Letter from Great Britain: The Psychiatric Social Worker and the Almoner in BritainAuthor(s): FRASER BROCKINGTONSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 44, No.1 (JANUARY 1953), pp. 12-15Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41980397 .

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Letter from Great Britain

The Psychiatric Social Worker and the

Almoner in Britain

FRASER BROCKINGTON M.R.C.S. (Eng.); L.R.C.P. (Lond.); D.P.H.; B.Chir., M.D. (Camb.),

M.A. (Camb.); Barrister-at-Law Professor of Social and Preventive Medicine

University of Manchester Manchester , England

Dear Editor,

A COMMITTEE under the chairmanship of Professor J. M. Mackintosh of the London School of Hygiene has recently sat to consider the function

and training of the social worker in mental health (Command 8260, June 1951). Social work for mental health is of relatively recent origin in both Britain and the New World. This new development owes much to the leadership of volun- tary organisations. The Central Association for Mental Welfare (formed to implement the Mental Deficiency Act, 1913, more fully), the National Council for Mental Hygiene ( for the closer study of general mental health problems and psychiatric training in medicine, formed in 1922) and the Child Guidance Council (first evolved to provide skilled treatment for children's behaviour disorders ) all have made their contribution. These organisations are now amal- gamated into the National Association for Mental Health (with headquarters at 39 Queen Anne Street, London W.I.). Since 1926, psychiatric social workers have slowly won recognition as essential members of the psychiatric team in mental hospital and clinic. Their function is to obtain a skilled social history, to maintain contact between patient and community, and to help relatives provide an environment in which the patient may have the best chance of support. They are found at work undertaking psychiatric social therapy in mental hospitals, clinics and out-patient departments, in child guidance, and more latterly a few, since 1946, in community mental health programs, includ- ing care and after-care services and advice centres. Training in psychiatric social work (a years post-graduate course at either the London School of Economics, or Manchester or Edinburgh Universities) is based primarily on a Social Science certificate, diploma or degree. The theoretical work consists of psychology, psychiatry, child development, mental deficiency, physiology, psychiatric social work, law and administration, and mental health and aspects of criminology. Personality and actual capacity for social work are fundamental to success.

In a quarter of a century since the psychiatric social worker began in Britain, the number has risen only slowly (331 in 1951). The nuimber of such skilled

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Jan. 1953 PSYCHIATRIC SOCIAL WORKER 13

workers is as yet wholly inadequate to meet the growth of the social approach to mental health problejms; the need for work outside the clinical set-up is only slowly being accepted by the profession as a whole. This shortage of trained workers has greatly increased the difficulty of making a new approach to the problems of health of the mind, which views the hospital or clinical care as only one part of the total effort. The situation in Britain today is complicated by the fact that the problems of mental health have been allowed to develop and find a solution largely outside the medical services. The care of the feeble- minded which resulted from the Mental Deficiency Act of 1913 (following upon the Royal Commission of 1904-08 ) evolved as a service, provided by the Counties and County Boroughs, under mental-deficiency committees which were generally quite distinct from the health committee. Organised social work for mental defectives has since that time been provided by mental-deficiency social workers and home teachers with little, if any, training in psychiatry. For those with personality disorders the Lunacy Acts, concerned so largely with the liberty of the person when certification was in question, prescribed in detail the various methods for gaining admission to a mental hospital. The operation of this procedure was largely within the field of the relieving officer under the Poor Law. For long years, in fact, the Local Authority was required to do no more than incarcerate, with expedition and efficiency, those who had lost their reason.

It is of the greatest significance that in 1946 the National Health Service Act made mental health in its entirety a subject for the Ministry of Health, taking it out altogether from the realm of the Poor Law and social disgrace. Regional Hospital Boards and Hospital Management Committees have taken over the running of potentially all hospitals and institutions for physical and mental health ( a few private and teaching hospitals have special arrangements and epileptic colonies for some reason appear excluded). Local Health Author- ities assume all remaining duties under the Lunacy and Mental Treatment Acts (Section 51) as well as the Mental Deficiency Acts; for good measure and as a challenge, the National Health Service Act requires (Section 28) that local health authorities shall assume two new functions, the care and after-care of mentally ill leaving hospitals, and prevention in general of mental ill-health. This new association of mental and physical health, both at the functional and administrative level, is in itself of great value since, as we now know, the two are indivisible. Yet the greatest advantage does not come from changed forms of administration or new plans, essential as these have been, but from a changing outlook in those who are actually in contact with people. It is the attitude of doctors, nurses and social workers which counts for most. The proper psychiatric equipment of these is vital; they need to think in terms of the mind, and particularly of what a patient may be thinking and feeling; as well as being sensitive to the state of current public opinion aņd, when neces- sary, helping to educate it. We are clearly at the beginning of a new era in which the social approach to mental ill health is about to be vigorously devel- oped. To some extent the pattern of the past remains little altered. The duty oí admitting to a mental hospital is now carried out under the National Health Service by a "duly authorised officer"; these are in only rare instances psychia-

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14 CANADIAN JOURNAL OF PUBLIC HEALTH Vol 44

trie social workers; most are part-time or whole-time officers who previously engaged in relieving work under the Poor Law.

The work of after-care in relation to discharge from mental hospital is not unlike that for other hospitals, though perhaps attended with more risks of failure and more anxiety of the staff. Despite lack of psychiatric social workers, especially in the provinces, arrangements are being made empirically to link the work of mental hospitals and mental-deficiency colonies with local health departments through such workers as are available. Health visitors and other local authorities' social workers furnish background reports and visit patients in their homes after discharge. The present lack of any generally accepted understanding and training and the need for co-ordination of various field workers is well-known and much thought is being given to it. The immediate future urgently demands that psychiatric social workers be appointed to all health departments; only so will it be possible to develop effective help, deal with special cases and guide the work of less trained home visitors and members of the mental health team. It cannot be said that psychiatric social workers themselves wholly appreciate the new width of their work. The be- ginning of the social approach for them was related largely to the psychiatric out-patient and child-guidance clinic and many of them regard their function as best performed in the hospital or clinic.

To some extent this is due to the uncertainty within the psychiatric world itself about the possibilities of preventing mental ill health. The earlier you get into any mental situation, except with low-grade defect, the more difficult it is to know what exactly you have got. No Act of Parliament can secure, as it were, by the wave of a magic wand, that all mental ill health shall be pre- vented. It is obvious that increasing care in detecting mental inadequacy, and improved schemes for special care of the dull chüd at school and of the defective in the community, must gradually lighten the burden of mental inadequacy, but we do not know with any certainty how we can prevent it or at what point schizophrenia might be arrested or psychoneurosis checked. The development in some parts of the New World and in this country of advice centres staffed by trained social workers to which patients may bring their early worries is only in its infancy.

In 1949 a committee under the chairmanship of Mr. Zachary Cope, F.R.C.S., sat to review the recruitment, training and qualifications of medical auxiliary workers defined "as persons who assist medical practitioners (otherwise than as nurses) in the investigation and treatment of disease by virtue of some special skill acquired through a required course of training." The Almoner found herself among this group of eight (the others were chiropodists, dietitians, laboratory technicians, occupational therapists, physiotherapists, radiographers and speech therapists).

The need for a social approach to the treatment of patients in hospital led to the development of the hospital almoner. As the name suggests, problems of finance in voluntary hospitals, and the need to adjust the recovery of cost of patients' needs, play a significant part in this. Unlike the health visitor, the almoner is not trained in nursing and she is quite distinct from the psychiatric social worker in her relative lack of psychiatric background. Her course of

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Jan. 1953 PSYCHIATRIC SOCIAL WORKER 15

three years of full-time study is generally based upon a diploma, certificate or degree in social science and includes a final year of specialised training under the direction of the Institute of Almoners. The progress of this form of hospital work has benefitted from the relief of duties of assessing means and collecting fees which came about with the National Health Service Act and the compre- hensive free service of 1948. It has been estimated that one almoner is needed for 75 beds in an institute or general teaching hospital, and one to 200 beds in a hospital for the chronic sick. Although progress has been made towards this ideal, it remains true that relatively few hospitals outside the large general hospitals and teaching centres are equipped with almoners on this scale; most of the many hundreds of small hospitals have none. The work of the almoner is in theory confined to hospital, with the exception of some large teaching hospitals, and for purposes of research she herself has not visited homes. Never- theless her work does overlap with that of the health visitor and it is as yet too early to state definitely what the final status and function will be of two such workers engaged substantially on the same type of work with entirely different training and background.

The almoner's work within the hospital is of the utmost importance; her function is to discuss with patients the social, economic and industrial re- lationships, with the object of overcoming difficulties associated with illness which retard recovery, and to enlist the help of outside voluntary and official agencies. In practice there is no great difficulty in securing the necessary links between the hospital almoner and the health department, although many con- sider that she would be best placed on the health department staff. The pattern of social work in Britain is extremely complicated, and nothing illus- trates this more than the distinct training and functions of the psychiatric social worker and the almoner. There is a growing feeling that these two forms of social work must be more closely related, and many hold the view that they could be combined in person.

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