Chapter 2 (In ‘Cabbage Syndrome’: The social construction of dependence, Colin Barnes



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Chapter 2 (In ‘Cabbage Syndrome’: The social construction of dependence, Colin Barnes (1990) The Falmer Press, pp. 17-39)

The Emergence of Day Centre Provision for the Younger Physically Impaired

It is often said that in Britain we have a tradition of welfare policies which separate dependent minority groups such as the physically impaired into segregated institutions (Manning and Oliver, 1985). It is a tradition, which although evident in the Middle Ages, became more widespread as a result of the Poor Law reforms of the nineteenth century. This tradition remained unchanged until the 1950s when 'community care' emerged as an official policy objective in government statements. In the following decades a number of services, including day centres, were developed to achieve this end.

My primary objective in this chapter is to draw attention to the principal similarities and distinctions between two particular forms of provision for the physically impaired. They are the 'traditional' residential institutions and the modern day centres. To complete this task the rest of the chapter is divided into four separate sections. The first focuses on the origins of English social policy for this group of people. The second covers the rise of institutional segregation and the differentiation of 'disability' during the nineteenth century. The third outlines the shift toward 'community care' and the establishment of day services for adults. The fourth section chronicles the emergence of the day centre, identifies its principal types, and discusses the major criticisms levelled at these structures from the perspective of the perceived needs of the young physically, impaired. The chapter concludes with an assessment of day centres for the disabled in relation to previous forms of provision. It is contended that like that of their precursors, the residential institutions, their development can be best understood as a social and political response to the growth in the number of individuals who, because of impairment, are excluded from the world of work, though this increase is partly a result of the social construction of disability.

The Origin of Social Provision for the Disabled

How a society treats individuals with impairments is closely related to the meanings it assigns the causes of those impairments (Miller and Gwynne, 1972).


In all societies the impaired, particularly the physically impaired because of their visibility, are perceived as abnormal in the purely statistical sense of belonging to a minority group. And although it may be argued that our attitudes to abnormality are coloured by deep-rooted psychological suspicion of the unknown, it is generally accepted that our perceptions of normality are partially if not wholly determined by others through the process of socialization and the transmission of ideology or culture. For Mary Douglas, culture

in the sense of the public, standardized values of the community,

mediates the experience of individuals. It produces in advance

some basic categories, a positive pattern in which ideas and

values are fully ordered. And above all it has authority, since each

is induced to assent because of the assent of others (Douglas,

1966, p. 39).

While it may be correct that individuals' perceptions of normality vary slightly, at the structural level cultural values are invariably more rigid.

Although there is evidence to suggest that in some non-occidental societies the meanings attached to the causes of impairment were arbitrary and those affected were fully integrated into the community (Hanks and Hanks, 1948), in the cultural and historical precursors to our own society there has been a consistent bias against impairment and disability. Examples are found in religion, Greek philosophy and European drama and art since well before the Renaissance. In the Old Testament, much of Leviticus is an articulation of the physical perfection deemed necessary for participation in Christian ritual (Douglas, 1966). While the ancient Greeks and the Romans placed a high precedent on the care of those disabled in battle, they were enthusiastic advocates of infanticide for deformed or sickly infants (Tooley, 1983). Shakespeare's depiction of Richard III clearly demonstrates the perceived association between physical deformity and evil. In the England of the Middle Ages, the impaired were viewed with a number of attitudes ranging from, at worst, fear and degradation to, at best, paternalism and pity. They were excluded from the mainstream of economic and social activity and were dependent on the benevolence of others.

Until the seventeenth century the impaired, along with such other dependent groups as the sick, the aged and the poor, relied almost exclusively on the haphazard, and often ineffectual, traditions of Christian charity and alms-giving for subsistence. Although disenfranchising them from religious ceremony, Christianity, like the other leading western religions, has traditionally acknowledged responsibility for the care of the disabled. During this period, however, as in the rest of Europe, the authority of the English clergy was greatly diminished by a series of confrontations between the church and the monarchy. These led to a decisive subordination of the former to the latter, which reduced the church's role in civil society. Monastic land was seized and redistributed and in consequence its ability to provide for the indigent classes was radically reduced.

The responsibility for provision shifted toward the emerging class of landowning gentry whose power replaced that of the feudal lord and the ecclesiastical elite (Trevelyan, 1944), But neither the monasteries nor private individuals made any serious attempt to match aid with need, or to provide an organized response to specific areas of dependency, It was generally accepted that this form of calculated, measured response was alien to a society where the urge to give to others was subject to the individual's felt need to ingratiate her/himself with God and thus ensure salvation (Scull, 1984), Impaired people were rarely lumped together under one roof, notwithstanding the probability that the most severely disabled were admitted to one of the very small medieval hospitals in which were gathered the sick, the bedridden and other 'honest folk' who had fallen into poverty. The ethos of these establishments was ecclesiastical rather than medical. They were devoted to care rather than cure (Scull, 1984). Throughout this period, however, there was a general increase in the numbers of people cut off from' normal' economic activity.

Between 1500 and 1700 England experienced a dramatic growth in the general population following a century and a half of stagnation and occasional depletion due to plagues. At the same time commercialization of agriculture and the spread of the enclosure system meant that employment opportunities in the countryside were diminishing. Successive poor harvests were also blamed for unemployment. As food prices went up, people had less to spend on manufactured goods and therefore jobs in the textile and manufacturing industries were reduced. There was also an influx of immigrants from Ireland and Wales. Wars, too, were cited for the increase in vagrancy, although accounts of the effect of war were often contradictory. Some theorists argue that a decline in local conflicts eliminated one of the principal social mechanisms for soaking up large numbers of restless males. Others suggest that too much war caused large numbers of injured and jobless soldiers to be released into the general population without financial support (Stone, 1985). All through the early Tudor period the fear of 'bands of sturdy beggars' preyed on the minds of local magistrates (Trevelyan, 1944). This inevitably stimulated a political response from the central royal authority.

Prompted by the need to maintain order, secure allegiance, and establish a more secure foundation for the newly heightened monarchical power, the Tudor monarchs came under increasing pressure to make some sort of economic provision for the poor. The passage of the Poor Law Act of 1601 marks an initial official recognition of the need for state intervention in the affairs of the destitute and the disabled. Parishes were now empowered to levy taxes to provide funds for the relief of the poverty-stricken. And although it is clear that Section 1 of the Act makes explicit reference to providing special facilities for the lame, the infirm and the blind, it is generally accepted that little effort was made to separate and define the various classes of the needy considered deserving of aid (Stone, 1985). Provision was also hampered by bureaucratic constraints concerning eligibility. Notably, there was already an institutionalized suspicion of those claiming to be unable to work and seeking alms. This was legally expressed in the statute of 1388 which mandated local officials to discriminate between the legitimate recipients of charity and those suspected of feigning impotency to avoid work.

In consequence of the traditions of restricting aid to people within the parish boundaries, a practice enforced by law in 1622, as many as 15,000 separate local administrations were involved in the management of the dependent (Scull, 1984). Although there was much scope for local discretion, there was a high degree of uniformity in the way the problems posed by impairment were dealt with at the local level. Every effort was made to keep the senile, the blind and the infirm within the community. The largest resources were directed toward 'household relief for individuals confined to the home. So intense were the pressures to achieve this objective, that funds were frequently provided to those willing to take on the responsibility for others unable to care for themselves. Major changes in this essentially non-institutional approach to the treatment of the impaired did not begin to be discussed or implemented until the nineteenth century.

The Shift Toward Institutional Care

Throughout the eighteenth century the practice of segregating the most severely disabled members of the community into hospitals and similar establishments was gradually extended to other sections of the indigent classes, until there was a general tendency to segregate them all into institutional settings (Stone, 1985). Consequently there was an unprecedented growth in the construction of institutions. Jones and Fowles have defined an institution as

Any long term provision of a highly organized kind on a residential

basis with the expressed aims of 'care', 'treatment' or 'custody'

Jones and Fowles, 1984, p.297).

These included hospitals, asylums, workhouses and prisons.

One explanation for the incarceration of the disadvantaged links it to the breakdown of earlier forms of poor law relief in the face of urban industrialization and the huge problems of poverty that ensued (Mechanic, 1964). It has been shown, however, that the impetus to build institutions was not associated in time and place with the expansion of English cities. It invariably preceded it and was frequently most pronounced in rural communities (Ingelby, 1983). A variation on this theme is posited by others, who see the incarceration of the impaired as a direct result of the transition from traditional agriculture and! or cottage-based industries to the factory system.

The spread of factory work, the enforced discipline, the time

keeping and the production norms, all these were a highly

unfavourable change from the slower, more self determined and

flexible methods of work into which many handicapped people

had been integrated (Ryan and Thomas, 1980, p. 101).

These accounts tend to play down or ignore the general moral ambivalence concerning disability that existed before the industrial revolution. A more radical approach looks specifically to the relations of production, in particular the spread of wage labour. Firstly, a family dependent on wage earnings could not provide for its members in times of economic depression, so that large numbers of dependents were created by the new system. Secondly, the Elizabethan system of parochial relief was directly at odds with the ascending liberal market economy.

To provide aid to the able-bodied threatened to undermine in

radical fashion and on many different levels the whole notion of a

labour market (Scull, 1978, p. 37).

Wage labour made the distinction between the able-bodied and non-able-bodied poor crucially important, for parochial relief to the able-bodied interfered with labour mobility. Segregating the poor into institutions had several advantages over domestic relief: it was efficient, it acted as a deterrent to the able-bodied malingerer, and it could actually create labour by instilling good work habits into the inmates (Ingelby, 1983). These considerations are reflected in the conclusions of the Report of the Poor Law Commission and the Poor Law Amendment Act of 1834 which succeeded it.

The 1834 Poor Law reforms introduced three new principles in welfare policy: national uniformity in welfare administration, denial of relief outside the workhouse, and deterrence as a basis for setting welfare benefit levels (Stone, 1985). However, these three principles were not implemented immediately and never fully.

At the beginning of the nineteenth century the administration of services varied radically at the local level. Centralization was, therefore, deemed necessary to discourage movement by workers in search of better welfare benefits or more generous treatment by Poor Law officials in other parishes. It was also believed that this policy would encourage labour mobility. Because aid was set at subsistence level only, and the treatment of the poor was to be universal, workers would go where the work was in search of higher wages. But Parliament set the minimum of guidelines and the policy was submitted to local officials by the Poor Law Commission through a series of circulars and orders. Consequently a high level of disparity between parishes continued.

As early as 1722 Parliament had granted local authorities the right to deny provision to anyone refusing to enter a workhouse, but the Amendment of 1834 went further by expressly prohibiting the provision of 'outdoor relief', or provision outside a workhouse. Stone (1985) has shown that this instruction was never strictly implemented. Until 1870 fewer than one-fifth of all adult able-bodied male paupers and no less than 15 per cent of all the destitute were on indoor relief, that is, confined to an institution.

Deterrence was evident in the principle of 'least eligibility', which stipulated that a pauper's situation should be less comfortable than that of an 'independent labourer of the lowest class' before relief could be granted. The workhouse was intended to be as unpleasant and unattractive as possible so that no one would enter it voluntarily. Families were broken up, inmates were made to wear special uniforms, there were no recreational facilities and socializing was strictly forbidden during working hours.

Routines were rigidly enforced and food was, limited to what was considered necessary for survival and work.

Stone (1985) has argued that these conditions were mitigated for certain groups since a number of regulations which succeeded the 1834 Act show there was a deliberate policy of exempting specific groups of the indigent from the principle of 'least eligibility'. Moreover, from the outset the Poor Law Commission suggested that workhouses should separate the incarcerated into four distinct groupings, namely, able-bodied males, able-bodied females, children and the 'aged and the infirm'. It was intended that the aged and infirm were to be housed in separate buildings and accorded separate care. In the following years these categories were refined still further, first, in order to determine who should be exempt from the prohibition against outdoor relief and, second, to establish separate facilities for different groups of paupers once they had entered the workhouse. The Poor Law officials developed five categories for dealing with those claiming aid. These were the sick, the insane, the aged and infirm, children, and the able-bodied. If an individual did not fall within one of the first four categories s/he was deemed able-bodied. There was some variation in the treatment of each group.

The term 'sick' was applied to those suffering from acute, temporary and infectious diseases. Chronic or permanent conditions were normally submerged within the category 'aged and infirm'. And although the position of the latter with regards to the granting of outdoor relief was often unclear, in terms of formal policy the rights of the acutely ill were quite specific. They automatically qualified for outdoor relief. Unfortunately there was much local variation of interpretation. In some areas the sick were granted medical aid, while in others they were subject to stringent means tests and forced to sell all their possessions before relief was provided. The central authority, however, encouraged local officials to provide aid in the home rather than in the workhouse. If admission was unavoidable separate facilities were to be provided, although here again conditions in different institutions and areas varied markedly.

Whether this group was to be subject to the principle of least eligibility and deterrence was never fully resolved. Some officials felt the sick 'were not proper objects' for such a system. Others took the opposite view, on the grounds that if the sick were exempt, it could discourage self-reliance or making provision for this type of misfortune through membership of friendly societies and insurance schemes. Official policy vacillated between the two. Eligibility for outdoor relief on the basis of acute illness was frequently, and increasingly as the nineteenth century progressed, left to the discretion of the local medical officer in conjunction with Poor Law administrators. If paupers were admitted to the workhouse as a result of sickness they were normally the responsibility of the medical officer. Doctors were generally considered by both inmates and administrators as more lenient than Poor Law officials (Stone, 1985).

Insanity was singled out for particular attention earlier than any other group. Despite the growth of public policy in this area during this period, insanity was never formally defined in official documents. The terms used varied from idiots, lunatics, the mad and the mentally infirm to 'persons suffering from diseases of the brain' (Stone, 1985). Consensus as to their meaning was not evident in the newly established psychiatric profession. For every treatise published on the subject claiming to set specific criteria for definition, another appeared rejecting it. As Scull (1978) observed, the definition of insanity involved a subtlety more easily accomplished in books than in practice.

There was, however, a universal recognition of the problems posed by mental illness, and there were two major strategies for dealing with it. The individual so labelled could be admitted to an asylum or other institution or boarded out on contract to families willing to be responsible for them. Several private asylums had been established during the seventeenth century. But public outcries over the atrocious conditions in many establishments; brought to light by a number of energetic and compassionate Benthamite and evangelical reformers, prompted the implementation of a public system in 1845, although the cruelty meted out to the insane in some institutions was often no worse than that afforded them in the community (see, for example, Roth and Kroll, 1986).

In terms of Poor Law policy the insane were exempt from the prohibition against outdoor relief. If admitted to a workhouse their special category status disappeared. Unlike other inmates they were subject to the jurisdiction of another body, the Lunacy Commission, whose influence in the workhouse was minimal. A further difference concerned the civil rights of the insane. Until 1871, Poor Law Officials had no authority to detain citizens within an institution against their will. But this did not apply to those labelled mad. During the seventeenth and eighteenth centuries the certification of insanity was the duty of the local lay officials, but after the 1845 Lunacy Legislation confirmation of mental illness was only valid if a doctor was involved. This has been attributed to the medical profession's successful struggle for control within private and public asylums, the general acceptance that mental illness was physiologically based and the view that it was responsive to medical treatment (Scull, 1984). Once defined as insane, an individual could be detained by both doctors and Poor Law officials, and transferred from one institution to another against her / his consent.

The term 'defectives' was used to describe those suffering from sensory deficiencies such as blindness, deafness or the inability to speak. This category later included the lame, the deformed and, after 1903, epileptics and mental defectives. This last label referred to children considered mentally subnormal. Like the above, members of this group were not prohibited from relief outside institutions but were singled out for special provision concerning vocational training and education. Although there is evidence of segregated structures providing these facilities, notably in the voluntary sector, their treatment within the workhouse was no different to that of other inmates. This was also true for the oldest of the categories used in Poor Law legislation to denote all those with serious incapacities, the aged and infirm.

Little controversy raged over their eligibility for aid in the community or in hospitals but once committed to the workhouse, their treatment, like that of the sick, posed problems. The provision of separate and better facilities within these structures conflicted with the principle of deterrence. The idea of the workhouse, or institutions generally, as a 'paupers' palace' was seen as giving little incentive for the young and healthy to plan for the future. As the nineteenth century progressed the pressures to commit more and more people to these establishments increased,

In 1871 welfare policies were tightened when Parliament disbanded the Poor Law Board and transferred its duties to a newly created Board of Local Government with the status of a Cabinet department. This new authority set about implementing the principles of the 1834 Amendment Act with renewed vigour. Particular attention was directed to a campaign against outdoor relief. The demand for welfare cutbacks followed a lengthy period of economic depression, rising unemployment and a rise in welfare expenditure. The severe winter of 1860-61 and the rise in unemployment due to the cotton shortage because of the American civil war meant that many more people were claiming aid (Stone, 1985). In an effort to reduce costs the Local Government Board officials decided on a more stringent and universal application of workhouse confinement, even to those hitherto recognised as exempt, the physically and cognitively impaired.

The campaign against outdoor relief was more eagerly supported by the employees of the new department than it was by the central authority. Despite recommendations to the contrary by Local Government Boards, official policy concerning exemptions never changed. But pressure on local officials to reduce the numbers of claimants was exerted in a number of ways. For example, information concerning the ratio of paupers to the general population, and the ratios of people on both indoor and outdoor relief in each local area were regularly published and circulated in order to embarrass local dignitaries in parishes with large numbers of claimants. Because these lists contained no data showing the different categories of paupers, their publication placed implicit pressure on local authorities to reduce aid across the board. Much emphasis was made by the inspectorate on applying the 'workhouse test' to all claimants in order to separate the incapacitated from the indolent. Hitherto there had been little pressure to validate eligibility for those classified under one or other of the categories of exemption. Even after 1885 when the initial fervour of the new regime died down and a more humanitarian approach was adopted, local officials were still instructed to scrutinize carefully those seeking aid, so that help should only be given to those of 'good character' . The net result of these policies was to further separate the impaired from the rest of the community.

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