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
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 disordershospitals 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.
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.
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 (DROs) 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. 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.
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 alcoholics 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 directors 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
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
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
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. Georges 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.
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
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
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.
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.
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 wouldnt be
here. One patient had been hospitalized over 50 years.
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 staffs responsibility and that they should take steps to end the
pilfering. When Dr. Main, the Medical Director, pointed out that the
staffs 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 patients 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
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
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
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
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 staffs 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.
The patients 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 patients socially unacceptable
behavior. Only as staff members are able to tolerate the patients
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 ones own behavior as well as the effectiveness of traditional
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. 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.
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 patients 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.
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 staffs 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 patients behavior in order to help him. This is often
coupled with the staffs 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 staffs behavior becomes crucial.
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.
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 patientthe 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.
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