Chapter III Chronic Patients and Institutions

The Rediscovery of Scandals

“A spate of social scientific research in the 1950s and 1960s ….devoted to the elucidation of the baneful effects of institutionalisation…. purported (.to show) for the first time…. that mental hospitals were anti-therapeutic.” The defects noted were not solely because of maladministration or inadequate resources but “reflected fundamental and irremediable flaws…”

Titles showed moral rules were broken: The Shame of the States; Human Problems of a State Mental Hospital.  Anyone familiar with 19th century reports had a sense of deja vu, the same story in 20th century jargon.

Critics a century before recognised asylums were prison-like, increasing the ‘pathology’ of inmates. “In all cases admitting of recovery or…. amelioration, a gigantic asylum is a gigantic evil….a manufactory of chronic insanity.” 19th century arguments for the creation of state funded and managed asylums were “humanitarian reform” and “financial economy”. The same reasons now point towards abandoning expensive, inefficient anti-therapeutic hospitals and decarcerating the troublesome people back to the community, “..the worst home is better than the best mental hospital.”  Community care is becoming the new humanitarian myth comparable to that which attended the birth of the asylum.

Why in a medicalised society, despite psychiatry’s attainment of full professional status, is the chimera  of care with dignity, if not cure, so elusive? Why do the same problems of malpractice, brutality, neglect recur in research hospitals,private facilities, large state institutions and small Homes in various countries?  To what extent is “the ‘medical model’ and the institutional arrangements for which it provides legitimation  implicated in the production and reproduction of scandals?

Goffman’s critique of ‘total institutions’ as an ideal-type construct indicated similarities of behaviour patterns and social relationships across a range of institutions. These result from organisational constraints, bureaucratic controls for processing mass batches of people, all of whose imposed activities occur in the same place with others, treated in the same routinised regimented ways. Institutions for the harmful, harmless, capable and incapable all show common features.

In hospital, one’s role is reduced to that of patient with  disease – all latent roles suspended.   For chronic patients, there are no latent roles, dependency and enforced idleness are encouraged by the orientation of medical training.   Dignity and integrity may be violated.   The danger, unpleasant­ness and depersonalisation involved in hospitalisation is mag­nified for chronic patients. Life is disrupted not so much by illness as routines designed for the convenience of others who are not interested in one’s overall welfare, only limited aspects.   “The very existence of the long-stay hospital shapes our concepts of mental disorder…values,..fears..willingness to assume that the problem is primarily one for medicine and nursing” .introducing obstacles in considering how best to serve the inmates.

The Hospital as an Organisation

Analysis of the mental hospital as an organisation has taken two main forms;

l.the structural functionalist model incorporates  the formal bureaucracy established to attain explicit goals, and informal social network of relationship whose goals may be diverse, latent and manifest.

2,the arena model in which emphasis is placed more on processes occurring rather than structural equilbrium. Means and ends emerge in the course of negotiations by members, rather than being assumed as givens from the perspective of leadership.

Much of the literature and official reports use the first model implicitly or explicitly. Strauss applied the second to explain the range of theoretical perspectives used in psychiatric practice, often existing concurrently in different wards and units of the same hospital. “Underlying all treatment ideologies” (somatotherapy, psychotherapy, sociotherapy) “there is a fundamental moral position, a general moral prescription and social mandate to help patients. Ideologies provide frameworks for judging both how patients should be helped and what is harmful for patients.

Perrow uses a socio-technical systems approach to review  studies describing defects of mental hospitals.   There are techniques and technologies for care, control and custody, but curative treatments to alter behaviour, (the primary task) are problematic. Various studies conclude problems arise because of poor communications, attendants’ power allows abuse, psychiatrists are inefficient administrators wanting to use psychotherapy but lacking resources. Therapeutic goals are displaced by oppressive custody not because of structural irrationality but there is no appropriate technology. Therapeutic goals have sym­bolic value, the real goal is custody, control and minimal care  of inmates who, as in the 19th century, are predominantly lower class, troublesome, incompetent, economically unproductive. The doctor is ineffective in attaining cure because there is no task-relevant technology.

Deutsch found most state hospitals used restraint. 19th century lay beliefs were commonplace despite Freudian theory and war shell-shock victims. Conditions were worse than Nazi concentration camps – filth, starvation, strapping to beds, black eyes, bruising indications that brutality occurred with ‘shocking frequency’

Belknap thought the state hospital was starved of funds due to public antipathy and ignorance.   Administrators shared lay beliefs with untrained attendants, who outnumbered trained nurses. The hospital’s culture was transmitted by patients and attendants, despite the latter’s high turnover. Lay attitudes included the belief that poorest patients were better off in hospital – there seemed little awareness of problems of institutionalisation.   Exploitation of patients was common: the more able worked on wards, possessions were stolen, civil liberties unprotected, no complaints procedures available. Punishment for disobedience included ECT, strait-jacket, confinement in baths, seclusion. As Scheff observed later, Belknap found attendants were gatekeepers deciding who saw the Doctor, got drugs, seclusion, transfer or discharge. Similar practices were noted at Farleigh.   The back wards are still the “relatively undisputed domain of lay personnel, who…(are) only slightly affected by supervisory presences of administrators, nurses, doctors  and little influenced by modern treatment ideologies.

The predominance of private medicine in USA does not explain defects in the state sector; the same patterns were found in the twelve different hospitals of Rosenhan‘s study, and in Britain before and since the NHS. In well-staffed private wards, disturbances were more due to staff disagreements than patients’ behaviour, they being largely ignored.   Similar effects were noted by Rosenhan. Staff and patients were strictly segregated. Contact other than for specific tasks was rarely initiated by staff; attempts by patients were cut short, eye gaze avoided. Patients reactions to attendants mistreatment was interpreted as symptomatic, because of family visitors, but never due to staff actions or hospital organisation.   Patients often behaved rationally despite repression when asking for  help staff considered them manipulative, responsible, sane. The likelihood that staff cannot distinguish sane from insane persons, motivated the Rosenham experiment. Doctors don’t question whether characteristics leading to diagnosis of mental illness reside in patients or social contexts. In distinguishing sick from well, they frequently make type 2 errors.   This was confirmed when no staff suspected the pseudo-patients  whilst some patients perceived they weren’t ‘real’ patients. As long as the medical paradigm predominates, all behaviours surveilled by staff are likely to confirm the diagnosis.

How the medical paradigm can structure the world-taken-for- granted is illustrated by interpretations and responses to patients described by Barton.   The syndrome of ‘institutional neurosis’ is perceived as symptomatic of organic pathology rather than social aetiology. Of the interacting aetiological factors staff brutality  is an important cause Barton did not recognise earlier from evidence of patients, ex-patients, relatives and staff. “The presumption that such things don’t or cannot happen has been shown …to be naive and fatuous.” “Both administrators and (nursing) aides manoeuvre to prevent themselves being held responsible in case of disaster. Death, injuries, escapes and many other events can bring…investigations.” Classificatory labelling of patients as violent, uncooperative, trouble-maker legitimates the ecological system of placement and widespread use of restraints, upgrading staff and downgrading patients.   Back wards can be a means of disposal for patients and staff who would otherwise impair the progressive image of other wards.   An elaborate system of incentives and disincentives built into every aspect of patients’ lives determines their in-patient moral careers.

Blaming ward staff for their brutality exemplifies victimology, diverting attention from economic and political factors. Shortages of staff and basic amenities causing stressful conditions “are the fault of management at all levels, not of ward staff….(who) are undoubtedly resentful of criticism…” Asylum nurses before 1914 “detected) the hypocrisy of authorities who publicly, expressed high ideals but left staff to struggle with minimal resources.”   The intrinsic value of mental nursing is still stressed in recruitment publicity. “The Jay report…. whilst cursorily acknowledging the demanding nature of the job” suggest staff will provide “warmth of care (with) few conditions attached…. are able to care for dependent people without falling into the trap of kindly control.”   That staff are doing society’s dirty work, caring for ‘moral’ filth of the ‘dangerous classes’ excluded, segregated, confined is rarely acknowledged.”Repulsive work we have to do, and bear obscene abuse….But if we make the slightest slip, ’tis counted as a crime.”

Contemporary members of COHSE make similar points. Ward staff and patients are at the receiving end of ‘Cinderella services’. Staff feel they are the scapegoats in an underfunded, badly managed service. However this is a partial explanation of abuse  where these are endemic rather than sporadic.   If some people think agents doing Society’s dirty work are brutal, others from their safe social and geographical distance are indifferent or justify whatever is necessary to control deviants.

Moral Treatment Reborn

As moral treatment was a rejection of brutal custodial practices and medical interventions of the past, its renaissance as milieu therapy is a reaction to institutionalisation and the dominant somatotherapy of 20th century psychiatry. The ideology   and practice of milieu therapy ‘was developed concurrently but independently by the Tavistock group   and Jones in Britain during the war. ‘ Incorporating social science theories, it is “based on the on the premise that (if) …a disordered personality may be produced by a pathological social environment, so a benefic­ial environment may remove such disorder.”

The hospital should not be “an organisation run by doctors in the interests of their own greater efficiency, but as a community with the immediate aim of full participation of all its members in the daily life..”   If the hierarchical structure of the hospital can be flattened, ‘unrealised therapeutic potential’ can develop within informal social relationships. In the resultant democratic community, self-discipline and responsibility are facilitated by allowing members to make choices and verbalize feelings. Permissiveness in the context of communal goals and activities aid cognitive reorientation and improve interpersonal skills.   Central to the implementation of therapeutic communities is the concept of social learning by  staff and patients through informal group meetings.

The Modern Psychiatric Nurse

The therapeutic community approach was accepted by spokes­men for psychiatric nursing when in 1956 WHO recommended nurses to ‘provide experiences in living’ for patients to facilitate interpersonal relationships. “Three aspects of the nurse’s work were distinguished, ‘technical, social and interpersonal’ …the latter described as the ‘essential part..'”   This change began to be implemented in some wards of some hospitals. By 1968 it was noted ‘the therapeutic value of the nurse is not fully recognised’; nurses should be trained to take a ‘more active therapeutic role’. However the subcommittee did not extend  nurses’ therapeutic role to subnormality hospitals.

Three years later the DHSS listed the main principles for mental handicap services. “Each handicapped person needs stimulation, social training, education…. purposeful occupation or employment…. to develop to his maximum capacity…”

After reviewing British studies, Towell concludes “nurses give rather less emphasis to personal relationships aspect of their role than do official reports.” American studies suggest nurses are still struggling for some kind of therapeutic identification, lacking commitment to any ideology.

No Change on Back Wards

There have been several sociological studies of subnormality hospitals and Homes, a few studies of institutions for old and disabled people,   but no major study of psychogeriatric  wards before Towell’s ethnographic work.  Most of these have appeared since scandals began to break in the 1960s,  illustrating how authoritarian, rigid routines incorporating outmoded lay beliefs about patients’ natures and needs, legitimate punitive custodial regimes.

Public awareness of a social problem was first aroused by Robb’s letter to The Times, 10th November,1965 detailing depersonalising practices in a psycho-geriatric ward. These included loss of dentures, spectacles, hearing aids, leaving the patient “to vegetate in loneliness and idleness.” Having asked for correspondents who could give similar instances, she was amazed by the response from nurses and social workers in all regions indicating pent-up rage. After investigating the authenticity and reliability of evidence, certain accounts were published in spring 1967 as ‘Sans Everything’.

In July, 1967, The News of the World forwarded a letter to the Minister of Health, subsequently published, alleging various malpractices at Ely Hospital: cruelty, verbal abuse, neglect of patients, senior staffs’ indifference to juniors’ complaints, pilfering of food, clothes and other hospital property. The committee of inquiry appointed in December to investigate was unable to summons witnesses or have legal support.

Despite the exposure and ongoing investigations at Ely, the Ministry’s brief report published in July, 1968, on the allegations of Sans Everything considered, “..we have no hesitation in saying ….there is no substance whatever in the allegations of cruelty..” Commenting on evidence regarding unhygienic practices, lack of cleanliness of bedpans, sluices, floors, communal combs and brushes, rudeness and rough handling of patients, technical nursing procedures done by untrained auxiliaries, the committee had no “doubt that trained staff, from Matron …to staff nurses,… would not tolerate the conduct complained of….we found no evidence of anything which called for disciplinary  action against anyone.”   This led the journalist, Rolfe, to comment, “Whitehall washes whiter.”

Rolfe could not know civil servants, aware from 1963 moral rules were being broken at Ely and elsewhere, had not informed the Minister or relevant RHBs,   and the publication of the Ely report received that summer was delayed.

In the foreward to Morris’ national survey of subnormality institutions published soon after the Ely report, Townsend considered the Committee of Inquiry’s belief that Ely lagged behind similar hospitals mistaken. The findings “could be applied to all subnormality hospitals.”   He should have said all chronic hospitals.

This was already apparent by December, 1968 when police received allegations of ill treatment at Farleigh hospital. No committee of inquiry was established until June 1970 after criminal proceedings ended.

The case of Whittingham psychiatric hospital typifies the general malaise and its causes latent at all chronic hospitals. Frustrations of student nurses, simmering since 1965, fortified by Sans Everything, surfaced without success, finally erupting in July, 1969 when the Secretary of State was approached directly.  Barton, lecturing to the NAMH in 1965 named Whittingham as a hospital where ill treatment occurred, was reprimanded and called before the BMA Ethics Committee. Allegations concerned ill treatment of patients, fraud and maladministration, suppression of nurses’ complaints. Police investigations following the auditor’s inquiry, ended in June, 1970. Subsequently a male nurse having assaulted two patients was convicted for manslaughter. Not until February 1971 was a committee of inquiry appointed. The 1969 allegations were mainly concerned with the female side, especially ward 16. In charge of 126 chronic psychiatric and psychogeriatric patients, many doubly incontinent, was a sister past retirement age, forty-seven years in that same ward, whose foreign-born deputy, an untrained SEN, had served eleven years. All this had followed requests to RHBs in 1967-8 to review conditions for their chronic and elderly patients. The message transmitted in a complacent tone to Whittingham’s HMC elicited the reply on 19-7-68 from senior nursing staff – having the previous day suppressed minutes of an angry students’ meeting -there was no cause for concern.

To date, over twenty reports of major inquiries have been published since the first four. Other investigations have been held whose findings are restricted or whose existence is unknown. An increasing number of GMC Disciplinary Committee hearings have been held.   It is obvious there have been few changes on back wards since Robb shone a spotlight into murky corners, despite a flood of circulars, guides, white papers and growing pressure group activity. Where some people see malpractice, others see routines based on commonsense and tradition. Different interpretations of “reality’ influenced by different moral meanings are produced by different actors. If the largely untrained back wards’ staff were unaware of moral treatment’s rebirth, why was there a “failure of relevant authorities to identify and remedy defects….at the time they arose”?

Alarmed by events, Crossman, despite medical resistance, tried to increase resources to chronic hospitals, and/initiated the Hospital Advisory Service, Davies committee, and advisory working party which produced the 1971 White Paper.   The latter emphasized need for closer collaboration between health and local authorities, and  a multi-disciplinary approach.   The Conservative government provided few extra resources. Morris’ suggestion for an educational/social training profession with equal status to the medical/nursing branch was considered by Briggs but fully debated by Jay.   Its recommendations are unlikely to be implemented for reasons of cost, professional hostility, and inability of Local Authorities to assume more responsibility.   Paediatricians, if not psychiatrists, seem to be developing a new interest in subnormality.

As the Whittingham report had been an unwelcome present for Sir Keith, so the Ockenden report was delivered to Castle in 1974. In the foreword she repeated, “All people charged with the management of a hospital….must have faith in their judgement and the evidence of their own eyes. If they feel something is wrong…. they must take appropriate action.”   What laymen and professionals judge as infractions of moral rules is problematic, as is their ability to surmount obstacles to voice complaints and jolt into action those accountable as subsequent reports showed. Introduction of CHCs and the Health Service Commissioner in 1974 did not prevent further scandals at St. Augustine’s, Normansfield or Rampton amongst others. Nor was a change from “custodial care to dynamic therapeutic programmes”   evident in the TV documentary of St. Lawrence’s and Borocourt Hospitals shown on 10-6-81. The facts about Normansfield were known at all managerial levels including the DHSS, local M.P., League of Hospital Friends and CHC. Management was disinclined to take appropriate action until staff went on strike.   Rampton is managed directly by the DHSS no regional or area management can be blamed. Sec. of State Jenkin rapidly took appropriate action by referring allegations to the DPP and appointing the Review Team a day before the TV documentary was screened.

Several initiatives were taken from 1975 including NDG, DT, Jay, RAWP, Joint Funding and Consultative Documents. Given the fact “the power of central control is largely illusion”  none could be expected to achieve miracles, but economic cuts, and change of government, 1979, have eroded potential momentum.

Meanwhile earlier changes were affecting hospital modes of operation. Within the NHS, nursing and ancillary staff have become more unionised and ‘militant’,   responding to the ‘new managerialism’ introduced with the Salmon structure, work study techniques and 1974 reorganisation.   For chronic sector staff an additional incentive to collective action is job insecurity because of bed reductions and hospital closures. Politicians borrowing capitalist rationality, management theories and practices from industry, created new problems of industrial relations, but did not question their effectiveness to meet stated goals given the dominant medical engineering paradigm. Services to which capitalist rationality cannot be applied, remain ‘Cinderellas’.

A centralist/managerial approach dominates analysis of the NHS and official committees of inquiry, influencing perception of problems and putative solutions.   Changes in the desired directions have not occurred because strategies for change lack local perspectives, ignoring internal dynamics. Power, values and interests of local actors determine decision making, not  central directives.   It is to the local situation at the level of the ward sub-culture that we now turn.