Mental Health – Crisis or Stagnation

Mental Health seminar

held on SUNDAY 23 MARCH 1975 at the

ASSEMBLY HALL, UNITY HOUSE, EUSTON ROAD, LONDON NW1.

Reported by Mr. T. W. HURST, F.H.A., A.C.I.S.

Published by

SOCIALIST MEDICAL ASSOCIATION 9 Poland Street London W1V 3DG Tel: 01439 3395

The chair for the morning session was taken by Dr. David Stark Murray, past President of the SMA. He said that the twentieth cen­tury has brought mental health sharply into focus. In developed countries psychiatric problems are a major issue. In the United Kingdom there have been a number of outstanding achievements; the introduction of the National Health Service has inte­grated psychiatric provision and made effec­tive help more readily available throughout the community. The Mental Health Act, 1959, brought an enlightened and contem­porary approach to replace concepts asso­ciated with the terms “pauper” “lunatic” and “relieving officer”. The creation of the Social Services has provided a suitable background for caring for those among the mentally disturbed who cannot attain full independence.

Despite these advances there is a critical situation in regard to mental health. A very limited amount of money is invested in research and the basic causes of common illnesses such as schizophrenia and manic-depressive psychosis remain unknown; there is no explanation of a majority of cases of severe mental handicap.

The service provided for the mentally ill and the mentally handicapped suffers from many serious defects. Despite the slogan “Com­munity Care” the big psychiatric hospitals which were inherited from a previous era have still to provide for a majority of patients. However, they remain totally un­suitable for contemporary needs; they are too big, too over-crowded and under-staffed.

There is an acute shortage of money for psychiatric needs as for other branches of the Health Service. Much of the basic work is done by recruits from overseas who are willing to accept low pay and carry out duties which fail to attract local residents.

Despite the gallant efforts of hospital staffs the situation results in a series of public scandals, further undermining public con­fidence in the service and discouraging staff recruitment.

The purpose of the seminar is to look at the services we provide for all who are men­tally ill — are these services in crisis or in a state of stagnation? It was pleasing to hear an announcement from the Chair that in accordance with SMA policy there would be no smoking during the seminar.

The first speaker, Professor Max Hamilton, Nuffield Professor of Psychiatry introduced the seminar by referring to the development of the practice of medicine and the organi­sation of medicine in our society. He referred to the boundary between disease and behaviour being badly defined and dealt with the work of Trade Unions in 1900 who took certain action which was followed by the National Insurance Act passed by Lloyd George, and later between 1946 and 1948 the action of Aneurin Bevan, the then Minis­ter of Health, who by the provision of the National Health Service Act had the service nationalised from July 1948. Professor Hamilton went on to explain that in his opinion the present crisis in the National Health Service is only an aspect of the crisis of society. The first cannot be dealt with adequately until the latter has received attention. As far as mental health is con­cerned Professor Hamilton felt there had been great developments since the NHS came into being. There had been a great increase in the number of doctors, the num­ber of nurses, social workers and staffs of all grades. The amount of capital which had been spent on psychiatry had been very great and much had been done to extend out-patient departments. In addition the Social Services are now an independent organisation providing a service to hospitals and to the community. In Professor Hamil­ton’s opinion there was now a slowing down while people were sorting out the reorgani­sation and he thought there might be a danger of reaching a point of stagnation.

He was very concerned that there were so few hostels and half-way houses, that the mental hospital was being run down and that many patients were now being sent to pri­son, and in spite of large increases in staff the large psychiatric hospitals were still grossly under-staffed. In his view there was need to give psychiatry services more weight for drug addiction, attempted suicides and especially for the old and senile. The elderly mentally confused were one of the biggest problems facing the National Health Service at the present time. He felt that the policy of replacing the large psychiatric hospital by the unit in the District General Hospital had much merit but by this change of policy there had been certain losses, including the lack of industrial therapy and sheltered workshop provision at the DGH.

Professor Hamilton referred to the claim-conscious community, certainly in the United States of America, where lawyers were taking much more interest in mental patients, and he hoped that this would not develop in this country. He felt there was still a prejudice against mental health patients and against psychiatrists. He felt some crooks were using psychiatry to cover up their ways.

Professor Hamilton spoke rather harshly about psychotherapy and thought that it was not the panacea to all ills. It had an important part but its effectiveness must not be over-emphasised. He was most anxious that the image of psychiatry should be improved. He explained that he found very few medical students were interested in taking up psychiatry as the image built up over the years was not a good one. There should be a public relations exercise to make sure that psychiatry develops an image which gives a clear picture of the important part it has to play in the health of the community.

THE NEEDS OF THE MENTALLY ILL

The second speaker, Dr. Isaac M. Marks, consultant psychiatrist of the Maudsley Hospital, explained that the first kind of treatment was cure; lasting relief from psychiatric depression was usually achieved by anti-depressant drugs. Then there was the question of behaviour psycho­therapy; he felt certain phobias and sexual problems could be dealt with very effec­tively with permanent cures. Other condi­tions could be relieved but there was need to have continuing attention and drugs to keep the condition in check. Finally, there were the long term patients who would require treatment all their lives and who would have to be under constant super­vision. There were, in addition, long term patients with senile dementia for whom there was no cure; all one could do was to try and maintain as much function as poss­ible.

Dr. Marks also spoke of the important sub­ject of prevention. He felt there was need for much more thought to be given to the prevention of mental illness, and in this connection some aspects of child rearing practices were of great importance. Genetic problems should receive much more atten­tion. He referred to experiments in teaching parents and teachers and social isolates; in addition the prevention of loneliness must be tackled. He also made reference to vested interests of political parties and pro­fessions. One of his main criticisms was that efforts were being made to plan ser­vices in the absence of proper knowledge and proper information. He referred to the lunatic fringe belt which was set up in 1870 when many hospitals were established in country areas and where, to a large extent, the patients were lost from the central community of London.

This was all part of an educational process which should apply to the community at large who were in many cases not yet ready for the enlightened treatment of psychiatric patients.

He went on to point out that in his opinion there was vital need for much more opera­tional research in the community and men­tioned a figure of something like £50 million being required for this purpose.

THE DEVIANTS IN OUR SOCIETY

The third speaker was Dr. John Stuart Whiteley, consultant psychiatrist of the Hen­derson Hospital, Sutton. Dr. Whiteley began by referring to the remarks made by Pro­fessor Hamilton whom he felt had poured scorn on psychotherapy. He went on to state that the unit at the Henderson is a very specialised unit dealing with disturbed social deviants — heavy drinkers, violent patients, irresponsible patients — and that there was a situation of intense feeling. He said that in the old days the patients in this category were isolated, suppressed or con­trolled and labelled mad or bad, and that the asylum buildings were to a large extent provided for them. He explained about the type of patient who came to his centre, the intoxicated individual, the psychopathic who behaves in a most strange way and does not fit into normal rules of society. Follow­ing the work of Dr. Maxwell Jones a special unit of the Henderson had been established where between 30-40 patients aged usually between 18 and 25 were taken with a staff of between 20 and 30, plus a group of stu­dents who are spending short periods. He explained frequently during the course of his talk that the Henderson was a living and learning situation and that the purpose was to promote maximal interaction between the clients. They meet two or three times a day and verbally try to under­stand and put down how the situation can be changed. Responsibility for the work of the unit is divided between the clients. They elect a chairman, a social worker, a caterer, a repairs man, and they all take responsi­bilities and look at the way they deal with their own particular jobs whilst at the unit. At the meetings the criticism of the beha­viour of everyone comes up and each client can then take away from the discussions what he needs to help him.

Dr. Whiteley pointed out that two patients had referred to their method as “real life speeded up” and “crash course in living”.

From the statistics that he had available it appeared that there was a 40% improve­ment in the patients who attended the Henderson.

He went on to explain that Normand House is a similar type of institution but here the whole family are taken together and their inter-action is watched and they are helped as a family group.

At the Henderson the clients usually stay about 6 months. If longer than that is re­quired they are not considered suitable for the Henderson. He regards the Henderson as a “think tank” and that all the time they were looking for new methods of treatment.

Dr. Whiteley referred to the new units which were being built and he felt that many of them were not very suitable for psychiatric patients. He was very anxious to have new buildings which provided areas where people could live together — the living learning centre.

Finally, Dr. Whiteley stressed that one unit cannot conquer the whole of the problems, that there are different needs which must be recognised and which must be dealt with quite separately. Psychiatry was a pro­fession where the boundaries of knowledge were being widened continually and there was need to review methods of psychiatry.

CHILD DEVELOPMENT AND MENTAL HANDICAP

In the afternoon session there were three speakers. The Chairman was Dr. John Dunwoody, President of the SMA. The first speaker was Dr. Brian H. Kirman, consul­tant psychiatrist at Queen Mary’s Hospital, Carshalton.

Dr. Kirman began his talk by telling the story of a child who had been mentally handicapped and had been in hospital for many years. Eventually the child was able to leave hospital and learnt to drive cars. Sometime later he went back to the hos­pital to meet the staff and a sister had said to him “I am delighted to hear that you are now able to drive and you own your own car”, and the former patient’s reply was “Sister, I own a whole fleet of vehicles”.

Dr. Kirman made four main points. The first he emphasised was that mental handicap was an ongoing battle and that it was vitally important to have a constructive approach. He considered that the size of the hospital or the institution is not of great importance. The vital point is the type of training the child receives wherever he may be resident.

His second point was: continuum of repro­ductive casualty. Dr. Kirman said that if a patient has gastro-enteritis imme­diate action is taken and all the know­ledge of medicine is concentrated on clear­ing up the condition. As far as the unfavour­able upbringing of children and infant mortality is concerned progress had been much slower. At the beginning of this cen­tury 155 children died before the age of one in every 1000 of the population. The figure was now below 20 and there had been fewer cases of brain damage than formerly. It was sad to reflect that in the UK we were well down in the infant morta­lity league table in spite of the National Health Service whilst Holland, Sweden and Denmark were moving ahead. There was still too high a number of damage to brain, neurological damage and epilepsy, and other conditions associated with insufficient care at birth. The total social structure was as important a matter as was the day-to-day care of children.

Dr. Kirman referred to long term develop­ments and was concerned about the pre­sent policies on school meals, and school milk. He wondered what effect these poli­cies would have on children in the future.

The third point made by the speaker was: campaign against mental handicap in the National Heath Service. Dr. Kirman con­sidered the Mental Health Act had been very valuable. Only a small fraction of patients were admitted to hospital and the Act could be regarded as a victory.

Away from the custodial approach the 1959 Act was a step forward. The Education Act of 1970 also removed barriers as far as mental handicapped children were con­cerned, but he pointed out that the care of these children was an uphill struggle and that there was still much to be done. Physical conditions were easier to define and action was more precise but mental handicap was not accepted by the public generally as an area where progress could be made.

Dr. Kirman went on to point out that most of the hospitals in which the children are now retained are over 100 years old. He looked forward to the White Paper to be published shortly which he hoped would stress the urgent need for mentally handi­capped children to be dealt with in the com­munity. He hoped there would be a great educational process and that community places would be found for many of the children who were now in hospital. He felt it was a moral duty to make provision for these children in the community and said the Manor Hospital was a good example of work in this direction.

The final point made by the speaker was research. He started by explaining that mankind can now send men to the moon, but as far as mental health is concerned very small sums are spent in research. The resources are not being mobilised. There js much child mortality which could be improved by better social conditions. There were genetic errors which could be avoided. Early in the century certain work had made it clear that abnormalities could sometimes be avoided by certain techniques, but it was not for 50 years that their techniques had been applied, and these did in fact reduce some abnormalities. There is no doubt that Dr. Kirman’s em­phasis on prevention and his dedicated and constructive approach greatly impressed his audience.

THE ROLE OF THE SOCIAL WORKER

The second speaker was Mrs. Barbara Hud­son, Lecturer in Social Work, London School of Economics. She started her add­ress by pointing out that social work is in a state of chaos. It was in her opinion the unloved profession. In the old days there were almoners, probation officers, mental welfare officers, relieving officers under the Poor Law Acts, psychiatric social workers etc., but now there was a new set-up under the Seebohm Committee proposals. The speaker emphasised the need for one family to have one social worker. She pointed out that in 1974 the hospital social workers joined the local authority social workers and that a Genetic Area Team was now established. The audience were surprised to hear that in a caseload of 320 cases only 15% required psychiatric attention. Cases like Maria Colwell had made it necessary to put the emphasis on the child care ser­vice. It was interesting to hear that the unemployed are in much greater contact with the Social Services than are the em­ployed and that social workers are usually called in when there is need to get a patient into hospital. The need for in-service training was also stressed and also the need to specialise in certain areas of work; for instance mental illness. The speaker went on to explain the various methods of helping psychiatric patients and referred to under-stimulation, the links with the outside world, the need for good hostel environment, occupation, rehabilitation, and the need to establish day centres. There was also the over-stimulation resulting from financial hardship, social security problems, over-maternally involved relative, the active relative group and the anti-family contingent. What was necessary was a caring and reli­able relationship and this is what social workers were keen to establish so that they could help patients through all phases of severe illness and those who were less ill. Mrs. Hudson stressed the need for good training of social workers and the part that nursing officers could take in helping to effect some improvement in patients’ con­ditions from the social point of view. The Royal College of Physicians were having a special training for psychiatric social workers and she welcomed the liaison between the college and social workers. Finally she stressed the great assistance which could be given by volunteers in the community. There should be no fighting between the various groups, they should all work together and develop therapeutic skills so that the patients in the community could be well catered for. A suggestion was that a volunteer should in fact be respon­sible for 8 families in the community, keep­ing in close touch with them, helping to assess their needs, and bring expert assis­tance when this was required.