THERAPEUTIC SOCIAL CLUBS (Hansard, 17 March 1950)

§ Mr. Snow (Lichfield and Tamworth)
Before starting my remarks this afternoon on the subject of therapeutic social clubs, I should perhaps inform the House that I am a member of the governing body of the society which organises these clubs, though I have no financial interest about which to inform the House. It is essential for a layman who raises in this House the question of mental ill-health and mental illness generally to be most cautious not to give any false implication which depends on scientific knowledge, but to be careful that if he quotes medical opinion it should be a quotation and not a representation of his own opinion.
What I wish to do this afternoon is to seek the Minister's encouragement for the promotion of more therapeutic social clubs. These clubs are at the present moment located predominantly in. the Metropolitan area. It might interest the House to know the history of these clubs so that hon. Members can form their own opinion as to their value. Shortly before the war a small group of psychiatrists came to the conclusion that purely institutional treatment for mental ill-health was not the complete answer. In any remarks that I may now make, I wish it to be fully understood that I cast no criticism at all on the mental hospitals and their staffs, because their great work is fully recognised, and the devotion of the people who work in these great hospitals is something which we all appreciate.
The conclusion that these psychiatrists came to before the war was based on many factors; factors such as, for instance, the difficulties about the segregation of sexes in hospitals, and the difficulties with which they were confronted when they came across so many people suffering from such symptoms as excessive shyness. They concluded that if they could provide a method of social intercourse through, for instance, a club, a method which would involve imposing self-responsibility upon mental patients, it might provide an answer. This was the origin of the so-called in-patient club. Perhaps I may put it another way. There 1511 was an instinctive feeling by some of these psychiatrists that, in spite of the most modern equipment, in spite of great improvements in accommodation and the demonstrable sympathy of the staffs in question, something was lacking in the science of understanding the psychology of a psychotic patient.
I think it is true to describe the evolution of mental treatment in this country in three periods. There was the punitive period of treatment, of evil memory, when lunatics were whipped in front of the public gaze in London. Then there followed the more enlightened scientific period, which one can describe as the philanthropic period, where the patient is the object of treatment. Now we have come, some of us think, to a period which I can describe as the participatory period, where the patient is the subject of treatment. It is this principle, where the patient can participate in treatment, that, we think, is assisted by enabling the patient to have a greater sense of responsibility. These clubs produce that instrument where the activity of the club is organised by the patients themselves; they become, in fact, partners in the operation of treatment.
Shortly after that in-patient type of club was started just before the war, the same people who had originated the club came to the conclusion that an outpatient club might be something better. At present there are a number of these clubs operating outside the precincts of the hospitals. I should like at this point to pay a great tribute to the London County Council, without whose aid little could have been done in this post-war period, and by whose aid these clubs now operate. We feel that the time has now come to try to get the idea of these clubs better known, so that they can be set up in Scotland and Wales and in provincial areas.
The underlying principles of the clubs can be conveniently considered under the two principles of prevention and cure. In the former, it is believed that many patients avoid, by their membership of the club, in-patient treatment; furthermore, that it prevents or obviates the necessity for periodic treatment and sometimes prevents relapses taking place. The observation by a psychiatrist at regular intervals in a social setting does, 1512 we believe, cast an entirely new viewpoint upon this whole question.
On the subject of cure—and at this point I must quote medical opinion, although, for obvious reasons, I cannot give names—we think that the use of these clubs justifies the Minister's very careful attention. A very eminent psychiatrist, holding the most important senior appointment in his branch in a London teaching hospital, has said to me: In my view the following types of patients could, generally speaking, be considered as potential members of Therapeutic Social Clubs:

(1) People who are abnormally reserved, solitary and shy and who find it difficult to adapt themselves to a normal social life.

(2) People who have had treatment at a Mental Hospital, such as a Leucotomy operation, and who may need about a year's rehabilitation before they are completely fit.

(3) Certain people who are constitutionally unstable and who find it hard to fit into life but can be kept in their jobs with a minimum of psychiatric treatment and help."

Another eminent psychiatrist has also said to me: The following categories are suitable for consideration as members of clubs outside the precincts of hospitals: psychotics, neurotics, delinquents, and parents as part of child guidance. I should have liked to elaborate on those four classifications but time does not permit. However, I believe that the correspondence which I have had with the Minister and his Department obviates-the need for me to justify the claims of those clubs at any great length. Yet a layman's description is justifiable even in the short time available, to try to paint for the House a picture of what these clubs do.
First, they reassure the relatives of patients because they know that the patients will be getting regular notice and attention. Then no time is lost if a relapse appears imminent. Again, patients can relax and join in ordinary social activity in the clubs. As many as 80 patients can have attention and receive beneficial treatment despite disparities of age. The two sexes can mingle despite wide disparities of social background. The clubs are under the day to day guidance of social therapists who receive their training in observation and reporting from trained psychiatrists.
1513 I have been to many of these clubs and I know that my hon. Friend the Member for Islington, East (Mr. E. Fletcher) and one or two other hon. Members have also visited clubs in their Divisions. I had this impression, that patients who go into these clubs find themselves on terms of equality. They regain the confidence that, for various reasons, they lost in the past. They can amuse each other, they can participate in discussion, dancing, games, and so on. In other words they find themselves on terms of equality with the rest of the world. I shall quote four cases taken from the records of the voluntary society to which I have made reference that illustrate my contention, and I have taken those cases as demonstrating the four groups mentioned just now.
The first is the case of Mr. X, a psychotic patient, who had been for many years in a mental hospital suffering from schizophrenia, a split mind. He improved slowly and his relatives, who were concerned about him, took him out on their own responsibility. However, he became so difficult and troublesome that they felt they had to return him to the mental hospital. Before taking this step they heard of the existence of therapeutic social clubs and, in due course, he was made a member of a club. This man, who had been deluded, difficult and a nuisance to his whole environment, has changed his behaviour considerably. His delusions have disappeared, he has become an easy and a good mixer, he has started work and is teaching others his craft.
This is a typical case of that category of chronic psychotic patient who would have been in a mental hospital as incurable for the rest of his life. Although it has not yet been achieved that he can work in the competitive open market, he has become a useful member of society. He is carrying on his craft during the day and teaching and training other adults and juvenile patients. It has taken only a few months to make this patient lose his symptoms and become a happy and useful member of society. If I read these reports. I think the House will bear with me because I am anxious not to give incorrect medical implications.
Then there is the second case, of Miss A who was a neurotic suffering from headaches, depression, and obsessional symptoms. As her parents lived in the country, her father was advised to send 1514 the patient to London to be treated in a therapeutic social club. He refused and preferred to send her for treatment to a mental hospital. After out-patient treatment had for many months failed to improve her, two years as an in-patient in a modern mental hospital failed to bring about an improvement and she went from bad to worse. Only then did her father agree to her travelling to London so that she could be treated at a therapeutic social club. It took only a few months for her to improve to such a degree that she lost all her symptoms and was able to go back to her former occupation, which is skilled employment not only as an employee but in a managerial capacity.
The third case is of a Mr. Y, a delinquent. Mr. Y had been referred by a prison psychiatrist. He was an intelligent young man who had committed a sexual offence in a moment of apparent mental blackout. He was a person who seemed very matter of fact and logical, but without feelings. While a child his curiosity of sexual matters had been suppressed, and he was never given an opportunity to be a naturally aggressive boy. Therefore all his energy had accumulated in him and sought a way out. He received sexual instruction in prison and admitted he committed the crime out of ignorance and curiosity. When he was discharged from prison he could find no friends and was a social outcast. He lost his courage and could not find work. At the club he was accepted as an equal. When he discovered he was not an outcast he found his courage again. Once he had found that, he went out and found work, which gave him all he wanted.
The last case with which I want to trouble the House comes under the heading I gave of "Parents as part of child guidance." Under this-fourth category experience has shown that in many cases child guidance problems originate from parental inadequacies. Later I shall describe a form of multi-dimensional treatment carried on in the clubs. This case, which is typical, concerns the child of people Whom I will describe as Mr. and Mrs. Z. Their child refused stubbornly to take food. The psychiatrist found that the mother was in a very tense state of mind. The main cause was that she had no social outlets. After both parents had attended the club, the child's behaviour changed completely and the mother said to the psychiatrist at the 1515 club, "What have you done to our child? We cannot stop him eating."
I have no delusions that, in the light of Parliamentary discussion within this last week on Supplementary Estimates, and in particular the Debate on the Health Services, that this is not perhaps a very happy augury for a plea for financial assistance, but, if I can prove to the Parliamentary Secretary that there is an economic advantage to be derived from these clubs, perhaps he and his officials will view the matter very sympathetically. We believe that these clubs save overcrowding in hospitals. Difficulties in connection with new buildings and staffing and the burden on the medical staff may be eased by the provision of further clubs.
I have the most reliable information that the cost of maintenance of a mental in-patient in the metropolitan area works out at £180 per annum. We think that in the case of in-patients, if as we believe in-patient treatment can be expedited to that extent, that the cost to maintain a patient at the rate of £180 per annum may be saved. In the case of out-patients, because the clubs permit the more economical use of psychiatrists, social therapists and the like, these clubs are an economic proposition. The cost of the clubs works out, according to the budgets now in operation, at about £7 per year, for a member in a club where there is a fairly large membership, and about f15 a year in one of the smaller clubs. There is a club, for instance, in the Division of the hon. Member for Kensington, North (Mr. Rogers) whom I see in the House. In that club the cost, including psychiatric sessional fees, works out at £7 a member per year. I ask the House to consider that compared with the cost of maintaining an in-patient at £180 per annum.
There is a highly qualified band of psychiatrists available to advise the Minister and his officials, regional boards and local health authorities on this matter. I wish to pay tribute particularly to the North-West Regional Board, which has been very helpful in this connection. There are further developments which derive from these clubs. For instance, there is the problem of maintaining a mental patient where his relatives are themselves wage-earners. We believe that near autonomous hostels are a 1516 possibility and should be considered by the Ministry.
There is the question of the day hospital to which I have made reference. Here the principle is to provide more intensive treatment for nervous and mentally ill patients than is available in the clubs. In view of the prejudice of the public towards the mental hospital in-patient treatment we think the day hospital bridges the gap between the hospital and the out-patient department, which are the two standard treatments of today.
But I do not want to distract attention from the main issue that I raised, the issue of these clubs. If in the course of my remarks I have appeared to offer medical or scientific advice I have done so inadvertently, but I feel, as many other hon. Members feel, that the state of affairs in some of our mental hospitals is causing great distress to patients, relatives, the public at large and to medical practitioners. I wish most strongly to emphasise to the Minister that consideration by his Department to spreading the idea of these clubs up and down the country is most important.
I shall have failed most signally this afternoon if I have somehow implied that these are new and momentous methods of treatment. On the contrary, nothing more is suggested than that a corner of the veil is being lifted. It is a veil which hides a great deal of human unhappiness. Perhaps I should not say this, but I believe it to be true: there are too many people in the world today, there was a time when I was one of them, for whom mental ill health has a horrific connotation. Too many people have preferred not to know what goes on in mental hospitals.
I ask the Minister to consider three points. The first is what steps he can take through ministerial channels to make known the general principles underlying these clubs. The second is whether, in so far as the research work has so far been carried out on a voluntary basis, he can devise ways and means for financial grants for research because the work needs to be scientifically established. That takes money and with the financial stringency that exists in these affairs it is not possible to carry on scientifically this project unless financial aid is given. I mentioned at the beginning of my 1517 speech the Institute of Social Psychiatry of which I am a governor. Because of that I say that any like body or voluntary association which is carrying on comparable work would, I hope, be considered sympathetically.
The third is to make known to authorities in general and to his Department in particular what are the economic applications of this project, the economic argument being that it might and should relieve congestion in our existing mental hospitals. I have the authority of the Chairman of the L.C.C. Health Committee to quote him as saying that if more of these clubs were available the present mental in-patient population could be weeded out to some extent. I believe that it was Anatole France who coined the phrase "A moment in the conscience of man." It is to that same conscience that I make this appeal.

§ Mr. Eric Fletcher (Islington, East)
I wish to say a few words in support of the eloquent plea which my hon. Friend has made on behalf of these therapeutic social clubs. I do so because there is one of the clubs in Islington. I have visited it on a number of occasions and have been extremely impressed by the very valuable work which is going on there. As my hon. Friend has said, these clubs serve a great human need. There are a great many people who have either been in mental homes or who are potential inmates of mental homes, people who are in need not merely of psychiatric treatment as individuals but are more particularly in need of such treatment as a group. These therapeutic social clubs exist for the purpose of giving these unfortunate people the means of social expression, developing their contacts and friendship with other people and organising social activities. I have been markedly impressed by the way they show dividends. After a short time at these weekly meetings in the not very expensive clubs, abnormal people rapidly develop a greater sense of self-confidence, a sense of responsibility and assurance.
I am sure that very valuable work is being done, but it does not seem right to me that this should be done entirely with the support of voluntary persons. It seems to me essentially something which should have the sympathy and assistance of the State. In London some of these 1518 clubs are assisted very notably by the London County Council. I hope that the Parliamentary Secretary will give sympathetic consideration to what has been urged on him this afternoon and realise that there is a responsibility on the State to take over the support of these clubs; and in particular to encourage and stimulate with financial assistance the very important work of research which is being done, and still has to be done, in this field.

§ The Parliamentary Secretary to the Ministry of Health (Mr. Blenkinsop)
All hon. Members in the House at this moment are grateful to my hon. Friend the Member for Lichfield and Tamworth (Mr. Snow) for raising this subject, and particularly for the interest we know he has taken in it and the time he has spent upon it. As he said, it is true that the whole problem of the treatment of mental suffering and illness is very serious; all the more serious because of the very great handicaps we are all facing in its treatment today, both with the overcrowded mental hospitals and the shortage of staff. I do not want to over emphasise that, because we should realise that in spite of these difficulties we are encouraged by the fact that now something over 60 per cent. of the admissions to our mental hospitals are voluntary. That indeed is a trend which is greatly encouraging and we are very anxious that it should develop further.
It would be wrong for us to dismiss any suggestion which might seem to help us in our problems. Some of the points my hon. Friend put forward are not new, as he said. For some time it has been the tendency in mental hospitals to develop the work of welfare clubs of one kind or another; both inside the hospital and also, to some much more limited extent, outside the hospital. There are clubs run by local authorities and mental hospitals outside the curtilage of the hospitals altogether. These clubs are doing comparable work too and we appreciate very much indeed the value of it.
It is also true that the old problem of the almost inevitable segregation of the sexes which did, and still does take place to a large extent in our mental hospitals, is being increasingly overcome by the endeavours to associate together or to en- 1519 courage the association of opposite sexes. To a much increased extent the general social activities in mental hospitals are being organised and run by the patients themselves. All this is a good and healthy trend in the direction we have been discussing.
The problem as I find it, after discussing this matter with our medical advisors, is in what field can these clubs best serve? In our view, while there is no doubt at all that the clubs can be of immense value, particularly on the welfare and after-care side—and indeed to some extent on the preventive side—it would be a mistake to over-emphasise their possibilities as an alternative to hospital or out-patient clinics. That is clearly where there is some difference of opinion between those medical experts who take the view expressed by my hon. Friend and those who take the view that the actual treatment side should be concentrated in hospital and out-patient clinics. That does not necessarily in any way detract from the value of the work done by the clubs, but suggests that we are not likely to find any great reduction of pressure upon our hospitals and outpatient clinics by the adoption and development of further clubs of this nature, although unquestionably they have a very valuable part to play.
For that reason, it might be a bit misleading to pay too much attention to the comparison between the cost of the maintenance of patients in mental hospitals and the cost of the social welfare work in one of the clubs mentioned by my hon. Friend. Up to the moment we have comparatively little experience of the working of these clubs outside the hospital perimeter. We need a good deal more experience of their working before we can judge satisfactorily in what way they should best be developed and encouraged. It is, of course, true that both 1520 the regional hospital boards and the local health authorities would be concerned, and I know that they have been studying this problem both in London and elsewhere. At this moment I am afraid it would not be possible for me to commit the Department to any expenditure of funds on these projects, nor would it be possible for me to guarantee that we could exert pressure on the local health authorities or hospitals boards.

§ Mr. Snow
I was not appealing for funds for the clubs, which would not come directly under my hon. Friend's Department, but for funds for research in establishing scientific work.

§ Mr. Blenkinsop
That is a matter we should leave mainly in the hands of the hospitals boards and the local health authorities, at any rate for the present. We feel that clubs arising naturally from the local health authorities and the regional hospital boards are more likely to be successful than any proposals originating nationally from the Ministry. I am afraid that it is true that, at any rate until we can get further through what I should still call this experimental period in their use, I cannot guarantee or give any assurance about financial or other support which the Ministry of Health could give. I am very much interested in the proposals which have been raised. I can assure my hon. Friend that we shall give them most sympathetic consideration and I would say, further, that I hope that this Debate itself will have helped to draw the attention of a wider public to the valuable work that has been done.