H OSPITALS
A unique therapeutic community
Julian Goodburn Paddington Day Hospital is a unique tellthera Peutic community. It opened almost years ago and has functioned continuously ever since, establishing liniques for therapy, training and liaison t7.41.1 local community services. During 'ese ten years, a particular culture has evolved through steady modification via e‘xPerience of those concepts which were 'here at its inception. Initially, it was tpeenceived as a half-way house located in e catchment area of Horton Hospital, rrtPicini (a large mental hospital twenty the population it serves). -Fort.eisiitofursoln ly, it was located in the same building as an adult out-patient psychotherapy clinic and a child guidance • The inter-relationship with these t'ho departments has been flexible; the r■ tee dePartments together can claim to a c rr• rr• omprehensive psycho wthherapeunvide tic service. During recent years, arisen consultant staff vacancies have I en, they have been replaced by 40eurns. „ In the summer of 1971 there were t7v4e,ral visits from a mixture of administrt!ve and clinical staff of the administenen already described and St Mary's vi;.e41118 hospital, Praed Street. The 'tors revealed that reorganisation might tWheell,,M.eall that St Mary's would take over At that point in time no one was buiPared to discuss current or future work 0,1.1'11Y questions of bricks and mortar. In G—th'er 1971, St Mary's Board of eu°vern,ors made its proposals to doctors eaehtlY working in the unit that, in view 'e fact that they were required to take ,_er district responsibility, they intended take over the building, to absorb and over the building, to absorb and th..4'garnate the child guidance clinic and stt.iadult psychotherapy department into etraotitimsfaerYr ishePsnycniatric Department and ay —ay Hospital to a psychiatri ekaPle't Yet to be built nearby. On closer linriation, this was not simply a rice as iriterned. far as the Day Hospital was The new day hospital was orga„tiled to offer short-term stay, primarily psYc Methods of treatment and little psYen,°heraPY; certainly not the kind of \vnairi-;-,"erapy currently practised, which ',1e impossible in view of the brevity tios 7.'Y and turnover envisaged. The Day Pita]. clair„.1 decided to fight this Proposal, day-3.1118 that whatever service St Mary s this t)1,8Pital would provide in the future, execould be in addition to, not to the skin of, that made available by the existing Paddington Day Hospital. More than half of the current forty patients have been previously admitted to mental hospitals, many on several occasions; a further proportion have been imprisoned; all suffer from a degree of psychological malfunction which necessitates radical psychotherapeutic intervention, as previous therapy has proved ineffectual or insufficient. Diagnostic categories include schizophrenia, depressive illness, severe phobic and obsessional states, character disorders. Patients are accepted of all ages after mid-adolescence. There is no waiting list. Applicants are seen in groups so that mutual selection can take place. Almost all patients referred who wish for treatment are accepted.
All work is conducted in staff/patient groups. Each day, five days a week, there are three formal group meetings, that is one small group psychotherapy session and two large community meetings. Discussions are free and unstructured. Psychoanalytic principles form the background but are modified in relation to this unique situation where all concerned can not only explore their inner worlds and check their findings by interaction with others (as in out-patient group psychotherapy), but also take social action where appropriate, for example, patients dissatisfied with inadequate housing — digs, hostels — raised money, rented a house and now manage their own affairs in this respect. Other group meetings offer continuing help to those who have passed through the full-time regime on a onceweekly basis in the evening or invite the families of those in treatment to explore the family situation. Another group formed at the request of local authority workers offers an exploratory situation for housewives in difficulty. For many who have suffered gross infantile deprivation, personality disorder has deprived them of subsequent real experience, and the milieu of the Day Hospital enables them to venture into the community at large, comparing their experience in a microcosm of society with that outside. Our results are considered by referring agencies to be highly successful but very difficult to demonstrate statistically, as it would be necessary to make longitudinal studies of the patients' lives. Junior staff receive an in-service training; student nurses and student social workers, trainee psychotherapists learn through placements at the Day Hospital. Regular visiting days are arranged for those interested In the Day Hospital's work from all walks of life. Professional workers in the community, finding they shared a common experience of isolation, formed themselves multi-disciplinary semi nars, including general practitioners, social workers, youth workers, community rela tions officers, probation officers, psychotherapists, to explore their professional roles and areas of overlapping function. This seminar provided the nucleus of the Community Action Group.
The campaign against closure has drawn on the positive wish of those within the unit, both staff and patients, to expand the awareness of the decision-making process within society with particular reference to this unit, the aim being to maintain the possibility of continuing the work described above; the very protest campaign can be seen as therapy itself. In practice, those members of the Day Hospital community have worked in conjunction with members of the Com munity Action Group, exchanging information through their own networks with professional colleagues, administrators, MPs, reporters from the media, and most important, members of the general public. This has led to widespread support from individuals and organisations.
All concerned in the campaign have become increasingly aware of the lack of consultation that exists within the National Health Service, so that decisions tend to be taken by those in authority without suf ficient consultation with those actually using the service, be they patients, referring agencies, or in this case, the staff of the unit. An obvious solution would be to bring the various interested parties together. A move in this direction was made when the North West Metropolitan Regional Hospital Board convened a meeting with St Mary's Board of Governors and representatives from the administrative and clinical staff of this clinic. Suffice to say that nobody was invited from the Day Hospital directly, no patients and no general practitioners were present. A representative of the Regional Board, himself a servant of the National Health Service, declared that the Board would invite who it chose to such meetings. Is this democracy in action?
As far as we can understand, the decision rests ultimately with Sir Keith Joseph, who takes advice in these matters from the Regional Board and teaching hospital board of governors concerned, and as our appeals for joint meetings are refused, we must rely on rumour which has it that April I is the deciding day.
Our direct questions about the unit's security and future have been evaded at all levels although we know that important discussions have taken place. It seems that a service which complies in all respects with plans for the future of the National Health Service, save that it is a David in comparision with the Goliath of the " district " hospital, is at risk unless the Department of Health and Social Security can be convinced that this experiment is a valid one which has a right to continue despite any bureaucratic inconvenience that may be caused.
Dr Julian Goodburn is Medical Director of Paddington Day Hospital.
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