EdenteV2, Istex, Corpus, bibRecord, 000F44

The Logic of Pragmatism in Mental Health Policy

Identifieur interne : 000F44 ( Istex/Corpus ); précédent : 000F43; suivant : 000F45

The Logic of Pragmatism in Mental Health Policy

Auteurs : Shulamit Ramon

Source :

CSP. Critical social policy [ 0261-0183 ] ; 1982-09.

RBID : ISTEX:1EF9C8C646B3309DF340477340F4FAEE3552C00B

English descriptors

KwdEn :
- Allen unwin, Basic books, Better services, Biological methods, British government, British policy, British psychiatrists, British psychiatry, Care system, Central government, Child guidance clinics, Cmnd, Community care, Community services, Court order, Family members, Hansard, Health approach, Hospital plan, Hospital system, Intervention methods, Labour party, Local authorities, Local authority, Main issues, Major feature, Major issues, Medical model, Medical profession, Mental deficiency, Mental health, Mental health policy, Mental hospital, Mental hospitals, Mental illness, Mental illness scene, Mental policies, Mental treatment, Mind publications, National health service, Open door policy, Permissive legislation, Policy decisions, Prentice hall, Professional circles, Psychiatric, Psychiatric patients, Psychiatric sector, Psychiatric services, Psychiatric wards, Psychiatrist, Psychiatry, Psychopathy, Psychotherapeutic communities, Psychotropic drugs, Public attitudes, Residential accommodation, Royal college, Royal commission, Royal commissions, Second half, Shulamit ramon, Social control, Social medicine, Social order, Social policy alternatives, Social research, Social structure, Social workers, Successive governments, Tavistock, Team work, Unsatisfactory state, Voluntary patients, White paper.
Teeft :
- Allen unwin, Basic books, Better services, Biological methods, British government, British policy, British psychiatrists, British psychiatry, Care system, Central government, Child guidance clinics, Cmnd, Community care, Community services, Court order, Family members, Hansard, Health approach, Hospital plan, Hospital system, Intervention methods, Labour party, Local authorities, Local authority, Main issues, Major feature, Major issues, Medical model, Medical profession, Mental deficiency, Mental health, Mental health policy, Mental hospital, Mental hospitals, Mental illness, Mental illness scene, Mental policies, Mental treatment, Mind publications, National health service, Open door policy, Permissive legislation, Policy decisions, Prentice hall, Professional circles, Psychiatric, Psychiatric patients, Psychiatric sector, Psychiatric services, Psychiatric wards, Psychiatrist, Psychiatry, Psychopathy, Psychotherapeutic communities, Psychotropic drugs, Public attitudes, Residential accommodation, Royal college, Royal commission, Royal commissions, Second half, Shulamit ramon, Social control, Social medicine, Social order, Social policy alternatives, Social research, Social structure, Social workers, Successive governments, Tavistock, Team work, Unsatisfactory state, Voluntary patients, White paper.

Abstract

The Logic of Pragmatism in Mental Health Policy: The implications of the government policy on mental health in the 1959 debate for the 80s.

Url:

https://api.istex.fr/document/1EF9C8C646B3309DF340477340F4FAEE3552C00B/fulltext/pdf

DOI: 10.1177/026101838200200508

Links to Exploration step

ISTEX:1EF9C8C646B3309DF340477340F4FAEE3552C00B

Le document en format XML

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<title-group><article-title>The Logic of Pragmatism in Mental Health Policy</article-title>
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<meta-value>38 The Logic of Pragmatism in Mental Health PolicyThe implications of the government position on mental health in the 1959 debate for the 80s SAGE Publications, Inc.1982DOI: 10.1177/026101838200200508 Shulamit Ramon London School of Economics The Logic of Pragmatism in Mental Health Policy: The implications of the government policy on mental health in the 1959 debate for the 80s. Abstract The article investigates policy decisions on mental illness taken by the British government during the fifties. The decisions are explored on two interconnected levels: 1 Interaction between the general scene of the period, attitudes of MPs to mental illness/health policy and public opinion about it. 2 The links with professional conceptual approaches and the intervention actually practised in the psychiatric services. After summarising the main developments from 1959 up to now the implications of the 1959 debate for policy decisions today are discussed: 1 Mental illness stayed as a major social problem. 2 So far the officially preferred policy of community care has not been implemented evenly and satisfactorily throughout the country. The roots of this situation are traced back to 1959, especially to the lack of sufficient commitment by central government towards community care. 3 It appears that the two main professional paradigms of 1959 - the medical-somatic vs community mental health - are still the most prominent ones today. Yet the necessary conceptual debate on them did not take place in 1959 and has hardly begun now in Britain. "I think it is a fact that psychiatry is the Cinderella of the Health Services". Dr. Broughton** "But we were once again the victims of the pragmatic fallacy; just plunge into your subject, collect as many facts as you can; think about them hard as you go along, and at the end use your common sense and above all feel for the practicable". A. Shonfield*** * The author thanks the Nuffield Foundation for a research award which enabled this study to be carried out. This article is based on an oral presentation at the Social Science & Medicine Conference, Holland, June 1981. ** Hansard, 573, 81, 8.7.1957 *** A. Shonfield (1980) In the Course of Investigation. In M. Bulmer (ed) Social Research and Royal Commissions. Allen & Unwin, p.59 3939 This article focuses on the British government's policy in regard to mental illness as expressed in the House of Commons debates during 1956-62. The debates were focused on the report of the Royal Commission on the law relating to mental illness and mental deficiency published in 1957 and the 1959 Mental Health Act. It is argued here that the major issues at stake in 1959 have remained central ever since and are with us in the eighties too. The article calls for the reopening of the debate on alternatives to the medical-somatic model for the care of the mentally ill. Such a debate has so far been muffled in Britain, where the traditional preference for pragmatic solutions at any cost has been dominant. Therefore the discussion should be reopened at a level different from the non-conceptual approach which so typified the last public debate on mental illness/health policies in 1959. Current numbers of mentally ill inpatients, users of outpatient facilities and the cost of hospital-based services continue to justify social concern in 1981 no less than they did in 1959: (see the 1959 numbers in the section on the mental illness scene): 1 97,000 admissions in 1978~~~ (excluding 59,000 elderly inpatients, of whom a considerable proportion suffer from psychiatric disturbances). 2 A 1,500,000 out-patient appointments and day patient population (2) 3 The cost of a hospital bed per week was £81 in 1978 (3) 4 The rate of full recovery is low for those who have been hospitalised, compared to that of physical illness. Moreover, the degree of chronicity and disability is high. (4) Both in 1959 and today the psychiatric services seem to be meeting the requirements for social control over deviant members of society. However, from its point of view, the government was confronted in 1959 - and still is - with an unsatisfactory situation of growing expenditure and not much in return apart from social control. The current wave of cuts in local authorities services will hit hard residential facilities for ex-patients and the very limited employment opportunities will make re- employment into a rarity. The government has just announced its amendments to the 1959 Mental Health Act(5). The new regulations focus almost entirely on patients' rights. While the importance of this aspect should not be undermined this article is concerned with the equally important issue of the avoidance of the component of community services for the mentally ill by the government. In order to be able to evaluate the eighties' alternatives an understanding of the 1959 debate and decisions is necessary. It is assumed here that policy decisions are taken within a specific frame of meanings* and attitudes towards the debated issues. In the context of mental illness/health policies the main parameters are the socio-economic context, professional explanations and interventions and public attitudes towards the mentally ill. Therefore this article will attempt to investigate: A The relationships between: 1 The socio-economic background of the fifties. 2 The mental illness scene during that period. 3 Prevailing models of explanations and intervention. 4 Government's stand and legislation passed on mental illness. B The relevance of this analysis to the current situation in the mental illness arena. meanings refer to a general ideadonal stance while attitudes are goal-directed positions and the feelings associated with them. The latter are based in part on the meanings attached. 4040 The Fifties: the socio-economic background The considerable social, political and economic changes which took place in Britain between 1930 (when the Mental Treatment Act was passed) and 1959 (when the Mental Health Act was legislated) have been amply documented and need not be spelled out here in full. (6) The most relevant features of these developments include the following: First, the introduction of the National Health Service (the NHS) was a major feature in providing non-selective welfare services. The care of the mentally ill became an integral part of the NHS.~7~ This sector was included in the NHS with a somewhat ambivalent attitude: in the negotiations of 1943 the ministry stated that mental illness would not be part of the NHS but it was put into the 1944 White Paper. (8) Secondly, the major differences and political battles between the two leading parties in regard to home politics seemed to have diminished during the fifties.~9~ The Conservatives have accepted in principle not only the welfare system but the Keynesian approach to economics. The majority of the Labour Party moved to the right with the notable exception of the supporters of CND within the Labour Party.(' 0) As for foreign policy, the CND movement and the Suez campaign were the points of disagreement. The passivity of the electorate became a main characteristic of political life. Thirdly, the impression of economic affluence was in the air from the mid fifties and onwards, expressed in the slogan 'You've never had it so good'.(' 1) It was more objectively so for the majority of working class and middle class people than before the war in terms of income and standard of living. Yet Britain went from one 'monetary' crisis to another between 1955-1961, accompanied by a constant increase in the rate of inflation. Emphasis on consumption of durable material goods emerged as a major feature of the style of life.(l2) Fourthly, specialisation and professionalism were growing in numbers and in social prestige.(13) Lastly, disenchantment with the affluent, materialist-minded society and with some of the uses of scientific achievements were expressed by a minority (CND and the 'Angry Young Men')'.043 The mental illness scene Hospital admissions numbered 105,000 per year, while the general population size reached 45 million. (15) The figures were four times more than the 1930 numbers, though the general population growth was only 13 per cent during the same period. The number of out patients' appointments was estimated as one million with 145,000 new ones. (16) The increase in numbers was put down to the combination of several factors including the availability of services free of charge, the increase of the probability of becoming mentally ill with the increase of longevity, greater public tolerance towards the mentally ill, earlier discharge and readmission patterns, the difficulties entailed for nuclear families in containing the mentally ill, and changes in psychiatric definitions.1 ' 17) The cost of maintaining a mentally ill in-patient in hospital was £4.16s.8d. per week compared to £7.Os.11 d. for the physically chronic patient and £ 16.Os.Od. for the acute patient. (18) The psychiatric sector was consistently allocated less resources than the physical illness sector considering that it occupied a third of the total number of beds.(19) This tendency relates to areas such as catering, administrative staff as well as to professional appointments and accommodation conditions of inmates (see table 1, p. ). By 1957 about 80 per cent of the patients in hospitals were there on a voluntary basis. (20) This percentage should be contrasted to 100 per cent compulsory admissions in 1930 and 90 per cent compulsory to 10 per cent voluntary ones in 1939. 4141 Shortages of accommodation and staff, the tendency towards highly regimented and impersonal life for the inmates were the target of criticism by professionals and lay people, MPs, the press, the BBC, and Mind (the association of voluntary organisations in the field of mental illness created in 1946).~21~ An unprecedented publication, edited by two MPs (Dr. Johnson and Mr. Dodds), of ex-patients' decunciations of the prevailing system appeared in 1958, titled: A Plea for the Silent. (22) Although influential, it would be misleading to assume that these groups represented the general public. Sympathy towards the mentally ill was expressed in many of the 25,000 letters sent in reaction to the BBC programme 'The Hurt Mind'.tz3~ Reactions towards the quick re-emergence of ex-patients from hospital and into the community were neither negative nor positive; just indifferent. The indifference can be easily maintained towards people who do not count socially but who are not disturbing actively. Such a reaction is understandable when the threat to 'the taken for granted', inherent in mental illness, is remembered. (24) Already in 1959, however, it was predicted that hospitalisation rates were to be reduced. This view was adopted by the Minister of Health and expressed in the 'Hospital Plan' published in 1962, where cuts in the number of beds were planned. This last approach was closely related to changes both in intervention methods as well as the importance given to management considerations and predictions by the Minister, Mr. E. Powell. (25) Table 1: Effective number of hospital staff, 1960° (by main categories and the ratio per 100 staffed beds at 31.3.1960) NHSAccounts, 1960, 15 Explanations and interventions The accepted model of explanation and intervention was the medical-somatic* one. It defined mental illness as a disease, with physical causes for it, even if the manifestations were not physical.(26) As a disease it was to be treated by professional doctors. The approach concentrated largely on diagnosis of the disease entity and treating 'it' specifically. In such a framework there was no place for attempting to understand the whole person and his milieu. Hospital medicine fitted well with this approach. By 195 9 the medical paradigm became part of the general cultural order. It is easily forgotten that medical men were not considered as part of the middle classes until the second half * medical - emphasis on the primacy of medical training, and hierarchy and power relations; somatic - emphasis on the soma. However it often leads to exclusion of non-somatic interventions. These foci do not imply disregarding the psyche of a person or the social context, but come to mean a greater emphasis on the physical side. 4242 of the nineteenth century, and that GPs stayed at a fairly low social position until the thirties. (27) The dominance of the medical model in medicine and psychiatry in the 20th century is primarily related to the changing attitudes towards science, technology, secular knowledge and prestige bestowed gradually on 'the professions' from the second half of the 19th century and onwards. (28) It had relatively little to do with achievements in psychiatry itself. Medicine was hailed as capable of curing a number of mass illnesses which receded at the end of the 19th century/beginning of the 20th century, notably tuberculosis and malaria. The only equivalent discovery in the field of mental illness was made by Wagner-~auragg, who found in 1917 what amounted to a cure for general paresis. (29) Despite its uniqueness it was nevertheless hoped that further scientific discoveries in psychiatry would lead to the same excellent results. The implication of the discovery was that all mental illnesses have a single cause at their root and it is a matter of time and effort within the framework of medical-somatic research before the causes would be located and controlled, primarily through chemical means. This point of view appealed to the lay person no less than to the professional psychiatrist or nurse, because of its.simple line of logic and the neat solution it offered. The adjunct model of the person was the 'faulty machine' type which follows the mechanistic/natural science thinking of the beginning of the century. (31) Intervention (a) The psychotropic drugs The change in methods of treatment from those available before the war was considerable. The most publicised by the professionals was the introduction and massive use of a new group of drugs - the Chlorpromazine and its derivatives which started in 1954 in the UK. The use of these drugs put ECT into a secondary place and made leucotomy into a rarity. The ease of administering the drugs, the lack of necessity for a highly qualified staff (required with both insulin and ECT) to deal with it was coupled with the ability to discharge people after a few weeks when symptoms were receding. All of these features won the case for the drugs. Much less attention was given to side effects or to the rate of readmissions or recurrence of symptoms. Issues such as drug dependency or the fate of the newly discharged patient who is neither actively ill nor healthy were not mentioned. The boost the 'drug revolution' gave to the adherents of the medical model was, of course, decisive. The appeal of the use of drugs coincided with a growing feeling of affluence and the government's readiness to invest financially in chemotherapy. (b) Change within the hospital system The changes within the hospital system were threefold. The first was the open door policy which meant literally the adoption of a policy of discharge whenever patients seemed fit to leave the hospital. It did not involve any particular chemotherapy or any other form of therapy, though the forms used during the forties were employed (insulin, ECT). Relatively little attention was given to the fact that in those hospitals which employed the 'open door policy' a dramatic decrease in length ofhospitalisation and in total inpatients numbers was observed prior to the introduction of the psychotropic drugs. (3 1) Therefore we have to ask ourselves why the history of British psychiatry was rewritten between 1954 (the year in which the psychotropic drugs were introduced) and 195 9, in such a way as to minimalise the effect of the open door policy and to enhance the assured impact of the drugs. The implicit belief in the supremacy of somatic medicine is likely to be the main reason for this process of rewriting. 4343 The second was the establishment of psychiatric wards in hospitals which, in contrast, received considerable acclaim. It was perceived as part of 'community care' and as leading to a decrease in the stigma attached to mental patients/hospitals. These wards symbolised the greater tie between psychiatry and general medicine.~32~ The third was the successful experiment of psychotherapeutic communities inside hospitals.(33) In both the psychotherapeutic communities' and the psychiatric wards' experiments it was implied that the big mental hospitals had largely become redundant in their prevailing form as a method of intervention. (c) Clinics Ideas on care of patients in the community - rather than in hospitals - were already expressed in the 1930 Mental Treatment Act but were left largely unimplemented by successive governments for reasons discussed in the section on the government's position. Nevertheless, outpatient clinics and child guidance centres started to develop more and more. They were financed by voluntary organisation and some local authorities. The spread of the child guidance clinics was in part due to the impact of psychoanalytic thought and practice in Britain (eg the Tavistock and Hampstead clinics). (34) The growth of out-patient clinics led to an increase in the numbers of psychiatric social workers(35) and clinical psychologists who were ready to undertake psychotherapeutic work. The alternative model of explanation and intervention: Community Mental Health. Community mental health (CMH) became the main alternative to the medical-somatic approach at a society-state levei.* Its specific roots date back to the moral approach and to the 19th century 'social medicine' movement.(36) Emphasis on the role of the environment in mental illness rather than exclusively on the pathology of the individual became prevalent in American sociology during the forties and the fifties.~~7~ This development led to parallel changes in some American psychological approaches to the understanding of the mentally ill. There the stress was put on inter-personal relationships and the role of socio-cultural factors in the socialisation of individuals and groups (eg Sullivan,(38) following G.H. Mead and _Erickson~39~) combining psychoanalysis, anthropology and structural-functionalism. The impact of these strands of thought was hardly reflected in the mental illness/health scene in the UK. Thus neo-Freudian theory, experiments in brief psychotherapy and crisis intervention during the second world war and after reinforced rethinking about traditional psychiatry and psychotherapy. It will not be attempted here to provide a full description of the community mental health approach. For the purpose of this paper the presentation will focus on the similarities and differences between the medical-somatic and the CMH approaches. Likewise, the evidence for each school will not be presented here. Suffice to say that most of the existing evidence is far from being conclusive. The presentation of the CMH follows closely Caplan's work(40) as his was the more accessible during the fifties. Conceptually the CMH approach shares with the medical-somatic one the following: * Although psychoanalytic thinking was influential in some professional circles at the time (notably in child guidance clinics) it never attempted to offer a general model for intervention in regard to mental illness at the level of a state-society. 4444 1 A view of mental disturbances as an illness of the individual. 2 Biological causes may be at the root of the disturbance. Consequently biological methods of intervention are likely to be relevant. 3 There is a primary place for professional intervention. 4 Society is not ill. It has the duty to care for its sick members as well as the right to defend itself from possible harmful consequences of their disturbances. 5 Both models accept the established psychiatric system of classification as a taken- for-granted attribute. The main differences between the medical-somatic and the CMH approaches are first, within the framework of the CMH school mental illness can be caused by either biological or psychological or social factors or by any combinations of these factors. Biological etiology is not seen as either primary or always in existence. Likewise biological methods of intervention provide only one option out of several and each has to be judged on its own merits in any particular case. (41) Secondly, while the disturbance is seen as located within the person, social reactions are recognised as playing a significant role in exacerbating and perpetuating the sick role of the person. These reactions need-to be modified if the ex-mentally ill are to become equal members of their society. (42) Thirdly, following from the first two points, medically qualified professionals have a valid but limited contribution to offer. Other professionals and lay persons have equally important functions to provide in any care system for the mentally ill. Fourthly, the model of the person differs radically from that incorporated into the medical-somatic one: implicitly the Ego Psychology school's viewpoint is endorsed. (13) The person's ability for conscious and creative activity - rather than defensive - is stressed, although the power of the unconscious and of childhood experience is recognised. The focus is on the adult rather than on the child. The adult is more of a social than a biological being, capable of overcoming conflicts or sustaining mature interpersonal relationships, interested in the world outside the family circle and in acquiring new competence. In this framework mental illness is seen as an understandable crisis, usually of a temporary nature. Lastly, the CMH is a fair reflection of the main ideological trends of the fifties: ie the optimism about possible radical changes in individuals and in systems of care. This belief was coupled with the basic acceptance of the prevailing social structure, despite the rejection of the way that system dealt with its mentally ill members. This inconsistence is an example of one of the internal contradictions within the CMH approach. The CMH model fits well Jaccoby's term 'conformist psychology'.(") It should have become clear by now that despite the similarities mentioned above the CMH and the medical-somatic approaches are conceptually incompatible in terms of: the understanding of mental illness offered, the interventions suggested, and the implications for the structure of the care system which follows. This incompatibility was not recognised by the different professional groups involved with it in the UK. The concept of CMH was not used in Britain; 'Community Care' became the key term. But the latter term and its boundaries were hardly ever discussed in the professional literature beyond equating it with any treatment outside the hospital. Likewise none of the professional groups came up with a suggestion for a conceptual and/or organisational framework for the implementation of community care (cc). Psychiatrists were - and still are - the more powerful and prestigious group of professionals in the field. It is therefore crucial to understand the roots of their attitude towards community care. This attitude was characterised by benevolent tolerance and plain indifference by the majority of British psychiatrists. A minority was enthusiastically engaged in it. Krietman studied in 1960 the beliefs held by a sample of psychiatrists in London. (41) 4545 He found a division into those who favoured an organic perspective (the medical-somatic one described above) vs those in favour of a psychogenic-oriented approach. The majority belonged to the first group. Reading the BMJ, the Lancet and the Journal of Mental Sciences (which became the B.J. ofPsychiatry in 1963) of the fifties leaves the reader with a similar impression to the one presented by Krietman.E46~ For example, all of the BMJ 1957 references are letters reacting to the BBC 'The Hurt Mind' programme. All of them focus on the issue whether general paralysis can/cannot be cured by penicillin injections. This point was made in the programme as a fairly minor one, compared to the totality of the experience of mental illness for the patient and his family members. Yet it seems as if only this topic caught the interest and imagination of the psychiatrists. In contrast, the very many letters written to the BBC by family members and ex-patients often contained unhappiness about the way they were treated by all professionals. (47) The main preoccupation of psychiatrists in that period seems to have been with using new means of intervention - a very legitimate concern. Yet this objective was pursued from a totally pragmatic angle: it hardly ever stopped to inquire why means are helpful or not, or where they should be located in the explanatory map of mental illness. The preoccupation with clinical intervention reflected the feeling of dissatisfaction within the profession as well as a reaction to public criticism. Barton's~48~ work on the effects of institutionalism represents the minority who did not share the euphoric feelings about the psychotropic drugs, and who were interested in developing a conceptual perspective. The bitter criticism expressed in publications like 'A Plea for the Silent' mentioned above led to the appearance of a defensive collection in the same year, 'Bridging the Gap'.~49~ The book is apologetic and tries to show that psychiatrists are conscientious (as no doubt most of them were and are). But it fails to provide an alternative thinking about the roots of the prevailing difficulties. Many small scale experimental programmes on the lines of CMH were operating during the 1950s in Britain.(50) They included day hospitals, social clubs, therapeutic communities and district domiciliary services. Services in the community were evaluated to be considerably less expensive to establish and run than the hospital ones.(51) Thus tenatively the CMH approach seemed to have potentially satisfactory answers to the issues with which the government was confronted. The long-term effects of drugs; psychotherapeutic communities; impact of the open door policy and psychiatric wards were all very under-researched up to 1959. Ennals, writing in 1973, indicates how little the situation has changed: the MRC spent only 10 per cent of its total budget on psychiatric research. (12) The lack of funds and manpower for research reflected the low priority given to mental illness by the government and the general public. The lack of a new conceptual language came from within the profession. It is claimed here that this absence reflected the lack of change in beliefs and practice of the majority of British psychiatrists. The political scene (a) The 1954 Royal Commission (on the law relating to mental illness and mental deficiency) The Commission was set up for several reasons. First, legislation had become too cumbersome as the 1930 Act did not repeal previous legislation (ie the 1890 Act). In addition the 1948 NHS Act did not legislate specifically for mental illness. Secondly the atmosphere of affluence encouraged contemplation of further legislation. Thirdly the media were exposing scandals related to manner of care and pressing for change. 4646 This pressure was coupled by complaints on conditions in hospitals made by MPs and professionals, as already mentioned above. Given the source of complaints the government could not easily have ignored them. Fourthly the soaring numbers of inpatients and out-patients implied that perhaps the system was not coping that well with the problems it faced. The Committee sat between 1954 and 1965. It produced its report in 1957. Committee members included psychiatrists, physicians, law experts, one nurse, one social worker, several MPs; no psychologist, no member of Mind, no representative of ex-patients or their families. From the Committee's report it would seem that the concepts of community care and/or community mental health were not discussed. The first term (cc) was taken for granted as one which carried positive connotations. The Committee did not offer a definition of these terms and/or a proposal for an organisational framework in which the move to community care could have taken place in a planned way.~53~ It also did not provide a cost-benefit analysis or a suggestion to carry out such an analysis. The Committee did not call for a systematic evaluation of the experimental projects on community care which were already operative. Several options are usually open for a Royal Commission to follow in the pursuit of its subject matter. (54) This particular Commission opted for some visitation but mainly for collecting written and orally submitted evidence and suggestions almost exclusively from professionals. The government officially endorsed the RC recommendations. Nearly all of the proposals have been incorporated into the 1959 Mental Health Act The two exceptions to be rejected were:1 The commission preference not to have a definition of psychopathy. 2 The recommendation to have an active, direct financial support from central government to local authorities in the area of cc. The possible reasons for these decisions will be discussed later. (b) The 1959 Mental Health Act It is reasonable to assume as Skew(55) suggests that the process of legislation was hurried up so that the Act would become law before the October 195 9 elections. The innovations of the 1959 Act included: 1 All previous legislation was repealed. 2 Psychopathy was added as a mental disturbance category. Psychopaths could be detained until the age of 21 and in some cases until the age of 25 on the strength of the diagnostic category. 3 The board of control was to be dissolved; its function transferred to the Ministry of Health. 4 Tribunals of appeal against certification or maltreatment were to be set up in an advisory capacity. They should consist of members of the public, primarily lawyers and doctors not employed by the area health authority in which the tribunal operates. Tribunals would not have to adhere to the usual court procedures of obtaining evidence or show patients documents written about them. Patients would have the right to appeal at certain fixed periods and the right to be represented by others. These rights also apply in principle to offenders under a treatment order. 5 No hospital would be designated any more, ie hospitals have the right to refuse entry as well as to admit people as they choose. But area health authorities have the duty to inform local authorities of availability of places in emergency.* * Some of the consequences of this legislation can be observed today in the refusal of hospitals to admit patients recommended for release from the special hospitals. 4747 6 Voluntary patients would not have to prove volition on admission (which they had to do under the 1930 Act). 7 Social workers became empowered to enter private premises and ask for a court order in cases of potential patients whose relatives refuse to let them be hospitalised. They were not empowered to authorise hospitalisation on their own, only doctors can do so. Judges have to be advised by doctors in cases of a court order. The Act was presented as a breakthrough in adopting a community care approach to the psychiatric services.<56) In fact the 1930 Act already postulated that local authorities were responsible for outpatients and aftercare services. The 1959 Act added residential care as part of the brief of local authorities. Both acts left the clauses on community care as permissive legislation. Likewise on both occasions the government of the day refused to provide financial aid towards the implementation of cc. However, the political standing of the two governments and the financial position of the country in the two periods could not have been more constrasting: the 1959 Conservative government had a clear cut majority in the House of Commons, compared to the minority position of the Labour government in 1930. The country was supposed to 'have never had it so good' economically in 1959. Even if this slogan was an exaggeration of the economic condition, the latter period was certainly much better than the 1930 depression. Then accumulated experience between 1930 and 1959 exhibited the highly unsatisfactory state of local authorities' services when taken as a whole and the extremely uneven distribution of services throughout the country. Nevertheless the government refused to make local authorities' duties mandatory. The only active move taken by the government was planning and carrying out cuts in the number of hospital beds for the mentally ill(57) without investing the money saved by the cuts into community-based services. In contrast, the Minister's paper on community care <5 8) did not contain any new initiative, indicating once more the lack of a genuine commitment for community mental health by the government. It should be remembered that the British government's policy stood in contrast to the one taken up in the early sixties by the American federal government. The latter offered generous financial aid for the first phase of CMH projects throughout the country as a means of encouraging its implementation.~59~ It is reasonble to assume as Goldberg and Scull~6a~ do that the American position was not motivated just by care for the mentally ill, but also out of social control and financial considerations. Such an argument raises the possiblity that the British government was not worried enough about the social control aspect to be motivated towards investing in community care. This may be the case; yet the Minister was trying hard to convince everybody that he was all for cc (see the quotation from the Standing Committee). (6]) The government's position was also in contrast to the one recommended by the RC. As mentioned above the latter suggested direct financial support from central government to local authorities' cc programmes.~62~ Given the background outlined above, the stand taken up by the ministry seems to be self-contradictory and in part self-defeating. As such it begs to be better understood. Some insight may be gained from looking at the ministry's policies and tactics throughout the debate on the Act and not only on cc. The ministry's reactions were characterised by the following: 1 Living with the existing system. At times the minister and his secretary outdid the case: for example they praised the Board of Control for its activities despite the mounting criticism against it and the decision by the ministry to abolish it. Likewise they refrained from agreeing to any critical comment on any component of the existing system. They refused to abolish censorship on voluntary patients' mail despite the knowledge that the system was impractical to operate. (63) 4848 2 Tightening up policy procedures. For example, the ministry pressed for a definition on psychopathy (the second exception to the rule of accepting the RC recommendation).~64~ Similarly it was the ministry which ensured the legislation of more (and more specified) instances of compulsory admissions.(65) 3 Expressing the belief in professional medicine eg the dedesignation of hospitals; the description of ECT as revolutionary treatment (indeed!); adding psychopathy to the list of responsibilities of psychiatrists (see point 4). (66) 4 Bestowing a greater degree ofprofessional power and responsibility on psychiatrists and social workers, regardless of whether members of these professions wanted it. Thus psychiatrists had psychopathy added to their brief despite the fact that the classification posed considerable diagnostic difficulties and that psychiatrists were unhappy about intervention outcomes. (67) (See Dr. Bennett's comments in the House of Commons.t6$> Dr. Bennett was one of the two MP psychiatrists in the House at the time and previously specialised in working with psychopaths). The considerable doubt as to whether psychopathy is a category of mental disturbance(69) was not raised in the Commons, but only in the Lords.(?°) Qualified psychiatric social workers were unhappy about their role in sectioning on grounds of professional ethicsP 1) This position was not even mentioned in Parliament. At the same time the ministry opposed an amendment which called for professionals training for mental welfare ofFcers.~~2> The ministry could do as it pleased because it took its cues from the broad consenus that existed within British psychiatry on the one hand and in the House of Commons on the other hand in endorsing the medical-somatic approach in the field of mental illness. Given the consensus, doubts about the appropriateness of medical intervention in principle were never expressed: queries and disagreement over specific events were voiced after. It should be stressed that the conceptual incompatibility between the medical-somatic model and the community mental health approach and its implication to practice were never discussed in Parliament On the contrary the two models were presented as complementary parts of one model, which is precisely how they have been portrayed in British psychiatry. It was never mentioned that while community mental health accepted medical-somatic intervention as one possibility the medical-somatic model rejected the main tenets of the first approach. Such a presentation nullified any doubts about the validity of the medical-somatic approach and implied that there was no need for fundamental changes in the roles and functions of psychiatrists; in the relationships with other related professionals; with patients and the community. This consensus fits well with the description of the fifties as a period lacking in major political battles between the two parties over home policies. It can easily be understood how it would appeal to successive governments (in particular to Conservative ones) not to accept any explanation which ties mental disorder to forces within the existing social order, be they overstress or achievement and lack of emotional expression in the family, belonging to a minority group or to the working class. The medical-somatic model does not involve any questioning of the existing social order and structure; it simply does not see them as relevant to understanding people who suffer from mental illness. Instead it focuses on individual pathology caused by factors beyond the person's and society's control. The consensus allowed the minister to claim that 'I yield to none in my desire for the steady progress and gathering acceleration of the local authority mental health services'{73), while doing nothing about implementing community services. As mentioned above, the unsatisfactory state of affairs of permissive legislation and its impact on cc was known to those interested in the field. Several MPs were among the campaigners for CMH, mainly Labour ones. They expressed clearly their opposition to 4949 this aspect of the legislation: 'It is a most unhappy coincidence that the idea of putting these new responsibilities on the local authorities should come at a time when the government is deciding to cut down the central grants to local authorities, because I feel that there is no hope whatsoever that the local authorities will carry out these recommendations in the spirit in which the RC made them unless they are given considerable encouragement, including financial encouragement, by the central government,.(74) Yet they shared the ministry's baseline of beliefs about mental illness. (75) Likewise they saw the 1959 Act as a very progressive one. Exchanges between the minister and the opposition in the debate were punctuated by mutual and self-congratulating phrases. (76) Such a tone does not go well with a determined opposition to a major part of a new bill. Similarly there were no protests from the Royal College of Psychiatry, the BMA, the Guild of Psychiatric Social Workers or the College of Nursing against the government's s method of implementing community care. The government's pragmatic approach is exemplified in the refusal to abolish censorship on voluntary patients' mail, the rejection of MWO (Mental Welfare Officers) training; acceptance of professional opinions yet forgoing these when it suited the government, encouraging a laissez-faire attitude of local authorities and AHA towards community care; opting for the financially more expensive policy in part out of refusal to reconsider seriously its options. MPs pragmatism is evident in fighting for minor points but not mounting the same effort on major issues of policy. (eg Mr. Dodds fought and won the case for paying patients in cash for work rather than in kind. )(771 Left totally at the pragmatic level and at the discretion of each local authority nearly everything could be read into the 'community care' element of the 1959 Act. The BMA and the Royal College of Psychiatrists could read into it the perpetuation of their view and of doctors' hegemony in the field. The supporters of the community mental health school could see it as a victory for their approach as long as they were ready to overlook its incompatibility with a medical-somatic approach, the snag about the permissive nature of local authorities' duties, the snag of lack of government's active contribution. Into the 80 s The fascinating variety of projects in community-based services for the mentally ill that followed the 1959 Acti78~ indicated the readiness and potential for change in the existing care system. The variations in the scope and quality of services offered among different local authorities deepened, partly as the result of the innovations that took place unevenly. Major obstacles were repeatedly reported throughout the country; these included difficulties in achieving team work, quality and quantity of residential accommodation, lack of sheltered employment, isolation and deterioration after a short stay in the community. Findings on the depressing quality of life of ex-patients started to come out in the seventies. (79) This aspect did not figure at all in the 1963 policy paper on community care, and is of no concern within the framework of the medical model (even though_ it may be of ethical concern to individual doctors). A number of the above-mentioned difficulties are hardly surprising in the context of continuing to work within the medical-somatic framework, yet hoping to achieve community mental health goals. Team work cannot be achieved when the hierarchical inter-professional relations typical of hospital settings are transferred to community-based services. Rehabilitation of patients will stay a low priority as long as chemotherapy is the most prestigious treatment. Shortage of residential accommodation for ex-patients will continue as long as local authorities are aware that community services for the mentally ill hardly receive support or attention from the central government. The ambiguities legislated 5050 into the work of the tribunals have emerged in terms of the weaknesses of tribunals as tools in defending patients' rights. (80) Doubts about the diagnostic validity of psychopathy and the value of conventional psychiatric intervention in such cases have, if anything, increased in the seventies.~8l~ In addition, it was realised that good CMH programmes are not as inexpensive as they were expected to be.~82} Yet the current available evidence still points to a lower initial investment in setting up CMH schemes and subsequent cost. (See for example the difference in cost of a hospital bed per week in 1978: £81 and that of a hostel place: £41.) (83) The use made of para-professionals in many such projects renders them less costly than if only qualified personnel would have been involved. Often cc services rely on other community resources and on the families of ex-patients, two components which are difficult to budget for in a precise way. The degree of burden put on families and the danger of `ghettoisation' of ex-patients in CMH centres'are two main issues which have to be looked at closely.(84) ' The only new model to emerge during the 1959-1980 period was the anti-psychiatry approach. (85) The anti-psychiatry movement reached its popularity peak around 1968, not unrelated to the politics of that year. In both the US and Britain it was more accepted by the young, nonprofessional people (including ex-patients) than within professional circles. The condemnation of the role of most professionals by the anti-psychiatry approach and its political message were the main reasons for its outright rejection by the majority of the profes$ionals in the field. The objection the anti-psychiatry school took to the western style of family life and to the traditional positive view of social conformity were additional reasons for the unacceptability of this approach to the establishment, including the ministry. Like psychoanalysis, this approach too did not concern itself with social policy alternatives within the existing social structure. As this article focuses on the fifties a presentation of the anti-psychiatry model and the evidence for and against this approach is beyond its scope. It should be remembered that this approach differs considerably from both the medical-somatic and the CMH models, though it shares some elements with the second and none with the first. It certainly was connected to the sociological studies which cast doubt on the validity and reliability of psychiatric diagnosis.~g6~ It seems that the provocative message of the anti-psychiatry approach led to very interesting spinoffs outside Britain rather than inside it, notably the dramatic changes in the Italian psychiatric scene.(81) It therefore seems that the two prominent approaches in 1959 have stayed in the eighties as social policy alternatives. Several white and green papers have been published during the seventies on mental illness, the most recent of which appeared in November 1981. Do they offer an alternative to the existing situation? The first white paper (Better Services for the Mentally Ill) was written from the viewpoint of a gradual implementation of a community care perspective. The main recommendations of the paper did not call for investment of additional money but for the reallocation of sums already made available within the psychiatric sector. (88) Significantly the second white paper (Review of the 1959 Act) carried only one reference to the first paper and refrains from suggesting positive initiatives in the field of community care. BASW (British Association of Social Workers) came up with a suggestion to have community care orders. This initiative was put in such a qualified way that the negative reaction of the ministry was made easy to guess.(89) Nearly all of the proposed changes in legislation of the 1978 white paper have been endorsed in the November 1981 paper. Most of the 1978 amendments are repetitions of amendments suggested by Labour MPs in 195 9 (for example: abolition of censorship 5151 on voluntary patients' mail; annual reviews of compulsory admissions by the tribunals; qualification of social workers). The only radical measure in the 1978 paper was the suggestion to have a panel of professional and lay people endowed with the authority to reach final decisions on irreversible interventions (ie psycho-surgery, ECT*). The 1981 paper, however, renders this measure toothless by restating that only doctors will be able to evaluate other doctors' decisions. 'Care in the Community' the 1981 green paper is the only ministerial paper to be concerned with methods of financing community services. It suggests means of transferring resources from AHA to local authority in exchange for community services created by the latter. Its authors assume that such transactions will be maintained only for an initial period. In the current economic climate such an assumption amounts to a disincentive for local authorities to initiate any new services. In real terms the number of residential places for the mentally ill was reduced between 1974 and 1977, from 5,922 places to 5,299.~9°~ Out of£20.9 millions spent on research on illness and health only 2.4 (11 per cent) went into psychiatric research.(91) These reductions took place prior to the massive cuts in local authorities' expenditure. Services for the mentally ill provide a docile target for the implementation of further cuts. Thus there is no visible change in the attitude of successive governments towards community care between 1959 and 1981. Has the orientation of British psychiatry changed since 1959? Clare, writing in 1976, suggested that four orientations are prevalent within British psychiatry: 'organic'; 'psychotherapeutic'; 'sociotherapeutic'; and 'behavioural modification'.~9z~ However he omits to tell us which of these categories is favoured by the majority or by a minority within the profession. Clare claims that British psychiatry is eclectic and 'over the past thirty years British psychiatry prided itself on its freedom from a particular ideological bias' (ibid., p5 3). Pallis and Stoffelmayer~93~ have demonstrated on a small sample that the preference for the organic orientation goes together with a high degree of conservatism. This finding will not surprise those ready to accept connections between professional and personal beliefs but it contradicts Clare's claim made above. Goldie~94> interviewed psychiatrists in a well known teaching institute (and one which does not necessarily represent the majority of British psychiatrists). Most of the interviewees seem to adhere to an inconsistent collection of beliefs in which eclecticism is' indeed the hallmark. Yet when it came to their practice they acknowledged their heavy reliance on chemotherapy. Indeed a look at current practice of psychiatry in Britain shows a very high use of chemotherapy and relatively little of any other type of intervention methods - ie the unquestioned organic approach is still prominent. Clare wrote that `the apparent failure of physical methods of treatment, as evidenced by the high rates of admission and readmission to hospitals was also employed as an argument to illustrate the demand for psychotherapy'. (95) This suggestion is ruled out by him on grounds of lack of psychotherapists by quoting Wing & Wing'S(96) comments on services in Camberwell. However, the huge financial investment into chemotherapy is neither questioned by Clare nor are its implications for scarcity of other methods of intervention ever considered. The fact that there is a diversity in the minority's beliefs implies a double message: 1. A continuous implicit debate is taking place. 2. The pressure power of each of these groupings cannot be strong because of their fragmentation. Interesting beginnings have been made during the seventies in outlining some of the main issues of the debate on CMH and on the role of psychiatry.~g7y "One wonders if this proposal is an indirect outcome of the impact of rethinking in the wake of the anu-psychiatry approach. 5252 Has there been a change in public attitudes towards the mentally ill? On the basis of the meagre research evidence available it would seem that there has not: the attitude is characterised by sympathy and pity, use of the mentally ill as symbols of modem man's s state in the arts(98) and primarily indifference when it comes to action.~99~ Past experience indicates that it is up to the professionals involved to initiate a debate into the options of social policy available to us. Unless put under heavy pressure successive governments seem to prefer the status quo in an area as uncertain and potentially threatening as mental illness. The mentally ill and their family members are a weak social group and cannot be expected to act as a sufficiently strong pressure group. Mind has been a prime mover in the debate but it too relies to a very great extent on professional support. So far lawyers - rather than members of the 'helping professions' - have been at the forefront of the policy change lobby. While civil rights of the mentally ill are worth fighting for, they do not compensate for the lack of a comprehensive service system. 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The Logic of Pragmatism in Mental Health Policy

The Logic of Pragmatism in Mental Health Policy

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