Comments on the vacuum in Social Care Since the 1959 Mental Health Act: Then and Now
Having unexpectedly arrived well into my ‘eighties,’ it seems timely to reflect on my personal experience of the mental health arena, past and present.
In May 1959, when I opened the doors of Lancaster Lodge, Richmond, it was with the aim of providing a place which would nurture and respect people who had nowhere decent to go on leaving mental hospital. Yet, what seemed to me to be an obvious response to need, did not commend itself to those from whom support might have been expected and I found that not a soul was willing to back me.
For a start, I was a foreigner whose credentials were highly suspect! I was a Divinity student from Holland who had come equipped “merely” with three years’ relevant training (and – more important – three years practical work, mostly as leader/carer of a group of adolescents, and as the so-called practical work supervisor of the 1st year Psychology students) at the Paedologisch Instituut of the Free University (Amsterdam). Following this I had completed a three year nursing training which was accepted in the U.K. and which qualified me as a State Registered Nurse. This was in addition to the experience gained through the stresses endured by my whole family during the War years! I learned to cope with the constant dangers of Nazi-occupied Holland, and to assist my mother in finding the means of survival not only for her nine children but also for a succession of illegal refugees from Germany and from the Dutch west coast.
Furthermore, in 1959 it was considered dangerous and irresponsible to create, in an ordinary house in an ordinary street, a Therapeutic Community for people who had been “Inmates” in mental hospitals. For a number of years, TCs had in fact existed in an army unit for traumatised soldiers and as specialised units in a number of mental hospitals, but even there they were often looked on with suspicion or scorn by other staff, who considered it “asking for trouble” to employ democracy and peer support with patients who were considered incapable of understanding and supporting one another.
And, of course, my project was not plain sailing, and that first year in Richmond was full of challenges. My fellow house-mates – some of whom had been discharged by the Cassel Hospital as “unsuitable for treatment”- came with strong dependency needs and, in some instances, with well-developed powers of manipulation! Our initial group meetings were focussed on me, and I came under pressure to accept the role of mother, nurse, cleaner, bread-winner – even mistress. It took several months and some tremulous perseverance on my part, before we had formulated, and agreed, a workable way of living together and of respecting boundaries, with the aim of enabling the recovery and independence of each person. All of which was a challenge and a steep learning curve for myself, as well as for my house mates.
However, having sat in on the debates in Parliament on what was then the Mental Health Bill 1959, I saw the danger of mini-institutions being created. These would tend to be staffed by those who, for want of specialist training would perpetuate patterns of care based on the long-term institutionalised concept of “mental patients” and their needs. Eager to avoid that trap, I chose to start from an assumption of shared “normality”, and from this to explore what was needed on the basis of our common experience. Yet, despite my wish to be on an equal footing with my fellow residents, an important principle emerged quite soon: I could not just be a member of the Community on a par with the others. Although there was amongst the residents a true spirit of care for one another, I was there to provide what others had come to receive, and willy-nilly I had to modify my definitions of my role and input. There was no escape!
Nor was I left in peace by the outside world. I was threatened with deportation when the Home Office (at the request of an organisation with an ostensibly similar remit) questioned my right to set up my small community. The objection raised was that, as a foreign student, I had neither a work permit nor permission to operate a service. I was able, however, to counter this by demonstrating that I had sat my Intermediate Batchelor of Divinity (with excellent results!) and was registered with London University. I had no position or salary for any activities and was merely sharing my home with free citizens who, on leaving mental hospital, had chosen to share my house with me. I conducted my own defence – successfully – and have since found that most issues which tend to be referred to a lawyer can in fact be resolved in person if one takes time to study the details and record them appropriately.
Meanwhile, the experience of the residents’ Psychiatrists, on the basis of their (typically) fifteen-minute monthly sessions, was that their patients showed substantial improvement, and that this appeared to be associated with the process of receiving help from, and of contributing to, the wellbeing of their fellow residents.
From this small and largely informal beginning, a more structured organisation began to be formed. An increasing number of psychiatrists formally referred residents, and the capacity of Lancaster Lodge, plus the surrounding flats which I had rented, could not accommodate more people. Fortunately, Surrey Local Authority promised 50 % funding for an additional building which was eventually found in East Molesey. As the Organisation grew, we held senior staff meetings to articulate and to commit to paper the principles and practice of our group life.
The evident benefits of the carefully debated and designed T.C. with its clear principles, practices and boundaries, became widely recognised, and resulted in a demand for such a resource from many parts of the UK. Subsequently demand grew from other developed countries, and also from countries whose mental health services were either non-existent or at a very primitive stage. The WHO requested a handbook that could be universally accepted and before the seventies a comprehensive manual existed that did not provide precepts so much as concepts.
The extension of therapeutic provision overseas naturally involved a whole new stage of this work. In each country a reliable and capable Board of Trustees needed to be appointed, and positive relationships built up with Governments, universities, churches and secular bodies. Prospective Managing Directors needed to be identified, who would then train in the UK – a training designed to enable them to translate their newly acquired expertise to their own country and culture. It was doubtless due to the fact that the time was ripe for the TC model – which recognises the potential in people to respond to being valued and validated – that this model became quickly recognised for its universal effectiveness and relevance. Such was the level of support, both from Governments and the community, that there now exists a worldwide group of Affiliates and Associates who have ongoing professional links as well as affectionate personal bonds with many of us in “ the old country.”
In 1959 – our first year of operation – I started our training function by organising a monthly meeting between clergy and doctors to explore mental health issues, and especially to consider how to be pro-active and how to respond to crisis needs. Our sessions always included our staff and from their participation it became clear that, although the majority came with professional degrees, they needed specific and relevant training in how to provide leadership in the TC, how to understand its group dynamics, and how to create a truly healing community in which members could develop the courage to be open and the ability to become sensitive to the feelings and rights of others. My next step, therefore, was to expand our training activities and, in 1966, to create a College providing enhanced training facilities for our staff, who had already been training on a one day per week basis as part of their employment contract. The College was then able to extend this programme to provide courses for the staff of Local Authorities and Charities, and to launch group dynamics “experiences” – not only for our own staff but also for those in leadership roles in, for example, schools, social services, and the Church. The external training was funded by the bodies involved, but the training of our staff had to be funded by ourselves – an expensive item for our budget, but worth every penny as far as the benefit for residents was concerned. A knock-on effect, of great benefit for the staff, was that they acquired skills which were welcomed widely in Universities and Social Services posts.
THAT WAS THEN; BUT WHAT OF NOW?
Today the papers are full of neglect and abuse of the elderly – which sadly, it appears, continues and worsens despite this publicity. Children have a somewhat better deal and, when they are neglected or ill-treated, the sadness and shame of it never leaves the headlines. But what about mentally ill adults of working age?
They were promised, in the July 1959 Mental Health Act and subsequently, a better deal – better alternatives to the large institutions, relevant care, opportunities to regain a full life – but where are the alternatives and where are the resources? Many are deprived of timely help, and many are at risk, wretched and desperate – not only outside the hospital but also within it, since available funding has been put into other needy parts of the Health Service, leaving precious little for therapy and therapeutic activities. And on leaving hospital (usually still struggling to cope) there are not the means to devote to relevant aftercare resources, and to address the problems that have in the past defeated them. A recurring consequence is the “revolving door” which too often follows discharge, i.e. a speedy re-admission to the hospital ward, which itself is critically short of beds and severely restricted in its resources. This is a pattern which is far more costly than a Therapeutic Care Home which can provide a “bridge” between hospital and community. The well-run therapeutic community has the best means to help those who feel defeated and alienated. It has the potential to restore self-respect and to nurture the ability to enter into a positive relationship with self and others.
However, the problem of lack of relevant care is not just the result of cut-backs: it derives also from short sightedness – a lack of recognition of the most essential elements of relevant intervention, and of planning and co-ordination – usually on the part of Government and of hard-pressed or uninformed Local Authorities. The tragic result is that modestly priced community rehabilitation resources remain underused and/or underfunded whilst those in desperate need are being deprived of relevant help and all too frequently return, again and again, to costly and over-subscribed hospitals, with a lessening of hope at every stage or, alternatively, giving up the struggle altogether.
Elly Jansen founded the Richmond Fellowship in 1959 and directed it for 32 years. The fellowship is now one of the largest voluntary sector providers of mental health support services in England.
You can find more information about the fellowship here