Put away
Pilkington, consultant psychiatrist and senior lecturer in the Department of Psychiatry at Edinburgh University, reviews the study
Dr. T. L. of the once
subnormality hospital
service
by Pauline
again the neglect that is all too familiar.
received such publicity at the time of its publication that there must be few who do not know what it is about. Briefly, it is the result of a four years study by a research team, headed by Dr. Pauline Morris, principal lecturer in Sociology at the Borough Polytechnic, London, of the physical, psychological and sociological environment which institutions provide for the mentally handicapped, this book
and of various staff problems. It is a long and detailed book (approximately 400 pages) and the Work on which it is based received a contribution of ?13,000 from the National Society for Mentally
Handicapped
Children.
Broadly, its findings are an indictment of the present hospital facilities for the mentally subnormal in England, and, as Professor Peter Townsend of Essex University says in his foreword, The disturbing conclusion has to be faced that the wrong system of care has been developed over the years for this minority of the population'. He goes on to say 'The problem is not simply one of finding more money and more staff, putting up new buildings and introducing comprehensive training schemes. It is one of reconstructing the system'.
Morris
which]underlines
The book itself gives many instances of neglect and even cruelty, though not necessarily intentional, experienced by patients and their relatives as a result of the present conditions of care. It analyses in some detail the staff attitudes and physical resources that contribute to the situation, and goes on to make some suggestions about both a philosophical re-orientation and practical methods of care and treatment. There are one to two minor errors in the book. The map on page 46, said to show the distribution of subnormality hospitals only shows the areas of Regional Hospital Boards. Your reviewer is criticized for suggesting that there is little active treatment for the majority of subnormal patients, yet nine pages further on Dr. Morris makes exactly the same statement. We both, of course, refer to specialised medical treatment. And, considering its authority, the book has some surprising omissions. In the chapter dealing with prevalence there is no reference to the work of the World Health Organisation Expert Committees on mental handicap and their published findings. In criticizing the attitudes of senior nursing staff there is no mention
of the important practical fact that their salaries (as do those of the lay administration) benefit by increase in size of the hospitals. Although there is extensive, and on the whole critical, probing of the opinions and attitudes of doctors and nurses, other equally important decision-effecting groups escape detailed scrutiny. It would be of value if the team could interview, with the same vigour, hospital secretaries, other lay staff, members of Hospital Management Committees, and Regional Hospital Board personnel. To say that these are persons whose actions do not affect the daily lives of patients would indicate ignorance of hospital organisation; the doctornurse team often carries vulnerable responsibility without the necessary authority. Nevertheless, it is of significance to note that only a quarter of the Medical Superintendents interviewed said that they deliberately chose subnormality because they were interested in it (these were mainly working in hospitals of under 1000 beds). On the Administrative Nursing side apparently 'The men mainly drifted in, or came in because pay and promotion prospects were considered good' (in the 1930's). On the other hand, it seems that 'far more females (nurses) than males came in because they were always interested in the work'. There is no doubt that this chapter on problems of staffing is one of the most important in the book. One chapter is headed 'Blackbrick and Cloverfield : a study of two subnormality hospitals', and contains a number of very critical statements about various people associated with them. In spite of the footnote explaining that these are fictitious names 'in order to maintain confidentiality', a brief study of hospital bed compliments and locations in the Medical Directory easily identifies them, and this rather sensationalistic method of presentation may have been an unwise choice. The book indicates several areas which seem worthy of further study. For example, the chapter on voluntary hospitals and homes contrasts markedly with the rest. Many of these private hospitals apparently avoid altogether the problems of the other hospitals, and cost less to run. Their main lack seems to be technical and professional advice; one wonders if there is an indication here for a better symbiosis with the State. The geographical location of hospitals also might be looked at more closely. Why, for example, have all the recent
public enquiries
at
subnormality
also 'Blackbrick' and 'Cloverleaf') been located south of a line through North Birmingham? And what about the position of Scotland? The teams were unfortunately refused access to Scottish hospitals, but, in spite of proportionally fewer beds and weaker local authority support, the joint Under-Secretary of State says
hospitals (and
that Scottish subnormality hospitals are not so bad as those in England. If this is so, is it due to the existence of a Mental Welfare Commission, an imminent Social Work Act, or variations in public affluence and national characteristics? These might give important leads to improving the English situation, and it is hoped that the same investigation team can be re-invited to the North to confirm the official statement. In the final chapters, Dr. Morris suggests some ways in which the situation can be improved. These are based on the premise that subnormality hospitals are not hospitals in the true sense of the word, and the majority of their patients require neither nursing nor specialist medical care. She suggests that this false 'patient' concept has led to the employment of poor quality medical, nursing and other staff who are regarded almost as impostors by the main stream of their professions. She proposes the separation of those patients requiring medico/nursing skills from those who do not.
To those of us who have been saying this for years, the book seems an expensive and timeconsuming way of underlining the obvious, although perhaps it is more in line with modern social engineering methods. But why did Dr. Morris not scrutinise more closely these 'medico-nursing requirements'? What are their paediatric, psychiatric, geriatric and general practitioner components, for example? What skills do we really ask from the specialised subnormality nurse? Has psychiatry now got any leading contribution to offer to these medically orientated services? To some extent, Dr. Morris has dodged the 64,000 dollar question. Nevertheless, 'Put Away' is a very readable account of an authoritative scientific probe into some fundamental aspects of our system of care and treatment of the mentally handicapped, and may well form the pivot for new legislation. Many patients and their relatives will be indebted to Dr. Morris and her team.
Away?a sociological study of institutions mentally retarded' by Pauline Morrisfor Published by Routledge and Kegan Paul, 60j\ 'Put
the
Pilkington, consultant psychiatrist and senior lecturer in the Department of Psychiatry at Edinburgh University, reviews the study
Dr. T. L. of the once
subnormality hospital
service
by Pauline
again the neglect that is all too familiar.
received such publicity at the time of its publication that there must be few who do not know what it is about. Briefly, it is the result of a four years study by a research team, headed by Dr. Pauline Morris, principal lecturer in Sociology at the Borough Polytechnic, London, of the physical, psychological and sociological environment which institutions provide for the mentally handicapped, this book
and of various staff problems. It is a long and detailed book (approximately 400 pages) and the Work on which it is based received a contribution of ?13,000 from the National Society for Mentally
Handicapped
Children.
Broadly, its findings are an indictment of the present hospital facilities for the mentally subnormal in England, and, as Professor Peter Townsend of Essex University says in his foreword, The disturbing conclusion has to be faced that the wrong system of care has been developed over the years for this minority of the population'. He goes on to say 'The problem is not simply one of finding more money and more staff, putting up new buildings and introducing comprehensive training schemes. It is one of reconstructing the system'.
Morris
which]underlines
The book itself gives many instances of neglect and even cruelty, though not necessarily intentional, experienced by patients and their relatives as a result of the present conditions of care. It analyses in some detail the staff attitudes and physical resources that contribute to the situation, and goes on to make some suggestions about both a philosophical re-orientation and practical methods of care and treatment. There are one to two minor errors in the book. The map on page 46, said to show the distribution of subnormality hospitals only shows the areas of Regional Hospital Boards. Your reviewer is criticized for suggesting that there is little active treatment for the majority of subnormal patients, yet nine pages further on Dr. Morris makes exactly the same statement. We both, of course, refer to specialised medical treatment. And, considering its authority, the book has some surprising omissions. In the chapter dealing with prevalence there is no reference to the work of the World Health Organisation Expert Committees on mental handicap and their published findings. In criticizing the attitudes of senior nursing staff there is no mention
of the important practical fact that their salaries (as do those of the lay administration) benefit by increase in size of the hospitals. Although there is extensive, and on the whole critical, probing of the opinions and attitudes of doctors and nurses, other equally important decision-effecting groups escape detailed scrutiny. It would be of value if the team could interview, with the same vigour, hospital secretaries, other lay staff, members of Hospital Management Committees, and Regional Hospital Board personnel. To say that these are persons whose actions do not affect the daily lives of patients would indicate ignorance of hospital organisation; the doctornurse team often carries vulnerable responsibility without the necessary authority. Nevertheless, it is of significance to note that only a quarter of the Medical Superintendents interviewed said that they deliberately chose subnormality because they were interested in it (these were mainly working in hospitals of under 1000 beds). On the Administrative Nursing side apparently 'The men mainly drifted in, or came in because pay and promotion prospects were considered good' (in the 1930's). On the other hand, it seems that 'far more females (nurses) than males came in because they were always interested in the work'. There is no doubt that this chapter on problems of staffing is one of the most important in the book. One chapter is headed 'Blackbrick and Cloverfield : a study of two subnormality hospitals', and contains a number of very critical statements about various people associated with them. In spite of the footnote explaining that these are fictitious names 'in order to maintain confidentiality', a brief study of hospital bed compliments and locations in the Medical Directory easily identifies them, and this rather sensationalistic method of presentation may have been an unwise choice. The book indicates several areas which seem worthy of further study. For example, the chapter on voluntary hospitals and homes contrasts markedly with the rest. Many of these private hospitals apparently avoid altogether the problems of the other hospitals, and cost less to run. Their main lack seems to be technical and professional advice; one wonders if there is an indication here for a better symbiosis with the State. The geographical location of hospitals also might be looked at more closely. Why, for example, have all the recent
public enquiries
at
subnormality
also 'Blackbrick' and 'Cloverleaf') been located south of a line through North Birmingham? And what about the position of Scotland? The teams were unfortunately refused access to Scottish hospitals, but, in spite of proportionally fewer beds and weaker local authority support, the joint Under-Secretary of State says
hospitals (and
that Scottish subnormality hospitals are not so bad as those in England. If this is so, is it due to the existence of a Mental Welfare Commission, an imminent Social Work Act, or variations in public affluence and national characteristics? These might give important leads to improving the English situation, and it is hoped that the same investigation team can be re-invited to the North to confirm the official statement. In the final chapters, Dr. Morris suggests some ways in which the situation can be improved. These are based on the premise that subnormality hospitals are not hospitals in the true sense of the word, and the majority of their patients require neither nursing nor specialist medical care. She suggests that this false 'patient' concept has led to the employment of poor quality medical, nursing and other staff who are regarded almost as impostors by the main stream of their professions. She proposes the separation of those patients requiring medico/nursing skills from those who do not.
To those of us who have been saying this for years, the book seems an expensive and timeconsuming way of underlining the obvious, although perhaps it is more in line with modern social engineering methods. But why did Dr. Morris not scrutinise more closely these 'medico-nursing requirements'? What are their paediatric, psychiatric, geriatric and general practitioner components, for example? What skills do we really ask from the specialised subnormality nurse? Has psychiatry now got any leading contribution to offer to these medically orientated services? To some extent, Dr. Morris has dodged the 64,000 dollar question. Nevertheless, 'Put Away' is a very readable account of an authoritative scientific probe into some fundamental aspects of our system of care and treatment of the mentally handicapped, and may well form the pivot for new legislation. Many patients and their relatives will be indebted to Dr. Morris and her team.
Away?a sociological study of institutions mentally retarded' by Pauline Morrisfor Published by Routledge and Kegan Paul, 60j\ 'Put
the
