WHO BECOMES CHRONIC? J. K. Wing MD, PhD

Chronic social disablement is caused by three types of factor: impairment, e.g. slowness in schizophrenia; social disadvantage, e.g. lack of opportunity to develop social or vocational skills; and an underconfidence or unduly low self-esteem which is reactive to impairment and disadvantage. The last of these factors is particularly evident in 'institutionalism', a condition in which the individual comes to acquire a contentment with institutional life and wishes to lead no other. Many long-stay patients in large mental hospitals used to be 'well-institutionalized' but it became recognized that retraining and rehabilitation could lead to successful resettlement outside hospital. For a time these striking successes suggested to some theorists that abolishing the hospitals would abolish disablement as well but it is now quite clear that this is not the case. Chronic impairments still occur and create a continuing need for sheltered environments. The frequency and type of problems still arising are discussed in the light of recent surveys in England. One small group requires highly-staffed accommodation, others need less supervised day and residential settings; all need longterm care. It is emphasized that some people living at home with relatives also have chronic mental disabilities as have a high proportion of the destitute. Such problems are less frequent than formerly but they still require detailed medical and social attention. THE BACKGROUND T h e three censuses of the population o f the U n i t e d States c o n d u c t e d in 1950, 1960 and 1970, allow a comparison o f the n u m b e r s who spent census night in an institution. I f hospitals and centers for the mentally ill o r r e t a r d e d , h o m e s for the d e p e n d e n t (including the aged and physically handicapped), chronic disease hospitals, and correctional establishments o f all kinds, are included u n d e r this heading, the n u m b e r s o f inmates increased markedly f r o m one census to the next, but only in p r o p o r t i o n to the increase in the population o f the United States. On all three census dates, about one percent o f the US p o p u l a t i o n were in institutions (Kramer, 1977). 1 T h e r e were, however, m a r k e d between-census changes in the c o m p o -

Dr. Wing is Pro{essor of Social Psychiatry, Institute of Psychiatry, London. Reprint requests should be addressed to Dr. Wing at the Institute of Psychiatry, London SE5 8AF, United Kingdom. 178

PSYCHIATRICQUARTERLYVOL.5O(S) 1978 0033-2720/78]1500-0178500.95 Copyright1978 Human Sciences Press

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sition of the institutional population. In 1950, 39% were in mental hospitals and centers and 19% in homes for the aged and dependent. By 1960 these proportions were 33% and 25%, and by 1970 they had become 20% and 44%. The other substantial category--those in prisons and reformatories-remained constant (17 %, 18%, 15%). By studying the figures in more detail, Kramer showed that the major change was that the care of the aged mentally ill had progressively been transferred from mental hospitals to nursing homes. Kramer also studied the changes likely to occur in social and ethnic composition of the US population up to the );ear 1985, and considered their implications for the development of mental health services. The most important factors are the continued shift toward the older age groups and the preponderant growth, at all ages, of the nonwhite population, When the age-color specific annual treated incidence rates observed in Monroe County, New York, in 1970 ~ were used to estimate incidence change in the total US population, it became clear that, by 1985, there would be large increases in first admissions tot conditions, like schizophrenia, which were particularly predominant among nonwhites, and among the age groups 15-44 at which the relative increase in the size of the nonwhite population was highest. The treated prevalence of mental illness would also be likely to increase, i.e., by 25% among whites, and 45% among nonwhites. These calculations did not take into accountpossible decreases in the mortality of mental illness during the next decade, which would emphasize the trends still further. It is true that concepts such as "schizophrenia" have a different connotation in the United States as compared with western Europe. 3-~ Kramer calculated that the lifetime expectation of "schizophrenia" in Monroe County was 3%, i.e., three times higher than rates found in the rest of the world. However, even if the figure includes a substantial proportion of conditions that would be given other diagnostic labels elsewhere, these conditions are likely to be just as disabling and to give rise to similar needs for services. T h e y must therefore be taken seriously. Kramer puts forward these sobering conclusions with caution, but they provide a marked contrast to theories put forward in the 1950s, which suggested that most of the handicap then clearly evident in long-stay mental hospital residents was due to the harmful effects of the institution itself, and not to the various disease processes implied by psychiatric diagnoses, particularly "schizophrenia." The social 'characteristics of two American state hospitals which were primarily custodial in function were described in detail by Belknap 6 and Dunham and Weinberg. 7 Their major function was to prevent a mentally disordered individual from harming himself or others and to ensure that he could not escape. Routines of supervision and control were developed which would leave nothing to chance--hence the railed airing courts, the locked doors, the windows that would open only two inches, and the warning whistle that every attendant carried. Given the twin facts of a large

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patient population and a small inadequately trained staff, it was inevitable that procedures adopted for the control of a few potentially dangerous patients should be generalized to the relatively amenable majority. Goffman 8 was one of the most influential theorists, partly because of the excellence of his prose, which few sociologists writing about psychiatry have since been able to match. The core of his argument was based on institutional practices which everyone knew, as soon as they were pointed out, to be indefensible. He showed that much time and trouble could be saved "if everyone's soiled clothing can be indiscriminately placed in one bundle, and laundered clothing can be redistributed, not according to ownership but according to rough size." Goffman did not attempt to test hypotheses and his style was literary rather than scientific. But he had the enormous merit of considering that people should not be treated as numbers. They are entitled to a reasonable human dignity. The traditions that persisted in the institutions studied by Goffman, and by the Cummings, 9 had their origins in early-nineteenth-century theories of training and segregation. Initially based on the idea that much social deviance (whether mental illness or crime) was due to pressures resulting from the new freedoms fostered by the enlightenment, the early institutions with their corrective regimes became identified as desirable in themselves, long after the increasing flow of admissions and decreasing proportion of discharges had demonstrated that they were unable to prevent or cure it? ° "The organizing concepts of the asylum disguised and even subtly encouraged a custodial operation. The exaggerated emphasis on physical structure, on the benefits inherent in institutions, promoted an attitude that automatically identified an asylum with a therapeutic milieu. Many superintendents suffered a declining number of attendants together with a swelling number of inmates without altering their belief that the setting itself was ameliorative" (Ref. 11, p. x). Paradoxically, the authoritarian regimes of mental hospitals were subsequently justified in terms of biological disease theories, for which there was no more evidence than for the earlier social theories, and which students like Goffman could discredit with relative ease. The fact that the new retormers had once again adopted social theories which identified "mental illness" with deviance, and put forward as little empirical evidence as the pioneers of a century earlier, was hardly noticed. It was demonstrated that part, at least, of the disablement suffered by long-stay patients was due to environmental characteristics and could be reversed. 12'1~ Clinicians discovered that some of their long-stay patients could be discharged without undue disadvantage to themselves or society. In Nottingham, England, Dr. Duncan Macmillan emulated Dr. Bell of Melrose, Scotland, by opening all the doors of his mental hospital, and went a step further by substantially reducing the numbers of beds in the hospital during the years between 1948 and 1954, well before the introduction of reserpine and chlorpromazine? 4 The methods used were chiefly educational and would not have been surprising to the pioneers of "moral treatment. ''~''6 These ideas became more structured, in the form of industrial

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rehabilitation, resocialization and aftercare. The concept of the therapeutic community lz was not, at that time, applied to the larger mental hospitals but it was later grafted on. 's With the addition of epidemiological and empirical social research designed to test the theories, a basis was laid for a social psychiatry that fuelled the enthusiasm of a generation of British psychiatrists and nurses, and was for a time the center of international attention. The late 1950s and early 1960s were a time of optimism. Much of the empirical work on the social effects of these innovations indicated that, although many long-stay patients could indeed be rehabilitated, and then resettled outside hospital with very little evidence of social disability, many others remained to some extent handicapped and required sheltered occupational or living arrangements if they were to survive at a reasonable social level. Yet others could not be discharged at all. There seemed to be three important types of handicapping factor, analogous to those found important by specialists in general rehabilitation medicine: "intrinsic" factors due to chronic psychological dysfunctions or impairments such as slowness in schizophrenia, "extrinsic" social disadvantages such as a lack of vocational skills, and adverse "secondary" reactions such as a loss of self-esteem and confidence in the ability to live independdently even when that ability was potentially present. Many patients had remained in hospital long after the acute phase of the condition responsible for admission had passed and even though there was little residual intrinsic impairment. Many extrinsic disadvantages could be corrected by programs of vocational and social retraining, and the chief factor militating against discharge was "institutionalism," that is, a dependence on the protection of the hospital that had been acquired gradually over the years and which could be counteracted by deliberate attention to changing attitudes. Some intrinsic impairment was also reduced and maintained at a low level. 13"1~22 These successes were obtained, in part, by correcting the secondary component in disablement, i.e., by undoing harm that had been done by the institution. They appeared therefore to confirm the theory that the large psychiatric hospitals actually generated disability and that abolishing them would prevent this iatrogenic effect. However, the studies also showed that many patients remained severely impaired, even when living in a hospital with a socially rich environment and with ample opportunities for retraining, e3,e4 This observation received less attention at the time. In addition to the discharge of long-stay patients, the use of the new forms of medication to suppress acute psychotic symptoms meant that fewer patients became long-stay, thus further reducing the number of beds in psychiatric hospitals. 2~,~6This trend had become clearly obvious by the early 1960s and planning authorities began to envisage a time when virtually no one would become long-stay at all. This would mean that the treatment of acute conditions could be undertaken entirely in small psychiatric units (in England, these were to be attached to general hospitals) and the long-stay hospitals could be dosed down altogether. This thinking underlay the Hospital Plan for England and Wales put forward in 1962. (In Scotland, there was a great deal more caution.)

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One factor that worried the planners was the steady increase in firstadmission and readmission rates. Much of the increase was due to the admission of people who formerly would not have been admitted to a psychiatric hospital at all, particularly those with personality disorders and those who had made relatively minor attempts at suicide. 27 Another category that showed a major increase, which still persists in the long-stay figures, was that of young people with head injuries, particularly those due to motorbike accidents. However, first the general readmission rate, and then the first-admission rate, reached a plateau, and even began to fall off somewhat. 2~'2u In the United States and in the Federal Republic of Germany also, admission rates are no longer increasing, a°'al It might have appeared, therefore, that the major battle had been won; that the large psychiatric hospitals, like the state in Marxist theory, would in due course wither away. Nevertheless, there were dissenting voices, and the subsequent controversy was summarised in two papers by Mendel a2 and Reider aa putting forward opposing views about the value of hospital care. One way to collect relevant data on which to base a rational opinion, both as to numbers and as to needs, is to consider the group of people who still, despite all best endeavors, become chronically handicapped. Recent experience in England is particularly useful because the comprehensive cover of the health and social services makes an epidemiological approach feasible. In the next section, recent studies of the new accumulation of long-stay patients in psychiatric hospitals will be considered. After that, attention will be turned to the problem of chronic disablement in other types of setting.

T H E "NEW" LONG-STAY IN PSYCHIATRIC HOSPITALS A census of residents in English and Welsh psychiatric hospitals on the last day of 1971 showed that nearly 23,000 had been in-patients between one and five years (21% of the total hospital population, or 47 per 100,000 general population). Just over half of this group were aged 65 or more and the ratio of females to males among the elderly was 3.3:1. Among those under the age of 65 there were approximately equal numbers of women and men. O f the remainder, 27% had been resident for less than one year and 52% for more than five years. 34 The "new" long-stay group represents a special challenge to any model of psychiatric services based on the assumption that psychiatric hospitals are needed only for the acutely disordered. It is therefore of prime importance to study the patients concerned and to determine why they stayed so long in hospital. Two surveys, the first a pilot study in an area of southeast London, 35 the second a sample of 15 hospitals, one from each of the 15 regions of England and Wales 36 provided detailed evidence. Attention was concentrated on patients aged less than 65 who were newly accumulating as longstay. Nearly all of them were socially isolated, unmarried, out of touch or at

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odds with their families or friends, and had few occupational skills. About one-third of the national sample (in hospital between 1 and 3 years) were thought to need further hospital care because of functional mental disorders (mostly schizophrenia) that had not yet responded to treatment or that gave rise to serious security problems. Most of this group still had active psychotic symptoms and half were under a formal commitment order. Most had a much longer history of disorder than their present hospitalization and had relapsed several times previously shortly after discharge. Very few of them, when asked, expressed a strong desire to leave. It could be argued that even this group need not be in "hospital," depending on what is meant by this term. On the whole, however, professions other than nursing are unwilling to take responsibility for them, and the need for a domestic setting within extensive grounds, where they could move freely without being immediately in the public eye, could not be met, either by a psychiatric ward in a general hospital or by accommodation "in the community." Another quarter of the patients in the national sample were thought to need supervised residential accommodation, although this need not be in hospital. A hostel with an experienced person (not necessarily a nurse) on the premises for most, if not all, the time seemed to be the most suitable setting, but was rareiy available in the locality. O f the various reasons why supervision seemed necessary, the commonest was a liability to self-neglect or wandering. Such patients needed to be reminded to wash, to dress adequately, and even to take proper meals. They tended to lapse into a state of apathy if not stimulated by others and rarely made spontaneous social contacts. The concept of "community" for such people tends to be an artificial one since they do not belong to a natural social group and do not create one of their own. Most had no roots in the local society outside hospital. In some cases, supervision was needed to detect an early recurrence of psychotic symptoms which, on past evidence, was likely to occur frequently. A few had fixed delusional beliefs or patterns of behavior which had made them unacceptable to landladies or fellow lodgers, although an experienced hostel staff member could have coped and helped other residents to accept it. Very few seemed able to deal with the demands of ordinary everyday fife, such as filling out forms (for financial benefits), cooking, shopping, or paying bills. Almost all were thought to need a protected day setting as well, and supervision would usually be needed in order to be sure that they did in fact get from hostel to day center and back. Some would have needed transport. A further 15 percent were thought to need less supervised accommodation since they could fend for themselves and many could, on past record, hold down jobs in open or sheltered industry. Supervision would be needed only to ensure that medication was continued or to detect early signs of relapse. These three groups accounted for three-quarters of the sample. The remaining 25 percent illustrated an important function of the psychiatric hospital: to provide accommodation for people who cannot find a place

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elsewhere. Many were suffering from presenile dementia or other chronic brain syndromes. Others were blind, deaf, epileptic, mentally retarded, or physically handicapped. They had, at some time, had psychotic symptoms in addition, or had shown disturbed behavior, but at the time of examination did not appear to need the specialized setting of a psychiatric hospital. No alternative accommodation was, however, available. These studies indicate that most patients now accumulating as a "new" long-stay group in psychiatric hospitals have severe impairments which determine their need for protected environments. Whether such settings are within what is conventionally called a "hospital" seems less important than that each individual's specific needs should be met. Many required continued treatment of various kinds, but the overriding need was for sheltered residential accommodation (on a domestic scale), providing care and supervision which could only be given by experienced staff, and for occupation within their capacity, usually in a sheltered workshop or day center. Although I am not aware of an equivalent epidemiologically based study in the United States, two surveys quoted by Pollack and Taube, 31 one of patients in Texas mental hospitals on July I, 1966, the other of patients in St. Elizabeth Hospital, Washington on May 31, 1970, suggest somewhat similar proportions requiring the various levels of care. One of the recommendations of the English national sample survey was that, since psychiatric hospitals were faced with a lack of alternative accommodation for the "new" long-stay, they should be given resources for setting up "hospital-hostels" which would provide a domestic-scale residence with spacious grounds within the local community. This suggestion was accepted on an experimental basis by the government department concerned 3z and the first such hostel has now been opened by the Maudsley Hospital in London. All patients who stay as long as a year are considered for the hostel and the experience is being monitored as part of studies based on the Camberwell Psychiatric Register.

CHRONICALLY DISABLED PEOPLE OUTSIDE HOSPITAL Length of hospital stay was never an adequate measure of chronic impairment (as opposed to social disadvantage or adverse personal reaction) but it can nowadays give no hint at all of the size of the problem. Only 4% of all patients admitted to hospital in England remain as long as a year but a much larger proportion remain handicapped, and require further care after discharge. In a study of schizophrenic patients admitted to three English psychiatric hospitals (each the main center for its area) in 1956 and followed-up five years later, it was found that just over half of the first admitted patients were functioning reasonably well socially while a quarter were still severely disabled. Readmitted patients had a much worse prognosis; about half being severely disabled five years later? s

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A recent international study carried out by the World Health Organization, found that about one-third of 543 patients with early schizophrenia had an unfavourable outcome two years later. The proportion was nearer 40% in centers in developed countries, a9 Very few of these disabled people were in a hospital, however. It is therefore necessary to examine other settings. Several studies have now been made of forms of residential accommodation that are alternatives to hospitals, such as hostels, hotels, group homes, and boarding-out schemes. One of the most useful, because it has an epidemiological base, was published by Hewett, Ryan, and Wing? T M In the United Kingdom, all those in need of care outside hospital are the responsibility of local government through the Social Service Departments of boroughs or counties. These departments either set up residential and day centers themselves or they pay for accommodations in units set up by voluntary organizations. Very few facilities are paid for privately. It is therefore possible to discover who is receiving such care. Three adjacent boroughs in southeast London, with a combined population of 750,000, were chosen for the survey. At the end of 1973, they were together supporting 104 people aged 16-64, who had earlier been treated in psychiatric hospitals. Most were living in hostels set up by voluntary organizations, but 28 were in a hostel run by one of the boroughs, and six were living in bed-sitting rooms established by a voluntary ttousing Association. The social characteristics of this group were remarkably similar to those of the "new" long-stay in hospital. Most had suffered from severe psychotic conditions (usually schizophrenia); they were middle-aged, out of touch with relatives or friends, and able to undertake only very unskilled and low-paid work, or none at all. However, the clients were considerably less disabled and showed much less behavior disorder. This was a condition of their staying in the hostels. Social isolation was the only marked behavioral characteristic of the residents shared with the hospital group. The fact that they were living "in the community" did not mean that they had made social contact with i~. Half of the hostels were set up with the expectation that clients could be rehabilitated and ultimately resettled in their own apartments or lodgings, paid for independently out of their earnings. Even in these settings, however, most clients had already become long-stay, i.e. they had stayed for more than a year. Very few wanted to move elsewhere and it was obvious why. The effort of maintaining themselves even in low-level jobs was exhausting. (Many were taking phenothiazines). They tended to return after work, eat the evening meal, and then go straight to bed. The standard of accommodation was quite high, since the houses, though old, were comfortable, warm and noninstitutional; much better than they could have expected if competing for apartments or lodgings on the open market. They did not have to do the shopping, cook the meals, pay the bills, provide their own company, be responsible for getting themselves up in the morning or even for taking their medication or maintaining a reasonable standard of cleanliness and appearance, since there was someone on hand to

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remind them of these things. The alternative for most was a solitary bedsitting room where they would have to undertake all these duties for themselves. The important role of sheltered employment services has been emphasized by the work of Fountain House 42 and by Bennett. 4a The investigators did not consider that a state of dependence was artificially being created but that the degree of shelter afforded by the hostels was appropriate to the degree of impairment, particularly for people who were working. Such staffed hostels are, however, expensive, and attention has since been shifted to "group homes," which are houses converted to bed-sitting rooms with a communal kitchen and parlour. These are most suited to people with a lesser degree of impairment who may attend a day center or, if older, are expected to find their own recreation. There is a greater or lesser degree of supervision from community psychiatric nurses or from social workers, depending on the needs of residents, but there are no staff members living in. Boarding with selected landladies is a further alternative now being increasingly used in the United Kingdom, but a great deal depends on the quality and experience of the landladies and therefore on the degree of supervision that social workers can exercise. The kind of people acceptable to those running all these types of care are much the same, with the main emphasis on ability to work or attend a day center, and on socially acceptable behavior. Considerable pressure is used to maintain these standards and clients who cannot do so have to move on. This means that there is a high degree of selectivity, although the criteria of selection are largely negative. Most of the "new" long-stay patients described by Mann and Cree a6 would not be acceptable. This is why they remain in hospital. However, there is another level of "community" accommodation where such people may be found. These are the decrepit hotels, the rooming houses, the Salvation Army hostels, and the other shelters for the near-destitute. Below this level there is always the street. Reich and SiegeP 4 thought that large numbers of patients discharged from hospitals in New York congregated in such places--"unsupervised, unmedicated, uncared for, frequently the prey of unscrupulous and criminal elements." Studies in London confirm that a substantial proportion of the men using government reception centers or voluntary shelters for the destitute are suffering from chronic psychotic disorders, both organic and functional?~- 4~ There is a strong suspicion in England that part of the growing problem of destitution is due to the fact that mentally disordered people are treated in hospital, leave prematurely, drift away from their relatives, fail to keep jobs, and eventually become unable to support themselves at all. In a study of 78 unemployed people of employable age, who had suffered from psychotic illnesses in the past but had not recently been in hospital, it was found that one was actually in a center for the destitute at follow-up two years later, and another was about to become so because the rooming house he was living in was being closed. Both were schizophrenic. 48 This number, in an area of 150,000 inhabitants, may not seem large, but it is minimal;

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there must be others who are not known to services. Moreover, Camberwell is well-served by medical, social and voluntary agencies, compared with most other areas in the United Kingdom, and it is not characterized by high population mobility as are so many inner-city areas. Even so, one individual with schizophrenia becoming destitute, per year, per 150,000 population, adds up to a substantial number across the whole country. The study also disclosed a high suicide rate, which has also been found elsewhere. 49 Finally, it is necessary to consider the chronically disabled who are living in a family setting. This is probably still a majority though exact figures are hard to come by. What is quite certain is that relatives are coping with the whole range of impairments, disadvantages, and reactions that are found in other settings. Recent work can be summarized by saying that relatives often have to take over the role performed by nurses in hospital or by supervisors in hostels and houses. Quite frequently, they have to do so without much professional help, and in the face of criticism from some professionals that they themselves have "tmxious influences upon the patient." It is remarkable, under the circumstances, how well many of them perform and not surprising that sometimes they fail. 5°'~1

IMPLICATIONS FOR SERVICES The evidence briefly summarized in this paper suggests that the undoubted progress made during the past quarter of a century has not resulted in the prevention of all chronic disability from psychiatric disorders. The correction of the neglect, pauperism, and institutionalism of the large old-fashioned hospitals, the use o f new methods o f resocialization and retraining, the introduction of methods o f behavioral modification and sha W ing, ~2 and an improved understanding o f how social and pharmacological treatments interact 53"54 have certainly improved the prognosis, but longterm handicap remains. Although poor environmental conditions can cause increased disablement (whether in hospital, hostel, bed-sitting room, lodging, or in the family home), even in the best social conditions that can be provided, some people will remain impaired. There is no way of drawing a sharp dividing line between medical and nursing services, on the one hand, and social services on the other. Most patients or clients need both. If, in any particular area, there is a responsible service, in the sense that anyone resident there is entitled to the help he or she needs; if there is a comprehensive range of facilities including sheltered communities (within their own grounds), as well as protected day and residential units that are part of the local scene; if professional staff are experienced in the art of expecting a little more than the individual's current performance, but never demand more than it is possible to achieve; if relatives are regarded as part of the treatment milieu (often knowing more than the professionals about any particular individual); and if all the staff and facilities are integrated, so that there are no large gaps or sudden

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c h a n g e s in e x p e c t a t i o n b e t w e e n t h e m , t h e n the service will be as g o o d as it c a n b e . 55"56 Despite the m a n y claims t h a t a r e m a d c , I d o n o t k n o w o f a service a n y w h e r c in the w o r l d that attains all these objectives, a l t h o u g h s o m e c o m e quite close to a t t a i n i n g o n e o r two o f t h e m . V e r y d i f f e r e n t p a t t e r n s o f service c o u l d be e n v i s a g e d t h a t w o u l d m e e t t h e m ; t h e r e is n o n e e d f o r all services to l o o k alike. Meanwhile, h o w e v e r , it m i g h t be best to call a m o r a t o r i u m on the kind o f claim t h a t suggests t h a t a n y single f a c t o r (such as the h a r m f u l effect o f institutions, o r the m a l e v o l e n c e o r i n c o m p e t e n c e o f relatives, o r the m a n i p u l a t i o n s o f psychiatrists o n b e h a l f o f the "establishm e n t , " o r the i n a d e q u a t e p r e s c r i p t i o n o f physical m e t h o d s o f t r e a t m e n t ) , is chiefly responsible f o r t h e c o n t i n u e d d e v e l o p m e n t o f l o n g - t e r m h a n d i c a p .

REFERENCES 1. Kramer M: Psychiatric Services and the Changing Insitutional Scne, 1950-1985. DHEW Publication No. (ADM) 77-433. Washington, U.S. Government Printing Office, 1977. 2. Babigian HM: Schizophrenia: Epidemiology. In Freedman AM, Kaplan HI, Sadork BO (eds): Comprehensive Textbook ofP©,chiatry, VoL H. Baltimore, Williams & Wilkins, 1975. 3. Cooper JC, Kendell RE, Gurland BJ, Sharpe L, Copeland JRM, Simon, R: Psychiatric Diagnosis in New York and London. I_~ndon: Oxford University Press, 1972. 4. World Health Organization: ThelnternationalPilot Study of Schizophrenia. Geneva, WHO, 1973. 5. Wing JK, Cooper JE, Sartorius, N: The Description and Classifvsation of Psychiatric Symptoms: An Instruction Manual for the PSE and Catego System. London, Cambridge University Press, 1974. 6. Belknap I: Human Problems of a State Mental Hospital. New York, McGraw Hill, 1956. 7. Dunham HW, Weinberg, SK: Culture of the State Mental Hospital. Detroit, Wayne State University Press, 1960. 8. Goffman E: (t961) On the characteristics of total institutions. In Cressey DR (ed): The Prison. New York, Holt, Rinehart and Winston, 1961. 9. Cumming J, Cumming E: The locus of power in a large mental hospital. Psychiatry 19: 361, 1950. 10. Jones K: A History of the Mental Health Services. London, Routledge, 1972. 11. Rothman DJ: The Discovery of the Asylum: Social Order and Disorder in the New Republic. Boston, Little, Brown and Company, 1971. 12. Wing JK: Institutionalism in mental hospitals. BrJ Soc Clin Psychol 1: 38, 1962. 13. Wing JK, Brown, GW: Institutionalism and Schizophrenia. London: Cambridge University Press, 1970. 14. Macmillan D: Hospital-community relationships. In Proceedings of the Thirty-Fourth Annual Conference of the Milbank Memorial Fund. New York, Milbank, 1957. 15. Bockoven JS: Moral treatment in American psychiatry. J Nero Merit Dis 124: 167-194, 292-321, 1956. 16. Rees TP: Back to moral treatment.J Ment Sci 103: 303, 1957. 17. Main TF: The hospital as a therapeutic institution. Bull Menninger Clinic i 0: 66-70, t946. 18. Jones M: Social Psychiatry irt the Community, in Hospitals, and in Prisons. Springfield, Ill., Charles C. Thomas, 1962. 19. Fairweather GW, SandersDH, Cresslee DL, Maynard H:CommunityLifefortheMentallylU. Chicago, Aldine Publishing Co., 1969. 20. Gruenberg EM, Huxley A (eds): Evaluating the Effectiveness of Community Mental Health Seroices. New York, Milbank Memorial Fund, 1960. 21. Wing JK: A pilot experiment on the rehabilitation of long-hospitalized male schizophrenic patients. B r J Prev Soc Med 14: 173, 1960.

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22. Wing JK, Bennett DH, Denham J: The'Industriat Rehabilitation of Long-stay schizophrem~c patients. Med. Res. Council Memo. No. 42. London, HMSO, 1964. 23. Catterson A, Bennett DH, Freudenberg RK: A survey of longstay schizophrenic patients. BrJ Psychiat I09: 750, 1963. 24. WingJK, Freudenberg RK: The response of severely ill chronic schizophrenic patients to social stimulation. AmJ Psychiat 118:31 I, 1961. 25. Brill H, Patton RE: Clinical statistical analysis of population changes in New York State Mental Hospitals since introduction of psychotropic drugs. AmJ Psychiat 119: 20, 1962. 26. Tooth G, Brooke EM: Trends in the mental hospital population and their effect on future planning. Lancet i: 710-713, 1961. 27. Godber C: Reason for the increase in admissions. In WingJK, Hailey AM (eds): Evaluating a Community Psychiatric Service. London, Oxford University Press, 1972. 28. Wing JK, Hailey AM (eds): Evaluating a Community Psychiatric Service: The Camberwell Register 1964-1971. London, Oxford University Press, 1972. 29. Wing JK, Fryers T: Psychiatric Ser'oices in Camberwell and SalJord. London, MRC Social Psychiatry Unit, Institute of Psychiatry, 1976. 30. Bauer M: Sektorisierte Psychiatric. Stuttgart, Enke Verlag, 1977. 31. Pollack ES, Taube CA: Trends and projections in state hospital use. In Zusman J, Bertsch EE (eds): The Future Role of the State Hospital. Lexington, Mass., Lexington Books, 1975. 32. Mendel WM: Lepers, madman--who's next? Schizophrenia Bull 11:5-8, 1974. 33. Pdeder RO: Hospitals, patients and politics. Schizophrenia Bull 11: 9-15, 1974. 34. Department of Health and Social Security: In-patient statisticsfrom the MentalHealth Enquiry for theyear 1971. Star. and Res. Rep. Series No. 6. London, HMSO, t973. 35. Mann S, Sproule J: Reasons for a six months stay. In Wing JK, Hailey AM (eds): Evaluating a Community Psychiatric Service. London: Oxford University Press, !972. 36. Mann S, Cree W: 'New' long-stay psychiatric patients: A national sample of 15 mental hospitals in England and Wales, 1972-3. Psychot Med 6: 603-616, 1976. 37. Department of Health and Social Security: Better Services for the Mentally Ill. Cmnd. 6233. London, HMSO, t975. 38. Brown GW, Bone M, Dalison B, Wing JK: Schizophrenia and Social Care. London, Oxford University Press, 1966. 39. Sartorius N, Jablensky A, Shapiro R: Two-year follow-up of the patients included in the WHO International Pilot Study of Schizophrenia. Psychol Med 7: 529-542, 1977. 40. Hewett S, Ryan P, WingJK: Living without the mental hospitals.J Soc Policy 4: 391-404, 1975. 41. Ryan P, Hewett SH, A pilot study of hostels for the mentally ill. Soc. Work Today 6: 25, 774-778, 1976. 42. Black BS: Occupational rehabilitation, day centers, and workshops. Psychiat Q 48: 549557, 1974. 43. Bennett DH: Techniques of industrial therapy, ergotherapy and recreative methods. In Kisker KP, Meyer JE, Mfiller C, Str6mgren E (eds): Psychiatrie der Gegenwart, III. New York, Springer-Verlag, 1975. 44. Reich R, Siegel L: The chronically mentally ill shuffle to oblivion. PsychiatrAnn 3:35-55. 45. Leach J: The evaluation of a voluntary organization attempting to resettle destitute men: Action Research with the St. Mungo Community Trust. In Cook T (ed): Vagrancy. New York, Academic Press, 1978. 46. Tidmarsh D, Wood S: Psychiatric aspects of destitution. In Wing JK, Hailey AM (eds): Evaluating a Community Psychiatric Service. London, Oxford University Press, 1972. 47. Wood, SM: Camberwell Reception Centre: A consideration of the need for health and social services of homeless single men.J Soe Pol 5: 389-99, 1976. 38. Wing L, Wing JK, Griffiths D, Stevens B: An epidemiological and experimental evaluation of industrial rehabilitation of chronic psychotic patients in the community. In Wing JK, Halley AM (eds): Evaluatinga CommunityPsychiatricService. London, Oxford University Press, 1972. 49. Ernst K, Kern R: Suicidstatistik und freiheitfiche Klinikbehandlung, 1900-1972. (Suicide and the open-door system). Arch Psychiat Nervenkr 219: 255-64, 1977. 50. WingJK: Impairments in schizophrenia: A rational basis for social treatment. In Wirt RD,

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Winokur G, Roff, M (eds): Life History Research in Psychopathology, Vol, 4. Minneapolis: University of Minnesota Press, 1975. Wing JK (ed): Schizophrenia: Towards a New Synthesis. New York, Academic Press, 1978. Moss GR, Liberman RR: Empiricism in psychotherapy: behavioural specification and measurement. BrJ Psychiat 126: 73-80, 1975. Goldberg SC, Schooler NR, Hogarty GE, Roper M: Prediction of relapse in schizophrenia outpatients treated by drug and sociotherapy. Arch Gen Psychiat 34:171-84, 1977. WingJK: The management of schizophrenia in the community. In Usdin G (ed):Psychiatric Medicine. New York, Brunner, Mazel, 1978. Lamb HR: Community Survival for Long-term Patients. San Francisco, Jossey-Bass, 1976. Wing JK: Planning and evaluating services for chronically handicapped psychiatric patients in the U.K. In Stern LI, Test MA (eds): Alternatives to Mental Hospital Treatment. New York, Plenm'a, 1978.

Who becomes chronic?

WHO BECOMES CHRONIC? J. K. Wing MD, PhD Chronic social disablement is caused by three types of factor: impairment, e.g. slowness in schizophrenia; so...
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