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    Historical Changes in Mental Health Practice

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    © All Rights Reserved
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    10 views10 pages

    Rose - 2011 - Historical Changes in Mental Health Practice

    Uploaded by

    Cristofer Smoka Lot
    Historical Changes in Mental Health Practice

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    © All Rights Reserved
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    of 10
    CHAPTER 2 Historical changes in mental health practice Nikolas Rose Introduction However we define ‘community psychiatry itis clear tha, in contemporary socstis, practices addressed to the mental roubles of individ have proifersted arons everyday life! Pychiatec interventions occur in mental hospitals, paychistric wards in gen- cal hospitals, special hospital, medi secure units, day hosp tals, outptien clinics, child guidance clinics, prisons, children’s mes, sheltered housing, drop-in centres, community mental, heath centres, damiilary care by community paychitie nares, mkipe forms of psychological therapies, and ofcourse, in the general practitioner's surgery, ot least trough the increasing pre- Scription of psychiatric drugs. No phase of lifes unknown to these practice: infer, pregency, birth and the postpartm periods tnfancyseldlood at home and a school sexval normality, per= ‘ersion, impotence, and pleasure family lie, marriage and divorce, employment and unemployment, nde cries, an fires to achiev; ol age, terminal ins, and bereavement. \Whereser problems arise—in our homes, onthe src in fac tories, schools hospitals, the army, courtroom, oF prison—expers vith specialist knowledge ofthe nature, causes, and cemedies for rental distress are on hand to provide is diagnoses and propose remedial action. And, of course, there is a wider penetration of psychiatry, broadly defined, into popular culture, as psychiatrists, ‘mental hospitals, those with mentally illes, andthe problems of ‘meatal health feature daily i politi and social dcbates, n one newspapers, in television documentaries, exposes, talk shows, and soap operas The languages that have been disseminated have 1 This is a revised and updated version ofa chapter entitled ‘Psychiatry: ‘The Discipline of Mental Health, which appeared in The Power of Poychiary edited by Peter Miller and Nikolas Rose (1986), Cambridge: Dolity Pres, More detailed references to original texts canbe found ‘there, and in Rose (1988). Thanks to Diana Rose for hee advice in pre- paring this version. Note that at each point inthe history tht} describe, TThave adopted the vocabulary that was used—the absence of rapested ‘scare quotes’ should not be taken For agreement. ven us new vocabularies in which to think and tak about our problems—stress trauma, depression, neuroses compulsions,pho- bias. Thay have alo provided us with new way of explaining, judg- ing, and accounting for our personel miseries, of distinguishing the normal and the abnormal, identifying what is ilines, when to seek assistance and from whom It would not, therefore, be too much of an exaggeration to say that we lived in a “psychiatric society. “Community psychiatry’, then, is one dimension of the ‘py- chiatric societies’ that have taken shape over the course of the 20th century. Theee have been many international vaiations in the historical paths followed in different national contexts, but the rationaites and practices tat have taken shape are remack- sbly similar across the Western world. In this chapter, focusing, upon the United Kingdom, 1 want to sketch out some ofthe key moments i this history? The territory of psychiatry The carly decades ofthe 20h century are sully understond as & tio’ winen ‘organism in psychiatry wasn sey, when the peutic pessimism dominated, and when pychisty and its pact toners, lke their patients, were entrapped within the enclosed insitional spaces that were the legacy ofthe asym movement of ‘the previous hundred years: asyiums that had now become little more than vast warehouse for containment of those thought to be of tunsound mind. At the oulbrek ofthe st Work War, thee were nearly 140,00 patients in mental hospitals and other nsttions in England and Wales and the average county ayhim housed over 1000 inmates. These figures were to increase over the subsequent four dc- ads, reaching a peak of over 150,00 inmates by 1854 (Jones, 1972 appendix 1). Conventional psychopathology by and large saw mental, pathology in terms ofa relation between an inherited constitution and the life treses to which it was subject. The inherited nervous 2 Except where specifically stated, referenceisto developmentsin England and Wales, 10 SECTION ORIGINS OF ‘COMMUNITY PSYCHIATRY’ system might be insufliciently equipped with nerve cells, association fibres, or be otherwise organically flawed. After conception, includ ing during the fn utero period, the nervous system might be damaged bby stress. The brain might be injured, or harmed by toxins such as alcohol or by lack of nutrition or defects in the blood supply. In addi- tion to such direct stress, the nervous system was also subject to the effects of indirect stress. Anxiety, inappropriate or over-demanding ‘education, worries about employment or finance, intemperance or sexual excess, even religious fanaticism could adversely affect the nervous system (Rose, 1985: pp.177-8: Rasen, 1959). ‘But this organicism stil allowed psychiatry to play a role outside the asylum. Epilepsy, alcoholism, mental defect, mania, melancho- lia, and other personal and social ills were regarded as expressions of an inherited neuropathic constitution which might ead to anti- and immoral conduct. Such undesirable behaviour might also provake the onset of explicit pathology in those with such a predisposition, and thus could be criticized on medical as well as ‘moral grounds, Careful management of infants was essential. For those children whose families had shawn pathology, this would strengthen the constitution and build up habits which would mini- mize the risk of onset. Itwas also vital in other families, for not even the strongest constitution was immune to damage. And, of course, the proiligate breeding of those with severely tainted constitutions could lead to a swamping of the nation with neuropaths and decline in national efficiency and the quality ofthe race. Hence the involvement of many key figures from the field of mental medicine in eugenic campaigns for the medical inspection, sterilization, or ‘permanent segeegation of mental defectives and others ofthe social ppeoblem group, and for their sterilization or permanent segrega~ tion (Parrall, 1985; Searle, 1976), ‘The wider sociopolitical role for psychiatry at this time was thus largely reactive and defensive: to help minimize and control the threat posed by insanity. But in the period following the First ‘World War, a number of psychiatrists developed a more positive strategy. This modelled itself on the arguments of the new public health that claimed to be able to address large-scale problems con- ‘cerning the size and quality ofthe population and its consequences, (Armstrong, 1983). In this preventive medicine, the political for~ ‘tunes ofthe nation came to be seen as dependent upon the physical Iealth of each individual; simultaneously individuals were thought ‘to playa significant partin the spread ofill health through thei per- sonal conduct. Hence reform of this conduct could promote social ‘well-being. A complex apparatus of medical inspection, education in domestic hygiene, repistration of births, infant wellare clinics, health visitors, school milk and meals, health clinics, and so forth ‘vas established to investigate these habits and to educate citizens to ‘conduct their personal lives in a hygienic manner; and, indeed, to ‘encourage them to want to be healthy. The new social psychiatry adopted many of these principles, and actively tried to promote rental welfare and mental hygiene, The frst focus of ths strategy ‘was ‘the neuroses. This term was applied to conditions that were considered to be mild mental disturbances: they did not disable ‘the individual completely, but were sufficient to cause social inef- ficiency and personal unhappiness If let untreated, these minor ‘troubles were thought likely to develop into more serious mental ‘problems, And it was argued that many of those in workhouses and, prisons—vagrants, criminals, delinquents, and others who were socially or industrially inefficient—suffered from mental pathology ‘which had probably begun in a small way in treatable neurosis, Hence the neuroses of childhood were of particular concern. They provided a fortunate early warning of troubles to come, and, given the malleability ofthe child, it was thought that, inthe majority of ‘cases, they could be successfully treated. ‘The neuroses came to light in all those sites where individu als could now be judged to fil in relation to institutional norms and expectations—in the production-line routines of factory Inbour, in the new expectations of universal schooling, in the newly established javenile courts, and, especially, in the unprec~ ‘dented demands upon the military in the First World War. Shell shock accounted for 10% of officer casualties in the 1914-1918 war, and for 4% of casualties from other ranks, More than 80,000 such cases were estimated to have occurred over the course of the war, and some 65,000 ex-servicemen were still receiving disability pen sions in 1921 because of shell shock. While senior military officers frequently regarded shell shock as merely a disguise for coward~ ice, organicist physicians considered the condition to be a genu- ine one resulting from minute cerebral haemorrhages caused by the blast (Hearnshaw, 1964: pp.245-6; Rose, 1985: pp.182-3). But doctors working in the shell-shock clinics and specialized hospi- tals that were set up to deal with these cases were unconvinced by such organic explanations, especially given the lack of independ cent evidence of the postulated lesions. Versions of the therapeutic ‘methods iavented by Janet in Paris and Freud in Vienna were tried ‘out on the shell-shocked with some success. Shell shock appeared 10 respond to a variety of approaches ranging from occupational training, through persuasion and a form of rational re-education, the use of suggestion, toa type of psychotherapy using hypnosis or fee association. Experience with this treatment converted many to a kind of dynamic theory of the will, using concepts such as instinct and repression, and attentive to the intecmixing of physical and mental symptoms. These beliefs played a key role in the mental hygiene movement: for the fist time, psychiatrists would collabo- rate with other professionals ina strategy forthe prevention, the carly detection, and the voluntary treatment of mental ill-health. ‘The rationale of mental hygiene, with its belief in « continuity between minor and major mental disorders and in the impor- tance of early intervention for individual adjustment and social efficiency, underpinned the argument made in a series of offt- cial reports from the 1920s to the outbreak of the Second World ‘War (discussed in detail in Rose, 1985: pp.197-209). Poor mental hygiene was thought to be the cause ofall sorts of social ills, pe- ventable by education in proper technigues for mental welfare and ‘mental hygiene, and by early detection ofthe signs of trouble fol- lowed by prompt and effcient treatment. It was believed that this, ‘as hampered by the stigma which surrounded lunacy, by the iso- lation of the asylum from other medical facilites, and by the legal procedures of 1890 which allowed asylums only to take patients certified through a cumbersome legal process. This discouraged individuals with mild problems from seeking help, and discour- aged doctors fiom utilizing asylums, turning them into institu- tions forthe incarceration of those considered beyond hope. Not only was this a counterproductive method of organizing services, it ‘was also conceptually unwarranted. As the Royal Commission on Lunacy and Mental Disorder pat it in 1926: insanity is, afterall, only a disease like other diseases. ..2 mind deranged can be minis- tered to no les effectively than a body deranged... The problem of insanity is essentially a public health problem to be dealt with on ‘modern public health lines. (1926: pp.16-22.) CHAPTER? HISTORICAL CHANGES IN MENTAL HEALTH PRACTICE Treatment should not require certification, compulsion, or incarceration. Facilities should be available in hospitals for outpa- tient and voluntary treatment to encourage easy access to help aten carly stage ofthe disease (Rees, 1945: p.29). This was the rationale that had led tothe establishment of the Maudsley Hospital, which ‘was completed in 1915 and the Cassel Hospital, which opened jn 1919 (Barnes, 1968: pp10-15; Jones, 1972; pp.235-6). It was for similar reasons that the Mental Treatment Act 1930 renamed asylums ‘mental hospitals’ and stipulated that, in the majority of cases, lunatics should be termed simply ‘persons of unsound ‘ind’. Patients could now be received for inpatient treatment on voluntary application, and local authorities were to make provision for the establishment of psychiatric outpatient clinics at general and mental hospitals? Disturbed individuals could come tothe clinics themselves, once they or others were educated in the signs of mental disturbance, and now free ofthe feats of stigma or incurabilty. Others were to ‘be referred to them from school, court, and elsewhere by statutory and voluntary agencies. In the clini, assessment and treatment would be carried out, reports would be supplied to courts or schools, individuals would be referred to other institutions. But the clinics would also provide the base fora system of mental hygiene Which could act more widely on the lives of patents, ex-patients, and potential patents. Social workers, psychiatric social workers, probation officers, school attendance officers, and others would operate between the clinic and home, school, ox courtroom, con- -veying information, advice, and education, The new meatal bygiene ‘was to provide the basis ofa project of general public education as to the habits likely to promote mental welfare, Mental health was to be a personal responsibility and a national objective. Community as therapy Despite these developments, in practice the pre-Second World ‘War psychiatric population was split between the ‘neurties\— maladjusted and delinguent chldsen, inefficient workers, and shell-shocked soldiers and the ike—and the ‘psychotics. These latter were those certified under mental health legislation, segre- gated from the sufferers of physical illness, and confined in the large, isolated, custodial mental hospitals. The provision of outpa- tient clinics was confined to few geographical acess only a smal ‘number of the more recently built sylumshad established separate facilities for new acute patients; very few beds for inpatient treat rent were provided in wards of general hospital; some, but not all, municipal hospitals had set up ‘observation wards’ where mental patients could be confined under shor sections for limited periods for assessment and diagnosis before being discharged or committed toa mental hospital In the 1930s, mental hospitals in England and Wales bad an average population of around 1200, but some contained up to 3000 patients. The majority were therefor long periods—if not permanently—and active therapeutic intervention was spas- -modic. It was accepted thatthe majority of patients were suffering 3 The responsibilities of local authorities for lanacy and mental daicieney services and aftercare had alceady been widened by provisions ofthe ‘Local Government Ac of 1929 which followed the recommendations of the Royal Commission on Lunacy snd Mental Disorder. Ror (1983) PpaAss-163. from psychoses which were often heveditary in origin and mostly incurable. The old ideals of moral teatment had largely been dis «ade, though forthe most fortunate patients, asylums did opet= ate as commumitcs where theylived ale of contented servtile, working as orders, storemen, or domestic servants fn a coset ‘world than that outside” (Clark, 1964). With the melancholi,pat= aphrenicor deluded, certain attachments formed between staffand patents: for others, the regimen varied from neglect, trough sut- vellance and containment, to degradation and brutality However questionable their claims to efficacy, the new physical treatments developed in the 1930s éid disrupt this stasis. They offered asylum doctorsan image of themselves as healers of the sc and not merely superintendents ofthe instiction. Waves of enthu= siasm for these treatments sep through the hospitals, Physical treatments from removal of tonsils to varieties of convulsion therapy—were selected accordingto thelatst eporesin the medica literature or the predilections ofthe medic. As withthe claims for ‘bleedings and purgings of the 18th century and forthe se of seda- tives such as chloral hydrate and bromides in the 19th century, such hopes were usually short-lived. But despite limite experiments- tion in asylums, or in units attached to them, the principal task of asylum doctors remained the containment of chronic patients, it often required the use of coercion, and offered few prospects for innovation other than more efficent administration ‘Within mental medicine, hostility was growing between the long-established sector of asylum superintendents who domi- nated the Board of Control, defenders ofthe need for separate and distinct institutions forthe treatment of the mentally ill, and physicians who sought the integration of the practic, taining, nd facies of psychiatry with those of the general hospital The future ‘of psychiatry was being shaped outside the asylum mainstream, in specialist units in gencral hospitals, in outpatient clinics, in private practice, in psychotherapy and psychoanalysis. The Second World ‘War was decisively to shift the balance betveen these two wings of psychiaty (of. Baruch and Treacher, 1978). John Ravilings Rees, Diector of the Tavistock Clinic, was appointed consulting psychiatrist to the Army, pethaps because the problems at issue in wartime were precisely those of fune~ tional nerve disorder over which the Tavistock had established its jurisdiction. Im any event, the consequence was that the new tasks of psychiatry were to be thought from within the rationale of mental hygiene. Psychiatrists tried to develop methods of slec- tion, both for the weeding out of potential problem cases and in the selection of those suitable for promotion. They tie to adjust nnlitey training techniques in order to enhance the it between themental and the organizational, and sought to maximize morale bby methods of man-management which would promote solidarity through acting on the psychiatrically important aspecs of group life, Whilst each of these developments would have significance for the expanded role ofthe ‘psy’ professions in the post-war period, most important for psychiatry itself wa the issue of teat- iment. Psychiatrists were involved in the treatment of casualties: inthe army alone they saw almost a quarter of million cases dar- ing the Second World War, even discounting those referred from army intakes, those seen in selection testing and patients seen in 4 On the concept of the psy professions (psychiatrists, psychologists, psychiatric social workers, and many more) se Rost (1996). n 2 SECTION 2 ORIGINS OF “COMMUNITY PSYCHIATRY’ psychiatric hospitals (Rees, 1945: p.46), Whilst only about 8000 ‘of these were diagnosed as psychotics, about 130,000 were consid ‘ered tobe neucotics. The invaliding rate for psychiatric disabilities ‘was over 30% of all discharges for medical causes. Whilst military neurosis centres did manage to return about 80% of their cases t0 duty, the results of treatment overall were poor. This emphasized the need for new treatment techniques. More fundamentally, it confirmed that psychiatry should not focus upon the canfinement of the small number of psychotically deranged persons. To fail ‘the task that society required, it needed to shift itsattention to the detection and treatment of those large numbers ofthe population ‘who were now known to be liable to neurotic breakdown, mal- adjustment, inefficiency, and unemployability on the grounds of poor mental health (cf. Jones, 1972: pp.262-82).. Perhaps the most significant invention in treatment concerned the institution itself. At the start of the Second World War, whilst confinement might have been a condition for certain types of ‘ueatment, it was not in itself considered to be therapeutic. But in the course of the war, for the fist rime since the heyday of moral treatment, some at least began to argue that che institution itself could be a therapeutic technology. Maxwell Jones credits Wilited Bion with the first recognition of the principle underlying the social therapies that ‘social environmental influences are them- selves capable of effectively changing individual and group pat- tems of behaviour (M. Jones, 1952: p.519 cf. Kratipl Taylor, 19585 ‘Manning, 1976). In 1943, Bion undertook an experiment in which he treated the unruly conduct of the inmates ofthe Training Wing of Northfield Military Hospital through manipulating authority tclations, believing that ifthe men themselves had to take respon sibility for organizing tasks, and for defining and disciplining ‘miscreants they would learn that the disruption was not grounded {in authority but in their psychological relations to authority Although the authorities terminated this experiment after 6 weeks, if was followed by a second ‘Northfield experiment’ in ‘which Thomas Main sought to produce what he referred to as a ‘therapeutic community’ in which the hospital was to be used ‘not 45 an organization run by doctors in the interests of their own ‘greater technical efficiency, but as » community with the imme-

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