Secure Lives: The Meaning and Importance of Culture in Secure Hospital Care by psychiatrist–anthropologist Annie Bartlett offers ethnographic insight into daily life and social relations in a high security hospital designed for people with severe mental illness who are also considered to be a danger to society. While not all of the patients have been convicted of crimes, some have, and all are subjects for whom ascriptions of madness and criminality have converged. Bartlett explores important questions about the nature of sociality, the paradoxes of power hierarchies, and how these manifest in institutional culture, both as it is lived by hospital health care staff and patients and how it is talked about by administrators. The institution confines and constricts patients, but it also aims, at least in the spirit of its institutional culture, to prepare some patients for life in the community. The book is, in Bartlett’s words, a “glimpse into lives less lived than they might have been” (p. vii), a succinct comment on the underlying tragedy of the lives of institutionalized mentally ill persons and the tensions in how society muddles through caring for these vulnerable subjects.
The data come from Bartlett and her team’s 20 months of participant-observation conducted in three wards (two for men with different levels of supervision and one for women) of a high secure hospital in a town in the United Kingdom, which she gives the pseudonym Smithtown. Though the research was conducted in the 1990s, and much has changed about the role of high secure hospitals in the United Kingdom, including the intersections with the National Health Services (NHS), the questions Bartlett asks about institutions, vulnerable subjects, and the meaning of culture are enduring problems in anthropology and mental health care.
The book is divided into four parts that segment the material into a history of high secure hospitals and previous studies of institutions like prisons and asylums; a detailed account of methodology; the researchers’ ethnographic observations of and discussions with patients, staff (mostly nurses, who make up the bulk of the professionals who care for patients day in and day out), and administrators at Smithtown; and a contextualization of the data in contemporary concerns about institutionalization of the mentally ill and the politics of health care in the United Kingdom. Throughout, Bartlett explores the anthropological and everyday meanings of culture, that foundational anthropological object, and power structures, impossible to ignore in any study of institutional life.
While Bartlett’s descriptions of the daily rhythms, disruptions, concerns, and disputes between patients and staff provide detail on aspects of institutional space that are typically closed to the public gaze, there is little that is surprising in her account. We read about mentally ill patients who are exploited by the staff, who are made to feel judged, whose very sense of autonomy and identity are stripped by confinement and therapeutic discourses. We see patients who cannot control the basic conditions of their physical and psychic life, including acquiring a toothbrush. And we learn about health care staff who sometimes care about their work and the patients, sometimes feel unsafe and threatened, and sometimes display indifference and disdain for their charges. We see camaraderie alongside conflict and shifting power dynamics, where sometimes patients’ potential for violence or for accusing staff of inappropriate behavior put them in a position of temporary power. Bartlett describes tensions between individual agency and institutional culture in organizing power relationships and moral judgments of patients. These are dynamics that are well known to readers who are familiar with the theoretical and ethnographic literature on institutions, disciplinary and control societies, and the many ways Western societies have approached the care—and risk management—of mentally ill persons.
One of Bartlett’s stated aims amid this familiar description of institutional life is to explore culture—what the concept is, how it is enacted, and how Smithtown managers in particular operationalize this word as they try to run and change the place. Within this inquiry, Bartlett devotes many pages of the book to asking “what culture is” and how anthropologists have approached it. These discussions provide an introductory view of the culture concept and some anthropological preoccupations with it. These theoretical offerings are quite belabored, especially in their heavy reliance on Geertzian frameworks with little attention to post-colonial critiques of culture and the political implications of how the concept has been deployed in anthropology. Similarly, the author spends a significant amount of time at the beginning of the book explaining what participant observation is and justifying the methodology as worthy to apply to the study of institutions. This is a helpful guide for someone with little to no experience of the method.
With so much attention to some of the basics of anthropology, this book is more suited to neophytes to the discipline, while anthropologists might find these parts of the book a breezy treatment of nuanced concerns and outdated in its referents. Bartlett also writes about how the notion of culture was operationalized, worked on, and valued by those in charge at Smithtown as they set the rules on how the institution should run and how it should change over time. But more of these observations of how people instantiate the notion of culture and give it meaning, rather than extensive musings into what culture is, would have strengthened the claim that culture is still interesting.
The ethnographic information Bartlett provides give some wonderful details about physical space and sociality at Smithtown—who says what, in what spaces, what people call each other and themselves, what nurses eat, and arguments over whether doors stay open or locked at night, romantic trysts, and patients’ work assignments. At times, however, it is difficult to get drawn into these descriptions as the field note and interview excerpts, in the three researchers’ different styles, are often provided without context of who the actors are, and much of the framing of excerpts is in passive voice. These writing tactics give the ethnography a detached feel, which belies how well immersed in the daily operations of Smithtown Bartlett and her team likely were.
Relatedly, the author’s reflections on her dual positionality as an ethnographer and psychiatrist are primarily at the beginning and end of the book. This duality has the potential to be one of the most interesting aspects of the research. By the end of the book, the author offers the argument that “it is what lies beneath the surface that determines an ethos of care” (p. 312). Yet, for all of the book’s insistence that the meaning of culture not be taken for granted, the meaning of care is. A more thorough inquiry into the complexities and nuance of care—fusing the author’s psychiatric lens—would have balanced the over-emphasis on culture and deepened a discussion of the moral stakes of institutionalized and deinstitutionalized mental health care.
Bartlett ensures that the decades-old data have contemporary relevance by tying them into contemporary mental health debates and the political ways the government, partly via the NHS, has conscripted mental health providers into approaches that are less about care of vulnerable individuals and more about managing risk to society. The book is written in accessible prose and provides detailed reviews of basic concepts and methodologies of anthropology, making it a useful tool for those unfamiliar with the discipline and its approach to confinement, the mentally ill, and mental health administration.