Social psychiatry and the beginning of community care

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After the Second World War, several influences led to further changes in psychiatric hospitals. Social attitudes had become more sympathetic towards disadvantaged people. Among psychiatrists, wartime experience of treating 'battle neuroses' had encouraged interest in the early treatment of mental disorder and in the use of group treatment and social rehabilitation.

In the UK , the advent of the National Health Service led to a general reorganization of medical services including psychiatry. The introduction of chlorpromazine in 1952 made it easier to manage disturbed behavior, and therefore easier to open wards that had been locked, to engage patients in social activities, and to discharge some of them into the community.

Despite these changes, services continued to be concentrated on a single site, often remote from centers of population. In the USA , Goffman (1961) argued that state hospitals were 'total institutions', i.e. segregated communities isolated from everyday life. He described such institutions as impersonal, inflexible, and authoritarian. In the UK , Wing and

Brown (1970) found that some of the large mental hospitals were characterized by 'clinical poverty' and 'social poverty'. Vigorous methods of social rehabilitation were used to improve conditions in hospital and to reduce the effects of long years of institutional living.

Occupational and industrial therapies were used to prepare chronically disabled patients for the move from hospital to sheltered accommodation or to ordinary housing (Bennett 1983). Many long-stay patients were responsive to these vigorous new methods. There was optimism that newly admitted patients could also be helped in these ways. For patients in the community, day hospitals were set up to provide continuing treatment and rehabilitation, and hostels were opened to provide sheltered accommodation.

As a result of all these changes, the numbers of patients in psychiatric hospitals fell substantially in the UK and in other countries. The changes were particularly rapid in the USA . Despite these changes, services were still based in large mental hospitals that were often far from patients' homes. Unfortunately, in many places the provision of community facilities was insufficient for the needs of all newly discharged patients.