The Rise of Asylums

Asylums dominated the care and treatment of people with mental ill health for over a century. Towards the end of the twentieth century, in the UK, Europe and America, asylums were replaced with the new policy of care in the community. It has been over 200 years since the introduction of the 1808 County Asylum Act, which authorised county and borough authorities to use public money to build asylums in Britain. The rise of the psychiatric asylum represented a rejection of outmoded practices that saw people with mental health problems relegated to the workhouse, private madhouses or prisons. 

The County asylums were to represent the principles of moral treatment, putting emphasis on both the social and physical environment and the healing power of everyday relationships as key to recovery, achievable within an ordered, secluded and generally rural environment, away from the stresses of emerging industrial society. The new asylums were built on open landscapes with extensive grounds to house sports pitches, gardens and farms to influence the wellbeing and restoration to health of the inmates.

Mapperley hospital in the city of Nottingham opened in 1880 and closed its doors in 1994. Half of the hospital has been repurposed into luxury flats, whereas the other half of the hospital houses the headquarters of Nottingham Mental Health Trust. The hospital was designed by George Thomas Hine, one of the foremost asylum architects on the 19th century who achieved national recognition for the design of local authority hospitals for the treatment of people with mental ill health. Mapperley hospital was built on an initial 30 acres of land and 20 more acres were added afterwards. The architecture and planning of Mapperley asylum was meant to influence the wellbeing and restoration to health of the patients.

The County Lunatic Asylum at Radcliffe, later known as Saxondale hospital, opened in 1902 and closed in 1988. The hospital estate was turned into luxury flats in the 1990s. The hospital was set in 130 acres of land, made up of extensive gardens, grounds and woodland; located on a hill, 8 miles from the city of Nottingham. The asylum seemed to have reflected the ideas of the time to provide a place for patients to recover, from the outset relatives were allowed to visit twice per week; patients were allowed to take walks in the grounds and be granted home visits for up to four days at a time.

Overcrowding overshadowed the 19th century ideal of the County asylums as places of refuge and rehabilitation, which reduced them to custodial and prison-like environments From mid-18th to the early 20th century, the organisation of the asylum was dominated by the ideas of regimentation, classification and separation as a means to control large populations, designed to induce passivity and dependence. Life in the asylum was defined by strict segregation, classification, routines, and methods of treatments.

Public concerns about ineffective and overcrowded regime of the County asylums including wrongful detention led to the 1930 Mental Treatment Act. The Act introduced voluntary admission and a greater focus on treatment and therapy. The 1930 Act changed the statutory name of asylums to mental hospitals; it also signalled the end of segregation but it still emphasised asylum-centred services for people with mental ill health. In 1930 a nationwide network of asylums had developed, 98 asylums were built, housing 120,000 patients; by mid-1930s 90% of patients continued to be detained on a compulsory basis and the number of long-stay elderly patients continued to increase.

Community Psychiatry in Nottingham

The Nottingham mental hospitals experienced great changes in the period following the Second World War. Duncan Macmillan, the last medical superintendent at Mapperley hospital (1941-1966), was a progressive psychiatrist who began programmes of reform, rehabilitation and deinstitutionalisation in Nottingham ahead of the rest of Britain, introducing the open-door system at Mapperley hospital in 1952. Macmillan became Medical Officer for the city of Nottingham in 1945, putting emphasis on prevention and early treatment of mental ill health. He was also responsible for clinical developments for the care of older people, namely psychogeriatrics. The development of support based in the community followed, including both short-term assessment, long-stay care and a geriatric day hospital from the mid-1950s onwards. It was reputed to be the first day hospital opened in the country to cater for long-term patients living in community.

The pattern of hospital use changed from a most basically long-stay institution into an institution in which most of the patients left very quickly after admission. Long-term stays in the community, interrupted by short term episodes of hospitalisation in periods of crisis, replaced long-term hospital stays. An early form of multi-disciplinary team working was developed through the integration of medical and social services to provide for the psycho-social needs of patients living in community. Psychiatric nurses began to work alongside psychiatric social workers from 1948 onwards which included pre-admission home visits. The emphasis was on the importance of the social environment by working with the family of people with long-term severe conditions. Early care in the community developed by moving long-stay patients out to the community and thereby reducing the number of beds in the long-stay wards. There was a significant reduction in the proportion of mental health patients who were admitted to hospital. Nurses working at Mapperley hospital in the 1960s recalled that the status of all patients changed from compulsory to voluntary with the advent of the 1959 Mental Health Act.

Global Impact

The impact of Macmillan’s community psychiatry from 1950s onwards is collectively remembered as a revolutionary legacy that improved psychiatric care in Nottingham before all other hospitals in Britain. The introduction of the open-door policy also attracted the interest of reformist psychiatrics from all over the world who visited the hospital in the 1950s. Ernest Matsner Gruenberg was an American psychiatrist who pioneered community mental health services in the late 1940s in the US. In 1981 he wrote a memorial of his friendship to Duncan Macmillan, describing him as one of the most important teachers in his career. When Gruenberg heard that Macmillan had improved the outcomes of mentally ill patients by removing all looks and security at Mapperley Hospital, he travelled to England in the late 1950s to see for himself. Although initially sceptical about the reported success of Macmillan’s own brand of community psychiatry, the experience taught him that patients in the hospital did not need such severe confinement, common in mental hospitals at the time. He recalled:

Gruenberg had never seen a mental hospital run with such openness before and, like other psychiatrists that had visited the hospital, he was amazed at the absence of conspicuous disturbance anywhere

Psycho-social Treatments

Macmillan made efforts to ameliorate care practices at the hospital by taking into consideration social and environmental factors in supporting recovery from mental ill health. Social rehabilitation was embraced from the 1950s onwards at the Nottingham mental hospitals, encouraging a psychotherapeutic atmosphere by introducing volunteering such as the League of Friends, a hairdressing salons, occupational and industrial therapy units and recreational activities such as sports and holidays.

Open days were instituted from 1952 onwards in an effort to reduce the stigma associated with the hospital site and to encourage greater cooperation between the patient and their families. These open days were an attempt to change the public perception of the hospital from a place of containment to a place of rehabilitation. Some of the therapeutic developments from 1948 onwards reported at the Nottingham mental hospitals included the emphasis on psychotherapeutic treatment in the form of group and individual therapy sessions designed to encourage patients to function as ‘social beings’. The influence of therapeutic community principles on staff-patient relationships improved the social environment at the Nottingham mental hospitals, transforming the hospital from a custodial to a therapeutic environment, where therapeutic relationships between staff and patients were seen as the key element of the recovery process.

The Introduction of Community Care

The policy of community care in the late 20th century centred on the hospital being no longer viewed as the preferred location for inpatient care, instead care was to be provided through developing services for every stage of the illness in community. This included hospital beds for both acute and chronic patients needing medical or psychiatric care, as well as residential and half-way accommodation, day hospitals, and health and welfare services, heralding integration rather than separation from the community.  

The National Health Service and Community Act 1990 aimed to introduce a new approach to public service management in order to put residential care on an equal footing with community-based options; it documented the cost ineffectiveness of residential care, ensuring its rapid reduction. It was the beginning of the demise of public residential provision as a whole through closure and sale of facilities. Most hospital sites were sold to private investors and redeveloped into luxury flats although a few hospitals retained parts of their buildings for the re-provision of inpatient and outpatient mental health related services. Successive governments continued their commitment to cutting public sector expenditure, which had a drastic effect on mental health care provision. Services for long-term residential care for people unable to manage in the community were never properly developed, prompting the government to acknowledge the failure of the community care model.

Care in the Community in Nottingham

The National Health Service and Community Care Act 1990 introduced a broad requirement for local authorities to help vulnerable adults remain in the community, preventing or delaying admission to institutional care with the view of closing down the mental hospitals nationally. The new focus in mental health policy was to encourage people with long-term mental health problems to live independently in the community. The idea was that individuals suffering from mental health problems should go to the general hospital to be treated like any other illness.

In the mid-1980s, Nottingham mental health services developed the Rehabilitation and Community Care Service (RCCS) to provide multi-disciplinary teamwork to support long-stay patients to move out of the institutions and into the community and provide community care to younger service users. Contemporary researchers identified as important in providing adequate care in the new care system through taking a new holistic approach to mental health recovery. There was a substantial expansion of social workers and occupational therapists in mental health services, working with psychiatric nurses to create multidisciplinary teams. RCCS became a national demonstration centre that lead the way to a more recovery focused approach to mental health ahead of the rest of the country. In the mid-1980s the Nottingham Advocacy group was one of the first service users group to develop in England, preceding the professionals’ acceptance of service user-involvement. During and after the closure of the mental hospitals, six mental health teams operated across Nottingham; some rehabilitation day services were set up to provide re-skilling for long-term service users such as SPAN. With the passing of time, gradually most services were reduced or removed due to cuts to mental health budgets, including day centres designed to provide psycho-social support for people with long-term mental ill-health.

You can learn about the changing dimension of the provision of care in Nottingham through the oral histories of former nurses, social workers and carers.