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 Australia. Because of the span and scope of this background, it is necessarily brief. It contains an overview of evolving models and responses to mental malfunction in UK, USA, and Australia since the Nineteenth Century, and an overview of the development, significance and the underlying theory of therapeutic communities in the psychiatric field from the mid 1940’s. Some defining features of therapeutic communities in the UK and United States are introduced along with some common terms. The debates and arguments for and against therapeutic communities are briefly discussed along with different theoretical/ideological positions. Community Mental Health, community mental health centres and community mental health support processes in those countries are similarly briefly defined and discussed. Current practices in therapeutic communities/mental health outreach/networks in the three countries are also briefly outlined.

 

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 Europe, a non-violent non-medical approach to mental malfunction was pioneered by Philippe Pinel (1745-1826) as apprentice to, and in association with Jean Baptiste Pussin (1745-1811). Together they evolved ‘moral treatment’. Dr. Grohol writes of Pinel:

 

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 America’s oldest psychiatric hospital, the Friends Hospital in Philadelphia USA in 1813 based on moral treatment. Among those individuals instrumental in founding Friends' Asylum was Thomas Scattergood, a travelling minister whose visit to England between 1794 and 1800 took him to The York Retreat, a prototype for Friends Hospital (as well as many other mental hospitals). There he observed firsthand founder William Tuke's use of moral treatment (A History of Friends Hospital 2005).

 

The York Retreat and the Philadelphia Hospital were early examples of a biopsychosocial approach. Mind and body functioning was viewed as somehow profoundly linked to interpersonal action in quality contexts. The idea was that the Retreat milieu would somehow create the transformation.

 

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 Great Britain, it reflected the importance of broad environmental factors in the etiology of mental disorders.

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 Experience

 

In the Nineteenth Century, the USA generally followed the harshness of the UK experience. Dorethea Dix (1802 – 1887) commenced a forty year humanitarian crusade for humane reform of public institutions for the mentally malfunctioning (South Carolina Department of Mental Health 1999; The History of Mental Illness 2005).

 

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 USA in 1950 to form the National Association of Mental Health (NAMH). These bodies and others, including charities, lobbied for Mental Health Treatment reform and rights for the mentally ill.

 

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 UK and USA. According to Shireav (1979, p. 27-43):

Psychiatry in New South Wales can be divided into four periods of varying administrative policy and treatment:

·         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). Callan Park was situated in the Sydney inner west on the harbour in Leichhardt Municipality.

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 Callan Hospital falling into disrepair and neglect.

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 Australia including the Kew Asylum in Melbourne. A report by J.B. Castieau (1880), inspector of lunatic asylums, to the Chief Secretary published in the Melbourne Age, 23 March 1880 about the treatment of inmates at Kew Asylum stated:

 

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 Australia, UK and USA were typically geared to meet the needs of psychiatrists and staff rather than patients. Many of the patients were confined to beds. Those deemed ‘incurable’ were placed in ‘back’ wards where they were to remain till they died (Main 1989; The History of Mental Illness 2005).