Mental health services: from the asylum to neoliberal reform

Abstract

This opening chapter provides historical and policy context for the fieldwork chapters that follow in the book. It begins by arguing that models of mental distress cannot be understood in isolation from the activities and action environments of which they form a part. Therefore, to develop a more contextually situated account of these forms of knowledge, the chapter proposes a socio-historical framework for understanding key phases in the development of policies and systems of mental health provision. These four ‘conjunctural settlements’ begin with the nineteenth century asylum, followed by the biomedical hospital system and community care in the twentieth century then contemporary neoliberal provision. Prominent ways of understanding and responding to mental distress associated with each settlement are introduced.

On the bullshitisation of mental health nursing: A reluctant work rant

“…Second, is the extent to which the real, face‐to‐face, conduct of mental health work has an unwelcome character associated with a systemic shift towards increasingly coercive practices, which largely become the nurses' duty to carry out. Arguably, the mental health nursing role and its precursor role of asylum attendant have always been coercive and controlling in character but it can be equally asserted that neoliberalism has consolidated such tendencies and fostered newer forms of both subtle and more explicit control (Moth, 2022; Recovery in the Bin et al, 2019; Thomas, 2016). These aspects of role are alienating for staff and service users alike, contradict a preferred, idealised occupational identity as purveyors of compassionate care and therapy and, as such, existentially undermine the sense that this work is meaningful.…”

“…Overlain and entangled with this, however, are less benevolently oriented impulses that are effectively baked into the system. These include defensive narrative practices associated with risk management within increasingly risk‐averse services or the oppressively time‐consuming task of recording no end of descriptive information regarding care inputs and assumed outcomes associated with impending or actual marketisation of healthcare under neoliberalism (McKeown et al, 2020; Moth, 2022). On a global scale, the insistence that healthcare objectives and outcomes are measured and recorded within a spiralling array of metrics with obfuscating acronyms is indicative of the neoliberal economic reimagination of life itself, with individuals now to be held responsible for their own disease and deaths which are deemed to result from poor personal choices (Kenny, 2015).…”

“…Overlain and entangled with this, however, are less benevolently oriented impulses that are effectively baked into the system. These include defensive narrative practices associated with risk management within increasingly risk-averse services or the oppressively time-consuming task of recording no end of descriptive information regarding care inputs and assumed outcomes associated with impending or actual marketisation of healthcare under neoliberalism (McKeown et al, 2020;Moth, 2022).…”

The problem of social care: A co-operative solution

“…There is an ever-present threat of co-optation and incorporation, with existing inequalities and power relations often reinforced rather than reduced (Turnhout et al, 2020). Critical commentators have argued that the full, collective potential of democracy across public services is constrained by the intrusion of neoliberal consumerism, quasi-markets and so-called new public management approaches (see Moth, 2022). Whilst the democratic potential of such work has to date been fairly limited, the demand for democratic participation in the organisation and delivery of health, care, and welfare services in the UK arguably begs two substantial questions.…”