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DEVELOPMENTS IN SOCIAL PSYCHIATRY
Observations in Five Selected English Hospitals

DENNIE BRIGGS, Lieutenant, MSC, USN
LINA STEARNS, Lieutenant Commander, NC, USN

Text and Permissions: Dennie Briggs
html: Craig Fees

 

U. S. ARMED FORCES MEDICAL JOURNAL (Vol. VIII, No. 2 February 1957) 184-194

From U. S. Naval Hospital, Oakland, California. Sponsored by the Neuropsychiatry Branch, Bureau of Medicine and Surgery, US Navy, Research Project NM 007 090.21, Comdr. Harry Wilmer, MC, USNR, principal investigator. Lt. Briggs is now assigned to the U. S. Naval Hospital, Yokosuka, Japan..

*We wish to thank Sir Walter McClay and Doctors Maxwell Jones, T. P. Rees, Tom Main, and Joshua Bierer and their staffs for time spent in showing us their treatment methods.

 

DEVELOPMENTS IN SOCIAL PSYCHIATRY
Observations in Five Selected English Hospitals

 

DENNIE BRIGGS, Lieutenant, MSC, USN
LINA STEARNS, Lieutenant Commander, NC, USN

For more than a month, we were fortunate in being able to spend full time with the staffs and patients of five unique English hospitals for the treatment of emotional disorders—hospitals selected as representative of the more recent trends in social psychiatry, with emphasis on institution management and treatment.* We were interested in knowing about (1) the types of illness treated within the hospital setting, (2) the actual process and extent of behavioral change, and (3) the specific procedures that had evolved. We wanted to see what had been achieved by applying these technics over a considerable period of time, in order to better evaluate the psychiatric admissions program that was begun at this hospital by Dr. Harry A. Wilmer, following a visit to England a year ago. In less than one year, the results of using these methods in a military setting had been more immediate and far-reaching than anticipated considering that in the English hospitals these social psychiatric methods had been in use for eight to 10 years and longer.[1]

This report will describe our impressions of the five hospital and discuss some of the areas and technics that we believe will be of value in other hospital settings, particularly within the armed services.

BELMONT HOSPITAL

Most of the month was spent in the Social Rehabilitation Unit of Belmont Hospital, in Sutton, south of London. The unit is housed in a building over one hundred years old, formerly used as a workhouse. It was badly blitzed during World War II and still shows evidence of the bombings. The hospital is an open ward hospital of 400 patients, emphasizing physical treatment of the neuroses. The unit of about 100 male and female patients is run autonomously, but under the management of the hospital proper. Patients are referred to the unit from all parts of England by courts, physicians, and psychiatrists. They represent the various character and behavior disorders and some neuroses. Many are those traditionally referred to as “psychopaths,” with social backgrounds replete with thievery, various types of addictions, sexual delinquency, and continual inability to make social and vocational adjustments. They are admitted for an undetermined time; however, the average stay is from four to six months, and no patients remain longer than a year.

The staff consists of the Medical Director, Dr. Maxwell Jones, three other psychiatrists, a head nurse (sister), two male staff nurses, a ‘night nurse, a psychiatric social worker, a psychologist, four workshop instructors, two secretaries, and two domestics. In addition, there are two Ministry of Labour Disablement Resettlement Officers (DRO’s) who assist in obtaining employment for patients upon their discharge from the hospital.

The unit “. . . is designed to help patients overcome their social fears and problems and to readjust to life outside.”[5] The idea of the therapeutic community originated nine years ago with Maxwell Jones from his experiences with rehabilitation of prisoners of war who needed to become resocialized before returning to their communities. “Similarly, patients in the unit needed comparable assistance in learning new values and ways of adjusting to society.”[5]

The fundamental aim in treatment is socialization of the patient, and the unit is designed to create a therapeutic atmosphere:

. . . where patients can . . . (see) themselves as they really are. By so doing, they can begin to learn to understand and, if possible, modify their behaviour through analysing their everyday relationships. Another aim of treatment is to give practical help in finding work and adjustment to the family outside.”[5,6]

The actual workings of the unit can perhaps best.be described y the following account given by the sister:

At least one third of the day is spent in one group or another. It is here that the unit life differs from ordinary life, for much of the treatment is based on trying to understand, by talking freely, the source of difficulty in relationships between people. The lessons learned in these psychotherapeutic groups are related to social life outside.

 

1. The whole community of patients and staff, totaling about 120 people, meets every morning from 8:30 to 9:45 a. m. People sit where they like in a circle two or three deep. There is no formal chairman, the doctor normally acts as timekeeper. Any topic can be discussed and raised by any patient or staff member. Thus the range of topics may include a discussion on drunken behaviour stimulated by an alcoholic’s drinking bout the night before; talking after lights out; homosexuality; pairing off; complaints about the hot water system or missing light bulbs; or criticism or praise of other patients and members of staff, etcetera.

2. From 9:45 to 10:15 a. m. the patients have coffee in their cafeteria, and the staff meet in the medical director’s office for tea and a discussion on the meeting. An attempt is made to analyze and understand some of the various factors contributing to the tensions as seen in the previous meeting. In addition, the staff meets twice a week for an hour to discuss and analyze staff tensions, et cetera.

3. At 10:15 a. m., each doctor takes his patients in a therapeutic group. Three doctors have two groups of 45 minutes each. The other doctor prefers to treat all 25 patients in one group) for one and one half hours.

4. After lunch each ward takes it in turn to have a weekly ward meeting from 12:30 to I p. m. A doctor, a sister, social therapists, and patients of the ward are present. Again any topic may be discussed.

5. The social therapists have a tutorial seven days a week with each member of the permanent staff in turn.

6. The instructors meet weekly to discuss workshop problems.

7. The domestic staff meets with the sister weekly to discuss domestic problems.

8. Every Wednesday a family group is held during visiting hours.’ One of the unique forms of treatment is the work group to which each patient is assigned upon entering the unit. These work groups were created to give the patient an opportunity to contribute the maintenance of the unit in a meaningful way, as well as to be therapeutic.

The activities include painting the interior of the hospital (the patients decide on the color of the paint to be used, when a particular room will be painted, and the manner in which it is to be painted), caring for the grounds of the unit, and providing fresh flowers for the hospital. The workshop group repairs and constructs furniture for the unit; the tailoring shop group makes and mends the patients’ clothing; and the home group is responsible for cleaning the wards and other parts of the unit. Patients are required to spend a certain number of hours in the work group and are assigned to keep a formal record of tardiness and absenteeism, which in turn is fed back to the entire community by name and by work group, thus providing for a spirit of competitiveness between the various work groups. The workshop instructors hold a weekly group meeting with the patients assigned to their particular group, and problems concerning work and interpersonal relations involved in the working situations are discussed and resolved.

There is an intensive program of social activities in the unit centering around a club room where nightly dances and other forms of social activities are run by the patients. Television is not permitted, because it would decrease socialization.

Efforts are made to extend the therapeutic process beyond the hospitalization of the patient, and along these lines a family group is held weekly, composed of relatives who are interested in coming to the hospital to learn more about themselves and the patient, various staff members, and any interested patients. This weekly group frequently includes as many as 50 members, and its success is measured in part by the frequent and regular visits of some of the relatives. An ex- patients’ group meets one night per week at St. George’s Hospital in London, where any former patient may come to talk about problems, renew old acquaintances, or gain courage to continue on in his daily life.

Much of the success of the treatment lies in the “social therapists,” who are 11 young girls primarily from the Scandinavian countries and Holland. They have various backgrounds, but usually are interested in one of the social sciences, like to be with people, and come to the unit for six to eight months to observe its functioning and to see the country. Their training though informal, is intense, consisting of afternoon tutorials seven days a week with the permanent staff. Here they are given a basic understanding of normal growth and development and an opportunity to learn about interpersonal relations from the daily experiences with the patients. Current anxieties are thus used in a therapeutic manner through the daily tutorial, which carries through the basic concepts of the therapeutic community by extending its methods to the staff as well as to the patients. That the girls are foreigners seems to be advantageous, as the patient who cannot adjust to society also feels he is a stranger and can accept her more readily than an English girl who might have prejudices, even at an unconscious level, which would hinder the treatment process. Their primary role is to be a person with whom the patient can learn technics of social relationships, and in the treatment program they encourage communication nd feedback between patients and between patients and staff.[8]

WARLINGHAM PARK HOSPITAL

This is a 1,200-bed mental hospital in Warlingham, Surrey, which is run entirely with open wards and treats all types of mental disorders, including chronic schizophrenic patients. The hospital is located in the countryside of southern England, lightly isolated from even the nearest small community. All additional types of psychiatric treatment are used here, including deep insulin coma, electroshock, psychosurgery (leukotomy), and the new tranquillizing drugs. The patients are admitted to two admission treatment units for male and female patients, about 50 of each. They remain here until their illness has become stabilized and they are able to go on to other wards. Many leave the hospital directly from these units, but some remain as long as three or four months on active physical treatment, before moving on to another unit.

We were especially interested in the management of the more severely disturbed patients on open wards, and visited two such “refractory” wards (one for males and one for females). The staff of the disturbed ward for approximately 40 male patients, consisted of two male nurses and one female student occupational therapist (visitor from the Menninger Clinic).

One of the most impressive procedures at Warlingham Park is the use of patients in the treatment program. Alcoholic patients are successfully used as instructors for older psychotic patients, teaching them crafts such as weaving, crocheting, et cetera.[9]

One is continually impressed with the degree of therapeutic sophistication of the entire staff of the hospital. All personnel are thoroughly familiar with the aims of treatment and seem to be highly skilled in carrying them out in all situations. The role of the nursing staff has been considerably modified from that in most mental hospitals, as the superintendent reiterated how he concentrated on meaningful occupations for the staff as well as the patients.

CHAMPION HOUSE

This hospital is a lovely old English estate in the countryside, some 10 miles from Warlingharn Park. It has about 30 male and female patients who, from a social and psychiatric standpoint, are not considered ever able to be discharged from a mental institution. These patients have been hospitalized for a long time and have no family or friends to return to, but are able to care for themselves within this type of setting and to perform normal tasks contributing to running the home. The staff of this unique hospital consists of a nurse and two or three domestic employees, and the major part of running the house and grounds is done by the patients.

Most of the patients have been hospitalized a good deal of their lives, one of the modern-day tragedies of mental institutions. The driver who took us to the hospital remarked, “had we known 20 years ago the things about treatment we know today, these patients wouldn’t be here.” One patient had been hospitalized over 50 years.

CASSEL HOSPITAL

Cassel Hospital is primarily for treatment of neuroses by intensive psychotherapy. It is an entirely open hospital, and physical treatment is not used. The orientation is psychoanalytic, and most of the permanent staff have had a high degree of training in psychoanalytic theory and technic. The head nurse is a qualified lay analyst, several other nurses have been analyzed, and one is an analytic candidate. The nurses do not wear uniforms or make ward rounds, but each has a specific function that is used therapeutically in working with the patients. Nurses are encouraged to work at tasks they enjoy doing, thus being models for the patients. One nurse, for example, enjoys sewing and keeps her machine in an easily accessible stair landing at the hospital. Patients may join her or drop by to visit. Through meaningful work which the nurse enjoys, the opportunity for social relations is extended in a manner which facilitates more rapid and complete recovery than could be achieved by a nurse in a white uniform seeing to keeping the ward in spotless order. Although the treatment is centered about individual intensive psychotherapy, the patients run the hospital to a large degree. Most practical matters in its administration are handled quite formally by committees, and decisions reached by the patients are carried through. The matter of patients’ letters being stolen from the mailboxes was brought up by a committee of patients and staff. The larger community had decided that this was the staff’s responsibility and that they should take steps to end the pilfering. When Dr. Main, the Medical Director, pointed out that the staff’s responsibility ended legally when they accepted the mail from the post, the committee considered other means. Various methods were considered, including reporting the matter to the police and bringing in plain-clothesmen. The staff deflected the responsibilities to the patient committee, who worked out a solution to ensure safekeeping of their mail, and this was taken back to the community for final approval.

One of the unique features of this hospital was the admission of the patient’s husband or wife and children if necessary, based on the premise that emotional illness is nothing to keep from the family and that they may, in fact, aid in the treatment process. Some of the mothers have to bring their children as they have no means to provide for them while hospitalized. The entire atmosphere of the hospital was natural rather than institutional.

Education and training of the staff is stressed continually and at all levels. The program includes informal training through working under close supervision with a highly trained staff, and formalized presentations of carefully developed theories of personality development, but it always emphasizes the normal personality rather than abnormal states. In the summer a course is given for nurses outside the hospital, dealing with growth and development and helping the nurse to see her role in relation to the patient’s treatment.[10]

MARLBOROUGH DAY HOSPITAL

This institution bears little resemblance to a hospital in the usual sense of the word. It is located in London and treats about 100 patients who come to spend the day in intensive treatment and return to their families or homes at night. The underlying philosophy is that total hospitalization might be inadvisable or even harmful by interfering with readjustment to society. An intensive treatment program includes individual psychotherapy, group psychotherapy, and recreational and occupational activities as well as social ones. There is an evening clinic for those patients who cannot receive treatment during the day because of their work schedules or who are reluctant to ask their employer for time off, for fear he may not understand emotional illness and they might lose their jobs. Meeting crises with direct action, thereby giving the patient hope and getting him into treatment sooner, is used frequently in the practical approach by Dr. Joshua Bierer and his staff at this hospital.

The hospital maintains a large number of “social therapy clubs” in the London area and throughout the world for ex-patients and others to meet together socially and be provided an opportunity for treatment.[12,13]

DISCUSSION

In relation to the technics developed by these five very different hospitals for treating emotional disorders, certain principles seem paramount and pertain most directly to the use of social psychiatry in hospital treatment.

Elevation of the Role of the Patient. Respect for the dignity of the patient seems to be the most fundamental idea in the treatment programs of the hospitals we visited. Formerly, the patient was regarded as “irresponsible,” “dangerous,” “psychotic,” “neurotic,” et cetera. These terms designate their behavior as unacceptable and serve to isolate them from human contact. Traditional mental hospitals further isolate patients because of the staff’s inability to tolerate their behavior; thus the over-use of physical therapy, “quiet” rooms, sedation, restraints, and other forms of treatment often lightly disguised as being “for the good of the patient.”[3] The patient’s behavior is increasingly seen as purposeful and meaningful to him, and the principal task of the staff is first to be able to accept the behavior, no matter to what lengths the patient may go to encourage reprisal, and then to understand what the patient is trying to communicate to others. The symptom of his illness, while serving to isolate him from human society, which he sees as distrustful and fearful, can thus be used as the first step in his rehabilitation. When this process is understood, it is transmitted to other staff members and to the patients, who actually carry out treatment according to their own abilities. It allows for the development of individuality in both patients and staff.

One of the initial impetuses for re-examination of the traditional roles of the staffs of mental hospitals was associated with the acute shortage of trained personnel following World War II. The whole idea of the patient-centered hospital involves the working-through of staff anxieties regarding their own acceptance of the patient’s socially unacceptable behavior.[14] Only as staff members are able to tolerate the patient’s behavior can they feel comfortable enough to allow and encourage the “well part” of the patient to emerge. As staff members are better able to examine their own anxieties, feelings, prejudices, et cetera, toward unacceptable behavior, patients become increasingly more responsible for running their own lives. This involves the often tremendously painful task of examining one’s own behavior as well as the effectiveness of traditional hospital procedures.

The socialization process begins when the patient is allowed increased participation in the total treatment program by sharing in administrative decision making, as well as helping other patients and staff! The change-over from a more authoritarian atmosphere to one where staff members feel comfortable enough to give up some of the more suppressive elements of their roles is not an easy or smooth adjustment.”[14] The hierarchic arrangement which the hospital fosters because of the wide divergence of training and experience of the various staff members must be critically examined when considering the establishment of an environment conducive to co-operation and mutual respect. For this reason, a continual education program is needed whereby new members can become acculturated and older members may continue to grow.[15]

Communication and Feedback. There appear to be two main areas where the patients contribute most to the treatment program in the therapeutic community-type hospital. These areas we may roughly designate as administration and actual treatment. Assuming that patients often talk to each other more readily than to the staff, it follows that patients often will more easily accept suggestions from other patients than from the staff. It would appear that communication between patients is facilitated or enhanced by staff-patient communication to the point where the patient feels increasingly comfortable with the staff. Intimate contact between patients in this type of hospital setting often encourages the initial revelation of important and frequently disturbing thoughts and ideas to other patients. In other instances the patient feels comfortable in revealing such material only to staff members. The basic premise in the therapeutic community is that both sources of communication will at one point or another be fed back to the entire community or to large segments of it. When the idea of free communication and feedback has been properly developed and used, the patient’s confidante may bring up the actual content of the material in the group or, if he is a more skillful therapist, will encourage the patient to appeal to the community for assistance and understanding of his behavior and thus attempt to arrive at acceptable solutions for his difficulty.

Insofar as staff members are able to allow patients to share in decision-making, the administration of this type of hospital also becomes therapeutic. The appeal to the group conscience becomes an enforcing agent and represents a highly developed type of social control which exercises the authority in a community. The degree of patient participation in administrative and therapeutic endeavors is perhaps most graphically illustrated by the extensive use of alcoholic patients in Wartingham Park Hospital. Here chronic alcoholics are used as therapists for older schizophrenic patients. They are assigned small groups of patients and work with them daily in various activities which they enjoy. As the alcoholic patient becomes increasingly more skillful in dealing with sicker patients, he is beginning to regain self-confidence and to develop a feeling of accomplishment in the total treatment program. In addition, he receives group and individual psychotherapy for his own disorder. In such instances we see developed a more highly refined process of the concept which Stanton and Schwartz have set forth as “administrative therapy.[16]

Training the Staff. In order to establish and perpetuate the fundamental ideals of a therapeutic community in a hospital setting there must be a means for indoctrination and continual growth of the staff members. By virtue of traditional medical training in a highly structured hierarchy, certain aspects of roles and role expectations must be “unlearned.” Since much of the success of social psychiatric methods depends on the constantly changing nursing staff, a method of education and re-education, taking into account the staff’s own dynamics, needs to be established. At the Social Rehabilitation Unit the use of “tutorials” has been found appropriate to the needs of the program. These are conducted seven days a week by a member of the permanent staff. The turnover of “social therapists’ is frequent and their backgrounds varied. Thus their training must include a basic knowledge of people and a minimum of specific nursing technics. The latter are taught by the nurse only as the situation arises, and the staff member then feels no pressure to be an expert on any phase of nursing. The nurse likewise can request assistance from the hospital proper if a specific nursing situation arises requiring specialized knowledge or technics. Too often .in their relationships with patients, psychiatric nursing personnel feel they must be able to deal with the patients in an unrealistic “therapeutic” manner. As the patient sometimes over-identifies with the staff member in a transference situation, role expectations become confused, and the staff member feels he must of necessity interpret the patient’s behavior in order to help him. This is often coupled with the staff’s own need to feel they are helping the patient in an active manner as formerly demanded in their medical training.

When making a transition from a traditional psychiatric hospital structure to a more “equalitarian” organization emphasizing understanding and dealing with interpersonal relations, attitudes of the staff must be closely scrutinized. As Jones and Rapaport have pointed out, much of the treatment procedure stems from the relations between individuals and groups within the institution, and the staff’s behavior becomes crucial.[17]

Our former methods of teaching nursing personnel are believed actually to perpetuate social distance between staff and patients, rather than facilitate communication and check distortions. Formal teaching of limited psychiatric material often fosters defensiveness on the part of the staff member and when his need to be a “junior psychiatrist” is met, rehabilitation of the patient is hindered. The concept of “social therapy” as distinct from “psychotherapy” has important implications. The primary role of the social therapist is one of providing opportunity for the patient to relate to others and to encourage him to feed back his feelings to the community in order that they may understand him and help him. In this way the treatment process is hastened, as he now receives help from all members, consistently and for 24 hours per day. Dangers and pressures of individual psychological interpretation are lessened, and social relations are fostered.[8]

As all staff members and patients learn to feed back information to the whole community, it is possible to arrive at therapeutic goals for each patient—the decisions become community ones, and everyone understands the goals and shares in the treatment process. The success of treatment in the relatively short time of hospitalization (e. g., four to six months at the Social Rehabilitation Unit and at the Cassel) for chronic character and behavior disorders and neurotic difficulties is thus understandable, as each patient has in a sense many therapists, and he too becomes a therapist. More important, he is living in a milieu which is consistently therapeutic, and treatment, as Maxwell Jones expressed it, is like being put in a “pressure cooker” to get the patient “well done” in a hurry.

 

REFERENCES

1. Wilmer, H. A.: Operation breakdown. Presented at Hawaiian Medical Association meeting, 24 Apr. 1956.

2. Wilmer, H. A.: Psychiatry service as therapeutic community. U. S. Armed Forces M. J. 7: 640-654, May 1956.

3. Wilmer, H. A.: Use and misuse of sedation and seclusion room in mental illness. Presented at the 1956 annual session of the California Medical Association, 2 May 1956.

4. Wilmer, H. A.: Psychiatric service as therapeutic community; 10-month study in care of 939 patients. U. S. Armed Forces M. J. 7: 1465-1469, Oct. 1956.

5. Jones, M.: The Therapeutic Community, New Treatment Method in Psychiatry, Basic Books, Inc., New York, N. Y., 1953.

6. Jones, M.: Concept of therapeutic community. Am. J. Psychiat. 112: 647-650, 1956.

7. Skellern, E. Therapeutic community. Nursing. Times, Apr.-June 1955.

8. Jones, M.: Role of social therapist. Unpublished manuscript.

9. Bloom, M. T.: Dr. Rees opens doors. Readers Digest 68: 115-118, May 1956.

10. Weddell, D.: Psychology applied to nursing. Nursing. Times, Sept. 1954; Mar. 1955.

11. Bierer, J.: The Day Hospital: Experiment in Social Psychiatry and Syntho-Analytic Psychotherapy. H. K. Lewis, London, 1951.

12. Bierer, J.: Day hospital. Soc. Welfare 9: 173-180, Oct. 1955.

13. Cozin, L. Z.: Place of day hospital in geriatric unit. Int. J. Soc. Psycbiat. 1: 33-41, Autumn 1955.

14. Tobin, A. D., and Briggs, D. L.: Considerations on transition from physical treatment orientation to one emphasizing psychotherapy. Unpublished manuscript.

15. Briggs, D. L., and Wood, N. R.: Advances in training neuropsychiatric technician. U. S. Armed Forces M. J. 7: 1615-1620, Nov. 1956.

16. Stanton, A. H., and Schwartz, M. S.: The Mental Hospital: A Study of Institutional Participation in Psychiatric Illness and Treatment. Basic Books, Inc., New York, N. Y., 1955.

17. Jones, M., and Rapaport, R.: Absorption of new doctors into therapeutic community. Unpublished manuscript.



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