Chapter
Three – The Emergence of Therapeutic
Communities and Community Mental Health –
History, Types and Significance
OVERVIEW
This chapter provides a background to my research into Neville’s
pioneering of therapeutic communities and community mental health in
THE EMERGENCE OF POPULAR/FOLK AND
SCIENTIFIC MODELS
Throughout human history there have been popular/folk models
about mental malfunction based upon culturally derived belief systems (Engel 1977). Prior to the Twentieth Century, in the United Kingdom, the
United States of America and other places, individuals with mental
malfunctioning experienced harsh inhumane treatment (Roberts 2005a; Roberts 2005b). Physical and mental
abuse was commonplace. There was wide use of straight jackets and heavy arm and
leg iron bands and chains (Roberts 2005a; Roberts 2005b). Kennard writes of what was called as early as 1796 ‘moral
therapy’ as an early precursor to notions of therapeutic community (2004, p. 298):
The application of therapeutic
community principles to work with the chronic
mentally ill is, in many ways, the closest version of therapeutic community modality to one of its most important predecessors, Moral Treatment.
This was the term used to describe a model of care first developed in 1796 by
the Quaker William Tuke at The Retreat in York (Tuke 1813; Borthwick
A., Holman C. et al. 2001).
In keeping with Quaker ideology, the mentally ill were
accorded the status of equal human beings to be treated with gentleness,
humanity and respect. This was quite revolutionary at the time, and The Retreat
also gave priority to the value of personal relationships as a healing
influence, to the importance of useful occupation, and to the quality of the
physical environment. Much of this early vision of a humane treatment for
mental illness was lost as the 19th century progressed and the mentally ill
were housed in increasingly large and impersonal asylums (Kennard 2004, p. 298).
In
What he observed was a strict non-violent,
non-medical management of mental patients came to be called ‘moral treatment’
though ‘psychological’ might be a more accurate translation of the French
‘moral’ (2005).
Notwithstanding the ‘humaneness’ of the approach, Pinel
condoned the use of threats and chains when other means failed (Dr. Grohol's Psych Central 2005).
Moral
treatment was also used by Sir William and Lady Ellis in
the 1900s (History of
Occupational Therapy in Mental Health 2005) who came
to be in charge of England's county asylums. Under the Ellis’, asylums as ‘community’ had a family atmosphere and the
men and women were encouraged to enhance their previous trades or establish new
ones in order to support purposeful activity. Sir and Lady Ellis were able to
prove that the mentally ill were not dangerous with tools, and were far less
dangerous than other unoccupied individuals. The Ellis' were also responsible
for developing the idea of an ‘after care’ house, very similar to the halfway
houses of today. These places functioned as stepping-stones from total care to
limited assistance living care.
The Religious Society of Friends founded
The York Retreat and the
In the later 19th and the early 20th centuries
psychiatry was in the process of seeking links with academic disciplines.
Medicine was doing the same thing (Engel 1977; Bloom 2005). While medicine had been evolving within biological
frameworks, Rudoph Virchow
writing in 1848 wrote that ‘Medicine is a social science’ (Rosen 1974).
Bloom identifies the rise
of biopsychosocial approaches in psychiatry in the 1920’s and traces the
professional links made by psychiatrists to evolve their specialty in the
1920s.
Bloom (2005, p.77) states:
Collaboration
between sociology and psychiatry is traced to the 1920s when, stimulated by
Harry Stack Sullivan and Adolph Meyer, the relationship was activated by common
theoretical and research interests. Immediately after World War II, this became
a true partnership, stimulated by the National Institute of Mental Health, the
Group for the Advancement of Psychiatry, and the growing influence of
psychoanalytic theory.
Bloom continues (2005, p. 81):
One piece of evidence of this development
was the emergence of the new subspecialty of social psychiatry. Initiated in
Colloquiums were held in 1928 and 1929 under the auspices of the American Psychiatric Association Committee on Relations with the Social Sciences. As well as psychiatrists, the colloquium attendees were psychologists, political scientists, anthropologists and sociologists. These two colloquiums helped forged psychiatry’s links with the social sciences.
In the context of this reaching out
to the social sciences and as an indication of the acceptance of psychiatry by
the medical profession in the 1920’s the APA chairperson White stated during
the 1929 Colloquium:
The specialty of psychiatry is
almost universally neglected by medical education (White 1929, p. 136).
Bloom (2005, p81.) quotes Grob
(1991) writing that it was,
…..the triumph of the psychodynamic approach….that
set the stage for the collaboration and cross-fertilization of psychiatry with
the behavioural and social sciences in the 1950s.
The effects of a sociology that focused on issues of health and illness proceeded to grow in medical education, research, and the treatment of mental illness until 1980, when a distinct shift of emphasis in psychiatry occurred.
After the rise of biopsychosocial approaches
in the 1920’s there was a move away from the biopsychosocial
to a biopharmacological model in the 1980’s (Bloom
2005, p. 77):
In
its role as educator of future physicians, post-war psychiatry developed a
paradigm of biopsychosocial behaviour but, after
three decades, changed to a biopharmacological model.
The
definition of mental illness as a deviant extreme in developmental and
interpersonal characteristics lost favour to nosological
diagnoses of discrete or dichotomous models. Under a variety of intellectual,
socio-economic, and political pressures, psychiatry reduced its interest in and
relationship with sociology, replacing it in part with bioethics and economics
(2005, p. 77).
Speaking of the 1950-1970 period Bloom (2005, p. 82)
discusses important changes in psychiatric approach and educational method:
…the focus was on human behaviour,
and the theoretic model was psychodynamic. George Engel, in what he called the biopsychosocial model, gave voice to this point of view
more than any other single voice.
Engel and others argued for both medicine and psychiatry to
be modelled on the biopsychosocial:
To provide a basis for understanding
the determinates of disease and arriving at rational treatments and patterns of
health care, a medical model must also take into account the patient, the
social context in which he lives, and the complementary system devised by society
to deal with the disruptive effects of illness, that is the physician role and
the health care system’s. This requires a biopsychosocial
model’ (1977, p. 32).
Bloom refers to Mechanic (1999) writing of the biopsychosocial being based on
a continuum and the biopharmacological being based on
discrete or dichotomous model. Mechanic
describes two definitions of mental health:
One presented a continuous model of
mental health and illness, the other a discrete or dichotomous model of mental
illness. In the first, mental health and illness are the opposite ends of a
continuum; the second rejects such a continuum, instead fitting a medical model
of specific disease categories with measurable symptoms (Bloom, 1997, p. 78).
Engel makes the point that:
Other factors may combine to sustain
patienthood even in the face of biochemical recovery.
Conspicuously responsible for such discrepancies between correction of
biological abnormalities and treatment outcomes are psychological and social
variables (1977, p.132).
In the Seventies the debate about appropriate models for
both psychiatry and medicine continued. Some argued the medical model is not
relevant to the behavioural and psychological domains.
Disorders directly ascribable to
brain disorder would be taken care of by neurologists, while psychiatry as such
would disappear as a profession (Engel, 1977, p.129).
In the late 1970’s one view of psychiatry
documented by Engel was:
Psychiatry has
become a hodgepodge of unscientific opinions, assorted philosophies and schools
of thought, mixed metaphors, role diffusion, propaganda, and politicking for
‘mental health’ and other esoteric goals (Engel 1977, p. 129).
Today psychiatry has typically maintained a biopharmacological model as a biomedical sub-specialty (Bloom, 2005).
The next section explores what was actually happening to
people suffering mental malfunction since the late 1800s.
NINETEEN AND TWENTIETH CENTURY
PRACTICE
USA
In the Nineteenth Century, the
The publication by Clifford Beers of his expose of his USA experience in
the state asylum system, ‘A Mind That Found Itself’ (1908) had a wide and immediate impact both in America and overseas towards
reforming and humanizing mental health practices. In the same year Beers
founded the Connecticut Society for Mental Hygiene, and the following year
founded the National Committee for Mental Hygiene. This entity merged with others in
the
Early Australian Experience
The
Central Sydney Area Mental Health Service’s (2004) ‘History
of Rozelle Hospital (formerly Callan
Park)’ reports that:
Social deviants were often treated brutally and
alcoholism was rife in the new colony. Governor Bourke in 1820 wrote that ‘a
lunatic asylum is an establishment that can no longer be dispensed with.
The
Australian experience followed that of the
Psychiatry in
·
1788 to
1839 - The Primitive Era. (The Beginnings)
·
1839 to
1860 - The Moral Treatment Era. (The Romantic)
·
1860 to
1945 - The Physical Treatment Era. (The Classical)
·
1945 to
the present day - The Modern Era. (The Revolution in Therapy)
On 1 July, 1876, Manning was
appointed by the Colonial Government as the Inspector of the Insane for mental
institutions in NSW (The Central Sydney Area Mental Health Service 2004). Manning was noted for his humanitarianism. His constant desire was to
ensure that his patients received treatment for their illnesses rather than
confinement in a ‘cemetery for deceased intellects’.
Despite overcrowding with 1,078
patients being recorded in 1890, the Hospital (Callan
Park) at the turn of the century was considered to be one of the ‘finest
Institutions in the Commonwealth for the housing and treatment of persons,
suffering from mental disorders’ (Leong 1985).
Photo 1.
Photo of Callan Park (Leong
1985)
Two World Wars and the Great
Depression brought social upheaval and hardship and further overcrowding.
Demands for financial austerity eventually lead to
Kenmore Psychiatric Hospital in Campbelltown which opened in January 1895 following a building program which started in
1893 and expanded to have over 1,800
patients (Mitchell 1964).
Other large asylums were also built
in
There is no doubt in my mind that the patients are kindly treated, and
that any attempts to ill-use them would, if they came to the knowledge of the
superior officers, be most vigorously dealt with.
Asylums in