The revolution in social attitudes The Second World War

  Psychiatry changed radically during the Second World War and gained new confidence because its contribution was highly valued (both in the selection of soldiers and in the acute treatment of combat disorders). Its increased profile and importance brought many doctors into it who would never have contemplated work in asylums. Fresh minds were brought to old problems. Previously healthy men transformed into nervous wrecks by battle challenged old fatalistic genetic hypotheses. Dramatic recoveries from battle-trauma with practical treatments (e.g. barbiturate injections to release or ‘abreact’ emotions from recent terrifying experiences) confirmed the role of stress and trauma. Psychiatry became an active and optimistic, almost glamorous, branch of medicine.

Therapeutic communities

  The treatment of acute war neuroses by drug treatments was not the only Second World War advance. Psychiatrists with a psychoanalytical training obtained influential military adviser posts in both the US and UK. They explored how organizations themselves could influence mental health and recovery and developed the ‘therapeutic community’.

  The therapeutic community emphasized that the organization of hospitals (or prisons or schools or offices for that matter) has a major impact on the well-being of those in them. For psychiatric patients it can be an opportunity for self-learning and recovery. Army psychiatrists noted the problems of treating ordinary private soldiers for psychological problems because they, the doctors, were senior officers. Rank and status simply got in the way. They actively reduced status differences in their units, encouraging informality and stressing the patients’ capacity to work together to help each other and solve problems. This allowed neurotic and disabled individuals to learn new ways of dealing with their problems in a democratic, tolerant, and enquiring group environment.

  The therapeutic community movement improved care in mental hospitals and subsequently in prisons and residential schools for disturbed children and adolescents. It is a victim of its own success, as its lessons have become so accepted (even in commercial organizations) that their origins are forgotten. Psychoanalysis has suffered a similar fate.

‘Institutional neurosis’ and ‘total institutions’

  About the same time it was recognized that traditional mental hospital environments could have a profoundly damaging impact on patients. Hospitals could themselves be the cause of some of the problems that they were striving to treat. Long-stay patients (usually those suffering from schizophrenia) who had been inpatients for years or decades, were noted to be apathetic, self-neglecting, and isolated. This had always been considered a consequence of schizophrenia (a so-called ‘schizophrenia defect state’) and the plight and dependency of these individuals was one of the arguments sustaining mental hospitals.

  This aspect of schizophrenia (unlike the acute symptoms of hallucinations, delusions, and agitation) did not respond much to the new drugs. But the hospital itself appeared to make a difference. It had always been known that there were good mental hospitals and bad ones. A study of three hospitals of similar size and staffing with equally ill schizophrenia patients in the 1960s found markedly different levels of apathy and self-neglect. The study showed that the differences related to the levels of activity and variety provided in daily routines.

  A psychiatrist, Russell Barton, went further and proposed that much of this apathy was a response to living in an institution which denied personal responsibility. The apathy was a consequence of disuse – you simply stopped looking after yourself because somebody else always did it for you. Barton called this ‘institutional neurosis’ to stress that its cause was the hospital, not the schizophrenia. He reorganized things to give his patients more independence, with remarkable results. Many patients flourished in the new regime and were soon discharged. Rehabilitation (helping patients regain their lost skills and abilities) became a preoccupation in most mental hospitals and optimism grew that most of these apathetic, disabled patients would no longer need inpatient care.

  ‘Institutional neurosis’ stimulated change but its extent was undoubtedly exaggerated. There is an apathetic state that develops as part of long-term schizophrenia but it had been magnified by hospital routines. There were even some patients who had recovered and the staff had simply not noticed! Many of Barton’s early patients embraced their independence effortlessly, but such ‘overlooked’ patients are now rare and ongoing support is usually needed.