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‘Often there is a Good Deal to be Done, But Socially Rather Than Medically’: The Psychiatric Social Worker as Social Therapist, 1945–70

Published online by Cambridge University Press:  17 May 2012

Vicky Long
Vicky Long
Affiliation:
Vicky Long, Lecturer in History, School of Arts and Social Sciences, Northumbria University, Lipman Building, Room 404B, Newcastle upon Tyne NE1 8ST, UK. Email: [email protected]
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Abstract

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Seeking to align psychiatric practice with general medicine following the inauguration of the National Health Service, psychiatric hospitals in post-war Britain deployed new treatments designed to induce somatic change, such as ECT, leucotomy and sedatives. Advocates of these treatments, often grouped together under the term ‘physical therapies’, expressed relief that the social problems encountered by patients could now be interpreted as symptomatic of underlying biological malfunction rather than as a cause of disorder that required treatment. Drawing on the British Journal of Psychiatric Social Work, this article analyses the critique articulated by psychiatric social workers based within hospitals who sought to facilitate the social reintegration of patients following treatment. It explores the development of ‘psychiatric social treatment’, an approach devised by psychiatric social workers to meet the needs of people with enduring mental health problems in hospital and community settings that sought to alleviate distress and improve social functioning by changing an individual’s social environment and interpersonal relationships. ‘Physical’ and ‘social’ models of psychiatric treatment, this article argues, contested not only the aetiology of mental illness but also the nature of care, treatment and cure.

Keywords

CareCureRecoveryChronic Mental IllnessPhysical TreatmentPsychiatric Social WorkSocial Psychiatry
Type
Articles
Information
Medical History , Volume 55 , Issue 2 , April 2011 , pp. 223 - 239
Copyright
Copyright © The Author(s) 2011. Published by Cambridge University Press

References

1 Edward Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (New York: John Wiley, 1997), 255.

2 William Sargant, The Unquiet Mind: The Autobiography of a Physician in Psychological Medicine (London: Heinemann, 1967), 148–9; chlorpromazine was marketed as Largactil.

3 Sargant, ibid., 36. This was the only reference to PSWs in the book.

4 Such treatments were also described as ‘somatic’, ‘biological’ or ‘medical’, and were contrasted to a body of therapies termed as ‘social’, ‘psychological’ or ‘psychotherapeutic’. The ‘physical’ treatments were grounded in the belief that mental illnesses were a product of biological malfunction and were best treated by remedying this biological malfunction; the ‘social’ treatments were based on the belief that mental illnesses were caused, or at least influenced, by environmental, psychological and interpersonal factors and could be treated by manipulating these factors.

5 M. Crump, ‘Social Aspects of Physical Treatment in Mental Illness’, British Journal of Psychiatric Social Work [hereafter BJPSW], 5, 1 (1959). 19–25: 21.

6 APSW Archive, MSS.378/APSW/2/1/9, ‘APSW Annual Report 1946–47’, typescript, 7. All APSW archives consulted for this article are held at the Modern Records Centre, University of Warwick.

7 For example, the Mental After Care Association deployed lady volunteers to visit its charity cases in their homes or places of work to check on their progress and resolve any difficulties. See Vicky Long, ‘The Mental After Care Association: Public Representations of Mental Illness 1879–1925’ (unpublished MA thesis: University of Warwick, 2000), and Vicky Long, ‘Changing Public Representations of Mental Illness in Britain 1870–1970’ (unpublished PhD thesis: University of Warwick, 2004), 178–232. The Central Association for Mental Welfare (founded in 1913 as the Central Association for the Care of Mental Deficiency) was also engaged in work with the mentally disordered within the community. Its work is discussed in Louise Westwood, ‘Avoiding the Asylum: Pioneering Work in Mental Health Care 1890–1939’ (unpublished DPhil thesis: Sussex University, 1999).

8 See Mathew Thomson, Psychological Subjects: Identity, Culture, and Health in Twentieth-Century Britain (Oxford: Oxford University Press, 2006), and Nikola Rose, Governing the Soul: The Shaping of the Private Self, 2nd edn (London: Free Association Books, 1999). Jonathan Toms’ PhD thesis explores how changing conceptualisations of subjective experience reshaped the mental hygiene movement: see Jonathan Toms, ‘Mental Hygiene to Civil Rights: MIND and the Problematic of Personhood, c.1900–c.1980’ (unpublished PhD thesis: University of London, 2005). The first objective listed in the APSW constitution was ‘to contribute towards the general purposes of mental hygiene’, and the APSW was represented on the National Association of Mental Health, the main organisation involved in the promotion of mental hygiene in Britain in this era. APSW Archive, MSS.378/APSW/2/1/1, ‘The APSW Annual Report for the Year 1936 (with foreword on the years 1930–5)’, 5.

9 For more information on the development of psychiatric social work training in America, see Elizabeth Lunbeck, The Psychiatric Persuasion: Knowledge, Gender and Power in Modern America (Princeton, NJ: Princeton University Press, 1994), 35–45.

10 Exemplified in the work of educational psychologist Cyril Burt, employed in 1913 to investigate cases of difficult children in London schools and to carry out treatment. See Deborah Thom, ‘Wishes, Anxieties, Play and Gestures: Child Guidance in Inter-War England’, in Roger Cooter (ed.), In the Name of the Child: Health and Welfare, 1880–1940 (London: Routledge, 1992), 200–19.

11 ‘The APSW Annual Report for the Year 1936’, op. cit. (note 8), 5.

12 Thus in 1937, for example, forty-three PSWs worked in hospitals and twenty-four were employed in child guidance. Noel Timms, Psychiatric Social Work in Great Britain, 1939–1962 (London: Routledge, 1964), 69.

13 Ministry of Health, Report of the Committee on Social Workers in the Mental Health Services (1951), Cmd 8260, 15.

14 Ministry of Health and Department of Health for Scotland, Report of the Working Party on Social Workers in the Local Authority Health and Welfare Services (London: H.M.S.O. 1959), 227–8.

15 For more detail on the origins of psychiatric social work in Britain and the establishment of the mental health course, see Timms, op. cit. (note 12). The figures for 1969 are drawn from APSW Archive, MSS.378/APSW/2/1/35, ‘The APSW Annual Report 1969’, 17. For work on child guidance clinics and the role of the PSW see John Stewart, ‘An “Enigma to Their Parents”: The Founding and Aims of the Notre Dame Child Guidance Clinic, Glasgow’, The Innes Review, 57 (2006), 57–76; John Stewart, ‘Child Guidance in Inter-War Scotland: International Context and Domestic Concerns’, Bulletin of the History of Medicine, 80 (2006), 513–39; John Stewart, ‘“I Thought You Would Want to Come and See His Home”: Child Guidance and Psychiatric Social Work in Inter-War Britain’ in Mark Jackson (ed.), Health and the Modern Home (London: Routledge, 2007), 111–27.

16 M. Ashdown, ‘Introduction’, BJPSW, 1, 1 (1947), 3–7: 6. I consulted the 1968 reprints of the British Journal of Psychiatric Social Work issued by Swets and Zeitlinger N.V. Amsterdam; page and volume numbers are listed accordingly.

17 M. Ashdown, ‘Editorial’, BJPSW, 1, 3 (1949), 3–6: 3.

18 When Swets and Zeitlinger took over publication of the Journal from 1968, they reissued volumes 1 to 8, covering the years 1947 to 1966, suggesting a demand for the earlier editions by this stage.

19 The emergence of these treatments are outlined in Shorter, op. cit. (note 1) 190–224, and more critically, in Phil Fennell, Treatment without Consent: Law, Psychiatry and the Treatment of Mentally Disordered People Since 1845 (London: Routledge, 1996), 129–50. Introduction rates for different treatments across hospitals varied: Shorter notes that insulin coma therapy was introduced in British hospitals by 1937 and had become widespread by 1939 (211). Convulsive therapy was first introduced in Britain in 1937 using cardiazol. Electro-convulsive therapy was introduced in 1939 and slowly supplanted the use of cardiazol: see Niall McCrae, ‘“A Violent Thunderstorm”: Cardiazol Treatment in British Mental Hospitals’, History of Psychiatry, 17 (2006), 67–90. Diana Gittins, however, found no evidence of the use of ECT or insulin coma therapy at Severalls Hospital until after the Second World War: Diana Gittins, Madness in its Place: Narratives of Severalls Hospital, 1913–1997 (London: Routledge, 1998), 196–7.

20 William Sargant and Eliot Slater, An Introduction to Physical Methods of Treatment in Psychiatry, 2nd edn (Edinburgh: E. & S. Livingstone, 1948), 1. This textbook had run to five editions by 1972.

21 Mental hospitals were nominally included within the Regional Hospital Boards and came under the formal control of the Ministry of Health, but in practice, psychiatric services appear to have been poorly integrated. See John V. Pickstone, ‘Psychiatry in General Hospitals: History, Contingency and Local Innovation in the Early Years of the National Health Service’, in John V. Pickstone (ed.), Medical Innovations in Historical Perspective (Houndmills: Macmillan, 1992), 185–99, and Steven Cherry, Mental Health Care in Modern England: The Norfolk Lunatic Asylum / St Andrew’s Hospital c.1810–1998 (Woodbridge: Boydell, 2003), 231–40. For more details of the 1959 Mental Health Act, see Kathleen Jones, Asylums and After: A Revised History of the Mental Health Services From the Early 18th Century to the 1990s (London: Athlone, 1993), 154–8.

22 National figures from C. Webster, ‘Psychiatry and the Early NHS: The Role of the Mental Health Standing Advisory Committee’ in German E. Berrios and Hugh Freeman (eds), 150 years of British Psychiatry, 1841–1991 (London: Gaskell, 1991), 103–16, cited in Cherry, op. cit. (note 21), 243. Figures for St Andrews from Cherry, idem, 245.

23 Jones, op. cit. (note 21), 161.

24 Sargant and Slater, op. cit. (note 20), 188, 189. These developments within the field of psychiatry reflected more general trends with medicine, as individualised care was discarded in favour of a standardised approach that offered a more efficient means to deliver mass healthcare through categorisation and classification. See Steve Sturdy and Roger Cooter, ‘Science, Scientific Management, and the Transformation of Medicine in Britain c.1870–1950’, History of Science, 36 (1998), 1–47.

25 See Shulamit Ramon’s analysis of the 1956 edition of Henderson and Gillespie’s A Textbook of Psychiatry (Oxford: Oxford University Press, 1956), and the first (1954) edition of W. Mayer-Gross, Eliot Slater and Martin Roth’s Clinical Psychiatry (London: Cassell, 1954); Shulamit Ramon, Psychiatry in Britain: Meaning and Policy (London: Croom Helm, 1985), 163–78.

26 Cyril Greenland, ‘At the Crichton Royal with William Mayer-Gross (b. 15 Jan. 1889, d. 15 Feb. 1961)’, History of Psychiatry, 13 (2002) 467–74: 470.

27 Crump, op. cit. (note 5), 23, 24.

28 Ramon, op. cit. (note 25), 213.

29 M.A. Lane, ‘The Effect of Leucotomy on Family Life’, BJPSW, 3, 3 (1956), 18–24.

30 ibid., 19.

31 ibid., 20.

32 Ibid., 21.

33 Shorter, op. cit. (note 1), 225–9.

34 See Jack Pressman, Last Resort: Psychosurgery and the Limits of Medicine (Cambridge: Cambridge University Press, 1998).

35 Quoted in Gittins, op. cit. (note 19), 208.

36 K. Iolo Jones and P.M. Hammond, ‘The Boundaries of Training’, BJPSW, 5, 4 (1960), 172–7: 173–4.

37 M. Power, ‘Community Care – A New Service’, BJPSW, 3, 3 (1956), 4–10: 7.

38 M.L. Ferard, ‘Notes on the Psychiatric Social Treatment of Mental Hospital Patients: Four Paranoid Schizophrenics’, BJPSW, 1, 1 (1947), 45–56: 45. Ferard subsequently took up a post in the London Family Welfare Association as a consultant supervisor. See M. Ferard, ‘Psychiatric Social Work and Social Casework in Other Fields: II’, in E.M. Goldberg, et al. (eds), The Boundaries of Casework: A Report on a Residential Course Held by the APSW Leciester, 1956, (London: APSW, 1959), 16–21.

39 ibid., 55–6.

40 Ibid., 48.

41 The work undertaken by Ferard and Eugene Heimler to enable people with mental health problems to gain employment is discussed in Vicky Long, ‘“A Satisfactory Job is the Best Psychotherapist”: Employment and Mental Health, 1939–60’, in Pamela Dale and Joseph Melling (eds), Mental Illness and Learning Disability: Finding a Place for Mental Disorder in the United Kingdom (London: Routledge, 2006), 179–99.

42 Discussed in Eugene Heimler, Mental Illness and Social Work (Harmondsworth: Pelican, 1969), 107–10; and Eugene Heimler, The Healing Echo (London: Souvenir Press, 1985), 13–16.

43 C. Driver, ‘Concentration Camp Graduate’, The Guardian, 8 April 1961, 4.

44 Heimler, Mental Illness, op. cit. (note 42), 119.

45 ibid., 54–5.

46 ibid., 122–9.

47 C. Driver, ‘Testing Social Normality’, The Guardian, 28 July 1964, 6–7.

48 See Tom Harrison and David Clarke, ‘The Northfield Experiment’, British Journal of Psychiatry, 160 (1992), 698–708; John A. Mills and Tom Harrison, ‘John Rickman, Wilfred Ruprecht Bion, and the Origins of the Therapeutic Community’, History of Psychology, 10 (2007), 22–43; Stuart Whiteley, ‘The Evolution of the Therapeutic Community’, Psychiatric Quarterly, 75 (2004), 233–48; D.W. Millard, ‘Maxwell Jones and the Therapeutic Community’, in Berrios and Freeman (eds), 150 Years of British Psychiatry, Volume II: The Aftermath, (London: Athlone, 1996), 581–604; Maxwell Jones, Social Psychiatry in Practice: The Idea of the Therapeutic Community (Harmondsworth: Pelican, 1968). Another initiative that stemmed from the experiences of the War was the Social After-Care Service. Operated by the National Association of Mental Health, the Service attempted to facilitate the social adjustment of ex-service personnel who had been discharged on psychiatric grounds. See Toms, op. cit. (note 8), 132–3.

49 Denis V. Martin, Adventures in Psychiatry: Social Change in a Mental Hospital (Oxford: Bruno Cassirer, 1962), 140–2

50 For a broad overview of the interaction of politics and human sciences in understanding and managing individuals and society, see Greg Eghigian, Andreas Killen and Christine Leuenberger, ‘The Self as Project: Politics and the Human Sciences in the Twentieth Century’, Osiris, 22 (2007), 1–25; the applied use of psychological ideas to create governable subjects is explored in Rose, op. cit. (note 8).

51 Mary C. Jarrett, ‘The Practical Value of Mental Hygiene in Industry’, Hospital Social Services, 3 (1921), 361–5: 364 cited in Joseph M. Gabriel, ‘Mass-Producing the Individual: Mary C. Jarrett, Elmer E. Southard, and the Industrial Origins of Psychiatric Social Work’, Bulletin for the History of Medicine, 79 (2005), 430–58: 434.

52 Ibid.

53 APSW, Psychiatric Social Work and the Family by the APSW. Part II: Illustrative Material: A Study in Preparation for the Second International Conference on Social Work (London: APSW, 1932), 7.

54 E.L. Thomas and K.M. Lewis, ‘Papers on the Role of the PSW Given to the AGM of the Psychiatric Session of the BMA in 1950’, BJPSW, 1, 4 (1950), 18–24: 22.

55 M. Harrington, ‘Psychiatric Social Work in a Borstal Institution’, BJPSW, 1, 4 (1950), 40–2: 40.

56 Report of the Working Party on Social Workers, op. cit. (note 14), 128.

57 E. Slater, interviewed by B. Barraclough in 1981, in Greg Wilkinson (ed.), Talking About Psychiatry, (London: Royal College of Psychiatry, 1993), 12.

58 Its roots can be traced back to the moral therapy approach adopted at the York Retreat, which framed patients as wayward children and sought to use social relationships to resocialise patients to normal patterns of behaviour. Stressing the increasingly disciplinary character of this approach, Anne Digby suggested that moral management displaced moral therapy. See Anne Digby, Madness, Morality and Medicine: A Study of the York Retreat, 1996–1914 (Cambridge: Cambridge University Press, 1985), 33–87.

59 Pressman, op. cit. (note 34), 220–31.

60 APSW, A Career as a Psychiatric Social Worker (London: APSW, 1960), 1.

61 APSW Archive, MSS.378/2/1:29: ‘APSW Annual Report 1963’, 7.

62 APSW Archive, MSS.378/APSW/P/14/4:120. From unnamed, undated paper, ‘Social Work – Who’s Out of Step?’ Judging from the phrasing of this article, it appears to be the one sent by PSW Jean Nursten to the editor of New Society reporting on the APSW conference ‘Psychiatric Social Work: Developments in Training and Practice’ held in Manchester from 8–13 September 1963. Nursten entitled her piece ‘A Question of Adjustment’: APSW Press Correspondence 1955–1965, MSS.378/APSW/P/14/3:106a.

63 See, for example, John Kenneth Wing, Douglas Harley Bennett and John Denham, The Industrial Rehabilitation of Long-Stay Schizophrenic Patients: A Study of 45 Patients at an Industrial Rehabilitation Unit (London: Medical Research Council, 1964); John Kenneth Wing and Brenda Morris, Handbook of Psychiatric Rehabilitation Practice (Oxford: Oxford University Press, 1981).

64 Themes developed by a number of contributors to Marijke Gijswijt-Hofstra and Roy Porter (eds), Cultures of Psychiatry and Mental Health Care in Postwar Britain and the Netherlands (Amsterdam: Rodopi, 1998), especially Colin Jones, ‘Raising the Anti: Jan Foudraine, Ronald Laing and Anti-Psychiatry’, in idem, 283–94.

65 For a critical overview of Bierer’s career, see Liam Clarke, ‘Joshua Bierer: Striving for Power’, History of Psychiatry, 8 (1997), 319–32.

66 Joshua Bierer and Richard I. Evans, Innovations in Social Psychiatry: A Social Psychological Perspective through Discourse (London: Avenue Publishing, 1969), 27.

67 Peter Barham, Schizophrenia and Human Value: Chronic Schizophrenia, Science and Society, 2nd edn (London: Free Association Books, 1993); Peter Barham and Robert Hayward, Relocating Madness: From the Mental Patient to the Person, 2nd edn (London: Free Association Books, 1995); Peter Barham, Closing the Asylum: The Mental Patient in Modern Society, 2nd edn (London: Penguin, 1997). On the failure to develop community services, see Jones, op. cit. (note 21), 181–96.

68 Barham, Closing the Asylum, op. cit. (note 67), 54

69 Barham and Hayward, op. cit. (note 67), 76.

70 ibid., 77.

71 Ratcliffe authored The Child and Reality: Lectures by a Child Psychiatrist (London: Allen & Unwin, 1967) and held posts at the Nottingham City Mental Hospital and Nottingham Children’s Hospital.

72 T.A. Ratcliffe, ‘Relationship Therapy and Casework’, BJPSW, 5, 1 (1959), 4–9: 4.

73 PSWs can be seen as belonging to the group of occupations working in the fields of health, education and social welfare that Chris Nottingham has recently described as ‘insecure professionals’, whose claims to professional status on the grounds of unique professional skills and knowledge, verified through qualifications, were vigorously challenged. See Chris Nottingham, ‘The Rise of the Insecure Professionals’, International Review of Social History, 52 (2007), 445–75. Similarly, Pamela Dale has deployed the term ‘lay professionals’ in her analysis, see Pamela Dale, ‘Tension in the Voluntary-Statutory Alliance: “Lay Professionals” and the Planning and Delivery of Mental Deficiency Services, 1917–45’, in Dale and Melling, op. cit. (note 41), 154–78. Vicky Long has explored how discussion within and between different occupational and voluntary groups within the field of mental health regarding the nature of mental illness and its treatment was shaped by differing levels of power and influence. See Long, ‘Changing Public Representations’, op. cit. (note 7).

74 Andrew Scull, ‘Somatic Treatments and the Historiography of Psychiatry’, History of Psychiatry, 5 (1994), 1–12. Lindsay Prior has also pointed to the interrelationship between professionalisation and practice, arguing that psychiatry produced beliefs and objects such as asylums and disease classifications that defined the nature of mental illness and led to mental illness being organised in a particular way, and that these organisational structures then reinforced the representations that created them in the first place. See Lindsay Prior, The Social Organization of Mental Illness (London: Sage, 1993).

75 Ramon, op. cit. (note 25), 206–19. Ramon drew on the BJPSW to evidence her argument but does not appear to have used the APSW archives or other publications produced by PSWs.

76 Report of the Committee on Medical Auxiliaries (1951), Cmd 8188. APSW Archive, MSS.378/APSW/2/1:18, ‘APSW Annual Report 1952–1953’, 6. There are clearly strong parallels here with the professional aspirations of medical social workers, another distinct group within social work, which also had to negotiate its relationship to both doctors and other social workers. See Chris Nottingham and Rona Dougall, ‘A Close and Practical Association with the Medical Profession: Scottish Medical Social Workers and Social Medicine, 1940–1975’, Medical History, 51, 3 (2007), 309–36.

77 Mary A. Lane and H.E. Howarth, ‘Social Workers’, British Medical Journal, 4983, supplement 2685 (1956), 5–6: 6.

78 Greenland, op. cit. (note 26), 469.

79 Jack Pressman argued that psychosurgery was viewed as a ‘salvage’ operation, seen as particularly suitable for patients with ‘nothing to lose’: Pressman, op. cit. (note 34), 199–207. Similarly, Andrew Scull’s study of Henry Cotton reveals that Cotton justified his riskiest surgical interventions on the grounds that they were a ‘last resort’ for chronic cases (although subsequent analysis of Cotton’s records would reveal that a much broader cohort of patients were operated on); see Andrew Scull, Madhouse: A Tragic Tale of Megalomania and Modern Medicine (New Haven: Yale University Press, 2007), 263–5.