HOSPITAL OR HOME? by W. A. L. Bowen &>'? W. A. L. Bowen

by

was Chairman of the Conference organised the N.A.M.H. under this title for senior staffs concerned with the care of adult psychiatric patients.

WO hundred professional workers met for 9 hours in London on the 9th and to consider the criteria for discharge of adult psychiatric patients from ?U a n sP^tals to community care. Those thus considering common technical problems |nter-disciplinary basis included eighty doctors, fifty-four nurses, and seventy$ix W0I"kers. One-third of the time was occupied by the principal speakers, d by discussion groups, and the remaining third by questions and comments in ^ ?Pen session. r* J- K. Wing considered statistically the morbidity of schizophrenia in hospital a^ lri the community. He pointed out that in one survey whereas in 1930 sixty-six Cent ^rst admissions remained in hospital for at least 5 years, in 1956 only 9 Per Cent stayed f?r 2 years or more. The number of schizophrenics spending time in the between hospital admissions had increased. Factors making for in hospital arose from under-stimulation producing negative symptoms of deiu ,ravval and apathy. Contrariwise, positive symptoms of behaviour disorder and systems could be produced in the community by a home which had too a degree of emotional involvement. The handicapped schizophrenic had, said [)r to walk the tightrope between over-stimulation and under-stimulation a^ ae lnS, needed help to keep this balance.

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some of the Mental Health Services were plainly not adequate considerable degree of morbidity, Dr. Wing stressed that when was made whether the chronic schizophrenic was better in hospital or must remember that it was a long-term illness, expressing itself as a

behaviour, or as a continuing disability, e^ly repeated episodes of disturbedservices should include in-patient units, day andS ??th. He urged that rehabilitation hospitals, out-patients, social clubs, sheltered workshops and an active d0rv1>n.1?bt This rehabilitation should be a continuous process and not Se?rn lary in time or function. The tremendous problems of co-ordinating the serv-ented Ces different authorities could be met one team of workers applied or

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area> a?d Dr. Wing urged a variety of pr0v-? ls'?ns for built-in independent operational tj0n of

such model services to be set up with research to yield a continuous evalua-

different methods of care. F. Early, Consultant Psychiatrist at Bristol, considered criteria making for ?d discharge prognosis, as opposed to methods which merely sent patients from h? *? hve as "second-class citizens" in the community. The first need was for the to be self-supporting before leaving hospital. The national lack of faci]??^ent ^?r tra'n'nS 'n such self-support had led Bristol to develop a three-stage ?n k ,w?rk training at a local level. The first stage was the introduction of patients f0r ?s?ital to industrial work of increasing complexity. The second stage was the of the Industrial Therapy Organisation. The third was the transfer of n*s from hospital to the open factory floor, either for further training or for per artent employment. An indication of the Bristol progress was that patients earn ?d ?40,000 in 1962, compared with nothing in 1948. e 'ack ?f national facilities for training patients to return to the community was Paraii 'ed by the difficulty of re-housing them when they had in fact done so. Describ* these difficulties, whether they concerned the provision of houses or hostels, a

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Early thought that it was again necessary for local organisations to make the, arrangements. He urged the need to prepare psychiatric patients for work the highest category of which they were capable and pleaded that their resid1*. psychiatric disabilities should be accepted as readily as were those of the physic3 handicapped. Dr.

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Variable standards Dr. J. J. A. Reid, speaking as a County Medical Officer of Health, noted variability of standards of care both in different hospitals and in different co munities, and suggested four important areas for action. The first was for contin11^ of medical and social care to be achieved by arranging for General Practitioners social workers to attend their patients in psychiatric hospitals. The second need ^ for adequate communication between the hospital and the family doctor and local Health Authorities; both the latter needed to know in advance the appropfl3, medical and social details of a patient about to leave hospital. The third need was provide support for the families of psychiatric patients and give them insight into problems of their ill relative. This could be done by general educati0"' campaigns, as well as specific support provided by social workers; and in both ( local Health Authority had a substantial role to play. The fourth need was * adequate community services. Local Authorities would have to spend more on P{ fessional social workers. Dr. Reid stressed the need for multi-disciplinary Resett ment Clinics to tackle the problems of the patient returning to the community. 3 pleaded for adequate co-operation amongst all those professionally involved in i decision regarding hospital or home care and he pin-pointed the need for joint st arrangements between the hospital and the local Health Authority. ...

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work and total resources Mr. John Heap, speaking as a Psychiatric Social Worker, considered first * problems which arose on hospital admission. He noted that the very fact of adfl1,1 sion might relieve certain problems but could aggravate others such as fa11", indebtedness, hardening of social attitudes, loss of self-respect and Such problems had been made more prominent by more rapid methods of psychiatr. treatment which had also increased the tempo of work of social workers and their anxiety. The parallel increase in extra-mural treatment had meant that the were in the community an increasing number of patients who would formerly been in hospital. Such an increasing volume of work necessitated the deployment social workers to deal with selected cases, It was necessary to avoid inefficient oV?* ( loading of case-work and it was equally necessary to provide necessary support newly trained staff. The increase of community treatment and the participation of the hospital in th? had blurred the boundaries between the local Authority and the hospital, so that f * was more than ever essential for those concerned to achieve a satisfactory basis working together in a form' of "District Psychiatry". Mr. Heap felt that in re-integrating a patient in the community it was necess3^ to know the total resources available. These were more than the statutory 3lj social services and included and recreation social, religious, occupational voluntary activities, through which resources social workers might work in the future. ended by urging strong links and good communications, frequent staff meetings an case discussions between the different community care services.

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Anxieties shown in discussion The discussion groups which met during the Conference afforded a particular j useful method of bringing together the techniques and perhaps also the and personal anxieties of different disciplines in relation to hospital or home The deliberations of these groups were reflected in some of the discussions la j held in open session in which the roles and difficulties of family doctors, men* ^ welfare workers, psychiatric nurses, social workers, relatives, home helps, were

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.red in rapid succession. Not only the types of workers but their numbers were with. In particular, the number of social workers needed even if only minimum

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to be exercised was mentioned. The need for research into the stressed clearly. The whole apparatus of the community services was erhaPs most usefully combined in the flexible concept of "District Psychiatry", Predicti?n ?f a patient's success in the community was thought to depend lot so much on symptoms in hospital as on the attitudes both to discharge and to ^ not only by the patients but also by relatives. Perhaps the best predictive test Was actual performance under appropriate observation. The importance of considering the patient as a symptom of family illness and of the factors in the family which might be thought to provoke psychiatric or influence recovery, was mentioned. In this context, not only support for e families of psychiatrically ill patients but also the need for public education

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The Conference did not confine itself to functional issues but dealt also with arrangements including, for example, the matter of hostels, whether superor unsupervised, mixed or unisexual and the value of such arrangements as boarding out of psychiatric patients in suitable families.

J^ctural e

departure

This account might be concluded by saying that more questions were sent in than u'd be answered and perhaps some of the questions that were sent in fell into same category. These and other questions remain. This, perhaps, might be taken keynote of this Conference representing, as it does, a new departure on the of the Clinical Services Committee of The National Association for Mental the staff of which put so much work into the preparation of the Conference 0 during the course of the coming months, be both receiving and inviting fe h t,?d-back comments related to the future policy of the adult psychiatric services in ?

ase pa^e f^rt ls

country.

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