DAVID ABRAHAMSON MBE, FRCPI, FRCPSYCH
From the early 1970s until the late 1990s Dr. David
Abrahamson, a consultant psychiatrist at Goodmayes hospital led a psychiatric
rehabilitation team that successfully transitioned long stay patients into
shared housing in the community. With the catastrophic failings of
deinstitutionalization in the United States and Canada there is much to learn
from the carefully planned approach taken by the Goodmayes team. In 2002 he was
awarded the MBE for services to Medicine in the UK.
This
article is adapted from Abrahamson D. "Shared housing and
long-term mental illness". Housing, Care and Support (2014): 47-41
Mental health services advance and
regress in unexpected and puzzling ways. It may be surprising to
discover that plans for shared houses to supplement asylum wards had been
created, but then abandoned, 150 years ago, even as these institutions became intolerably
overcrowded. Yet "cheerful and home-like" houses were developed from
offices in the grounds of the Devon County Asylum by Bucknill, its Physician
Superintendent, who set out plans for them to replace up to half the wards of
an "average" asylum, to be shared by patients and married attendants
(Bucknill, 1858).
The first group home for patients from
Goodmayes Hospital, which then served a population of about 400,000 in
the London Boroughs of Newham and Redbridge, was opened in 1972. The initial seven residents had spent over
200 years in the hospital between them and were prepared for discharge in the Occupational
Therapy Department. They were supported by visits from ward nurses and none
were re-admitted. The house is still in operation with the number of places gradually reduced to provide single rooms.
With the contribution of the preparation (or "half
way") houses described below, some 20 group homes were eventually opened by
the Springboard Housing Association and other associations,
PREDISCHARGE
PREPARATION OF PATIENTS: A CRITICAL STEP
In 1973 a
pre-discharge preparation house was developed on the Goodmayes Hospital campus which
was eventually followed by five others, including the former Physician Superintendent's
home, with three to eight places in
each. Selection depended mainly on interest in leaving hospital; but
reluctance to do so had been shown to reflect lack of information about alternatives
and concerns about coping outside (Abrahamson and Brenner, 1982; Abrahamson et al.,
1989) rather than determined by the
"institutionalisation" which was said to produce a gradual loss of
interest in the outside world with increasing length of stay (Wing and Brown,
1970).
Patients were given initial opportunities to
involve themselves by visits to
the house and short periods of day attendance; full-time residence
usually lasted a few months but could extend to a year or in a few instances longer. Several patients undertook
preparation more than once prior to successful placement and this was
facilitated by the variety of accommodation that eventually became available.
The houses were staffed during office hours by occupational therapy helpers who
modelled and promoted daily living and social skills; they were highly committed
and developed warm, informal relationships with residents. Nursing staff provided
visiting support at other times, and there was also a high level of involvement
from the rehabilitation team.
THE
IMPORTANCE OF PATIENT CHOICES
To the rehab
team and myself, it was remarkable how well patients accomplished the
transition to small houses after
decades in wards of 30 or more beds. But it became clear that more choice was desirable, especially as physical and emotional closeness was
uncomfortable for some.
Springboard Housing Association was able to redevelop
a former nurses' home in Newham. Opened
in 1983, it incorporated a "core" building with seven bedsitters
and three self-contained fiats, and a further eight self-contained fiats at the
end of its garden. A
kitchen/dining room and two lounges in the main building were open to all
residents, as the social
"core".
This complex facilitated both
privacy and a variety of social interactors and thus could cater for both
intensely withdrawn and volatile residents, a significant issue (Falloon and
Marshall,1983).
Although a proportion of the residents had
clinical and behavioural characteristics for which 24-hour staffing
would now be considered appropriate, it operated successfully until 2010 with three staff on site only during
office hours and backup from other housing staff and the rehabilitation team.
In 1990 eighteen studio flats and an attached
four-place house was opened and demonstrated that flats and communal facilities within a spacious framework enabled both privacy
and community; in this case as a "new and indistinguishable terraced
addition to a Victorian tree-lined terraced street" (Murphy, 1991).
This format facilitates the provision of
24-hour staffing without intrusiveness and eases the introduction of new
residents when vacancies arise, both of which may be problematic in single houses.
It also meets particular needs of women residents and members of ethnic
minorities, and provided
specialist requirements for a group of deaf patients who had been isolated on hospital wards.
Many had begun regularity
to visit pubs, shops and cafes in the vicinity.
Three similar developments by other housing associations
followed that provide 12-16 self-contained flats each, in one case with four additional
flats close by, and spacious communal facilities; each project has distinctive structural
and geographical features.
A number of staffed group homes of varying size were also
developed during this period. All of these were supported by the Newham rehabilitation team,
in part via two out-patient clinics for long-
term patients that combined an open group with individual appointments (Abrahamson and Fellow-Smith, 1991).
REEVALUATION
OF CONVENTIONAL VIEWS OF LONG STAY PATIENTS
The early asylums
were sometimes compared to surrogate extended families and Bleuler
(1978) considered "the active communal
relationship" with doctors, nurses, other patients,
family "or with anyone at all" the most important
principle of treatment. But as size and
overcrowding increased, the organisationally
convenient view gained ground that long-term patients functioned as
isolates. Lines of stooped, expressionless long-stay
patients became iconic of the Institutional Neurosis that was
claimed by Barton (1959) to be inevitable in all patients with schizophrenia, although his text also refers to
active, cheerful patients. In another
hugely influential book Goffman (1968) suggested that the main feeling between mental hospital patients was
antipathy and R.D. Laing, published a very negative account of those on a
longstay ward (Abrahamson, 2011).
My own
experience as a newly appointed consultant in 1971,with responsibility for
several long-stay wards seemed at first
to confirm such views. But closer engagement and awareness of concern for
others even from deeply withdrawn patients pointed to their inadequacy.
This re-evaluation
was supported by later experience in the housing projects and in
the combined group
and individual out-patient clinics mentioned above, where almost
90 per cent of the
attenders had diagnoses of schizophrenic disorders, with an average
duration of 23 years. It was notable that emotionally
charged matters, including
bereavements, were
discussed with appropriate affect and support from other group
members; even the habitually silent members appeared to feel
involved (Abrahamson and
Fellow-Smith, 1991).
THE
HEART OF THE MATTER: SOCIAL NETWORKS
A series of
studies of long-stay patients' social networks (Abrahamson and Brenner, 1982; Abrahamson,
1993) showed mean network sizes in Goodmayes of ten to 12 constituents, which was larger than those previously considered
typical of psychotic patients, although there was wide variation, with some very small networks of four or less and
others of 25 or more. They
consistently distinguished between acquaintances and friends, who on average
formed one-third of the
contacts; relationships with patients from other wards were about a quarter
overall of those reported and were
significantly more likely than own-ward contacts to involve friendship, trust and confiding; it was
thought that this was because they were a stronger expression of choice. Nurses on the respondents' present ward or
elsewhere formed about one-third of the network constituents and many patients clearly regarded them as friends. There
were few relationships with people outside hospital and these were
almost always with ex-patients or staff, apart from an important component of relatives who provided about 10 per cent of the
total contacts and were significantly the most trusted.
Some contacts had been maintained for long
periods within and across wards; but networks were largely ignored officially
or undermined by the practice of moving patients from ward to ward for ward
management convenience, without regard to their relationships.
Networks
expanded in the 1983 project, despite losses of ward contacts: two studies in
its first year showed more than
doubling of the mean size. Most of the constituents had present or past involvement
with mental health services or were staff who were considered friends, but
relatives now constituted 17 per cent compared to the 10 per cent in the
Goodmayes study (Abrahamson and
Ezekiel, 1984). A social club for patients of the rehabilitation team and
others later increased the
opportunities for new relationships, and the number of acquaintances made in
public places such as churches, shopping places, cafes and pubs appeared also
to increase; this is recognised as an important features of modern urban
living and has been specifically addressed in Newham (Dines et al. 2006).
CONCLUSIONS
One of the most enlightening aspects of the transition was the empowerment of residents
by the recognition that they were in their own homes and the influence this had on their relationships with
visiting staff, family and others, which
became more informal, close and equal.
When funding became available to facilitate hospital
closures, the general response, promoted by legislation, was to employ a
high level of staff working on a shift basis, without due consideration of its effect on the
self-identities of residents and possible intrusiveness where the only
private spaces are bedrooms. These issues are much less problematic with the
individual flats and communal
spaces of the larger projects described above. Security of tenure is a feature of the housing ethos that was
particularly important for long-stay patients
who had virtually no say in their frequent ward transfers.
Moving to more individual accommodation is always an option if desired
and housing associations are well placed to assist residents already known to
them to do so. However, moving-on has became the main measure of success for
community projects, often based largely on residents potential to "get
by" in terms of self-care and underestimating the risk of their social
isolation. It was evident at Goodmayes that lack of interest in leaving
was better addressed by offering choice
and preparation, considering existing and future social networks. and providing
information about the long-term support that would be available, than by
pressure to move to meet preconceptions
or official targets which might be counterproductive (Abrahamson and Brenner, 1982; Abrahamson et al. 1989).
Appropriate housing for long-term
patients is essential if community care is to improve or even for drastic
decline to be prevented; they are otherwise likely to return to their only too
familiar status of Cinderellas within a Cinderella service (Abrahamson, 2011).
It is hoped that this account will draw attention to their particular
requirements and remarkable attributes.
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