From incarceration to decarceration : care in the community in two hostels for the homeless
This thesis is based on an ethnographic study of the way in which care in the
community was delivered in two privately run specialist hostels for homeless
people. One was for people recovering from severe mental illness, the other for
people with addiction to alcohol. Medication was a significant part of the intended
therapy and its use and management was rooted in the wider culture of the two
The study aimed to understand what care in the community meant for the lives of
the people who lived in these hostels.
I set out to discover what kind of care such hostels were providing and to evaluate
the provision against the aspirations expressed in the community care legislation
and guidelines. The main aims of care in the community included: a reduction in
the numbers in hospitals, a reduction in the negative effects of institutionalisation,
improving standards of accommodation, humanising the care, developing more
psycho-therapeutic approaches, recognising the civil rights of vulnerable groups,
directing the right services to the right people who needed them, develop systems
that ensured the CO-ordination and continuity of care and involving service users in
formulating, implementing and reviewing care.
The model of care espoused in both hostels was skills-based rehabilitation towards
independent living but analYSis of the data evoked enduring aspects of the culture
of care that echoed life in Goffman's (1961) "Asylums".
While much had changed in the physical environment and in the expressed
objectives by staff data collected from participant observation and interviewing fell
broadly into two categories: staff practices that worked in harmony with residents'
patterns of needs and those that repeatedly resulted in control and conflict.
Medication use had to be seen in this context. Analogies could be drawn with what
Goffman (1961) conceptualised as "privileges" and "mortifications". Further
similarities with Goffman's study were apparent in the way hostel staff rationalised
their actions. Goffman's approach to "career" and "stigma" were also used in an
analysis of discourses in the social life of the two hostels. I drew on Foucault's
(1967, 1982) work on discourse to make links with power and knowledge
structures in relation to mental illness. Two discourses were evident; one based on
risk-as-danger and stigma and the other on liberal independence and integration.
Risk-as-danger discourses were dominant. This discursive framework also links to
wider policy and practice, including legislation and guidelines. The notion of
surveillance (Foucault 1977) adds further insight into the issues of danger, control
I argue that these continuities reflect a culture of control that has transcended the
closure of the total institution. I locate the causes in social stigma, the
unaccountable autonomy of hostel managers, the lack of staff training and a model
of rehabilitation that focuses on basic domestic tasks, rather than specific
therapeutic interventions appropriate for individual recovery. The conflict around
medication, the mistrust of care givers and the breaks in the continuity of care
when residents moved to independent living tended to lead to relapse and
readmission to hospital. Although residents benefited greatly from the social
relations they developed with one another.