Some perspectives on making the mental hospital more therapeutic in post-war Britain

DB Double, Consultant Psychiatrist and Honorary Senior Lecturer, Norfolk & Suffolk NHS Foundation Trust & University of East Anglia, Norwich, UK

Abstract

The idea of the mental hospital as a therapeutic institution was coined in 1945 by Tom Main in an experiment at Northfield military hospital to orientate the whole hospital to a healthy socialisation of neurotic casualties of the Second World War, most of whom expected to return to civilian life. Although the importance of active therapy in mental hospitals, including work and occupational therapy, was recognized before the war, it was not until afterwards that an occasional medical superintendent encouraged their patients to accept more self-determination and responsibility for their activities. This was the start of the open-door movement. The unlocked door became the symbol of progress in many mental hospitals, although the value of open doors had been known previously. For example, TP Rees was one of these pioneers at Warlingham Park. He was a member of an Expert Committee on Mental Health of the World Health Organisation that produced its Third Report in 1953, in which the need to create a therapeutic milieu in hospital was recognised. Elements of this therapeutic atmosphere included encouraging patients' self-respect and sense of identity; and the general assumption that patients are trustworthy and retain capacity for a considerable degree of responsibility and initiative. Purposeful, planned activity was promoted in a patient's day.

These therapeutic community approaches may well have contributed to England being the first country to start reducing the numbers of its mental hospital patients in 1954. The highest prevalence ratio of patients per 1000 population was actually slightly higher than 1954 before the war, as the total population in the country was smaller. Also, admissions continued to increase even though the number of beds occupied was reduced. Nonetheless England reached its mental hospital population peak before other European countries.

The war gave an impetus to the development of social measures in psychiatry, partly because of the sheer number of cases, which could not be treated on an individual basis. The need to treat psychological casualties of war led to an equivalent acceptance of a social responsibility for the psychological casualties in the struggles of everyday life.

Maxwell Jones at the Effort Syndrome at Mill Hill from 1942 introduced large group lecture-discussions, sociodramatic performances and nurses as therapeutic aides to educate patients towards an acceptance of group responsibility. At the end of the war, he replicated this regime at an ex prisoner-of-war unit in Dartford. In 1946, he moved to Belmont for the treatment of psychopathic patients that had a poor employment record, developing a proper therapeutic community, which in 1959 became the Henderson hospital. Similarly, after the war, Tom Main became medical director at the therapeutic community at the Cassel hospital.

These therapeutic communities proper were relatively small compared to the size of mental hospitals. It was not until 1962 that Maxwell Jones became medical superintendent at Dingleton hospital in Scotland. The hospital had already been one of the first British mental hospitals to have a comprehensive open door policy under George MacDonald Bell. As in other countries, the dismay and disgust with the old asylum system, and recognition of the negative effects of institutionalisation led to the development of alternative community services and the decline of the traditional mental hospital.

Talk

What I want to do is talk about the origins of the therapeutic community in psychiatry in and immediately after the second world war.

Two psychiatrists, in particular, are important in this story: namely, Tom Main (1911-90) and Maxwell Jones (1907-90).

These therapeutic community ideas influenced the process of making the mental hospital more open and active in rehabilitation.

After the war, an occasional medical superintendent, such as TP Rees at Warlingham Park, were pioneers of the open door movement.

These therapeutic community approaches may have contributed to England being the first country in Western Europe to start reducing the numbers of its mental hospital population.

The psychoanalyst, Tom Main, was for many years the Medical Director at the Cassel Hospital in London. He was largely responsible for the development of the therapeutic community there.When he was in the British Army, he planned psychiatric services for the Normandy Invasion.

Few army psychiatrists could practice only in individual personal terms with patients, if only because they were mindful of the demands and discipline of the army system. Psychiatrists working with units in the field became aware that there were certain battalions in which individual breakdown was common and others in which it was rare.

Main and others tried to find out what made this difference, recognising the ways in which the morale of battalions was affected, with effects on the mental health of the individuals who comprised them.The structure of battalions were by their nature the same and any difference seemed to be more intangibly due to human relations inside the social structure.

The importance of group dynamics was, therefore, a major conceptual shift within psychiatry in the war.

Social psychiatry became possible with the study and treatment of social entities and their effects on individuals as their subsystems.

Northfield was a large military hospital in Birmingham and Main went there in early 1945.What came to be known as the first Northfield experiment had been conducted by Wilfred Bion in 1942.

Bion became exasperated with the indiscipline of his soldier patients in the training wing and told them at a daily ward parade that their behaviour was their responsibility and he refused to be responsible for it.

The ward became filthy, beds were not made, and absence without leave and drunkenness increased.. Over time the soldiers were said to gradually grow responsible and the ward was apparently seen as the most efficient in the hospital.

What was not written up was that Bion was sacked from Northfield after 6 weeks because his commanding officer was not able to tolerate the chaos and Bion’s refusal to accept responsibility. The arguments about the experiment came to the attention of higher authority and the commanding officer was also sacked after Bion had left the hospital.

At the time Main went to Northfield in 1945, it was not a therapeutic community but a community in which therapy was occurring mainly in groups. Michael Foulkes was the outstanding therapist and teacher and it was largely because of him that group treatment was used for the majority of patients in every ward. The idea emerged in the second Northfield experiment in 1945 that the whole community might be therapeutic.

Patient-organised rather than staff-organised groups were developed.

Foulkes following Main’s invitation became a trouble-shooting consultant who sometimes needed to do major group therapy when patient-organised groups got into trouble.

Groups also started to be used to examine other crises and inefficiencies.

By 1946, the hospital was a new kind of institution in which both patients and staff sought to explore the tensions in the lives of individuals and of the small groups in which they lived.

However, non-therapeutic staff felt ignored and saw it as their responsibility to run things, not the patients. Main’s commanding officer made it plain that his tolerance with the psychiatrists was at an end.Main was keen to avoid the fate of Bion and recognized that the tensions needed to be resolved.

He said that it suddenly occurred to him that the whole community, all staff as well as all patients, needed to be viewed as a troubled larger system that needed treatment. The question was – Could the total institution become therapeutic for all?

Main coined the term ‘therapeutic community’. Military staff slowly began to join groups and attempts were made to give their concerns equal status to everybody else’s.

Main says he left Northfield a few months after arriving at the notion of the therapeutic community. His paper “The hospital as a therapeutic institution” was published in 1946 in a special edition of the Bulletin of the Menninger Clinic. Karl Menninger had been fascinated by his visit to Northfield from America.

The paper describes the passive nature of being a patient in hospital.

It talks about patients being desocialised in hospital making the task of reintegration into society more difficult

Because of the numbers of patients, individual treatment for everyone in hospital is not seen as a practicable proposition. Instead, in Main’s words, perhaps the hospital “must become a therapeutic institution”.

Main describes the second Northfield Experiment as “an attempt to use a hospital not as an organization run by doctors in the interests of their greater technical efficiency, but as a community with the immediate aim of full participation of all its members in its daily life and the eventual aim of the socialization of the neurotic individual for life in ordinary society”.

Psychiatrists no longer own their patients like captive children and they renounce their authority.

Instead, patients face together the demands of immediate social reality.

Although Main coined the term therapeutic community, it owes most of its meaning to Maxwell Jones.

Jones was part of a team from the Maudsley Hospital in London that went to Mill Hill Emergency Hospital in 1942. An effort syndrome unit was set up under the joint directorship of Jones and a cardiologist.

The emphasis lay in the application of sociological and psychological concepts to treatment.

As an aside, it may be worth emphasizing that the war did not only encourage social psychiatry but also physical treatments.

A second team from the Maudsley was set up at Sutton Emergency Hospital.

It came to be associated with short-term treatments for war neurosis, such as modified insulin, ether abreaction, continuous narcosis and narcoanalysis.

Both William Sargant and Eliot Slater worked there and their book An Introduction to Physical Methods of Treatment in Psychiatry (first published in1944) became very influential.

Patients with effort syndrome complained of breathlessness, palpitations, chest pain, giddiness, fainting attacks and fatigue, with their symptoms in the main related to exercise. Most patients thought they had heart disease.

As the understanding of individual symptoms developed, it became clear that effort syndrome was a psychosomatic complaint.

Information was given to patients in a discussion format about the physiological mechanisms involved in the production of symptoms.

The educational approach was found to affect the patients’ attitudes to their symptoms, even if the symptoms did not disappear.

Patients began using the discussion groups to raise problems bearing on ward life.

The use of drama as a technique of social therapy developed in 1944, beginning with nurses acting out the lives of a fictitious family with three daughters, whose personalities were schizoid, psychopathic and hysterical. Patients started writing their own plays on social problems, such as alcoholism and illegitimacy, and began projecting their own problems into these themes with the appearance of frankly personal presentations.

An attempt was made to think of treatment as a continuous process throughout the entire waking life of the patient whilst in hospital. The hierarchy of doctors, nurses and patients was broken down with free communication between these groups, perhaps facilitated by the fact that it was a temporary war-time hospital, without the usual strong hospital traditions.

After the war, in May 1945, Jones moved to an ex-prisoner-of-war unit set up at Southern Hospital, Dartford.

The social structure followed the pattern of the effort syndrome unit, with talks, discussions, psychodrama and discussions about problems affecting the hospital community.

Also, the unit developed relations with the local community and patients who were well enough undertook work therapy with local employers.

An active cultural life developed within the hospital with, for example, the performance of plays and the production of a unit newspaper.

The results of Dartford, together with the much larger experience of civilian resettlement after the war led to a considerable interest in therapeutic communities. In April 1947, an industrial neurosis unit for the treatment and resettlement of chronic unemployed psychiatric casualties was set up at Sutton Emergency Hospital, later changing its name to Belmont hospital. Cases were sent from all over England.

There were various workshops in which the patients undertook semi-skilled or unskilled work of social value with the aim of reinstating the habit of work.

Nurses, as social therapists, encouraged patients to participate in the various social, work and community treatment, such as psychodrama.

The whole of a patient’s time spent in hospital was thought of as treatment.

In summary, the war gave an impetus to the development of social measures in psychiatry.

This was partly because of the sheer number of cases, which could not be treated on an individual basis.

The need to treat psychological casualties of war led to an equivalent acceptance of a social responsibility for the psychological casualties in the struggles of everyday life.

The Belmont hospital eventually in 1959 became the Henderson hospital, one of the most famous therapeutic communities, using sociotherapeutic methods.

Similarly, after the war, Main became director of the Cassel hospital, where there was a tradition of psychoanalytic treatment.

He established his model of the therapeutic community, which in many ways might be called a psychotherapeutic community, rather than sociotherapeutic community.

These were therapeutic communities proper and a distinction needs to be made from the therapeutic community approach in general, a distinction first made by David Clark.

Awareness of the Northfield and Mill Hill experiences meant that the concepts of the therapeutic community were taken up generally by psychiatrists after the war. The therapeutic communities proper were relatively small compared to the size of mental hospitals, so the specific principles were not readily applicable.

Instead, the ideas helped develop the impetus to make mental hospitals more open and active in rehabilitation.

The importance of active therapy in mental hospitals, including work and occupational therapy, had been recognised before the war.The value of open doors had even been known.But it was not until after the war that an occasional medical superintendent encouraged their patients to accept more self-determination and responsibility for their activities. This was the start of the open-door movement.

The unlocked door became the symbol of progress in many mental hospitals.

For example, TP Rees was one of these early pioneers at Warlingham Park.

He was an influential member of an Expert Committee on Mental Health of the World Health Organisation that produced its Third Report in 1953.

The need to create a therapeutic milieu in hospital was recognised in this report.

Elements of this therapeutic atmosphere included encouraging patients' self-respect and sense of identity; and the general assumption that patients are trustworthy and retain capacity for a considerable degree of responsibility and initiative. Purposeful, planned activity was promoted in a patient's day.

These therapeutic community approaches may well have contributed to England being the first country to start reducing the numbers of its mental hospital patients in 1954. The highest prevalence ratio of patients per 1000 population was actually reached earlier than 1954 before the war, as the total population in the country was smaller. And, even though the number of beds occupied was reduced, admissions continued to increase. Nonetheless England reached its mental hospital population peak before other European countries.

The following years were taken up with the difficult task of implementing the therapeutic community principles in practice, in spreading the work and maintaining it across the country.

Therapeutic communities proper were developed in some wards of psychiatric hospitals.

In 1962 Maxwell Jones became medical superintendent at Dingleton hospital in Scotland allowing him to implement his therapeutic community ideas across a whole large mental hospital.

The hospital had already been one of the first British mental hospitals to have a comprehensive open door policy under George MacDonald Bell.

By 1963 80% of English psychiatric patients were in open wards. The advantages were said to be striking: tension reduced, violence declined, ‘escapes’ were no longer a problem and staff were able to give their attention more to therapy rather than custody.

As in other countries, what motivated dehospitalisation was what David Clark called the “dismay and disgust with the old asylum system”.

The recognition of the negative effects of institutionalisation led to the development of alternative community services and the subsequent decline of the traditional mental hospital.

In conclusion, the second world war encouraged social psychiatry and the development of the therapeutic community.

Immediately after the war, the focus was on the resettlement of ex-prisoners of war and industrial rehabilitation of psychiatric casualties of the war.

Recognition of the need to create a therapeutic milieu in hospital led to the opening of the doors of the traditional mental hospital and the development of alternative community care

Mental hospital populations peak years:-

England	1954
United States	1955
Canada	1962
Italy	1963
France	1972
Germany	1973
Denmark	1976
Sweden	1977
Netherlands	1979
Belgium	1981
Spain	1981

However, welfare arrangements differ between countries and these factors may have been more to do with the differences between countries than concepts such as the therapeutic community.

Changes in mental hospital population totals:-

	Peak year	1950-85	1970-85
England	1954	-51.2	-44.8
United States	1955	-47.7	-18.9
Italy	1963	-36.1	-50.2
France	1972	22.5	-6.0
Germany	1973	27.1	-11.0
Denmark	1976	-29.9	-28.6
Sweden	1977		-40.0
Netherlands	1979	-3.0	-9.4
Belgium	1981	7.2	-20.2
Spain	1981	46.7	-26.3

In Germany and France there was a perceived deficit in in-patient capacity in the 1960s with a consequent rise in mental hospital bed space, explaining these countries peaks in the early 1970s.

In Denmark and Sweden the mental health population stayed stable until mid-1970s with subsequent decline, whereas in the Netherlands the decline was slower.

Spain, Portugal and Greece showed little decline in bed stocks at all until mid-1980s.

Italy seems have been affected by influence of Psichiatria Democratica and the implementation of law 180.