- Email: [email protected]
THE WHIRLIGIG OF TIME A Cautionary Tale
1409
Very Special Articles
psychological disorders. But in the ’60s, under guise of spiritual therapy or pastoral counselling, they increasingly did so. In the early ’70s enthusiasm gradually waned, and churchmen, after their brief flirtation with psychiatry, reverted to problems they could more easily solve-such as the purpose of life, the existence of God,
manage
the
THE WHIRLIGIG OF TIME A
Cautionary
Tale*
NEIL KESSEL M.R.C.P., D.P.M.
and
M.D. Cantab.,
PROFESSOR OF PSYCHIATRY, UNIVERSITY OF MANCHESTER
Wen Iy wos lookn throo th relevnt litrachur prepairn miy thorts faw this papr ly kaim akros th ovprint ov an artikl biy Feste, publishd in 1995, oanli larst yur, but wich ly doo not rimembr reedn bifor. Th jurnl Konsum. Siykiat. was nyoo too mi. Konsum. Wot kood that stand faw? Konsyoomer, posibli, faw this is an aij wen th pashents welfair has faw th furst tiym bikum paramownt. No. Most probabli it stood faw Konsummat. Indeed Iy now reekawl heern ov a nyoo jurnl wich wood selebrait th emerjenz ov siykiatri from th dark peeriyod bitween 1945 and 1975 wen pashents wur sakrifiysd on th too orltars ov Farmakologikl Egsooberanz and Komyooniti Kair. Thows ov us hoo bilong to th old skool, hoo developd thair iydeers in th urli sikstis, mai fynd it hard to agree kompleetli with th awthr but his argyooments are kojnt and fawsfl. So with his purmishn, heer it is. Yoo will awlredi hav notd that ly am not at eez yet with Rashnl Speln; pleez fawgiv mi thairfaw, if Iy reeprodyoos it in th styl with wich ly am maw familya.
so on.
By the mid-’60s the mode was all for " generalhospital units ", often even poorer in amenities than the old mental hospitals. The unsuitable conversion of existing medical wards provided too little space for necessary recreational facilities. Small wonder then that the patient was treated in the community for as long as possible, despite the difficulties this caused to him, his relatives, and his general practitioner. INNOVATORS AND EVALUATORS
Yet all these developments must have seemed sensible and worth trying at the time, for psychiatrists were almost as intelligent then as they are now. But the innovators were so sure that the changes were beneficial that they did not evaluate them. New drugs were never administered without adequate clinical trials; but treatment procedures of a management kind were hardly ever properly assessed. The innovators, indeed, were chary of evaluation. They thought evaluators unreasonable to ask them to state their goals precisely; moreover, this often proved unexpectedly difficult. Their grand designs seemed strangely reduced in the process. Innovators often believed that their programmes would in some way promote the mental health of the whole community and were loth to be pinned down to purely treatment goals. They suggested that the benefit accruing from their proposals should not be Konsum. Siykiat, 1995, 3, 780-783. measured because it could not, and that it could not LIBERATION OF PATIENTS because it concerned intangibles like human happiness by and immeasurables such as the degree of recovery. In N. V. FESTE this the innovators were wrong, but there was some M.D. Illyria, F.R.C. Psych. justification for the disfavour with which they viewed the At last we can say that the inglorious era of the Comoperational units of mensuration that evaluators customunity Care movement is at an end. The notorious marily adopted. Such items as length of time in hospital, period of 1945 to 1975, which saw a spate of precipitate or out of it, were oversimplifications of a complex matter. Innovators were dubious, too, of the use of test measures releases of only partly recovered patients, is over. Patients and statistical techniques which they did not properly are now once more being treated with concern, compassion, and respect for their human dignity. Treatment understand. Somehow they lost control of the evaluative is once again becoming a function of the medical prostudy as it entered the mathematical mill; they were fession. suspicious that the evaluator might produce, by some THE PAST statistical sleight-of-hand, some computerised prestidigiof did the How creators community-care programmes tation, an adverse verdict which they could not quite comprehend and were therefore powerless to rebut. Quis go so badly astray ? It was because psychiatrists brought aestimabit ipsos aestimatores?The weakest argument of in all their innovations, each one hot on the heels of the the innovators, though perhaps the most powerful last, without pausing to evaluate them. Mental-hospital directors vied with each other to do something new and emotionally, was their conviction that the changes they proclaim it. The years 1945-1950 saw the ejection of were advocating were good and that to furnish proof of chronic patients, often homeless, who readily found a job, this was supererogatory. The evaluators on the other hand were by nature nullbut less often their feet, in society. This was followed by the era of early discharge, when, on the untested principle hypothesis-minded. They approached any innovation certain only in their questioning of its efficacy. They that it was better to be out of hospital than in, patients found it difficult to get the innovators to state precisely were discharged as soon as their behaviour had improved sufficiently, but before they had properly recovered. As their aims. Since detail was not forthcoming from the the number of chronic patients capable of being disinnovators, the evaluators had themselves to suggest it, and they found it hard work to persuade the innovators industrial rehabilitation charged dwindled, began. of the appositeness of the operational definitions and One historical peculiarity deserves special mention. This was the reawakening of interest in psychiatric care functional measurements they proposed. Lastly they by religious organisations. Not since the 17th century feared (with good reason sometimes) that little account had ministers of religion regarded it as their province to would in the end be taken of their findings, should they * conflict with the innovators’ expectations. Some excuse Based on a paper presented at a U.S. National Institute of would be found-that the wrong sorts of measurements Mental Health international research seminar, May 17-20, 1966. "
"
1410
had been made
or that the assessment period was not adequate-for setting aside all their painstaking labour. Potential evaluators, who generally possessed the skills of the epidemiologist, had many other claims made on their time and were not attracted to this task, though they recognised its importance. Those who financed all these developments must accept a large share of the blame. They were content to pay for developments without demanding evidence that they would work or did work. Great capital sums were disbursed to set in action projects of untested merit (which is just excusable) without demanding any future test (which is not).
THE NINETIES
Now, however, the whole community care movement has been halted. Today doctors receive, during their training, a thorough grounding in psychological disorders and they are recognised to be the right people to treat patients. The bad old days are over, when an army of social workers or mental welfare officers, employed by local authorities and guided by a medical officer of health who had had little or no formal education in psychiatry, supervised the progress of the mentally ill. Psychiatric patients no longer have to live at home, upsetting, or being upset by, close relatives, whose emotional involvement precluded the dispassionate care and attention that was needed. Those without homes are no longer urged to go into lodgings or hostels. Today we no longer force patients to work. Perhaps our new leisure economy, with an abundance of labour, is one reason for this. Criticism of our predecessors must be tempered with a realisation of the grim industrial situation which then beset Britain. Every ablebodied person was needed to work. Automation was only in its infancy. Nevertheless, even then it should have been appreciated that an able body was not enough to man a machine; an able mind was also a desideratum. Such was the coercion to work that many mental hospitals set up factories in their own grounds-forcing-houses for the labour market. The propaganda convinced patients that this was to their advantage, and they vied with one another to attend. Disintegrated men stood and pulled levers for eight or ten hours a day, without communicating at all with their companions; indeed, often they were unable to communicate, so absorbed were they with their hallucinations and disordered private thoughts. We can only marvel that a situation which Shaftesbury would not have tolerated a century before was regarded as humane and
progressive. The largest change, of course, has been the provision of ample suitable accommodation for psychiatric patients. Thanks to the enormous advances made by the profession of hotel management it became possible to provide desirable places for several thousand people in the countryside close to the communities in which they had always lived. When naming these establishments, great care was taken to avoid the stigma of the term " community mental health ". Patients had become as reluctant to enter a community mental health service as they had previously been to go into the asylum or the mental hospital. Eventually, the term " withdrawal house " was adopted. Retreat had been a popular suggestion, but was finally discarded at the request of the psychiatrists of the Armed Services. Withdrawal houses are situated within their own private parkland and provide comfortable dormitory accommo-
ample opportunities for recreation; or help with the farm if they are so minded and for those who prefer indoor amusements special games and occupations are provided. The accent is on craft work, such as the weaving of baskets, rather than on the production of anything useful. This is so that the patients realise there is no need for their work. It is recognised that not all such pursuits are aids to treatment. The assistants who help patients to divert themselves with these pastimes are no longer called occupational therapists, and, although many patients like to paint, this activity is no longer pretentiously described as art therapy. For most of the day the patients are left to their own devices with little or nothing that they have to do. The domestic staff preserve the archaic title of nursing assistants ", though they need only the simplest of training. Few are required since most of the patients see to their own simple wants. dation. There
patients
can
are
garden
"
There is no shortage of accommodation in the withdrawal houses, and no patients are turned away. This is in sharp contrast to the harsh period of the ’60s when mental hospitals in Britain were so concerned with their curative role that it became next to impossible to secure the admission of patients who needed temporary asylum but could not be expected to undergo any long-term change in their psychological state. Moreover, no patient has to leave hospital unless he wants to. CONCLUSION
conviction that what we are doing is good Despite and beneficial, some of the older psychiatrists take a contrary view. They believe that present-day trends are retrogressive and comfort themselves by believing them to be no more than an unfortunate swing of the pendulum. They still maintain that community care had great merits and was an important advance in psychiatric care. Why then, one must ask, did they not demonstrate that their methods were good ? They had their opportunities and did not take them. There is an object lesson in this for us all. Happily there is no chance of our making the same mistake today. For the benefits of our present system are plain for all to see and clearly do not need to be tested. We are fortunate to be living in such an age. our
’*’
’*’
’*’
It oanli rimainz faw mi to stres Festes wurds. Sumwair thur is an objekt leson in this faw us orl. If wi do not heed it wi mai hav caws to rimembr th rimark ov an urlya Feste: " And thus th wurligig ov tym brings in his revenjs." "
Once we have devised programs with a genuine capacity for self improvement a rapid evolutionary process will begin. As the machine improves both itself and its model of itself, we shall begin to see all the phenomena associated with the termsconsciousness ’, ’intuition ’, andintelligence ’ itself. It is hard to say how close we are to this threshold, but once it is crossed the world will not be the same. It is reasonable, I suppose, to be unconvinced by our examples and to be sceptical about whether machines will ever be intelligent. It is unreasonable, however, to think machines could become nearly as intelligent as we are and then stop, or to suppose we will always be able to compete with them in wit or wisdom. Whether or not we could retain some sort of control of the machines, assuming that we would want to, the nature of our activities and aspirations would be changed utterly by the presence on earth of intellectually superior beings."—MARVM L. MINSKY, Scientific American, September, 1966, p. 260.
Very Special Articles
psychological disorders. But in the ’60s, under guise of spiritual therapy or pastoral counselling, they increasingly did so. In the early ’70s enthusiasm gradually waned, and churchmen, after their brief flirtation with psychiatry, reverted to problems they could more easily solve-such as the purpose of life, the existence of God,
manage
the
THE WHIRLIGIG OF TIME A
Cautionary
Tale*
NEIL KESSEL M.R.C.P., D.P.M.
and
M.D. Cantab.,
PROFESSOR OF PSYCHIATRY, UNIVERSITY OF MANCHESTER
Wen Iy wos lookn throo th relevnt litrachur prepairn miy thorts faw this papr ly kaim akros th ovprint ov an artikl biy Feste, publishd in 1995, oanli larst yur, but wich ly doo not rimembr reedn bifor. Th jurnl Konsum. Siykiat. was nyoo too mi. Konsum. Wot kood that stand faw? Konsyoomer, posibli, faw this is an aij wen th pashents welfair has faw th furst tiym bikum paramownt. No. Most probabli it stood faw Konsummat. Indeed Iy now reekawl heern ov a nyoo jurnl wich wood selebrait th emerjenz ov siykiatri from th dark peeriyod bitween 1945 and 1975 wen pashents wur sakrifiysd on th too orltars ov Farmakologikl Egsooberanz and Komyooniti Kair. Thows ov us hoo bilong to th old skool, hoo developd thair iydeers in th urli sikstis, mai fynd it hard to agree kompleetli with th awthr but his argyooments are kojnt and fawsfl. So with his purmishn, heer it is. Yoo will awlredi hav notd that ly am not at eez yet with Rashnl Speln; pleez fawgiv mi thairfaw, if Iy reeprodyoos it in th styl with wich ly am maw familya.
so on.
By the mid-’60s the mode was all for " generalhospital units ", often even poorer in amenities than the old mental hospitals. The unsuitable conversion of existing medical wards provided too little space for necessary recreational facilities. Small wonder then that the patient was treated in the community for as long as possible, despite the difficulties this caused to him, his relatives, and his general practitioner. INNOVATORS AND EVALUATORS
Yet all these developments must have seemed sensible and worth trying at the time, for psychiatrists were almost as intelligent then as they are now. But the innovators were so sure that the changes were beneficial that they did not evaluate them. New drugs were never administered without adequate clinical trials; but treatment procedures of a management kind were hardly ever properly assessed. The innovators, indeed, were chary of evaluation. They thought evaluators unreasonable to ask them to state their goals precisely; moreover, this often proved unexpectedly difficult. Their grand designs seemed strangely reduced in the process. Innovators often believed that their programmes would in some way promote the mental health of the whole community and were loth to be pinned down to purely treatment goals. They suggested that the benefit accruing from their proposals should not be Konsum. Siykiat, 1995, 3, 780-783. measured because it could not, and that it could not LIBERATION OF PATIENTS because it concerned intangibles like human happiness by and immeasurables such as the degree of recovery. In N. V. FESTE this the innovators were wrong, but there was some M.D. Illyria, F.R.C. Psych. justification for the disfavour with which they viewed the At last we can say that the inglorious era of the Comoperational units of mensuration that evaluators customunity Care movement is at an end. The notorious marily adopted. Such items as length of time in hospital, period of 1945 to 1975, which saw a spate of precipitate or out of it, were oversimplifications of a complex matter. Innovators were dubious, too, of the use of test measures releases of only partly recovered patients, is over. Patients and statistical techniques which they did not properly are now once more being treated with concern, compassion, and respect for their human dignity. Treatment understand. Somehow they lost control of the evaluative is once again becoming a function of the medical prostudy as it entered the mathematical mill; they were fession. suspicious that the evaluator might produce, by some THE PAST statistical sleight-of-hand, some computerised prestidigiof did the How creators community-care programmes tation, an adverse verdict which they could not quite comprehend and were therefore powerless to rebut. Quis go so badly astray ? It was because psychiatrists brought aestimabit ipsos aestimatores?The weakest argument of in all their innovations, each one hot on the heels of the the innovators, though perhaps the most powerful last, without pausing to evaluate them. Mental-hospital directors vied with each other to do something new and emotionally, was their conviction that the changes they proclaim it. The years 1945-1950 saw the ejection of were advocating were good and that to furnish proof of chronic patients, often homeless, who readily found a job, this was supererogatory. The evaluators on the other hand were by nature nullbut less often their feet, in society. This was followed by the era of early discharge, when, on the untested principle hypothesis-minded. They approached any innovation certain only in their questioning of its efficacy. They that it was better to be out of hospital than in, patients found it difficult to get the innovators to state precisely were discharged as soon as their behaviour had improved sufficiently, but before they had properly recovered. As their aims. Since detail was not forthcoming from the the number of chronic patients capable of being disinnovators, the evaluators had themselves to suggest it, and they found it hard work to persuade the innovators industrial rehabilitation charged dwindled, began. of the appositeness of the operational definitions and One historical peculiarity deserves special mention. This was the reawakening of interest in psychiatric care functional measurements they proposed. Lastly they by religious organisations. Not since the 17th century feared (with good reason sometimes) that little account had ministers of religion regarded it as their province to would in the end be taken of their findings, should they * conflict with the innovators’ expectations. Some excuse Based on a paper presented at a U.S. National Institute of would be found-that the wrong sorts of measurements Mental Health international research seminar, May 17-20, 1966. "
"
1410
had been made
or that the assessment period was not adequate-for setting aside all their painstaking labour. Potential evaluators, who generally possessed the skills of the epidemiologist, had many other claims made on their time and were not attracted to this task, though they recognised its importance. Those who financed all these developments must accept a large share of the blame. They were content to pay for developments without demanding evidence that they would work or did work. Great capital sums were disbursed to set in action projects of untested merit (which is just excusable) without demanding any future test (which is not).
THE NINETIES
Now, however, the whole community care movement has been halted. Today doctors receive, during their training, a thorough grounding in psychological disorders and they are recognised to be the right people to treat patients. The bad old days are over, when an army of social workers or mental welfare officers, employed by local authorities and guided by a medical officer of health who had had little or no formal education in psychiatry, supervised the progress of the mentally ill. Psychiatric patients no longer have to live at home, upsetting, or being upset by, close relatives, whose emotional involvement precluded the dispassionate care and attention that was needed. Those without homes are no longer urged to go into lodgings or hostels. Today we no longer force patients to work. Perhaps our new leisure economy, with an abundance of labour, is one reason for this. Criticism of our predecessors must be tempered with a realisation of the grim industrial situation which then beset Britain. Every ablebodied person was needed to work. Automation was only in its infancy. Nevertheless, even then it should have been appreciated that an able body was not enough to man a machine; an able mind was also a desideratum. Such was the coercion to work that many mental hospitals set up factories in their own grounds-forcing-houses for the labour market. The propaganda convinced patients that this was to their advantage, and they vied with one another to attend. Disintegrated men stood and pulled levers for eight or ten hours a day, without communicating at all with their companions; indeed, often they were unable to communicate, so absorbed were they with their hallucinations and disordered private thoughts. We can only marvel that a situation which Shaftesbury would not have tolerated a century before was regarded as humane and
progressive. The largest change, of course, has been the provision of ample suitable accommodation for psychiatric patients. Thanks to the enormous advances made by the profession of hotel management it became possible to provide desirable places for several thousand people in the countryside close to the communities in which they had always lived. When naming these establishments, great care was taken to avoid the stigma of the term " community mental health ". Patients had become as reluctant to enter a community mental health service as they had previously been to go into the asylum or the mental hospital. Eventually, the term " withdrawal house " was adopted. Retreat had been a popular suggestion, but was finally discarded at the request of the psychiatrists of the Armed Services. Withdrawal houses are situated within their own private parkland and provide comfortable dormitory accommo-
ample opportunities for recreation; or help with the farm if they are so minded and for those who prefer indoor amusements special games and occupations are provided. The accent is on craft work, such as the weaving of baskets, rather than on the production of anything useful. This is so that the patients realise there is no need for their work. It is recognised that not all such pursuits are aids to treatment. The assistants who help patients to divert themselves with these pastimes are no longer called occupational therapists, and, although many patients like to paint, this activity is no longer pretentiously described as art therapy. For most of the day the patients are left to their own devices with little or nothing that they have to do. The domestic staff preserve the archaic title of nursing assistants ", though they need only the simplest of training. Few are required since most of the patients see to their own simple wants. dation. There
patients
can
are
garden
"
There is no shortage of accommodation in the withdrawal houses, and no patients are turned away. This is in sharp contrast to the harsh period of the ’60s when mental hospitals in Britain were so concerned with their curative role that it became next to impossible to secure the admission of patients who needed temporary asylum but could not be expected to undergo any long-term change in their psychological state. Moreover, no patient has to leave hospital unless he wants to. CONCLUSION
conviction that what we are doing is good Despite and beneficial, some of the older psychiatrists take a contrary view. They believe that present-day trends are retrogressive and comfort themselves by believing them to be no more than an unfortunate swing of the pendulum. They still maintain that community care had great merits and was an important advance in psychiatric care. Why then, one must ask, did they not demonstrate that their methods were good ? They had their opportunities and did not take them. There is an object lesson in this for us all. Happily there is no chance of our making the same mistake today. For the benefits of our present system are plain for all to see and clearly do not need to be tested. We are fortunate to be living in such an age. our
’*’
’*’
’*’
It oanli rimainz faw mi to stres Festes wurds. Sumwair thur is an objekt leson in this faw us orl. If wi do not heed it wi mai hav caws to rimembr th rimark ov an urlya Feste: " And thus th wurligig ov tym brings in his revenjs." "
Once we have devised programs with a genuine capacity for self improvement a rapid evolutionary process will begin. As the machine improves both itself and its model of itself, we shall begin to see all the phenomena associated with the termsconsciousness ’, ’intuition ’, andintelligence ’ itself. It is hard to say how close we are to this threshold, but once it is crossed the world will not be the same. It is reasonable, I suppose, to be unconvinced by our examples and to be sceptical about whether machines will ever be intelligent. It is unreasonable, however, to think machines could become nearly as intelligent as we are and then stop, or to suppose we will always be able to compete with them in wit or wisdom. Whether or not we could retain some sort of control of the machines, assuming that we would want to, the nature of our activities and aspirations would be changed utterly by the presence on earth of intellectually superior beings."—MARVM L. MINSKY, Scientific American, September, 1966, p. 260.