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Title: Where the Shoe Pinches Author: Colin Ward Date: June 1961 Language: en Topics: health, Mental Health, medicine Source: Retrieved on 8th October 2020 from https://libcom.org/library/where-shoe-pinches Notes: Originally published in Anarchy #004
There is a word in use among administrators, âinstitutionalizationâ,
meaning putting people into institutions. It follows that there must be
an even more regrettable word âde-institutionalizationâ, meaning getting
them out again. It has only one thing to recommend it : it puts my theme
in one word. By institutions, in the general sense, we mean âan
established law, custom, usage, practice, organisation, or other element
in the political or social life of a peopleâ, and in a special sense, we
mean âan educational, philanthropic, remedial, or penal establishment in
which a building or system of buildings plays a major and central role,
e.g., schools, hospitals, orphanages, old peopleâs homes, jails.â
Since I am concerned with an anarchist approach, I must also define the
aims of anarchism, and for this purpose I will use a sentence from
Kropotkin :
It seeks the most complete development of individuality combined with
the highest development of voluntary association in all its aspects, in
all possible degrees, for all imaginable purposes, ever modified
associations which carry in themselves the elements of their durability
and constantly assume new forms which answer best to the multiple
aspirations of all.
If you accept these definitions you will see that anarchism is hostile
to institutions in the general sense; hostile that is to say, to the
institutionalization into pre-established forms or legal entities, of
the various kinds of human association. It is predisposed towards
de-institutionalization, towards the breakdown of institutions.
Now de-institutionalization is a feature of current thought and actual
trends in the second or special sense of the word. There is a
characteristic pattern of development common to many of these special
institutions. Frequently they are founded or modified by some individual
pioneer, a secular or religious philanthropist, to meet some urgent
social need or remedy some social evil. Then they become the focus of
the activities of a voluntary society, and as the nineteenth century
proceeds, gain the acknowledgment and support of the state. Local
authorities may fill in the geographical gaps in the distribution, and
finally, in our own day, the institutions themselves are
institutionalized, that isâ to say, nationalised, taken over by the
state as a public service. But at the very peak of their growth and
development, a doubt arises. Are they in fact remedying the evil or
serving the purpose for which they were instituted, or are they merely
perpetuating it. A new generation of pioneer thinkers arises which seeks
to set the process in reverse, to abolish the institution altogether, or
to break it down into non-institutional units, or to meet the same
social need in a non-institutional way. This is so marked a trend, that
it leads us to speculate on the extent to which the special institutions
can be regarded as microcosms or models for the critical study of the
general institutions of society.
A generation ago the accepted âidealâ pattern of childbirth was in a
maternity hospital. The baby was taken away from the mother at birth and
put behind glass by a masked nurse, to be brought out at strictly
regulated hours for feeding. Kissing and cuddling were regarded as
unhvgienic. (Most babies were not born that way, but that was the
ideal). â Today the ideal picture is completely different. Baby is born
at home, with father helping the midwife, while brothers and sisters are
encouraged to âshareâ the new acquisition. He is cossetted by all and
sundry and fed on demand. (Again most babies are not born that way, but
it is the new accepted ideal). This change in attitudes can be
attributed to the swing of the pendulum of fashion, to common-sense
re-asserting itself, or it may be the result of the popularisation of
the findings of anthropologists and psychoanalysts and of the immensely
influential evidence collected by John Bowlby in his WHO report on
maternal care. Professor Ashley Montagu writes:
there was a disease from which, but half a century ago, more than half
of the children (who died) in their first year of life, regularly died.
This disease was known as marasmus from the Greek word meaning wasting
awayâ. This disease was also known as infantile atrophy or debility.
When studies were undertaken to track down its cause, it was discovered
that it was generally babies in the âbestâ homes and hospitals who were
most often its victims, babies who were apparently receiving the best
and most careful physical attention, while babies in the poorest homes,
with a good mother, despite the lack of hygienic physical conditions,
often overcame the physical handicaps and nourished. What was lacking in
the sterilised environment of the babies of the first class and was
generously supplied in babies of the second class was mother love. This
discovery is responsible for the fact that hospitals today endeavour to
keep the infant for as short a time as possible.
The conflict between the two âidealâ patterns of childbirth is
frequently debated in the press today, partly as a result of two recent
official reports, the Cranbrook Report (of the Maternity Service
Committee, 1959) and the report on Human Relations in Obstetrics (1961).
Today between 60 and 70 per cent, of births take place in hospitals or
nursing homes, and a larger percentage probably would if more beds were
available, but it is still true that âMany mothers compare their
reception and management in hospital unfavourably with confinement at
home. Of one series of 336 mothers who had at least one baby in hospital
and one at home, 80% preferred home confinement and only 14% hospital
confinementâ. (The Lancet 22/4/61). These apparently contradictory
percentages simply mean of course that mothers want the advantagesâ of
both âidealsââ medical safety and a domestic atmosphere. The real demand
is in fact for the de-institutionalization of the hospital. Thus in
opening the new obstetric unit of Charing Cross Hospital (23/2/60)
Professor Norman Morris declared that âTwentyfive years of achievement
have vastly reduced the hazards of childbirth, but hospitals too often
drown the joys of motherhood in a sea of inhumanity.â There was, he said
âan atmosphere of coldness, unfriendliness, and severity more in keeping
with an income tax office. Many of our systems which involve dragooning
and regimentation must be completely revised. No sister should be
permitted to exercise her authority by means of a reign of terrorâ. And
at the Royal Society of Health Congress (29/4/61) he described many
existing maternity units as mere baby factories. âSome even seem to
boast that they have developed a more efficient conveyor belt system
than anything that has gone beforeâ.
The widespread acceptance of the view which has become known as
âBowlbyâs maternal deprivation hypothesisâ has profoundly affected
attitudes to the treatment of young children in hospital. The American
pediatricians Ruth and Harry Bakwin observed that : The effect of
residence in a hospital manifests itself by a fairly well-defined
clinical picture. A striking feature is the failure to gain properly,
despite the ingestion of diets which arc entirely adequate for growth in
the home. Infants in hospitals sleep less than others and they rarely
smile or babble spontaneously. They arc listless and apathetic and look
unhappy. The appetite is indifferent and food is accepted without
enthusiasm. Respiratory infections which last only a day or two in the
home are prolonged and may persist for weeks and months. Return to the
home results in defervescence (disappearance of fever) within a few days
and prompt and striking gain in weight.
Bowlby notes the same thing and remarks that the condition of these
infants is âundoubtedly a form of depression having many of the
hallmarks of the typical adult depressive patient of the mental
hospitalâ. The pioneer of the de-institutionalisation of childrenâs
hospitals was Sir James Spence who, in 1927, set up a mother-and-child
unit at the Babiesâ Hospital, Newcastle. In 1947, writing in the British
Medical Journal about the reforms needed in long-stay hospitals for
children he advocated the breaking-down of institutional hospitalisation
of older children, remarking that
it would be better if the children lived in small groups under a
house-mother, and from there went to their lessons in a school, to their
treatment in a sick-bay, and to their entertainment in a central hall
...
The findings of Bakwin, Bowley and Spence, and of James Robertson, of
the Tavistock Child Development Research Unit (who made the films A
Two-year-old Goes to Hospital and Going to Hospital with Mother) were at
last given official endorsement when the Ministry of Health accepted the
Piatt Report on âThe Welfare of Children in Hospitalâ which recommended
that for young children institutional care should be the last resort,
that institutional care should be broken down into small informal units,
that the visiting of children in hospital should be unrestricted and
that provision should be made for admitting th mothers of under- lives
to help in their care and to prevent the distress of separation. Two
years later there have been several attempts to gauge the extent to
which these recommendations have been carried out. Isabel Quigly
{Spectator 24/2/61 and correspondence in subsequent issues) found that
âone hospital and the next, under the sam National Health Service,
seemed as different as Dotheboys Hall and a Montessori classâ, and James
Robertson {Observer 15/1/61 to 12/2/61) found both wards which were a
model of enlightened practice and at the other extreme many âin which
practice is so rigid and, in effect, so inhumane as to warrant the
utmost concernâ.
The observations of the effect of the institutional environment on sick
children are also true of physically healthy children. One of the first
comparative studies of orphanage children with a matched control group,
conducted by the Iowa Child Welfare Research Station in 1938, led the
observers to remark :
No one could have predicted, much less proved, the steady tendency to
deteriorate on the part of children maintained under what had previously
been regarded as standard orphanage conditions. With respect to
intelligence, vocabulary, general information, social competence,
personal adjustment, and motor achievement, the whole picture was one of
retardation. The effect of from one to three years in a nursery school
still far below its own potentialities, was to reverse the tide of
regression, which, for some, led to feeble-mindedness.
In Britain during the war Dorothy Burlingham and Anna Freud reported in
Infants Without Families the striking changes in children showing every
symptom of retardedness, when their residential nurseries were broken
down to provide family groups of four children each with their own
substitute mother, and since then a great number of such comparisons
have been made in several countries, which Barbara Wootton sums up in
these words :
Repeatedly these children have been found to lag behind the standards of
those who live at home; to have both lower intelligence and lower
developmental quotients, and to be, moreover, relatively backward in
both speech and walking. Goldfarb, who has been one of the most active
investigators in this field, records that those who had spent their
earliest yeâars in infantsâ homes were apt to be retarded both in
general, and in particular in speech. They were also more destructive
and aggressive, more restless and less able to concentrate and more
indifferent to privacy rights than other children. They were, in fact,
impoverished in all aspects of their personality.
The change in public and official opinion in this country began with a
letter to The Times in 1944, from Lady Allen of Hurtwood, who followed
it with a pamphlet drawing attention to the grossly unsatisfactory
conditions of childrenâs homes and orphanages, giving examples of
unimaginative and cruel treatment. As a result an inter-departmental
committee was appointed in the following year, and its report, the
Curtis Report on the Care of Children was issued in September 1946,
severely criticising the institutional care of children, and making
recommendations which have been so widely accepted that Bowlby was able
to write in 1951 :
The controversy over the merits of foster-homes and of institutional
care can now be regarded as settled. There is now no-one who advocates
the care of children in large groupsâ indeed all advise strongly against
it.
It is not surprising that the methods and attitudes which have proved
most successful with normal children and ânormallyâ sick children should
be even more striking with children who are afflicted in someway, for
example, spastic or epileptic children, and with mentally handicapped
children. Dr. Tizard and Miss Daly of the Maudsley Hospital are carrying
out a three-year research project, financed by a voluntary association,
at Brooklands, Reigate, where a group of 16 âimbecileâ children from the
Fountains Hospital, matched with a control group at the parent hospital,
are being cared for on âfamilyâ lines. Even after the first year they
increased by an average of 8 months in mental age on a verbal
intelligence test as against three months for the controls. In personal
independence, measured on an age scale they had increased by six months
as against three by the controls and there were significant developments
in speech, social and emotional behaviour and self-chosen activity. âBy
contrastâ comments Len Chaloner,
children cared for by changing groups of nurses in a ward of perhaps
thirty beds find it difficult to make close relationships with any one
person. They are apt to be provided for on a mass basis at all levels,
and again because of the numbers involved, the daily round has to be
pretty closely regulated. If these conditions tended to retard the
normal âdeprivedâ child, as the Curtis Committee found, how much more
must they affect the subnormal?
Similar experiences of the benefits of small, permissive family groups
have rewarded those who have sought to de-institutionalize the
residential care of âdelinquent* or maladjusted childrenâ George Lyward
at Finchden Manor, or David Wills at Bodenham, for instance.
For many generations the word institution meant, to the majority of this
countryâs inhabitants, one thing: the Institution, the Poor Law
Infirmary or Union Workhouse, admission to which was a disgrace and a
last refuge, regarded with dread and hatred. The Poor Law has gone, but
Brian Abel-Smith in his contribution to the symposium Conviction reminds
us that we are still surrounded by the Poor Law tradition âwhich taught
us that people in need were second-class citizensâ, and that four out of
five old people in LCC welfare accommodation are living in the old
workhouses.
After the war the Rowntree committee on Problems of Ageing and the Care
of the Aged noted that
The committeeâs field surveys have shown that of old people a high
proportion lead independent lives ... It is certain, however, that a
considerable number of old persons who are leading independent lives and
many who are living as guests of their children are really unfit on
physical or mental grounds to do so. Many cases have been encountered
... of old people maintaining a hopeless struggle against adversity in
order to cling to their last vestige of independence. Such excessive
devotion to independence can be explained partly by the serious lack of
suitable homes for old people, partly by the regulated life which is
widely believed, not always with justice, to be the common feature of
all Institutions.
Mrs. Margaret Neville Hill who was a member of the committee remarks in
her recent book An Approach to Old Age and its Problems that the
institutions and homes which it visited â only 14 years ago â showed
only too clearly why old people did their utmost to keep out of
institutions. After many years work in establishing a variety of
housing, homes and communities for old people, the first of her
conclusions is clearly stated: âAll who can do so should, irrespective
of age, continue to live their own lives in their own homes as long as
possible, hence the need of adequate numbers of small convenient
dwellings.â She also illustrates the value of small homes run on hostel
lines, small residential communities, short-stay geriatric units and
âhalf-way housesâ bridging the gap between hospital treatment and the
return home, and she points out that one group of old peopleâ the
permanently infirm who should not remain in hospital but cannot live
aloneâ have needs which are hardly ever met, simply because they fall
between the responsibilities of the Health Service on one side and the
local authorities on the other. Her book has many anecdotes of the
startling change, amounting literally to a new lease of life, which some
old people have experienced as a result of moving from a chronic
hospital or from the cver-solicitude of relatives, to a good residential
home with an atmosphere of independence and tolerance :
Probably the first thing for anyone to learn who has old people to care
for is the need to allow them the utmost freedom of action, to realise
that their personality is still individual and that social significance
is essential to happiness. It is all too easy to take the attitude that
the old are past doing anything and encourage resting and doing nothing.
This is mistaken kindness, thought it may be an easy way of satisfying
the conscience compared with the more exacting way of continual
encouragement to be active, to go out, to find worthwhile occupation.
The latter course, however, is much more likely to promote happiness and
to forestall the troubles which may arise later on, from infirmity and
apathy.
The deinstitutionalization of the treatment of mental illness began in
the eighteenth century when William Tuke founded the York Retreat and
Pinel, in the same year (1792) struck off the chains from his mad
patients in the Bicetre in Paris. But in the nineteenth century with
what Kathleen Jones in her Mental Health and Social Policy calls the
triumph of legalismâ, the pattern was laid down of huge isolated lunatic
asylums as a sinister appendage to the Poor Law, which are the heritage
against which modern pioneers have ^ m ^^.^^%3 his remarkable lecture on
prisons, delivered in Pans in 1877, took Pmel as the starting point for
the âcommunity care which is now declared policy for mental health :
It will be said, however, there will always remain some people the sick
if vou wish to call them that, who constitute a danger to society Will
it not be necessary somehow to rid ourselves of them, or at least
prevent them from harming others? No society, no matter how little
intelligent, will need such an absurd solution and this is why. Formerly
the insane were looked upon as possessed by demons and were treated
accordingly. They were kept in chains in places like stables, rivetted
to the walls like wild beasts. But along came Pinel a man of the Great
Revolution, who dared to remove their chains and tried treating them as
brothers. âYou will be devoured by them cried the keepers But Pinel
dared. Those who were believed to be wild beasts gathered around Pinel
and proved by their attitude that he was right believing in the better
side of human nature even when the intelligence is clouded by disease.
Then the cause was won. They stopped chaining the
Then the peasants of the little Belgian village, Gheel, found something
better They said: âSend us your insane. We will give them absolute
freedom.â They adopted them into their families, they gave them places
at their tables, the chance alongside them to cultivate their fields and
a place among their young people at their country balls. âEat, drink and
dance with us. Work, runabout the fields and be free.â That was the
system that was all the science the Belgian peasant had And liberty
worked a miracle. The insane became cured. Even those who had incurable,
organic lesions became sweet, tractable members of the family like the
rest. I he diseased mind would always work in an abnormal fashion but
the heart was in the right place. They cried it was a miracle. The cures
were attributed to a saint and a virgin. But this virgin was liberty and
the saint was work in the fields and fraternal treatment.
At one of the extremes of the immense âspace between mental disease and
crimeâ of which Maudsley speaks, liberty and fraternal treatment have
worked their miracle. They will do the same at the other extreme.
Very slowly public sentiment and official policy has been catching up
with ihis attitude. The first reform in the care of the mentally ill in
America put the insane into state hospitalsâ writes J. B. Martin in The
Pane of Glass, 4 the second reform is now in progressâ to get them out
againâ. Exactly the same is true of this country. Until the reforms of
1930 it was not possible to be a voluntary patient in a public mental
hospital, and not surprisingly the great advances in effective treatment
were made outside them. Since then, there have been fewer
certifications, more vountary admissions, more discharges, more cures,
more doubts about institutionalisation. A key piece of research was that
of Milliard and Munday (âDiagnostic Problems in the Feeble-Mindedâ, The
Lancet 25/9/54). At the Fountain (Mental Deficiency) Hospital, London,
they found that 54% of the âhigh-gradeâ patients were not in fact
intellectually defective. Commenting in the light of this on âthe false
impression of the problem of mental deficiencyâ resulting from present
classifications, they added the significant observation that âsuch
patients may be socially incompetent, but in many cases institutional
life itself has aggravated their emotional difficultiesâ
The successful experiments of some local authorities and regional
hospital boards were belatedly followed by the Royal Commission on the
Law Relating to Mental Illness and Mental Deficiency in 1957 and the
subsequent Mental Health Act of 1959, sweeping away the whole process of
certification and seeking the treatment of mental sickness like any
other illness and mental deficiency like any physical handicap.
Out-patient facilities, occupation centres and the variety of provisions
known as âcommunity careâ are to replace institutions wherever possible.
The National Council for Civil Liberties which has been agitating for
years about the locking away in institutions of people who are no danger
to themselves or others, believes that the new provisions are still open
to administrative abuse and that they, will in effect legalise the
detention of the 3,078 men and women (at Feb. 1959) who, since the case
of Kathleen Rutty, have been shown to be illegally detained. Norman
Dodds says that most of these people had been sent to institutions by
local authorities as they had nowhere else to send them, and that they
were being kept as âslave labourâ since without them the hospitals and
institutions could not be kept running. You can easily imagine what
happens in such cases : a local authority put a child who was a bit dim
or a bit of a nuisance and had no parents into an institution, and the
institution did the rest of the damage, so that by the time he grew up
he was incapable of making a decision for himself or of going into the
outside world, and stayed there as a useful and harmless drudge until he
was prematurely senile.
The new approach has had some exciting successes. The Worthing
experiment in community care, the Henderson Social Rehabilitation Unit â
a therapeutic community for psychopaths, the factory at Bristol known as
the Industrial Therapy Organisation, the new independent factory at
Cheadle Royal Hospital which is to grow from the workshop there. The
âbasic re-orientationâ which Dr. Wadsworth, the Medical Officer at
Cheadle Royal describes as the first result of taking the locks off the
doors, was what he calls âthe replacement of a custodial authoritarian
system by a permissive and tolerant culture in which the patients are
encouraged to be themselves and share their feelingsâ. Explaining the
purpose of the new wing at Coppice Hospital, Nottingham, as the result
of private subscriptions and a Nuffield grant, the superintendent, said,
âIt is to be run by the patients themselves. The hospital staff,
although ready to give advice and guidance, will only enter at their
express invitation. The patients will decide what they wish to do with
their time and organise themselves into doing itâ
The research organisation PEP is conducting a three-year study of the
way in which the emphasis on community care works out in practice. The
first report, in the broadsheet Community Mental Health Services
studying the plans and proposals of 120 local authorities is not
particularly encouraging. Community care ought to mean something more
than simply local authority care, and the report calls for a systematic
study of public attitudes to mental disorder, which, it is thought, have
âan important irrational componentâ. The same point was raised last year
at the conference of the World Federation of Mental Health, where Dr. D.
F. Buckle commented that there were strong psychological reasons, hidden
from the people in the community which caused them to put away people
they could not abide or who raised the level of anxiety, and Dr. Joshua
Bierer said
I and my collaborators are convinced that it is our own anxiety which
forces us to lock people up, to brand them, and to make them criminals.
I believe if we can overcome our own anxiety and treat adults and and
adolescents as members of the community, we will create fewer mental
patients and fewer criminals.
In linking criminality with mental disorder (considering crime in the
psychologistâs rather than in the legalistic sense), he brings us to the
most sinister of institutions, the prison. Karl Menninger, founder of
the Menninger Clinic, addressing the American Bar Association, said
âIt is not generally the successful professional criminals upon whom we
inflict our antiquated penal system. It is the unsuccessful criminal who
gets caughtâ the clumsy, desperate and obscure, the friendless,
defective and diseased. In some instances the crime he commits is the
merest accident or impulse. More often the offender is a persistently
perverse, lonely and resentful individual who joins the only group for
which he is eligibleâ the outcast and the anti-social.
And what do we do with such offenders? After a solemn public ceremony we
pronounce them enemies of the people, and consign them for arbitrary
periods to institutional confinement. Here they languish until time has
ground out so many weary months and years. Then, with a stupidity
surpassed/ only by that of their original incarceration, they are dumped
back on society, with every certainty that changes have taken place in
them for the worse.
He calls for diagnosis of the offender, investigation of the most
suitable techniques in education, industrial training and psychotherapy,
noting the experience of mental hospitals of the desirability of moving
patients out of institutional control swiftly and concludes that âonce
we adopt diagnostic treatment directed towards getting the prisoners out
of jail and back to work, the taboo on prisons, like that on mental
hospitals, will begin to diminishâ. The prison will in fact cease to be
a prison. In this country Barbara Wootton, in her Social Science and
Social Pathology discusses the institutionalization of crime in these
terms:
To be convicted of a crime (other than that which is condoned by the
prevailing mores) is to acquire a special experience; and shared
experience is the basis of a common culture. Graduation from a period of
probation to residence in an approved school, and thereafter to
Detention Centre, Borstal or prison is itself as much a way of life as
is a graduation from Eton to Oxford and thence to one of the
professions. And more is involved in this shared experience than
contamination in the sense of exposure to explicit suggestions for
future criminal activities from offenders of greater experience.... We
have, indeed, to face the disagreeable paradox that experience of what
are intended to be reformative institutions actually increases the
probability of future lapses into criminality; it has, for example, been
shown that a previous residence in an approved school is one of the best
predictors of recidivism among Borstal boys. The effects of such
exposure have, however, been relatively little studied in criminal
investigations: indeed they tend to be discounted.
For anarchists, of course, this point of view will be familiar. William
Godwin wrote 170 years ago in Political Justice that
The most common method pursued in depriving the offender of the liberty
he has abused, is to erect a public jail, in which offenders of every
description are thrust together, and left to form among themselves what
species of society they can. Various circumstances contribute to imbue
them with habits of indolence and vice, and to discourage industry; and
no effort is made to remove or soften these circumstances. It cannot be
necessary to expatiate upon the atrociousness of this system. Jails are,
to a proverb, seminaries of vice; and he must be an uncommon proficient
in the passion and the practice of injustice, or a man of sublime
virtue, who does not come out of them a much worse man than when he
entered.
And 80 years ago in his lecture in âPrisons and Their Moral Influence on
Prisonersâ, Kropotkin summed up the problem in these trenchant words :
Whatever changes are introduced in the prison regime, the problem of
second offenders does not decrease. That is inevitable: it must be so â
the prison kills all the qualities in a man which make him best adapted
to community life. It makes him the kind of person who will inevitably
return to prison ...
I might propose that a Pestalozzi be placed at the head of each
prison.... I might also propose that in the place of the present guards,
ex-soldiers and ex-policemen, sixty Peslalozzis be substituted. But, you
will ask, where are we to find them? A pertinent question. The great
Swiss teacher would certainly refuse to be a prison guard, for,
basically, the principle of all prisons is wrong because it deprives men
of liberty. So long as you deprive a man of his liberty, you will not
make him better. You will cultivate habitual criminals.
Penal policy today is a fantastic mess of conflicting theories and
practices: retribution, restitution, deterrance, therapy, desperation,
inertia, fear, and force of habit. The Home Secretary himself is a split
personality â half of him wants to get tough and the other half has lost
faith in the value of prisons. But who can doubt, that in spite of
primitive public attitudes and official parsimony, we are groping, in a
half-hearted and contradictory fashion towards the
de-institutionalization of the treatment of delinquency just as mental
and physical sickness and deficiency, childhood and old age are slowly
being rescued from the dehumanizing effects of the institutional
environment?
To what extent is de-institutionalization opposed to being merely talked
about? The this statistically was a paper given by Brian Pinker to the
Manchester Statistical Society in they studied changes in the use of
institutions While they had to ignore changes in criteria and length
found (according to The Guardian) that actually taking place as only
attempt to answer Abel-Smith and Robert Pinker to Manchester Statistical
Society in February 1960, in which between 1911 and 1951. of stay, they
found (according to The Guardian) that
In welfare care the proportion of the population looked after in
institutions apparently fell by nearly 51% It appeared that between 1911
and 1951 the physically ill increased by 21% and the mentally ill by 26%
more than would have been expected from: demographic changes alone.
Errors of classification probably accounted for some of the difference;
but it seemed probable that the proportion of the population in hospital
was lower in 1951 than in 1911. In mental hospitals the proportion has
increased only by a small amount.
With law-breakers the most striking change was the decline in the age of
offenders. Among the most numerous group of single men the prisons of
1911 contained 0.45% of men aged 45â64, 0.31% of men aged 65â74, and
0.21% of men aged 15â44. In 1951 the highest proportion came from the
age group 15â44 (0.38%) and the proportion declined as age increased.
In these 40 years there was a considerable increase in the proportion of
children in institutional care while the proportion of the aged fell. In
1951 many sick people, many law-breakers .and many people needing
welfarie care were living at home with the support of district nurses,
probation officers, childrenâs officers, and many other workers.
A few other figures : Of 61,580 children in the care of local
authorities in 1960 nearly a half are boarded out with foster-parents.
(In 1950 the proportion was one-third). Of our 120,000 mentally
handicapped people slightly less than half live at home or in hostels
and are self-supporting in some industry. A fifth are partly
self-supporting and a tenth are useful at home if nothing else. Figures
given in The Lancet (1/4/61) show that it should be possible within 20
years to reduce the number of mental hospital beds from 3.5 to 1.8 beds
per thousand of population. In Worthing, with its fine experiment in
community care, four out of five mental patients are out-patients.
What none of the figures can tell us of course is the very thing we
would really like to know: the extent to which institutions have been or
are being transformed into non-institutional units.
A great many good ideas have advocates who extend them beyond their
validity. Thus Bowlbyâs findings on maternal deprivation has been
extended by some people into a deterministic theory that the deprived
child is hound to become a maladjusted child who can never develop
affectionate relationships with others. The same thing is true of
aspects of the anti-institutional trend. In the name of keeping the
family together at all cost, there has already appeared a point of view
which would return a maladjusted child to the source of his
maladjustment, or would insist that the proper place for a handicapped
child is in his own family, even though he may be unable to get there
the remedial care and understanding that he needs, or even though he may
become an intolerable burden to the rest of the family. Or the argument
may be that grandma ought to live with her relations even though she
may, on the one hand disrupt the whole family relationship by her
tyrannical demands, or on the other, may be treated with such
indifference and neglect that she feels she must apologise for still
being alive. Or that babies ought to be born at home regardless of
conditions there or the peace of mind of the mother. This kind of
absolutist argument is as foolish as its opposite, because both ignore
the immense variety of individual circumstances and temperaments.
Unfortunately too, the case for breaking-down institutions may be put
simply as a matter of reducing the cost of the social services rather
than for its effect on the lives of individuals. Possibly in the long
run it might be cheaper, but in fact the immediate cost is likely to be
greater, because so much needs to be done. What, asks Abel-Smith in
Conviction, should we do to rebuild the social services in such a way
that they really serve? He answers :
We would rebuild hospitals on modern lines â outpatients departments or
health centres, with a few beds tucked away in the corners. We would
close the mental deficiency colonies and build new villas with small
wards. How many could be looked after by quasi-housemothers in units of
eight just like good local authorities are doing for children deprived
of a normal home life? How many could be looked after at home if there
were proper occupational centres and domicilary services? We would
plough up the sinister old mental hospitals and build small ones in or
near the towns. We would pull down most of the institutions for old
people and provide them with suitable housing ... We would provide a
full range of occupations at home and elsewhere for the disabled, the
aged and the sick. We would discharge prisoners into the psychiatric
hospitals and try and cure them. The criminal law would become a social
service and stop being so bloody majestic ...
One of the things that emerges from the study of institutions is the
existence of a recognisable dehumanised institutional character. In its
ultimate form it was described by the psychiatrist Bruno Bettelheim in
his book The Informed Heart (where he relates his previous studies of
concentration camp behaviour and of emotionally disturbed children, to
the human condition in modern âmass societyâ). Bettelheim was a prisoner
at Dachau and Buchenwald, and he describes those prisoners who were
known as Muselmanner (âmoslemsâ), the walking corpses who âwere so
deprived of affect, self-esteem, and every form of stimulation, so
totally exhausted, both physically and emotionally, that they had given
the environmental total power over them. They did this when they gave up
trying to exercise any further influence over their life and
environmentâ.
But even the moslems, being organisms, could not help reacting somehow
to their environment, and this they did by depriving it of the power to
influence them as subjects in any way whatsoever. To achieve this, they
had to give up responding to it at all, and became objects, but with
this they gave up being persons.
At this point such men still obeyed orders, but only blindly or
automatically; no longer selectively or with inner reservation or any
hatred at being so abused. They still looked about, or at least moved
their eyes around. The looking stopped much later, though even then they
still moved their bodies when ordered, but never did anything on their
own any more. Typically, this stopping of action began when they no
longer lifted their legs as they walked, but only shuffled them. When
finally even the looking about on their own stopped, they soon died.
This description has a recognisable affinity to phenomena observed in
ânormalâ institutions. âOften the children sit inert or rock themselves
for hoursâ, says Dr. Bowlby of institution children. âGo and watch them
staring at the radiator, waiting to dieâ, says Mr. Abel-Smith of
institution pensioners. Dr. Russell Barton has given this âman-made
diseaseâ the name Institutional Neurosis (which is the title of his
splendid monograph on the subject), and has described its clinical
features in mental hospitals, its differential diagnosis, aetiology,
treatment and prevention. It is, he says
a disease characterised by apathy, lack of initiative, loss of interest*
especially in things of an impersonal, nature, submissiveness, apparent
inability to make plans for the future, lack of individuality, and
sometimes a characteristic posture and gait.
Permutations of these words and phrases, âinstitutionalisedâ, âdullâ,
âapatheticâ, âwithdrawnâ, âinaccessibleâ, âsolitaryâ, âunoccupiedâ,
âlacking in initiativeâ, âlacking in spontaneityâ, âuncommunicativeâ,
âsimpleâ, âchildishâ, âgives no troubleâ, âhas settled down wellâ, âis
co-operativeâ, should always make one suspect that the process of
institutionalisation has produced a neurosis.
He associates seven factors with the environment: in which the disease
occurs in mental hospitals: (1) Loss of contact with the outside world.
(2) Enforced idleness. (3) Bos sin ess of medical and nursing staff. (4)
Loss of personal friends, possessions, and personal events. (5) Drugs.
(6) Ward atmosphere. (7) Loss of prospects outside the institution, and
discusses the way in which these factors can be modified, and the stages
of rehabilitation by which the disease may be cured.
Other writers have called the condition âpsychological institutional â
ismâ, or âprison stupor, and many years ago Fenner Brockway, in his book
on prisons, depicted the type exactly in his description of the Ideal
Prisoner.
The man who has no personality: who is content to become a mere cog in
the prison machine; whose mind is so dull that he does not feel the
hardship of separate confinement; who has nothing to say to his fellows;
who has no desires, except to feed and sleep, who shirks responsibility
for his own existence and consequently is quite ready to live at othersâ
orders, performing the allotted task, marching here and there as
commanded, shutting the door of his cell upon his own confinement as
required.
This is the ideal type of Institution Man, the kind of person who fits
the system of public institutions which we inherited from the nineteenth
century, and it is no accident that it is also the ideal type for the
bottom people of that centuryâs social institutions in the general
sense. It is the ideal soldier (theirs not to reason why), the ideal
worshipper (Have thine own way, Lord/Have thine own way/Thou are the
potter/ I am the clay), the ideal worker (Youâre not paid to think, just
get on with it), the ideal wife (a chattel), the ideal child (seen but
not heard), the ideal product of the Education Act of 1870.
The institutions were a microcosm, or in some cases a caricature, of the
society which produced them. Rigid, authoritarian, hierarchical, the
virtues they sought were obedience and subservience. But the people who
sought to break down the institutions, the pioneers of the changes which
are slowly taking place, or which have still to be fought for, were
motivated by different, values. The key words in their attitude have
been love, sympathy, permissiveness, and instead of institutions, they
have postulated families, communities, leaderless groups, autonomous
groups. The qualities they have sought to foster are self- reliance,
autonomy, self-respect, and as a consequence, social responsibility,
mutual respect and mutual aid. When we compare the Victorian antecedents
of our public institutions with the orpins of working class mutual aid
in the same period, the very names speak volumes. On the one side the
Workhouse, the Poor Law Infirmary, the National Society for the
Education of the Poor in Accordance with the Principles of the
Established Church; and on the other, the Friendly Society, the Sick
Club, the Co-operative Society, the Trade Union. One represents the
tradition of fraternal and autonomous associations springing up from
below, the other that of authoritarian institutions directed from above.
Peter Townsend, in an interesting discussion of the current trend, N The
Institution and the Individualâ, The Listener 23/6/60), suggests that
the phenomenon of institutional neurosis arises from the deprivation of
family life in the sense of the frustration of the âneed to give as well
as receive affection and to perform reciprocal services within a family
or quasi-family groupâ. But must we not also conclude that it is not
merely the non-familial, but more especially the authoritarian character
of institutions which produces institutional types, not only among the
inmates, but among those who administer the institution?
Thus Dr. Barton declares that âit is my impression that an authoritarian
attitude is the rule rather than the exceptionâ in mental hospitals and
he relates this to the fact that the nurse herself is âsubject to a
process of institutionalization in the nurses home where she livesâ. He
finds it useless to blame any individual for âindividuals change
frequently but mental hospitals have remained unchangedâ and he suggests
that it is a fault of the administrative structure. Richard Titmuss in
his study of The Hospital and Its Patients attributes the âbarrier of
silenceâ so frequently met in ordinary hospitals to the effect on people
of working and living in a closed institution with rigid social
hierarchies and codes of behaviour.
... these people tend to deal with their insecurity by attempting to
limit responsibility and increase efficiency through the formulation of
rigid rules and regulations and by developing an authoritative and
protective discipline. The barrier of silence is one device employed to
maintain authority. We find it so used in many different settings when
we look at other institutions where the relationships between the staff
and the inmates is not a happy one.
and John. Vaizey, remarking that âeverything in our social life is
capable of being institutionalized, and it seems to me that our
political energies should be devoted to restraining institutionsâ says
that âabove all ... institutions give inadequate people what they want â
power. Army officers, hospital sisters, prison warders â many of these
people are inadequate and unfilled and they lust for power and controlâ.
In The Criminal and His Victim, von Hentig takes this view further:
The police force and the ranks of prison officers attract many aberrant
characters because they afford legal channels for pain inflicting,
power-wielding behaviour, and because these very positions confer upon
their holders a large degree of immunity, this in turn causes
psychopathic dispositions to grow more and more disorganised ...
Finally.. Dr. Bettelheim sees even Hoess, the Commandant of Auschwitz,
as a victim of the institution. âThat he never became a âmoslemâ was
because he continued to be well fed and well clothed. But he had to
divest himself so entirely of self-respect and self-love, of feeling and
personality, that for all practical purposes he was little more than a
machine.â
The profound changes which are coming or can be predicted in the social
care of the deprived, the disabled or the delinquent, cannot happen in
isolation. Just as progress in psychological investigation has proceeded
from the abnormal to the normal, so the process of critical evaluation,
must move from the special institutions to the general ones. The
criticism of the anti-human quality of institutions cannot remain
isolated in the field of social medicine or social pathology. Changing
attitudes in one must lead to the demand for a change in attitudes in
the other.
We may draw quite striking implications of this kind from a Ministry of
Education report, that of the Underwood Committee on Maladjusted
Children (1955). The Committee remarked that the regime in ordinary
schools is sometimes âa precipitating or contributory factorâ in
maladjustment Barbara Wootton makes extended comment on this in her book
Social Science and Social Pathology. Our reluctance, she says,
to examine the imperfections of our institutions as thoroughly as we
examine the faults, failings or misfortunes of individuals has also
other and curious consequences. Among them is the fact that, in cases
where individuals cannot adjust themselves to what exists, it is often
found easier to invent new institutions than to improve the old ...
Formidable administrative complexities, as well as, on occasion, strange
contradictions follow.
This process is well illustrated by developments in the field of
education and child training. One might reasonably suppose that the
primary function of the school was to train the child in the business of
adapting himself to the culture in which he has to live, and to help him
to make the best contribution of which he is capable in that culture ...
Notoriously, however, a certain number of children fail to adjust
themselves to the educational institution which is thus intended to
adjust them to life. Indeed it now appears that the ordinary school, far
from achieving the adjustment which is its normal aim, sometimes
actually has an exactly opposite effect.
She then quotes the findings of the Underwood Committee on what she
tartly calls âthese risks of exposure to the educational systemâ and she
goes on:
An obvious way of avoiding these catastrophes would seem to be to modify
the regime in the ordinary school so that it might succeed better in
what it is intended to do. But that is too difficult. On the principle
that it is easier to create a new institution than to modify an existing
one child guidance clinics and schools for maladjusted children have to
be invented to deal with the misfits of the normal educational system.
At these clinics, we are told, âas the psychiatrist comes to be acceped
as an ally ... the child is helped to bring his problems to the surface
and face them, and through his relationship with the psychiatrist he
gains the confidence needed to go forward and to meet whatever the
future has in store for himâ (she is quoting the Report).
Yet âgoing forward with confidence to meet whatever the future has in
storeâ is, surely, just what schools of every kind might be expected to
help their pupils to achieve; and the teacher, no less than the
psychiatrist, might be expected to be the childâs ally, not his enemy.
If in practice schools and teachers fail in these roles, commonsense and
economy alike would suggest that whatever is wrong with them should be
put right, rather than that a whole fresh layer of institutions should
be created to make good the deficiencies of those that we already have.
Yet the latter is apparently the easier course. So we end with schools
designed to supplement and to correct what ie done in homes, and clinics
or special educational institutions designed to supplement and to
correct what is done in schools ...
Though schools differ greatly from one another, it is probably fair to
say that those which are included in the public educational system (and
a high proportion of those outside it) are on the whole imbued with
authoritarian values and employ authoritarian methods. The virtues which
they inculcate are those of discipline and hard work, of respect for,
and obedience to, properly constituted authority. Children are at least
expected to behave politely and respectfully towards their teachers.
But not towards their psychiatrists. Typically, the climate of the
clinic is permissive rather than authoritarian: the roleâ of the adults
is to help, indeed to serve, not to command the children ...
Her remarks illustrate graphically the collision of two opposing trends
of thought, libertarian and authoritarian. The result can either be the
abandonment of the therapeutic approach altogether because it conflicts
with the authoritarian values of society as a whole, or in change in the
schools and change in the social values which dominate them.
Alex Comfort, in Authority and Delinquency in the Modern State, the most
important anarchist contribution to sociology since Kropotkinâs Mutual
Aid, makes a similar point in terms of criminology :
It is only within the last few years that psychiatry has been formally
invited by legal, administrative and executive authorities to intervene
in the problem of crime. It worked its way into penal and legal
procedure from the outside, by modifying public opinion and by throwing
light on problems of delinquency in the course of purely medical
studies, and the formal invitation comes when a generation of lawyers,
prison commissioners, and legislators has grown up in the intellectual
tradition which social studies have created. Psychiatry therefore brings
into its contacts with law a tradition of its own. cutting across the
preconceptions of law and government which come from the pre-scientific
tradition of society.
The attempt to establish criminology as a distinct branch of knowledge .
encounters immediate difficulties. Anti-social conduct and delinquency,
in the sense of action and attitude prejudicial to the welfare of
others, are psychiatric entities: crime, on the other hand, is an
arbitrary conception embracing both aggressive delinquency, such as
murder or rape, and actions whose importance is predominantly
administrative, such as the purchase of alcohol after closing time.
Since the concept of crime depends directly upon legislation it may be
altered at any time to embrace any pattern of behaviour. Under modern
conditions it is quite possible for the criminal psychiatrist to be
confronted with the task of reforming an individual whose conflict with
society arises from a high rather than a low development of sociality.
Refusal to participate in the persecution of a racial minority, or in
the military destruction of civilian populations, have recently figured
as crimes in civilised Western societies. Under these conditions the
independent tradition of the psychiatrist must lead him to decide at
what point the psychopathy of the individual exceeds that of society,
which he should attempt to fortify, and by what standards. More
important perhaps is the growing awareness that, great as is the
nuisance value of the criminal in urban society, the centralised pattern
of government is today dependent for its continued function upon a
supply of individuals whose personalities and attitudes in no way differ
from those of admitted psychopathic delinquents. Society, so far from
penalising anti-social behaviour per sc. selects the forms, often
indistinguishable, which it will punish, and the forms it must foster by
virtue of its pattern ...
In spite therefore, of the extent and seriousness of delinquency as a
social problem, its most serious aspect for humanity today is the
prevalence of delinquent action by persons immune from censure, and by
established governments. The importation of science into the study of
crime is an irreversible Mep, and its outcome can only be the
suppression of science itself or the radical remodelling of our ideas of
government and the regulation of behaviour.
Lady Wootton describes the clash between the therapeutic approach and
authoritarian values; Dr. Comfort puts it bluntly as a clash between the
therapeutic approach and government itself. Thus from the criticism of
the authoritarian, hierarchical, institutional structure of the
instruments of social medicine and social pathology, we move to the
challenge to authority and hierarchy in the institutions of society
itself.
The anti-human characteristics of the general institutions give rise to
the existence of the special institutions. Paul Tappan remarked that the
fact is that we prefer our social problems to the consequences of
deliberate and heroic efforts so drastically to change the culture that
man could live in uncomplicated adjustment to an uncomplicated world.â
But it is not so much the complexity of our culture as its
authoritarianism which is at fault : we need if we are to achieve the
most complete development of individuality, a complicated society, a
society (to go back to Kropotkinâs definition of the anarchist approach)
to which pre-established forms, crystallised by law are repugnant; which
looks for harmony in an ever-changing and fugitive equilibrium between a
multitude of varied forces and influences of every kind, following their
own course.
Are we ever going to make these âdeliberate and heroic effortsâ to
analyse and open up the general institutions â family, the school, the
factory, the wage system, the social divisions of class and status, the
industrial and commercial structure, the physical environment, the
bureaucracy, the state and the war machine and punitive apparatus which
are inseparable from it?
Take, for example the school. The changing relationships between parents
and teachers, parents and children, teachers and children, between work
and leisure, between education and play, could lead to an entirely
different conception of the school, âcalculatedâ as Godwin wrote (m
1797):
entirely to change the face of education. The whole formidable apparatus
which has hitherto attended it, is swept away. Strictly speaking, no
such characters are left upon the scene as either preceptor or pupil.
Or as Bakunin put it in 1870 :
From these schools will be absolutely eliminated the smallest
applications of the principle of authority. They will be schools no
longer, they will be popular academies, in which neither pupils nor
masters will be known, where the people will come freely to get, if they
need it, free instruction, and in which, rich in their own experience,
they will teach in turn many things to the professors who shall bring
them the knowledge which they lack.
Nobody took much notice of them, but In our own day a number of
experiments have foreshadowed the changed school in one way or more of
its aspects â the Cambridgeshire Village Colleges and the ideas of Henry
Morris, the Pioneer Health Centre at Peckham before the war, or
Prestolee School (which was an elementary school in Lancashire
revolutionised by its late headmaster Teddy OâNeil) where
timetables and programmes play an insignficant part, for the older
children come back when school hours are over, and with them, their
parents and elder brothers and sisters.
Or the ideas and practice of A. S. Neill and other pioneers of the
school as a free community of children and adults. Or the idea of the
school as an extension of the family, as a family centre in which,
according to the needs of the individual, the cohesion of the nuclear
family could be heightened or its tensions loosened, as a source of
autonomy and reciprocity, as a community workshop, as a centre for the
exchange of skills and experiences. The Peckham Experiment and its
findings about the positive aspects of health, was an immense source of
clinical material. âWe had found from experienceâ, wrote the Peckham
biologists, âthat seven out of ten uncomplaining members of the public
entering our doors had not even the negative attributes of health â
freedom from diagnosible disorder. Still less had they the positive
attributes â vitality, initiative and a competence and willingness for
living.â It is these very qualities that the special institutions we
have discussed are found to have inhibited. And significantly the social
environment with which the Peckham biologists sought to release these
qualities was, in the words of the founder, Dr. Scott Williamson, âa
sort of anarchyâ.
Or take housing. One quarter of the population of England and Wales live
in the three-and-a-quarter million dwellings owned by local authorities.
But is there one municipal housing estate in this country in which the
tenants have any control over and any responsibility for the
administration of their estate, their physical environment? Or industry,
with its authoritarian structure, its hierarchical chain of command and
its meaningless routines. Does not the industrial neurosis (like the
âsuburban neurosisâ of lonely housewives) which has so often been
diagnosed bear a significant relation to Bartonâs institutional
neurosis? When are we going to evolve a programme for the
de-institutionalization of the factory system (see Anarchy 2 â Workersâ
Control). When for that matter, are we going to de-institutionalize the
trade union movement? Or work itself. Occupation is so rigidly
institutionalized that it is impossible to move from one occupation to
another without being economically penalized, and virtually impossible
to enter many occupations at all unless you do so on leaving school. Why
should people condemn themselves to a lifetime in one occupation. why
not an outdoor job in. the summer and a nindoor one in the winter, or an
alternation of brain work and manual work? Why, in fact, do we ask so
little out of life?
Because of the process of conditioning that begins in infancy to make us
fit the institutions. Bettelheim noted that the âoldâ prisoners, those
who adapted successfully, sought to look and behave as much like their
guards as possible and developed the same brutality and ruthlessness.
And J. A. C. Brown in The Social Psychology of Industry observed that
the âfaithful servantâ type of employee was the one who had been so
browbeaten throughout his life that he had adopted the values and
attitudes of management â which is precisely why he was appreciated.
Institutional society successfully imbues people with its values so that
they mindlessly perpetuate the institutions. They become tolerant, in
the medical sense, of the intolerable.
Rene Cutforth illuminated this point beautifully in his radio programme
about the motives and characters of people on the Aldermaston March :
Consider for a moment the times we middle-aged men have lived through in
this monstrous century. First the huge terrible casualty lists of the
First World War. Then the mass unemployment, the misery, and the
injustice of the early Thirties. Then the spectacle of Europe under the
heel of a murdering maniac, Belsen, Auschwitz, the Jews in the gas
chambers. Then another war. Then Hiroshima and Nagasaki. And finally for
us, an exhausted, meaningless state, intent on the âlollyâ.
In medical matters thereâs a principle called tolerance. If some poisons
are fed to a human being over a long period he acquires a tolerance of
them, and can survive a lethal dose, though his whole metabolism may
have to change to meet the challenge. The young are those who have so
far never breathed the poisons we have had to try to contrive to
survive, and their minds are unclouded with them.
With every increase of tolerance we have lost a human sensitivity. And
now it seems quite possible that these marchers, whatever their impact
on the bomb, or the future impact of the bomb upon them, these
Aldermaston marchers may well already be the only people left alive in
Britain.
The rest, he implies, like the institutionalised patients and victims,
have lost the capacity to react.
This is why the trend which we have examined in the philosophy of social
welfare seems to me so important, and to imply very much wider
conclusions. Social ideas, says Richard Titmuss, âmay well be as
important in Britain in the next half-century as technical innovationâ.
We are moving away from an institutional philosophy, says Peter
Townsend, âand have not yet found an alternative philosophy to put in
its placeâ. I believe that the alternative philosophy is one which seeks
to release the spontaneity, individuality and initiative, the
unsuspected human potentialities, which an authoritarian society has
buried in institutionalized life, and that the pioneers of the
break-down of institutions are part of a broader struggle between
opposing values, which may legitimately be called the struggle between
anarchists and bureaucrats.