DO WE NEED PSYCHIATRIC HOSPITALS? ANTHONY WHITEHEAD and DAVID ENOCH comprehensive community care is argued by Dr. Whitehead of Prestwich Hospital, while the need to retain the hospital is put by Dr. Enoch of Shelton Hospital, Shrewsbury The



Admitting people with psychiatric illness to hosoften produces more problems than it solves and also exposes them to the dangers of 'institutional neurosis'. Many schemes have been devised

pital to

prevent unnecessary admission, particularly community care programmes, day hospitals and hostels. But



no one seems

to have tried to


therapeutic psychiatric service for a community without in-patient facilities in any highly developed country such as ours. This is a proposal for a pilot study of such a service. Institutions tend to resist change and many mental hospitals are still out of touch with the realities of our society. Progressive hospitals and units may be up to date today, but tomorrow they are likely to follow their predecessors into the rigid acceptance of what was thought to be right. The provision of total community care without any in-patient facilities might eliminate most of the dangers and disadvantages of hospital care. Stigma should be reduced, since people would not 'go away'. a

Problems would have to be solved in the situation in which they occurred and treatment tried out in realistic conditions. The patient would not be isolated from the the family, which would have to be involved in the therapeutic situation. There would be a greater chance of changing the public's stereotype of psychiatric illness, since it is more difficult to build up distorted pictures of 'madness' when the patient is not hidden away. This type of programme envisaged might do something towards combating the 'Queequeg Syndrome', which is an induced psychiatric illness, due to the patient being treated as abnormal. The cause is similar to that of institutional neurosis, but it affects patients outside hospital and is due to the attitudes of family, general practitioner, community workers and society. The patient is now expected to be more normal than normal. Normal anxieties and idiosyncrasies are looked upon as evidence of continued illness or recurrence, generating fears in

relatives, sometimes leading to re-admission to hosand in turn induce feelings of abnormality


and oddness in the patient. Disturbed behaviour often only lasts for a short time and is often made worse by all that is involved in removal and admission to hospital. It is possible to deal with disturbed behaviour in the home, provided skilled personnel are available to go out to the patient at once and remain in the home until the situation is under control. This is usually only for a short period, after which further treatment can continue on an out-patient or day

hospital basis. Providing hostel accommodation and a boarding-out scheme, backed up by the team of com' munity workers and 24-hour cover from an emergency service would make it possible to support almost all patients outside a hospital set* ting. And nowadays, few, if any, psychiatric treatments require continuous in-patient care. However, there could be a danger of the hostel becoming 3 mini-hospital. Certain patients would present genuine problems when hospital care was not available, such as those with aggressive personality disorders and those witfe severe dementia. In fact, many hospitals are loatb to admit these patients now, preferring to accept those who may present few problems, in or out ot hospital. A few patients with dementia may require institutional care and these should be coped with in a special local authority hostel, or in normal welfare accommodation, provided the full com* munity psychiatric services are available to help in their care. In this way, it is likely that better use could be made of available resources, with little need f?r more staff than at present. Too much nursing time is still taken up with obsessional rituals, futi administrative duties and other non-therapeutic

activities. Such


service should be based

including offices, night




accommodation for erner*

Sency staff,

day hospital facilities,

Millie, occupational,



and recreational and physiotherapy. X-ray and pathological Services could be made available by siting the c?mmunity care centre near a district general hosindustrial




staff for each area would possibly consist consultant psychiatrist with appropriate junior a group of nurses who would work in coderation with existing community workers in the Cents' homes and day hospital, an administrator, Secretary, occupational therapist and social worker. emergency team, manned by the staff on a r?ta basis, would be available twenty-four hours a day. This team should consist of a doctor and or two other staff, depending on availability. General practitioners would be involved in the serVlce as far as possible and maximum use would be of all other community workers, such as men^ Welfare officers, home helps, night sitters and workers. To test the hypothesis of total community care, Pilot study should be set up, with a team conlsting of a psychiatrist, nurse, administrator and worker. They would need to choose a suitarea, examine in detail its present facilities potential case load and decide what additional ervices and staff would be required. The feasibility study should take between six ^ nine months. If it was then thought advisable ,? Proceed, the full service would need to operate ?r two to three years before being evaluated. T\v0 pilot studies might be necessary?one in a a






town (population 50,000 to ^pdium-sized ,lh associated rural The other an


80,000) in part

a large city, since cities present special problems. This study must be carried out at some time if stitutional care and all its disadvantages is ever ^?lr?g to be removed from our concept of dealing ?

llh mental illness.

David Enoch ,


whitehead's constant theme has been the

of 'institutional neurosis'. This idea stressed (,atlger fact that much of e

of the handicaps patients wards had arisen directly from their rather than from the illness itself. explains the underlying motivation for his thesis of getting rid of all hospitals. In this, he falls into the trap of swinging from e extreme to the other; seeing things as black 0 / White and forgetting that most life situations e grey. Of course, the basic causes of institutional must not only be eliminated, but never be ?vved to rear their ugly heads again. But new j are an established fact, reflecting a need and emphasising that there are conditions and situations which demand hos-

j :



^tral ()0lIig




is a classical example of how have been in this sphere. In 1963 the then Minister of Health envisaged the complete elimination of the old, ugly Victorian mental hospitals within ten years. Whereas there has been an overall decrease in the number of inpatients, not one of these has been closed and seven years of the ten-year period has passed. Are we really to expect that over a hundred of the remaining ones will be closed in the next three

pitalisation. There predictions



In fact, there are basic feelings which are likely guarantee the continuation of hospitalisation in our society. There are certain characteristics of psychiatric illness, such as lack of control, in-


ability to cope, inadequacy, dangerous impulses, insignificance, isolation (to name a few) which demand removal, restraint and refuge. Protection and security for both patient and others are crucial needs in some situations. No psychiatrist, facing the awful spectacle of an active suicidal or homicidal patient, can fail to appreciate the therapeutic value of compulsory hospitalisation then. Here then, the method and the means are justified. Where hospitalisation is by voluntary agreement, surely it is even more justified. Situations and conditions do occur where there has to be a minimum of symptom removal, remotivation, gaining of insight, changing of attitude, before a person can tolerate the world outside and before the world outside can tolerate him. During this transient, temporary phase, the change can only occur away from everyday society. Hospitalisation is one factor among many which contributes to patient treatment. It is the hospital setting alone which at times will accept behaviour and thought disorder unacceptable to society. Acceptance at that particular time means salvation for the moment and hope for the future. In the hospital setting, not only will the patient be removed from stress, but be accepted in his own right. The mere act of hospitalisation reflects a concern, that someone really cares, for he has already 'failed' in the group outside, or at least the group has failed him. In the hospital setting the patient should also be encouraged to see himself as retaining the right to dignity and the respect of others. This is a very important aid to recovery; for it has been missing in the outside group. Often, his disorder has been merely the tip of the iceberg, or the group disorder, and he has been merely a scapegoat for that family or

group. There are other positive results of hospitalisation, such as gaining confidence through routine, normality and order. Above all it fosters hope that control of distress is possible and that there is a potential for the development of an integrated 23

personality that is socially acceptable. Hospitalisation is also an effective means of preventing suicide. I have been impressed, time and again by the relief gained by such patients as soon as they enter hospital and feel its controlling and normalising elements. At the same time it demands that the patient accepts some degree of responsibility, and encourages him to see himself as not totally inept, inadequate and incompetent. Dr. Whitehead would accuse the hospital setting as encouraging dependency feelings and regressive acceptance. These do occur but should be transient and may well be the paramount needs of the hour. An aggressive show of independence and bombast is often merely a facade for an unbearable weakness. Dr. Whitehead makes a special point that in treating patients out of hospital problems would have to be solved in the situation in which they occurred and treatment tried out in realistic conditions. But often this is exactly what cannot occur; patients seek a situation of support

and succour so that they may achieve at least a minimum of recovery that will lead to acceptance by the family. Hospitalisation can often afford greater opportunity for more effective psychotherapeutic work. Indeed, there is as much danger in not admitting a patient that should be admitted early as there is in admitting him too soon, too or for too long. But then, Dr. Whitehead contradicts himself, f?r having given the title of a 'Service without a Hospital', he goes on to advocate Day Hospitals and night accommodation. Others have advocated Night Hospitals and all kinds of hostels under psychiatric cover. What are all these if not parti? hospitalisation? These have their advantages, i*1 that the management of the patient is shared and their treatment community based, but nevertbe' less, the hospitalisation is an essential feature. Hospitalisation is merely an incident in a diag' nostic and treatment programme?at times at others crucial.



Do We Need Psychiatric Hospitals?

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