COMMUNITY CARE COMMUNITY CARE COMMUNITY CARE COMMUNITY CARE CO MMUNITY CARE COMMUNITY CARE COMMUNITY CARE COMMUNITY CARE COMIV
Focusing on
individual needs Hugh Freeman
When this magazine started life (as 'Mental Health') in 1947, the treatment of psychiatric disorder was a matter almost exclusively for large mental hospitals. Certainly, there were a number of out-patient clinics in general hospitals but, apart from a few which provided some psychotherapeutic treatment for neurotic patients, these too were merely satellites of mental hospitals seeing people before or after admission. Added to all the familiar drawbacks of the mental hospital its usually remote situation, its forbidding towers and corridors, the anonymity of its huge wards there were, in the late 1940s, the effects of years of wartime neglect and a severe staff shortage. Nevertheless, the hospital did at last have something of real value to offer the depressed or schizophrenic Patient; this was electrical treatment, which was a tremendous advance on merely sedating people and Protecting them from harm until a natural improvement eventually occurred. Such custodial care was all that had been possible before ECT came into general use, apart from the operation of prefrontal leucotomy, which was still in an early and rather crude form. In spite of all the cogent reasons, therefore, for not going into mental hospitals, people were admitted to them in ever-increasing numbers. Certainly, more people were also discharged, since more went in at a curable stage of illness and treatment was better, but the balance was always on the side of larger numbers being inside hospital. Since there was practically no new building, overcrowding grew year by year and added even further to the hospitals problems. But, if many patients were going in mainly to be treated with ECT and were not so disturbed as to -
-
need constant
nursing supervision or security, why a different setting, which did not
not treat them in
hospital? This simple yet revolutionary thought (like the invention of the wheel or the safety-pin) occurred to a number of people about this time. It was argued most cogently by Dr. Will Sargant, who has recently retired from the directorship of the psychiatric unit at St. Thomas's Hospital, London. Improvising within a small amount of space, he began to treat very large numbers of patients suffering from schizophrenia, depression or anxiety states. Some cases eventually had to go to a mental hospital, but the great majority didn't; they were treated as out-patients or with a short stay in a general teaching hospital and the contact with their homes and families was preserved all the time. Of course, psychiatric beds were not completely unknown before in general hospitals. But they were usually in a small corner of a ward, grudingly conceded by a physician or surgeon and looked on by the rest of the hospital with the greatest suspicion. Any patient admitted to one of these beds had to be relied on to cause no trouble; otherwise, his departure to a mental hospital was likely to be swift. To treat people effectively in a general hospital, have all the drawbacks of the mental
there had to be a unit of reasonable size with its own nursing staff and space for activities like occupational therapy or group meetings. Units of this kind did begin to appear now, not in London, but mainly in the cotton towns of Lancashire. Again, these were improvised from old accommodation, but sitting right in the middle of the communities they served, they soon showed that it was possible for them to treat the great bulk of serious psychiatric disorder arising in their populations, in the same way that people with other kinds of illness were treated at a local hospital. When the revolutionary advances in drug treatment took place, in the mid 1950s, producing the tranquillisers and anti-depressives, the whole process opened
up even further. Many patients could now be treated by general practitioners without reference to a psychiatrist, many more could be treated by psychiatrists without having to be admitted to hospital. From the other direction, there were many patients in mental hospitals who could now be discharged, providing they continued to have regular treatment. The peak of resident numbers in mental hospitals was
reached in 1954; from then, the total has fallen
steadily, year by year. One further change which helped this process along was the growth of'part-time hospitalisation', mainly in the form of day care, but sometimes allowing patients to come in just at night or for week-ends. Flexibility and informality allowed a much more effective use of hospital resources. All this was very encouraging, but it posed a set of new problems in their turn. The patients in a mental hospital (who might number up to 3,000) were all under one roof; if one decided on a policy of treatment or
rehabilitation for them and had the
apply
resources to
it, then the
logistics were relatively simple. But approach involved what has been called a 'dispersed institution'. If we think of the population of a medium-sized town, it will be served by a variety of mental health resources. These will probably include now a unit in a general hospital (for in-patients, out-patients and day patients), beds in a mental hospital (which may be some distance away), sheltered accommodation (hostels, group homes and lodgings), a service of social workers (based in the local authority), the help of general practitioners and possibly community nursing, therapeutic social clubs and a sheltered workshop. In all these facilities, there may be a contribution by voluntary organisations, such as local the
new
mental health associations. This multiplication and dispersal of resources has been one of the most important changes of recent years, particularly in the period following the 1959 Mental Health Act. Just to enumerate the different buildings and people who are now concerned gives some idea of the problems of communication and management which arise when a service is community-based, rather than institution-based. Yet it is obviously right that services should be focussed on the needs of the individual person, rather than forcing patients to conform to the demands of the institution, like a sausage machine. The peculiar processes of the large institution, so well described by the sociologist Irving Goffman in his book 'Asylums', can be as harmful to staff as to patients, especially when continuing over long periods of time. To avoid the secondary handicaps resulting from this process of institutionalisation, (in addition to the
primary effects of the illness itself) is tremendously important. It can only be done by providing treatment and care ior psychiatric disorder through a wide range of varying, but integrated resources. It requires, first and foremost, that we get rid completely of the process of labelling a vast number of people, who have very different needs, as 'mental' and then of handling them all in the same unvarying way. This was perhaps what was most wrong with the system that existed largely unchanged up to about twenty years ago and which was based on the large mental
hospital. The greater effectiveness of psychiatric treatment methods has helped enormously in the decentralisation of services. One important recent advance in treating schizophrenia has been the development of long-acting tranquillisers, which are given by injection and are effective for up to a month. Because schizophrenic patients were generally very unreliable about taking tablets regularly (which is a failing that also affects other people), they were likely to become severely ill again and to have to return to hospital, often in circumstances that were very distressing to all concerned. Research has shown that regular injections can make these further breakdowns much less likely.
Almost obsolete But if the effective decentralisation of treatment is
be achieved, it will inevitably demand the efforts of of the various medico-social professions, rather than the traditional idea of the individual doctor and his patient. In fact, the 'Doctor Finlay' image of medical care never applied to more than a minority of our population and it has become almost entirely obsolete today, particularly for forms of severe psychiatric disorder which last for many years and need a whole range of services beyond the resources of the single family doctor. No individual whether a doctor, a nurse, a social worker or any other professional can be available and over the of time that is incontinuously length volved with these conditions. Nor can it be expected, when the overall responsibility for the service rests with the state, that each of these medico-social workers should personally have to provide a 'locum' to cover his absences even if this was possible. The medical model, which assumes that a doctor treats a patient for a particular episode of illness and that things then return to normal, has to be largely abandoned because it cannot cope with either the complexity of these situations or the periods of time they are to a
team
likely In
to cover. recent years
there has been
a
change
towards
multi-disciplinary professional teams taking over the responsibility which formerly belonged to the doctor
alone and this assumes that the team's decisions are arrived at jointly, rather than dictated. The three basic professions of the team are medicine, nursing and social work; it will also often involve clinical psychology and occupational therapy, as well as other remedial groups. However, the change has only been slow and partial up to now; it is being strongly resisted by a large part of the medical establishment, which remains committed to its omnipotent image of the past and demands that it should continue to 'supervise' everything done by other professions. Social workers have been the first to shake themselves free from this subservient role; the Local Authority Social Services Act of 1970 established their independence, at least outside hospitals, and the new social services departments have now been operating for nearly two years in most areas. Frequently the upheaval involved in this reorganisation has been associated with muddle, bitterness and disappointment. Local authority health departments have often deeply resented the loss of staff and facilities to social services and some Medical Officers of Health even went so far as to pursue a 'scorched earth' policy of destroying records which they insisted could only be used in departments run by doctors. For their part, some Directors of Social Services, over-sensitive about their new autonomy, have dismantled long-standing arrangements of co-operation with hospitals and family doctors. There have been almost universal complaints that social workers given the responsibility of dealing with mental health cases have been completely at a loss, because their training was in child care or welfare. These criticisms are justified, but only to a certain extent. In the first place, any new system must be given a reasonable chance to settle down; the National Health
Service reorganisation scheduled for next year will undoubtedly produce even more of these problems, but it is still needed. Secondly, the setting up of new social services departments has brought with it a tremendous increase in the demands and expectations of the community for these services; the 1970 Act for
the Chronic Sick and Disabled and the new Children's Act added further to this. Many social services departments are already providing facilities on a scale that was never known before. Thirdly, criticisms tend to come most strongly from areas that had a good mental health service before Seebohm; but these were certainly not typical of the country as a whole and as far as many other areas were concerned, it was really not possible for things to become worse. The majority of local authorities had quite failed to carry out the assumptions and implied promises of the Mental Health Act about community care, during the time that Medical Officers of Health were responsible. Already, there has been a big increase in the numbers of social workers operating in local authority services, whilst the quality of staff and their level of training are
improving steadily.
All these considerations give ground for reasonable optimism about the future of social services in relation to mental health, though as 'Dymphna' pointed out in one of our issues last year, there are no limits to their potential responsibilities. But what has been achieved up to now in the development of community-based mental health services can only be thought of as a beginning; the concepts are still crude and the facilities sometimes primitive. Integrated services for the rehabilitation and sheltered occupation of chronically handicapped people have scarcely been started. It is certain, however, that developments on the scale that is needed will be tremendously expensive and sooner or later, the nation as a whole will have to decide just where these fit in to its list of priorities.
Focusing on
individual needs Hugh Freeman
When this magazine started life (as 'Mental Health') in 1947, the treatment of psychiatric disorder was a matter almost exclusively for large mental hospitals. Certainly, there were a number of out-patient clinics in general hospitals but, apart from a few which provided some psychotherapeutic treatment for neurotic patients, these too were merely satellites of mental hospitals seeing people before or after admission. Added to all the familiar drawbacks of the mental hospital its usually remote situation, its forbidding towers and corridors, the anonymity of its huge wards there were, in the late 1940s, the effects of years of wartime neglect and a severe staff shortage. Nevertheless, the hospital did at last have something of real value to offer the depressed or schizophrenic Patient; this was electrical treatment, which was a tremendous advance on merely sedating people and Protecting them from harm until a natural improvement eventually occurred. Such custodial care was all that had been possible before ECT came into general use, apart from the operation of prefrontal leucotomy, which was still in an early and rather crude form. In spite of all the cogent reasons, therefore, for not going into mental hospitals, people were admitted to them in ever-increasing numbers. Certainly, more people were also discharged, since more went in at a curable stage of illness and treatment was better, but the balance was always on the side of larger numbers being inside hospital. Since there was practically no new building, overcrowding grew year by year and added even further to the hospitals problems. But, if many patients were going in mainly to be treated with ECT and were not so disturbed as to -
-
need constant
nursing supervision or security, why a different setting, which did not
not treat them in
hospital? This simple yet revolutionary thought (like the invention of the wheel or the safety-pin) occurred to a number of people about this time. It was argued most cogently by Dr. Will Sargant, who has recently retired from the directorship of the psychiatric unit at St. Thomas's Hospital, London. Improvising within a small amount of space, he began to treat very large numbers of patients suffering from schizophrenia, depression or anxiety states. Some cases eventually had to go to a mental hospital, but the great majority didn't; they were treated as out-patients or with a short stay in a general teaching hospital and the contact with their homes and families was preserved all the time. Of course, psychiatric beds were not completely unknown before in general hospitals. But they were usually in a small corner of a ward, grudingly conceded by a physician or surgeon and looked on by the rest of the hospital with the greatest suspicion. Any patient admitted to one of these beds had to be relied on to cause no trouble; otherwise, his departure to a mental hospital was likely to be swift. To treat people effectively in a general hospital, have all the drawbacks of the mental
there had to be a unit of reasonable size with its own nursing staff and space for activities like occupational therapy or group meetings. Units of this kind did begin to appear now, not in London, but mainly in the cotton towns of Lancashire. Again, these were improvised from old accommodation, but sitting right in the middle of the communities they served, they soon showed that it was possible for them to treat the great bulk of serious psychiatric disorder arising in their populations, in the same way that people with other kinds of illness were treated at a local hospital. When the revolutionary advances in drug treatment took place, in the mid 1950s, producing the tranquillisers and anti-depressives, the whole process opened
up even further. Many patients could now be treated by general practitioners without reference to a psychiatrist, many more could be treated by psychiatrists without having to be admitted to hospital. From the other direction, there were many patients in mental hospitals who could now be discharged, providing they continued to have regular treatment. The peak of resident numbers in mental hospitals was
reached in 1954; from then, the total has fallen
steadily, year by year. One further change which helped this process along was the growth of'part-time hospitalisation', mainly in the form of day care, but sometimes allowing patients to come in just at night or for week-ends. Flexibility and informality allowed a much more effective use of hospital resources. All this was very encouraging, but it posed a set of new problems in their turn. The patients in a mental hospital (who might number up to 3,000) were all under one roof; if one decided on a policy of treatment or
rehabilitation for them and had the
apply
resources to
it, then the
logistics were relatively simple. But approach involved what has been called a 'dispersed institution'. If we think of the population of a medium-sized town, it will be served by a variety of mental health resources. These will probably include now a unit in a general hospital (for in-patients, out-patients and day patients), beds in a mental hospital (which may be some distance away), sheltered accommodation (hostels, group homes and lodgings), a service of social workers (based in the local authority), the help of general practitioners and possibly community nursing, therapeutic social clubs and a sheltered workshop. In all these facilities, there may be a contribution by voluntary organisations, such as local the
new
mental health associations. This multiplication and dispersal of resources has been one of the most important changes of recent years, particularly in the period following the 1959 Mental Health Act. Just to enumerate the different buildings and people who are now concerned gives some idea of the problems of communication and management which arise when a service is community-based, rather than institution-based. Yet it is obviously right that services should be focussed on the needs of the individual person, rather than forcing patients to conform to the demands of the institution, like a sausage machine. The peculiar processes of the large institution, so well described by the sociologist Irving Goffman in his book 'Asylums', can be as harmful to staff as to patients, especially when continuing over long periods of time. To avoid the secondary handicaps resulting from this process of institutionalisation, (in addition to the
primary effects of the illness itself) is tremendously important. It can only be done by providing treatment and care ior psychiatric disorder through a wide range of varying, but integrated resources. It requires, first and foremost, that we get rid completely of the process of labelling a vast number of people, who have very different needs, as 'mental' and then of handling them all in the same unvarying way. This was perhaps what was most wrong with the system that existed largely unchanged up to about twenty years ago and which was based on the large mental
hospital. The greater effectiveness of psychiatric treatment methods has helped enormously in the decentralisation of services. One important recent advance in treating schizophrenia has been the development of long-acting tranquillisers, which are given by injection and are effective for up to a month. Because schizophrenic patients were generally very unreliable about taking tablets regularly (which is a failing that also affects other people), they were likely to become severely ill again and to have to return to hospital, often in circumstances that were very distressing to all concerned. Research has shown that regular injections can make these further breakdowns much less likely.
Almost obsolete But if the effective decentralisation of treatment is
be achieved, it will inevitably demand the efforts of of the various medico-social professions, rather than the traditional idea of the individual doctor and his patient. In fact, the 'Doctor Finlay' image of medical care never applied to more than a minority of our population and it has become almost entirely obsolete today, particularly for forms of severe psychiatric disorder which last for many years and need a whole range of services beyond the resources of the single family doctor. No individual whether a doctor, a nurse, a social worker or any other professional can be available and over the of time that is incontinuously length volved with these conditions. Nor can it be expected, when the overall responsibility for the service rests with the state, that each of these medico-social workers should personally have to provide a 'locum' to cover his absences even if this was possible. The medical model, which assumes that a doctor treats a patient for a particular episode of illness and that things then return to normal, has to be largely abandoned because it cannot cope with either the complexity of these situations or the periods of time they are to a
team
likely In
to cover. recent years
there has been
a
change
towards
multi-disciplinary professional teams taking over the responsibility which formerly belonged to the doctor
alone and this assumes that the team's decisions are arrived at jointly, rather than dictated. The three basic professions of the team are medicine, nursing and social work; it will also often involve clinical psychology and occupational therapy, as well as other remedial groups. However, the change has only been slow and partial up to now; it is being strongly resisted by a large part of the medical establishment, which remains committed to its omnipotent image of the past and demands that it should continue to 'supervise' everything done by other professions. Social workers have been the first to shake themselves free from this subservient role; the Local Authority Social Services Act of 1970 established their independence, at least outside hospitals, and the new social services departments have now been operating for nearly two years in most areas. Frequently the upheaval involved in this reorganisation has been associated with muddle, bitterness and disappointment. Local authority health departments have often deeply resented the loss of staff and facilities to social services and some Medical Officers of Health even went so far as to pursue a 'scorched earth' policy of destroying records which they insisted could only be used in departments run by doctors. For their part, some Directors of Social Services, over-sensitive about their new autonomy, have dismantled long-standing arrangements of co-operation with hospitals and family doctors. There have been almost universal complaints that social workers given the responsibility of dealing with mental health cases have been completely at a loss, because their training was in child care or welfare. These criticisms are justified, but only to a certain extent. In the first place, any new system must be given a reasonable chance to settle down; the National Health
Service reorganisation scheduled for next year will undoubtedly produce even more of these problems, but it is still needed. Secondly, the setting up of new social services departments has brought with it a tremendous increase in the demands and expectations of the community for these services; the 1970 Act for
the Chronic Sick and Disabled and the new Children's Act added further to this. Many social services departments are already providing facilities on a scale that was never known before. Thirdly, criticisms tend to come most strongly from areas that had a good mental health service before Seebohm; but these were certainly not typical of the country as a whole and as far as many other areas were concerned, it was really not possible for things to become worse. The majority of local authorities had quite failed to carry out the assumptions and implied promises of the Mental Health Act about community care, during the time that Medical Officers of Health were responsible. Already, there has been a big increase in the numbers of social workers operating in local authority services, whilst the quality of staff and their level of training are
improving steadily.
All these considerations give ground for reasonable optimism about the future of social services in relation to mental health, though as 'Dymphna' pointed out in one of our issues last year, there are no limits to their potential responsibilities. But what has been achieved up to now in the development of community-based mental health services can only be thought of as a beginning; the concepts are still crude and the facilities sometimes primitive. Integrated services for the rehabilitation and sheltered occupation of chronically handicapped people have scarcely been started. It is certain, however, that developments on the scale that is needed will be tremendously expensive and sooner or later, the nation as a whole will have to decide just where these fit in to its list of priorities.
