by Amy Munson- Barkshire
A Dissertation submitted as a course requirement of the CNAA for the M.Sc. in Sociology, at the Polytechnic of the South Bank 1981
The aim of this dissertation is to consider the kinds of recurrent behaviours and practices, attending the care of persons designated as chronic ‘patients’, which when visible to the population outside care institutions are intermittently perceived as deviant and labelled scandalous. The concern is to elucidate who perceives what kinds of circumstances as social problems, what processes are set in motion to investigate the truth of allegations and causes of malpractices, and to consider the impact of official responses. The organisation and structural location of custodial institutions, historically and in the context of the modern Welfare State in a capitalist economy, are examined to gain understanding of how and why such scandals are produced and reproduced. This requires reference to the nature and ideologies of the medical and para-medical professions and staff-patient relationships. The argument is that given the existence of professional dominance, chronic sector inmates represent in an extreme form the subordination and vulnerable status of the social category, patient.
Within recent years there has developed growing public awareness, aided by media coverage, of forms of behaviour nominally non-criminal but socially unacceptable, thus constituting a problem which calls for action. Some of the perceived maltreatment occurs in informal settings, amongst ordinary people. Instances include child abuse, battered wives, and granny bashing. Other forms of problematic behaviour are quasi-legal forms of violence in institutional settings. If there are no actual laws or rules legitimating the behaviour, it is usually justified by custom and practice. Caning of school children has a long tradition supported by upholders of law and order, but deplored by others.
Institutionalised violence also occurs in the treatment by police and prison officers of convicted and putative offenders. The focus of this dissertation is the perceived maltreatment of chronic hospital patients by staff on ‘back wards’. Examination of the normative properties of the concept, scandal, and the social conditions under which it is assigned to the care of certain categories of ‘socially troublesome people’ is a necessary prerequisite. Social relationships between different levels of staff, between staff and patients, the ward sub-culture and organisational features which affect patterns of behaviour will be discussed. One must also take account of attitudes, actions and decisions made at secondary levels of the NHS, including the Welfare State apparatus of central government, in the context of contemporary post-industrial capitalism.
In the first chapter, I shall examine the nature of normative rules and their relation to the perception of social problems and social policy development generally. The application of this theoretical perspective to the care of chronic Patients will follow. A general understanding of moral rules, how conflicting values give rise to “problems” and the restraints operative which affect their “solution” should illuminate the processes involved in the making of hospital scandals. An indication of the issues raised will be outlined and developed more fully in subsequent chapters.
Three stages in the medicalisation of deviance constitute the second chapter. The third surveys the literature on chronic hospitals and prevalent practices, indicating the concerns of social scientists, medical practitioners and government committees. Social science literature has been critical of the care provided. The word, scandal, is not necessarily used, but the discourse generally implies or asserts that practices are negatively evaluated. Phrases such as “mortification of the self”, dehumanizing process, or ‘the snake pit’ are not value free.
Limitations of space preclude a full discussion of the ontological status of illness, particularly mental illness. One is cognisant of the ongoing debates underlying disputed claims that psychiatry is a medical specialty dealing with disease entities. Much of past and continuing criticisms of psychiatry are based on unease with both the medical model and expansion of its application for social control of a range of behaviours formerly the province of law or religion. The issue of “the proper boundaries of medicine and the extent of its legitimate control” are pertinent. Scandals investigated by members of government committees of inquiry, past and present, assume the medical mandate claimed by the profession is valid. Most medical and para-medical staff working in mental hospitals do likewise.
Although contemporary mental health services date from 1959 documentation from earlier periods will be used to illustrate how the same issues resurface. The series of official reports reflect the concerns of sociological literature. Sophistication and thoroughness of inquiries increases over time. Explanations of ‘what went wrong’, conclusions and recommendations and lack of success in effecting significant change reflect the centralist/managerialist ideology of the NHS, power of professional hierarchies and largely symbolic rhetoric of policy pronouncements. These centralist assumptions are in contrast with the everyday reality of ward life. The social reality of the micro-social system is a very different construction to that envisaged by chair-bound administrators or the occasional visitor who crosses the boundary into back wards to view a specially presented and prepared enclave.
Some impressions from an observational study at a psycho-geriatric unit are included in footnotes. I felt an opportunity to observe at first-hand would usefully complement other sources, but limitations of space prevent discussion of findings. Finally this dissertation raises questions about the appropriateness of the continued use of a medical rather than a social/educational model. The former still dominates although language in recent reports and policy statements is shifting, and advocating community care. Whilst ‘decarceration’ locates the person outside the hospital, this does not mean provisions are available to support individuals or their families, or that alternative residential institutions are proof against the occurrence of scandals.