The mental hospital as an institution

Sot. Sci. di Med. 1973, Vol. 7, pp. 407-424. Pergamon Press. Printed in Great Britain.

THE MENTAL

HOSPITAL AS AN INSTITUTION* GEORGEW. BROWN

Reader in Sociology, Department of Sociology, Bedford College, University of London, Regent’s Park, London, N.W.1. “In proportion as habit makes us execute them with more ease and promptitude, it restrains our faculties and hinders them from being extended outside the same circle.” P. MAIRE de BRYAN Influence de I’Habitude sur la Faculte de Penser, 1803, in Oeuures,(Edited by P. Tisserand II) tr. M.D. Boehm, Baltimore, 1929. AI&ract-Mental hospitals in the past have gone through periods of reform and decline. Recent improvements in the cam of the chronically handicapped psychiatric patient are not immune from this cycle. It is argued that this tendencystemsfrom aspects ofsocial organimtion, and also from the beliefs of the medical profession concerned with these institutions.

HOSPITAL

CARE FOR THE SEVERELY

HANDICAPPED

IN BRITAINit is declared government policy to do away with the large mental hospital altogether [l]. Few will need persuading of its capability for inhumanity and even cruelty and many will sympathize with the view that it is best to by-pass the whole issue of reform by dispensing with such hospitals altogether. However, it is possible that the large mental hospital will be with us for many years to come-perhaps with a somewhat altered clientele -but with us nonetheless; it is also difkult to believe that the problems surrounding it can be solved so neatly. Even if “community care” gets the hind of support it needs, there will still be psychiatric patients with severe long-term handicaps, a significant proportion of whom will doubtless require lengthy periods of care in some form of organizational setting. Although the argument presented is largely restricted to the workings of mental hospitals, it is not without relevance for patients living in other institutions [2]. AU will not necessarily be well when patients with long-term handicaps are treated in small local units whether in hostels or in wards attached to general hospitals. Indeed, association with the general hospital in itself seems particularly lame as a solution. Such hospitals have continually to struggle to balance technical efhciency and humane care [3]; they offer no model for longterm care. Some see compelling parallels with the past. Psychiatric care has previously gone through periods of reform and decline. The most well-documented example concerns “moral treatment” practiced in a number of asylums in Britain and North America over 100 years ago, based on principles similar to many generally accepted today. But, even when well-established, “moral treatment” did not last long [4-91. The hospitals that followed were largely concerned with the safe custody of patients at low public cost. That these institutions can

Revised version of a paper presented at the Second International Symposium on Psychiatric Epidemiology, Mannheim, July 2629th, 1972. 407 S.S.M. 716-A

l

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GEORGEW. BROWN

change markedly and quickly is clear from a study in which one such hospital, Severalls at Colchester, was visited a few weeks after the arrival of a new medical superintendent committed to reform; the major changes that followed were observed over the next eight years [lo]. Research at this and two other hospitals, Mapperley at Nottingham and Netherne in Surrey, indicated that much of the morbidity shown by the long-stay schizophrenic patients stemmed from the hospital itself. The critical factor appeared to be the amount of time the individual patient spent unoccupied-although when this was allowed for, the amount of restrictiveness on the day to day behaviour of patients also brought about clinical handicap. There was some suggestion that the process of reform could reverse itself. Mapperley and Netheme had experienced major changes before 1960 and also showed improvement after 1960 in terms of restrictiveness on the ward, attitudes of nurses, number and range of personal possessions and so on, as well as in the clinical state of their patients; but after 1962 both hospitals deteriorated for the next 6 years until the measures of restrictiveness and clinical condition had reached the 1960 level again. The improvements already achieved by the time of the original visit in 1960, however, remained. At Severalls the reform had largely petered out by 1966 and indeed some of the least handicapped of the patients were allowed to become less active and showed more socially withdrawn behaviour. Within a year or so, therefore, wards at Severalls became more restrictive after an initial dramatic improvement, but the whole range of restrictions found at the time of the first visit did not return. One purpose of this paper is to explore how such planned improvement can be sustained. Is there a risk that something like this could happen to our present mooted large-scale reforms ? A hospital is a complex structure. It does not have a single line of authority [l I], and does not fit classical descriptions of bureaucratic organizations [12]. In Britain many are now run on a “firm” system with much authority vested in medical consultants who have considerable opportunity to run their part of the hospital along the lines they want. Administrative and nursing personnel form yet other hierarchies. The actual disposition of authority and power differs from hospital to hospital and depends on a host of organizational and personal factors. Some view power in terms of various coalitions of individuals and groups which may only come together over particular issues [I 3-151. Clear and agreed general organizational goals are unlikely to play much part in the day to day running of the organization, and priorities will often have to be worked out by negotiations between the various coalitions. But even negotiated goals can be vaguer than they first appear [16]. The demand for particular resources, such as new buildings, or more personnel, may be clear enough but the underlying objectives are often vague and little questioned in detail. There may, for instance, be a general aspiration to increase social worker support but little detailed attention to what it will do, beyond some vague reference to follow-up work or community care. Because goals tend to be vague and tied to particular sub-groups rather than to the whole organization, the hospital can get by with considerable latent conflict. Cyert and March have given an excellent description of how industrial organizations manage to live with such situations by what they call the “quasi-resolution of conflict”: organizations can thrive with considerable latent conflict in goals by simply by-passing it [14]. They often attend to one goal at a time and avoid facing conflict between the goals themselves. ROUTINE

ON

THE

WARD

One has to start somewhere in such a maze and a convenient beginning is the staffing of the ward. A notable feature of ward procedure is the many rules and routines governing

The Mental

Hospital as an Institutioh

409

activity. Lack of such conventions may create serious difficulties. One nurse has recounted some of her day to day problems soon after she arrived at a hospital: two doctors denying that a patient is their responsibility, failure of food to arrive from the kitchen, inability to get scheduled drugs, frequent failure of staff to turn up on duty, syringes taken by the outpatient department without notice when they had just been laid out to be used, bread delivered for several days to the ward upstairs who made no attempt to do anything about it, lack of towels, failure to get needed anti-biotics from the dispensary because of some special rule about ordering them, an assistant nurse who handed out all the drug dosages on the ward from memory, failure after 20 odd requests to the engineers to repair a banging door and so on [17]. Most of the nurse’s problems were due to lack of rules or routine, her ignorance of them, or the failure of others to keep to those which did exist. Life in a hospital can be hell without coordinating routines, but this does not mean that all of them are essential or desirable. Routinization can have unfortunate effects on both patients and nursing staff. On the old style “back” wards there was much restriction and control; and many of the practices can still be seen [lo, 181. These went with the neglect of skills (or the lack of opportunity to develop them), ignoring of conventional greetings and the use of overfamiliar terms of address and so on 1191.One can, without exaggeration, talk of a tendency to dehumanize the patient in the welter of routine. There is little reason to believe that more than a handful of the routines were imposed from “outside” the ward itself; and it is unlikely that all could be explained in terms of the exigencies of caring for a large number of patients. Certainly they were not all particularly efficient; and indeed some practices seemed no more than a self-imposed search for order on the part of the staff [lo]. Of course, some rules are laid down outside the ward itself, and many will once have had the welfare of the patient in mind, such as the “bathing parade” originally begun as a rational precaution against infectious disease [20]. However, most routines probably did not have this relationship. Moreover, externally imposed rules often had an ad hoc quality with little attention to wider consequences. The Ely Hospital Report [21], for example, suggests that nurses in subnormality hospitals should not be allowed to eat on the ward, ignoring the fact that this will deny the inmates just one more “normal” experience [18]. The meeting of one possible abuse will often create another. A nurse has a good deal of latitude in what she does even in the old-style ward. To some extent her work is an -‘art” requiring judgement about what should be done. This is clearly seen, for example, in the information that is fed back to the doctor or how “difficult” behaviour is handled. We can classify her possible rewards in three ways. There are extrinsic rewards obtained from money, power and prestige that can be obtained from doing the work. There are intrinsic rewards accruing from the work itself and the feeling of achievement and successful accomplishment that stems directly from the work. Herzberg has noted that something must actually be achieved if there is to be such reward [22]. Lastly there are ancillary rewards which are attached to the role itself and since they are more or less constant through time they are seen as part of the job rather than income received from extra effort. Examples may be security, a reasonable pension, a chance of an open air life and so on [23]. Research in industrial settings has established complex relations between such rewards and other variables; dissatisfaction, for example, may have little influence on output. Katz has argued that the motivation to produce is quite different from the motivation to remain in the organization, and that this helps to explain the lack of a relationship between job satisfaction and productivity [24]. Low intrinsic reward found in assembly work in the car

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Gm~cie W. BROWN

industry can be coped with by emotionally “opting out” of the work and emphasizing the importance of monetary rewards [25]. But the effects of such “opting out” are serious where the care of human beings is concerned. Apathy and general lack of interest as such cannot be conveyed to a component of a car, but they can to a patient; and yet often patients are treated essentially as objects. The common decencies and rituals of everyday life are either ignored or performed in so perfunctory a manner as largely to negate them. There is insufficient involvement for any kind of genuine appreciation of the person’s needs-even to the degree of becoming aware of them in the pragmatic sense of a good clinician or interviewer so that the job of influencing the person may be more efficiently achieved. Minor aspects of the task tend to dominate as with the. labour exchange clerk concerned only to send people out to a job (so he can chalk up a “contact”) quite ignoring the match of person and job [26]. How does this kind of thing occur? In the long run organizational factors are crucial, particularly in the intrinsic rewards they make possible from the work. In industrial research and consultancy there has been concern with ways in which to increase the “intrinsic” reward of work (although how far this influences actual practice can be exaggerated). “Participatory decision making” has been held out especially as a means of improving the morale and performance of workers [27]. In fact “intrinsic reward” is far from essential in industry. Lawrence and Lorsch suggest that high control and specification of working procedures are efficient where the environment is stable, predictable, unchanging and noncomplex [28]; and it can be added also where relatively minor departures from standard practice may have disproportionately serious consequences as, for example, in the case of an aircraft crew [29]. Where the environment is unstable, diverse and rapidly changing, clear specification of procedures is not e5cient. The result of specifying procedures depends, therefore, on the complexity of the task faced by the organization. It is sometimes overlooked that the nature of the work itself will limit the amount of genuine discretion and participation on the part of a worker, and in the long-run discrepancy between promise and fact is likely to be sensed and ‘resented [30]. However, where the care of human beings is concerned the complexity of the task depends on how the organization chooses to define the nature of the work. There is considerable scope for the beliefs surrounding the “output” to influence the nature of the work itself and, therefore, the rewards obtained. It must be allowed that at any particular time working conditions themselves may be obvious and straightforward explanations for lack of intrinsic reward in the work. But this is too limited a view. The most difhcult and demanding nursing can be found rewarding. Many tasks associated with motherhood or professional work are excessively dull, if not downright unpleasant, but the overall activity is not necessarily experienced as intrinsically unrewarding. Much depends on the broader aims. If activities arc tied to some overall goal which the person accepts as worthwhile, the actual nature of the task itself may not be of critical importance. Reward from a particular unpleasant task may be intrinsically neutral or even negative but the overall work a “positive” experience. Intrinsic satisfaction should not necessarily be equated with feelings immediately released by specific tasks. Nonetheless, routine tasks undoubtedly give less “intrinsic” reward. This is a persistent human predicament. Tomkins refers to the ideo-affective density consequent on the attainment of a skill : by which he means the degree to which an activity concerns and engages the awareness, feelingsand the ideation as well as the action of the individual [31a]. As a person becomes more proficient in a skill, such as a morning shave, his awareness, his affect and thought about it declines, so that he is hardly aware that he is shaving.

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411

“It will tteuer happen that I look in the mirror at the end and beam at myself-‘You are an extraordinary human being-you have done it again!’ We cannot be aware, let alone deeply enjoy iusrthose achievements in which we are most skilled, because these result from the compression of information into programmes which run off with minimal awareness and monitoring. Such reduction in idea-affective density has the function of reducing the load on the channel, freeing it for new learning. The price, however, may be quite severe because it results in the paradoxical consequence that we can be rewarded least by what should give us most satisfaction, i.e. the achievement of our highest skill”. [31b].

Tomkins believes that such routines can lead to experiences of tastelessness and depression with life and that individuals and societies must learn to enjoy the process of problemsolving if they are to experience enduring reward. Clearly there are exceptions. Skills can continue to prove rewarding if outcome is uncertain; indeed the difficulty of a job may be expected to increase intrinsic rewards as long as the person is not paralysed by low probability of success [32]. However, Tomkins’s general point has obvious relevance for organizational activity. There are often strong pressures from the person himself, his colleagues and his superiors to routinize activities, although this can, if he is not careful, lead to a sense of alienation from his work. At some stage the process of routinization can be dramatically hastened by a more or less conscious decision to keep the role as a sheet anchor and seek real satisfactions elsewhere. For some this may be increasing absences from the occupational setting itself, but the person tied to the work-place may do something like the nurses, described by Coser, who retreated into their 051~s to talk and drink coffee [33]. The discussion has so far centred on some longer term negative consequences of routiniz&ion; but routinization can have attractive short-term gains. It may, for example, assist collaboration; and anxiety about disturbed and ill patients may be reduced by keeping them at a distance [34). It is not only a matter of individual choice: organizational factors also encourage routinization and therefore risk of boredom and lack of commitment. Simon notes Gresham’s Law of Planning: “Programmed activity tends to drive out non-programmed activity from a job. Increasing routinization of the area controlled by an executive implies that his attention will be held by the programmed decisions” [35). There are other pressures. Hospitals, for example, have to deal with succession. A new incumbent to a job may take over the activities of his predecessor with little experience of the ideo-affective correlates, to use Tomkins’ term, surrounding the activity. Grob notes in his remarkable history of Worcester State Hospital 1830-1920 how the second superintendent took over the collection and analysis of the statistics of admission and discharge used with such effect by his predecessor. “Though he continued the practice, Chandler never gave much thought to the probability that such material would provide answers to unresolved problems; he continued to collect statistical data simply because his predecessor had began the practice. Thus while Woodward . and Chandler outwardly may have appeared to follow the same procedure the underlying rationale changed markedly.” IS].

The danger is not only that the activities will be less well done, but the encumbering routines may well lessen the new person’s chance of developing a perspective and commitment of his own to the job. This is not to suggest that routine can be avoided altogether; that would be a foolish and impossible aim. But where possible, work should be arranged so that non-routine activities play an important if not dominant role. SURVEILLANCE

AND

CONTROL

Organizational theorists have converged in their work on the importance of the specificity

412

GEORGEW. BROWN

of role prescriptions and the range of legitimate discretion [36]. They have described bureaucratic and charismatic [ll], mechanistic and organic [37], formalized and flexible arrangements [38], all making much the same distinction. In a somewhat similar way the importance of routines is emphasized in this paper. But the degree of routineness in the work situation should not be confused with the tightness of control and supervision. There is a great deal of variability in organizations of the same kind between the amount of routine in the work and the amount of surveillance. There is so much variation that Mohr has suggested that the predelictions of individuals are often crucial [39]. However, a number of the routines of ward life involve some kind of contact with persons of higher status. We know, for instance, a considerable amount of time can be spent by a ward sister making out reports to the higher nursing echelons; and members of the nursing hierarchy may make fairly frequent visits to the ward. And yet this is apparently compatible with gross maltreatment of patients. Such extreme abuse is probably not all that common, but its existence does highlight the issue of control. Ward life can be riddled with rules and yet there can be a surprising degree of autonomy. Crozier in a study of a particular state-owned French industry has shown one way this may occur [40]. He described how workers, maintenance engineers, low level supervisors and other groups fought to preserve and enlarge the area over which they have some discretion and to limit as far as possible their dependence on other groups. This is associated with strong pressures to conform to group standards and pressure to show loyalty to the group. Crozier’s key point is that once explicit rules are laid down they can be used by subordinates to control those above them: by keeping to the rules, and thus preventing interference, they can gain a good deal of independence from day to day surveillance. “Conformity is not a non-sided process. Subordinates will bargain with their own conformity and use it as a tool with which to bind management. This is just another aspect of the fight for control. Subordinates tacitly agree to play the management game, but they try to turn it to their own advantage and to prevent management from interfering with their independence. When this double pressure is stabilized and leaves very little freedom for adjusting difficulties, then an organization has become deeply rigid. This was the case with the earlier ritualistic clerk who made a point of following his instructions to the letter and ignored the reality with which he had to deal, not only because of his ‘trained incapacity’, but because he needed protection against too harsh treatment in the case of error.” [40].

In the mental hospital if there is general pessimism about what can be done for the patient there may be actual co-operation between status groups to reduce relevant rules to a few general principles, such as safety of the patient and cleanliness of the ward, so that all groups can live with the situation with a minimum of fuss. All parties will have an interest in reducing to a minimum the flow of information about what is “really going on”. Mechanic deals with related issues in his discussion of the considerable power that can be achieved by “lower participants’* in organizations such as the mental hospital [41]. The widespread pessimism will rob doctors and other non-ward personnel of significant work and there will be a general agreement to let nurses get on with the job. However, cause and effect cannot be always neatly separated: vicious circles are well known to students of bureaucracy [42]. For example, once communication between status groups is reduced there may be greater punitiveness over the few rules that are recognized; it is easier to punish someone who is hardly known. (At some hospitals a nurse could be immediately dismissed if a patient escaped.) This encourages rigid adherence to the rules and the development of embellishments to make double-sure punishment is avoided. Lack of communication will also enable those outside the ward to avoid having to recognize what is really

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going on; and they will then not be tempted to increase surveillance. This is not simply a matter of ignorance. Almost certainly most know reasonably well what is “going on”. If, however, they never have to deal with a formal “complaint”, they can directly avoid having to face what is going on and the resulting pressure to act upon the knowledge. Malinowski gave a classic description in one Melanesian village how all were aware that for years a fundamental rule was being broken by their chief (giving important favours to his own sons and not to his sister’s sons) but nothing was done until the sister’s sons in exasperation over a particular crisis shouted out at night what was happening for the whole village to hear [43]. Then those directly involved acted-Malinowski, I think, would argue had to act. In the hospital situation the nurses also know that complaints will encourage unwelcome interest in their ward. Many organizations develop ways of preventing “private” knowledge from becoming “public”. Some of the notorious difficulty in transmitting information up the hierarchy in a bureaucracy can be a result of the collaboration of those who most complain about it. It may appear as though participants actively develop such strategies. An alternative or complementary view is that there are certain persistent tendencies in organizations for routines, “short-cuts” and “failures to communicate” to occur and that these require considerable determination and energy to rectify. Convenient or advantageous “mutants” will therefore tend to be accepted; in this sense the sort of patterns of behaviour which have been outlined can evolve with little need for the participants to formulate clear strategies, although there may well be some awareness of what is happening, and a lively awareness of the advantages of the resulting situation. It is typical in organizations to find the kind of web of interacting and self-reinforcing causes just outlined. Others could be added. It is difficult to develop effective methods of control when they cannot be supported by the kind of easily measured “output” criterion so often found in industry. Further, if the work is potentially complex and assessment criteria only vaguely defined, any criticism can easily be seen as arbitary and therefore leading to tension. For this reason alone subordinates will try to “negotiate” for the recognition of a few “hard” criteria to judge their work and senior staff may well collaborate in order to avoid difficulty. This may well be common. For example, in judging the suitability of Town Planning applications, professional local government engineers, in giving advice to a lay Town Planning Committee, will use technical and legal criteria rather than get involved in aesthetic judgements which are difficult to defend. This may lead to a quite restricted set of criteria on which applications are judged; the same sort of process may occur in work with the handicapped. There may be surprisingly few ways used to judge the quality of care, particularly when bearing in mind the usual general plenitude of rules (towels must be laid out neatly at the end of the bed, etc.). Other themes could be added (any rules set up by those in authority may be used to set lower limits on performance [44]), but the general picture has been sufficiently sketched. Surveillance and rules and routines can vary independently and indeed highly developed rules and routines may be associated with little effective surveillance. Apathy and neglect are not the only possible consequences of pessimism and routinization. Outright cruelty can occur. This may stem from an unexpected source. Humanitarian beliefs and therapeutic pessimism can be a fatal conjuncture-they present the person in close contact with the patient with a conflict. The conflict is essentially similar to that dealt with by Festinger in his discussion of cognitive dissonance [45]; to reduce the dissonance of coexisting humanitarian beliefs and therapeutic pessimism it is possible either to

GEORGE W.

414

BROWN

change the objective circumstances, to change beliefs or to leave the job as nurse altogether. The iirst would be extremely difbcult, although there have been examples of nurses making major changes in the care of longstay patients largely on their own initiative. For those that do not leave there will be a tendency either to develop or to accept beliefs that dehumanize the patient. These need not be seen as developing from prejudice or some basic flaw in the Iiersonality of the individual-indeed, in a sense, they stem from just the reverse. If those in closest contact with the patient are going to live with some of the things that go on, and keep some kind of self respect they will be helped by the ideas and feelings surrounding such terms as “vegetables “, “dozies” and “animals”. Such terms immediately open up the way for still greater abuse. Great cruelty is possible in any social situation once persons have in some sense been defined as non-human. It is another example of a bureaucratic feedback loop. But such beliefs are far from irreversible. One can sometimes sense two quite separate sets of values held by nurses in custodial mental hospitals. One nurse when interviewed at Severalls Hospital cried openly about life on the ward she had been running for many years. She said she had known in a way that what had been going on had been wrong; that her patients had not really needed to sit around the walls of the ward day in and day out like cabbages doing nothing. But no one had told her. This nurse had worked at the hospital for many years and I suspect had not been unduly worried by such thoughts. Deeply felt humanitarian views which are present in most hospital workers will need strong social support to become generally effective. ORGANIZATIONAL

BELIEFS

ABOUT

THE

PATIENT

Nothing is probably more central in influencing the degree of routinization in hospital than the beliefs currently held about the patient and the efficacy of treatment. In the history of the mental hospital such beliefs have tended to be broadly consistent with the kind of care provided. There is no better documentation of this than in Grob’s history of Worcester State Hospital [8]. Reformers in the early 19th century believed that at some stage organic changes appeared in those suffering from mental illness which would make the disease incurable; but before the establishment of such permanent lesions psychological treatment could be effective. Therapy was judged by its apparent results. After 1850 when moral and psychological treatment apparently became less and less successful there was a tendency to revert to outright somatic theories which led to therapeutic nihilism, for until it was possible to correlate lesions with abnormal behaviour, no therapy-physical or otherwise-would be possible. A more recent example of the intimate link between beliefs about the patient and the care provided, concerns the role of the major tranquillizing drugs. One of the most important effects of such drugs in hospitals serving London was probably to change the attitudes of the medical and nursing stafT toward the desirability of discharging patients not visited in the month or so after their admission, the great majority of whom had previously been retained to become longstay patients [46]. Beliefs about the patient changed as a concomitant of changed beliefs about the efficiency of therapy. This is not to deny that the drugs had some direct effect; but the study of psychiatric practice suggests that the perception of the disorder to be treated and the perception of the efficacy of treatment have always been at least as significant for the care of the patient as the “natural course” of the disorder or the efficacy of treatment. It is difficult, for example, to interpret the success of insulin treatment in any other way [47]; and drugs can have powerful interactions with social factors [48 and 491. A key feature of psychiatric beliefs has always been a basically somatic interpretation of

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the various conditions treated in mental hospitals. Acceptance of a somatic basis for psychiatric disorder does not rule out the role of psychological and social factors in the aetiology and course of the disorder, but the basic model held by most hospital psychiatrists has always been a somatic one; symptoms are seen as internal events and tend, in day to day clinical practice, to be separated from the current social context. There is a tendency to think and to act in either-or terms. Or course, this is quite unnecessary; recognition of a genetic or somatic basis in a condition does not rule out the possible dominant importance of environmental factors in the aetiology or course of the disorder. We all know this; but in practice we tend to act as though one rules out the other. This is not just careless thinking but is tied to broad professional interests. Grob notes that: “Insistence upon the somatic nature of mental illness was of fundamental importance because of the consequences that followed. It permitted the psychiatrist to retain authority over the care and treatment of the insane who were sickor illaccording to the medical model of disease. Thus nurses, attendants social workers and other groups might be of use in the mental hospital, but only in an auxiliary and peripheral way; decisions remained in the hands of the psychiatrist. That the latter insisted upon such an explanation of insanity is not ditIicult to understand. His schooling and training were within the medical tradition; his interpretation of mental illness within that tradition was hardly novel. Indeed, had he taken the opposite view-that mental disease was not equivalent to physical illness and did not necessarily involve lesions of the brain or nervous system-he would have been immediately confronted with the problem of why he, as a physician, should have the 6nal authority in decisions atfecting tbe insane. Perhaps other specialities were more competent and better equipped to deal with a problem that was social and environmental rather than physical in nature.” [8].

There is no reason to amend this point to-day. Authority to detlne phenomena in certain ways is basic to the power, influence and success of a professional group. This has nothing to do with the correctness of the perspective as such; power can flow equally from truth and falsity. For some time there has been an influential movement identified with writers such as R. D. Laing attacking much current psychiatric practice. A good deal of the criticism is patently dishonest, but to dwell on this would be to miss a critical point; the attack is partly to do with the consequences of allowing psychiatrists to dew what are psychiatric phenomena. Claims about the nature of the conditions themselves are used as debating points. Because of this an important question is easily missed: what are the unintended consequences of holding certain medical beliefs (however correct) when they are not fied to an e&ctive therapeutic technology? Looked at historically, considerable harm has come from the use of a disease model in the care of those with persistent handicaps. Criticism of the unintended consequences of using a disease model as the basis of the care of the psychiatrically disturbed should not be confused with a critique of its scientific status. They are separate issues. Poor care may exist with basically sound theory about aetiology if the latter is not tied to an effective treatment programme. At the same time an effective treatment programme does not necessarily require sound theory about aetiology. It seems unlikely that an appropriate basis for the care of the handicapped can be found without the belief that something can be done, that the patient can be influenced in some way. Such optimism does not have to be based on a medical foundation as can be seen in the marginal role played by medical personnel in the early days of the Retreat at York. Nor, if a disease model is used, need such optimism be based on physical treatment or anything approaching ideas of cure or recovery. However, medical aspirations are geared primarily to ideas of cure based on immediate intervention preferably of a physical kind. Anything that is much short of this can lead to pessimism and the idea that nothing can be done.

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Coser in an interesting paper relates the goal of curability so dominant in the medical ethos to the apathy and alienation of a group of nurses caring for the chronically sick [33]. She examines two types of adaptation discussed by Merton in his well known paper on anomie: ritualism in which active striving has been given up though “one continues to abide almost compulsively by institutional norms”, * and retreatism in which there is an abandonment of culturally approved means as well, that is an escape active involvement in either goals or means [50]. There are certain difficulties in applying Merton’s scheme in an organizational setting, but basically Coser is concerned with a situation where there is a collective response, where the organization “itself has little of a culturally valued goal orientation”. She believes that a goal that is scaled down from curing the sick to merely caring for them encourages either ritualistic or retreatist behaviour. Stated beliefs about the patients provide a definition of the situation: “Wkat is considered disruptive in one situation is considered rewarding in the other. If patients are defined as “temrinal activities.” [33].

and custodial”,

plans to discharge them can be seen as disrupting

When the aim of discharge is not seen as feasible, when it is accepted that discharge is only likely to lead to readmission and when no alternative worthwhile goals are supplied, “work is not seen as a means of achievement but as ‘a job to be done”‘. Coser described meansorientated and goal-orientated attitudes and behaviour (similar to institutionally-orientated and child-orientated patterns of behaviour noted by King and his colleagues [lg] in the care of children). Nurses who are means-orientated tend to avoid the human implications of their work; work is mechanical. As one of her nurses explained: “Well, my dear, I don’t know. There isn’t anything that I find unpleasant. I have done it for so long, I just automatically do it.” Pessimism may take many forms and need not be clearly articulated : most commonly it simply leads to lack of interest. It is easily conveyed not only to patients but to nurses. One of the persistent failures of the medical profession in the care of the handicapped has been to ignore the need for setting, in conjunction with other professional groups, a sufficiently graded series of goals which both other stti and themselves could use to find the work useful and rewarding. For this it is unnecessary to cure a patient. Once it is recognized how little can be done a worker can be greatly rewarded by quite slow progress. The level of aspiration and the kind of feedback and reward provided by the organization is critical. The extreme case is where no change in the patient can be expected but where care can prevent deterioration. Here, since change cannot be perceived, recognition of what is going on must flow from institutional definitions of reality. Heartening progress has been made along these lines [51], but the aim must be to make it general throughout all psychiatric institutions. The possibility must be faced that a good deal of what has so far been done has been in response to situations of “crisis”, and we may still have to establish how decent patterns of care can be provided and maintained without the stimulus of extremes of neglect. We have discussed beliefs about patients’ medical status and general humanitarian standards. “Values” obtaining in society at large are also carried by patients. An empirical example is provided by general medicine. Two studies in the United States have shown that factors such as age, education, social class, occupation, parenthood, physical condition and alcoholism have been found to be an influence on the degree of effort made by medical personnel to save dying patients [52, 531. These are dramatic examples, but it is likely that psychiatric personnel as members of a broader social community are also influen-

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ted by such values. In addition conditions such as subnormality and dementia are also accorded less value than more “normal” ailments. They can add to the effect of more strictly medical values in determining the degree of interest shown in patients. Indeed, in the long run these more general social values may be of vital importance as determinants of what the medical profession finds interesting. Certainly they are likely to have an effect on the quality of care without special organizational values to combat them. WORKING

CONDITIONS

ON THE

WARD

It has been argued earlier that where there is little intrinsic interest in work the development of routines is most likely to have free play and various vicious circles may get underway to make the situation worse. It is unclear, however, how much weight one should place on the nurse’s perception of her job as a mechanical type of activity, contributing little to her sense of social identity, and how far it is the actual deadening and unpleasant nature of the work itself which is important. How far do nurses bound up in “means-orientated” and “goal-orientated” activity actually do the same things? Clearly both perception and actual behaviour play a part. The role of the beliefs about the work is critical, but any move toward routinization might be expected to decrease “intrinsic” reward and one need not dwell on the appalling working conditions that can develop in a crowded, poorly staffed and neglected ward. Indeed, many will say, most of the shortcomings in ward life can be explained by the fact that so often staff have far too many patients and too little time. The importance of such factors cannot be ignored. But they certainly do not explain the entire phenomenon. Hospitals can experience major changes with little increase in staff numbers. Under certain circumstances of shortage it might be impossible to improve conditions, but an increase in staff by itself will not necessarily lead to desirable changes. The organizational pattern of shift work, for example, may hamper the most efficient use of personnel and in such circumstances change in the patient to staff ratio is unlikely alone to have much effect on what is going on in the ward. There is a.point where conditions of wards will make poor care almost inevitable; but there is probably a wide range of circumstances that can lead to almost any kind of care. The main concern is with factors that determine good or poor care under such circumstances. The need for doctors to collaborate with other groups in the search for worth-while goals and to become intimately involved in the work at a ward level has been indicated. There are various ways in which such’ collaboration can be achieved. But there is a contlict that should perhaps be more honestly faced. A good deal can be said for the view that many handicapped patients need little more than that given by “moral treatment” which rests on a set of basically optimistic ideas about what could be done and conveying a sense of hope to the patient. In practice it meant “kind, individualized care in a small hospital with occupational therapy, religious exercise, amusements and games, and in large measure a repudiation of all threats of physical violence and infrequent resort to mechanical restraint” [S]. This is a reasonable aim for most, if not all, chronically handicapped patients. Perhaps it is enough. The trouble is that it is not necessarily seen as professionally challenging and demanding. Vague treatment schemes such as that proposed by the “therapeutic community” movement have been very influential [19, M-571 ; but their chief merit may be the continuous interest shown in the patient. Rosengren has interpreted the propensity for such regimes to develop “pseudo-crises” about individual patients in just these terms [58]. One threat to such programmes is that they are so poorly grounded in theory and research that they are vulnerable to swings of fashion and negative findings of systematic research

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[59]. Perrow [60] overemphasizes psychiatry’s lack of an effective set of treatment techniques (seeing things very largely in curative terms), but there is a real risk in the care of those with long-term handicaps that what can be done will appear inadequate when set against what is ideally required. It is tempting to suggest that care outside a medical system based on common sense humanitarian notions might be the most effective solution. Ring, Raynes and Tizard discuss the shortcomings of a nursing training, for example, for the care of subnormal children [18]. But this is not the same as suggesting that common sense notions are enough. The most effective hostels in their study were managed by staff trained for local authority child care work; the worst voluntary home was run by untrained staff. It may be that the effective care of handicapped individuals requires some kind of special flair and experience and that the purpose of training is not necessarily to provide systematic knowledge, but to give some sense of purpose to those involved in the work. If care is going to remain in the hands of the medical profession, it must remain vitally involved in the work. Coser considered that complex patterns of interaction between staff on the ward were necessary to support an effective system of care for severely handicapped patients. Various professional groups worked next to each other, with each other and sometimes in competition with each other. They were held together, she believed, by their common commitment to the goal of returning patients to the community. Controversy, differences of opinion and tension were common. Informal and formal contact provided a way of judging the work of others, and a means of social control. The conflicting expectations and problem solving on the job enabled the staE to obtain a better idea of their work and a professional self-image that differentiated them from other groups. It is not the existence of different statuses in itself that is important but the fact that they are forced into close contact with each other-contact that cannot readily be controlled by the kind of strategies described by Crozier in the French industrial setting. Of course, such a working arrangement can have its difficulties and unsettled conflict can lead to grave personal difficulties and withdrawal that has harmful effects on the organization itself [61]. There is also always the possibility that detrimental standards of work will develop in any type of unit. Miller and Rice have recently discussed this in terms of the task group (individuals required to do a particular task) and sentient group (individuals prepared to commit themselves, and depending on each other for emotional support) [28]. There can be various degrees of coincidence between the two. They argue that where task and sentient groups coincide on a more or less permanent basis only short-term effectiveness can be achieved. “In the longer term such groups can inhibit change and hence lead eventually to deterioration of performance and, in consequence, to social and psychological deprivation rather than satisfaction”. Miller and Rice suggest temporary project systems as a solution. Such temporary work groups discourage the formation of group standards detrimental to organizational efficiency, while providing sufficient social relationships to satisfy personal needs. The model is consistent with the emphasis placed in this paper on the possible untoward effect of routinization, but it is not easy to work out the implication of their argument for the care of the handicapped. That a nurse should be employed on the same hospital ward at Whittingham hospital for 47 years was clearly undesirable [62], but at the same time some continuity is necessary. Indeed, it may well be that one weakness of the kind of multiple status group described by Coser is that it suffers from much too great a turnover of staff (although this has not been demonstrated), making it difficult to maintain stability of its belief system and personal knowledge of individual patients. In a teaching hospital, for

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,419

instance, the whole atmosphere, outlook and working style of a unit may be radically changed at the time of the six-monthly transfer of registrars. We need to know more about the consequences of the rate and kind of turnover of staff on the quality of work in different kinds of working group.

THE

LARGER

ORGANIZATIONAL

SYSTEM

The ward is part of a larger organization where there will be a political system geared to settling the allocation of resources [63]. Co&s well staffed rehabilitation unit may only have been possible in the particular local circumstances because of the gross neglect of the rest of the hospital. Coalitions and individuals attempt to get the organization to focus on their goals. Here again the beliefs about what can be done for patients are vital. They can, for example, be used as weapons in the struggle. Allocation of resources is often made on the basis of some kind of special pleading about some local need and the strength of the coalition plugging it rather than in terms of an overall plan [14]. Complex bargaining positions may develop and beliefs and values manipulated rather cynically. Where there are many tasks (different grades of handicap, out-patient work, research and so on) a particular allocation will always be in danger of revision. Apparent success or failure of a programme may equally provide the opportunity for some kind of cut-back. Both may lessen the persuasiveness of the case that can be made for continued support and the willingness of persons to fight for the allocation. Care of the chronically handicapped in a pluralistic organizational system faces special difficulties. The work must have firm support in the higher reaches of the organization. (Although I ignore it, some members of the wider professional group will need to influence the political system outside the immediate organizational system). Good work at a ward level is, in the end, unlikely to prevent deterioration in standards of work even on that ward. The wider system in the long run is bound to influence the smaller sub-units if it is ignored. There is always the danger with so much else going on that supporters will get involved in work of a more crisis-orientated or “interesting” kind. The Whittingham Hospital Committee of Inquiry noted that one consultant who had eight sessions per week at the hospital spent seven in his deaf unit of 26 beds and devoted only one to 625 long stay beds. The unit also had the only whole-time social worker in the 2000 bedded hospital. There was one part-time worker for the rest [62]. This kind of pressure to “specialize” may be so strong that there is an actual attempt to subvert the goals of the organization-by, for example, a senior doctor taking on at his own initiative the treatment of behaviourally disturbed adolescents in a hospital devoted solely to the care of subnormal children. Another risk is that the needs and weaknesses of a particular section may come to influence the whole organization. A few understaffed wards may lead to a general demand for particular nursing practices appropriate only to understaffed wards throughout the whole hospital; and even if this does not occur there is the chance the “old” patterns will follow in the wake of transferred staff. Such risks will have to be faced with little hope of a permanent solution. Since basic disagreements over the allocation of resources are unlikely to be resolved there is always the risk that retirement of a charismatic figure or a similar event will start a period of decline. But large multi-purpose institutions have potential advantages. For example, by careful playing on inequalities of provision, large gains may be made for more unprivileged sections. However, small, relatively autonomous units have perhaps more obvious advantages. In

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BROWN

particular they have less need to develop the web of routines so important for survival in a large organization. But it would be foolish to see them as a panacea. Political support will have to be sought at some level of the organizational system in which they are a part. They may at times find it more difficult to attract good quality doctors who may therefore be under less informal pressure from their peers. The influence of the beliefs brought to the unit by professional training may still be overwhelming. King, Raynes and Tizard suggest that a nursing training may override the effect pf the size of the unit in determining institutionally-orientated child-care practices [18]. Well-staffed local units may mean neglect elsewhere. It is hardly profitable to pursue this kind of speculation without more empirical data. But it should be rememberedthat while it is relatively easy and tempting to experiment with small units, successful procedures may be difficult to repeat away from the glamour and publicity of an evaluative study. The “Hawthorne effect’* has become something of a hackneyed warning, but pertinent for all that. Two points are worth bearing in mind regarding demonstrative research. Work in industry suggests that small and limited tinkering with a social system is unlikely to lead to long-lasting changes [64, 661; and that projects need to be shown to have (to use Campbell and Stanley’s terms) “external’* as well as “internal” validity [67]. To show intervention has an effect is not enough; will it work without the paraphernalia of a research investigation? A demonstrative research project run by an enthusiastic director can, quite probably, show that almost anything will work. THE

FUTURE

Psychiatry has a dilemma. It cannot base itself solely on a short-term curative outlook while so many of its patients remain with longterm handicaps. There are already suggestions that those retained in local general hospital units for longer than a year may have to be transferred to other places [68]. This in itself may be all right but it has an ominous ring. I have assumed that some longterm provision will be required-some of it perhaps on a hostel-type basis. Care can be organized on a bureaucratic type structure which if efficiently done will avoid extreme and obvious abuse. There is good evidence that where a task is clearly specified surveillance can lead to improved performance, but most of the work which has been done is related only to “industrial” and “administrative” tasks [69] and even here the process can be taken too far. For example, Marks and Spencers have recorded the massive savings stemming from a scheme to give workers more discretion. Inventory replacement cards, sales receipts, time clocks, and similar procedures were eliminated with a general increased discretion at the lower administrative levels [70]. Quite new factors are involved when we deal with the longterm care of human beings and we face the question that runs throughout this paper-can care of those with longterm handicaps be humanely and efficiently run on a routine, bureaucratic basis? I do not know the answer; we do know such care can easily deteriorate, and it is difficult to be enthusiastic about this kind of organizational basis. Certain things are, however, reasonably clear. The medical profession must become much more aware of the dangers that stem from the very thing they most value-their training. Quite specific goals are ideally required (such as reduction of time patients spend doing nothing) always remembering that such practices can easily deteriorate into empty routines without an appropriate motivational climate. Practices will need to be tied to specific belief structures that can be seen to be relevant [65]. Feedback and surveillance from work teams containing a variety of professional statuses is to be preferred to formal surveillance through a lengthy hierarchial system, but the benefits that can be obtained from .

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simple systematic and relevant reports and visits should not be overlooked. The main danger has already been stated. Because of his training the care of the longterm handicap may not interest the psychiatrist enough and processes will be set in motion whereby only “part” of the patient is dealt with. This does not arise necessarily from falseness of the disease model itself-the idea that it is something inside the patient that is critically important. If it were there would be much less of a problem. The success of the new local general hospital units [l] is likely to depend on how far and in what way accumulated “residues” of handicapped patients are “split off”. The Whittingham Hospital Committee of Inquiry has voiced disquiet at the so-called “closing” of the large hospital (H.M.S.O. 1972). There is a tendency in the current wave’of reform to siphon off the more “curable” to local units and leave the residue in the larger institutions at the same time indicating that the usefulness of the institution has about run out-which for this reason alone may fail to reform or may degenerate into custodial-style hospitals. It is probably not a coincidence that Whittingham hospital is a part of the Manchester Hospital Regional Hospital Board which has placed particular emphasis on new local units and the closing down of the large mental hospital. It is obvious that the new units should, if possible, cope eventually with all patients from their catchment area; but there has been what would appear to be a remarkable underestimation of the number of beds that will be eventually required to do this [71, 721 and a case can certainly be made for the need for most of our large hospitals for many years to come [73]. Whatever happens it seems likely that chronically handicapped patients are likely to be “split off” in some way, if only within a local unit. This kind of dispersion might involve the reallocation of authority. Whitehead and Fannon [74] have described an interesting innovation where a senior nurse took over the routine medical responsibility for a group of longstay patients in a large psychiatric hospital-a clear example of increasing discretion and intrinsic reward. My concern is that most medical reform simply tinkers. Psychiatry must face the definite possibility that what happened in its large hospitals was not only the result of factors such as size and understa&ng. The current position about who is responsible for the care of the chronically handicapped is far from clear. The recent government circular on “Hospital Services for the Mentally 111”states : “Those who organize and run hospital services will need to discuss with local authority social services departments the extent of the need for community services, including hostels, group homes, supervised lodgings schemes and social work support. There- should be agreement between the hospital, local authority department and local medical committee on discharge and t-e-admission policies, especially for those patients who will need to use local authority residential or other social or health services. It should be the responsibility of the local authority social services department, where necessary, to find suitable residential accommodation for patients discharged from hospital, and to do so in consultation with the hospital staff. Local authority social workers are usually best placed to arrange admission to local authority accommodation and also to registered homes, and to find and supervise suitable landladies. In some areas hospital staff at present carry out this function, where they do it is essential that they should do so in close collaboration with the loca! authority social workers who will be concerned with after-care.” [l].

Clearly those needing long-term care are involved here: and clearly no definite policy has been worked out. Whether it will be medical or non-medical authority that will in future bear the major responsibility has yet to be settled. At present social service departments are not all eager to follow the possible implications of government policy. But if in the long run the attitudes of medical personnel about psychiatric conditions are critical determinants of the quality of care, what reason have we to believe that the same

GEORGEW. BROWN

422

processes will not evolve, on a smaller scale, in the hostels and iongstay units of a locally based psychiatric system of care? In these settings personnel still need to be motivated; still need an appropriate belief system. Psychiatrists are still likely to play a critical role even if they no longer have immediate responsibility. Here again I do not refer to the best, but what might generally occur. The principles of preventing institutionalism will apply equally to a local authority horpe as a hospital. In the end the individual is of critical importance even within a highly bureaucratic organization. “The act of choice . . , places the individual in the forefront of organizational behaviour. In the final analysis men think, feel, choose and act. Responsibility in these unique forms of individual behaviour cannot be abdicated in the name of organizations and institutions.” [75]. Our view of the responsibility of psychiatrists should be extended to include not only the patients’ health and welfare but also the morale and motivation of ail individuals concerned with his care. Professional training should emphasise this heavy responsibility. There is here an intricate and delicate balance of professional responsibility, commitment to the work and self interest which I hesitate to explore further. It seems obvious though that if psychiatrists do not give up their authority for the care of those with long term handicaps, they might well find a substantial sharing of the responsibility not without benefit for their charges. REFERENCES t of Health and Social Security, Hospiral Services for the Mentally Ill. H.M.S.O., London,

1. z?men

2. 3. : 6. 7. 8. 9. 10. 11. 12. 13.

G. W., BONE, M.. DALISON,B. and WING. J. K. Schizophrenia and Social Care, Maudsley Monograph, No. 17. Oxford University Press. London, 1966. R~SENGREN, W. R. and Lapro~, M. Hospital and Patients. Atherton, New York, 1969. BOCKOVEN, J. S. Moral treatment in American psychiatry. J. neru. ment. Dk. 124, 167, 1956. BROH~N, G. W. Length of hospital stay and schizophrenia: a review of statistical studies. Acra psychiot. neural. scami. 35,4lU30, 1960. CQWY, J. l% neattnenr of he Imane without Mechanicxal Restraints. Smith & Elder, London, 1856. DEUTXH, A. l%e Mentally Ill in America. Columbia University Press, New York, 1949. GROW,G. N. 7Re State and the Mentally Ill: A History of Worcester State Mental Hospiral. Massachuserts x830-1920. University of North Carolina Press, Chapel Hill. 1966. Rtzs, T. P. Back to moral treatment. J. metu. Sci. 103,302314, 1957. Wmo, J. K. and BROWN, G. W. InsGtuGonalism and Schizophrenia. Cambridge University Press, Cambridge, 1970. HENRY,J. The formal structure of a psychiatric hospital. Psychkztry 17, 139-154, 1954. WAGER,M. l%e Theory of Social and Economic OrgwnizaGon. The Free Press, New York, 1947. BUCHER,R. and STELLING,J. Characteristics of professional organizations. J. Hlth & sot. Behau. 10, 3-15. CYERT,R. M. and MARCH, J. G. A Behauioural Theory of the Firm. Prentice-Hall, New Jersey, 1963. BRO&,

14. 15. STRAUSS,A., SCHATZMAN,L., EHRLICH,D., BUCHER,R. and SmHm, M. The hospital and its negotiated order. In 7%~ Hospital in Modern Society (edited by FREUX~N, E.) The Free Press, New York, 1963. 16. PERROW,C. The analysis of goals in complex organizations. Am. Social. Rev. 26,854-866, 1961. 17. ROBB,B. SUIJSEverything. Nelson, London, 1967. 18. KEG, R. D., RAYN~S, N. V. and TIZARD, J. Patterns of Residential Care. Routledp & Kegan Paul, London, 1971. 19. GOFPMAN,E. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Doubleday, New York, 1961. 20. CLARK, D. H. Administrative Therapy. Tavistock, London, 1964. 21. Denartment of Health and Social Security, Report of rhe Committee of Inquiry into Allegations of IIIl’kiarrnenr of Patients and other Irregularitk at-the Eiy Hospital, CaraT... H.M.S.O., London, 1969. 22. HEIUBERG,F. One more time: how do you motivate employees? Harv. Bus. Rev. 46, i, 53-62, 1968. 23. tiRlIE, D. C. The balance of control and autonomy in elementary school teaching. In The Semi-Professions and their Organization (edited by ET~IONI,A.) The Free Press, New York, 1966. 24. KATZ, D. The motivational basis of organizational behaviour. Behaul Sci. 9, 131-146, 1964. 25. GOLDTHDRPB, J. H., LOCKWOOD,D., BECHHOFER, F. and PLATT,J. The Afluent Worker in the Class System. Cambridge University Press, Cambridge, 1969.

The Mental Hospital as an Institution

423

l

26. BLAU,P. M. 7lte Dynamics ofBureuucracy. University of Chicago Press, Chicago, 1955. 27. LENIN, K. Field Theory in Social Science. Tavistock, London, 1952. 28. LAWRENCE, P. R. and LQRSCH,J. W. Organization and Environment. Graduate School of Business Administration, Harvard University, Cambridge, 1967. 29. MILLER,E. J. and RICE, A. K. Systems of Organization: The Control of Task and Sentient Boundaries. Tavistock, London, 1967. 30. ETZIONI,A. interpersonal and structural factors in the study of mental hospitals. Psychiatry 23, 13-22,196O. 31a. TOMKINS,S. A modified model of smoking behaviour. In Smoking, Health and Behaviour (edited by BOROA~A,E. F. and EVANS,R. R.) Aldine, Chicago, 1968. 31b. To-s, S., Personality, theory and social science. In interdisciplinary Relationships in the Social Sciences (edited by SH~IUF,M. and SHERLL,C. W.) Aldine, Chicago, 1%9. 32. PATCHEN, M. Participation, Achievement and Involvement on the Job. Prentice-Hall, Englewood Cliffs, New Jersey, 1970. 33. CUSER,R. L. Alienation and the social structure: case analysis of a hospital. In Tire Hospital in Modern Society (edited by Fita~~so~, E.) The Free Press, New York, 1963. 34. CLANCEY, I. L. W., CUMMMG,J. and GUMMING, E. Training psychiatric nurses: a m-evaluation. Con. psychiat. Ass. 1. 2, 26-33, 1957. 35. SIMON,H. A. The New Science of Management Decisions. Harper, New York, 1960. 36. HICKSON, D. J. A convergence in organizational theory. Admin. Sci. Q. 11,22&237,1966. 37. BURNS,T. and STALKER, G. M. The Management of Innovation. Tavistock, London, 1961. 38. WHYTE,W. F. Incentives for productivity: the Bundy Tubing Company case. Appf. Antkrop. 7, l-16, 1948. 39. MOHR, L. B. Organizational technology and organizational structure. Admin. Sci. Q. 16, 444-459, 1971. 40. CROZIER,M. The Bureaucratic Phenomenon. Tavistock, London, 1965. 41. MECHANIC.D. Sources of Dower of lower particimmts in complex organizations. Admin. Sci. Q. _ _ - 7,. 349-364,1662. 42. MARCH,J. G. and SIMON,H. A. Organizations. Wiley, New York, 1959. 43. MALINOWSKI, B. Crime and Custom in Savage Society. Routledge & Kegan Paul, London, 1962. 44. GOULDNER. A. W. Patterns of Industrial Bureaucracy. Glenwe, Illinois, 1954. 45. FE~T~NG~R, L. A Theory andcognitive Dissonance. Stanford University Press, 1957. 46. BROWN.G. W. Social factors influencinn- lenath _ of hosnital stay of schizouhrenic natients. Br. Med. J.

ll, 1300-1302, 1960. 47. ACKNER,B. and OLDHAM,A. J. Insulin treatment of schizophrenia. A three year follow-up of a controlled study. Lancet i, 504-506,1962. 48. BENNETT, D. Socialtherapy and drug treatment in schizophrenia: a review. In nertu!s in the Mental Health Services, Vol. 2 (edited by FREEMAN, H. and FARNDALE, J.) Pergamon, oxford, 1967. 49. RATHOD,N. H. Tranquiliizers and patients’ environment. Lmtcet i, 611-613, 1958. 50. MEXTON,R. K. Social structure and Anomie. In Social Theory end Social Structure. The Free Press, New York, 1957. 51. WING, J. K. Social treatment, rehabilitation and management. In Present Devetbpments in Schizophrenia (edited by COPPEN,A. and WALK,A.) Royal Medico-Psychological Association, London, 1967. 52. GLASER,B. G. and Snuvss, A. L. Time for Dying Aldine. Chicago, 1968. 53. SUDNOW,D. Passing On: The So&l Organization of Dying. Prentice-Hall, E&wood Cliffs, 1957. 54. JONES,M. Social Psychiatry: A Study of Therapeutic Communities. Tavistock, London, 1952. 55. JONES,M. Social Psychiatry in the Community, in Hospitals and in Prisons. Thomas, Springtield, 1962. 56. JONES,M. Beyond the Therapeutic Community. Yale University Press, New Haven, 1968. 57. MARTIN.D. V. Adventure in Psychiatry. Gxssirer. London, 1962. 58. ROSEN&EN,W. R. Communication, organization and conduct in the “Therapeutic Milieu”. Admin. Sci. Q. 9, 70, 1964. 59. RAPOPORT,R. N. Community as Doctor. Tavistock, London, 1960. 60. PERROW,C. Hospitals, technology, structure and goals. In Handbook of Organizatians (edited by MARCH,J. G.) Rand McNally, Chicago, 1965. 61. KAHN, R. L. WOLFE,D. M., QUINN,R. P., SNOEK,J. D. and ROSENTHAL, R. A. Organizational Stress. Wiley, New York, 1964. 62. Her Majesty’s Stationery Office, Report of the Committee of Inquiry into Wkittingkam Hospital, Cmnd. 4861, London, 1972. 63. BURNS,T. On the plurality of social systems. In Operational Research and the Social Sciences (edited by LAWRENCE, J. R.) Tavistock, London, 1966. 64. BLAKE,R. R., MOUTON,J. S., BARNES,L. B. and GREINER,L. E. Breakthrough in organization development. Harv. Bus. Rev. 42, 133-155, 1964. .s.s.?d.7/6-B

GEORGEW. BROWN

424

L. B. and ZAL~ZNIK,A. The Distribution of Authority in Formal Organizations. 65. DALTON,G. W., BARNES, Harvard University Graduate School of Business Administration, Cambridge, 1968. 66. Lowt~, A. Participative decision making: a model, literature critique, and prescriptions for research. Organ1 Behav. & hum. Perform. 3, 68-106, 1968. 67. CAMPBELL,D. T. and STANLEY, J. C. Experimental and quasi-experimental designs for research on teaching. In Handbook of Research on Teaching (edited by GAGE, N. L.) Rand McNally, Chicago, 1963. A. G. and &ED, I. A. Forecasting psychiatric bed needs. Lancer i, 251-253. 1972. 68. MIZZEY, D. The Relationslip between Administrative Activities and Hospital Performance, Center 69. NEUHAUSER, for Health Administrative Studies Research Series 28, University of Chicago, Chicago, 1971. 70. BECKER,S. W. and GORDON, G. An entrepreneurial theory of formal organizations: Part 1. Admin. Sci. Q. 11,315-344,1966.

71. Department of Health and Social Security, On the state of the Public Health. Report of the Chief Medical Oficer. H.M.S.O., London, 1969. 72. WING, J. K. How many hospital beds? Psychof. Med. 1, 185-190, 1971. 73. StaiBng our asylums. Br. Med. J. I, 523-524, 1972. WHIT~H~AD.J. A. and FANNON.D. A clinical role for senior nurses. Lancet ii. 756-758, 1971. ;:: ZALESNIK, A. Human Dilemmas of Leadership. Harper & Row, New York, 1966.