In 1970 there were four wards in Fulbourn functioning as therapeutic communities and proudly boasting of it. In 1982 the BBC came to Fulbourn and made a film about the therapeutic community in Burnet House. By 1990 there was no ward left in Fulbourn which called itself a therapeutic community. From a peak in the late 1960s the number of therapeutic communities in British psychiatric hospitals steadily declined until by the 1990s most therapeutic communities in England were in probation hostels, halfway houses, residential homes and so on not within the National Health Service. How did this change come about and why?
Within Fulbourn, a number of reasons can be seen for the decline of the therapeutic community in its original form. The group that benefited most from the therapeutic communities were the patients (and staff) trapped in long-stay wards. By 1980 most of those patients had left hospital. Quite a few of the practices of the therapeutic community were by now accepted as normal in Fulbourn mixed-sex wards, no staff uniforms, ward meetings, staff discussion groups and open and free discussion between professions. There was plenty of encouragement for patients to help each other and to talk openly with staff, as well as active involvement of and discussion with relatives of patients. However, some of the more unusual experiments of the seventies, such as the Doctors Sensitivity Meeting on Fridays (with its egalitarian sharing), the Hospital Innovation project and the culture of growth, had disappeared. The doctors meeting stopped in the late seventies with the development of academic psychiatry. Several of the therapeutic community wards stopped working in that mode; others stopped using the term. By 1990 there were only two wards in Fulbourn Hospital still operating as therapeutic communities Burnet House and Street Ward and in both of these the meetings consisted of patients and nurses only; the ward doctors seldom attended, the consultants never. There are, however, two therapeutic communities still operating in the Cambridge area Winston House and Glebe House (a facility for disturbed adolescents) and there are many operating in Britain and overseas.
This retreat from therapeutic community work was seen throughout British psychiatry. During the 1960s therapeutic communities had started in many psychiatric hospitals; Henderson, Claybury, Littlemore, Fulbourn, Dingleton and Ingrebourne became well known. In the 1980s therapeutic community wards stopped operating, units were closed, hospitals famous for being committed to therapeutic community principles, such as Claybury, dwindled in size and ultimately were being closed down.
The causes of this change have been much debated and different views prevail. In my opinion the root cause is the incompatibility of an egalitarian, democratic ward culture with the authoritarian, bureaucratic organisation which the National Health Service has gradually become. A therapeutic community is an excellent system in which troubled people can come to understand and modify their disturbed and disturbing behaviour. It works well when it meets a major social need and has a flexible management to support it. But it does make great demands on the staff and often causes difficulties and embarrassments for managers. In the 1950s the NHS was a new organisation keen to find new ways of handling ancient problems such as the awful old county asylums. Experiments were applauded and supported. Money was forthcoming for funding new ideas and departments and to improve conditions for patients and staff. At Fulbourn we were fortunate to have an effective and supportive Hospital Management Committee led by flexible, far-sighted Chairmen (especially Lady Adrian and Pauline Burnet) who were prepared to back our experiments, and more important, to speak up for us when things went wrong.
By the 1990s the NHS was a beleaguered, battered and demoralised organisation, starved of funds and under criticism from a government devoted to market economics and private medicine. NHS hospitals were now run by managers who were under constant pressure from Central Government to save money, cut costs and to keep things generally under tight control. Most of their time and energy was given to general hospitals which had a clear traditional social structure of doctors doing their skilled work, nurses assisting and organising, and patients lying passively in bed awaiting cure. A unit where patients make decisions, where disorder is apparent and from which unacceptable demands may come, perplexes and angers tidy-minded and harrassed managers so that they readily support demands for enquiries, disciplinary action and closure.
Basic premises of the therapeutic community are the abolition of hierarchy and authority, the establishment of all contributions as equally valid, the tolerance of open confrontation and challenge, and the acknowledgement of patients responsibility for their own lives and for the running of their wards. These have proved unacceptable in a National Health Service where power and authority is statutorily entrenched with administrators, consultant doctors and senior nurses and where patients are usually treated as passive, incompetent, ignorant people whose only task is to await the attention, skill and compassion of those paid to look after them.
During the 1990s too, British psychiatry has moved away from an interest in social therapy. With a wider range of new drugs available, many young psychiatrists concentrate on improving their skill in diagnosing, assessing symptoms, prescribing drugs and monitoring side effects. They tend to ignore what goes on around them and their patients in the psychiatric ward. Psychoanalysts and psychotherapists have withdrawn into their consulting room and the one-doctor, one-patient situation. Both groups say they are doing this because it is good for their patients but it also removes them from the open challenge of a ward meeting. The insecure and inadequate doctor feels far safer in a white coat examining a half-naked patient with a stethoscope or in a comfortable armchair out of sight behind the psychoanalytic couch, than working in an environment where he would be open to scrutiny and criticism by patients and nursing staff.
The phrase Therapeutic Community was coined by a psychiatrist, Tom Main, and developed by another, Maxwell Jones. These communities are one of the most effective ways of helping people in residential institutions who show disturbed and disturbing behaviour, but who are fairly competent socially and have a capacity to develop insight. In a therapeutic community they can explore themselves, reach a greater understanding, change and grow. Therapeutic communities work well in adolescent units, rehabilitation hostels, probation hostels and units for drug addicts. It may be that future social historians will see it as accidental that therapeutic communities were first developed by psychiatrists, and that for a time, in the sixties, they flourished in some of the old mental hospitals during their final decades.
During the 1970s I came to realise that the vitality of a therapeutic culture derived from the people in it junior nurses, occupational therapists, young doctors, social workers, porters and nursing assistants and, of course, the patients themselves. It was their attitudes that determined whether a persons stay in hospital was a time of change, growth and progress or whether it was a time of defeat, shame, misery, degradation and brutality, as was common in the old custodial hospitals and in jails and security hospitals. The task of senior officers like myself, the power holders in the organisation, was supportive creating an atmosphere where hope could develop. This support was, however, essential since bureaucratic forces would always be pushing for economy, stasis and predictability, forever stifling personal growth, initiative and risk taking.
By the early 1980s, we were fairly clear in Fulbourn what we meant by Social Therapy. The basic premise was that of the Moral Treatment pioneers the belief that the way that patients lived in a mental hospital was a potent factor in deciding whether they progressed, became better and took their discharge or whether they sank into stultified, resentful chronicity. By now, however, we had the advantage of the insights of social science research. We had learned how damaging many of the traditional practices of the asylum were, even when they had been adopted for the best of motives. The official practices (such as the locking of doors, constant oppressive security, continual counting of people, cutlery, bed linen and so on) were bad enough, but far worse were the unofficial happenings the beating up, the garrotting, the use of padded cells and ECT as punishments, the occasional killing. Social science studies had helped us to discover for ourselves the value of open doors and open communication which made everything public and open to scrutiny. We had become aware of the malignant effects of a punitive, fault-finding authority structure on the altruism and enterprise of nursing staff. This had led us to adopt open community methods and consensus decision-making, giving staff the freedom to challenge and change obstructive management. We had become aware of the social gulf between the stifling, though supportive, cocoon of the asylum and the frightening world outside it and the consequent need for transitional facilities of every kind. By 1980 we still retained our original triad of aims Freedom, Activity and Responsibility but we had now added to it Rehabilitation and Personal Growth. We had realised that these were important for everyone in the hospital community possibly even more for the staff than the patients.
In retrospect the development of Fulbourns Social Therapy can be seen to fall into three separate phases, each a response to a particular problem and each leaving certain permanent lessons. The first phase, the Open Doors campaign of the 1950s, had the effect of changing the stultifyingly custodial, therapeutically nihilistic pattern of the first century of the asylum. It created in Fulbourn an open, humane, liberal way of life. By the 1980s similar changes had taken place in most British mental hospitals, but it is worth remembering that this has still not happened world-wide. As I learned during my travels, the majority of mentally disordered people in the world are still locked up, confined in impoverished idleness and often brutally treated. The value of the Open Door Hospital is still not appreciated yet in many countries.
The second phase was that of the Therapeutic Community, during the 1960s and 1970s. We tried out the revolutionary ideas of Maxwell Jones and found they were very successful with long-stay active patients, nearly all of whom were able to leave hospital. It taught us to value the contributions of all the people who worked with patients and showed us the immense power of social forces in the life of the ward. Though it remains a valuable ideal, it has not remained part of Fulbourn Hospital. This was partly because its success removed many of the problems; the patients capable of self-government mostly left the hospital. But the hostility of powerful senior doctors to a system that devalued their expertise and challenged their power worked against it and the National Health Service Bureaucracy of the 1990s, with its emphasis on business management, strict economy, and answerability upward could not tolerate a system so challenging, so revolutionary and so irregular. Enthusiasm and hope do not appear in accounting systems. There were still flourishing therapeutic communities in Britain in the early 1990s but they were mostly in small residential units not tied into any major accountable bureaucracy halfway houses, probation hostels, Concept Houses, Richmond Fellowship houses. In them Maxwell Jones ideas of equality, confrontation, reality testing and a systems approach are still valued.
The third phase was that of the Rehabilitation Service, which started in the 1970s and developed fully in the 1980s. We had moved most of our long-term patients out of hospital into group homes, halfway houses, sheltered accommodation and so on. We were visiting and supporting them there. We had developed an effective system of Care in the Community long before it became official government policy. But the Cambridge Psychiatric Rehabilitation Service developed its own principles based on our previous 30 years work. We emphasised lifetime support, individual, skilled help for patients and transitional facilities but the Cambridge Service also retained many of the beliefs established in the therapeutic community period. These included the idea that clients should make their own choices of where to live and what to do; that entry to hospital and exit from it should be flexible and sensitive to individual needs; that transfer of patients between wards should be fully explored by discussion with all concerned; that all patients were capable of some progress.
It is these attitudes that made the Cambridge Psychiatric Rehabilitation Service different from some which rely on depot injections, constant surveillance, and the use of legal methods of control.
When I finished writing this account of my time at Fulbourn I felt there were some questions to be answered, such as Was Fulbourn unusual in what it did?, Were the results we achieved really so very different from those of other mental hospitals at that time (who were also emptying their back wards, changing their functions and finally withering away in the 1990s)? and Has the old mental hospital and its story any relevance to the work and challenges to British psychiatry in the twenty-first century? What follows is my attempt to answer these questions. The passage of time will prove whether I am right or wrong, but for what they are worth, these are my conclusions.
WHY AT FULBOURN AND WHY THEN?
There were several reasons why there was such a ferment of activity at Fulbourn Hospital in the 1950s. Fulbourn in 1953 was demoralised; for 30 years (192353) nothing much had happened there at a time when other psychiatric hospitals were actively adopting the new methods of treatment. By 1953 Fulbourn Hospital was dilapidated, grossly overcrowded and understaffed in a worse state than most other county asylums. The staff were looking for a new lead. There had been paralysis higher up; the old Visitors Committee had been disbanded in 1948 and Fulbourn placed under the Committee for Newmarket Hospital. It was only in 1951 that a new Management Committee was set up headed by Mrs Adrian. Next, I was appointed as Superintendent and brought two useful personal characteristics with me a passionate desire to do something better for the long-stay patients, and the brash over-confidence of youth and inexperience. The fact that I had never before worked in an English County Asylum turned out to be an advantage (though I did not feel it to be so at the time). What mattered for the staff and the hospital was that I had youth, energy and apparent confidence. Because I cared about the long-stay patients, it became possible for the rest of the staff to start caring about them too and then begin doing new things. Their leadership came from the combination of a new Management Committee led by an energetic reformer, Mrs Adrian, a young enthusiastic Superintendent and a Regional Board prepared to spend money and back experiments. All this happened at a time when mental hospitals were on the brink of change because English society as a whole wanted authoritarian institutions to become more liberal.
For these reasons the changes at Fulbourn happened fast. In 1950 all the ward doors of Fulbourn were locked, as they had been for 92 years. By 1958 they were all open. Was the speed and degree of change at Fulbourn unique? Nearly so, I believe. In 1953 three other British hospitals were already Open Door (Dingleton, Mapperley and Warlingham) and others were soon to be. But few changed as fast as Fulbourn. Dingleton, Mapperley and Warlingham all had Superintendents personally committed to patient freedom, but Bell, McMillan and Rees had all been in charge of their hospitals for years, since the war, and had prepared for Open Doors slowly.
It was only in a few hospitals that the conjunction of a hospital ready to change and a Superintendent who wanted to change things quickly coincided so happily as at Fulbourn. Many senior psychiatrists in the fifties had other priorities research, psychotherapy, physical treatments; many lacked the energy or the resolve to push for changes and were defeated by the inertia of staff wedded to the old ways and reluctant to change. In some hospitals strong senior nursing figures and a strongly entrenched custodial culture amongst the nurses delayed the changes.
WHAT WAS ACHIEVED?
What did the Fulbourn revolution achieve? Most importantly in the 1950s, it improved the life of the long-stay patients immensely; from being locked up in squalid congestion, they were allowed a lifestyle providing more freedom and dignity. In the sixties these patients began to move out of hospital and with the aid of Winston House, the group homes and the rehabilitation programme many achieved and maintained good, independent lives despite their continuing psychological disabilities. When I meet my former patients in the streets of Cambridge many still express gratitude at being delivered from their confinement in the 1950s.
During the 1970s and 1980s tens of thousands of long-term patients were discharged from mental hospitals in England and the USA. Did we carry out this process at Fulbourn better than other places? I think we did. Many hospitals emptied the wards too quickly, with inadequate support facilities. We took longer over the process. We set up a wider range of transitional facilities. We prepared people carefully for discharge. We supported them in the community. We certainly had remarkably few episodes of suicide, social breakdown or public disaster over the years while we were opening the doors. The people of Cambridge, even the people of our two neighbouring villages of Cherryhinton and Fulbourn, welcomed the change and were proud of what their local institution had done for a pathetic group of people. Even in the 1990s I often meet people who recall with pleasure and pride how their asylum changed in the 1950s and 1960s.
Another group of people who benefited from the Fulbourn Social Revolution were the staff, particularly the long-stay nursing staff. For most of them work in the locked asylum had been a dispiriting job in a place of which they were ashamed, only alleviated by the cricket, the staff club and the early pension. After the changes they took pride in their hospital and the public and professional admiration it received. They found their work more challenging and interesting, and most important, they found the relationship with their patients radically changed. As one said Im glad the keys have gone. Before I felt like a gaoler. The patients saw me as the man who locked them up. Now they see me as a friend. All these changes have lasted. In Cambridge and in the general hospital psychiatric units throughout Britain there are nurses and other staff who spent time working at Fulbourn. There they learned a way of relating to disturbed, unhappy people which makes them more effective as staff than those trained in traditional ways.
IS SOCIAL THERAPY RELEVANT ANY MORE?
Those of us who changed and opened psychiatric hospitals in the 1950s learned about Social Therapy on the job. First we rediscovered the principles of early nineteenth-century care for the mentally ill the principles called moral management by Tuke, Pinel, Conolly and others. The founders of humane asylum management asserted that wards should be small, home-like and friendly; that there should be plenty of activity both work and play for the patients; that staff should work with the rational and responsible part of the disordered person and ignore or minimise the irrational; that coercion and restraint should be minimal; that there should be no violence, brutality, oppression or degradation. We relearned all those lessons in the fifties. Then, applying the findings of the twentieth-century social scientists, we took our ideas further. We developed transitional facilities, halfway houses, group homes, sheltered accommodation. We set up sheltered workshops and industrial units and organised supportive rehabilitation using networks of social workers, community psychiatric nurses and community occupational therapists, and so on. We then went even further and experimented with the social structure of the hospital ward, developing self-governing wards and finally therapeutic communities.
Is any of what we learned and taught still relevant? I believe most of it is. Some of the effects of the social revolution in postwar British psychiatry remain and will I believe be permanent. Psychiatric nurses today see their main tasks as listening to patients, counselling them and understanding them. They know they do this best in a supportive, friendly humane culture. Most British psychiatric wards and units are now Open Door. In many units nurses, patients and creative therapists meet in groups and in ward meetings. This is a far cry from the psychiatric nursing culture of the forties with its emphasis on order, uniforms, discipline and its undertone of brutal oppression.
The care of people with long-term psychiatric disability in England has changed utterly. Very few of them are now in hospital wards. Many live in the community, with their families or in sheltered accommodation. They attend day centres and workshops and are supported by teams of social workers and community nurses. We have created in Britain a framework of Psychiatric Rehabilitation and a range of trained professionals to support it. It is true that this framework sometimes fails, particularly in the big cities where people with chronic mental illness live as tramps, finding their food in garbage dumps and sleeping in cardboard boxes. But these are the exceptions. Most long-term mentally ill people in Britain now live good lives out in the community.
It is fashionable in the 1990s for some mental health activists, when criticising the shortcomings of the present care in the community system, to speak nostalgically about the advantages of the old asylum. I feel these people should talk to those who worked, or worse, were imprisoned, in the old county asylums. Although people may sometimes reminisce about good things which happened in the old days, I have never heard a former patient express a wish to be back in one of the old locked wards.
Major principles of Social Therapy were that when people are gathered in an institution the way that they live and interact is more important for their welfare and recovery than any individual attention they may receive; that it is more important to work with the whole institution than with the individual; that attention must be paid to the beliefs held by the staff and the patients and to what they do to one another.
It was these principles that led us to open the doors and to introduce activity, freedom, responsibility, rehabilitation and choice into the life of the patients and the staff at Fulbourn Hospital. In following these principles we constantly looked at what we were all doing and how we interacted with each other. That, in turn, led us to set up discussion groups, ward meetings, sensitivity groups and to examine constantly our patterns of authority and responsibility.
Has this all been forgotten? Some psychiatrists believe and indeed, hope so. Although they welcome a more humane atmosphere in their wards they do not believe that such an atmosphere is really important. They do not realise that by retreating to authority-based positions and refusing to look at what really happens on their wards, they are in danger of sliding into a repressive culture as bad as that of the old asylums.
A malignant trend in English society in the 1990s is the growth in the number of gaols and secure institutions. England has the dubious distinction of having a higher proportion of its citizens locked up than any other European country. The secure hospitals Broadmoor, Rampton, Ashdown are now being refurbished and extended. Regional Secure Units are being created and developed and enlarged. There is pressure from frightened managers and uncaring psychiatrists to lock up wards again. All the melancholy patterns of institutional oppression which created the old asylum culture is being repeated. The conditions that created the need for Social Therapy in asylums are being set up again in gaols, secure institutions and locked wards.
Wherever society locks up people it dislikes and pays other people to keep them in, an oppressive and cruel culture is likely to develop. If society designates these prisoners insane and hires doctors and nurses as gaolers, they will create the same medicalised, hypocritical gaol culture as in the old asylums. British secure hospitals are racked by scandals which reveal all the old patterns of staff brutality, corruption and medical tyranny. The Secure Units and locked wards are growing in number and size and it will not be long before scandals erupt in them. So all the patterns of the old country asylums will be created again and a Social Therapy Revolution may once again be necessary.
Social Therapy its lessons and its methods will always be relevant wherever people considered mentally disordered are gathered into residential institutions and doctors and nurses are hired to care for them. The choice for doctors and nurses is not whether or not to practice social therapy. The choice is to do bad social therapy by default or to do good social therapy by active attention to the social structure of the institution. If the staff do not attend to what goes on on the ward, malignant social therapy is occurring by default. Locked doors, over-medication, oppressive custodial nursing practices will lead to staff brutality and squalid deaths in cells and side rooms. After a few years of this we shall once again see the crowds of apathetic people locked into resentful institutional dependence that characterised the worst of the old asylum. It will then become necessary to rediscover the methods of positive Social Therapy to lead the imprisoned people once again to independence and human dignity.
The Human Nature Review © Ian Pitchford and Robert M. Young - Last updated: 28 May, 2005 02:29 PM