The Difference Between Prison and Institutions
Institutions are far worse than prisons and yet we have not weaned ourselves from using them to exclude and abuse people. We've not made people aware of how unnecessary this all is.
Yes, because in prison at least you know where you stand. You have a sentence - till the whistle blows. Of course, they can always tack on another sentence, but they don't have to, and in principle you know that sooner or later they're going to let you out, right? Whereas in a mental institution you're totally dependent on the will of the doctors...
Joseph Brodsky in conversation with Solomon Volkov
In the UK we remain totally complacent about the basic abuse of people's human rights by the excessive use of institutions and hospitals. We seem immune to the fact that there is no evidence that these institutions work and only too much evidence that they fail: encouraging abuse, suicide, depression and increasing problems for their inmates.
I recently came across an honest assessment of the true problem from R D Laing:
It is not easy. What do we do when we don't know what to do? I want that guy out of sight, out sound, out of mind… The situation keeps cropping up in our society, when no matter how liked, esteemed or loved, some people become insufferable to others. No one they know wants to live with them. They are not breaking the law, but they arouse in those around them such urgent feelings of pity, worry, fear, disgust, anger, exasperation, concern, that something has to be done. A social worker or psychiatrist is 'brought in'.
This is honest, but also frightening. Is this really the best we can do?
My own experience is that there is much we can do to avoid the path to institutionalisation and much we can do to help people escape institutions. But the forces that keep these institutional arrangements in place are immense. A recent study showed that 'out of area institutional placements' were costing the NHS £175,000 per head. This is money that is being invested in abuse and wasted lives.
It is not the economics of rational commissioning that keep institutions going - it is the fear and anxiety that Laing describes. Professionals, families, sometimes even the individual themselves, all lose faith in the possibility of any sensible solution. The existing community care support offerings are woefully inadequate and for many people they quickly breakdown:
- Day centres that lead nowhere and which are often boring and fruitless
- Care homes that force people to live in groups they don't choose
- Domiciliary care that works to its own rules and its own time tables
In other words we force people to fit into systems that work to their own institutional logic, and then we blame the person for failing to fit in. When these 'community care' solutions fail we then send the person even further away to an institution that will fail even more dramatically - at greater expense - but at a 'safer' distance. The very fact that we spend so much money is perhaps partly a salve to the conscience: look we care - see how money we are prepared to spend!
Brodsky (who was forced to live in both prison and the institution for refusing to accept the justice of the USSR) rightly observes that with the institution there is no time limit to this madness - in the institution imprisonment can be endless.
The question then arises: Why could we not start by actually working with the individual, their family and their community, to provide what really does work? Instead of abandoning them we could work with them to find solutions that strengthen them and those that care about them.
Those of us who have worked in this way know that it works. What will it take to encourage the system to defend human rights and develop personalised support?