2002, Morgan 2004). The strength and breadth of the opposition to the 2004 Bill convinced the Government to abandon the Bill in 2006 and instead to amend the 1983 Act.

Many of the aspects of the Government’s reforms discussed above remained in the final 2007 amendments, including the retention of new mechanisms for compulsory treatment in the community and the widening of the treatability test, now referred to as the ‘'appropriate treatment test’, making it easier to compulsorily treat people with personality disorders, and the widening of the definition of mental illness. The amended legislation kept enough of its original focus that the Mental Health Alliance, an umbrella organisation of consumer and mental health professional groups, concluded that the legislation was authoritarian and stigmatising (Mental Health Alliance 2007: 9).

8.5 Risk as a Policy Object

My research on the use of risk and its relationship to policies of confinement reveals five key findings about how, and to what extent, ideas of risk are used in relation to policies of confinement of people with mental illness. First, the use of risk has significantly increased over time, and the idea of risk has increasingly framed policy rationales for confinement. Second, risk has emerged reflexively as an unintended consequence of deinstitutionalisation; it is an example of Beck’s (1995: 12) notion of ‘manufactured risk’. Third, this ‘manufactured’ risk relates to the undermining of the legitimacy of state provision of mental health care in the community. Fourth, there has been an increasing bifurcation in policy, with policy increasingly separating out the ‘risky’ from safe. Fifth, the use of risk is more strongly related to a renewed focus

170 on confining forms of care than spatially decentred ones, counter to what Castel and Deleuze’s theorisation suggests.

My historical research showed that risk has become an increasingly central element of the way policy is framed. From the 1840s until the 1990s there was little reference to risk. Cure was the main explicit rationale for policy until the mid 20th century. This is partially a reflection of the way that control was so taken for granted that it did not need to be made explicit. Drawing on Clear and Cadora's (2001) distinction between risk control and risk management the period prior to the late 20th century can be seen as a period of risk control. During this period there was no need for risk management and risk reduction as it was possible to exert total control over people with mental illness. This meant that risk did not appear as significant aspects of policy. However, since the mid 1990s risk has been accorded a central place in public policy.

Risk has become the rationale through which confinement of people with mental illness is justified. As I showed in Chapter Two state responses to the deviance of mental illness walk a delicate path as mental illness falls somewhere unsettling between illness, which requires treatment, and badness, which requires punishment. Castel argues (1988) that the modern psychiatric system came into existence to cope with this very problem, to remove a political problem by creating a technology which allowed madness to be administered. Psychiatry remedied a political problem by turning it into an administrative one. However the impact of deinstitutionalisation and community care undermined this role for psychiatry, as it meant that treatment could occur outside of institutions. Thus confinement could no longer be justified primarily on the grounds of treatment. This has meant that new rationales have been required to justify confinement. Risk has largely fulfilled this role.

Risk has emerged as a form of manufactured uncertainty; as part of the reflexive nature of modernity. It is reflexive in the Beckian sense that it arises from autonomised modernisation processes which are blind and deaf to their own effects and threats (Beck 1996: 28). Risk emerged and grew in importance in mental health policy as a direct result of the increased gaze on people with mental illness following deinstitutionalisation (Moon 2000). The very process of deinstitutionalisation has helped facilitate a renewed emphasis on confinement, by increasing the public focus on people with mental illness. This is particularly the case where deinstitutionalisation has been poorly conducted, leaving many people with mental illness in poverty and homeless (Belcher 1991). The visibility of people with mental illness to the public

171 resulted in a self-reinforcing mechanism, which is common to how risks operate. A focus on particular risks often leads to an increased importance being attached to them, as Lupton (1999a: 13) argues:

Risk meanings and strategies are attempts to tame uncertainty, but often have the paradoxical effect of increasing anxiety about risk through the intensity of their focus and concern.

The focus on risk is also linked to a crisis of legitimacy of the state, as reflected by the institutional and regulatory roll back under neoliberalism (Peck and Tickell 2002, Peck 2004). As the inquiries into mental health services during the 1990s have shown there was increasing concern about the ability of the state to control danger associated with people with mental illness in England and Wales. This crisis of legitimacy has contributed towards undermining the legitimacy of state forms of care for people with mental illness, particularly community care. Beck (1995: 16) argues that it is typical of the risk society for new forms of uncertainty to undermine the traditional ways of determining and assessing risks, leading to a questioning of the legitimacy of bureaucracy. As Giddens (1990) notes doubt is an essential part of the modern world, knowledge is no longer certain. One impact of the new emphasis on doubt is that it places the expert knowledge of the mental health system in doubt. It reduces public certainty in the ability of the government and psychiatric professionals to keep the community safe from potential harms. Deinstitutionalisation was reliant on the belief that psychiatric professionals could cure, or at least alleviate mental illness, as this has come into increasing doubt so have community forms of care. As the competence of the state is increasingly undermined there is a shift to more direct and punitive forms of control.

Beck, and other risk theorists argue that risk identifies a change in society, a shift that has come about as a way of dealing with the growing ambiguity or liquidity of society (Bauman 2000). As Beck suggests this raises some important questions, not the least of which is the way that society will cope with this new ambiguity. My analysis suggests that there is the use of both old instrumental rationalities and the development of new ways of acting that affirm ambiguities in England and Wales. New forms of acting which attempt to accept ambiguities appeared in the form of deinstitutionalisation and community care. Ultimately deinstitutionalisation and community care were, at least in part, a reaction to a changing notion of mental illness which recognised that the concept of mental illness was not a simple binary. Policies and notions of community care emerged to offer a more flexible system of

172 care that could cope with individual differences through more individualised mechanisms of care and control.

The use of these forms of care that recognise ambiguity has been tempered by the resurgence of the use of traditional instrumental forms of control, such as confinement. Risk has been used in mental health policy since the mid 1990s not as a way of affirming ambiguity, but rather as a way of exerting greater control over the uncertainty that relates to mental illness. One effect of this has been the creation of a bifurcation in policy and thinking between those people with mental illness who embody risk to the safety of society and should thus be spatially isolated, and those who should not. This bifurcation means that mental health policy has become more closely framed around dealing with ‘severe’ mental illness. Risk has come to perform, as Douglas (1992) argued, a role of border maintenance between the normal and the abnormal. It has taken on the role of identifying the normal from the abnormal and justifying the removal of the abnormal from public space. In this way neoliberal governance seems not to act as a facilitator of the ‘conduct of conduct’ as Rose (1999) would suggest, but as a way of identifying individuals for state control of their risk. This accords with Joseph and Kearns’ (1999) characterisation of people with mental illness in New Zealand as misfits in the neoliberal moral landscape of New Zealand. In both cases neoliberal governance is primarily about identifying individuals for appropriate regulation of behaviour, rather than for encouraging self- governance by the individual.

The emphasis on risk in public policy is directly linked to a move towards a renewed emphasis on controlling forms of care, including greater emphasis on confinement. Risk is used as a rationale for arguing for, and providing, more controlling forms of care. Thus in the case of England and Wales, risk does not act in the way Castel argues to allow community care through systematic pre-detection, but rather is used as a strategy for controlling uncertainty through confinement of the potentially risky. While Beck posed the question of how society would deal with the ambiguity associated with risk, Castel (1991) and Deleuze (1992) (in their own ways) suggested that risk itself was a way of coping with ambiguity and it was through the technologies of risk that ambiguity could be dealt with by aggregation and spatial dispersion of control. Yet as this case study of mental health policy in England and Wales demonstrates, risk has not been used primarily as a way of affirming ambiguity, but rather as a way of justifying a renewed emphasis on more direct forms of spatial control, through the confinement of people with mental illness. In this way

173 risk acts to facilitate the anti-nomadicism that Foucault identifies as integral to the disciplinary society (1977a: 218). It is through the language of risk that the continuation of social control through fixing in space becomes justifiable.

8.6 Conclusion

In this, the third and final chapter of my England and Wales case study I have addressed my third research question. In this concluding section I reiterate how my research in this chapter has answered this research question. I then briefly reflect on how the case study as a whole has helped to achieve my research aim. This is a discussion which prefigures a more in-depth discussion, in reference to both case studies, in Chapter Twelve.

The primary aim of this chapter was to answer my third research question in relation to the case of England and Wales. There are two key components to this question: first the extent to which ideas of risk are used in contemporary policies of confinement of people with mental illness; second how these ideas of risk are used.

In response to the first part of the question I have illustrated the way in which risk has become an increasingly central part of mental health policy. I argued that the increasing focus on risk in mental health policy was a response to a series of inquiries into traumatic events which resulted in an emphasis on safety and security. Following these inquiries in the mid to late 1990s mental health policy, and particularly rationales for confinement, became increasingly framed around risk. This was most apparent in the Government’s plans for legislative reform in which the control and prevention of risk became the major focus of policy and legislation. My study of English and Welsh policy has demonstrated that risk has become absolutely central to the way in which mental health policy is framed.

Second I examined how these ideas of risk have been used in relation to policies of confinement. The focus on risk as control is indicative of how risk has been used in framing policies of confinement. As I have shown risk has been used as a policy object in a complex and sometimes contradictory way. In some uses it appears to be nothing but, as Douglas (1992: 40) would have it, a decorative flourish on the term danger. In these uses risk appears to be nothing but a modern term for the old idea

174 of embodied danger, here risk takes on no actuarial or calculative meanings. On other occasions risk is used with an actuarial sense, but this is the minority of cases.

In the majority of cases risk is used as a synonym for danger in order to justify continued policies of confinement of the deviant. This conclusion points towards the key finding from my English and Welsh case study in relation to my research aim. This aim, as outlined in Chapter One, is to understand the role of risk in framing confinement and spatial control in contemporary mental health policy. The role of risk in framing mental health policy is complex, but ultimately risk has primarily been used to justify confinement based on an individualised conceptualisation of danger. This is an example of the continued influence of disciplinary forms of material and spatial control.

In the following three chapters I look at these same issues in the context of my Queensland case study. In my final chapter I address my research aim in light of both case studies.

175 Chapter 9. The Use of Confinement, Queensland

9.1 Introduction

In this chapter I begin my discussion of my research on the Queensland case study. The structure of this part of my research is the same as the structure for my England and Wales case study. There are three chapters discussing the Queensland case study, each chapter addresses one of my research questions. Although there are many similarities in the way the jurisdictions of the two case studies operate there is one significant difference in the governance arrangements. The jurisdiction of England and Wales was a relatively straightforward case, as there is a strong centralised government which has been responsible for policy development. In contrast Queensland is a state within a federal system. This means that there are two levels of government that affect the policy framework in Queensland. Historically the Commonwealth Government has not had a significant impact on policy, but, since the 1990s, it has exerted increasing influence over both service provision and policy development. This means that there is an additional level of government to consider in relation to mental health policy in Queensland.

In this first chapter I address the first of my research questions in the context of Queensland, namely: How significant is the role of confinement within contemporary mental health systems?

The key aim of this chapter is to establish the empirical foundation from which to discuss my policy and theoretical analysis in the next two chapters. The primary ambition of this chapter is an empirical one. As I illustrated in Chapter One there has been insufficient research on the degree to which confinement continues to play a role in modern mental health systems. The aim of this chapter is to begin to remedy this in the case of Queensland. The chapter does not claim, or aim, to provide a completely comprehensive study into the role and importance of confinement in Queensland. Rather it aims to identify key trends in relation to confinement and to be a starting point for further research and discussion.

I begin the chapter by outlining the process and impact of deinstitutionalisation in Queensland, which demonstrates the relatively slow and steady nature of that

176 process. I then discuss the impact that growing Commonwealth Government influence has had on compulsion and confinement in Queensland. Finally I focus on contemporary trends of confinement and compulsion. In the concluding section I consider how trends of confinement compare with England and Wales.

9.2 Deinstitutionalisation

The Queensland mental health system has traditionally relied on a small number of large specialist psychiatric facilities for the provision of mental health services. Throughout the twentieth century there was a heavy reliance on confinement within these specialist mental health hospitals as the primary form of care. Although there was a turn towards the rhetoric of community care and deinstitutionalisation in the 1960s, this was not followed by action. Indeed the conservative Joh Bjelke-Petersen Government, which governed from 1968 to 1987, was largely opposed to deinstitutionalisation. It preferred a paternalistic approach which placed the primary emphasis on confinement and care. This meant that deinstitutionalisation occurred much later in later in Queensland than in many comparable Western jurisdictions, including England and Wales.

Although mental health services in Queensland have been largely custodial there have been reactions against this. In the 1860s The Lunacy Act 1869 created alternatives to long-term institutionalisation. It established reception houses where magistrates could commit ‘lunatics and inebriates’ as a mechanism for avoiding long term incarceration. Despite this policy a focus on confinement persisted, which led to chronic overcrowding in Queensland asylums during the first half of the 20th century. There were persistent complaints from asylum superintendents about overcrowding and the adverse implications of this for patients (Patrick 1987).

Overcrowding was a problem across Australia and was one of the main criticisms made by the 1955 Report on Mental Health Facilities and Needs of Australia (the Stoller Report), a report commissioned by the Commonwealth Government on the future of mental health facilities. This report highlighted a number of problems with mental health services, particularly overcrowding, and estimated that the Australian mental health system needed an additional 20,000 beds. The Stoller Report led to a Commonwealth subsidy scheme that provided one pound for every two pounds a state spent on capital works (and simultaneously removed the minimal patient

177 maintenance funding previously provided by the Commonwealth) (Stoller 1955). The subsidy system resulted in a continued focus on the use and expansion of large- scale psychiatric facilities across Australia. By the mid 1960s, however, overcrowding had ceased to be such a problem in Queensland. There were up to 500 vacant beds in the four mental hospitals, due largely to the transfer of senile patients to general hospital wards (Patrick 1987: 132). This transfer of senile patients was one of the first signs of deinstitutionalisation in Queensland.

There has been relatively little in-depth investigation of exactly how the process of deinstitutionalisation occurred in Queensland (Doessel, Scheurer, Chant and Whiteford 2005). This is largely a result of the limited data available about the people in psychiatric hospitals. In particular there is little data about the diagnoses of patients (Richmond and Savy 2005). This is significant as much early deinstitutionalisation is likely be accounted for by changes to populations that we would no longer class as mentally ill, including many elderly people (Doessel et al. 2005).

There was a significant decline, of almost a third, in the resident population in psychiatric hospitals during the 1960s, but this decrease can largely be accounted for by two key factors (Lewis 1988: 93): 1. The separation of facilities for people with intellectual disabilities; and 2. The removal of people with senility to annexes associated with general hospitals (which was one of the main recommendations for Queensland of the Stoller Report).

Despite this initial decline in patient numbers deinstitutionalisation in much of Australia, and particularly in Queensland, was slow, especially compared to countries such as the USA and the UK. However by the time of the election of the Commonwealth Labor Government in 1972 (The Whitlam Government) all the major parties, at the Commonwealth level, were promoting the benefits of community- based services. The Whitlam Government established an interim Committee of the National Hospitals and Health Services Commission, which recommended that the Commonwealth provide payment for the recurrent costs of community facilities. The Whitlam Government set up the scheme, but the subsequent 1975 National Country/Liberal Fraser Government provided very little financial support to it. By 1978/79 the scheme was only using $58 million out of a total $2.9 billion spent by the

178 Commonwealth on health (Lewis 1988). As a result there was very little financial support for community services.

Deinstitutionalisation was given a major boost by the Inquiry Into the Health Services for the Psychiatrically Ill and Developmentally Disabled (Richmond Report) (Department of Health NSW 1983), which advocated a swift and comprehensive shift from institutional care to community care in NSW. Although the report was principally concerned with mental health in NSW it was influential throughout Australia in establishing a justification for the closure of stand-alone psychiatric hospitals (Savy 2005). Beginning in the 1980s there was a large decrease in patient numbers across Australia with the number of people in psychiatric hospitals or institutions falling from 21,700 in 1981 to 9,200 in 1991, dropping further to 6,100 by 2001 (Australian Bureau of Statistics 2003).

Despite the decrease in the number of mental health patients and beds most of the funding remained focused on psychiatric hospitals. In 1992/93 only 29% of all states mental health resources were spent on community care and 73% of specialist psychiatric beds were in stand-alone psychiatric hospitals (Whiteford et al. 2000). This changed dramatically as a result of the Commonwealth National Mental Health Strategy in 1992, which encouraged a much wider mix of services. Between 1990 and 1997 the number of beds in public psychiatric hospitals decreased by 75% (a reduction of 5391 beds) across Australia (Moore, Shaw, Grant and Braddock 2000: 75).41

Queensland lagged behind other states in the speed of deinstitutionalisation. As late as the early 1990s the mental health system in Queensland still depended primarily on four large psychiatric institutions, based in Toowoomba, Wacol, Townsville and Charters Towers, with over 1100 inpatient beds in those four hospitals alone (Queensland Government 2005: 5). Queensland had a higher reliance on inpatient services than any other state or territory in Australia, with 79% of all mental health resources directed to inpatient care in 1992 (Queensland Government 2005). This changed during the 1990s so that by 1999-00 42% of expenditure was on community mental health services compared with 21% in 1992-93. Expenditure on stand alone psychiatric hospitals reduced from 47% to 28% of total mental health investment

41 It is important to recognise that psychiatric beds in general hospitals replaced some of these beds, although exact numbers are not available.

179 (Department of Health and Ageing 2003), as shown in Figure 10, however total spending on inpatient care remained steady.

Per capita expenditure on mental health services

20 (Constant Dollars)

Per capita expenditure 10

0 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99 1999-00 2000-01 2001-02 2002-03 Year

Stand alone Total Total Community hospitals Inpatient

Figure 10: Expenditure on Mental Health Services in Queensland Source: Table 8 (Department of Health and Ageing 2005a)

The outcome of this shift in expenditure was an 18% reduction in the number of inpatient beds between 1993 and 2004 (Department of Health and Ageing 2005a) as illustrated in Figure 11. This reduction is not dramatic compared with the percentage decrease experienced in other countries. In England and Wales bed numbers decreased by 32% over the same period, and decreased at much faster rate in the preceding years (Department of Health 2007a). The reduction of inpatient beds in Queensland was accompanied by a shift in the location of beds, with stand-alone beds reducing 63% over this time indicating a shift away from large specialist psychiatric facilities. An attempt to make care more geographically dispersed meant that inpatient beds were relocated from regional centres in South East Queensland including Toowoomba, Charters Towers and West Moreton. These were relocated to more dispersed regional centres to ensure a more equitable distribution of resources across the State and to facilitate access. Decentralisation of inpatient beds was completed in 2002.

180 1,800 1,600 1,400 1,200 1,000

Beds 800 600 400 200 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Year

Total Inpatient Beds Stand Alone Beds Colocated Beds

Figure 11: Total Inpatient Psychiatric Beds Queensland Source: Table 14 (Department of Health and Ageing 2005a)

This reduction of inpatient beds occurred despite recent claims by the Queensland Government that ‘deinstitutionalisation was not a principal goal of mental health reform in Queensland’ (Queensland Government 2005: 20). There were, however, several schemes which aimed at moving people out of institutions, most notably ‘Project 300’. This scheme was aimed at assisting people who were long-term residents of inpatient facilities to be returned to their communities with support packages (Queensland Government 2005: 20). Project 300 was a much more intensively supported form of deinstitutionalisation than has occurred in many other jurisdictions. One extensive evaluation showed that Project 300 has been very successful in assisting people move into community settings, while maintaining good mental health and living conditions (Meehan, O’Rourke and Drake 2001).

In summary the process of deinstitutionalisation in Queensland was much later and slower than in many comparable jurisdictions. This is particularly evident in comparison with the case of England and Wales discussed in Chapter Six. Deinstitutionalisation formed a much more significant part of the policy agenda in England and Wales during the 1960s and 1970s, as is reflected in the much faster decline in the number of specialist psychiatric beds. In contrast large-scale deinstitutionalisation did not occur in Queensland until the early 1990s. The lateness of deinstitutionalisation in Queensland reflects the dominance of a confining approach to mental health care in that jurisdiction.

181 9.3 Contemporary Context

One of the greatest changes in mental health policy in Queensland over the last 25 years has been the increasing influence that the Commonwealth Government has exerted over policy. Until the 1990s the Commonwealth Government had relatively little input into, or power over, state mental health policies. However this has changed as the Commonwealth Government has become more directly involved in the funding of health services generally. Before the 1970s health funding was almost entirely supplied by the states, but now the Commonwealth Government provides the majority of health funding (Singh, Benson, Weir, Rosen and Ash 2001). It provides this funding through two major subsidy schemes: Medicare, a form of socialised health insurance which subsidises payments for services provided by doctors and optometrists; and the Pharmaceutical Benefits Scheme (PBS) which subsidises around 65% of medical prescriptions in Australia (Whiteford et al. 2000: 404). This shift towards greater Commonwealth input reflects a more general trend towards greater federal power over the states (Duckett 1999). This shift has resulted in an increasing use of joint Commonwealth-State agreements to frame strategic mental health policy, and to distribute funds.

A major catalyst for Commonwealth action on mental illness arrived from outside the mental health sector in the form of the 1993 report from the Human Rights and Equal Opportunity Commission, Human Rights and Mental Illness: Report of the National Inquiry into the Human Rights of People with Mental Illness (the Burdekin Report). This report investigated human rights abuses experienced by people with mental illness. It concluded that people with mental illness suffered from widespread and systematic discrimination and were being consistently denied access to mental health services across Australia. It further concluded that the money that had ostensibly been saved through deinstitutionalisation had not been channelled back into mental health services. The publicity surrounding the Burdekin Report gave additional impetus to the National Mental Health Strategy (NMHS), which had been launched shortly before in 1992 (Whiteford 2001). The NMHS was a nationally coordinated strategy that agreed on twelve priority areas for action by both the states and Commonwealth Government over a five-year period. This strategy has been influential in shaping mental health service provision in Queensland since 1992.

182 9.4 Mental Health Services in Queensland

The relatively late and slow nature of deinstitutionalisation in Queensland meant that trends in the use of confinement and compulsory care have been quite different in Queensland than in England and Wales. As I demonstrated in Chapter Six there has been a very strong and distinctive trend towards a renewed emphasis on confinement in England and Wales. In contrast in Queensland the process of deinstitutionalisation has only relatively recently been completed and the use of confinement largely reflects this.

9.4.1 Compulsory admissions

The process of compulsory admission was significantly changed by new legislation passed in 2000, which made compulsion considerably more difficult. The Mental Health Act 2000 was based on the National Model Mental Health Legislation prepared by the Commonwealth Government, as well as the United Nations Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care. The Act, which came into force in 2002, substantially reformed the regime for compulsory treatment. It introduced an approach that emphasised the principle of ‘least restrictive care’. This was an explicit rejection of the approach of the Mental Health Act 1974, which was focused on making compulsory treatment relatively easy to obtain. In particular the 1974 Act included strong powers of police detention of people suspected to be suffering from mental illness. The emphasis on compulsion had led to widespread criticism that the 1974 Act breached the United Nations Declaration of Human Rights (Lewis 1988: 93).

The process for involuntary treatment under the 2000 Act is a more stringent process than that under the 1974 Act, which had both longer time frames and looser rules. One example of the looseness of the rules under the 1974 Act was that there were no particular criteria for assessment except that the person was suffering from a mental illness to a degree that warranted detention. In contrast the 2000 Act has an extensive list of criteria that a doctor must certify that a patient fulfils before that patient can be detained. Timeframes for action were significantly tightened in the 2000 Act. For example the 1974 Act allowed detention for up to 21 days, after assessment by two doctors, before a specialist psychiatric assessment was required. This was reduced to three days in the 2000 Act. Overall the 2000 Act provides much more circumscribed powers of detention, with much shorter deadlines before reviews

183 of decisions. Despite these changes the initial (limited) data indicates that there has been no significant decrease in the number of involuntary admissions since the 2000 Act came into force.

9.4.2 Confinement

Confinement has historically played a significant role in Queensland’s mental health services. Historical rates of confinement reflect the institutional emphasis of mental health policy in Queensland. Total admission rates were relatively low in the late 1800s and increased in the early to mid twentieth century with the rate of admission increasing from 2.57 per 1000 in 1881, to 2.90 in 1891, to 3.50 in 1950 (Lewis 1988). Total rates of admission declined steadily after the early 1970s, despite the 1974 Act having sweeping powers of detention. The reduction in the number of admissions was largely caused by the fairly quick decline in ‘regulated’ (compulsory) admissions in the 1970s (Figure 12).

3,000

2,500

2,000

1,500 Number 1,000

500

0 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 Year

Total Patients on Books Total Admissions per year

Figure 12: Total Compulsory Psychiatric Admissions Queensland 1975 –1990 Source: Annual Reports on the Health and Medical Services of the State of Queensland (1975-1982) Annual Reports of the Director-General of Health and Medical Services (1985-1990)

Following a period of decline in admissions from the 1970s to the mid 1990s there has been an increase in the number of both involuntary and voluntary psychiatric admissions. This has been most apparent in voluntary admissions, but has also occurred to a lesser extent in involuntary admissions. Since the late 1990s

184 Queensland has had a significant increase in psychiatric separations.42 This includes a 67% increase in voluntary separations between 1998 and 2004, and a 34% increase in involuntary separations over the same period as shown in Figure 13. This contrasts with stable numbers of admissions across Australia, with an average yearly increase of 1.2% in the number of overnight admissions across the country since 1999/00 (Australian Institute of Health and Welfare 2005: 93).

800 700 600 500 400 300 population 200

Admissions per 100,000 100 0 1998 1999 2000 2001 2002 2003 2004 Year

Total Separations Involuntary Separations

Figure 13: Psychiatric Admissions Queensland Source: (Australian Bureau of Statistics 2004a, Table 5.4 Australian Institute of Health and Welfare 2005)

Currently about 30% of psychiatric patients who are in the Queensland mental health system are involuntarily treated (Queensland Government 2005). Because of the changes surrounding the Mental Health Act 2000 it is difficult to judge trends after 2002, when the Act came into force. In the short period that the 2000 Act has been in force there was an increase in involuntary assessments from 4921 episodes in 2002- 2003 to 5364 2004/05 (Queensland Health, 2004). Additionally there was a much bigger jump in the number of emergency assessment orders from 2519 in 2002-2003 to 3499 orders issued in 2003-2004 (Queensland Health 2004: 14).

The data available suggests that despite the legislative changes, that would have been expected to limit confinement, there has been no obvious decrease in the use of compulsory admissions. Indeed there appears to have been a continuation of the

42 A ‘separation’ is simply a measure of an episode of treatment. More precisely it refers to ‘The process by which an episode of care for an admitted patient ceases’ (Australian Institute of Health and Welfare 2005: 293).

185 trend towards higher levels of use of compulsory admissions. As I discussed in the case of England and Wales there are many factors that could account for the apparent increase in the levels of compulsory admissions. As in the case of England and Wales there is insufficient data available in Queensland to weigh up the likely impact of these changes such as decreased lengths of stay and readmissions.

9.4.3 Private care

There has been a growth in the number of people utilising private psychiatric services over the last twenty years. Across Australia there was a 400% increase in the number of ambulatory mental health separations43 provided by the private sector between 1993 and 2003 (Department of Health and Ageing 2003).

Part of the growth of private psychiatric care can be explained by the decreasing social stigma associated with mental illness. People, especially those with private health insurance (43% of the population (Australian Institute of Health and Welfare 2006)) are increasingly using private psychiatric services voluntarily, rather than ignoring or covering up psychiatric problems (Fielding 2001).

120k

100k

80k

60k Total 40k

20k

0k 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Years

Total separations Overnight Separations

Figure 14: Private Sector Separations- Australia Source: Table 47 (Department of Health and Ageing 2003)

The private health system holds a large proportion of Queensland’s mental health beds. There are 10 specialist psychiatric units or wards among the 54 private hospitals in Queensland which hold a total of 404 beds (Australian Bureau of

43 These are services that do not require a patient to be admitted into the hospital.

186 Statistics 2006). Across Australia private hospitals provided 22% of all psychiatric beds in 2002/03, up from 14% in 1992/93 (Department of Health and Ageing 2005b: 56). In 1996/97 there were only 15 private hospitals with specialist psychiatric units or wards containing 550 beds in all the states outside of NSW and Victoria (Australian Bureau of Statistics 1997).44 By 2001/02 there were 11 hospitals with psychiatric wards, containing 467 beds in Queensland alone (Australian Bureau of Statistics 2004b). The private sector has thus come to play an increasingly significant role in the treatment of people with mental illness in Queensland. This however was almost entirely in relation to voluntary treatment, as private hospitals accounted for 35% of voluntary separations, but less than 1% of involuntary separations (Australian Institute of Health and Welfare 2005: 118-121).

The increasing importance of the private sector was also apparent in England and Wales. As I showed in Chapter Six the private sector in England and Wales has not only greatly increased in size because of voluntary admissions, but has increasingly become a provider of care for compulsory admissions as well as for forensic care. By contrast in Queensland the private sector accounts for very few episodes of involuntary treatment. The rapid growth of the private sector in Queensland indicates that it may be able to provide more involuntary and forensic care in the future, should numbers requiring those forms of care increase.

9.4.4 Forensic care

Queensland forensic mental health services assume full control over prisoners who have been found of unsound mind. Under this system the Mental Health Court or a Jury makes a forensic order as to whether a person is of unsound mind or unfit for trial. Once the finding is made the criminal justice system no longer has responsibility for that person; responsibility for their care goes to mental health services.

In addition to people found to be of unsound mind within the court system there is also a category of ‘classified patients’, who are patients admitted to mental health services from either court, or custody. Once a person is transferred to mental health services they still need to go through the same process as all other patients in order to be treated involuntarily. Like all other patients they are then given an involuntary treatment order (ITO), which can include limited community treatment rather than confinement.

44 Because the figures are so small a state-by-state breakdown is not available.

187

The Queensland system is unusual in having forensic patients so strongly integrated into the mental health system as a whole. A recent review of the forensic mental health system, triggered by a patient absconding, concluded that Queensland had one of the most sophisticated forensic services in Australia (Mullen and Chettleburgh 2002: 2). The number of specialist forensic beds has rapidly increased since 2000, more than doubling between 2000 and 2005 as shown in Figure 15.

The rapid growth in the forensic sector is further illustrated by the significant amount of spending on forensic care. Queensland spends relatively more on forensic services compared to the Australian average, with 7.2% of mental health spending devoted to forensic care in 2003, compared to the Australian average of 5.8% (Department of Health and Ageing 2005b: 70). Thus, as in the case of England and Wales there is evidence of an increased importance being placed on forensic mental health services.

180

160

140

120

100

60 Number of Forensic Beds 40

0 1994 1998 2000 2001 2002 2003 2004 2005 Year

Figure 15: Number of Forensic Beds Queensland Source: Table 20A (Department of Health and Ageing 2007)

9.4.5 Criminalisation

At the same time as deinstitutionalisation of people with mental illness was occurring there was a nation-wide increase in the number of prisoners from 15,866 in 1993 to 25,353 in 2005. This equates to an increase in the rate of imprisonment from 119 to

188 162.5 prisoners per 100,000 adults (Australian Bureau of Statistics 2005a, b). The current rate of imprisonment in Queensland, at 176.7 per 100,000, is higher than the total Australian rate of 162.5 (Australian Bureau of Statistics 2005a). The Queensland rate of imprisonment has largely mirrored the Australian wide trend of a large increase since the early 1990s. This rise was particularly pronounced in Queensland with an almost doubling from the low point of 89 per 100,000 in 1992 to 176.7 in 2005, as seen in Figure 16 below.

200

180

160

140

120

100

Prisoners per 100,000 population 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Year

Queensland Australia

Figure 16: Rates of Imprisonment Queensland and Australia Source: (Carcach and Grant 1999, Australian Bureau of Statistics 2005b)

The limited data available about the prevalence of mental illness in the Queensland prison system makes it difficult to identify any trends (Puplickam 2005). One study found that more than 50 per cent of female prisoners self reported a previous diagnosis of mental illness (Young, Waters, Falconer and O'Rourke 2005). This data is consistent with international trends, and with a comprehensive study conducted in the NSW prison system.45 The NSW study found very high levels of mental illness (Butler and Allnutt 2003). The study found that the twelve month prevalence of psychosis was thirty times higher than the general population, that 78% of male and 90% of female reception prisoners were classified as having had a psychiatric disorder in the previous twelve months, and that between 4% and 7% of reception inmates suffered a functional psychotic mental illness. The high level of metal illness among prisoners in NSW indicates that criminalisation, or the incarceration of people

45 Also see Frieburg (1994) Henderson (2003) Mullen et al. (2000) and Walker (2002) for information about criminalisation in Australia.

189 with mental illness in prisons instead of mental health facilities, is a serious issue in the Australian context and is likely to be present on a similar scale in Queensland.

9.5 Community Care

Due to the lateness of deinstitutionalisation in Queensland the development of community services was also slow until the mid 1990s. Indeed Queensland continues to have relatively low spending on the provision of community services, but such services have grown rapidly, increasing from a very low starting point, of just 425 staff in 1992/93 to 1336 staff in 2004/05 (Queensland Government 2005: 15). This is still the lowest number of staff per capita of any Australian state or territory, at 31 FTE clinical staff per 100,000 population compared with the average of 37 (Department of Health and Ageing 2005b: 36). This is indicative of Queensland’s relatively low expenditure on community services which equated to $37 per capita for community mental health services in 2003 compared to the Australian average of $51 and considerably lower than the level seen in the Australian Capital Territory, which spent $76 per capita in 2003 (Department of Health and Ageing 2005b: 34).

In addition to traditional community services a form of compulsory treatment in the community was introduced in the Mental Health Act 2000. This is a mechanism for ‘limited community treatment’, which aims to provide inpatients with a transition to the community prior to release and involves short periods of compulsory treatment in the community. One of the major features of the community compulsory treatment system is its flexibility. It essentially operates the same as confining forms of compulsory treatment and it is very easy to move a patient from confined treatment to the community and vice-versa. The Mental Health Tribunal, which reviews ITOs can decide to change the category of an ITO from in-patient to community (or vice- versa).

Compulsory community treatment has been aggressively pursued around Australia with around 15% of community mental health contacts involving people with ITOs (Australian Institute of Health and Welfare 2005: 71). It is unclear how widely used such treatment is likely to be in Queensland, because of the relative newness of this legislation. In addition obtaining exact figures on community care services in Queensland has proven difficult, as Commonwealth departments have commented:

190 Queensland does not consider that it provides community residential services and prefers to describe its new bed-based units being built in the community as extended inpatient care (Department of Health and Ageing 2005b: 44).

This preference for regarding these services as inpatient care is reflected in recent criticism by Sane, a national mental health charity, that Queensland has been ‘drawing back community-based services into hospitals’ (Sane 2004:12).

In summary community care started from a low base in the early 1990s in Queensland and continues to lag behind other Australian states. This reflects the overall structure of mental health services in Queensland which despite deinstitutionalisation has continued to prioritise institutional forms of care.

9.6 Conclusion

In Chapter One I presented broad-brush evidence of a renewed focus on ‘institutionalisation’ and confinement in a number of European jurisdictions. In Chapter Six on England and Wales I presented more in-depth evidence which showed that there had been a renewal of confining forms of care in that jurisdiction following a long period of deinstitutionalisation. In this chapter I have presented evidence from the case of Queensland to answer my first research question: How significant is the role of confinement within contemporary mental health systems?

My examination of the use of confinement in Queensland has demonstrated that there has been no clear revival of confining forms of care, as was the case in England and Wales. This is largely a consequence of the relative slowness of moves towards deconfining forms of care, compared to many other Western jurisdictions. Simply put in the case of Queensland confinement was never as minimal as it was in England and Wales. Traditionally mental health care in Queensland was dominated by a small number of large psychiatric hospitals. There has been a distinct shift away from this structure, but this has been towards a larger number of smaller dispersed facilities, rather than to ‘community care’. The continued reliance on institutional modes of care is illustrated by the fact that even as recently as 2000 only about 40% of mental health funding was being spent on community care, and specialist, stand alone, psychiatric facilities received almost 23% of mental health funding, indicating their continued importance in the mental health system in Queensland.

191 There has been a slow, but steady increase in the number of involuntary admissions since the mid 1990s, indicating that confining practices continue to play a significant role in mental health in Queensland. There was however also an increase in voluntary admissions over this period which indicated a greater demand for mental health services overall. As in the case of England and Wales there has been a rapid expansion of specialist forensic beds in Queensland.

The relatively slower pace of deinstitutionalisation in Queensland means that there has been not been a surge in confinement, like that which has occurred in England and Wales. Rather the current use of confinement and compulsion can best be characterised as a continuation of the historical use of confinement. This begs the question of whether it is the case that Queensland is simply lagging behind other jurisdictions such as England and Wales and there will eventually be an upswing in the use of compulsion. It is hard to judge whether this will be the case. The evidence for a move towards a renewed focus on confinement is still mixed across jurisdictions. As I argued in Chapter One there is evidence for a renewal of confinement in a number of (particularly Western) jurisdictions. But as I also pointed out there are wide variations across jurisdictions and it is still difficult to discern the influences on these trends. It would therefore be a mistake to assume that moves towards a renewed focus on confinement were in any way inevitable. In addition, as I have argued, the focus on confinement on England and Wales was a strongly reflexive reaction to processes of deinstitutionalisation and community care. The relative slowness of deinstitutionalisation in Queensland might mean that such a reflexive reaction is less strong.

192 Chapter 10. Historical Analysis of Risk and Confinement in Queensland

10.1 Introduction

In this chapter I address my second research question in the context of Queensland, namely: How have ideas of risk been utilised in past mental health policies and how has this related to the use of confinement?

I utilise my analysis of historical policy documents and archives to show the way that ideas of risk and confinement were used in Queensland mental health policy from 1843 to 1992.46 This historical analysis also lays the framework for Chapter Eleven, which shows how risk is used in contemporary policies of confinement of people with mental illness in Queensland.

The Queensland case has a number of similarities and differences with the example of England and Wales. One of the major similarities is that in neither case was the notion of risk significant as a policy object until near the end of the twentieth century. This means that, as in Chapter Seven, I focus much of my analysis in this chapter on two issues. First, whether through this historical analysis I can establish if the use of risk in the contemporary era is something distinctly new. Second, how spatial confinement has been historically rationalised. Analysis of these two issues helps to provide the basis to satisfy my ultimate research aim: to understand the role of risk in framing confinement and spatial control in contemporary mental health policy.

In the course of the chapter I identify some of the historical continuities and discontinuities in the rationalisation of confinement as a spatial strategy of control. I show how this rationalisation has related to ideas of risk, and of safety and dangerousness. I also demonstrate how the framing of policy has been influenced by the crisis driven nature of mental health services in Queensland, and also by the paternalistic character of politics in Queensland in the later part of the 20th century.

46 A list of the sources analysed is contained in Appendix Two.

193 Drawing on my analysis I argue that danger and safety started becoming important rationales for confinement of people with mental illness as a reflexive reaction to deinstitutionalisation and community care. This, I suggest, points to the continued importance accorded to the spatial control of people with mental illness. However I also find that the language of risk was not significant in policy during this period, thus indicating that, as Castel (1991) argues, risk has become prominent only in late modernity.

10.2 Policy in Queensland: Neglect, Crisis, Action

Historically mental health policy and legislation in Queensland has been crisis driven. There have been long periods of neglect of mental health services, followed by crisis and brief periods of action to address these deficiencies, followed by institutional relapse into neglect. As a result mental health policy has primarily been shaped by a series of Royal Commissions and other official inquiries which have reacted to these crises. The pattern of crisis and neglect was evident from the opening of the first Queensland asylum, the Woogaroo Lunatic Asylum west of Brisbane, in 1864 (Lewis 1988). The Woogaroo Asylum was soon embroiled in controversy over patient conditions and was subject to numerous inquiries, including one by a Select Committee in 1867 (Queensland Journals 1868-69), just three years after opening. Another inquiry followed a mere two years later, in 1869, headed by the Civil Service Commissioner (Queensland Journals 1869). The findings of the later inquiry, that there were no problems with patient care, failed to quell concerns about conditions at the asylum. A new Select Committee investigation quickly followed, which recommended that new legislation be passed (Queensland Journals 1869), replacing the New South Wales legislation that Queensland was then utilising.

Thus within 30 years of the opening of Woogaroo Asylum in Queensland there had been two Royal Commissions, two Select Committee reports and several other inquiries. This early pattern of crisis and neglect set the tone for the influence that official inquiries have had in setting the agenda for mental health policy in Queensland. In particular it has meant that policy in Queensland has been characterised by sudden shifts in approach. Policy has been like a pendulum, swinging between the extremes of a strongly medical approach and a strongly legalistic approach to the framing of policy. These swings have been driven by evidence of the failings of the dominant approach at a particular time.

194

Throughout the entire period of my historical analysis (1843-1992) there has been relatively little emphasis on developing comprehensive and consistent policies for the care and treatment of people with mental illness. As a result the service framework for mental health services has been set almost entirely by the relevant legislation, rather than any separate specific policy. Indeed until the mid 1960s there was virtually no specific policy relating to the system of care and treatment, let alone rationales for how the system operated. My analysis has, therefore, had to rely primarily on legislation and the debates surrounding the legislation, which were often perfunctory.

10.3 Prevention of Crime: 1843-1858

Initially mental health legislation emphasised control over the dangerously insane, which established confinement as largely a judicial rather than medical process. The focus of law, and confinement, was on crime prevention rather than cure or social wellbeing. Until the Insanity Act 1869 was passed the care and treatment of people with mental illness in Queensland occurred under the auspices of the New South Wales Lunacy Act 1843.47 The 1843 Act was a minimalist law; it consisted of only 12 clauses. The focus of the Act, as stated in the preamble, was on ‘making provision for the safe custody of and prevention of crime being committed by persons insane’. The focus within this framework was primarily on the prevention of crime, rather than the treatment of people suffering from mental illness. In order to be committed a person had to be found by two medical practitioners to be ‘a dangerous lunatic or dangerous idiot’ (s.1). In addition they had to be apprehended:

Under circumstances denoting a derangement of the mind and a purpose of committing suicide or some crime for which if committed such a person would be liable to be indicted (s.1).

There were thus two main elements to how confinement, as a spatial strategy of control, was justified under the 1843 Act. First the mere presence of mental illness was not sufficient to justify committal; rather dangerousness was a precondition for state instigated confinement. Control of abnormality was not sufficient cause for the abrogation of the freedom of the individual. Confinement had to be justified on explicit grounds of criminality. Second, the state was prepared to act on a predictive basis in

47 Following Queensland’s constitution as a separate colony in 1859 it continued to rely on NSW legislation.

195 order to promote safety and order. This predictive basis was an individualised one. It was not operating in the sense of predetermined factors which were applied abstractly, which Reichman (1986) argues is characteristic of how the concept of risk is operationalised in the current era. Instead an individualised understanding of danger was used based on individual, face-to-face judgements about the danger of the particular person in question.

While the 1843 Act required some indication of criminality to justify state driven confinement there were separate provisions that provided broader grounds for family initiated committal. These (primarily s.11) allowed one or more relatives to apply to the Governor to have a relative committed. The family provisions widened the grounds for committal, but to be committed a person still had to be found by two medical practitioners to be ‘a dangerous lunatic or dangerous idiot’. In addition family initiated committal required a personal warrant from the Governor. Obtaining a warrant from the Governor was a difficult and time consuming process, which was not undertaken lightly (Lewis 1988).

In both the cases of state and family initiated committal dangerousness was an essential element of the criteria for confinement. Under this regime there was no need, or role, for cure and treatment in justifying confinement. In this early period confinement operated mainly as a form of control over dangerousness and criminality. It operated as a form of boundary maintenance, a separation of the abnormal from society, with no substantial rehabilitative or integrative rationale. It was an individualised notion of control over those who appeared to pose specific criminal threats. This is an example of pure social control being exerted over people with mental illness with no reformative ideal (Cohen 1985). The way the legislative framework operated was an example of exactly how Castel (1991) argued that the concept of danger has functioned, namely on the basis of the individualised identification of hazard and individualised control of hazard through spatial fixing.

The extent to which the legislation was pure control of dangerousness reflects the much more limited role of the state and lack of infrastructure in Queensland. In England and Wales, at the equivalent time, there were already extensive institutions in the form of private hospitals and state workhouses. Queensland lacked the infrastructure to confine large numbers of people. Queensland had no psychiatric facilities and limited jails (Patrick 1987). This early era in Queensland was the only time that danger operated so explicitly as the key justification of spatial control. As I

196 will show from the late 1850s, as psychiatric infrastructure increased, cure and treatment began to replace criminality and dangerousness as the key rationales for confinement. As the power of the state grew there was a new emphasis on confinement as the control of abnormality through treatment.

10.4 A Growing Emphasis on Care: 1859-1884

Between 1859 and 1884 medicalised approaches towards mental illness grew stronger. These medicalised approaches, and the resultant emphasis on cure and treatment, became the main rationale through which spatial control became justified. A distinct shift occurred whereby an explicit aim of mental health policy became to ensure that services were not solely about control and punishment, but were conducive to cure and treatment. This shift brought the rationales for confinement much closer to what was being experienced in England and Wales at the equivalent time. In effect it was during this time that mental illness came to exist in that position between illness and badness which has posed so many problems for state responses to mental illness (Dallaire et al. 2001). Prior to this mental illness was conceived primarily as potential dangerousness. With the growing predominance of medicalised approaches mental illness became a state that was remediable, and thus confinement for the primary purpose of punishment was no longer as acceptable.

The focus on cure was exemplified by the early concerns expressed by members of the Legislative Council48 about the detention of ‘lunatics’ in Brisbane Gaol before the opening of Woogaroo Asylum (Queensland Journals 1860: 206-209). Prior to Queensland becoming a separate colony lunatics were sent to the Tarban Creek Asylum in NSW. But by the late 1850s, in the lead up to Queensland becoming a separate colony, NSW refused to continue with this practice. Thus before Woogaroo Asylum was opened in 1864 Queensland’s lunatics were imprisoned in jail. This concerned the Legislative Council, which asked for a list of all ‘lunatics imprisoned in Brisbane Gaol from 1 Jan 1855 to 31st December 1859’ (Queensland Journals 1860: 206) as part of their case for building a Queensland asylum. Members of the Legislative Council argued that it was inappropriate that people suffering from a medical problem be held with criminals, and that this could be remedied through building a lunatic asylum to provide specialist mental health care.

48 This was the upper house of the Queensland Parliament until its abolition in 1922.

197

The arguments and rationales of the Legislative Council illustrate the growing conviction that lunatics should not be confined in the same way, and for the same reasons as criminals. The rise of psychiatric confinement in Queensland gives credence to Castel’s (1988) argument that psychiatry arose as an answer to a political problem of government. In Queensland psychiatry justified the socio-spatial control of people that could no longer be justified purely on the grounds of badness by adding a reformative aspect to control.

During the period following the opening of Woogaroo Asylum there was public and parliamentary concern about allegations of poor treatment of patients and the abrogation of their liberties. These concerns resulted in a Royal Commission on the Workings of Woogaroo Asylum (Queensland Journals 1868-69) and a subsequent Select Committee Inquiry formed to:

Inquire into, and report upon, all matters connected with the management of the Lunatic Asylum at Woogaroo, and into the fitness or otherwise of the building and premises for which they are appropriated (Queensland Journals 1869: 7).

The major focus of the Inquiry was on ensuring that the asylum was being used for the purpose ‘for which they are appropriated’.

The way that the Select Committee and the Royal Commission understood the purpose of the asylum illustrates the extent of the shift in the rationale of confinement of lunatics. Their understanding indicated a shift away from the early focus on criminality towards a medicalised approach. The medicalised approach held that the purpose of an asylum was to treat and cure people with an illness rather than to punish them like a jail. There was thus a shift towards an understanding of madness as illness, rather than badness (Dallaire et al. 2001). This shift in understanding created a new focus on cure of illness as the purpose for confinement, rather than the prevention of criminality and dangerousness, which earlier drove the system.

These views on the importance of cure are reflected in the criticisms made by the Royal Commission into problems at Woogaroo Asylum. The Commission found that conditions at Woogaroo were too much like a prison. They noted that Woogaroo Asylum had a ‘galling sense of a gaol-like imprisonment’ (Queensland Journals 1869: 297). They claimed that Woogaroo Asylum’s deficiencies maybe ‘epitomised as including either the insufficiency or utter absence of everything popularly supposed to

198 be desirable for the successful treatment of lunacy’ (Queensland Journals 1869: 297). Similarly the Select Committee Report recommended doing away with jail-like accoutrements and ‘would recommend no punishment whatever: the patients are sick and require to be cured’ (Queensland Journals 1869: 744). The focus on cure moved the rationalisation of confinement much closer to how confinement was justified in England and Wales at this time. In both jurisdictions the notion of cure was increasingly important in explaining the confinement of people with mental illness.

The concerns about the prison-like nature of Woogaroo Asylum and the framework for treating madness resulted in the Select Committee recommending the establishment of a receiving house in Brisbane (Queensland Journals 1869: 717). These recommendations served as the framework for the Lunacy Act 1869. The 1869 Act established reception houses where people who suffered from mental illness could be evaluated as to how quickly they might recover from their illness. The idea behind creating reception houses was to prevent long-term incarceration and encourage quick recovery for the less seriously afflicted. This again has close affinities with the case of England and Wales. As I showed in Chapter Seven (section 7.3.3) the notion of early cure was also essential to how specialised psychiatric confinement was justified in England and Wales. The establishment of reception houses in Queensland was also an example of the growing influence of the medical professionals who lobbied for them.

10.4.1 Formalisation of a medicalised approach

The 1869 Act reflected the increasing dominance of the medical view of mental illness. The purpose the 1869 Act (as stated in the preamble) demonstrated the formalisation of a focus on care and treatment, and an official move away from the focus on preventing criminal activity in the 1843 Act. This was the beginning of a much greater emphasis on the role of the state in providing medical treatment in response to mental illness. The Act was based on the idea that early treatment was essential to treating people with mental illness justly, as the Colonial Secretary noted in the debate over the Bill:

The absence of reception-houses was fraught with great injury to those persons who were afflicted with insanity. Owing to this want, there were, last week, not less than five cases in the Brisbane gaol (Parliamentary Debates 1869: 852).

The focus on avoiding unnecessary incarceration was further demonstrated in debates about amendments made to the Lunacy Act in 1871. These amendments

199 doubled (to two months) the period of time a person could be held in a reception house. Parliamentarians expressed concern that this was too long and could compromise the focus of reception houses on early treatment and cure (Parliamentary Debates 1871-72: 136-137). This concern was symptomatic of the attitude of the legislature in that there was an increasing emphasis on patient treatment and on the protection of patient liberties. The emphasis of the 1869 Act was on confinement as a mechanism for treatment rather than for punishment. Although the grounds for committal included reference to dangerousness, treatment was the primary reason through which spatial confinement was justified.

The emphasis on limiting the incarcerating aspects of mental health care was illustrated in the annual reports from the Woogaroo Asylum Surgeon-Superintendent. In these reports he was careful to stress how unlike a jail the asylum was, and how the main emphasis was on treatment. For instance in his 1870 report he noted that ‘personal restraint has seldom been employed, and then chiefly for short periods’ (Queensland Journals 1870: 52). In his next report he noted the removal of iron bars from the windows (Queensland Journals 1871: 52). In 1872 he complained about the clothes of patients which ‘in appearance smacks too much of prison’ (Queensland Journals 1873: 268). These comments were indicative of the growing influence of a medicalised approach to madness, which revolved around confinement for the purpose of cure and treatment and explicitly repudiated any aspects of punishment associated with care. The approach of the Surgeon-Superintendent reflected the influence of moral treatment, which was becoming influential in Australia based on trends in England and Wales (Garton 1988).

10.4.2 Dangerousness and medicalisation

The 1869 Act did not resolve concerns about the poor treatment of patients, and there was another Royal Commission into the management of Woogaroo Asylum in 1877 (The Royal Commission Appointed To Inquire Into The Management Of The Woogaroo Lunatic Asylum And The Lunatic Reception Houses Of The Colony) (Queensland Journals 1877: 547-588). The degree to which the focus of the state had shifted towards care and away from prevention of criminal activity and danger was illustrated in the lack of focus on safety and danger in any of the inquiries or Royal Commissions. The major focus was on ensuring good treatment of patients so that they could recover from their illnesses.

200 This lack of emphasis on dangerousness and safety was characterised by the report of a Board of Inquiry into allegations in 1880 against Dr Patrick Smith, Surgeon- Superintendent of Woogaroo Asylum. One of the allegations was that he allowed a ‘loaded gun in possession of a lunatic’ (Queensland Journals 1880: 350). The Board found that:

On investigation as to the character of the patient, the board do not consider that much risk was incurred, and that no one was better able to be judge of that risk than the Surgeon-Superintendent, who was responsible for his action in the matter (Queensland Journals 1880: 362).

There were two relevant features of this inquiry. First, there was a rare (for this time period) reference to risk. This framing of risk revealed the degree to which risk was conceptualised as both an individualised state and also a matter for clinical judgement, rather than a concept around which policy revolved. Second, the lack of concern about a ‘lunatic’ being in possession of a weapon demonstrated the way that danger was not automatically associated with everyone who was committed. Rather risk continued to be calculated on an individualised basis, subject to judgement about the particular individual and not ascribed on the basis of abstract factors. The way that the language of risk was used in this example was entirely synonymous with danger. Risk was identified, as Lupton (1999) characterises the notion of danger, namely as a precise hazard located in a concrete individual which was amenable to individual judgement.

As I have shown, from the 1850s a medicalised approach began to define the way that confinement was justified. According to that approach confinement existed primarily to ensure the care and treatment of people who were suffering an illness and that should be the primary objective of mechanisms of government. This view was particularly apparent in the rejection of the idea of confinement as punishment. This largely mirrored trends in England and Wales at the same time, which were firmly centred on confinement for the swift treatment of illness.

The growth in the focus on care was similar to the shift that Castel (1988) identifies in his history of the regulation of madness in France. There, he argued, psychiatry and institutions developed to cope with the indeterminate position madness inhabited between illness and badness, being neither fully one nor the other. This position meant that new forms of control had to come into being which could provide new rationalisations for control over the deviance of madness. Thus psychiatry came to prominence as a way of providing a rationalisation for spatial control that

201 encompassed both care and control. The period between 1859 and 1884 in Queensland mirrors this shift, where the rationale for confinement shifted, but the impulse towards spatial control remained strong.

10.5 A Broadening of the Net: 1884-1935

By the late 19th century and into the first thirty years of the 20th century there was growing disillusionment with medical approaches to the control of madness. Again this trend broadly parallels developments in England and Wales, where medical approaches to madness were increasingly criticised for failing to achieve their aims. Nonetheless, particularly with the influence of the eugenics movement (Lewis 1988), confinement in Queensland remained justified primarily through the need and obligation to provide treatment rather than through the desire to prevent danger.

From the 1880s a much more comprehensive system was established for the regulation of insanity, through the Insanity Act 1884. The 1884 Act widened the grounds for committal and further formalised the medicalised approach to rationalising confinement. The grounds for government initiated committal encompassed both medical grounds and a criminal focus similar to the 1843 Act, whereby people could be committed if insane and suspected of potentially committing an offence. Section 25 set out the grounds for committal, namely that a person could be committed if insane and: a) without means of support; or b) wandering at large; or c) suspected of potentially committing some offence; or d) not under proper treatment; or e) cruelly treated or neglected.

The widening of the grounds for committal was circumscribed by the definition of ‘insane’ under s.4. Under this section a person could only be found insane if ‘of unsound mind and incapable of managing himself or his affairs’. This definition showed the formalisation of confinement being about the good of the person being confined, either in terms of effecting a cure, or alternatively to prevent them from making poor decisions.

There was also a focus on protecting liberties. One of the key aims of the 1884 Act was to provide ‘a better guarantee than now existed that persons not insane should not be sent into an asylum’ (Parliamentary Debates 1879: 187). Although there was a

202 widening of grounds for committal a system of leave was also introduced, relaxing the confining nature of committal. This was a system where patients could be given leave of absence (while remaining patients) to visit friends and family. In his 1885 annual report the Medical Superintendent described this provision as ‘a very convenient and humane one’ (Votes and Proceedings 1885: 788). This easing of leave requirements, like the attitude towards escapes, illustrated a relatively relaxed attitude towards people with mental illness being in the community, if they were considered to have received appropriate treatment.

The continued relative lack of concern about safety as a goal of policy was reflected in the Report of the Inspector of Hospitals for the Insane in 1924, which noted that out of ten escapees ‘three were convalescent and were written off the books’ (Parliamentary Papers 1924: 1038). This was a continued trend. The 1929 report, for instance, noted that out of 5 escapees from Goodna Psychiatric Hospital ‘one was well on the road to recovery and has been written off the books of the hospital’ (Parliamentary Papers 1929: 1019). This lack of concern about escapes was very similar to that in England and Wales (see section 7.3.1). In both cases the notion was that if people were able to both escape and avoid capture for some length of time then this proved that their illness was not so severe that they could not function in society. The ability to escape and avoid immediate recapture was a form of proof of sanity. In effect it was almost treated as self-discharge. The way that escapes were responded to further demonstrates how important notions of cure were in justifying control of people with mental illness. While control of dangerousness was part of the rationale for confinement, the notion of dangerousness was identified strongly with the illness, rather than inherent to the individual. Thus, if the individual was apparently cured then danger was no longer nearly as significant a concern.

My primary analysis has shown that between 1886 and 1935 there were no references to mental illness in the Parliamentary Debates, aside from the tabling of the annual reports on asylums and the 1915 Royal Commission. The only official papers from this period were the annual reports of the Medical Superintendent of Asylums (which during this period became Reports of the Inspector of Hospitals for the Insane). These reports were much more officious and perfunctory than prior reports. They focused primarily on presenting the bare facts such as admissions, discharges and reasons for admissions, and contained much less commentary than earlier annual reports. This was indicative of the decrease in focus on mental health and the instrumental approach taken towards mental health care. Cure and treatment

203 continued to be the main reasons provided for confinement. However there was a growing emphasis on the protection of individual liberties that started to challenge these rationales.

10.6 Individual Liberty: 1935-1962

The lack of focus on mental illness between 1884 and 1935 was changed by the growing professional power of psychiatrists, who waged a campaign to make involuntary admissions easier. Psychiatrists attacked earlier legislation as being too preoccupied with the liberty of patients, and argued that the ‘fetish of liberty’ (Lewis 1988: 34) was preventing people from getting the treatment which could help them. The lobbying and campaigning of medical professionals influenced further legislation passed in 1938 and 1962. That legislation made it easier for doctors to involuntarily treat people through widening the grounds for commitment. During this period the idea that confinement of people with mental illness was for the protection of the community started to become more explicit.

In 1938 there was a major change in the orientation of Queensland’s mental health legislation with the passing of the Mental Hygiene Act 1938. The 1938 Act was drafted by Dr Stafford, Superintendent of Ipswich Asylum, after an international study tour which aimed to understand best practice (Patrick 1987). The resulting Act made genuine attempts to reduce the stigma associated with mental illness. This was reflected in the changed terminology of the Act, such as mental hospital instead of asylum and mental illness instead of insanity. It also allowed for voluntary admissions and for local authority expenditure on outpatient facilities. The Act was closely modelled on the English and Welsh Mental Treatment Act 1930.

The 1938 Act demonstrated a change in approach to the treatment of mental illness. It had both a much stronger medical focus and a much more explicit weighing up of the rights of individuals against the rights of the community. This was reflected in the introductory comments of the Queensland Home Secretary when amendments leading up to the 1938 Act were made. He noted that:

One hesitates to interfere with the liberty of the subject more than is absolutely necessary for the preservation of good order in the community (Parliamentary Debates 1935: 1464-65).

204 The introduction of amendments in 1935 was a direct reaction to several patients successfully suing in relation to wrongful imprisonment (Parliamentary Debates 1935: 1464) (as had also happened in England and Wales during the 1920s (see section 7.5.1)), resulting in a legislative emphasis on individual rights.

In addition to emphasising individual liberty the 1938 Act was also the first really explicit statement that one of the key principles of mental health law was ‘the protection of the public interest’ (Parliamentary Debates 1938: 1044). This was demonstrated in the definition of ‘mentally sick person’ in section 2 of the 1938 Act as: ‘a person who owing to mental sickness requires care, treatment and/or control for his own good or in the public interest’. Under this definition a person could not be considered mentally sick unless they posed a threat to themselves, or the ‘public interest’. The way that the phrase ‘public interest’ was used in the Act incorporates both the public interest in safety against danger, and the public interest in people behaving in an orderly manner. The change in definition of mental illness made explicit that one of the key goals of the legislation was to exert control over potential disorder.

This emphasis on the protection of public order was apparent in the greater powers of the police (under s.40(2)) to apprehend a person believed to be mentally sick and who: a) Is without sufficient means of support; or b) Is wandering at large; or c) Has been discovered under circumstances indicating a purpose of committing some offence against the law; or d) Is suicidal or dangerous; or e) Acts in a manner offensive to public decency

The greater role for police and wider grounds for committal were indicative of the growing emphasis on confinement for the public good and public order. The growing role of the police also demonstrated the beginning of the shift away from psychiatry providing an absolute justification for the control of the deviance of madness. As psychiatry expanded to provide services outside of institutional care it no longer provided as compelling a justification for spatial control of madness and other justifications, such as protection from danger, became stronger. Despite the changing role of psychiatry there was a continued commitment to the spatial exertion of control over people with mental illness, which was characteristic of disciplinary modes of control (Philo 2004).

205 10.7 Community Care and its Rejection: 1962-1992

By the 1960s mental health care had become a more pressing issue for the Queensland Government. The early 1960s saw the adoption of community care as a preferred mode of care and a decision to reduce the role of specialist stand-alone psychiatric hospitals. This shift was largely repudiated in the 1970s. Further legislation passed in 1974 adopted a paternalistic approach to mental health. The rejection of community care was framed by the political circumstances of the time, which saw Queensland governed by the conservative and authoritarian Joh Bjelke- Petersen Government from 1968 to 1987 (Evans 2007). Danger began to be utilised as a way of justifying confinement of people with mental illness. I argue that the growth of the use of the concept of danger within the policy realm needs to be understood within the highly paternalistic nature of public policy in Queensland during this period. As Scull (1977) makes clear, changes in the way social control operates are always linked to the character of the social systems in which they operate. Under the Joh Bjelke-Petersen Government a relationship of dependency was created between citizens and government. In return for conformity to a range of standards, the Government would offer protection from dangers and risks. This is an example of what Pratt (1995) refers to as governance based around social protection against danger and is an illustration of the way that paternalism operated to emphasise spatial control over deviance.

10.7.1 The introduction of community care

Queensland was significantly slower than many Western jurisdictions to implement wide scale deinstitutionalisation. Many people with mental illness remained in large institutionalised psychiatric facilities until well into the 1990s. Despite the slow pace of comprehensive deinstitutionalisation Queensland was quick to adopt community care as an official approach in the early 1960s. As early as 1961 the Government was pursuing a policy ‘that no more new mental hospitals would be built in Queensland in the foreseeable future’ (Parliamentary Debates 1961-62: 547). This policy was in contrast to the Commonwealth supported policy of increasing the number and size of psychiatric hospitals, as outlined in the Report on Mental Health Facilities and Needs of Australia (the Stoller Report). The Stoller Report advocated for continued institutional care and recommended an almost doubling of the number of specialist psychiatric beds. Queensland instead adopted a policy of ‘integrating the psychiatric facilities of the State into our general hospital services’ (Parliamentary

206 Debates 1962: 1797). This policy was consolidated by the passage of the Mental Health Act 1962, which claimed to be based on ‘reducing social stigma’ (Parliamentary Debates 1962: 1797).

The 1962 Act was based on the Mental Health Act 1959 in the United Kingdom (Parliamentary Debates 1962: 1798, Queensland State Archives 53808, 406285), and was focused on creating procedures for community care and encouraging voluntary commitment in hospitals. One of the key aims of the Act was the integration of care into the mainstream hospital service (Queensland State Archives 20324). The way that the 1962 Act was framed supports the notion that as community care became an increasingly viable and well used option for the care of people with mental illness the significance accorded to public safety increased. As psychiatry no longer provided a total justification for spatial control of mental illness other justifications started to fill this role.

The 1962 Act created new mechanisms of community care with an emphasis on recognising the importance of individual liberty. The Minister of Health described the provisions of the Act as:

Designed to preserve, at all times, the very necessary safeguards of the liberty of the subject. No less important are those clauses designed to ensure the safety of the community (Parliamentary Debates 1962: 1798-99).

There was, however, a double edge to this emphasis on balancing liberty and safety, namely that it resulted in a new focus on the need to ensure community safety. This emphasis was apparent in the principles underlying the Act, as outlined by the Minister of Health, including the following principle:

c) The right of the public to have adequate safeguards where such are necessary in the interests of the patient or for the protection of the community (Parliamentary Debates 1962: 1799).

This principle was indicative of the much more overt concern for the protection of the community which became apparent at this time. The emphasis on community protection was reflected in the grounds for detention established in the Act. Those grounds included that a person needed to be found to have a mental illness and ‘that he ought to be so detained in the interests of his own health or safety or with a view to the protection of other persons’ (s.18(2)b). There was thus a much stronger emphasis on the idea that the community had rights that needed protecting against people with mental illness. The primary right being protected for the community was

207 safety, with the implication that people with mental illness posed a danger to the community that needed to be safeguarded against.

Thus although the Act and official statements emphasised the significance of voluntary treatment, this was balanced by a renewed focus on justifying compulsion as a key part of the mental health system. As internal departmental archives suggest:

Care and treatment without compulsion is to be commended, but when it seems that the only way of giving the patient treatment… which he badly needs or when it is necessary for the protection of others; then there should be no hesitancy in exercising the compulsory powers which the Act provides. Consequently the compulsory powers will often be used (Queensland State Archives 20324: 2).

This mirrors the process that occurred in the English and Welsh case study, namely that as alternatives to confining forms of care began to be utilised it became necessary for the state to more explicitly justify the remaining use of confinement. As in the case of England and Wales danger emerges in a Beckian style reflexive response to the modernisation processes, i.e. community care. As community care gained in importance the reflexive effect was a stronger focus on danger. The significance of danger was reinforced through the development of specific mechanisms to deal with ‘dangerous’ patients. This era in Queensland had many similarities with the case of England and Wales. In both jurisdictions there was a more explicit focus on public safety, as the emphasis on individual liberty grew stronger.

10.7.2 ‘Dangerous patients’

I argue that the identification of ‘dangerous patients’ in the 1962 Act signified two important changes relating to risk and the justification of confinement. First, it illustrated a growing bifurcation, within institutional thought and practice, of people with mental illness between the dangerous and the safe. Second, it was a key turning point where the use of confinement as a form of control over dangerousness became much more overt. I argue that this is a further example of the way that a focus on safety arose as a reflexive effect of community care.

The 1962 Act was the beginning of a process of creating two classes of patients, normal patients and ‘dangerous patients’. In his introduction to the Bill the Minister of Health emphasised the ‘far-reaching beneficial effects for both patient and community alike’ (Parliamentary Debates 1962: 1797) of community care policies.

208 However, he also noted that in addition to this there were a ‘relatively few patients for whom custodial care must be provided, both in their own interests and for the protection of the community’ (Parliamentary Debates 1962: 1797). Once again the way that this discursive differentiation was framed was very similar to the example of England and Wales in signalling a bifurcation of policy as community care policies are adopted. Indeed the Queensland Minister of Health deliberately drew on the example of the United Kingdom to support his emphasis on continued detention of particular patients:

Of course there are those who need security…there are some hospitals (in the United Kingdom) devoted to the care of the psychopathic and those who are dangerous. These would amount to about 12 per cent of all patients in mental hospitals (Parliamentary Debates 1962: 1798).

This was the beginning of a differentiation between ‘normal’ patients and ‘security patients’, which grew stronger during this period. In particular the 1962 Act introduced new provisions around the detention of people with mental illness who were facing criminal charges. In section 33(1) the Act established a special category of ‘security patients’ who would be detained in security hospitals, which remained under the administration of the prison system.

Security patients were those individuals who had already committed some violent or disorderly offence. The categorisation of individuals in this security category was thus linked to concrete behaviour of the particular individual, rather than an assessment of a probability of some form of dangerousness or of abstract judgements about the individual. In this way the concept of security patients is a very traditional individualised notion of dangerousness rather than one that relies on abstract calculative technologies of risk (Rose 2002). The creation of this new category of security patients laid the framework for an increasing bifurcation in mental health care between the dangerous and the safe. This categorisation began a formal differentiation between those who were ‘safe’ and thus could be controlled on the basis of their illness, and those who were dangerous and thus should be controlled on the basis of their ‘badness’. This process of separation acted as a way of reinforcing the need for disciplinary modes of control over those classified as dangerous. As Foucault (1977a) emphasised, discipline depends on the distribution of individuals in space. The bifurcation created by forensic services facilitated the continuation of these disciplinary modes of control over particular people with mental illness.

209 The increasing differentiation between the safe and the dangerous was illustrated in how escapees were dealt with in the legislation. In previous legislation all escaped patients were treated the same. However under the 1962 Act there was a provision that allowed for a warrant to be issued for people considered as ’dangerous’, which meant they would remain liable for capture at any time. Otherwise the provision remained that non-dangerous patients could be considered as automatically discharged after three months.

Another element of the 1962 Act that signalled a shift towards greater concern with safety was the increase in police powers of detention. The 1962 Act (s.26) created powers for the police to immediately remove a person to a ‘place of safety’ if they appeared to be suffering from a mental illness and in need of immediate treatment or control. The Minister of Health justified this power in terms of community safety. He argued that it should be:

Mandatory for a member of the Police Force to apprehend a person in a public place who appears to that police officer to be suffering from mental illness and in need of treatment or control. This is a basic principle to be observed for the protection of the community at large, and for the protection of the person himself. The community should not be intimidated by people who act in a manner suggestive of disordered mental processes (Parliamentary Debates 1968: 576).

His explanation of this power not only emphasised the newly overt focus on community safety and the policing of the mentally ill, but it also signalled the turn towards a paternalism of care that became a key feature of policy during the 1970s.

In particular the notion of ‘the right of treatment’ came into use. This was a more overt explanation of the focus on cure and treatment than previously. This principle of ‘right to treatment’ held that patients should receive treatment whether or not they wanted it, as the Minister put it treatment needed to occur for those:

Who may even be recalcitrant determined not to submit to medical examination, or to seek treatment…It is important that person is placed in a hospital where he can receive treatment and at the same time remove from within the community a potential danger, either to himself or to members of the community (Parliamentary Debates 1962: 2214).

The above quote draws attention to what I argue are the two key features of this legislative change that accompanied the first moves towards deinstitutionalisation. The first is the link between a move towards community care and a more explicit framing of the rationale for compulsion and confinement as being to ensure community safety. The second is that this move towards safety as a justification for

210 confinement was complicated by the paternalism of care associated with policy in Queensland from the late 1960s. Under this paternalistic approach confinement became driven by the notion that people with mental illness may not be capable of making appropriate decisions about their own care, and thus the state needed to compel them to receive this care. In this way spatial control of the deviance of illness (not just badness) was revitalised. As I have shown the rise of community care, for example in England and Wales, acted as a way to facilitate decentred forms of control over mental illness. From the late 1960s the Queensland Government used paternalism to overturn this shift and argue for a return to the notion that spatial control should be strongly exercised over all mental illness, to ensure that the illness was dealt with properly. This paternalistic approach to mental illness was part of the wider agenda of the Joh Bjelke-Petersen Government which emphasised strong control over all forms of deviance from the conservative norm (Evans 2007).

10.7.3 Paternalism

Paternalism, deriving from a socially conformist conservatism, was a prominent feature of governance in Queensland from the 1960s, and in particular with the election of the Joh Bjelke-Petersen Country/Liberal Government in 1968 (Evans 2007). This paternalism was prominent in the Mental Health Act 1974, which emphasised the requirement of treatment for people with mental illness. The paternalism of that legislation was also apparent in the focus on confinement as being in the best interests of the person in question. This justification through the idea of best interests meant that safety was a less significant justification for confinement than under the 1962 Act.

The paternalism of the Joh Bjelke-Petersen Queensland Government and the 1974 Act was accompanied and strengthened by a resurgent medical focus. The main rationale presented for the confinement in the 1974 Act was to ensure quick treatment for patients, regardless of whether they acknowledged they needed it (Queensland State Archives 406462, 406484).

One of the most striking aspects of the 1974 Act and the justification for it was the explicit rejection of community care. The Queensland Minister for Health introduced the 1974 Act into parliament with a clear repudiation of community care as being an appropriate policy for mental health care. He noted that:

211 In theory, the responsibility of making alternative arrangements for patients displaced by these policies would be accepted by the community at large. In practice, some communities have failed to accept that responsibility, and many former patients have found themselves homeless and destitute. This government has never considered that people should be uprooted from the mental hospitals and thrown back into the community merely to appease its conscience (Parliamentary Debates 1973-74: 2202-03).

This rejection of community care was symptomatic of the paternalistic approach of the 1974 Act. The Queensland rejection of community care preceded the English and Welsh rejection (as discussed in Chapter Eight, section 8.3) by almost fifteen years. In the case of England and Wales the repudiation of community care resulted in a turn towards confinement based on the prevention of danger. But in the case of Queensland this was complicated by a renewed focus on confinement for the purposes of cure and treatment.

The principles that guided the formation of the 1974 Act included: ‘the protection of the community against dangerous patients; the protection of the patient against himself’ (Parliamentary Debates 1973-74: 2004). The Minster for Health referred to the desire to balance the needs of the community and the needs of the individual in the Act:

There is therefore the balance that we spoke about between the needs of the community for protection, the needs of the patient for treatment, the needs of the patient for protection against himself and the necessity that every person who is suffering from any form of mental illness is able to secure the necessary assistance that is his right as a citizen (Parliamentary Debates 1973-74: 2220).

In this balance there was little space for the liberty of patients. There was however a focus on protection for the community and for the patient against themselves. Indeed the Minister criticised civil liberties groups for having ‘no appreciation of the fact that the person’s own interests may best be served by depriving him of his liberty for a period’ (Parliamentary Debates 1973-74: 2817). The way that confinement became framed in the 1974 Act subsequently lends weight to one of my key claims. This is that danger, and ultimately risk, have become key rationales for confinement as other justifications for confinement have become discredited. As I argued in Chapter Two, the state requires a continued justification for the removal of social disorder from society. My England and Wales case study gave weight to Rose’s (1998) claim that contemporary mental health policy is effectively the legalisation of risk status rather than about illness. In contrast the rise of paternalism in Queensland presented another rationale for confinement, which explains why dangerousness did not

212 become nearly as prominent in framing mental health policy in Queensland during the 1970s and 1980s as it did in England and Wales.

10.7.4 Bifurcation

The 1974 Act also strengthened the policy bifurcation between dangerous and safe patients introduced in the Mental Health Act 1962. This included the creation of an entirely new category of patients, ‘restricted patients’. The creation of this new category shows that despite the larger focus on the best interests of patients there was still growing concern about managing danger. The category of ‘security patients’ in the 1962 Act primarily included those who were already part of the prison system and had thus already demonstrated their dangerousness. That categorisation was thus more about offering services to those who were already confined for the purpose of control and remediation. In contrast the category of ‘restricted patient’ in the 1974 Act was about creating a new category of mentally ill people for the purpose of spatial control. It involved identifying potentially dangerous patients who had not been convicted of criminal activity. The Minister explained that the new category was aimed at preventing ‘the inadvertent release of a patient who is known to be dangerous or is believed to be potentially dangerous’ (Parliamentary Debates 1973- 74: 2822).

The creation of the category of ‘restricted patients’ points to one of the first times that the idea of dangerousness was explicitly linked to probability of calculable future hazard. The idea of potential gets at the heart of the analytical distinction between ‘danger’ and ‘risk’, and marks a distinct shift in policy towards the notion of risk. Danger, as I have already emphasised, is about hazard embodied in a particular individual based on their past behaviour, such as a criminal conviction (Giddens 1999). Risk involves the notion of potential hazardous behaviour in the future based on more abstract judgement, not necessarily derived directly from the past behaviour of the individual in question. The creation of this category of ‘restricted’ patient is an ideal example of Beck’s (1992) argument that the incalculable threats of presociety are transformed into calculable risks in the course of the development of instrumental rational control which the process of modernisation promotes. The creation of a category of ‘restricted patients’ marked the beginning of the way that risk became a technology of policy used to justify instrumental control. The notion of ‘restricted patient’ was an attempt to make disorder and uncertainty more controllable. It is exactly this type of strategy that brings the technology of ‘risk’ into being and selects

213 certain phenomena as being 'risky' or requiring management (Beck 1995). In this case the identification of particular individuals as bearers of risk acted as the justification for the assertion of disciplinary modes of control over those individuals. Thus risk acted as a way of reasserting spatially fixed modes of control.

10.7.5 Continued rejection of community care

The concepts of paternalism and safety, given prominence in the 1974 Act continued to dominate mental health policy and practice during the 1980s. This was a period of little policy development and relatively little parliamentary or policy focus on mental health, aside from some amendments made to the Mental Health Act in 1984. There was however a gradual shift towards greater emphasis on the prevention of danger.

The 1984 amendments emphasised continuing government scepticism of community care as an adequate approach to mental health policy. The Minister of Health explicitly compared Queensland with the United States, claiming that it was too difficult to have a person committed in the United States resulting in a failure to give mentally ill persons the treatment that they need (Parliamentary Debates 1982-83: 3634). He contrasted this with the Queensland approach which emphasised treatment and care as the primary purposes of mental health services.

The 1980s saw the beginning of a political opposition by the Labor Party to paternalism and a rare debate on the role of the state in relation to people with mental illness. The Minister for Health propounded that a central role of the state needed to be deciding who was dangerous, as ‘someone has to decide what is dangerous’ (Parliamentary Debates 1984-85: 343). This approach was indicative of the continuing influence of paternalism throughout this policy period. The continuing view was that the state knew what was best for the individual and for the community. However by the early 1980s there was some reaction against paternalism. This was apparent in concessions towards civil liberties in the 1984 amendments. The definition of mental illness was changed to explicitly exclude a person from being classified as suffering a mental illness solely by reason of their political belief, religious belief, moral opinion or activity.

Despite these changes the continued paternalistic influence on the legislation can be seen in section 26 of the 1984 amendments. This section provided that there could be warrantless detention where urgent action was required because of the imminent

214 possibility of harm to a person or to others. The continued paternalism of policy approaches was further highlighted by the Government’s refusal to allow legal representation at the Patient Review Tribunal. The Government argued that legal representation would not be in the best interests of patients and the goal of ensuring that patients got the necessary care (Parliamentary Debates 1984-85: 73). This was, the Government claimed, because legal representation might result in a reduced likelihood of involuntary treatment, thus acting against the ‘interests’ of people with mental illness.

In summary, the 1970s and early 1980s were characterised by an explicit rejection of community care and the adoption of a paternalistic approach to people with mental illness. The role of the state was seen to be to act in the best interests of people with mental illness, as they were inherently unable to act in their own interests. The Government also argued that it was their role to act in the interests of the community by protecting it against danger. Confinement was thus justified as being necessary for the control of both badness and illness.

10.8 Historical Uses of Risk

My analysis has demonstrated that, despite occasional references, the concept of risk was barely used in Queensland mental health policy from 1843 to the mid 1980s. Thus, as in the case of England and Wales, my historical analysis of policy suggests that the answer to my second research question is that ideas of risk have not been utilised in any substantial manner in mental health policy prior to the 1990s.

As in the case study of England and Wales my finding that the language of risk has not been used in mental health legislation or policy poses two additional issues. The first issue is how the use of confinement, as a spatial strategy of control, has been justified in policy. Examining this helps to illuminate how and why the way risk is used in justifying confinement in the contemporary era differs from how confinement has been justified historically. The second issue is what role concepts of danger and safety, which can be seen as precursors to the idea of risk (Douglas 1992), have had in policy. My analysis of this helps to set the stage for determining whether the use of risk in the contemporary era is substantively different from the use of ideas of danger, as Castel (1991) contends.

215 10.8.1 How confinement has been justified

As I have illustrated there have been many similarities between the cases of Queensland and England and Wales. This is not surprising as Queensland was part of an English colony and the Queensland legal system is based on the English legal system. Similarly, as I have shown, the 1938 and 1962 legislation was based on the English and Welsh legislation of that time. It is no surprise, then, that the way that confinement has been justified in Queensland was very similar to the way it was justified in England and Wales, at least until the 1970s. In Queensland confinement was initially justified on the basis of the prevention of criminal activity. This quickly changed, however, once Queensland started to develop psychiatric infrastructure, such as asylums and reception houses. By the 1860s confinement was being justified primarily on the basis of the benefit of treating and curing patients.

As in the case of England and Wales, as community forms of treatment became more widely utilised psychiatric justifications of confinement for the purpose of cure became less compelling. Also as in the case of England and Wales this resulted in less confinement, but it also meant that other justifications for confinement began to fill the role that cure had previously played. In particular public safety and protection from danger became increasingly prominent as reasons for confinement. However these did not become as significant in Queensland as in England and Wales, because of the role of paternalism in Queensland. The use of paternalistic notions of the ‘need for treatment’ renewed the idea that confinement of people with mental illness could be justified on medical grounds (alongside safety grounds).

As I have argued above (section 10.7.3) the way that this divergence occurred gives credence to my argument that danger and safety became prominent justifications for confinement once other rationales, primarily cure, were no longer acceptable. In the case of Queensland the protection of community safety was not as dominant a rationale for confinement in the 1970s and 1980s as it was in England and Wales. I suggest that this was because paternalism was fulfilling the role of justifying confinement.

The existence of these multiple rationales for confinement points to the flexible role of institutionalisation. As Castel (1988) and Dallaire et al (2001) argue madness has existed in an uneasy position between illness and badness. The shifts in the way confinement has been rationalised in Queensland have largely been between an

216 emphasis on either the illness element, or the badness element of madness. Yet despite the shifts in focus and rationalisation confinement has remained at the centre of policy for most of the period analysed in this chapter. This points to the continued flexibility of institutionalisation as a way of managing deviance. Although the justifications for confinement have changed, the emphasis on the kind of spatial fixing of deviance characteristic of Foucault’s (1986) notion of the disciplinary society have remained strong.

10.8.2 Uses of danger, safety and risk

Although protection against danger was not as prominent in Queensland as it became in England and Wales public safety was still an increasingly important part of policy. Indeed notions of danger as part of the reason for confinement are discernable throughout the history of Queensland. From the 1840s through to the 1970s the notion of danger was overwhelmingly individualistic. This meant that identification of danger was assessed on past behaviour with little actuarial or calculative intent. Danger was ascribed to individuals, who could then be controlled through disciplinary modes of control which included spatial control.

A predictive, calculative idea of danger started to be used with the formation of forensic policy in the 1970s. As I argued above this introduced an aspect of actuarial thinking to policy. The bifurcation of policy between the dangerous and the safe, which became part of forensic policy, acted as a way of categorising those requiring spatially fixed modes of discipline and those who could be controlled through decentred networks of control.

10.9 Conclusion

In conclusion my historical analysis shows that risk was not substantially utilised as a way of framing Queensland mental health policy from the 1840s to the 1980s. Nor has risk been used as a justification for confinement of people with mental illness. This finding gives credence to Castel’s (1991) notion that there has been a shift from dangerousness to risk in the governance of mental illness. This proposition is the subject of the following chapter, which shows how, and to what extent risk is used in contemporary mental health policy in Queensland and how that relates to confinement. I am then able to compare this with the historical justifications of confinement that I have identified in this chapter.

217 Chapter 11. Risk and Confinement in Contemporary Queensland

11.1 Introduction

In this chapter I answer my third research question, namely: To what extent, and how, are ideas of risk used in contemporary policies of confinement of people with mental illness?

There are two main parts to this question, each of which is addressed in turn in this chapter. First I show that risk has become an increasingly prominent part of the framing of Queensland mental health policy over the last twenty years. I argue that the framing of policy has shifted from the paternalism and emphasis on cure, which characterised the 1970s and early 1980s. It has been replaced by a focus on safety, with an emphasis on risk assessment and risk management. As in the England and Wales case study legislative reform has played a significant role in shaping the mental health policy environment in Queensland. A new Mental Health Act was passed in 2000 replacing the Mental Health Act 1974 and illustrating the shift away from paternalism and towards control over risk as the major rationale for mental health services. This chapter begins with a discussion of the use of risk in legislation before showing how risk has become increasingly central throughout policy development in Queensland.

Second I demonstrate how concepts of risk have been utilised in mental health policy and what is meant by the terminology of risk. This research is based on my discourse analysis of Queensland mental health policy documents from 1992 to 2007 (as listed in Appendix Four). The analysis shows that despite the increasing emphasis on risk assessment and risk management there is seldom any clarification of what is meant by the notion of risk. Instead risk is treated as though it were a self-evident concept. I use the techniques of discourse analysis to draw out the different meanings associated with the language of risk. As I explained in Chapter Five (section 5.3.8), my primary interest is in the object of ‘risk’. By this I mean that my key concern is with how the specific terminology of ‘risk’ became, and is, used as an object of public policy. My major focus is specifically on the language of risk, rather than practices associated with risk or risk as an empirical effect.

218

I frame my discussion of how the language of risk is used within the increasingly active role being taken by the Commonwealth Government in seeking to shape and influence policy at a state level. I argue that the role of the Commonwealth Government has led to a greater influence of public health approaches on mental health in Queensland.

Through my analysis I show that, as in the case of England and Wales, risk has become a significant rationale for mental health policy as a reflexive effect of the growth of policies of community care. I also argue that this focus on risk has been as a way of trying to exert greater control over uncertainty. There is a central tension over this attempt to control uncertainty between macro-level deregulation and the need for a micro-politics of surveillance. This tension is particularly evident in the way risk is utilised in the dual role of exerting control over both aggregate groups and the individual. I conclude the use of risk as a way of framing mental health policy in Queensland is more complicated than in England and Wales, but that it is primarily used as a way of reasserting spatial control over people with mental illness.

11.2 Risk in Legislation

My analysis shows that the way risk is framed within legislation has helped to establish how the concept of risk is used in public policy.49 In Queensland changes resulting in the Mental Health Act 2000 demonstrate the extent to which the concept of managing risk has become a central element of public policy. My examination of the lengthy process of reform of the legislation concludes that the 2000 Act was a deliberate rejection of the paternalism of the 1974 Act and placed risk at the centre of decision making about confinement of people with mental illness.

The 2000 Act was part of a concerted effort to show that Queensland had moved beyond the conservative “Deep North”50 perception that dogged it during the 1970s and 1980s. The 1974 Act epitomised the social and political conservatism of Queensland at that time. While most jurisdictions around the world, including most

49 This is not to suggest that policy is merely ‘read off’ legislation. The relationship can be best conceived of as a dialectical one, whereby each informs the other (Fischer and Forester 1993). Legislation does, however, have a particular place of importance in framing practice, as the latter is dependent on the legal powers contained in the Act. 50 The “Deep North” was an epithet applied to Queensland during the 1970s and 1980s, alluding to the allegedly “red neck” culture there supposedly similar to the “Deep South” of the USA. It was popularised in the 1979 book “The Deep North” (Wells 1979).

219 Australian states, were moving to liberalise their mental health laws and encourage deinstitutionalisation Queensland was moving in the opposite direction. The 1974 Act utilised a paternalistic justification for involuntary treatment (as discussed in Chapter Ten). The 2000 Act replaced paternalism with risk.

11.2.1 Central role for risk

As my analysis shows risk has replaced the concept of ‘best interests’ as the primary rationale that justifies confinement. Risk became the central element of the admission criteria necessary for involuntary treatment to take place under the 2000 Act. The admission criteria explicitly include that involuntary treatment can take place if:

There is a risk that the person may— (i) cause harm to himself or herself or someone else; or (ii) suffer serious mental or physical deterioration; (s.13(1)(d)).

Not only is risk central to the involuntary treatment criteria, but it is also the key factor in emergency examination orders that can be used by police and ambulance officers to confine people for emergency assessment. These emergency powers can only be utilised based on a judgement by a psychiatric professional that the risk of harm associated with not compulsory treating someone is sufficiently great that it overrides concerns about individual rights, or more specifically where:

(b) because of the person’s illness there is an imminent risk of significant physical harm being sustained by the person or someone else; and (c) proceeding under division 2 would cause dangerous delay and significantly increase the risk of harm to the person or someone else; (s.33(a)).

Although risk is crucial in the application of both involuntary treatment and the exercise of emergency powers, it is not in itself sufficient as a factor to justify confinement. Risk emerges as a necessary, but not sufficient, criterion for involuntary treatment. In addition to being a key criterion for justifying confinement, risk also becomes a key factor in deciding when to cease confinement.

11.2.2 Risk management as the goal of confinement

The concept of risk effectively comes to replace the notion of cure and treatment in decision making about when confinement should cease. This is a shift away from earlier models of care in which decisions about release from involuntary treatment were predicated on the notion of cure. As I showed in Chapter Ten protection and

220 safety have played a role in justifying confinement in Queensland. However this was a role that was always underpinned by the notion that confinement would result in treatment, and ideally cure. In the 1974 Act the assumption was that involuntary treatment would finish once a person was either cured, or their illness had become significantly less severe. In contrast in the 2000 Act the end of involuntary treatment is framed around assessing the risk associated with a person. Confinement thus ends not with the cure of the patient, but with the alleviation of ‘risk’, which may or may not include the cure of illness. What exactly this ‘risk’ is, which needs to be alleviated, is never entirely clear.

I argue that the shift away from cure reflects a changing understanding of mental illness, which highlights the socially constructed nature of mental illness. Over the period of my contemporary analysis, 1992-2007, binary notions of mental illness became less dominant. Under the 2000 Act, and associated policy, it is no longer assumed that treatment of mental illness will end with a cured patient. This shift reflects an increasing rejection, within health policy, of dichotomised notions of mental health implying a state of either mental illness or mental health. Instead, and driven strongly by the consumer movement, mental illness and mental health are increasingly seen as two ends of a continuum (Goodwin 1997b). This approach has been increasingly evident in Queensland policy, as in the Sharing Responsibility for Recovery: Creating and Sustaining Recovery Oriented Systems of Care for Mental Health document, which articulated this view of mental health as a continuum (Queensland Health 2005b).

The concept of a continuum of health places the idea of ‘cure’ in jeopardy. If it is no longer anticipated that people will permanently be located at one end of the mental health spectrum, but rather constantly traverse it, then this undermines the notion of cure as a rationale for confinement. As public discourse retreats from the idea of cure and towards ‘recovery’ the rationale of confinement for cure is no longer as convincing. This is where risk begins to play a significant role in justifying confinement. As concepts of mental health shift away from the traditional binary, the uncertainty associated with managing mental health becomes greater. The ability of expert systems to manage illness becomes less certain, an illustration of Giddens’ (1990) argument that doubt is an essential part of the modern world, that knowledge is no longer certain. Increasing doubt about the ability of the state to guarantee safety from, and of, people receiving community care has given particular resonance to the terminology of risk. Reddy (1996) suggests that risk has come to replace uncertainty

221 as it allows bureaucracies to avoid the appearance of uncertainty through the use of the probabilistic language of risk. Risk appears to be a way of overcoming the uncertainties associated with community care, through exerting more probabilistic and forms of care which resonate with the idea of mental health as a continuum.

In summary risk has become an integral element of mental health legislation in Queensland, particularly in relation to confinement. It forms the central legislative rationale through which decisions are made about confinement of people with mental illness, replacing the paternalistic rationales of the 1974 Act. The central role of risk in legislation is indicative of the wider use of risk in the policy decisions leading to legislative reform, and in policy following the 2000 Act. Although the language of risk has become increasingly important in how confinement is justified, exactly what is meant by ‘risk’ is unclear. The meaning of risk is the focus of the remainder of this chapter. In the following sections I examine how the language of risk is mobilised in the Queensland context, and ultimately how this relates to justifications for confinement.

11.3 How Risk is Utilised in Policy

My analysis of how risk is utilised in policy identified a wide range of meanings associated with the language of risk. In particular I have focused on who is at risk of what. Through focusing on these issues my research reveals the extent to which risk is something new to the contemporary era, and how much it is merely a change in terminology from previous trends. By analysing these continuities and discontinuities I address what the role of risk is in contemporary policies of confinement.

11.3.1 At risk

A central element in the use of risk, in managing the uncertainty associated with mental illness, is the identification of those ‘at risk’ of mental illness. This is at the heart of one of the key tensions in the relationship between risk and mental health in Queensland policy, namely that people with mental illness can simultaneously exist as both a group ‘at risk’ of harm and a group which poses ‘a risk’ of harm. These tensions are played out in the way that the subject positions of people with mental illness are constructed within policy.

222 The idea that people with mental illness are a group ‘at risk’ from harm has historically been an important part of how intervention in their liberty has been justified (as illustrated in the discussion about the 1974 Act in Chapter Ten). This is the case when confinement has been justified as being for people’s own good to prevent them from suffering harm. Although there has been a rejection of paternalism the idea of being ‘at risk’ has become relevant again in Queensland in the context of health promotion. The notion of public health relates to the use of the concept of ‘at risk’ in that the identification of those ‘at risk’ is a crucial aspect of the way public health operates in Queensland, as illustrated here:

At one level the population as a whole and especially, identified ‘at risk’ groups, are the focus of efforts to prevent mental ill health and promote and maintain optimal mental health in the community (Queensland Health 1993a: 7).

There is a tension inherent in this identification of being ‘at risk’. In some circumstances this relates to population groups, such as youth or Aboriginal and Torres Strait Islanders, but at the same time being ‘at risk’ can also be about identifying specific individuals as being ‘at risk’. One example of this refers to the individual embodiment of the potential for risk in relation to priorities for service development: ‘specialist intensive treatment and support for identified “at risk” individuals’ (Queensland Health 1996b: 16).

The individualistic notion of risk is particularly apparent in the way ‘at risk’ is used to identify people with mental illness in Queensland not just for prevention and treatment, but also for greater security and control, as in: ‘This can place them [people with mental illness] at risk of deterioration or even of causing harm to themselves or others’ (Queensland Health 2005a: 131). My study shows that the use of the concept of being ‘at risk’ reveals the extent to which individualised embodied notions of hazard remain at the core of concerns expressed through the language of risk, rather the identification of risk groups based on abstract factors. This complicates Castel’s (1991) notion that there has been a shift to management of risk through abstract notions. It also suggests that the notion of Foucauldian biopower and Deleuze’s (1992) associated notion of a shift towards ‘societies of control’ are trends which are not comprehensive. This complicated relationship between targeting the individual and/or groups is even more apparent in the influence of public health approaches to mental illness.

223 11.3.2 Public health

The public health approach is particularly prominent in Commonwealth health policy, which has increasingly shaped and influenced Queensland mental health policy. Historically health policy, including mental health policy, has been a state responsibility. The main Commonwealth role has been the provision of funding. However since the early 1990s the Commonwealth Government has increasingly turned its funding role into a more substantive policy role in a range of areas, including mental health (Duckett 1999).

The Commonwealth Government’s focus on public health was established with the National Mental Health Plan in 1992. The plan identified health promotion and illness prevention as crucial elements of mental health policy:

The development of effective mental health promotion, prevention and early intervention strategies and the enhancement of training and support for primary care service providers, is fundamental to the achievement of these objectives (Commonwealth Department of Health 1992: 2).

One of the aims of the promotion and prevention focus of Commonwealth policy has been to create individual responsibility for monitoring one’s own mental health. Individualised responsibility operates through being aware of the ‘risk factors’ (both internal and external to the person) that may harm one’s mental health. This individualised notion of responsibility for health has become stronger over time. The 1991 Commonwealth Mental Health: Statement of Rights and Responsibilities held that:

The individual has the right to protection from negative influences on mental health or factors which increase the risk of developing mental health problems or mental disorders including poverty, exploitation and other major adverse social influences (Commonwealth Department of Community Services and Health 1991: 2-3).

In this formulation the individual could expect the government to help protect them from risk factors. By 2003, with the third National Mental Health Plan 2003–2008, there is instead a focus on developing ‘mental health literacy’, where individuals are encouraged to develop mental health literacy namely:

Knowing how to seek mental health information; knowledge of risk factors for and causes of mental health problems and mental illness; knowledge of self- treatment and of professional help available (Australian Health Ministers 2003: 35).

224 Thus by the third plan there is a focus on individual responsibilities, which characterises Commonwealth health policy and is symptomatic of the individualised notion of risk in contemporary public health. The notion of an individualised responsibility for health is characteristic of what Rose (1999) refers to as government through freedom. Rose argues that risk has been used within neoliberal contexts (such as Australia (Henderson 2005)) to reinforce the notion of citizens as active subjects who are expected to govern themselves as normalised subjects.

The Commonwealth public health focus has influenced the way policy operates in Queensland, which has increasingly adopted an approach shaped by the public health perspective. There thus continues to be a focus on individualised notions of risk in Queensland, rather than a total shift to the management of mental illness through more abstract techniques of aggregation and probability.

The influence of a public health approach is apparent in Smart State: Health 2020 a Vision for the Future (Queensland Health 2002b). This strategy emphasises the promotion of health and the prevention of illness as the basic principles of health policy. The pubic health approach epitomised by this strategy is shaped through the dual notion of identifying those ‘at risk’ (as discussed above) and also through the identification of ‘risk factors’, which can then be targeted for action.

11.3.3 Risk factors

Risk factors are used both in an aggregative sense of identifying particular groups likely to suffer from mental illness, as well as a way of identifying individuals who are more likely to suffer from mental illness. The use of the notion of risk factors is the clearest use of an aggregative meaning of risk, where an individual’s belonging to a certain group or groups is identified as posing the potential for mental illness. Particular groups identified include Aboriginal and Torres Strait Islander populations and people from culturally and linguistically diverse backgrounds (Queensland Health 1994a: 68, 2003: 8, Queensland Government 2005: 36).

There is a tension here, in that belonging to a group is itself a risk factor, and simultaneously there is the identification of factors, which lead to greater risks for members of these groups. In most cases the primary focus is on identification of groups to which belonging is itself a risk factor. There are occasional exceptions in policy that focus on why belonging to these groups is a risk factor. The major

225 exception is for Aboriginal and Torres Strait Islanders, where a range of risk factors are explicitly identified as leading to more mental illness among this group. These factors include:

Cultural and separation issues, loss of parenting skills, the impact of substance abuse, physical and sexual abuse of children and domestic violence (Queensland Health 1996a: 12).

The failure, in most cases, to identify what makes certain ‘risk groups’ risky is symptomatic of the increasing expectation that people should become responsible for managing their own risk factors. The identification of ‘risk groups’ is primarily undertaken with the aim of encouraging members of these groups to maintain their individual mental health, as the following quote illustrates:

Awareness and understanding of mental health issues, including protective factors for wellbeing, risk factors for mental health problems and common treatment modalities, enables people to take responsibility for protecting their own mental health and respond quickly to developing mental health problems (Queensland Health 2003: 8).

As Petersen (1997) has argued, the concept of risk has increasingly been used as a mechanism for forcing the self management of risk. The case of Queensland illustrates that risk is sometimes used as a way of encouraging, or requiring, individuals to enter into the process of self-governance. This is a prime example of the Foucauldian governmentality notion of the ’conduct of conduct’ (Gordon 1991). Here people are encouraged and facilitated to govern their own behaviour. In some respects the use of the concept of risk factors allows the state to give responsibility for the regulation of health to the individual in the first instance. Thus the state only needs to play a role once self-management has failed. This gives the state a more compelling rationale for intervention, as they can then point to the failure of the individuals in question to manage their own health.

I argue that the simultaneous focus on both the individual and the group within the Queensland public health approach reveals a problem with the generalisation made by ‘new public health’ theorists. These theorists have drawn on the notion of biopower to suggest that with the influence of a public health approach the focus on individual health has increasingly been superseded by an aggregative approach to health (Petersen 1997). In the case of Queensland, however, the gaze on the individual has not been superseded by the gaze of surveillance on the population, but instead complemented by it. The focus on the individual ‘at risk’ has not disappeared with the introduction of a population approach. This is a contradiction that is crucial to

226 understanding the impact of the public health approach to mental health and its relationship with the use of risk. Public health has increasingly reflected an individualised notion of citizenship (Petersen and Lupton 1996). The increasingly individualised shift in public health reflects the encroachment of neoliberal political and policy principles in Queensland and more widely in Australia This means that although risk groups may be identified through abstract notions, the assumption is that the individual citizen has a responsibility to moderate their own behaviour and actions to minimise or eliminate the risk associated with them personally; otherwise the state will step in to control the risk associated with them.

11.3.4 ‘Risk of’

The question that arises from my analysis of the identification of ‘at risk’ groups is what exactly they are at risk of. In most cases what the imputed risk is of is entirely unspecified. My research identified three main meanings associated with ‘risk of’: risk of harm, risk of worsening illness, and risk of offending.

The first meaning of ‘risk’ was risk of harm, which included both risk of self harm and harm to others. This dual notion of harm is reflected in the way that the 2000 Act is written, which allows for involuntary treatment if:

because of the person’s illness there is an imminent risk of significant physical harm being sustained by the person or someone else; (s.33(b)).

The second meaning was the risk of continued or worsened mental illness. This intersects with the public health understanding of risk, where risk becomes a way of identifying population groups and individuals at risk of suffering from mental illness. In this way mental illness itself becomes a risk.

The third meaning concerned criminal offending, which was particularly apparent in forensic mental health policy. This had two components; there was the sense in which forensic mental health policy was justified by the increased risk of offending by (the group of) people with mental illness, as for example:

There are a small number of people with severe personality disorders, who because of their disorder, pose a high risk of offending (Queensland Health 2002a: 3).

There was also the sense in which the aim of forensic mental health policy was to decrease the risk of individual reoffending:

227 If effective and appropriate interventions are provided, not only will the mental health of these individuals improve but also the risk of repeat offence is reduced (Queensland Health 2002a: 7).

In this way forensic policy mirrors the dual approach discussed in the previous section with a focus on both the individual and simultaneously on identifying and managing population groups.

The breadth of the meanings associated with what risks to be controlled are of highlights how broadly risk thinking has been used in policy. In effect the language of risk has been used to justify confinement for all the rationales that have historically been used. As Chapter Ten showed confinement in Queensland has been historically justified on three main grounds. These were the prevention of criminal activity, ensuring that people got treatment, and stopping harm to the community. The way that the contemporary language of risk operates almost exactly mirrors these historical justifications for risk. This reveals the extent to which risk is merely a change in language used to justify the same historical grounds for control and confinement of deviance.

11.3.5 ‘Risk to’

Understanding the role of risk, in relation to confinement, requires knowing who is the subject of risk. My analysis found that in almost all cases the subject of risk is stated in generalised terms as being the patient and either ‘others’, or ‘the community’. Thus the risk is expressed as relating to both the person with mental illness and to the wider community. A typical example is the phrasing of the 2000 Act:

The administrator of an authorised mental health service … must be satisfied the person’s assessment at the health service does not present an unreasonable risk to the safety of the person or others (s.54(2)).

The dual construction of the subject of risk, and the fact that the subject of said risk is almost never solely ‘the other’, is closely related to the very rationale of mental health policy. One of the most important justifications for the abrogation of liberties associated with much of mental health policy has been the claim that such policy is protecting people with mental illness from harm. This is apparent in the way that policy and legislation is, and has been, framed in both Queensland and England and Wales. It is, however, rare for the subject of risk to be solely the person over whom control is to be exerted.

228 The construction of the subject of risk in mental health policy in Queensland remains the same within forensic policy. Even here risk to the patient (in addition to the community) remains a key feature, as in this example:

The test requires that the patient can only be released if the patient does not represent an unacceptable risk to his or her safety or the safety of others (Queensland Health 2006: 49).

The continuation of this dual construction, even within forensic policy, highlights the continued importance of justifying involuntary care in terms of the benefit to the patient. This further illustrates the continuation of the uncertain positioning of mental illness between illness and badness. Even in the contemporary era this positioning means that there remains a strong imperative to avoid the notion of confinement as purely a punishment, or existing entirely for the public good. The way that ‘risk to’ is framed keeps the options open for confinement to be justified on either the grounds of illness or badness, rather than foreclosing one of these options.

11.3.6 Actuarial notions of risk

Within the professionalised medical approach to mental health there is a strong actuarial and clinical focus on the way the notion of risk is understood (Greig 1997). In this mode of thinking risk is understood to provide an objective way of assessing the probability of future danger. However this clinical approach towards understanding and attempting to quantify risk does not flow directly into policy frameworks. As the sections on risk management and risk assessment (below) show there is an implicit acceptance of professionalised actuarial notions of risk. However within policy discourse there is little direct reference to, or implication of, actuarial notions of risk. My research shows that some aspects of an actuarial notion are apparent in relation to concepts of clinical risk and in use of levels of risk but even these are fairly limited.

Traditional actuarial notions of risk are associated with identifying probabilities of risk and making judgements about how acceptable certain probabilities of risk are (Bernstein 1996). In the case of Queensland policy there is no quantification of concepts of risk or explanation of what might be considered as unacceptable levels of risk. The main way any actuarial or probabilistic notion of risk is used is through the mechanism of dividing risk into broad categories, or levels, of risk. There is a pattern in that those documents that did adopt the language of levels of risk are those

229 relating to the reform of legislation, and the 2000 Act itself. The main quantification of risk is into two levels of high or serious and medium or less serious.

The 1994 document Review of the Mental Health Act 1974 adopted a language that emphasised a focus on ‘significant’ or ‘serious’ risk. In this review the level of risk is explicitly identified as the key criterion for the application of compulsory treatment: ‘The level of risk should act as the trigger for action to be taken without the consent of the person’ (Queensland Health 1994b: 39), and ‘The person’s right to choose cannot be breached unless a certain level of risk to self or others exists’ (Queensland Health 1994b: 39). Some elements of this language did eventuate in the 2000 Act, where there are several references to the notion of ‘unacceptable risk’, such as:

The Mental Health Court must not approve limited community treatment unless it is satisfied the patient does not represent an unacceptable risk to the safety of the patient or others (s.275(2)).

In these cases it is a negative construction of unacceptable risk, in that it must be shown that the person in question does not pose an unacceptable risk, rather than it being proven that they do. Furthermore what constitutes ‘unacceptable’ in relation to risk is left undefined and to the judgement of service providers or the courts. The undefined nature of this terminology illustrates that this cannot be considered an actuarial or probabilistic understanding of risk.

Even within forensic policy there has been relatively little explicit recognition of various levels of risk, although assessing risk has been a key part of how forensic policy has been framed. What limited reference there is draws on a differentiation between high and medium levels of risk (Queensland Health 2005a: 125). This division of risk into these two categories is an extension of the bifurcation that began to occur in the 1960s (as discussed in Chapter Ten). That bifurcation divided the dangerous patients from the non-dangerous and was initiated in the Mental Health Act 1962. The 2000 Act divides the dangerous into further categories and in doing so breaks down that previous bifurcation by acknowledging that there are differing levels of dangerousness. However, like the England and Wales example (section 8.3.3), the concept of levels of risk is still a static and categorical way of thinking about hazard, more akin to traditional ideas of danger than to the conceptual continuum and operational flexibility associated with risk (Reddy 1996).

230 The undeveloped and vague nature of the notion of unacceptable risk, as used in forensic policy, led to a major review of the forensic mental health system Promoting Balance in the Forensic Mental Health System (Promoting Balance). This review criticised the focus on ‘unacceptable risk’ as undermining public confidence in the forensic system, through creating too limited and uncertain a test of risk (Queensland Health 2006: 109-110). The basis of this criticism was that the division of risk into categories of acceptable and unacceptable created too high a burden of proof to exert effective control over those who needed it. The review recognised that the division of risk into a few specific categories undermined the probabilistic advantage of risk thinking. Their argument suggested that adopting a continuum of risk is a more effective means of exerting control as it allows for greater flexibility in decision- making.

Despite rare references to clinical meanings of risk there is little to suggest any actuarial notions of risk in the broader policy framework. The lack of specifically actuarial notions of risk reflects both the broadness of the use of notions of risk in mental health policy and the extent to which risk is used in a way that is reflective of earlier meanings of danger and safety. This is similar to the way that O’Malley (2004) suggests the language of risk has been used in the criminal justice system. Early theories of risk and its relation to the criminal justice system, such as by Reichman (1986) and Simon (1987), held that aggregative and actuarial meanings of risk were influencing the way the criminal justice system operated. O’Malley’s (2004) later evaluation is that actuarial or risk based crime control has not come to dominate the justice system as some theorists thought it would. He does, however, acknowledge that these understandings of risk have had some impact on the operation of criminal justice policy, particularly in countries strongly influenced by neoliberalism, such as the United Kingdom and the United States. Similarly, as the Queensland case study reveals, ideas of risk as used in mental health policy do not typically involve actuarial meanings.

11.3.7 Risk management

Risk management has become a central element in how the mental health system operates. The centrality of the idea of risk management is illustrated by the development of a position of ‘risk management coordinator’ for the Queensland mental health system in 2002. This position was established to review processes and policies of risk management across Queensland, particularly around the

231 management of involuntary and other ‘high-risk’ patients. The job involved establishing a ‘risk-register’ and ‘statewide clinical risk assessment and management training project’ (Queensland Government 2005: 27).

Risk management has become a particularly vital and contentious component of forensic policy, such that a recent review recommended that ‘all mental health services introduce mandatory training in risk management for mental health clinicians’ (Queensland Health 2005a: 22). This emphasis on forensic risk management has been driven by two reviews (the Review of Queensland Forensic Mental Health Services (the Mullen Chettleburgh Report) and the Achieving Balance: Report of the Queensland Review of Fatal Mental Health Sentinel Events (Achieving Balance)) that concluded that the existing risk management systems for forensic patients in Queensland were inadequate.

These reviews culminated in a recent recommendation that risk assessment should be compulsory in decisions on treatment options and plans (Queensland Health 2006: 19). The reviews also focused on risk management, including the need for a statewide policy for reducing or eliminating risk factors (Queensland Health 2006: 25).

These reviews and the Government response to them highlights two modes through which I argue risk management is conceptualised and utilised in the Queensland context. The first mode is risk management as surveillance in which knowledge of past behaviour of specific individuals is an important emphasis:

Services should always provide vital information about risk and significant past history of self harm or forensic background even if the client is no longer under involuntary provisions of the Mental Health Act 2000 (Queensland Health 2005a: 139).

Risk management as surveillance accords with the way that Clear and Cadora (2001) conceptualise risk management, as about identifying risks so that they can be both anticipated and reduced. This approach assumes that risk can never be completely eliminated and can only ever be alleviated.

The second mode in which ideas of risk management are used in Queensland policy is much more like Clear and Cadora’s concept of risk control. This is an attempt to take power over risk and to exert control in such a way as to completely remove risk from society through material control, such as confinement. In the Queensland case

232 this involves the justification of the physical management of risk (Queensland Health 2002a: 7). It emphasises that surveillance is an important precondition for risk management, but that management also involves the ability to physically intervene to manage risk by confinement. This second meaning includes an individualised notion of management, where management is physically exerted over particular individuals through confinement (Queensland Health 2006: 35).

To summarise in Queensland risk management is used in a dual sense that effectively encompasses notions of both management and control. Unlike Clear and Cadora’s argument about the criminal justice system, there is no clear sense that ‘risk control’ is replacing ‘risk management’. Rather both senses are operating simultaneously in Queensland policy.

11.3.8 Risk assessment

A prerequisite for the management of risk is assessing what is a risk. How a risk is identified and assessed goes to the heart of the question of how the concept of risk is used in relation to policies of confinement. Looking at the role of risk assessment helps to clarify what is considered a risk and whether risk is assessed mainly at an individual or an aggregative level. Risk assessment has been emphasised as an important component of recent policy developments, particularly around forensic policy (Queensland Health 2002a, 2006). Unlike other aspects of the usage of risk, the difficulties with the idea of risk assessment have been identified and critiqued within health policy.

The emphasis that is placed on assessing risk alludes to the recognition that uncertainty is a key component of risk and that any decision taken about risk requires making judgements about uncertainty and individual rights. The actuarial concept of risk is about weighing up, or assessing, uncertainties, yet the very notion of uncertainty is largely absent in the Queensland policy framework. This points to a shift that Reddy (1996) argues has occurred such that risk has colonised and replaced uncertainty, particularly in relation to bureaucracy. The notion of probabilistic, or actuarial, thinking associated with the concept of risk has allowed bureaucracies to avoid the appearance of the problems of uncertainty. Resorting to risk appears to make the unforeseeable foreseeable and thus gives the state a justifiable rationale for making decisions restricting individual rights, that would seem unjustified in the terminology of uncertainty.

233

Many of the main references to risk assessment highlight the difficulties that mental health professionals have in assessing risks, with a recognition of the ‘inherent difficulty of risk assessment… even when conducted by experienced and committed professionals’ (Queensland Health 2005a: 11). The problems of assessment were highlighted to emphasise the difficulties of mental health care and the impossibility of always being right about the likelihood of hazards occurring, ‘The community is not necessarily aware of the inherent difficulty of risk assessment’ (Queensland Health 2005a: 36). As the Queensland example has demonstrated the notion of risk can be an ambivalent power for bureaucracies as it creates an expectation of effective objective identification of all hazards and control over uncertainty.

Public policy has continued to emphasise the importance of risk assessment despite recognising the many problems associated with it:

in view of this high level of risk, the Committee supports an approach that includes greater emphasis on formal risk assessment (Queensland Health 2005a: 15).

Risk assessment is repeatedly identified as a crucial element of the operation of mental health services and as essential to the very idea of providing such services (Queensland Health 2005a: 22). This has resulted in a concerted effort to develop some standard forms of risk assessment, as noted in one of the recommendations of Achieving Balance. This emphasis on risk management and assessment also formed a key part of the Promoting Balance review of the forensic aspects of mental health services in Queensland. An entire chapter of the report is dedicated to risk management practices, including a range of sweeping recommendations which aim, ‘to improve measures for risk assessment and management’ (Queensland Health 2006: 2). This illustrates the increasingly central role of risk management in Queensland policy and the importance of assessing risk for this purpose

There is little detail provided at the policy level about the procedures of risk assessment. The implication is primarily that risk will be assessed at the level of individual hazard, for instance with the discussion of clinical risk screening tools that operate at the individual level. Thus, as in the case of England and Wales, risk assessment mainly operates as a way of identifying individual risks. It is about making a judgement about the hazard posed by an individual in their particular

234 circumstances. In this use risk is more akin to traditional ideas of danger than any actuarial or aggregative meaning.

11.4 Risk and Confinement

In the following sections I concentrate on the relationship between the use of risk and the rationale for confinement in contemporary Queensland mental health policy. I draw on Bauman (1996, 2001) and Beck’s (1995, 1996) notion that when uncertainty becomes more significant the desire to overcome that uncertainty becomes an increasingly central aspect of society. As uncertainty has grown about the effectiveness of the forms of control associated with community care so has the explicit policy emphasis on ensuring public safety and on risk avoidance. As Beck (1995:10) suggests ‘the less we can rely on traditional certainties, the more risks we have to negotiate’. Ensuring public safety through risk assessment and management is presently a key concern in policy. The centrality of safety is illustrated in a recent report lauding the focus on safety (through treatment) as one of the key strengths of the Queensland mental health system:

The virtue of the Queensland system is that it promotes public safety by ensuring as far as humanly possible that people with mental illness receive treatment and thereby lessen the risk to themselves and the community from that illness (Mental Health Review Tribunal 2005: 4).

Safety is constantly associated with ideas of risk, albeit in a variety of forms. The main form of this association is the need to protect the safety of the community against risks posed by people with mental illness. This was apparent in the 1993 review of the Mental Health Act (which included Review of the Mental Health Act: Background to the Review, Review of the Mental Health Act: Treatment of People with Mental Illness and Review of the Mental Health Act: The Forensic Provisions), which was framed as an attempt to balance rights against safety:

The rights of the individual to freedom must be balanced with the rights of the community to protection. Although involuntary treatment may be seen as significantly restricting the liberty of the individual, the risk to the health and safety of others must be considered (Queensland Health 1993b: 5).

The message of this series of reports was that the individual rights of people with mental illness remained important, but that they could be limited where there was a perceived threat to safety, which was framed in terms of risk:

235 The conditions under which intervention is justified should be as clear as possible. Intervention should only occur when a person’s mental illness results in the person posing an unacceptable risk to his or her health or safety or to others, and where the person refuses or is unable to seek treatment (Queensland Health 1994b: 4).

Review of the Mental Health Act: Treatment of People with Mental Illness even argued that some of the restrictions existing in the 1974 Act should be extended in recognition of alleged of fear about community safety:

It is proposed that provision be maintained for conditions to be set on leave, but these should be limited to those which are required for clinical management or to protect the mental state or safety of the person or the safety of others against imminent risk (Queensland Health 1994b: 66).

The impact of these reviews is apparent in the central place which public safety plays in the 2000 Act. Public safety becomes a crucial feature of the justification of compulsion. Under section 9, safety and protection are the criteria that must be met to restrict people’s rights. The central role of safety in the 2000 Act demonstrates, as in the England and Wales case, that safety has become much more explicitly the concern of mental health policy than has historically been the case. Further the principal way that the idea of safety is constructed is through the concept of protection against risks. The emphasis on safety through the prevention of risk is particularly apparent in forensic services.

11.4.1 Safety and forensic services

The delineation that the Queensland system makes between the forensic and general mental health system means that particular emphasis has been placed on public safety from risks caused by people in the forensic mental health system. Legislation and policy relating to the forensic mental health system emphasises the need to manage risks to provide safety for the community. This focus on safety has strengthened since the early 1990s.

Queensland’s initial 1992 forensic psychiatry policy, The Forensic Mental Health Service Policy, discussed the need to manage risk relating to forensic patients. But the policy also focused on the rights of forensic patients to the best treatment: ‘the primary focus of forensic mental health services is to provide high quality specialised services to forensic patients’ (Queensland Health: Mental Health Branch 1992:1). There was an acknowledgement that people in the forensic system were not the same as other people convicted of crimes, but instead they were people whose

236 disadvantages made them vulnerable (Queensland Health: Mental Health Branch 1992: 1). For this reason the primary focus of forensic mental health policy was on appropriate treatment, rather than confinement as a form of punishment:

it is now recognised that forensic mental health facilities are not simply places of containment and are not extensions of the prison system nor places of punishment (Queensland Health: Mental Health Branch 1992: 1).

The 1992 policy served as the framework for forensic mental health until the 2000 Act was passed. The passage of the 2000 Act was characterised by an emphasis on the better treatment it would ensure for people with mental illness. The one exception to this was the forensic provisions of the Act; where the Government stressed the greater emphasis on community safety. The importance of safety was repeatedly stressed in parliamentary debates:

The new Act takes very strongly into consideration the issue of community safety. The previous Act did not, but the new Act does (Parliamentary Debates 06 May 2002: 347). (Also see Parliamentary Debates 11 Sep 2001, Parliamentary Debates 19 Feb 2002).

The subtext to recent developments in forensic mental health policy is outlined by Promoting Balance. This review made a number of recommendations for strengthening the safety components of legislation and regulation based on the position that:

For there to be trust in the system the public need to be assured that their safety is given appropriate priority (Queensland Health 2006: 31).

This quote demonstrates a shift to the position that was taken so strongly in the England and Wales case study, namely that policy should be shaped around the notion of public safety in order to engender wider public support for government policy. The recommendations made in Promoting Balance are driven by the view that:

Members of the public are entitled to expect that where mentally ill persons have committed criminal offences, particularly serious violent offences, the system will take the necessary steps to ensure treatment of the person has full regard to the need for public safety in managing the risk of re-offending (Queensland Health 2006: 5).

This review highlights the increased importance placed on safety in framing forensic policy. However the review does not make explicit what safety means. As I have already shown safety can be approached through the notion of treatment or it can be approached through confinement and control. The first meaning of safety is that

237 safety is provided through the provision of treatment for risk bearers. The second is that providing a spatial separation of risk bearers from the general population provides safety. Both framings of safety appear in Queensland policy, although forensic policy tends towards the later framing. As the quotes above illustrate this emphasis on material control through spatial separation is further evidence for Bauman’s (1996, 2001) and Beck’s (1995, 1996) arguments that as uncertainty increases so does the desire to exert explicit control over that uncertainty.

11.4.2 Community care

As in the case of England and Wales I conclude that the emphasis on the prevention of risk became more pronounced as community care became a more entrenched and dominant aspect of mental health policy in Queensland. The way that community care is discussed within policy lends weight to this argument. One of the ways that the Queensland Government has attempted to encourage public support for community care has been to promote the fact that there are alternative forms of care, which exist for people with mental illness and thus ensuring that only the safe receive community care.

The desire to alleviate public concern about community care means that it is presented as something that is only available to those who do not pose any potential threat to public safety. In these policy formulations community care is only supposed to be accessible to the less risky patients:

The decision to undertake involuntary assessment and treatment in the community rather than in a hospital setting would be based upon the needs and preferences of the person being assessed, the assessment of risk, the availability of resources to provide the services (Queensland Health 1994b: 60).

The corollary of this is that those who are not in community care are inevitably cast as a source of risk.

Even the terminology around ‘community care’ is significant, as the term ‘community treatment’ is the preferred term in Queensland policy. This indicates that recent Queensland governments have not embraced the concept of community care, preferring to say that they provide treatment in community settings (Department of Health and Ageing 2005b: 44). The emphasis on treatment in this framing is a deliberate attempt to indicate that people are not being abandoned and left untreated. It also implies that potentially dangerous people are still being actively

238 treated. This is further emphasised by the creation of a special ‘limited community treatment’ category for forensic patients. The addition of the term ‘limited’ emphasises the notion that people are not completely unrestricted in the community:

Due to their mental illness, some patients’ access to the community remains very limited. These decisions are based on a range of factors related to the risk that the patient represents to himself or herself and the wider community (Queensland Health 2006: 109).

Risk begins to become prominent in policy related to community care with the development of limited community treatment plans. The policy of limited community treatment was formulated with the specific aim of having a greater focus on risk management and assessment within the community care paradigm:

It is expected that the project will develop best practice guidelines in relation to limited community treatment plans encompassing risk assessment and compliance monitoring into any plan development. (Queensland Government 2005: 27).

Risk has increasingly been enrolled as a way of reassuring the community about concerns of safety related to community treatment, particularly for forensic patients. The focus on risk aims to reassure the public that the government is attempting to ensure safety. These trends are increasingly similar to the way in which mental health policy was framed in England and Wales during the 1990s. In both cases there has been an increasingly overt focus on public safety to reassure the public that mental health policy is working well. However, as was the case in England and Wales this seem to be further evidence for Lupton’s (1999a: 13) argument that risk strategies attempt to tame uncertainty, but ultimately increase anxiety through the intensity of the focus on risks.

11.4.3 Danger

I argue that the way that danger has been used in Queensland policy reveals the extent to which the language of risk has come to replace the role the language of danger once played. Danger has virtually disappeared from the lexicon of policy, replaced by the language of risk. The use of the concept of danger is more closely associated with earlier policy documents. An example of this transition is the 1993 Review of the Mental Health Act: Treatment of People with Mental Illness which uses language like:

No person who is capable of rationally evaluating his or her illness, need for treatment and the relative benefits of treatment options should have his or her

239 right to consent overridden, except where they are a danger to their own health or welfare or to others, and refuse, or are unable to consent to treatment (Queensland Health 1993b: 2).

Here, as in other examples, danger was used in a sense that is almost entirely interchangeable with risk, with few distinctions apparent between the meaning of risk and danger. Gradually the language of risk has replaced these references to danger.

Some distinction between risk and danger appears in 2000 Act, which makes use of the concept of danger in the sense of imminent risk. In this way danger implies a hazard that exists right now, compared to the use of risk that implies a hazard that may exist in the future. This suggests that there is sometimes a differentiation between risk and danger. However in most instances they are used in the same way, giving credence to Douglas’ (1992: 40) argument that although the term 'risk' is inherently probabilistic, the public often transcribe it to mean 'unacceptable danger'.

The uses of the terms danger, safety and risk exhibit a chronological trend. There are two parts to this trend. First, as was apparent in my historical analysis, ideas of danger, safety, and ultimately risk have become more prominent over time as explicit rationales for the involuntary treatment and confinement of people with mental illness. Second risk has come to replace the use of language of danger, but not in a consistent way. On some occasions risk is used as if it is totally synonymous with danger. On other rare occasions risk is used in an actuarial sense, which implies something entirely different from danger. Ultimately, as I have argued in the last two chapters, the language of risk has come to replace that of danger as risk implies a greater ability to exert control over uncertainty.

11.5 Risk as a Policy Object

My analysis of the use and meanings of risk and its relationship with policies of confinement in Queensland reveals a number of similarities and differences with the case of England and Wales. In both cases risk has become a far more prominent aspect of how mental health policy, and confinement in particular, has been framed. However this is less significant in the Queensland case, and the way in which the concept of risk has been used in Queensland is more varied.

240 11.5.1 The extent to which risk is used in policies of confinement

Risk has come to be extensively used in the justification of confinement in contemporary policies in Queensland. Indeed risk has become the main way through which confinement is both operationalised and rationalised. The operationalisation of confinement has become strongly framed by the concept of risk management. The legislative and policy frameworks that support the process of compulsory treatment and confinement are based on making decisions about risks posed. Similarly decisions about when to cease involuntary treatment are also framed around the elimination of risk. In this way risk has displaced earlier notions of best treatment and the provision of care as the way that spatial control is rationalised. The way in which risk management has become a key framing of policy gives further support to the basic accuracy of Beck’s notion of risk society (1992). This is that risk emerges as society struggles with how to exert control over a world that appears ever more uncertain and changeable.

This emphasis on the management of risk is an attempt to put safety at the core of mental health policy. As was the case in England and Wales the rationale of safety has become much more important in the framing of confinement as community care has become more ubiquitous. Beck (1992, 1995) argues that practices of risk management and risk assessment have been used to normalise and control the world of uncertainties. In the case of Queensland there are, I argue, two key uncertainties which lie at the heart of contemporary mental health policy. The first is the uncertainty over the effectiveness of control exerted over people with mental illness through the mechanisms of community care. As I discussed in the case of England and Wales, as there has been a decrease in trust of both bureaucracy and of psychiatry there has been a shift to more direct and punitive forms of control. This is much less evident in the way policy has been framed in Queensland than it was in England and Wales. But as I have shown, it is becoming more evident in Queensland, particularly in forensic policy.

The second, and more fundamental, uncertainty is the very notion of cure for mental illness. As I illustrated in Chapter Ten cure has been at the core of rationales for confinement over most of the last 150 years. This notion of confinement for the purpose of cure has been undermined as Queensland policy has increasingly been shaped around the notion of mental illness as a continuum. This idea rejects binary notions of illness and health and instead holds that mental wellbeing always occurs

241 along a continuum. One result of this perspective is that the idea of cure, which has previously been central to the purpose of mental health policy becomes clouded and elusive (Rosenman 1994, Arrigo 1996). If health is a continuum then the focus turns to ‘recovery’ rather than cure. Cure can no longer be the expected outcome of the provision of mental health services. This change in focus means that people’s mental state is fundamentally and inevitably uncertain.

These twin uncertainties have resulted in a greater concern with safety. As illustrated in Chapter Three, the increasing uncertainties of the modern era have resulted in a focus on safety as the normative project of society (Beck 2000a). This is reflected in Queensland where the government has emphasised a focus on safety as a way of trying to consolidate support for community care. The emphasis on safety has increasingly been expressed through the mechanisms of risk management and risk assessment. As Beck (1995) has argued risk becomes central as traditional certainties crumble under the pressure of reflexive modernity, and safety and security emerge as ways to regain control over these new uncertainties.

11.5.2 How risk has been used in policies of confinement

The attempt to exert control over uncertainty is at the heart of the question of how risk has been used in policies of confinement. It is also at the heart of a central tension in the way risk has been used in Queensland policy. This is the tension between risk as a way of identifying and controlling individual embodied hazard and risk as exerting control in an actuarial sense over aggregative groups. This is an example of the tension identified in Chapter Four (section 4.2.2) between macro-level deregulation and the need for a micro-politics of surveillance. In the case of Queensland the macro-level deregulation has occurred through deinstitutionalisation, yet there has been a continued demand for fine scale control over some people with mental illness.

The emphasis on public health in Queensland has meant that the use and meaning of risk and how it relates to confinement and control is more complicated and contradictory than in the England and Wales case study. Risk is used in Queensland in both the aggregative sense, identified by public health theorists (see for instance Petersen and Lupton 1996, Petersen 1997), as well as in the sense of embodied danger. The public health meaning focuses on identifying ‘risk factors’ across the population. This accords with Castel’s (1991) argument that the subject has

242 increasingly disappeared and been replaced with factors of risk. Yet the subject has not disappeared from mental health policy. The subject of the ‘dangerously mentally ill person’ still forms a central rationale in mental health policy. Risk is also applied to the control of this individual subject.

As I have shown in some formations and uses risk operates to identify individualised embodied hazard for the purpose of exerting physical control over that hazard. The individualised use of risk is symptomatic of the continuation of ideas of danger. The way the language of risk is used is often exactly synonymous with how danger has been used in earlier policy discourse. The focus is on the identification of particular individuals in order to exert spatial control through confinement. This creates the physical separation of hazard from the body of society, which is part of the continuation of a disciplinary style micro-politics of control. Risk is used to reinforce the embodiment of danger, where risk has increasingly moved away from something that is exerted on people towards something that is embodied in particular people. This is symptomatic of the increased individualism of our time, which demands individual causes to which individuals can attribute their common fears (Bauman 2000).

In other formations and uses risk operates to identify hazard at a population level, for the purpose of exerting control at a larger decentred scale. The aggregative use involves the identification of particular groups, such as ethnic groups, for the prevention of hazard at the aggregate levels. In these framings the focus is on identification of groups, and/or factors which have been identified as posing hazards and their management through prevention and surveillance. The use of aggregation is about the prediction of danger and it’s management, and is an example of Deleuzian ‘societies of control’.

The tension between individual and aggregative meanings of risk is apparent in much of Queensland mental health policy where particular discourses of risk are used with different meaning at different times. The dual utilisation of risk is particularly clear in the role of risk in public health approaches to mental illness. At the Commonwealth level risk is used almost entirely in a public health sense. The continued role of the individual in relation to risk in the public health use is symptomatic of the tensions in the way risk is utilised as a policy object. Although there has been a broadening of the focus of control over mental health to include the aggregate this has not meant that the focus on individual control has been superseded.

243

11.6 Conclusion

In this chapter I applied my third research question to a case study of Queensland mental health policy. In doing so I looked at the extent to which, and how, ideas of risk are used in contemporary policies of confinement of people with mental illness. I argue that the language of risk has become the primary way through which confinement has been justified. But this use of risk is not consistent; rather it operates in two different and contradictory ways to identify both individual and aggregative hazards. I contend that the tension inherent in these uses points to the reason for the utilisation of the language of risk within policy, namely that it provides the flexibility to justify both spatially decentred forms of management and spatially controlling forms of control.

The Queensland example shows that risk is not fulfilling a simple role of providing a new technology of control to cope with the spatial dispersion of care. It does not, however, act simply as a replacement for prior ideas of danger in offering a rationale for confinement. The explication of this complicated relationship is the subject of the following, and final, chapter.

244 Chapter 12. Conclusion: Risk and the Spatiality of Control of Mental Illness

12.1 Introduction

In this final chapter of the thesis I bring together my research and analysis from the two case studies to answer each of the three research questions. I address each of my research questions in turn before reflecting on how the answers to my research questions address the overall research aim. In particular I evaluate the models of both Clear and Cadora (2001) and of Rose (2000b) and O’Malley (2004) according to how these models can explain the complicated relationship between risk and spatial control. I conclude that ultimately risk has been utilised primarily to support the continuation of spatially fixed forms of control, rather than to facilitate decentred forms of control over people with mental illness. I then discuss some of the future research avenues that my thesis has identified. Finally I summarise the key contributions of my thesis.

The primary focus of my thesis has been on understanding the role of risk in framing confinement and spatial control in mental health policy. I began my thesis by discussing how strongly the care and treatment of people with mental illness has been characterised, in the Western World at least, by a dimension of social and spatial control since at least the mid 19th century. I argued that the marking out of people with mental illness as abnormal has served as a form of boundary maintenance, which helps to reinforce what is normal behaviour within a particular society. The strong correlation between spatial and social control of people with mental illness has been challenged by policies of deinstitutionalisation and community care during the later part of the 20th century. These changes resulted in new spatially decentred forms of care and treatment of people with mental illness.

With the predominance of a policy of ‘least restrictive treatment’ the basis of the care and treatment of people with mental illness began to change. This change posed a number of questions about the way social control operates in these ‘post-asylum’ landscapes of care. The most influential argument to explain these changes was made by Castel (1991) who, drawing on governmentality theory, explored how and why the administration of mental illness had changed towards deinstitutionalisation in the contemporary era (Turner 1997, Moon 2000). Castel claimed that the shift from

245 spatially centred forms of control of people with mental illness towards spatially decentred forms of control was accompanied by a shift in governance from dangerousness to risk. He concluded that a focus on risk allowed control to be exerted more abstractly rather than through physical controls. This is an argument that resonates with Deleuze’s (1992) claim that new societies of control have emerged where centralised forms of control have increasingly been replaced by dispersed networks of control operating across society, so called ‘societies of control’.

I argued that these claims by Castel and Deleuze need to be examined in more depth, particularly from a geographic perspective. There is, as Hannah notes (2007), a strong spatiality to these theories, yet they have been subject to little research by geographers. Indeed there has been very little focus by geographers, with the exception of Moon, Kearns and Joseph (2005, 2006) (also see Moon 2000), on the continued role of confinement within the mental health system. One of the key ambitions of this thesis has been to challenge this lack of both empirical and theoretical geographic attention to the continued role of confinement within the mental health system.

The key departure point for this thesis was my suggestion that the arguments of Castel and Deleuze failed to account for the continued influence and role of confinement in Western mental health systems. As I have shown, there is evidence for a strong, and in some places increasing, role for confinement in mental health systems. This raises the question of why spatial confinement remains an important part of these systems and to what extent Castel and Deleuze are correct in their arguments about the diffusion of social control through technologies associated with risk. These issues formed the heart of the thesis, and were examined through the three research questions that have guided the thesis, namely: 1. How significant is the role of confinement within contemporary mental health systems? 2. How have ideas of risk been utilised in past mental health policies? 3. To what extent, and how, are ideas of risk used in contemporary policies of confinement of people with mental illness? In the remainder of this chapter I answer these three questions, and my research aim, in light of the information that my review of the literature and two case studies has provided.

246 12.2 Research Question One

My first research question was: How significant is the role of confinement within contemporary mental health systems?

The key aim of this question was to challenge the geographical literature which, as Moon (2000) has put it, has characterised the asylum and confinement as an old and outmoded form of care and community care as the almost inevitable future of mental health services. In Chapter One I briefly highlighted research which suggested that there has been a renewed focus on psychiatric institutionalisation in a number of Western European jurisdictions. This data particularly showed the substantial growth in confinement in forensic mental health services.

The broad evidence of Chapter One was confirmed by both of my case studies, which demonstrated the continuing importance of confinement in mental health systems in both England and Wales and Queensland. The case of England and Wales was particularly striking with a large increase in compulsory admissions in the 1990s and a rapid growth in forensic admissions in the last decade. The example of Queensland was much less clear. However Queensland differs from England and Wales in that it did not undergo nearly as dramatic a process of deinstitutionalisation. Deinstitutionalisation in Queensland was a much more gradual affair than the rapid and large-scale deinstitutionalisation which occurred in England and Wales. Queensland is more aptly characterised as having a strongly continuing role for confinement, whereas England and Wales had both much stronger deinstitutionalisation and a much stronger swing back towards an emphasis on confinement. In the case of England and Wales the turn towards a renewed emphasis on confinement was a much more explicit policy decision of government, which has adopted a stance of concern about the impact of community care on community and patient safety.

Together these case studies demonstrate the strong and continuing role for confinement within both mental health systems. As I discussed in Chapter Two there has been a strong relationship between confinement and social control over people with mental illness. This relationship, as I demonstrated in that chapter, is an historical one. Spatial control is not, as Philo (1997: 79) rightly argued, an inevitable response to mental illness. This means that the resurgence of confinement as a way of managing mental illness needs to be understood in relation to its social role, not as

247 the reassertion of an inevitable relationship. I argue that the social role of confinement has increasingly been to exert control over uncertainty.

The attempt to exert control over uncertainty is particularly clear in the increasing bifurcation of people with mental illness within institutional thought and practice. I argue that this bifurcation illustrates an emerging split in the way people with mental illness are conceived in policy, as either definite bearers of risk, or as relatively safe. This bifurcation is most apparent in the growth of the importance placed on the forensic mental health system. In both case studies there has been a renewed emphasis on the forensic mental health system, with an increase in both beds and patient numbers. Accompanying this increase has been a process of much more specific policy attention to the forensic mental health system. The emphasis on services that provide an additional level of security above that of normal compulsory care facilities is illustrative of a much stronger drive towards policies focused on safety.

The growing bifurcation is not primarily reflecting traditional diagnostic splits between ‘serious mental illness’ and other forms of mental illness, but the division of people with mental illness into those who are seen to embody risks and those that do not. As I argue contemporary mental health policy is effectively the legalisation of risk status rather than about illness. This shift reflects a historical trend away from confinement being justified through the need for cure towards confinement being justified primarily in terms of control.

The bifurcation of people with mental illness, particularly in the growth of forensic services, is a way of addressing the positioning of mental illness between badness and illness. As I showed in Chapter Two the exertion of social control over people with mental illness has been complicated by the position of mental illness as neither entirely badness, which can be controlled through punishment, nor entirely illness, which can be controlled through cure (Dallaire et al. 2001). Forensic policy has acted as a way of trying to bypass this uneasy positioning. It is a way of separating out those whose deviance is closer to ‘badness’. Thus the growth of forensic care has been a way of justifying both confinement and community care by clearly separating out those who required strict spatial segregation.

In summary the two case studies shows that confinement remains a key, and increasing, part of the structure of the mental health systems in both England and

248 Wales and Queensland. I argue that the renewed focus on confinement has been driven by a desire to exert greater control over risk and uncertainty. This arguably is a rejection of the efficacy of decentred forms of control of the sort implied by deinstitutionalisation and community care. However this is not a wholesale rejection of community care, indeed community care continues to play an important, but not totally dominant, role in both the England and Wales and Queensland mental health systems. The role of confinement, as I have suggested above, demonstrates an increasing split in the way people with mental illness are conceived within policy, between those who embody risk, and those who do not.

12.3 Research Question Two

My second research question was: How have ideas of risk been utilised in past mental health policies and how has this related to the use of confinement?

This second question is focused on the historical relations of risk. The aim of this question was to provide the basis to explain whether there is something new about the way that the notion of risk is utilised in contemporary policy. The etymological origins of the language of risk stretch back to the 17th century, as I showed in Chapter Three. As I also showed in Chapter Three the question of whether the notion of risk in the contemporary period signifies something new has been contentious. One of the main critiques of Beck is that he overemphasises the novelty of risk (Rigakos and Hadden 2001). This critique points to what I argued, in Chapter Three, was one of the major problems of explorations of risk society, namely that they have been largely atemporal and aspatial. By this I mean that much of the research that has explored the role of risk in the contemporary world has not been explicitly located in sufficient historical or spatial context. I framed my research to remedy that problem by locating it in specific historical and spatial contexts.

Through my historical analysis of public policy and legislation in the case studies I was able to see whether the apparent emphasis on risk in the contemporary period is new either in intensity or in how the concept has been utilised. In addition through my historical research I was able to show how spatial confinement of people with mental illness has been justified historically. As Rothman (1985) has argued understanding the past is essential to understand contemporary social control, as modes of social

249 control exerted in the past become part of the moral and definitional context of the present.

In both case studies explicit references to risk were rare until the 1990s. There was little that could be seen to even imply risk in its contemporary actuarial or probabilistic sense until the middle on the 20th century and even these uses remained rare. What is even more striking is that in both cases explicit ideas of dangerousness and safety, as rationales for confinement, were relatively rare until the 1960s. The similarity between the policy trajectories of these two cases is strong, which can partially be explained by the way Queensland drew on legislative examples from England and Wales.

In both case studies cure was the primary explicit rationale for confinement until at least the middle of the twentieth century. The rationale for confinement began to shift more towards the prevention of danger as there was a move towards deinstitutionalisation and community care. Once care could be provided outside of institutional settings cure was no longer as convincing a rationale for confinement. Protection from danger began to replace cure as the primary way in which confinement was justified. This shift demonstrates the continued importance that spatial control of deviance has played. It demonstrates the continued commitment by the state to spatial forms of demarcation of the normal from the abnormal.

The language of danger and safety was primarily used, in both case studies, in an individualised sense as something that was embodied in particular individuals. As danger is identified in particular individuals it serves as a justification of confinement of those individuals. The way that danger is used is exactly how Castel (1991), Lupton (1999) and Rose (2002) suggest it has been, namely as a precise hazard located in a concrete individual which was amenable to individual judgement. On those occasions when the terminology of risk was used in policy prior to the 1990s it was deployed virtually synonymously with the meaning of danger. Risk was consistently used in the sense of individualised hazard, instead of an aggregative sense, or as part of a flexible continuum. Before the 1990s risk was used in mental health policy almost exclusively as Douglas (1992: 40) suggests, namely as a decorative flourish on danger.

In framing my historical approach I specifically drew on Foucault’s notion of the history of the present. I drew on this approach as part of a tradition of non-

250 teleological historiographies, which recognise that history is not about progress to a particular endpoint. My aim in adopting this approach was to be alert to recognising that the present is just as arbitrary as any other time. Utilising this approach is a way to problematise present concepts and to recognise the insensibility of them. Part of my rationale for adopting this approach was to problematise the use of risk in the contemporary period through showing how it relates to and differs from other rationales for confinement of people with mental illness. Ultimately my historical analysis acts as a reminder of the contingency of the present.

12.4 Research Question Three

My third research question was: To what extent, and how, are ideas of risk used in contemporary policies of confinement of people with mental illness?

The historical use of danger and safety as concepts that framed mental health policy was very similar in the two case studies. However the contemporary emphasis on risk is less similar. Risk is a less significant part of how confinement in mental health policy is framed in Queensland than in England and Wales where risk has increasingly dominated policy approaches. In addition the way that the concept of risk is utilised in Queensland policy is far more complex than in England and Wales where risk refers almost entirely to embodied physical danger. I contend that this is a direct reflection of the much more prominent role of deinstitutionalisation in England and Wales. I argue that risk has become a key concern through a reflexive relationship with deinstitutionalisation and community care. The greater emphasis on risk in England and Wales, than in Queensland, supports this contention.

England and Wales has followed a distinct policy trajectory whereby mental health policy has increasingly focused on risk assessment and management largely at the expense of other considerations. The language of risk identification and management emerged during the 1990s in direct response to a number of highly public incidents that received a great deal of media and public attention and placed community safety at the heart of the policy agenda. There was a deliberate decision by the government to focus on trying to control risk in order to engender public support for the mental health system as a whole. Thus the techniques and language of risk were used as a way to exert control over the increasing uncertainty associated with the policies of deinstitutionalisation and community care. This accords with Beck’s (1992, 1995)

251 notion that risk becomes important in late modernity as a way of trying to bring uncertainty under control.

In the case of Queensland risk has also been an increasingly important aspect of how mental health policy is framed. As in the case of England and Wales a focus on risk was an essential element of legislative reform. Decisions about confinement and deconfinement have increasingly been shaped around the assessment of risk. However the meanings of risk have been much less uniform in Queensland. In some contexts risk acts as a modern synonym of danger, but in others it is used in an aggregative sense which is identified with public health. Here risk is used as a way of identifying population groups to target and actions to take, which could potentially reduce the impact of mental illness. Risk is not just about control, but also plays a preventative role in the Queensland case. The public health focus on risk, in Queensland, gives some support to Castel’s arguments about the use of risk as a way of exerting aggregative control. However the use of risk in an aggregative sense of population control (as in biopower) is only very partial, even in Queensland.

In most cases risk is not used, as most social theory suggests, namely as something that is on a continuum with operational flexibility (Reddy 1996, Rose 2002). Castel 1991) and Rose (2002) both argue that a shift from dangerousness to risk has occurred where dangerousness mutates from something embodied in the individual towards factors, situations and statistical probabilities. In contrast my case study suggests that risk has primarily (but not entirely) remained deployed in very similar ways to how danger was used. My analysis of the way that danger was conceptualised in an individual sense provided the basis for my conclusion that risk in the contemporary period has also primarily been conceptualised in a highly individualistic manner, similar to how danger has historically been used.

My historical research confirms that the use of risk in the contemporary period has both continuities and discontinuities with previous periods of history. On the one hand the language of risk has only recently been deployed in relation to mental health policy. This indicates that use of the language of risk does indicate a change in approach. However on the other hand the way in which risk is used in the contemporary period has strong similarities with the earlier use of concepts of prevention of danger and provision of public safety. There is little use of risk in a probabilistic or aggregative sense.

252 In summary in England and Wales the language and techniques of risk have largely centred on embodied risk. The language of risk is used to identify and control specific individuals who are thought likely to pose specific risks to either themselves or the larger community. In England and Wales risk emerged primarily as a way of trying to exert control over uncertainty and it lacks the aggregative aspect of meanings of risk sometimes utilised in Queensland. This is particularly apparent in relation to the concept of being ‘at risk’, which plays such a large part in the way risk is used in English and Welsh policy. To be ‘at risk’ is an ambiguous concept, which ruptures the traditional relationship between individual action and the probability of some hazard. To be at risk is no longer about what you do; it is also about who you are. In this way risk becomes a fixed attribute of the individual.

The degree to which risk becomes a fixed attribute of an individual reveals what Rose (1998) identifies as one of the primary paradoxes of risk thinking. This paradox is that risk thinking, which relies on fluidity and calculation, is being used to make and justify decisions about individuals which are inherently determinist in their effect. This paradox is an effect of the uncertainty of late modernity, where the emergence of uncertain, porous, and mobile social forms led to a demand for practices which seek to fix identities and to quarantine whole sections of society (Garland 2001: 165). The increasing recognition of uncertainty leads to a desire to exert greater control. This is evident in risk assessment in mental health systems, which is couched in terms of actuarial evidence but more accurately represents a societal response to what constitutes sufficient risk within that particular society. Risk serves as a way of trying to exert control over the uncontrollability that is inherent in mental illness.

Ultimately the two case studies show that ideas of risk are essential to how contemporary policies of confinement operate. Indeed it is possible to argue that these case studies give credence to Rose’s (1998) claim that contemporary mental health policy is effectively the legalisation of risk status rather than about illness. In both jurisdictions confinement is clearly more predicated on risk rather than patient care or benefit. As a result, psychiatric institutions can be seen as existing primarily for the purpose of secure confinement until decisions about risk can be made. Confinement has now become primarily the physical and spatial control of risk, particularly in England and Wales.

253 12.5 Research Aim

My overall research aim was: To understand the role of risk in framing confinement and spatial control in contemporary mental health policy.

Beck’s fundamental principle in proposing the concept of the ‘risk society’ accurately reflects changes in the governance of mental illness in my case studies. The departure point for Beck’s theory is that the period of ‘late modernity’ is characterised by increasing uncertainties, and also by attempts, by both individuals and governments, to formulate responses to these uncertainties. This is an accurate reflection of the broader governance of mental illness. As I have demonstrated the notion of risk became significant in both case studies as a way of trying to exert control over increasing uncertainties relating to the care of people with mental illness (or at least the appearance of increasing uncertainties). In both case studies governance has, as Beck (1995) claims, been increasingly organised around addressing safety and security. Beck’s theory provides a good explanation for broad changes in governance. However it is less useful for understanding exactly how the language and concepts of risk are utilised in policy, and with what effects.

Castel (1988) argues that psychiatry provided the means, tools and technology to enable madness to be administered as a technological problem, rather than a political one. The language of risk has had much the same effect. It has been utilised as a form of technology which allows the state to suppress the notion of uncertainty. As I showed in Chapter Two risk became significant because it appeared to transform the notion of fate from something outside of human control towards something humans could control (Hacking 1990, Bernstein 1996). This technical use of risk gave credence to the idea that humans could exert control over uncertainty. As Reddy (1996) argues modernity attempted to replace ‘uncertainty’ with ‘risk’.

Ultimately risk has been used to reassert a very material and physical approach towards control of the deviance of mental illness. It has been used to reinforce what Foucault (1977a: 218) calls anti-nomadicism. Risk provides the justification for the continuation of disciplinary modes of control, which seek to exert control through spatial fixing. This is not to claim the total predominance of the disciplinary society, as Foucault (1991: 102) made clear the concept of discipline was never conceived as a totalizing explanation of society. What it does show, however, is that disciplinary society has not been superseded to the extent Deleuze suggested. It also illustrates

254 that risk has not been used, as Castel (1991) argued, to facilitate decentred forms of control, rather it has been used in policy to support the continuation of spatially fixed forms of control through confinement.

The way that risk is used primarily to reassert physical control runs counter to the argument of governmentality theorists, such as Rose (1999). These theorists suggest that risk is part of a neoliberal form of governmentality that acts less through direct oppression and more through freedom as a technology of governance. This is not to claim that risk is never used in the sense of encouraging subjects to manage their own conduct. In the case of Queensland, the influence of public health approaches to mental health policy contained aspects of self-regulation. In both case studies, however, the notion of risk as facilitating individualised responsibility for health was limited. My case studies have shown that societies dominated by neoliberal policies in reflexive modernity can be seen as returning to previous forms of discipline in relation to individuals and social groups that are identified as being ‘at risk’, or imposing risk on others, and ignoring underlying social causes of risk. The focus on the individual within neoliberalism is less on the individual as self-regulating subject, and more on the individual as the embodiment of risk.

12.5.1 Risk and spatial control

As I have shown above risk has primarily been utilised to justify continued spatial control. However I have also shown that ideas of risk in policy are not utilised uniformly. There are ways in which the language of risk is used to facilitate decentred forms of control. In this section I evaluate two models (discussed in Chapter Four) to help understand and analyse the tension between these two uses of risk. The first model is Clear and Cadora’s (2001) which argues that approaches to risk can be classified as either risk control, or risk management. The second model proposed by both Rose (2000b) and O’Malley (2004), conceptualises attempts to manage risk as being either based around inclusion or around exclusion. According to this model risk strategies can be divided into two categories of operating either through inclusionary mechanisms or through exclusionary mechanisms.

Clear and Cadora’s (2001) model, which was developed on the basis of events in the criminal justice system, has the advantage of being relatively simple to use analytically. It provides a compelling analysis of the England and Wales case study. A strong case can be that a distinct shift towards a risk control agenda is starting to

255 dominate mental health policy in England and Wales. In contrast the model does not explain or reflect the case of Queensland very well. In particular the model that Clear and Cadora propose argues that there has been a shift from risk management towards risk control, rather than the ongoing coexistence of both factors. In the example of Queensland there are aspects of risk control at work, particularly in regard to forensic care, but there is no trajectory away from risk management and towards risk control. This teleological aspect of Clear and Cadora’s model is its most unconvincing feature.

In contrast the inclusionary/exclusionary model proposed by Rose (2000b) and O’Malley (2004) does not assume a teleology of change. It does not presume that there has been a shift from one type of strategy revolving around risk to another, but rather holds that these two different strategies coexist. The first seeks to operate through inclusion, to include people in networks of control. These inclusionary strategies exert control through decentralised mechanisms, rather like Deleuze’s notion of societies of control. The second strategy operates through exclusionary mechanisms that seek to remove those acting outside the norms of society from the bounds of that society. Rose and O’Malley’s model appears to match much more closely the findings of the case studies in that it accounts for the continued importance of models of community care simultaneously with a resurgence of a focus on confinement.

There are, however, problems with the inclusion and exclusion model beyond the ordinary deficiencies of binary models. Most notably it can be difficult to pinpoint exactly what should be considered as exclusionary and inclusionary. As both Beck (1998) and Bauman (2000) point out there is a problem with conceptualising ‘exclusion’ in late modernity. In particular Beck notes that boundaries become blurred and identities mingled. He argues that under conditions of late modernity the social construction of the stranger can no longer rely on the cultural self-understanding of a closed social circle, as the definition of the self becomes problematic. As the identity of the self becomes blurred an almost inexhaustible mosaic of possible exclusions becomes possible, so it is naïve to speak of ‘inclusion’ or ‘exclusion’.

These mosaics are a part of mental health care. As Parr (2008: 181) points out services and spaces that create inclusion for some people, such as artistic spaces, can simultaneously ‘engender their own exclusions'. Again this is exemplified by the powers of compulsion in the community. The intent of these mechanisms is to

256 prevent exclusion, by allowing people to continue to receive care in community settings rather than spatially excluded settings, but the practice can often be exclusionary.

Moreover, it is not even evident that confinement in institutional care is inherently ‘exclusionary’. As Gleeson and Kearns (2001) (in the context of intellectual disability), and Finnane (2003) argue, in some circumstances institutions did provide a more caring and positive environment than that which resulted from deinstitutionalisation.51 The idea that institutions can provide a positive human experience is given further weight by the strong body of evidence concerning the exclusionary nature of much of the community care landscape (Belcher 1991, Hudson 1991).

Neither Clear and Cadora’s (2001), nor Rose (2000b) and O’Malley’s (2004) approach is entirely satisfactory in explaining historical shifts in the relationship between social and spatial control in the care and treatment of people with mental illness. Clear and Cadora’s approach is the more successful if the teleological aspects of their claims are ignored. Instead of seeing a shift from risk management towards risk control it is more useful to recognise that both of these uses of risk are operating simultaneously in different contexts. There is increasing diversity in the way care and control operates in relation to people with mental illness. This is not an inevitable shift back towards confinement and away from community care, but rather an expansion of the techniques of control which include both the management of hazard and in certain circumstances the attempt to exert physical control over hazard, such as the use of physical isolation. Forms of confinement are only one moment in a wider network of control, but still an important one.

12.6 Critical Reflections and Future research

Inevitably any research approach has particular strengths and weaknesses. Here I briefly reflect on some of the weaknesses of my approach, as a way of identifying future research possibilities. There were three main weaknesses in my research approach, all of which I have previously referred to. The first weakness was the decision to focus primarily on finalised policy documents and legislation, a decision made for pragmatic reasons. This failed to address how policy is implemented.

51 Indeed it is worth remembering that one of the first major institutions in England, the York Retreat, was founded by Quakers as a direct reaction to the brutality and shabbiness of care then being meted out to people with mental illness in the pre psychiatric institution period.

257 Inevitably the application of public policy is both negotiated and resisted at a number of levels. In addition the focus on policy documents assumes a unity in the government and policy apparatus which does not exist. There is scope for more detailed research that focuses on how policies and practices of contemporary confinement are negotiated and resisted both in government and wider society.

Second, my research addressed the question of how significant policies and practices of confinement were in my two case studies. To answer this question I drew on and brought together secondary research and government data. The research for this part of the study was inevitably broad, and missed a great deal of detail. This was sufficient for the purpose of identifying the continued and significant role of confinement in my two case studies. Compiling these data did, however, reveal the urgent need for a wide range of research relating to confinement. In particular the following research is needed: 1. An evaluation of the factors which impact on levels of compulsory admissions. Although my research showed an increase in compulsory admissions (particularly in England and Wales) it was not possible to assess the degree to which this was an artefact of other changes. Changes likely to have influenced the rate of compulsory admissions include increased readmissions, changed lengths of hospital stays and a greater propensity for compulsorily admission because of bed shortages. Each of these areas should be the subject of further investigation in order to develop a more nuanced understanding of contemporary confinement. 2. Analysis of the role of criminalisation in the confinement of people of people with mental illness. In Chapters One, Six and Nine I highlighted the degree to which people with mental illness are being confined within the criminal justice system. This is a crucial issue for understanding the role of confinement of people with mental illness in the contemporary world. Unfortunately due to time and space constraints I was not able to do more than identify the issue. There is, as I illustrated in Chapter One (section 1.3.3), already a range of sociological and criminological research into criminalisation. There is however little which attempts to tease out the relationship between compulsory admissions and criminalisation. In particular there is an important role for a greater empirical and theoretical understanding of the role of criminalisation as part of wider networks of control over people with mental illness. 3. Analysis of changes in the demographics of those being confined.

258 My research indicated that in England and Wales there has been an increase in the number of young men being compulsorily admitted. Not only is this an important area for further research, but also it points towards the larger issue of how changing understandings of what mental illness is impacts on the mental health system. While it is largely accepted that there has been and continues to be a change in how mental illness is understood there has been surprising little consideration of how this effects the nature and operation of mental health services.

The third key weakness of my research was the degree to which I used confinement as a ‘taken-for-granted’ concept. I largely treated confinement as though it was a simple concept which always remains the same. This was a necessary simplification for the purposes of my larger research aim, however it does highlight the need for further research on confinement and institutionalisation. Moon, Joseph and Kearns (2005, 2006) have argued that the boundaries between the institution and community have been blurring. They investigated this in relation to the role of the private asylum. My research is also suggestive of the blurring of these boundaries. There is however still further scope for a detailed investigation of how useful these categories are in the contemporary world. Is the concept of institution meaningful and how do hybrid forms such as compulsory care in the community problematise the spatiality of previously existing forms of care?

12.7 Conclusions

In this final conclusion I reiterate how my thesis has addressed my initial research aim and outline the three main contributions my thesis has made. The research aim that guided my work was to understand the role of risk in framing confinement and spatial control in mental health policy. I achieved this aim through an analysis of policy in my two case studies. I found that risk plays a multi-faceted and often contradictory role. There are, as Castel suggests, elements in the way risk is used which support decentred forms of care and control over people with mental illness. However risk is more prominently used as a new way of justifying the old instrumental forms of control. Here risk is used as a way of justifying spatial control over people with mental illness, replacing other rationales for control that have become less accepted or effective. Risk has become progressively more acceptable as a rationale for confinement as it appears to offer a way to address the uncertainty

259 associated with the behaviour of people with mental illness. Ultimately risk enters policy discourse primarily as a way of the state reinforcing its role as a wider provider of safety and security from deviance.

In addressing my research aim my thesis has made three main contributions. First I have demonstrated the continuing (and renewed) role of confinement within Western mental health systems. In doing so I have demonstrated that geographers need to renew their focus on the role of confinement in the spatial control of people with mental illness. I have shown that there remains a strong commitment to control of people with mental illness exerted through the spatial fixing of confinement.

Second I have placed the use of risk in mental health policy in context. In Chapter Three I showed that risk has too often been used as an all embracing explanatory framework. In this thesis I took seriously Rose’s (2002) call for a diagnostic approach to understanding the role and use of risk. Through my work I demonstrated the historical continuities and discontinuities of the use of risk in relation to confinement. I was able to show that although the language of risk was new to mental health policy, the meanings associated with it largely were not.

Third I have critically examined the relationship between spatiality and social control in contemporary mental health policy. As I showed in Chapters Two, Three and Four there has been an increasing body of literature which has identified a decentring aspect of social control associated with the rise of the use of the concept of risk. My thesis subjected this literature to empirical and theoretical scrutiny and problematised the literature by showing the strong relationship between risk and spatially centred forms of confinement. I have demonstrated that the concept of risk has primarily been used to support the continuation of spatially fixed modes of control over people with mental illness, at least in my two case studies.

Through these three key contributions my thesis has added to the body of geographic knowledge of mental health care and services. Finally I turn to the point I raised in the conclusion to my introduction. Although my research has related to policy discourse it is important not to forget that people are at the core of my research interest. The renewal of an emphasis on compulsion and confinement and the general policy shift towards safety and security has material implications for people with mental illness. As Hudson (2003) has argued due process and individual rights are increasingly being subjugated by concern for community safety. My own

260 research has helped to open up the way that risk is associated with mental illness and unsettle the rationales for the spatial confinement of people with mental illness.

261 Appendix One: Sources Analysed for Historical Analysis England and Wales

This appendix records the sources which I used in preparing my analysis of the historical use of risk, and rationalisation of confinement, in England and Wales. This records in abbreviated form all the sources analysed. Full references for those sources I cite in the body of the thesis are included in the full list of references.

Key: Mental Health Archives Number refers to the reference number within the National Archives of the United Kingdom

Legislation

Lunacy Act 1845 County Asylums Act 1845 Lunacy Regulation Amendment Act 1882 Lunatics Law Amendment Act 1885 Lunacy Act 1890 Mental Treatment Act 1930 National Health Service Act 1946 Mental Health Act 1959 Mental Health Act 1983

Government and Select Committee Reports

Date Title 1844 Report of the Metropolitan Commissioners in Lunacy to Lord Chancellor 1859 Report from the Select Committee on Lunatics 1860 Report from the Select Committee on Lunatics 1877 Report from the Select Committee on Lunacy Law 1878 Report from the Select Committee on Lunacy Law 1882 Criminal Lunacy Commission 1908 Royal Commission Care and Control of the Feeble Minded 1918 A Review of the Conditions of Defectives and Lunatics in Poor Law institutions Report of the Proceedings of the Conference to Consider in What Directions 1922 Lunacy Administration and the Treatment of Persons Suffering from Mental Disease May Be Improved 1926 Report of the Royal Commission on Lunacy and Mental Disorder

262 1957 Royal Commission on Mental Illness and Deficiency (Percy Commission) 1961 Special Hospitals: Report of Working Party 1961 Enoch Powell’s ‘Water tower’ Speech 1963 Health and Welfare: the Development of Community Care 1975 Butler Report: Report of the Committee on Mentally Abnormal offenders 1975 Better Services for Mentally Ill (White Paper) 1976 Review of the Mental Health act 1959 1981 Reform of Mental Health Legislation Public Support for Residential Care: Report of a Joint Central and Local 1987 Government Working Party. 1988 Community Care: Agenda for Action. 1989 Working for Patients 1990 Community Care Act Review of Services for Mentally Disordered Offenders and Others Requiring such 1992 Services

National Archives of The United Kingdom

This table records the archival sources I analysed. The reference number is the official reference number of the National Archives of the United Kingdom.

Date Reference Title Special Medical Report on the Cumberland Paupers for the 1846 MH 51/35 Years 1845 to 1846 Lunacy and Lunatics: Lunatic Asylums Act: Adoption of Act by 1847 HO 45/1436 Various Towns Rule Books of Asylum at Liverpool, Aylesbury, Exeter and 1851 MH 51/ 44B Manchester; Report of the Liverpool Royal Lunatic Asylum, 1851-1852 Lunacy and Lunatics: Bethlehem Hospital: Report of Lunacy 1852 HO 45/4186 Commissioners List of Opinions on Various Lunacy Acts 1857-1890, Mental 1857- MH 51/747 Deficiency Act 1913 and Asylum Officers Superannuation Act 1913 1909 1858 HO 45/6548 Lunacy Act Amendment: Suggestions 1859 HO 45/6686 Lunacy: Lunatics (Care and Treatment) Bill Enquiry into Justification for Detaining a Criminal Patient, 1863 MH 51/57 Helen Englefield, In Northumberland Asylum Lord Shaftesbury, First Chairman of Lunacy Commission: File 1875-85 MH 51/ 721 of Miscellaneous Letters 1876 MH 51/773 Patients Going on Leave of Absence 1881 LCO 1/68 Lunacy Rules and Orders 1883-84 LCO 1/62 Lunacy Acts, Proposed Reforms 1884- Questions Arising on Lunacy Acts 1890 and 1891, MH 51/748 1891 Commissioners Rules and Criminal Lunatics Act 1884

263 1885- MH 80/1 Lunacy Acts Amendment Bill 1889 Lunacy Act Amendment Bill, 1885, Observations and 1885 LCO 1/64 Suggestions for Incorporation Lunacy Act Amendment Bill, 1885, Observations and 1885 LCO 1/65 Suggestions for Incorporation Lunacy Act Amendment Bill, 1885, Observations and 1885 LCO 1/66 Suggestions for Incorporation Lunacy Bill: Amendments Suggested by Secretary of State to 1885 MH 51/ 830 Lord Chancellor Wandering Lunatics (Lunacy Acts Amendment Act 1885 1887 MH 51/ 784 Section 68) 1889 LCO 2/6 Lunacy Bill: Home Secretary's Observations on Lunacy Bill 1891 MH 51/834 Lunacy Act: Comments 1891 MH 51/835 Lunacy Act: Comments Criminal Lunatics Act 1884; Reception into Asylums of Ex- 1896 MH 51/ 797 Criminal Lunatics 1899 MH 51/ 838 Lunacy Bill: Memoranda 1899- LCO 2/132 Lunacy Bill, 1900: Papers Relating to 1901 Lunacy: 1) Memoranda on Powers and Duties of Secretary of HO State. (Except With Regard to Criminal Lunatics) 2) Care of 1901-06 45/101/B29752 Non-Certifiable Idiots Etc. Leading to Royal Commission on the Feeble-Minded 1911-13 LCO 2/230 Lunacy Legislation: Proposed New Rules 1911 CAB 37/105/17 Lunacy Bill Parliamentary Business; Revenue Bill; Lunacy Commission; 1911 CAB 41/33/7 Portugal; Plural Voting 1922 LCO 2/475 Lunacy Bill 1922 Mental Treatment Bill, 1923: Representations and 1923 MH 58/91 Consideration of Clauses Royal Commission on Lunacy and Mental Disorder, Evidence 1924-26 LCO 2/952 Given by Lord Chancellor to; and the Official Report Mental Health: Royal Commission on Lunacy and Mental 1924-29 HO 45/13372 Disorder Royal Commission on Lunacy and Mental Disorder, 1926: 1925-48 MH 51/640 Report Royal Commission on Lunacy and Mental Disorders: 1925-26 MH 51/ 827 Questionnaire and Auditor's Report Report and Recommendations Involving Legislations Revised 1926-28 MH 58/216 Draft of Mental Treatment Bill, 1923 1927 MH 58/95 Lunacy Amendment Bill, 1927 (Draft 1928-30 MH 80/11 Mental Treatment Bill 1929 MH 79/421 Mental Deficiency and Lunacy: Mental Treatment Bill 1929 1929 MH 51/568 Mental Treatment Bill: House of Lords 1929

264 Mental Treatment Bill 1929: Arrangement of Clauses and 1929 MH 51/714 Proposed Amendments 1930 MH 80/12 Mental Treatment Bill Mental Treatment Bill, 1929: Second Reading; Brief for 1930 MH 58/63 Member Presenting Bill 1935-56 MH 51/ 356 Consolidation of Lunacy and Mental Treatment Acts 1938 MH 51/569 Criminal Lunatics Act 1938 1941 CAB 75/11/1 Lunacy and Mental Treatment Acts, 1890 to 1930 1947-55 MH 51/610 Proposals for New Mental Health Lunacy Legislation 1954 MH 121/6 Setting Up of the Royal Commission Royal Commission on Mental Illness and Mental Deficiency: 1953-54 MH 79/640 Papers on Setting Up of Commission Royal Commission on Mental Illness and Mental Deficiency: 1954-58 MH 79/641 Joint Evidence by Ministry of Pensions and Board of Control Royal Commission on Mental Illness and Mental Deficiency: 1954-58 MH 79/642 Review of Recommendations Royal Commission on Mental Illness and Mental Deficiency: 1954-58 MH 79/643 Future of State Institutions 1956-65 CAB 124/1690 Mental Health 1957-59 MH 137/407 Proposals for Setting Up of Mental Health Review Tribunals Royal Commission on Mental Illness and Mental Deficiency: 1957 MH 102/2471 Home Office Observations on the Royal Commission's Report 1958 HO 291/15 Mental Health Bill 1958 1958 HO 291/16 Mental Health Bill 1958 Admission of Patients Concerned in Criminal Proceedings: 1958-60 MH 140/46 Introduction of Part V of Act 1959 MH 137/410 Mental Health Bill 1959: Notes on Clauses 1959 MH 137/411 Mental Health Bill 1959: Second Reading Mental Health Act 1959: Consultation with Other Government 1959 HO 291/252 Departments; Notes for Second Reading of Bill 1959 MH 140/1 Mental Health Act 1959: General Policy Questions Mental Health Act 1959: General Briefs and Notes for 1959 MH 140/3 Speeches 1959-60 MH 140/ 62 Submission of Evidence Special Hospitals Working Party Mental Health (Hospital and Guardianship) Regulations: 1960-61 MH 140/ 36 General Policy Questions Matters Arising From Report From Special Hospitals Working 1960-61 MH 140/59 Party Working Papers and Minutes of Meetings From Special 1960-61 MH 140/ 60 Hospitals Working Party 1962-63 MH 154/122 Draft White Paper: Mental Health Mental Health Services: House of Lords Debate on 1965 MH 154/516 Community Care; Comments and Papers 1967 CAB 153/195 Health and Mental Health Services

265 White Paper "Better Services for the Mentally Ill" Drafts, 1973-74 MH 154/926 Comments and Submission to Ministers 1974 MH 154/538 Revision of Mental Health Act MHB Papers 1974-79 MH 154/540 Working Party Reports: Papers; Draft Submission 1975 MH 154/934 Long Term Plans for Comprehensive Care of the Mentally Ill: White Paper on Mental Illness. Memorandum by the Secretary 1975 CAB 129/184/10 of State for Social Services White Paper on the Review of the Mental Health Act 1959: 1976 MH 154/1333 Consultation and Comments Steering Committee on the Review of the Mental Health Act 1977 MH 150/975 -9 1959: Consultative Document; Comments and Correspondence

Additional Sources

Great Britain, House of Commons Parliamentary Debates (Hansard) 1844-1992 Great Britain, House of Lords Parliamentary Debates (Hansard) 1844-1992

266 Appendix Two: Sources Analysed for Historical Analysis Queensland

This appendix records the sources which I used in preparing my analysis of the historical use of risk, and rationalisation of confinement, in Queensland. This records in abbreviated form all the sources analysed. Full references for those sources I cite in the body of the thesis are included in the full list of references.

Legislation

Dangerous Lunatics Act 1843 Benevolent Asylums Ward Act 1861 Lunacy Act 1869 Lunacy Act Extension Act 1872 Insanity Act 1884 Immigration Restriction Act 1901 Mental Hygiene Act 1938 Mental Health Act 1962 Mental Health Act 1974

Government and Royal Commission Reports

Date Title Report of the Commissioners Appointed to Inquire into the Lunatic Asylum, 1869 Woogaroo Report of the Select Committee on Woogaroo Lunatic Asylum: To Inquire into, and Report upon, All Matters Connected with the Management of the Lunatic Asylum 1869 at Woogaroo, and into the Fitness or Otherwise of the Building and Premises for which they are Appropriated Report of the Royal Commission Appointed to Inquire into the Management of the 1877 Woogaroo Lunatic Asylum and the Lunatic Reception Houses of the Colony Report of the Board of Inquiry, Woogaroo Asylum: To look into Charges against Dr 1880 Patrick Smith, Surgeon-Superintendent Royal Commission to Enquire into the Management of the Hospital for the Insane, 1915-16 Goodna 1955 Mental Health Facilities and Needs in Australia Comments on a Paper entitled "Psychiatric Hospitals in Queensland" by James 1979 Gardner and Paul Wilson

267 Cabinet Minutes

Date ID Decision 16/11/59 406242 2009 16/05/61 406263 3359 10/07/62 406285 4778 28/06/63 406292 5221 09/09/63 406298 5607 13/03/67 406363 10026 15/05/67 406366 10245 02/12/68 406395 12406 17/07/73 406484 19012 19/11/72 406493 19667 07/08/73 406462 17438 17/07/73 406484 19012 25/06/74 406508 20758 25/06/74 406508 20761 17/03/75 406525 22085

Queensland Archives

Date Reference Subject June 1960 538008 Notes Prepared for Premiers Conference June 1960 27/07/62 20324 Memo: Re: Mental Health Legislation Letter to Dr Stafford, Director of Psychiatric Services from L.E. 19/07/63 20324 Skinner Under Secretary of Justice. 1960s 20324 Memoranda in Connection with the Mental Health Bill 1960s 538008 Batch Files: Mental Health Services

Other Sources

• Queensland Legislative Council, Queensland Journals 1860-1901 • Queensland Legislative Assembly, Votes and Proceedings 1861-1901 • Queensland Parliament, Journals of the Parliament of Queensland 1902-1922 • Queensland Legislative Assembly, Journals of the Parliament of Queensland 1922-1992 • Queensland Legislative Council, Parliamentary Papers 1901-1992 • Queensland Parliament, Queensland Parliamentary Debates (Hansard) 1864- 1921 • Queensland Legislative Assembly, Queensland Parliamentary Debates (Hansard) 1922-1992

268 Appendix Three: Sources Analysed for Contemporary Analysis England and Wales

This appendix records the sources that I used in preparing my analysis of the contemporary use of risk, and rationalisation of confinement, in England and Wales. This records in abbreviated form all the sources analysed. Full references for those sources I cite in the body of the thesis are included in the full list of references.

Policy Documents

Date Policy Document Author The 10 Point Plan for Developing Successful and Department of Health Press 1993 Safe Community Care Release H93/908. Introduction of Supervision Registers for Mentally Ill National Health Service 1994 People (HSG(94)5) Management Executive Guidance on the Discharge of Mentally Disordered National Health Service 1994 People and their Continuing Care in the Community Management Executive (HSG(94)27) Steering Committee of the A Preliminary Report on Homicide: Confidential Confidential Inquiry into 1994 Inquiry into Homicides & Suicides by Mentally Ill Homicides & Suicides by People Mentally Ill People. Report of the Inquiry into the Care and Treatment of Jean H. Ritchie, Donald Dick, 1994 Christopher Clunis Richard Lingham 1995 Final Report of the Mental Health Task Force Mental Health Taskforce Guidance on Supervised Discharge (After-Care 1996 Department of Health under Supervision) and Related Provisions 1997 The New NHS: Modern, Dependable Department of Health Modernising Mental Health Services Safe, Sound 1998 Department of Health and Supportive The National Service Framework for Mental Health: 1999 Department of Health Modern Standards and Service Models Managing Dangerous People with Severe 1999 Personality Disorder: Proposals for Policy Home Office Development Reform of the Mental Health Act 1983: Proposals for The Secretary of State for 1999 Consultation Health The National Confidential Safer Services: National Confidential Inquiry into Inquiry into Suicide and 1999 Suicide and Homicide by People with Mental Illness Homicide by People with Mental Illness Reform of the Mental Health Act 1983: Part I the Secretary of State for Health 2000 Legislative Framework and the Home Secretary 2000 Reform of the Mental Health Act 1983: Part II Secretary of State for Health

269 Managing Risky Patients and the Home Secretary The NHS Plan: A Plan for Investment, a Plan for 2000 Department of Health Reform The Governments Response to the Health Select 2000 Department of Health Committee’s Report into Mental Health Services The National Confidential Safety First: Five-year Report of the National Inquiry into Suicide and 20001 Confidential Inquiry into Suicide and Homicide by Homicide by People with People with Mental Illness Mental Illness 2001 The Mental Health Policy Implementation Guide Department of Health The Journey to Recovery: The Government's Vision 2001 Department of Health for Mental Health Care 2002 Women's Mental Health: Into the Mainstream Department of Health 2002 Consultation on Draft Mental Health Bill Department of Health Personality Disorder: No Longer a Diagnosis of Exclusion - Policy Implementation Guidance for the 2003 Department of Health Development of Services for People with Personality Disorder Improving Mental Health Law - Towards a New 2004 Department of Health Mental Health Act Government Response to the Report of the Joint 2005 Department of Health Committee on the Draft Mental Health Bill 2004 Best Practice in Managing Risk: Principles and Guidance for Best Practice in the Assessment and 2007 Department of Health Management of Risk to Self and Others in Mental Health Services Professor Louis Appleby, Mental Health Ten Years On: Progress on Mental 2007 National Director for Mental Health Care Reform Health Mental Health Bill - the Government's response to 2007 the Report of the Joint Committee on Human Rights Department of Health 2007

Legislation

The Mental Health Act 1983 The Mental Health Act 2007

Parliamentary Sources

Great Britain, House of Commons Parliamentary Debates (Hansard) 1993-2007 Great Britain, House of Lords Parliamentary Debates (Hansard) 1993-2007

270 Appendix Four: Sources Analysed for Contemporary Analysis Queensland

This appendix records the sources which I used in preparing my analysis of the contemporary use of risk, and rationalisation of confinement, in Queensland. This records in abbreviated form all the sources analysed. Full references for those sources I cite in the body of the thesis are included in the full list of references.

Queensland Government Policy Documents

Date Title Author Minimum Service Standards: Mental Health Services in 1992 Queensland Health Queensland

Review of the Mental Health Act: 1993 Queensland Health Background to the Review

Review of the Mental Health Act: Treatment of People 1993 Queensland Health With Mental Illness.

Mental Health Services in Queensland 1993: Continuity of 1993 Care, Accessible Services, Relevant Services, Quality Queensland Health Services

1993 Queensland Mental Health Policy Queensland Health

1994 Review of the Mental Health Act 1974: Green Paper Queensland Health

1994 Queensland Mental Health Plan Queensland Health

1996 Ten Year Mental Health Strategy for Queensland 1996 Queensland Health

Queensland Mental Health Policy Statement Aboriginal 1996 Queensland Health and Torres Strait Islander People

Victims of Crime and the Mental Health Act – Discussion 1999 Queensland Health Paper

Achieving Balance: Queensland Review of Fatal Mental 2003 Queensland Health Health Sentinel Events 2002 – 03

2002 Queensland Forensic Mental Health Policy 2002 Queensland Health

2002 Smart State: Health 2020. A Vision for the Future Queensland Health

Queensland Health Response to the Mullen – 2002 Queensland Health Chettleburgh Report

2003 Queensland Mental Health Strategic Plan 2003-2008 Queensland Health

2004 Queensland Mental Health Act -Annual Report Queensland Health

271 Sharing Responsibility for Recovery: Creating and 2005 Sustaining Recovery Oriented Systems of Care for Mental Queensland Health Health

Queensland Health, Mental Health Branch, Policy for 2005 Management, Reviews and Notifications for A Person of Queensland Health Special Notification

Queensland 2005 Mental Health Services in Queensland 2005 Government

2006 Promoting Balance in the Forensic Mental Health System Queensland Health

Discussion Paper of Review of Queensland Mental Health 2007 Queensland Health Act

Commonwealth Government Policy Documents

Date Title Author Mental Health: Statement of Rights and Commonwealth Department of 1991 Responsibilities Community Services and Health

Commonwealth Department of 1992 National Mental Health Policy Health, Housing and Community Services

Commonwealth Department of 1992 National Mental Health Plan Health, Housing and Community Services

1998 Second National Mental Health Plan. Australian Health Ministers

2000 National Action Plan for Promotion, Prevention Commonwealth Department of and Early Intervention for Mental Health Health and Aged Care Promotion, Prevention and Early Intervention for Commonwealth Department of 2000 Mental Health—A Monograph 2000 Health and Aged Care

2003 National Mental Health Plan 2003 – 2008. Australian Health Ministers

Council of Australian 2006 National Action Plan Governments

National Statement Of Principles For Forensic 2006 Unnamed Mental Health

Legislation

The Mental Health Act 2000

Parliamentary Sources

Queensland Legislative Assembly, Queensland Parliamentary Debates (Hansard) 1992-2007

272 Appendix Five: Legislation

This appendix lists all legislation referred to in the text: English and Welsh Legislation

The Lunacy Act 1845 The County Asylums Act 1845 The Lunacy Act 1885 The Lunacy Act 1890 The Mental Treatment Act 1930 The National Health Service Act 1946 The Mental Health Act 1959 The Mental Health Act 1983 The Mental Health (Patients in the Community) Act 1995 The Mental Health Act 2007

Queensland Legislation

The Dangerous Lunatics Act 1843 The Lunacy Act 1869 The Insanity Act 1884 The Immigration Restriction Act 1901 The Mental Hygiene Act 1938 The Mental Health Act 1962 The Mental Health Act 1974 The Mental Health Act 2000

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