Hospital. Aim of the Work The aim of the work was to stimulate interest

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1 Diversionl nd Eductionl Activities in Mentl Hospitl An Experiment. 1948?1950.! By ANNE COGHILL, M.A. History of Experiment In 1936, British Institute of Adult Eduction becme interested in providing eductionl ctivities in hospitls nd, with help of grnt from York Trust, y begn orgnizing such ctivities in severl different types of hospitl. The work ws on voluntry bsis. It cesed during wr, but, in 1948, Mentl Hospitls Committee of London County Council, under stimulus of lte Councillor, Mrs. E. H. Hubbock, considered providing se ctivities in ll its hospitls. Discussions held with British Institute of Adult Eduction nd with number of medicl superintendents; it ws greed to ppoint one orgnizer to promote ctivities in six hospitls t Epsom. A few months lter, in April, 1948, I ws ppointed orgnizer t- Clybury Hospitl in order to crry out more extensive work of sme sort t one hospitl. Aim of Work The im of work ws to stimulte interest mong ptients in cretive, intellectul nd socil ctivities for following purposes : (?) To rebuild personlity of ptients recovering from mentl illness by re-wkening ir former interests nd thus diverting ir ttention from mselves. (?) To develop ltent tlent, hirto frustrted, so tht y would hve resources within mselves, with which to meet future difficulties. (c) To help m to regin self-confidence, both in ir work nd in ir socil reltionships. (d) To enrich life of chronic ptient. The Field The field ws lrgely new one. In severl hospitls, one or two eductionl ctivities hd We regret tht owing to pressure on spce, sttisticl Tbles relting to this experiment hve hd to be omitted.?editor. I?Editor.

2 been by Occuptionl Therpy Deprtby member of medicl stff, but hospitl hd wide progrmme of ctivi- run ments or in no out. The first essentil ws to wht ctivities would hve greter ppel nd vlue. This depended on type?f ptient. Before Ntionl Helth Service Act, Clybury Hospitl served Est End of London; now, it serves its own loclity, so tht more recent ptients tend to be better educted thn older, long-term ones. When experiment strted, most populr ctivities those in which ptients mselves took prt: pinting ws preferred to tlks on pprecition of rt nd singing to tlks on music. There re 1,000 mle nd 1,300 femle Ptients in Clybury; 100 of se re psychoneurotic ptients. Aprt from se, mjority of both men nd women re elderly chronic ptients who hve been in hospitl f?r mny yers. About 60 per cent, of both sexes re sufficiently fit to do some sort of work, ^ut mny of older ones prefer to sit in ir Wrds in evening rr thn tke n Prt in ctivities. Five hundred ttend film shows nd vriety concerts nd 300 weekly ties been crried discover c^lve dnce. Owing Ptients to vrious ctivities in which engged during morning (work hospitl or Occuptionl Therpy re Aprtments) ctivities it ws decided to hold in fternoons nd evenings. Co-opertion new of Locl Eduction Authority It ws not possible for one person to tke number of clsses, so Ilford Eduction Committee ws pproched nd y greed to supply instructors for two experimentl clsses, Slnging nd dress-mking. These proved successful, so furr instructors ppointed to tke over or clsses run by?r?nizer (drm, puppetry nd pinting), leves her free to begin work in some of cute These instructors pid by Ilford Eduction Committee, only mterils 0r clsses being supplied by hospitl. The difficulty of finding suitble instructors Ws lrgely solved by Ilford Eduction *~?nimittee circulrizing schools nd drwing UP pnel of those interested in such work. Ws found essentil for instructors to hve, Asides knowledge of ir subject, sufficient self-confidence nd enthusism to overcome Pthy nd self-bsorption of ptients. ^rge ^rds. 97 Activities mong Recoverble or Short-term Ptients These ptients consisted minly of two groups: () Psychotic ptients?dmitted to cute dmission wrds; when better, y sent to convlescent vills. (b) Psycho-neurotic ptients?dmitted direct to convlescent vills. These vills held 50 mle nd femle ptients respectively; bout two-thirds of m usully fit enough to ttend ctivities. During summer, most of ptients in se vills llowed out on prole fter this cused numbers ttending te; ctivities to fll. Activities in Convlescent Vills Dress-mking This clss ppeled to women becuse it ws prcticl ctivity which would be useful to m when y returned to norml life. While in hospitl, it enbled m to improve ir wrdrobe. Underwer, blouses nd children's frocks most frequently mde; one or two ptients mde mselves frocks. The clss ws held in fternoon, so numbers remined firly high throughout yer. Drm The members of this group strted with chrdes nd went on to reding of one-ct plys. After few weeks, it ws decided to produce concert nd rehersls held twice week. None of ptients hd cted before; y convinced tht y would not be ble to lern ir lines, but, by mens of intensive rehersing, this difficulty ws finlly overcome. Acting ws found to provide n outlet for ptients who especilly gifted in this direction nd to help ors to gin self-confidence while rehersls provided entertinment for everybody. Lectures These held once fortnight from Mrch, The subjects included locl government, trvel, stronomy, September, 1948, to economic problems, English folk music nd music pprecition. Music ws lwys populr, but or subjects hd such mixed reception, tht it ws decided to replce lectures by weekly clss on music pprecition. The im of lectures ws to stimulte discussion nd rouse interest in vriety of topics, but difficulty of tlking to group who not only

3 98 lrgely unintellectul, but bsorbed in ir individul troubles nd unble to concentrte for ny length of time, ws formidble nd only few lecturers succeeded in getting ir subjects cross. Film Shows These held once fortnight during winter of They given, free of chrge, by Centrl Office of Informtion nd Gs Compny, who brought ir own screen nd projector. They consisted of short films on topicl subjects such s production of steel, police force, how to feed difficult children, or crtoons illustrting need for Town nd Country Plnning. Probbly becuse it needed less concentrtion to look t film thn to listen to tlk, films very populr. In September, 1949, hospitl bought 16 mm. film projector; since n, convlescent ptients hve hd weekly film show consisting of long film, documentry nd crtoon. Music Apprecition This clss took plce of fortnightly lectures. On whole, ptients preferred listening to music rr thn to lerning bout it, so only few remrks mde bout ech record. This clss ws populr mong some of older ptients. Bllroom Dncing This clss ws specilly requested by ptients. It ws tken by qulified instructor, nd ppeled chiefly to younger ptients, helping those who shy or uncertin in ir socil reltionships, to gin confidence. Some of ptients becme sufficiently interested to continue to ttend clsses run by this instructor outside hospitl, fter ir dischrge. Shorthnd-Typing The object of this clss ws to help in rehbilittion of convlescent ptients. Some of chronic ptients keen to join nd dmitted when possible. During winter of second clss ws strted s it ws found impossible to tech more thn six t time s y ll needed personl ttention. This clss ws run by member of clericl stff who ws pid by hospitl. Discussion Group The lectures hd filed to stimulte discussion, but it becme pprent in utumn of 1949, tht femle ptients felt need for more informl type of discussion nd it ws decided to strt group mong women, under ledership of Rev. R. Brtholomew, Visiting Non-conformist Minister. The ptients encourged to suggest ir own subjects. At first y diffident, but lter, y gined confidence nd most of m took ctive prt in discussion. Some of chosen : Is honesty best How to lern to lugh when you wnt to cry. Difficult Children. Mny of ptients' personl problems touched upon, but discussions kept on n impersonl level. This is one of ctivities tht ptients ttend without persusion; severl of m sid it ws most interesting ctivity of week. It is hoped to strt similr group mong mle ptients. n subjects policy? The Socil Club At of My, 1948, it ws decided Socil Club mong ptients in Convlescent vills. The Club ws to be run by ptients mselves nd ws to be responsible for orgnizing socil nd recretionl ctivities. A meeting ws clled t which committee nd officers elected. The Club ws given nme nd ll members who could fford it to py penny week into Club to provide prizes for Whist Drives, Socils, etc. It ws greed to hold Generl Meeting once month, t which new members could be elected onto Committee, suggestions could be put forwrd nd grievnces ired. The club committee ws to meet once week. The following ctivities hve been run by Club: Whist Drives; Socils; Quizzes; Record Recitls; Community Singing nd quiet socil evenings t which ptients hd chnce to get to know one nor. The Club hs run stisfctory on se lines for two yers, lthough re hve been difficulties. During winter, when ptients could not go out on prole, Club fulfilled rel need nd it ws possible to build up trdition. This ws mde difficult even in winter, by chnging membership. Ptients styed, on n verge, three months nd during only two of se y usully fit enough to tke prt in ctivities. In summer, ctivities fell off considerbly. By utumn, with n lmost entirely new set of ptients, Club hd to be rebuilt. Aprt from se difficulties, which peculir to Mentl Hospitl, re those common to ll Clubs; scrcity of suitble members to tke on responsibility of orgnizing ctivities nd cute personl rivlries to form beginning

4 between leding members which thretened to split Club. sometimes Activities mongst Short-term Psychotic (Not yet Convlescent) Bllroom Dncing Clss Ptients This clss ws strted in femle cute dmission wrd nd lter trnsferred to where it wrds. or from ptients The ptients generlly rr ptic when clss begn, but y enjoyed music, nd, by end of fternoon, most of m Were dncing. A little individul instruction Ws given, but min object ws to keep Ptients on ir feet. Occuptionl Therpy Deprtment, ws open to femle 99 Puppetry Puppetry is both n rt nd crft; it requires skill in wood-work, needle-work, dress-design, cting nd mnipultion of puppets. But puppetry ws new ctivity for mjority of ptients nd it ws difficult to persude m to ttend clss sufficiently long to grow interested. The clss ws first strted in femle convlescent vill, but ptients styed too short time to grow interested nd it ws decided to dmit only long-term ptients. In Jnury, 1949, clss re-strted under n outside instructor. A few ptients grew enthusistic, but it ws found impossible to continue clss with such low membership. Singing Activities Amongst Irrecoverble Ptients Before April, 1948, evening ctivities mong se ptients consisted of weekly mixed socil nd film show, with vriety concerts once month during winter. The number of ptients ttending ctivities strted since n, tended to fll in summer becuse prole ptients went out fter te; nonprole ptients, who might hve liked to ttend, A nucleus of 12 mle nd femle ptients hve ttended this clss regulrly since it begn. They strted with such well-known tunes s, Abide with The Londonderry Air nd Me When y hd overcome ir initil diffidence, y went on to Brhm's Lullby The Lss with Delicte Air nd Hndel's The clss formed choir Silent Worship which sng in two of ptients' concerts. At Christms, y prctised crols for Church Services. The ttendnce of non-prole ptients ws irregulr, depending on vilbility of nursing stff. Pinting Book-keeping c?uld not do so becuse re not sufficient stff to escort m. A few short-term psychotic Ptients, who not yet fit enough to go to Convlescent Vills, ttended se ctivities. held in fternoon nd, mintined its membership through- This clss refore, ws 0lIt summer. Only prole ptients it ws impossible to provide nursing stff for clss. Pinting ppeled strongly smll number of ptients, who worked nd lwys hours for of lntently couple reluctnt to stop. Some of m drew objects?uch s fruit or flowers; ors drew from ir imgintion. Most of ptients used wterthe clss ws one or two used oils. held in of which wlls room, lrge, iry Were decorted with members done by pintings?t needed group. Most of ptients of Encourgement; few sufficiently sureclss.nemselves to ccept criticism. The deluded severl high grde mentl defectives, With super-dded psychotic illness, nd se Were found to hve good sense of colour nd During summer of 1949, n ExhibiHll 'on of yers work ws held in Min hospitl. Ninety of best pictures dmitted colour; s This clss ws run in non-prole wrd on mle side by chrge nurse. It ws open to mle ptients from or wrds. The work ws firly elementry, but it helped to occupy minds of irrecoverble ptients nd to rehbilitte short-term ptients. It ws specilly ttrctive to those who hd mmticl minds. Bllroom Dncing This clss ws strted in femle cute psychotic wrd in Februry, The music hd stimulting ffect on ptients nd helped to get m on floor. A few of m dnced with one nor, but most of m hd to be tken individully. During ech clss, period of free expression ws held, during which ptients encourged to mke up ir own movements to music. ^.esign. Community Singing shown. fortnight. Nerly non-prole) joined This ws tken by chrge nurse, once ptients (prole nd singing. For some, ll in

5 100 it ws only time y used ir voices. Hlf wy through evening, three or four went up on stge to entertin ors with solos. At first, y diffident, so rehersl of soloists ws held every or week during winter of They begn by singing in groups of three or four, but, by end of winter, most of m preferred singing on ir A diffident Welsh girl developed own. powerful soprno. Hving estblished herself, she helped young mn who ws shyer thn herself, by teching him songs nd singing m with him. A middle-ged epileptic mn of unprepossessing ppernce nd uncertin courge, gined confidence visibly while he sng. His hnds went into his trouser pockets nd his chest cme out. Anor mn, who hd not spoken for five yers, entertined rest with comic songs. The chrge nurse reported tht behviour of severl of his non-prole ptients who ttended session regulrly, hd improved. They becme less qurrelsome nd more mngeble nd could be herd humming tunes on wrd. in Serious Music The Council for Music in Hospitls orgnized monthly concerts of serious music t chrge of 12 guines concert. In June, 1948, Clybury Hospitl offered three such concerts t reduced fee of 10 guines ech, s n experiment. Three to four hundred ptients ttended; twothirds of m enjoyed more populr tunes, but bored by serious music. It ws, refore, decided to rrnge smll concert recitls in future, in order to cter for minority tht enjoyed serious music. During winter, , series of fortnightly concert recitls rrnged. The Pioneer Concert Group gve four. The rest given by Miss Elizbeth Prker, pinist. Miss Prker brought different soloist with her for ech recitl, thus giving series continuity nd vriety. The progrmme for ech recitl ws crefully plnned, more serious music being introduced s seson progressed. This hd if too mny to be done very cutiously; unfmilir pieces plyed, udience becme restive. The ptients told little bout ech new piece tht ws plyed. After recitl, y discussed progrmme nd mde suggestions for future recitls. Experiments Concerts Produced by Ptients The ptients hve just produced ir third concert in two yers, nd fourth is in rehersl. The tlent cme mostly from mong psychoneurotic ptients, though re usully one or two soloists from mong psychotics. The first concert ws of comprtively high stndrd. It consisted of songs, sketches (rehersed in Drm clss), nd dnces nd contined 22 items. The concert provided n im towrds which ptients worked, t first doubtfully, but with gring enthusism. The excitement tht ccompnies every production, finlly infected most ptic. The ptients felt tht, for first time, y entertining insted of being entertined; invittions sent round to or wrds nd y felt justly proud fterwrds when some of ptients from Min Building remrked tht it ws best concert y hd hd for yers! Severl of ptients who took prt in sketches normlly over-ctive; lthough y found disciplined outlet for ir emotion in cting, directly concert ws over, y suffered severely from sense of nti-climx. This could be voided, eir by rrnging for nor performnce lter, which would mintin tension t lower level, or by rehersls being strted t once for new project. The stndrd of lst two concerts ws not so high, prtly becuse tlent ws lcking, prtly becuse, with so mny or ctivities, re ws less time to reherse. They very much enjoyed, however, by both udience nd plyers. Art Therpy Pinting, for those ptients who persuded to express mselves in this be cn medium, cn become window into mind for psychitrist. Repressed thoughts nd feelings re reveled in subjects pinted nd colours used. Symbols occur frequently. From study of se, it would seem tht different ptients tend to use similr symbols to express similr thoughts. A weekly clss ws strted in September, 1948, in psychotic femle dmission wrd; results disppointing. It ws decided tht clss must be held more frequently if ptients' work ws to be help to doctor. From November onwrds, one or two ptients tken three times week. Working under instructions of one of Senior Medicl Stff, Dr. Krmbch, ptients persuded to express mselves freely nd to interpret ir work s fr s possible. The pintings n pssed on to him s dditionl mteril for nlysis.

6 psychotic weekly clss femle wrd where ptients more severely ill, from December, 1948, onwrds. Here ptients needed less persusion to express mselves freely so one clss week Ws sufficient. Aprt from generl rpeutic vlue of se clsses, e.g. ptients engged in n ctively cretive occuption, work of some ptients ws found to forecst A ws held in ir future mentl stte; this ws most obvious where ptient hd some technicl bility. Individul Tretment A certin mount of work. ws done with individul psycho-neurotic nd psychotic Ptients. A cse in which culturl ctivities Plyed prt ws tht of girl of 19 who ws dmitted in October, She hd lived in?ne room for five yers, her hed covered with from ill-defined fers. On she sid she liked pinting nd becme interested in designing bck cloth for puppet tre. She pinted n elborte design lter, on some mteril for costume of one of puppets. The work ppeled to her becuse it hd no connection with outside world, of which she ws frid. She ws shown reproductions of modern pintings nd encourged to discuss m. In New Yer, she begn to lern pino. The ctivities tempted her to express her feelings nd overcome some of her inhibitions. During her insulin tretment, she surmounted se sufficiently to strt pinting some of thoughts which doubled her. The pintings of disturbln8 nture nd proved tht, lthough she ws outwrdly mking progress towrds more n?rml life, initil cuse of her fers hd not been discovered. During ensuing she pinted her thoughts two or three lmes week. Her pictures contined recurring svnibols (dggers, knives, grves, devils), nd c?lours (blck nd red, with touch of green she ws getting better), nd provided?ctor with mteril which he ws unble to get sheet, suffering dmission, j^onths, ^hen y or mens. Outside Expeditions 101 ptient's mind, y (1) By occupying gve him n opportunity to escpe from perpetul circle of his own thoughts s one ptient put it. This point ws stressed by succession of psycho-neurotic ptients. (2) They plyed n ctive prt in rehbilittion of short-term ptients, not only by restoring confidence nd reviving old interests, but by discovering new ones. (3) They gve richer pttern of life to long-term ptient. The Shorthnd-Typing clss in prticulr ppered to benefit number of different types of ptient. For some of m it ws refresher course, but for ors, it ws n entirely new interest. An epileptic of 29, with intelligence of boy of 11, ws very keen to join clss. He worked well, nd, fter four months, retined his enthusism. An intelligent, but uneducted, of 53, who hd suffered from series of brekdowns for three yers, ws in stte of considerble nervous tension when she joined clss nd ws unble to concentrte. She prctised typing for six hours week for three months. While she typed, her nervous fcil twitches cesed, nd she found herself forced to Lter on, she took up full-time concentrte. job in clerk's office, working t firly simple clericl job. Her improvement hs continued. It would seem tht typing nd simple clericl work could be used much more extensively thn it is both s n occuptionl rpy nd mens of rehbilittion for more educted type of ptient. womn Diversionl Activities These diverted ptient's interest from himself by entertining him nd lso provided him with new socil contcts. Gmes tht needed certin mount of concentrtion found helpful to those who found concentrtion difficult. The Socil Club gve ptients sense of common interest nd of responsibility one for nor. They helped mselves by lerning to help ors while running of club did much to rehbilitte succession of cpble men nd women who hd lost confidence in mselves nd ir bilities. (b) Three expeditions mde, with smll of psycho-neurotic ptients, two to xhibition of French Lndscpe Pintings, nd one by Music Apprecition Clss to her (c) Art Therpy ln? Recitl by Solomon t Ilford. All This proved to be of help in dignosis nd ery much enjoyed by ptients. tretment of cses where ptient found it difficult to express his feelings in words. A Vlue of se Activities 'Eductionl gret del more could hve been crried out rhese ctivities proved of vlue in three wys: hd time permitted.?roups

7 102 The Need for more Time One of mjor problems for orgnizer ws division of her time. The supervision of twelve clsses week, running of Socil Club, nd orgnizing of Vriety Concerts nd Concert Recitls, left limited This ws used for Art mount of free time. Therpy nd for tking individul ptients for pino lessons, elocution, etc. When concert ws being produced, some of se ctivities hd temporrily to be suspended. Or Difficulties Shortge of Medicl Stff, nd ir consequent lck of time prevented mny of m from visiting ctivities to see wht work ir ptients doing. It lso prevented m from ttending Socil Club ctivities. When shortge becomes less cute, it is hoped tht members of both medicl nd nursing stff will tke prt in tlks nd debtes with ptients. Shortge of nursing stff often prevented those ptients most in need of tretment, from coming to clsses, since non-prole ptients must be escorted to, nd supervised during, ctivities. Some difficulty ws experienced in fitting It new ctivities into ptient's progrmme. ws policy of Hospitl tht ll ptients (mle) should work in mornings nd ftereductionl nd Socil ctivities hd, noons. refore, to be limited to evenings on mle side, nd psychotic ptients who did essentil work in Hospitl llowed to ttend one fternoon clss week. If number of clsses for psychotic ptients is to be incresed, possible solution is to run m in Occuptionl Therpy Deprtments, where nursing stff re lredy vilble. This is being done with one of bllroom dncing clsses nd it is plnned to re-strt puppet group in femle Occuptionl Therpy Deprtment s soon s suitble instructor is found. Qulifictions Necessry for Orgnizing se Activities The first essentil is n interest in ptient's welfre nd n understnding of his needs. Experience in orgnizing dult eduction groups proved n sset. A short course deling with min cuses of mentl illness nd ir tretment would be n dvntge, not only in helping orgnizer in her pproch to ptients, but in estblishing her uthority to del with m, in reltion to rest of stff. Acknowledgments Sincere thnks re due to Dr. Hrris nd medicl nd nursing stff for ir help in crrying out experiment, nd to Dr. Schmidt nd Dr. Krmbck for ir interest nd Miss encourgement. To Sicely (Hed Occuptionl Therpist on femle side) for her co-opertion in llowing some of clsses to tke plce in her deprtment, nd to Mr. Millington (Hed Occuptionl Therpist on mle side), for his co-opertion with Puppet Clss. Mny thnks re lso due to Chrge Nurse Gry who hs been such n enthusistic compere t Community Singing sessions, nd hs tken Book-keeping Clss, nd to Miss Allen for her ptience nd persevernce in Shorthnd-typing clsses. The willing co-opertion of Borough Eduction Officer, Mr. G. J. Miles, nd enthusism of outside instructors, hve lso plyed lrge prt in mking scheme success. SOCIAL WORKERS IN THE SERVICE The long nd egerly wited report of Mckintosh Committee on Socil Workers in Mentl Helth Service, ppointed by Minister of Helth in July, 1948, is published s go to press. It is sociologicl document of considerble vlue which should be studied by ll who re in ny wy concerned with Mentl Helth Service, or indeed with ny or field of socil Its contents include n informtive work. section on historicl bckground of socil work in mentl helth, present position in regrd to use of psychitric socil workers nd or mentl helth personnel by vrious we Authorities, supply ties, discussion nd demnd, on present trining fcilimentl content of Helth Courses nd of Courses in Socil Science, s to schemes for trining of new recruits nd of workers lredy in field who re t present unqulified. It my be remembered tht Committee issued n Interim Report?which ws not mde vilble for generl distribution?t of when certin lst beginning yer, nd recommendtions recommendtions mde, including suggestions for most effective use of vilble personnel, need for dditionl mentl courses nd for n pprenticeship system helth for

8 Preliminry prcticl trining of ssistnts in Centl welfre work, nd instituting of emergency courses of trining in mentl deficiency. These recommendtions re, in this finl Report, mplified nd fully discussed, nd following points re stressed: () Tht wheres re re t present 331 psychitric socil workers in field, it is estimted tht pproximtely 1,500 re needed, nd tht for mentl welfre work lone one worker per 100,000 of popultion should be (b) Tht employed. in socil science is foundtion for ll forms of socil work. 44 Tht re should be system of in service under trining supervision of experienced psychitric socil workers or mentl welfre workers, for officers of locl uthorities engged in mentl helth duties without hving hd previous n (c) bsic course indispensble experience or trining. (d) Tht officers of locl helth uthorities newly entering mentl helth service should hve preliminry n of under period trining experienced worker to provide generl bckground nd to determine personl suitbility. (e) Tht for specified period, officers qulified by experience who hve 103 spent not less thn five yers in responsible socil work should be eligible for specil recognition nd registrtion. (/) Tht to ttrct new recruits into service, re should be trinee scheme orgnized through regionl hospitl bords who would be responsible for pyment of mintennce to cndidtes, selection to be undertken by joint committee in ech region, representing employing uthorities, techers nd ssocitions of professionl workers. It is furr recommended tht re should be consulttive committee to co-ordinte regionl schemes nd to mintin stndrds. On this Committee should serve representtives of Universities with mentl helth courses, Assocition of Mentl Helth Workers nd Assocition of Psychitric Socil Workers, Ntionl Assocition for Mentl Helth, Ntionl Assocition of Authorized Officers nd Royl Medico-Psychologicl Assocition. To consider how this Report cn be implemented should now be first priority in progrmmes of vrious uthorities nd bodies directly concerned with its recommendtions.