Below is the opening chapter of a book about the history of a local organisation called BITA Pathways founded in Birmingham in 1963. The organisation was established as the Birmingham Industrial Therapy Association by a psychiatric consultant, Dr Norman Imlah who was based at All Saints Hospital in Winson Green.
The first chapter of the book, published in 2003 gives a history of mental health services from the 1950s and the development of the 'work as therapy' concept:
Chapter One
HISTORICAL BACKGROUND
By the middle of the twentieth century the predominant care of the seriously mentally ill was contained, within Britain, in a large number of institutions, built mainly during the latter half of the nineteenth century. Over the years the majority of the population of these institutions, originally designated asylums, became permanent inhabitants. Some became permanent from the first admission, others from a second or third admission. A minority had a serious illness from which they had a full remission or had several admissions with remissions and relapses.
Well over half the permanent population of the institutions were diagnosed as having a form of an illness which came to be generally known as schizophrenia. Even today there is no clear agreement on whether schizophrenia is a single entity or a group of related illnesses. Whatever the differences in presentation the fate of the great majority was to occupy the long stay wards of the asylums with the prefix label of "Chronic".
Even by 1950 there seemed little prospect of this situation undergoing radical change. Despite attempts to treat schizophrenia by various methods, in particular from the nineteen thirties onwards, by insulin therapy, convulsive drugs, electro-shock therapy and brain surgery, the best that was achieved in the majority of cases was some temporary remission. Even before the advent of these treatments, there had been many approaches based on theories of causation which have been discarded. In Birmingham, between the wars, the theory of causation by focal sepsis was promoted vigorously, and ended with many patients losing their tonsils, teeth, appendices and other potential sources of infection, but still remained in the asylum with their illnesses unremitted.
Some serious illnesses did respond to new treatments. Some types of depression responded to electro-convulsive therapy, and psychotic illnesses brought on by the late effect of venereal disease, began to disappear after the advent of Penicillin killed the primary infection. Nevertheless, the post-war population of the asylums rose steadily and by the early nineteen fifties all of them were seriously overcrowded. This rise was not an indication of a rise in the incidence of serious mental illness, but was predominantly brought about by the improvements in treatment of physical illnesses through antibiotics.
Tuberculosis was a constant problem in large institutions and most asylums had their own sanatorium or provision made within a group of hospitals where one would care for the considerable number of patients who developed tuberculosis. In addition, outbreaks of other chest infections and intestinal infections played their part in keeping population numbers down. Once these conditions were largely eliminated as causes of death, the numbers and the ages of the mental hospital populations began to rise steadily with no corresponding levels of therapeutic improvement for the mental disorders.
From the outset there was a widespread recognition by the doctors and nurses in the asylums that work was therapeutic; that it did not cure any illnesses, but was beneficial by giving interest, meaning and a measure of fulfilment. If one reads the annual reports of many of these institutions there are references in the earliest of these reports to the benefits of work. The first medical superintendent of the Birmingham City Lunatic Asylum (latterly All Saints Hospital) refers regularly to the therapeutic benefits of meaningful activity, both work and recreational.
Work for the inmates took a number of forms, depending upon any special skills, and relative stabilities. Many became regular employees in the various hospital departments such as kitchens, gardens, carpenter's shop, upholsterer's shop and all the various other departments which existed within the virtually self-contained communities. In the process they contributed significantly to the economy of the establishment. Payments were generally in the form of pocket money, in kind (usually cigarettes) or by special privileges, such as having their own ward key. Others less skilled, but still capable of working daily were put into squads which kept the grounds tidy, cleaned the wards and corridors or more prestigiously worked in the hospital farm.
Many asylums ran their own farms with a farm manager and a squad of selected inmates, usually supervised by one or two attendants whose own background had been in farming. These farms were major contributors to food supplies in the asylum and the labour cost very little. However, there were still large numbers of the asylum population who were either too disturbed by the effects of their illness, or too apathetic after years of being locked away that they neither worked or played.
In the nineteen fifties, new and hitherto unforeseen means of treating schizophrenia changed this situation quite rapidly. It was preceded by the introduction of the National Health Service when all the asylums were taken over, and soon designated mental hospitals. Initially, most major mental hospitals had their own management committees, many of them run by a quite different type of person, with a different philosophy of care. The prevailing influence in the early days of the NHS came from the political left, deeply committed to the socialist ideology of "total care from the cradle to the grave".
In the six years between the advent of the NHS and the introduction of new ways of treating schizophrenia there was a change in attitude to patient workers. As the, then innocent, belief prevailed that the state would provide everything, the pressure to shore up the economy by patient labour was lessened, although in many hospital departments it continued. One of the early casualties were the hospital farms. It was said at All Saints Hospital that the decision to dispose of its farm, taken over with the hospital in 1948, came when the new management committee were informed that the prize bull, for which they had paid a considerable sum, was found to be infertile, and without offspring. The realisation that fecundity could not be purchased concentrated the minds of the committee that as managers of farms they were out of their depth.
For this, and different but analogous reasons, by 1954 a lot of the traditional occupations in the old asylum had disappeared along with the name. In 1954, two drugs, independently researched, were found, by chance, to produce remarkable improvements in the treatment of schizophrenia. One of these, Reserpine, did not survive for long because of it's side-effects, but the other, Chlorpromazine was the first of a range of drugs, initially called major tranquillisers, or neuroleptics, which are still the mainstay of treatment today. Despite their enormous significance they do not actually cure schizophrenia, and although they have been improved upon in various ways in the near fifty years since their introduction, there is still no true cure for this most destructive of illnesses.
The introduction of the drugs did however transform the course of the illness, and with it the whole ethos of the mental health hospital changed. Disturbed behaviour was greatly reduced and destructive symptoms eliminated or suppressed. It became evident that many previously seriously disturbed patients were now well enough to leave hospital and re-enter society.
It was from this background that industrial therapy units developed. Improved treatment, overcrowded mental hospitals and a lack of facilities to observe and acquire work skills led to the setting up of workshops and factories in many hospitals in Britain. As early as 1955 a survey of industrial therapy units in Europe was reported in the Lancet. The authors envisaged the mental hospital of the future as "a school for social learning where the psychotic, discarded by society as a whole" would acquire the social and work skills to return to the community or live at an enhanced level within the hospital.
Although the majority of the units in Britain started inside the mental hospital and many continued thus, for some the ideal position was to take the industrial unit outside the hospital. The pioneer in this development was Dr. Donal Early, Medical Superintendent of Glenside Hospital, Bristol who in 1960 formed a private company, The Industrial Therapy Organisation (Bristol) Ltd. Its objects were to provide a gradient of employment from projects in hospitals through more complex training at the factory, to independent employment, and combining with it social rehabilitation, preparing the long stay patient to resume ordinary life outside the hospital.
From these beginnings industrial therapy in Britain developed along independent and haphazard paths. No firm national policy was laid down, and it was left very much in the hands of local hospitals, and individuals in those hospitals, to develop the process. Many chose to continue their industrial therapy within the hospital, many providing a mixture of an industrial type unit in the hospital, traditional occupational therapy and domestic and other duties within the departments of the hospital. These hospital based units varied in size, and in the way they were run. Some hospitals ran the units with their nursing or occupational therapy staff whilst some employed supervisors with an industrial background to manage the hospital unit.
However, in different areas of the country, the Bristol model of an organisation providing training for work and social skills within the community was the preferred option. For the most part, like the hospital based industrial workshops, they sub-contracted work from local industry, reflecting the work that might be available to the rehabilitee. Some concentrated on marketing their own goods notably Cheadle Royal Industries Ltd in Manchester where three quarters of their production concentrated on the manufacture and marketing of paper carnival goods, rosettes, cake frills etc. Most developed a mixture of sub-contracted local industry and production of own products with, in most cases, more emphasis on the former because it was easier to develop and readily available.
It was against this background that the Birmingham Industrial Therapy Association was formed in 1963 and subsequently developed. It was not the first, but in its intent and constitution it took the first, at Bristol, as its model. It was therefore one of the early pioneers of this type of approach and a major contributor to the retraining of people leaving hospitals, many after many years, and returning them to the community, able to take their place in that community. Like all the others, it developed over the years, its own distinctive approach, an approach which has had to be periodically re-evaluated and restructured to meet ever-changing patterns of care and economic changes.
Today most of the old asylums, or mental hospitals as they became, are closed, and with their closure, their industrial therapy units. The various industrial therapy associations have disappeared also over the years, with one exception, the Birmingham Industrial Therapy Association.
It is about to celebrate the fortieth anniversary of its formation. As the sole survivor of those pioneers it seems an appropriate time to tell the story of its formation and subsequent history.
The first chapter of the book, published in 2003 gives a history of mental health services from the 1950s and the development of the 'work as therapy' concept:
Chapter One
HISTORICAL BACKGROUND
By the middle of the twentieth century the predominant care of the seriously mentally ill was contained, within Britain, in a large number of institutions, built mainly during the latter half of the nineteenth century. Over the years the majority of the population of these institutions, originally designated asylums, became permanent inhabitants. Some became permanent from the first admission, others from a second or third admission. A minority had a serious illness from which they had a full remission or had several admissions with remissions and relapses.
Well over half the permanent population of the institutions were diagnosed as having a form of an illness which came to be generally known as schizophrenia. Even today there is no clear agreement on whether schizophrenia is a single entity or a group of related illnesses. Whatever the differences in presentation the fate of the great majority was to occupy the long stay wards of the asylums with the prefix label of "Chronic".
Even by 1950 there seemed little prospect of this situation undergoing radical change. Despite attempts to treat schizophrenia by various methods, in particular from the nineteen thirties onwards, by insulin therapy, convulsive drugs, electro-shock therapy and brain surgery, the best that was achieved in the majority of cases was some temporary remission. Even before the advent of these treatments, there had been many approaches based on theories of causation which have been discarded. In Birmingham, between the wars, the theory of causation by focal sepsis was promoted vigorously, and ended with many patients losing their tonsils, teeth, appendices and other potential sources of infection, but still remained in the asylum with their illnesses unremitted.
Some serious illnesses did respond to new treatments. Some types of depression responded to electro-convulsive therapy, and psychotic illnesses brought on by the late effect of venereal disease, began to disappear after the advent of Penicillin killed the primary infection. Nevertheless, the post-war population of the asylums rose steadily and by the early nineteen fifties all of them were seriously overcrowded. This rise was not an indication of a rise in the incidence of serious mental illness, but was predominantly brought about by the improvements in treatment of physical illnesses through antibiotics.
Tuberculosis was a constant problem in large institutions and most asylums had their own sanatorium or provision made within a group of hospitals where one would care for the considerable number of patients who developed tuberculosis. In addition, outbreaks of other chest infections and intestinal infections played their part in keeping population numbers down. Once these conditions were largely eliminated as causes of death, the numbers and the ages of the mental hospital populations began to rise steadily with no corresponding levels of therapeutic improvement for the mental disorders.
From the outset there was a widespread recognition by the doctors and nurses in the asylums that work was therapeutic; that it did not cure any illnesses, but was beneficial by giving interest, meaning and a measure of fulfilment. If one reads the annual reports of many of these institutions there are references in the earliest of these reports to the benefits of work. The first medical superintendent of the Birmingham City Lunatic Asylum (latterly All Saints Hospital) refers regularly to the therapeutic benefits of meaningful activity, both work and recreational.
Work for the inmates took a number of forms, depending upon any special skills, and relative stabilities. Many became regular employees in the various hospital departments such as kitchens, gardens, carpenter's shop, upholsterer's shop and all the various other departments which existed within the virtually self-contained communities. In the process they contributed significantly to the economy of the establishment. Payments were generally in the form of pocket money, in kind (usually cigarettes) or by special privileges, such as having their own ward key. Others less skilled, but still capable of working daily were put into squads which kept the grounds tidy, cleaned the wards and corridors or more prestigiously worked in the hospital farm.
Many asylums ran their own farms with a farm manager and a squad of selected inmates, usually supervised by one or two attendants whose own background had been in farming. These farms were major contributors to food supplies in the asylum and the labour cost very little. However, there were still large numbers of the asylum population who were either too disturbed by the effects of their illness, or too apathetic after years of being locked away that they neither worked or played.
In the nineteen fifties, new and hitherto unforeseen means of treating schizophrenia changed this situation quite rapidly. It was preceded by the introduction of the National Health Service when all the asylums were taken over, and soon designated mental hospitals. Initially, most major mental hospitals had their own management committees, many of them run by a quite different type of person, with a different philosophy of care. The prevailing influence in the early days of the NHS came from the political left, deeply committed to the socialist ideology of "total care from the cradle to the grave".
In the six years between the advent of the NHS and the introduction of new ways of treating schizophrenia there was a change in attitude to patient workers. As the, then innocent, belief prevailed that the state would provide everything, the pressure to shore up the economy by patient labour was lessened, although in many hospital departments it continued. One of the early casualties were the hospital farms. It was said at All Saints Hospital that the decision to dispose of its farm, taken over with the hospital in 1948, came when the new management committee were informed that the prize bull, for which they had paid a considerable sum, was found to be infertile, and without offspring. The realisation that fecundity could not be purchased concentrated the minds of the committee that as managers of farms they were out of their depth.
For this, and different but analogous reasons, by 1954 a lot of the traditional occupations in the old asylum had disappeared along with the name. In 1954, two drugs, independently researched, were found, by chance, to produce remarkable improvements in the treatment of schizophrenia. One of these, Reserpine, did not survive for long because of it's side-effects, but the other, Chlorpromazine was the first of a range of drugs, initially called major tranquillisers, or neuroleptics, which are still the mainstay of treatment today. Despite their enormous significance they do not actually cure schizophrenia, and although they have been improved upon in various ways in the near fifty years since their introduction, there is still no true cure for this most destructive of illnesses.
The introduction of the drugs did however transform the course of the illness, and with it the whole ethos of the mental health hospital changed. Disturbed behaviour was greatly reduced and destructive symptoms eliminated or suppressed. It became evident that many previously seriously disturbed patients were now well enough to leave hospital and re-enter society.
It was from this background that industrial therapy units developed. Improved treatment, overcrowded mental hospitals and a lack of facilities to observe and acquire work skills led to the setting up of workshops and factories in many hospitals in Britain. As early as 1955 a survey of industrial therapy units in Europe was reported in the Lancet. The authors envisaged the mental hospital of the future as "a school for social learning where the psychotic, discarded by society as a whole" would acquire the social and work skills to return to the community or live at an enhanced level within the hospital.
Although the majority of the units in Britain started inside the mental hospital and many continued thus, for some the ideal position was to take the industrial unit outside the hospital. The pioneer in this development was Dr. Donal Early, Medical Superintendent of Glenside Hospital, Bristol who in 1960 formed a private company, The Industrial Therapy Organisation (Bristol) Ltd. Its objects were to provide a gradient of employment from projects in hospitals through more complex training at the factory, to independent employment, and combining with it social rehabilitation, preparing the long stay patient to resume ordinary life outside the hospital.
From these beginnings industrial therapy in Britain developed along independent and haphazard paths. No firm national policy was laid down, and it was left very much in the hands of local hospitals, and individuals in those hospitals, to develop the process. Many chose to continue their industrial therapy within the hospital, many providing a mixture of an industrial type unit in the hospital, traditional occupational therapy and domestic and other duties within the departments of the hospital. These hospital based units varied in size, and in the way they were run. Some hospitals ran the units with their nursing or occupational therapy staff whilst some employed supervisors with an industrial background to manage the hospital unit.
However, in different areas of the country, the Bristol model of an organisation providing training for work and social skills within the community was the preferred option. For the most part, like the hospital based industrial workshops, they sub-contracted work from local industry, reflecting the work that might be available to the rehabilitee. Some concentrated on marketing their own goods notably Cheadle Royal Industries Ltd in Manchester where three quarters of their production concentrated on the manufacture and marketing of paper carnival goods, rosettes, cake frills etc. Most developed a mixture of sub-contracted local industry and production of own products with, in most cases, more emphasis on the former because it was easier to develop and readily available.
It was against this background that the Birmingham Industrial Therapy Association was formed in 1963 and subsequently developed. It was not the first, but in its intent and constitution it took the first, at Bristol, as its model. It was therefore one of the early pioneers of this type of approach and a major contributor to the retraining of people leaving hospitals, many after many years, and returning them to the community, able to take their place in that community. Like all the others, it developed over the years, its own distinctive approach, an approach which has had to be periodically re-evaluated and restructured to meet ever-changing patterns of care and economic changes.
Today most of the old asylums, or mental hospitals as they became, are closed, and with their closure, their industrial therapy units. The various industrial therapy associations have disappeared also over the years, with one exception, the Birmingham Industrial Therapy Association.
It is about to celebrate the fortieth anniversary of its formation. As the sole survivor of those pioneers it seems an appropriate time to tell the story of its formation and subsequent history.
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