TOWARDS COMMUNITY CARE IN THE LOCAl AUTHORITY MENTAL HEALTH SERVICES? by Rhona Morrison The following paper by Miss Rhona Morrison, Lecturer in Social Administration at the University of St. Andrews, was read at a meeting held in Scotland by the National Institute for Social Work Training in October 1962 and attended by officers of local authorities and members of other interested bodies. HOPE the meeting will forgive me if I deal entirely with local authority services for the mentally ill. It seems that whereas in meeting the needs of mental defectives the local authorities have considerable experience and themselves know where they wish to go, local authority work for the mentally ill, though more advanced in some areas than in others, is in a state of creative chaos, with many fruitful ideas not yet crystallised; and that this is a very good moment in which to ask ourselves where we are going. It appears that we are travelling towards the provision of Community Care.
I
Rising The
fact
that
soClfjf
refl1^ ^
readmissions
admissions continue
^
declined as to require no more the remainder, it seems likely that,j future not only will mental hosp', treatment be shorter, but fewer of , mentally ill will be allowed to Ke, down and to give up for the being the struggle to live in "It is not now generally considered the best interests of patients who % fit to live in the general communis says the Report of the Royal Co ^ mission on the Laws Relating Mental Illness and Mental Deficit' "that they should be in large or institutions such as our present or mental deficiency hospitals." seeks in vain for the steps by ^ this firm conclusion was reached,
mental
hospital
to rise every year
does not really affect this. We know that in England and Wales half the admissions in any one year (49% in 1960) are readmissions and that this percentage is rising year by year, a sign of a situation in which discharge from hospital is early, in which people with a recurring illness are not kept in hospital during remissions, in which many of the mentally ill, except in acute phases, are trying to live in the community. It may be that we are going towards a time when they will be compelled to make this attempt. In England and Wales, a reduction in mental hospital beds from 3.3 per thousand of population to 1.8 per thousand is planned for 1975. As many of these remaining beds will be needed for psycho-geriatric cases, and as we can hardly be certain that other kinds of mental illness will have so 108
preoccupied as they were ^ ( remodelling compulsory admiss! with re-categonsU procedures, mentally-disordered people and ^ de-designating mental hospitals, j writers of the Report of this ?1 -
Commission in fact devote very space to what may well be a far &? historic change.
Better out?or in? j5 It is taken for granted that ll.j better to live outside a mental hosp1. .
if you can. The mentally ill who is able to return to the cO munity may find that life outside hospital makes him tired, or 1 ottel or frightened. He assumes, and so i we, that it is better to struggle
PetS^
somehow?tired, lonely or frighted ?in the community, than to stay in U mental hospital and be provided ^. sufficient food, sufficient rest, compa j when he wants it, little errands to make him feel
jobs useful,
1
doctors peon i?ntoofma^e
and other learned feel interesting, and friends, and
visit s from family oft quite beautiful surroundings, Cnta* h?sPitals in Great Britain are
jJ1
bar Som.etimes
big
too
arerack-like, but
^ddle-sized, awfully enduring character
che
jng
Co
too
of the build-
have inherited often masks
i-
a r
thpi
and
great many of them pleasantly situated, furnished. The ponderous a
'lCaHy improved
ess> though life *s ^aster'
and^Hity s?me
interior. Neverin the normal niore
dangerous,
less callous think it quite that the mentally ill should be to withdraw from it and go to in large or remote institutions. h(w? not want to idealise the mental ^ut consider what, in addition to ^ tment' ma7 offer to its Pati he ??ts. When a patient is admitted Put to bed and may be given in /^ing to help him to sleep. He is aCt re^uced to babyhood, with all his Set? FesP?nsibilities removed. As he ter it will be part of his hospital eXn that the responsibilities of life the' l tasks to be carried out and ^ons to be made, will be ?rad at a UallV laid upon him again, so that his recovery he has as resPonsibility as he can take, fr0 n?t enough to discourage him a little more, until fytall attempting he is ready, willing and able t0 ajvj 0ulder the whole of his own life ieave the hospital behind. This gfa(j process is disguised as giving a the ward, going to occupatioiial : therapy, having an afternoon's PaSs to go shopping, and so on. end of the process he may be Q cured, ready to go back to his .nary life and neither needing Hor 0Cc .Ashing for any after-care. hcwSl?nally also in the mental strong, solitary chara ctersy?uwhomeetmake their own Pers rat^er 0 * though not shared by an onlooker, others who have been through it K. We must surely so design our clK for patients and ex-patients that ability to help each other is and used. But the authorities sboli; also keep in mind the difficulties 1 ill people in the future who, when beds have been reduced, will not allowed to break down, and will living in the community, much we hope by its services, but with ^ dread unrelieved.
do^
^ respe^
beVjf,
Models to follow The purpose of these reflections; suggest to the local authorities Community Care of the mentally j, is not going to be a simple matterwill not be enough to build host? half-way houses and clubs, though , is probably with these that we m j 3 , start. A hostel may be too small too dull to stimulate a patient ^ responded to the variety of comp^j, in hospital, while to attend a cl, meeting may be too terrifying enterprise for a shy patient who nev theless is starved for
^.j
to
,
Tolerance,
comp3jv
good will, and "stigma"?whatever ^
even
removal of means?is of
no
use
to
the kind
discharged patient who makes demands of his neighbours, lives ^ digs, draws his pension, speaks jj no
one, and dwells on the
society
surface
,j
Community Cafe anything must afford j
like dust.
it is to mean the mentally ill in the normal W
,
kind
admitting a variety of the local authorities should look for models of helpful social groupings which could be repeated in the world outside. This can be a wonderful service for the recovered mental patient, for, as we have seen, he does not want to stay in his large remote hospital even if it is the best place for him. Or it could be a service which never reaches him. If it is to be a good service it will challenge the imagination and ingenuity of the authorities and, let us face it, it will cost them a great deal of money.
of stimulation, the kind of and the kind of shelter too much of either which they nd in the mental hospital. Psychiatric Social Worker who Will if be indispensable in such a service w- 1 jn 8 need to add to her hospital trainan increased awareness of groupand group-satisfactions as affect the mentally ill. The ntal hospitals have built up great ex tha n 'Se??reater 1 think perhaps ^ they themselves are aware of? adjustment of people and or uPs. To the hospitals then, as long ^
as they patients,
discussion
is detected in a short space of time but having dealt with the incident and obtained a return to school, the process is repeated with another child of the family and the officer has to repeat his visits and deal with the subsequent offences. It is not surprising that children of some working mothers are not properly trained
r?.
f'e"Playing,
ji.essures
J1*
point
the mother outside the home is often ^as aroused much controversy in rec ent years and in this matter it is unwise t0 to I'enerahse. It is common experience n(^ that h many children whose mothers VVorked during their school life, have Positions of eminence, socially s?rti educationally- ^ IS the concern of mothers ^or ^e welfare of their chi]H ren that has impelled them to .suppleme father's income or their widow's pen They strive to see that their do not suffer in consequence of gre erabsence from home during the part of the day. suPPly ?f school meals has eased lhe t^iat arises from the employr^ent m?thers. We have to conclude that esPite the many exceptions we have me tU0 '?ned, the natural place for the *s 'n the home, and in many Case absence from home is detria to the children, who need her
Working mother,
as
^Vor^cs
call?
*ttae V?ed .
ehji^s.
theirren ?
care
iocr
and
supervision. dren working
an(j'ned are at
mothers
are
to absences due to
over-sleeping often tardy in going to school. ,"ere is a tendency to keep children 0rtle
ren* man'
rtlan' and similar callers, out6,errands and to substitute
insur" to carry
n,
for the
of of
,Cr Working in the home. This kind bsence is often covered up by excuses
Vim 1C^ness? which breed deceitfulness and
ruthfulness.
This situation is
-one
that
are
and are not
naturally "good"
or
that
they
should succumb to temptations open to unsupervised children, with the misuse of money left in their care, reactions to isolation from parents of wastefulness, destructiveness, and even violence in Officers often feel their duty some cases. is to warn this type of parent of the dangers that beset their children and enlist the help of agencies able to remedy the situation. Extract from an article entitled "A Survey of School Attendance in 1961" in the November, 1962 issue of "The Education
Welfare Officer".
I
Rising The
fact
that
soClfjf
refl1^ ^
readmissions
admissions continue
^
declined as to require no more the remainder, it seems likely that,j future not only will mental hosp', treatment be shorter, but fewer of , mentally ill will be allowed to Ke, down and to give up for the being the struggle to live in "It is not now generally considered the best interests of patients who % fit to live in the general communis says the Report of the Royal Co ^ mission on the Laws Relating Mental Illness and Mental Deficit' "that they should be in large or institutions such as our present or mental deficiency hospitals." seeks in vain for the steps by ^ this firm conclusion was reached,
mental
hospital
to rise every year
does not really affect this. We know that in England and Wales half the admissions in any one year (49% in 1960) are readmissions and that this percentage is rising year by year, a sign of a situation in which discharge from hospital is early, in which people with a recurring illness are not kept in hospital during remissions, in which many of the mentally ill, except in acute phases, are trying to live in the community. It may be that we are going towards a time when they will be compelled to make this attempt. In England and Wales, a reduction in mental hospital beds from 3.3 per thousand of population to 1.8 per thousand is planned for 1975. As many of these remaining beds will be needed for psycho-geriatric cases, and as we can hardly be certain that other kinds of mental illness will have so 108
preoccupied as they were ^ ( remodelling compulsory admiss! with re-categonsU procedures, mentally-disordered people and ^ de-designating mental hospitals, j writers of the Report of this ?1 -
Commission in fact devote very space to what may well be a far &? historic change.
Better out?or in? j5 It is taken for granted that ll.j better to live outside a mental hosp1. .
if you can. The mentally ill who is able to return to the cO munity may find that life outside hospital makes him tired, or 1 ottel or frightened. He assumes, and so i we, that it is better to struggle
PetS^
somehow?tired, lonely or frighted ?in the community, than to stay in U mental hospital and be provided ^. sufficient food, sufficient rest, compa j when he wants it, little errands to make him feel
jobs useful,
1
doctors peon i?ntoofma^e
and other learned feel interesting, and friends, and
visit s from family oft quite beautiful surroundings, Cnta* h?sPitals in Great Britain are
jJ1
bar Som.etimes
big
too
arerack-like, but
^ddle-sized, awfully enduring character
che
jng
Co
too
of the build-
have inherited often masks
i-
a r
thpi
and
great many of them pleasantly situated, furnished. The ponderous a
'lCaHy improved
ess> though life *s ^aster'
and^Hity s?me
interior. Neverin the normal niore
dangerous,
less callous think it quite that the mentally ill should be to withdraw from it and go to in large or remote institutions. h(w? not want to idealise the mental ^ut consider what, in addition to ^ tment' ma7 offer to its Pati he ??ts. When a patient is admitted Put to bed and may be given in /^ing to help him to sleep. He is aCt re^uced to babyhood, with all his Set? FesP?nsibilities removed. As he ter it will be part of his hospital eXn that the responsibilities of life the' l tasks to be carried out and ^ons to be made, will be ?rad at a UallV laid upon him again, so that his recovery he has as resPonsibility as he can take, fr0 n?t enough to discourage him a little more, until fytall attempting he is ready, willing and able t0 ajvj 0ulder the whole of his own life ieave the hospital behind. This gfa(j process is disguised as giving a the ward, going to occupatioiial : therapy, having an afternoon's PaSs to go shopping, and so on. end of the process he may be Q cured, ready to go back to his .nary life and neither needing Hor 0Cc .Ashing for any after-care. hcwSl?nally also in the mental strong, solitary chara ctersy?uwhomeetmake their own Pers rat^er 0 * though not shared by an onlooker, others who have been through it K. We must surely so design our clK for patients and ex-patients that ability to help each other is and used. But the authorities sboli; also keep in mind the difficulties 1 ill people in the future who, when beds have been reduced, will not allowed to break down, and will living in the community, much we hope by its services, but with ^ dread unrelieved.
do^
^ respe^
beVjf,
Models to follow The purpose of these reflections; suggest to the local authorities Community Care of the mentally j, is not going to be a simple matterwill not be enough to build host? half-way houses and clubs, though , is probably with these that we m j 3 , start. A hostel may be too small too dull to stimulate a patient ^ responded to the variety of comp^j, in hospital, while to attend a cl, meeting may be too terrifying enterprise for a shy patient who nev theless is starved for
^.j
to
,
Tolerance,
comp3jv
good will, and "stigma"?whatever ^
even
removal of means?is of
no
use
to
the kind
discharged patient who makes demands of his neighbours, lives ^ digs, draws his pension, speaks jj no
one, and dwells on the
society
surface
,j
Community Cafe anything must afford j
like dust.
it is to mean the mentally ill in the normal W
,
kind
admitting a variety of the local authorities should look for models of helpful social groupings which could be repeated in the world outside. This can be a wonderful service for the recovered mental patient, for, as we have seen, he does not want to stay in his large remote hospital even if it is the best place for him. Or it could be a service which never reaches him. If it is to be a good service it will challenge the imagination and ingenuity of the authorities and, let us face it, it will cost them a great deal of money.
of stimulation, the kind of and the kind of shelter too much of either which they nd in the mental hospital. Psychiatric Social Worker who Will if be indispensable in such a service w- 1 jn 8 need to add to her hospital trainan increased awareness of groupand group-satisfactions as affect the mentally ill. The ntal hospitals have built up great ex tha n 'Se??reater 1 think perhaps ^ they themselves are aware of? adjustment of people and or uPs. To the hospitals then, as long ^
as they patients,
discussion
is detected in a short space of time but having dealt with the incident and obtained a return to school, the process is repeated with another child of the family and the officer has to repeat his visits and deal with the subsequent offences. It is not surprising that children of some working mothers are not properly trained
r?.
f'e"Playing,
ji.essures
J1*
point
the mother outside the home is often ^as aroused much controversy in rec ent years and in this matter it is unwise t0 to I'enerahse. It is common experience n(^ that h many children whose mothers VVorked during their school life, have Positions of eminence, socially s?rti educationally- ^ IS the concern of mothers ^or ^e welfare of their chi]H ren that has impelled them to .suppleme father's income or their widow's pen They strive to see that their do not suffer in consequence of gre erabsence from home during the part of the day. suPPly ?f school meals has eased lhe t^iat arises from the employr^ent m?thers. We have to conclude that esPite the many exceptions we have me tU0 '?ned, the natural place for the *s 'n the home, and in many Case absence from home is detria to the children, who need her
Working mother,
as
^Vor^cs
call?
*ttae V?ed .
ehji^s.
theirren ?
care
iocr
and
supervision. dren working
an(j'ned are at
mothers
are
to absences due to
over-sleeping often tardy in going to school. ,"ere is a tendency to keep children 0rtle
ren* man'
rtlan' and similar callers, out6,errands and to substitute
insur" to carry
n,
for the
of of
,Cr Working in the home. This kind bsence is often covered up by excuses
Vim 1C^ness? which breed deceitfulness and
ruthfulness.
This situation is
-one
that
are
and are not
naturally "good"
or
that
they
should succumb to temptations open to unsupervised children, with the misuse of money left in their care, reactions to isolation from parents of wastefulness, destructiveness, and even violence in Officers often feel their duty some cases. is to warn this type of parent of the dangers that beset their children and enlist the help of agencies able to remedy the situation. Extract from an article entitled "A Survey of School Attendance in 1961" in the November, 1962 issue of "The Education
Welfare Officer".
