Chapter 8

The National Association for Mental Health - and its Critics

In 1946 three voluntary mental health organisations amalgamated to form the National Association for Mental Health, which today has roughly 2,000 members. Those organisations were the Central Association for Mental Welfare, the Child Guidance Council and the National Council for Mental Hygiene.

There are two opposing views about the desirability of such amalgamations. One is that it is always satisfactory and economical that one organisation should grow strongly where several perhaps struggled (and even competed) before. The other is that the need find a consensus usually entails the sacrifice of some of the more progressive ideas and perhaps the death of a ginger group. My own experience has suggested that most reformist and pressure groups move across the stage, so to speak, from Left to Right; and that as their leaders disappear into respectable conformity there always appears from the other wing a new group of Wild Men, brandishing freshly lit torches and shouting utopian slogans. Before these in turn disappear into limbo on the Right, their torches dimmed and their shouting over, some of those slogans will have been translated into common practice. It should be acknowledged, no doubt, that some of the shouting will express internecine rivalry, and of this there exists no more strident example than what the scientologists say about their rivals in such transports as their 'Campaign Against Psychiatric Atrocities'.

Anyone who could take an Olympian view of the social reform movements might be a little saddened by the mutual detestation that sustains them on their road to sometimes identical goals; but the scientologists' invective (whatever their goal), as they relieved their feelings about the National Association for Mental Health, would have made startling reading on Olympus.

An article in Hospital World for August 1969, took the favourable view of amalgamations. It was headed QUIET REVOLUTIONARIES. 'Any organisation which sets out to change things', it said, 'must be prepared to change itself. If it cannot do this it will be left behind and fail in its purpose.' The Hospital World thought the NAMH amalgamation had 'managed to cope with this uncomfortable process', and that 'in so doing it has developed from a polite, re-assuring body, uttering words of comfort to all those involved with mental health, to an organisation which is now firmly on the side of the patient and not at all scared of speaking its mind when the need arises'.

Twenty years ago the NAMH embarked on a programme of public education about mental disorder; and it claims today, I believe with justification, that public opinion now accepts this kind of illness as something to be cured, or at least hopefully and humanely treated, instead of something to be feared and shunned. The Association sees itself as a bridge between providers (the statutory authorities) and consumers (the patients and their friends and families). 'Sometimes,' I was told by one of its spokesmen, 'we will appear to be leaning too heavily in one direction, but we really have a foot on each side.' The Association's declared aims are:

To foster a wider understanding throughout the community of the importance of mental health in all relationships of everyday life, and to encourage and promote the establishment of treatment and training facilities for adults and children suffering from mental and nervous disorder, or who are mentally subnormal, or who have behaviour problems.

It keeps an eye on all 'fringe medicine' which purports to help people suffering from mental disorder of any kind, and in 1960 it duly noted the arrival of the scientology movement at Saint Hill Manor, East Grinstead. It sees mental disorder as the largest single medical problem in this country. (Nearly half the total number of hospital beds are occupied by people suffering from some kind of mental disorder; and some of them, legatees of the unenlightened treatment methods of the past, have been in hospital for forty years.) It is true to say that until 1963 the NAMH provided the only training course leading to qualification as a teacher of the mentally subnormal - the NAMH diploma is a recognised qualification and the training course was a blueprint for those now run by the Central Training Council; and now that teacher-training is being assimilated into the work of central and local government, the NAMH considers itself more free to pioneer in other areas of neglect. It still runs courses for wardens of hostels for the mentally ill and the elderly, for GP's and clergy and heads of schools. As a voluntary organisation it can experiment with new methods of (for example) residential care.

Accordingly it has undertaken a number of ambitious pioneer projects in the care of emotionally disturbed children. In 1950 it established a home for mentally confused old ladies - who, but for this, would almost certainly have been in the geriatric back wards of psychiatric hospitals. It administers 'community homes' (until lately known as approved schools) where psychiatric supervision is provided for very disturbed young offenders. And it fulfils an important national role in the provision of advice and information for press, radio, television and public use, and the production of a quarterly magazine and numerous booklets.

Seventy-five local (and autonomous) Associations for Mental Health are affiliated to the NAMH, and they represent the growing involvement of the public in promoting and sustaining the mental well-being of the population. About a dozen of them run hostels for former patients, providing a bridge between hospital and community, and others arrange educational activities or visit and 'adopt' friendless patients: their activities are too diverse to list.

Sometimes the Association is asked to submit evidence when Parliamentary bills are being drafted. Sometimes it comments pungently without being asked. At the time this book was being prepared it was urging upon the then Secretary of State for Social Security, Mr R. H. S. Crossman, who was proving hard to convince, that a proposed - and long overdue - 'Inspectorate for Hospitals' should be quite independent of and outside the Ministry. 'It may seem curious', said the Association in a memorandum dated 13 May 1969, 'that pressure for an inspectorate should arise ten years after the passing of the Mental Health Act and contrary to the opinion of the 1957 Royal Commission, which found that "A central Inspectorate outside the Minister's own department is neither necessary nor desirable". But we believe', the NAMH continued, 'that events have shown the Royal Commission to have been too sanguine. When its report was written, hospitals were concentrating on the run-down of long stay patients, while the massive increase of helpless geriatric cases had not reached its present proportion. In the subnormality world all eyes were on the return of the subnormal to the community, after training in hospital. The inevitable concentration of severely disabled subnormals in hospital, as a result of this policy, and their increased life expectancy, was barely under discussion.'

The Royal Medico-Psychological Association and the British Medical Association also argued strongly for an independent hospitals Inspectorate. It was seen that such an Inspectorate would serve two important and closely related purposes:

  1. To make those responsible for the management of a hospital aware of standards and practices in the best hospitals; and
  2. To investigate complaints referred by members of the public, by hospital staff or by patients.
Nevertheless, for the time being, the Ministry seemed satisfied with a new 'Hospitals Advisory Service', operating within the Ministry's ambit and reporting to the Minister. There was widespread dissatisfaction. The idea was seen as little more than a gesture in the direction of improved mental care and the problem of the 'anti-therapeutic hospitals'. The campaign for a Hospitals 'Ombudsman', whether he was to be called a Hospitals Commissioner or a Health Commissioner, was intensified; particularly when it was discovered and finally believed that the stop-gap 'Hospitals Advisory Service' would be required by its own rules to notify in advance any Hospital Management Committee and the senior medical and nursing staff that it proposed to make a visit. The NAMH declared in the Memorandum already cited that it 'received from time to time letters from patients and their relatives complaining of neglect or lack of consideration in particular hospitals,' and that 'letters of this kind are naturally more frequent when there has been newspaper publicity, or following publications such as Sans Everything [1. Sans Everything: A Case to Answer. Edited by Barbara Robb. Nelson & Co. 1967.]; and, more recently, the Report on Ely Hospital'.

Sans Everything, a collection of essays and articles published in 1967, was a disturbing indictment of seven hospitals by doctors, nurses and patients, revealing conditions of neglect and incidents of ill-treatment and brutality that were almost certainly the outcome of overcrowding, frayed nerves and even despair. It led to Parliamentary debates and eventually to the appointment of seven 'independent committees of enquiry' to look into the allegations concerning the seven hospitals. Each was chaired by a Queen's Counsel nominated by the Lord Chancellor. Each repudiated the allegations made in Sans Everything and then made recommendations to ensure that the things which had never happened should never happen again.

It was while the future of such enquiries, and the nature and authority of a proposed 'Hospitals Ombudsman' or 'Health Commissioner' [2. Ombudsmen were finally set up by the National Health Service Reorganisation Act 1973.] were under discussion that the scientologists must have decided that the time had come for them to take over the National Association for Mental Health. It was an effete, establishment-minded 'front group', they seemed to say, composed largely of psychiatrists who raped their patients or, when that had lost its appeal, broke their heads open with chisels or fractured their bones and tore their muscles by means of electro-convulsive shock therapy. Nothing would improve in the hospitals (and there were copious quotations in Freedom Scientology from Mrs Robb's book Sans Everything to show what it was like in the hospitals) until the NAMH acquired the dynamic quality that scientologists could provide. On the one hand the scientologists complained that psychiatry, even in its more restful intervals between rape and murder, never did anyone any good, though you will search the scientologists' literature in vain for an alternative idea about the treatment of mental disorder (they merely say - now - that they don't treat it themselves). On the other hand, there stood the National Association for Mental Health, whose rather more methodical approach to that problem was perfectly typified in the concluding paragraph in its Memorandum of 13 May 1969:

We end by stressing our belief that the proposed Inspectorate should lie within the office of the Lord Chancellor. We realise that statutes will be involved and that Parliamentary time will have to be set aside. There will inevitably be delay. While we have set out what we consider the ideal solution, we would support any move towards improving knowledge between hospitals and towards improving the Minister's own information about conditions. We see no reason why, in anticipation of legislation, peripheral panels should not be organised immediately and without legal enactment and we hope such a move might be made as a matter of urgency.

The NAMH, in fact, faced a perennial problem: what to say about which elements of the truth. How could it reassure the public about the possibilities of treatment and cure, while exposing the shortcomings of the mental health services - which few of their personnel would deny? In its annual report for 1968/9 the NAMH posed the problem in these terms:

How, in successive Mental Health Weeks, were we to break down the stigma which still attached to mental disorders and at the same time tell the truth about the conditions in many of our mental hospitals? Should we not be hitting at a devoted and hardworking profession if we said that overcrowding and understaffing were bidding fair to undermine the good picture of the mental hospitals which the undoubted advances in treatment had built up? Was it wrong to entitle a subsequent conference 'What's Wrong With the Mental Health Services?' when we knew that all was not well? Could we, unless these questions were frankly discussed, expect public support and thereafter political action and money to come towards the mental health services unless opinion was awakened to the plight of the hospital services? And did any of this undermine any of our admiration for doctors and nurses working in very difficult conditions? Not since the passing of the Mental Health Act in 1959 has the future of the mental health services been under such open and continuous discussion.

We welcome that. Nobody doubted in 1959 that the policy of open doors, treatment in the community, the use of new drugs and the progressively early treatment of psychiatric illness by general practitioners and in psychiatric wards was the beginning of a small millennium for the mentally ill. Nobody doubted that the mentally subnormal, given opportunities to be trained to the limits of their capacity, could take their place outside the walls of the mental subnormality hospitals. All was hope and progress.

There were, however, faint warning voices. The Royal Medico- Psychological Association asked that an inspectorate outside the Ministry of Health should be retained to exercise some of the functions previously carried out by the Board of Control. The NAMH described a future when patients who could respond to early treatment would be treated in general hospitals, while the mental hospitals reverted to long-stay units, out of sight and out of mind.

Is this now the truth which has come upon us? Is it the truth that people in long-stay wards in our mental and mental subnormality hospitals are there because society has thrown them out? Not cases needing treatment but cases needing care?

The country faced a nursing crisis brought on by its inability to 'care in the community for those mentally disabled by old age, or socially disabled by subnormality, plus the lack of a caring family. It is not now patients who have been in hospital for many years who form the core of long-stay patients,' said the Report, 'but those who come late in life ...' How will the present crisis be resolved?

Not by a defensive attitude to the criticisms which have arisen, but by a frank appraisal of what the problems are. We disregard them at our peril. Everyone concerned may want to forget the causes celebres of 1939 - Sans Everything, Shelton, Ely, Farleigh: the public because it is distasteful, the Government because it cries out for a massive reallocation of funds, and the hospital service because it damages their image. But we believe the time has come when everybody should be urged to remember, to think and to discuss a subject which inexorably will become a major medical, political and social problem in the seventies.

In 1969 the NAMH took the opportunity offered by the Ely Hospital report [1. Report of the Committee of Enquiry into Allegations of Ill-treatment of Patients and other Irregularities at the Ely Hospital, Cardiff, Cmd. 3975, HMSO, March 1969.] to urge a shocked public, by advertisements in The Guardian, The Observer, the Financial Times and the News of the World that (to quote the last-named) it was

pledged to expose, then improve, the desperate plight of the mentally ill and subnormal. If you are satisfied with standards like those at Ely, turn over. If not, send a donation NOW to the National Association for Mental Health, 33 Queen Anne Street, London, W1.

It was an advertisement that failed to commend itself to some of the Association's subscribing members, and there were protests. The advertisements implied (it was said) that 'all hospitals were Ely hospitals' and that Hospital Management Committees were not doing their job. In fact the advertisements had said no word about Hospital Management Committees, some of which nevertheless were manifestly not doing their job; and among the circumstances that were then exposed to fresh public discussion was the fact that some local authorities, who were not doing theirs either, were using potentially good Hospital Management Committees as scapegoats. The NAMH seemed less concerned about apportioning blame for Ely than about ameliorating the conditions that led to it; but as always when an administrative scandal has been exposed, there was something of a sauve-qui-peut among those upon whom blame might have fallen. And one angry hospital doctor telephoned the NAMH to say that, but for these unfortunate press advertisements, the public might soon and decently have forgotten the whole Ely affair. One hopes he was told that the NAMH existed to ensure that they never would.

Hardly more acceptable to the gradualists in the field of mental health reform was a pungent editorial by Dr Hugh Freeman in the Association's Quarterly Journal, Mental Health. [2. Summer 1969: - 'Ely Shuffling the Money Around'.] This Journal has never, in my own experience, minced its words; and on the occasions when I have been privileged to write for it, nothing I have wanted to say has been watered down. The following extracts from Dr Freeman's editorial article may suggest that the tradition is maintained:

If nothing else, the Report on Ely Hospital has more than justified the existence of the NAMH and of this journal. For many years past, recommendations like those of the Howe Committee have been made by the Association and have been recorded here. The difference now is that a dramatic scandal has finally brought to the public's attention matters which had been regularly swept under the national carpet before. With a few honourable exceptions, nobody wanted to know. But since the Ely Report, there have been competitive expressions of horror and concern, which in some cases have a rather hypocritical ring. After all, the facts were there all the time - they just didn't constitute a hot political issue. This makes it all the more vital that, while the issue is still live, there should be positive and constructive action to prevent such things happening again. Is the Department of Health's first reaction a very useful one, though? Regional Hospital Boards are having their arms politely twisted to transfer money from the budgets of general hospitals to those of psychiatric and subnormality hospitals. We know that far less has been spent on psychiatric and subnormal patients than on others since the beginning of the NHS (and before it). But there is a great danger that this money will be hurriedly applied to tarting up a number of crumbling and isolated buildings (which is the quickest thing to do). The public will get a good impression and some useful figures will be available to answer Parliamentary questions. Will the patients - and the staff who care for them - really be any better off?

This unseemly haste in robbing Peter to pay Paul really ignores all the fundamental problems of which the Ely affair was only a symptom. In the first place, as a nation we are not spending enough on health. Both the percentage of Gross National Product devoted to health and its rate of increase are well below those of comparable developed countries. Since the 1966 squeeze, general hospitals also have been under great financial pressure and making actual cuts in their allocations this year (even if in a good cause) which could well have damaging effects on their services to the public. If we want better facilities for the mentally ill and subnormal, we will have to spend more on health as a whole - not just shuffle the money round. Secondly, it would be very misleading to suggest that a mere increase in money (or in staff) for existing hospitals will change things much for the better. Research, such as that of Tizard, Kushlick and Craft, has cast very serious doubt on the need for many subnormal patients to remain in hospitals - particularly in large specialised ones. Wouldn't this extra money have been better spent on more hostels and day centres in the community, on employing more social workers, or on converting wards for the subnormal in children's hospitals (which often have empty space nowadays)? Was this possibility, which could have relieved subnormality hospitals of part of their burden of numbers, ever considered by the Department of Health? It certainly can't be left to Regional Hospital Boards, which, apart from Wessex, have scarcely begun to consider alternatives to the large institution for the mentally subnormal. It now appears that the Department is starting a comprehensive research project on this question in the Sheffield area, but much more money may flow down the drain before results can begin to influence policy.

This brings us to the third major problem, which is the absurd and irrational split - administratively and financially - between the different parts of the National Health Service. At present it is impossible to transfer any savings from one service to another, and patients stay in expensive hospital beds because there is no money to provide cheaper hostel places for them. The anomalies which result from this situation have an Alice-in-Wonderland quality of nonsense about them, only equalled by the March spending spree of annual hospital budgets. At the very time when the Ely Report showed up the need for much greater community facilities, at least one local authority (Salford) was in the process of cutting its services for financial reasons, while others have scarcely started to provide any - ten years after the Mental Health Act.

'Management' is the key word to the next problem area - there was none at Ely Hospital in any effective sense and the same is true of many hospitals throughout the country, though rarely with such disastrous results. Will we now admit that the Hospital Management Committee - as constituted in 1948 - has been a ghastly failure? By its nature, it is incapable of doing its job, which is the determination of policy. It either rubber-stamps the actions of hospital officers (when it is superfluous) or interferes constantly in matters of detail (when it is positively harmful). The quality of members is often abysmally low and there has been virtually no attempt to see that they acquire any information about the matters they are supposed to be deciding.

Finally, there is the question of maintaining standards by inspection. It has long been an absurdity that within a system of medical care financed by national taxation, there should be such enormous variations of quality from place to place. The NAMH has drawn attention to this situation repeatedly, before the Ely Report, and the whole question was analysed some five years ago by Dr Arthur Bowen in Psychiatric Hospital Care [edited by Hugh Freeman: Bailliere, Tindall, and Cox (1965)]. The NAMH believes that such an inspectorate should be independent of the Department of Health and of hospital administrative bodies. Its annual report should be published, so that the shortcomings and achievements of one area can be compared with those of another.

Its members should serve for a limited period, to avoid rigidity and to make sure that they are people with recent personal experience of working in (or concerning) the medical services. It is essential that any hospital employee should have free access to the inspectors, and not be dismissed for complaining (like the two nurses at Ely).

It would be disastrous if the national conscience on this matter were satisfied by the spending of a little extra money and making scapegoats of a few nurses who were given impossible conditions to work under. The whole nation has a responsibility for what happened at Ely Hospital and it is time that it came to grips with the fundamental problems in the National Health Service.

An important consequence of the Ely Hospital exposure was that 'the man on the Clapham omnibus' became aware, as never before, that there was a National Association for Mental Health.

The scientologists had been aware of it for rather longer.

There were, of course, other mental health organisations whose approach to the problem sometimes differed strikingly from that of the NAMH, and it was always right and necessary that there should be. Among them were the Association of Psychotherapists, which exists because psychotherapy is seldom available through the National Health Service, and which advises about private treatment at moderate fees; the Ex-Services Mental Welfare Society; the Camphill Village Trust, which maintains 'working communities' for the mentally handicapped in widely-separated parts of the country; the Mental After-Care Association; the Richmond Fellowship, running family- type homes for mainly professional-class people who are mentally and emotionally disturbed: and the Philadelphia Association, established in 1965 to 'change the way the facts of mental health and mental illness are seen'.

The Philadelphia Association merits some special attention here, because one of its founding members is the distinguished psycho-analyst, Dr R. D. Laing, whose published views were called in aid by the scientologists in their lawsuit against the NAMH. It declared in a report published in 1969 that the 'existing medical model' of research and therapy needed to be changed. In many cases, it said, the trouble was not that some 'illness' attacked an individual but that something was wrong with society. 'There is a complex disorder of a social field, which includes the chemistry of the people in it: only recently have sociologists, psychiatrists, anthropologists and other social scientists come to the view that schizophrenia has to do with communication.' It had, hitherto, been naively put down to some undiscovered physical cause, whereas in fact:

people are driven into a corner in their human environments by contradictory wishes, demands and expectations flung at them, without awareness by other people around them and by themselves. When driven far and forcibly enough into this corner all anyone can do is 'go up the wall'.

Accordingly the Philadelphia Association offered this programme:

The medical model pre-defines any field to which it is applied in its own terms, namely, diagnosis, prognosis, treatment, remission of symptoms and signs, cure of illness, relapse, etc. This elaborate system has served its purpose well, and continues to do so, in many branches of medical practice. However, it is our view that this model is applied to some classes of social situations in a way now more confusing than useful, and that psychiatry is the unhappy and uneasy field of medicine where this happens. Medical expertise should be brought into play to eliminate the possibilities of epilepsy, brain tumour, metabolic disorders, etc. In the vast majority of cases studied by psychiatrists, medical investigations are negative.

Our society has certain rules of conduct as have all societies. Many of these rules are, or can be, written. Many rules are, or can be, spoken but not written. Each family has its unwritten book of rules. It is not quite the same as the unwritten or unspoken code of conduct in any other family. When anyone breaks any of these rules, something has to happen. The breach may be regarded as small enough to be passed over, but otherwise something has to be done. The rule must either be rescinded, or the person who has broken it must be induced not to do so in future. All ways of inducing people not to break rules again can be classified under two heads: punishment and therapy. If it is felt that the person is responsible for his breach of the rules (deviant behaviour), he is punished. If it is felt that he is not responsible, if he cannot help it, he must be 'treated'.

Convinced that this attitude to schizophrenia, at least, was a mistaken one, the Philadelphia Society in 1964 set up a household of four people, three of whom were schizophrenics from a mental hospital; and they found, as they expected, that 'schizophrenia' could be understood better there than in a mental hospital. Then they leased the former community centre known as Kingsley Hall, in East London, where between June 1965 and August 1969, accommodation was provided for 113 alleged 'schizophrenics'. It was a place where

people get up or stay in bed as they wish, eat what they want when they want, stay alone or be with others, and generally make their own rules. Everyone has his or her own room. It is a place where people can be together and let each other be. There have been no suicides.

It was in fact 'community care' rationalised and made possible by the simplest possible organisation; and among its supporters and advisers were such distinguished people as Professor Marie Jahoda, Dr Maxwell Jones, Professor Eric Trist, Dr Michael Young and Dame Eileen Younghusband.

It was this kind of experiment that was to confer borrowed authority, in due course, on the scientologists' criticisms of psychiatry.

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