The central question of this important book is best expressed in Barham's own words: 'The question to pose today, therefore, is whether we are in a position to resolve the historical problems of the marginalised and excluded mental patient... to provide a systematic revaluation of mentally disturbed people and their place in social life. Or is it more likely, we shall need to ask, that policies of deinstitutionalisation are fated to find themselves in thrall to the same conflicts and pressures in modern society that have kept the mad apart and underlined their 'differentness'?'

That this question represents today as profound a challenge to mental health policy-makers and practitioners as it did when it was originally posed by Barham in the first edition of this book underlines its significance. Through insightful and clearly argued chapters, Barham traces the history of the institutionalisation of people with mental illness in order to establish the origins and consequences for users of the notion of 'mental patienthood'. He suggests that therapeutic pessimism still pervades professional attitudes, and that as a consequence staff too often accept 'a highly impoverished view of the former mental patient in the community'. If this marginalisation and pessimism continues, it is my view that community mental health teams will be reduced to monitoring the threadbare lives of one of the most socially excluded groups in our society: they will become the custodians of the virtual long-stay hospital, and users the reluctant inmates.

Writing in 1992, Barham described the 'contract culture' in health and social services as holding out the promise 'of a framework for social care which parts historical company with narrow patient-bound conceptions of the subjects of care and locates healthcare needs within a richer and more nuanced understanding of the social needs of the person'. In the new, and for me disappointing, concluding chapter added for the second edition, Barham does not return to explore how far this promise has been fulfilled.

More surprisingly, he does not examine the potential of a Labour government committed to tackling social exclusion, offering the hope of a genuine challenge to the double exclusion of people who are both poor and have a history of serious mental health problems. Elements of the New Deal - for instance, the disability strand of the welfare to work programme - open up the prospect of mental health service users being given a chance to surmount the most significant obstacle to enhanced community membership: the lack of a job.

However, Barham's analysis alerts us to one of the most disconcerting aspects of the re-integration of the mental patient back into the mainstream of life. The problem around users gaining work, for example, may not lie with the users (who, research suggests, want to work) or the employers (who, research suggests, have positive experiences of offering them employment) but rather with the professional staff paid to treat and care for them.

Notwithstanding the occasional lapse into familiar generalisations unsupported by evidence - 'the policy of 'community care' has to a considerable extent been brought into disrepute as a cover for an elaborate cost-cutting exercise' - and the failure to bring the same sharp intelligence to bear on the new material which he applied to the original research, Closing the Asylum remains required reading for anyone involved in mental health. For managers, it must raise crucial issues about their contribution to transforming the lives of users from paupers to employees, and from patients to citizens, now that the age of the Victorian asylum is drawing to a close.


Director, centre for mental health services development, King's College London.