Brit. J. prev. soc. Med. (1960), 14, 173-180

PILOT EXPERIMENT IN THE REHABILITATION OFLONG-HOSPITALIZED MALE SCHIZOPHRENIC PATIENTS

BY

J. K. WING

Medical Research Council Social Psychiatry Research Unit, Institute ofPsychiatry, Maudsley Hospital

A national register of disabled persons andfacilities for their industrial rehabilitation and re-settlement in suitable work were set up after thepassing of the Disabled Persons (Employment) Actof 1944. A description of the methods employed inthe Industrial Rehabilitation Units and an evalua-tion of how they were carrying out their functionswere included in the Piercy Report (1956). Untilrecently these units have not taken any very largeproportion of schizophrenic patients. The Ministryof Labour (1958) has published the follow-up figuresrelating to the total entry to all Units during 1956(9,608 persons). 19 per cent. terminated the courseprematurely and were not followed up. The rest weresent a letter inquiring how they were getting on6 months after discharge from the unit. 10 5 percent. did not reply to this letter, 21 9 per cent. saidthey were unemployed or sick, and the remaining48 * 6 per cent. said they were employed or training.The diagnosis of schizophrenia was not singled outfor separate mention, but similar figures are avail-able for the category of "functional psychosis"(403 persons). This includes affective and schizo-affective psychosis, and acute, as well as chronic,schizophrenia. 27 3 per cent. terminated the courseprematurely, 14 -1 per cent. did not reply to thefollow-up letter, 23 1 per cent. said they were un-employed or sick, and 35 * 3 per cent. said they wereemployed or training. It is difficult to predict fromthese figures what the results would be with schizo-phrenic patients alone. At one unit, where there hasbeen rather more experience of the problem becauseof the proximity of several mental hospitals, 46 percent. of the 22 ex-schizophrenic patients (acute andchronic) admitted during 1956 were employed6 months after discharge (unpublished data), whichis equivalent to the national average. Chronic, long-hospitalized patients represent a still further selec-tion, no doubt because of factors of personality and

social background as well as of illness, so thatresults are very difficult to predict. There is a dearthof properly conducted follow-up studies which wouldgive an indication of the employment prospects ofsuch patients who are discharged without going toIndustrial Rehabilitation Units in spite of the factthat the fashion nowadays is to discharge as many ofthem as possible. Brown, Carstairs, and Topping(1958), in their study of patients discharged afterat least 2 years in a mental hospital, found that41 per cent. worked for 6 months or more during theyear of follow-up. They also noted that 97 per cent.of these employed patients remained out of hospitalfor at least one year (their criterion of success), whileof the 43 per cent. who were never employed only46 per cent. were successful in remaining out ofhospital.Although it seems likely that the Industrial Re-

habilitation Unit results with chronic schizophrenicpatients are not as good as average, they are not toodiscouraging when it is remembered that this is acomparatively new field and that principles forselection and treatment have not been fully workedout. There is no published literature on the subject,apart from a paper by Maxwell Jones (1956) whichwas mainly introductory and statistical. He showedthat the arrangements for patients to attend Unitswhile living in hospital were working satisfactorilyand with reasonably good results, and he recom-mended their extension.From a survey made of four Birmingham mental

hospitals, it appears that a large majority of patientsrequire only routine supervision and that their maintherapeutic need is for adequate occupation. At least12 per cent. are in hospital for purely social reasons(Garratt, Lowe, and McKeown, 1957; Cross,Harrington, and Mayer-Gross, 1957).

This paper is concerned with a small pilot experi-ment designed to evaluate the effect of a course of

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rehabilitation at an Industrial Rehabilitation Unit onlong-hospitalized male schizophrenics, comparedwith an equivalent period of time spent in hospital.The hospital concerned is located in Epsom, Surrey,and is 25 miles from its catchment area, the East Endof London. It is a fairly characteristic hospital of theLondon area, and its schizophrenic patients areprobably typical of those in any mental hospital.

METHOD

The Physician Superintendent was asked to supplya list of male schizophrenic patients, aged 25 to 45,who had been in hospital for more than 2 years, whowere occupied without close supervision, and whomight be willing to attend an Industrial Rehabilita-tion Unit. These patients (33 in all) were inter-viewed, the diagnosis was confirmed, and tentativeinquiries were made to find out which men would liketo take advantage of a course of industrial rehabilita-tion if the opportunity were offered. Three whodeclined were excluded; the remaining thirty tookpart in the experiment.

Since no specification was made as to any otherform of supervision, nor as to mental state, therewas a wide range of severity of illness. A psychiatristunconnected with the project was asked to see all thepatients and to assess the mental state of each one inthe following way. Four categories of symptoms weredistinguished-flatness or incongruity of affect;speech disorder; delusions; and hallucinationseach of which could be rated on a 5-point scaleaccording to its prominence during the interview.If no symptom was present, a rating of 1 was made.Minimal symptoms were rated 2, moderate symp-toms 3, severe and very severe symptoms 4 or 5. Onthe basis of these ratings the patients were dividedinto one group of fifteen patients with severesymptoms (a rating of 4 or 5) in one or morecategories, and a second group rating 1 to 3. Fromthese two groups patients were allocated at randomto an experimental group of twenty patients or to acontrol group of ten patients. At this stage twopatients had to be rejected from the experimentalgroup-one because he escaped from hospital andwas thereafter placed under strict supervision; theother because he was placed on physical treatmentand had to miss the course. These patients werereplaced by two others fulfilling the original criteriaand equivalent in mental status. None of themoderately ill patientshad been severelyill (accordingto their case records) during the previous 3 months.At this initial stage the two groups were not

significantly dissimilar in respect of age (means

34 * 2 and 37 * 1, range 25-44 and 27-44 years), lengthof stay in hospital (means 4-8 and 5 4, range 2-20and 2-11 years), highest previous occupation (abouthalf of each group had been unskilled manualworkers), or legal status (about two-thirds of thepatients in each group were certified).Each patient was then rated by the investigator on

his attitude towards leaving hospital and his plansfor the future (see Tables IV and V for details ofthese ratings and the composition of the experi-mental and control groups in respect of them). Nopatient said he wished to stay in hospital, pre-sumably because of the conditions of selection.

Finally ratings were made of the social behaviourshown by the patients on the wards. The chargenurses were asked to observe the patients' be-haviour during the course of a week and then tocomplete a schedule of fourteen items, each ofwhich could be rated as present in marked degree(+2), present in moderate degree ( + 1) or absent (0).Six items (social withdrawal, lack of conversation,lack of interest or curiosity, slovenliness of dress,slowness of movement, underactivity) were relatedtogether, and formed a subscale of "Social With-drawal". The other eight items (suspicion, excessiveself-assertion, overactivity, irritability, hostility,gesticulations, talking to self, laughing to self) wererelated together, and formed a subscale of "SociallyEmbarrassing Behaviour". In preliminary work itwas shown that the two subscores were not signi-ficantly related together (r = +019 and -0 08 intwo samples), and that after four independent sets ofratings, the mean r for "Social Withdrawal" was+0 85, and for "Socially Embarrassing Behaviour"+0 72. Further details about this schedule arepresented elsewhere (Wing, 1959; 1960a). It is con-sidered that the two subscores measure differentaspects of behaviour and that each is reproducible.There were no significant initial differences betweenthe experimental and control groups (see TablesII and III) for either score.

ADMINISTRATIVE PROCEDURE

The patients were admitted to the IndustrialRehabilitation Unit a few at a time in order to keepthe maximum proportion at the Unit at any onetime below 10 per cent. (the total capacity was 100persons). Since over half of them were certified, andsome doubts were felt concerning their good be-haviour, they travelled to and from the hospital byhired bus accompanied by a nurse. This procedurehad definite disadvantages, as it made it plain from

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the outset that these patients were in some wayexceptional. In addition, no test was possible of theirindividual time-keeping, though this was laterarranged for certain of them. However, the patientsthemselves preferred the arrangement to "going in agaggle on a public bus in the charge of a nurse", asone of them put it. No special arrangements forsupervision were made at the Unit. This is in anycase fairly close. It was made clear that the patientswere attending voluntarily and could terminate thecourse any time they wished. The patients receivedthe usual money given to all Unit entrants, but thiswas paid directly to the hospital and deductions forboard and lodging were made before the remainder(about £1 weekly) was paid to the patient. Thisarrangement, while it was suitable for the severely-ill patients, did not give the others as much freedomfrom restriction as might have been thought desir-able to counteract "institutional" attitudes.Once at the Unit the patients were treated in

exactly the same way as the other entrants. Thecourse lasted an average of 8 weeks. Each patientwas assessed individually by the Unit staff andassigned work in one or more of the Unit workshops.Towards the end of the course certain patients weresent to their local employment exchanges which hadalready received detailed instructions as to theiremployment capabilities. Other patients wererecommended for training in some trade, others forreturn to hospital. At the end of the course theoriginal scheme of rating (mental state, behaviour,and attitude) was repeated. The patients were thenfollowed up, by social-worker visits, letters, and theemployment exchanges, for at least one year. Theten patients in the control group remained inhospital and were treated exactly as they would havebeen if they had not been included in the experiment.They were re-rated after a period of 10 weeks andfollowed up for a year.

RESULTS(1) FOLLOW-UP RESULTSThe follow-up status, 12 months after the second

rating, of the thirty patients in the experiment, isshown in Table I.

Six of the ten moderately-ill patients who attendedthe Industrial Rehabilitation Unit were out ofhospital one year later and had been self-supportingfor at least 6 months. One had completed a refreshercourse in tailoring and had found a job in the trade.One had completed a probationary period withRemploy Ltd. (learning to make orthopaedic boots)and had given full satisfaction. The other four hadbeen placed into simple manual jobs with littleresponsibility attached. Only one of the patients wasliving at home, but four had relatives or friends whowere able to give some help. Another patient hadcompleted a training course in plumbing-he hadbeen discharged from hospital (though rather un-willing to leave) and was attending as an out-patient.He had not yet found work. Another patient hadcompleted a course in bench-fitting and was workingwell from hospital. He was completely self-support-ing but, because of a doubt about his capacity forkeeping himselfclean and reasonably tidy, he had notbeen discharged. Two patients were in hospital andnot employed outside. One had left hospital (againstadvice) during a bus strike, had been unable tocontinue his course at the Unit from his hostel, andafter a short period was re-admitted elsewhere. Theother, although he did fairly well in a lowly capacityat the Unit decided firmly that he neither wanted toleave hospital nor to work outside. He had first beentaken ill when 16 years old and had been con-tinously in hospital from the age of 21 to the time ofthe experiment-over 20 years. Although he couldhave done some manual work, it was thought thathe would never acquire the confidence to leave thehospital, and he wanted to end his days there. He

TABLE I

FOLLOW UP STATUS, 12 MONTHS AFTER SECOND RATING

No. in Discharged from Hospital Still Resident in HospitalGroup Severity of Illness Group .______ ______Group Severity .of Illness Group

Self supporting Not Employed Self supporting Not Employed

ModeratelyIll .. .. 10 6 1 1 2Experimental .S. Ie- I-9Severely Ill ....... .. 10-1- 9

ModeratelyIll .. .. 5 - 1 _ 4Control .. I

Severely 11 .. |5 - _ _ 5

In this and subsequent Tables the "Second Rating" refers to the examination made after the completion of the Industrial RehabilitationCourse for the Experimental group, and at a similar interval, about 10 weeks after the First Rating, for the Control group.

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176 J. K.

resisted the modest pressure which was put upon himand it was not felt justifiable to persuade himfurther.Four ofthe five moderately-ill patients inthe control

group were still in hospital one year after the secondrating. The fifth, a 27-year-old man who had beendestined for a solicitor, returned home after 9months but has not so far found work. He needsvocational guidance and would be a good subject forthe Industrial Rehabilitation Unit. One moderately-ill patient discharged himself from hospital duringthe experiment (possibly as a result of the inter-views). He failed to find work, however, and wassoon re-admitted. The superiority of the experi-mental over the control group is thus clearly evidentso far as the moderately-ill patients are concerned.The ten severely-ill patients who went to the

Industrial Rehabilitation Unit did not fare very well.At follow-up only one was living outside hospital.He was a 35-year-old man with marked incoherenceof speech who had improved very considerably at theUnit and had been recommended for sheltered workfrom hospital. Such work could not be found, but heleft hospital and at follow-up was supported by hiswife; although she realizes that he is not capable ofopen employment and he is not otherwise a liability,this is not a satisfactory arrangement. Anotherseverely-ill patient was returned to hospital withoutcompleting his course because of marked sociallyembarrassing behaviour. He improved on Prochlor-perazine and was later discharged, but could followno regular employment, and shortly afterwards hadto be re-admitted. Another patient was dischargedfrom hospital and worked as an electrician's matefor 3 months before relapsing. He was re-admittedto the local hospital and is still there. One otherpatient, although remaining severely deluded, foundwork locally and was employed for 2 months whileremaining in hospital. He lost this job because hewas too erratic and he, together with the rest of thisgroup, was resident in hospital and not employedoutside at the time of follow-up. Five of the tenseverely-ill patients were recommended for shelteredemployment, but it was not possible to implementthis because of lack of facilities.

All five severely-ill patients in the control groupremained in hospital throughout the follow-upperiod and the question of employing any of themoutside never arose.

(2) RATINGS OF MENTAL STATE, BEHAVIOUR, ANDATTITUDE

There was no substantial change in the ratings ofany of the four categories of abnormal mental

WING

phenomena. However, ten patients in the experi-mental group were given a rating on the secondoccasion, which was one point better than the firstrating in one or more of the four categories. Thishappened with only one of the control group(Fisher's exact probability, two-tailed = 0-075).Only one patient (the one who improved aftertermination when given Prochlorperazine) waschanged in grouping from severely ill to moderatelyill, and he later relapsed.The mean social behaviour scores, on the two

occasions, of the experimental and control groupsare presented in Tables II and III.

TABLE IIMEAN SOCIAL WITHDRAWAL SCORES FOR EXPERIMEN-TAL AND CONTROL GROUPS BEFORE AND AFTER

INDUSTRIAL REHABILITATION COURSE

Mean ScoreSeverity No.

Group of in First SecondIllness Group Rating- Rating-

Before AfterCourse Course

Experimental Moderately Ill 10 3 * 3 2-1Severely Ill .. 10 3-7 3-4

Control .. Moderately Ill .. 5 3 * 2 3*8Severely Ill . . 5 6 5*8

TABLE IIIMEAN SOCIALLY EMBARASSING BEHAVIOUR SCORESFOR EXPERIMENTAL AND CONTROL GROUPS BEFOREAND AFTER INDUSTRIAL REHABILITATION COURSE

Mean ScoreSeverity No.

Group of in First SecondIllness Group Rating- Rating-

Before AfterCourse Course

Experimental Moderately Ill 10 2-6 1-4Severely Ill 10 6-4 4-1

Control Moderately Ill 5 3*2 3 *2Severely Ill 5 5 *0 6-8

Analysis of variance disclosed no significantchange in the "Social Withdrawal" score in anygroup. The analysis of variance of the scoresrepresenting "Socially Embarrassing Behaviour"disclosed a significant interaction effect betweenratings and groups (F = 6 53;p = <0 05). Subse-quent t-tests showed a significant decrease in scorein the severely-ill experimental group. The severely-illcontrol group showed an increase in mean score butthis did not reach significance.

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The. data concerning attitudes to discharge andplans for the future are presented in Tables IV and V.

TABLE IVATTITUDES TO DISCHARGE BEFORE AND AFTER

INDUSTRIAL REHABILITATION COURSE

Experimental Group Control Group

Attitude to Moderately Ill Severely IIIDischarge __

First Second First Second First SecondRating Rating Rating Rating Rating Rating

Strong Desireto Leave .. 1 7 - 1 - 1

Moderate De-sire to Leave 3 1 1 3 2

Vague Desireto Leave .. 6 1 6 2 6 6

Indifferent .. _ - 3 2 2 1Wish to Stay - 1 - 2 - 2

Total in Group 10 10 10 10 10 10

TABLE VPLANS FOR THE FUTURE BEFORE AND AFTER

INDUSTRIAL REHABILITATION COURSE

Experimental Group Control Group,

Plans for the Moderately Ill Severely IllFuture First Second

First Second First Second Rating RatingRating Rating Rating Rating

Realistic .. 2 8 - 2 1 1

Unrealistic 5 1 7 6 5 4

None .. 3 1 3 2 4 5

So far as attitudes to discharge are concerned, themajor change is a crystallization of attitude. In themoderately-ill experimental group, six patients had avague desire to -leave hospital before going to theIndustrial Rehabilitation Unit; in four of them thedesire became definite, while one became sure thathe wished to remain in hospital. Similarly, in theseverely-ill experimental group, four patients be-came definite about leaving or staying, whereasbefore they had been vague. There could be no caseof reversal of attitude because no patient in theseries said initially that he wished to remain inhospital. In the control group there was littleimprovement.

Plans for the future became more definite andmore realistic in the moderately-ill experimentalgroup. Within the severely-ill experimental groupand the control group there was little change.

The relationships between attitudes and follow-upstatus are shown in Tables VI and VII. Thirteenpatients were rated on the second occasion as havinga definite desire to leave hospital. Six of them werein fact outside one year later and seven were inhospital (four of these had been discharged for shortperiods of time). Of the seventeen patients who werenot rated on the second occasion as definitely want-ing to leave hospital, only three were outside atfollow-up. (These three had all had a vague leaningtowards discharge). These relationships do not reachstatistical significance (Fisher's exact probability,two-tailed = >0 10).

TABLE VIRELATIONSHIP BETWEEN SECOND RATING OF ATTITUDETO DISCHARGE AND FOLLOW-UP STATUS ONE YEAR

LATER

Attitude to Discharge at Second Rating

Status One Year after Strong or Vague Desire toSecond Rating Moderate Desire Leave,

to Leave Indifferent,or Wish to Stay

Living outside Hospital 6 3

Living in Hospital .. 7 14

TABLE VIIRELATIONSHIP BETWEEN SECOND RATING OF PLANS FORTHE FUTURE AND FOLLOW-UP STATUS ONE YEAR LATER

Plans for the FutureStatus One Year after at Second Rating

Second RatingRealistic Unrealistic or None

Employed outside Hos-pital .. 7

Not Employed outsideHospital .. .. 4 19

Eleven patients were rated on the second occasionas having fairly realistic and sensible plans for thefuture. Seven of them were employed at follow-up,and four were unemployed (three of these four hadheld down jobs for several months). All the remain-ing nineteen patients were unemployed and none ofthem had worked outside hospital during thefollow-up period. (Fisher's exact probability, two-tailed = <0 001).

(3) DESCRIPTIVE ANALYSIS OF OBSERVATIONS MADEAT THE INDUSTRIAL REHABILITATION UNIT

In order to provide a framework for the descrip-tive material, and to allow a fairly objective decisionas to what should be presented and what omitted,

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the descriptive phrases used by various members ofthe Unit staff at the first and final case conferenceswere recorded and analysed. This analysis has beenpresented in detail elsewhere (Wing, 1959) and onlycertain of the findings will be presented here.

It was clear from a glance at the lists of phrasesthat no change in behaviour had occurred, in thesense of a reversal of traits previously observed. Nopatient was said to be unreliable on admission andreliable on discharge, or to have changed fromapathetic to interested, from slowmoving to ener-getic, from withdrawn to sociable. On the otherhand, there was a very definite change of emphasisfrom derogatory remarks, which were common atthe first case conference, to positive descriptions afew weeks later. This impression was strikingly con-firmed if a simple count was made of positive andnegative remarks about each patient. Of 62 phrasesused about the ten moderately-ill patients at the firstconference, 46 (74 per cent.) were disparaging. Onthe occasion of the final conference only 28 out ofsixty (47 per cent.) were negative. However, for theten severely-ill patients, 83 per cent. of 75 phraseswere derogatory on the first occasion and 75 percent. of 73 phrases on the second. Thus there was avery significant change of emphasis in the remarksmade about the moderately-ill group (X2 = 9 7;df = 1; p = <001), but not in those concerningthe severely-ill patients (X2 = 1 2; df = 1; p =>005). At the first case conference, both groupswere adversely commented on, irrespective ofseverity of illness, while at the final case conferencethere was a significant discrimination in favour ofthe moderately ill. Since the two groups wereinitially very different in mental state, social be-haviour, and attitudes, and since no reversal ofbehaviour was described, two interpretations maybe offered. In the first place, the moderately-illpatients may have been encouraged to displayqualities which were latent in them already butwhich did not show up during the first week at theUnit. In the second place, the attitudes and ex-pectations of the senior staff of the Unit may havechanged, as the moderately-ill patients demonstratedthat they were no different from the other, non-schizophrenic, patients. Probably both explanationshave some validity.Among the phrases used to describe the patients'

social behaviour, manners and attitudes, a commonreference was to "unrealistic" attitudes. These wereparticularly evident in seven patients with severeflorid symptoms whose attitudes were influenced bytheir delusions and incoherence of speech. Elevenpatients (including all the severely-ill group) weresaid to have a manner which would be unacceptable

to an employer. Remarks were made about theacceptable manner of six of the moderately-illpatients. This concept of acceptability (based largelyon appearance, spontaneity of speech, and friendli-ness) plays a very large part in the thinking of thesenior members of the Industrial RehabilitationUnit staff. Eight patients were said to be verysolitary. Three were said to mix well. The otherswere reticent and passively withdrawn but mostlypleasant and amenable so that their withdrawal didnot stand out as unfriendly. No patient was said toimprove in this respect.Twelve of the twenty entrants were described as

unskilled, four displayed a fair degree of skill (orskill "potential"), and four showed slight skill. Aneed for detailed supervision was also emphasized("Does everything he is told perfectly, then stops andwaits"; "Must demonstrate everything in detail";"Must be given very simple instructions", etc.).Several such remarks indicated an inability to makea series of decisions ("Cannot master four operationson a machine"; "Cannot put him on a machine witha choice of handles", etc.). At its most severe thiswas an incapacity to make any decisions at all (e.g."Must be told every single simple operationseparately-then he can do that one-then he hasto be told again"). Several patients showed a degreeof this incapacity. Other patients were able to decide(sometimes quite rapidly) but they made the wrongdecisions, and could not be trusted on machinesbecause they spoiled materials. In general, these twotypes of handicap corresponded with the absence orpresence of florid symptoms such as incoherence ofspeech or coherent delusions. (In patients withoutflorid symptoms, the main features were flatness ofaffect and poverty of speech). These observations,taken together, explain the recommendation ofsimple, repetitive manual work, with little opport-unity for decision-making, which was offered fortwelve out of twenty patients; three were unsuitablefor any kind of job, and only five were thoughtcapable of any kind of skilled work.The concept of "workshyness" was applied to six

patients-all except one of whom were severely ill.This was partly a misconception, due to the difficultyof categorizing behaviour traits which could be seenin non-schizophrenic individuals as symptoms of aschizophrenic illness. However, there was un-doubtedly a strong feeling about a few patients thatthey occasionally exaggerated their psychotic symp-toms in order to avoid work they considered toohard.None of these phrases was specific to this schizo-

phrenic population; all represented problems whichwere familiar in non-schizophrenic entrants to the

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Unit, though the pattern revealed by this analysis ismore typical of the less skilled physically-handi-capped entrants.

DISCUSSIONOn this evidence, the practical results of offering

courses of industrial rehabilitation to moderately-ill,chronic schizophrenic patients, who, initially, wishto leave hospital, seem fairly good. Only one of theten patients terminated his course prematurely, andsix were satisfactorily resettled one year after dis-charge. Another patient was supporting himself butliving in hospital. This proportion compares veryfavourably indeed with the national figure of 49 percent. of all entrants known to be employed or train-ing 6 months after leaving the Industrial Rehabilita-tion Units. The five moderately-ill patients who didnot have the advantage of a course of industrialrehabilitation did not fare so well; four were still inhospital and one was at home but not working at thetime of the follow-up.

In a study of the attitudes to discharge of samplesof male schizophrenic patients who were under60 years of age and had been in hospital over2 years, it was found that 27 out of 185 (15 per cent.)were moderately ill and had some desire to leavehospital (Wing, 1960b). The two hospitals concernedin the survey were thought to be representative, andother hospitals are not likely to have a smaller pro-portion of patients in this category.The results might have been even better had

facilities existed to implement the recommendationof sheltered employment which was made for five ofthe severely-ill patients. It cannot be concluded thata similar degree of success could not have beenachieved by the use of similar methods within thehospital without the aid of the Industrial Rehabilita-tion Unit since the experiment was not designed toanswer this problem. But, given the existing hospitalservices, and without a considerable increase insocial work and disablement resettlement facilities,it is very doubtful whether the results of the controlgroup could have been much improved.The handicaps revealed by the Rehabilitation

Unit course can be classified in much the same wayas the symptoms shown in hospital. Patients showingmainly flatness of affect and poverty of speech(whether moderate or severe) are likely to be slow atwork, to lack initiative, to be incapable of complexwork, and to be socially withdrawn. They are oftenwilling and amenable and capable of simple processwork requiring no complicated decision-making.Patients with "florid" symptoms tend to rush theirwork, to be unrealistic (thinking they are doingbetter then they are), and to do worse the more

complex the task. They often have abundantenergy, however, if the right job can be found. Thusboth groups require fairly unskilled work. The fourpatients who had some degree of skill (three of whomlater took training courses) had all been semi-skilledmanual workers before the onset of illness. Severalother patients had achieved relatively higher work inother fields (clerical, physical training, etc.), but thisexperience did not seem to stand them in as goodstead.

This experiment took place during a period ofrelative economic recession, which, however, wasnot as marked in London as in other parts of thecountry. There is no evidence that this affected thechances of any of these patients very considerably.Labouring jobs and simple machine-operating jobswere not difficult to get. Indeed, jobs from which allthe skill has been extracted are becoming more andmore common. Many of these patients were wellable to do such work and did not seem bored by it.Taking up work within their capacity is a reasonablemethod of adjusting to their handicaps and makinguse of their residual ability.

There was no improvement in these primary workhandicaps during the Rehabilitation course, nor wasthere any marked change in mental state. Socialwithdrawal, as rated by the nurses in hospital, didnot decrease significantly, but socially embarrassingbehaviour did show a significant improvement inthe severely-ill group. The schedule used has thelimitations of a narrow range of scores and noprovision for rating positive behaviour. Severalnurses did spontaneously comment on an improve-ment in appearance and manner of some of themoderately-ill patients: this might be measurable onan extended schedule. However, Brown, Carstairs,and Topping (1958) found that their schizophrenicpatients discharged after 2 years in a mental hospitalseemed to do better when they were able to avoidintimate social contacts. Social withdrawal couldbe looked upon as a protective feature. Sociallyembarrassing behaviour was rare in the moderately-ill patients and there would be little room forimprovement in this respect.

Secondary handicaps (represented by unsatis-factory attitudes to discharge and plans for thefuture) did diminish markedly, and attitudes andplans became more definite and more realistic. TheIndustrial Rehabilitation Unit enabled the patient'sworking ability to be demonstrated, not only tohimself but to his doctor, the Unit staff, and theDisablement Resettlement Officer. The resultingchanges in attitude were probably mutually rein-forcing. The adoption of a new role by the hithero"institutionalized" patient was made possible by the

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realistic setting and the presence of a majority ofnon-schizophrenic workers. The inculcation ofworking habits suitable to such a new role is part ofthe deliberate policy of the Unit. These three factorswould be difficult to replicate in the protective settingof a mental hospital. They constitute a considerablesocial pressure on the patient quite different fromthose he has been used to, and may explain thedecrease in manifestations of socially embarrassingbehaviour in the severely-ill patients. In turn, thepatients increased in social "acceptability" as

employees and as persons in general. It cannot beclaimed, from this small material, that the change inattitude is a cause of the later successful resettle-ment, though there is a strong implication in thisdirection. Among the moderately ill, all those whoimproved in attitudes and plans were relativelysuccessful at follow-up. Those who remainedhesitant, or adopted more unfavourable attitudes,were unsuccessful.

Although plans for the future were significantlyrelated, at the second rating, to future employmentstatus, attitude to discharge was not related towhether the patient was in or out of hospital one

year later. This curious divergence may possibly beexplained by the fact that patients were givenspecific work practice at the Unit, and thus could see

the actual situation for themselves and base theirattitudes on it. However, they were still living inhospital and travelling by hospital bus, and theywere given no specific experience of what living out-side hospital meant, such as might, for example,have been provided by a hostel or by supervisedlodgings. This hypothesis is clearly an importantone and deserves further attention.No patient in this series said initially that he

wished to stay in hospital. However, in the survey

already mentioned, 47 per cent. of moderately-illpatients did say this, and it is doubtful whether theresults of the present experiment could be applied tothem. The age limit of 45 which was imposed is alsoa considerable limit to generalization. Moreover,there is a substantial group of patients on theborderline between moderately and severely ill whichcould possibly benefit from an Industrial Rehabilita-tion Unit course combined with some form ofsupervision or care thereafter. It is of some import-ance to determine the extent to which the presentresults can be extended in these various directions.How far, if the rehabilitation process could have

been carried on for 6 months to a year, the pressures

of the Industrial Rehabilitation Unit would havegradually affected the severely-ill patients, it isimpossible to say. The evidence that the severe andchronic symptoms of the illness were diminishing isnot conclusive, and these are the limiting factors tothe final level of resettlement. What is fairly clear isthat such a prolonged process of rehabilitationwould enable advantage to be taken of any naturalremissions in the disease process, and would preventthe continual accumulation of secondary handicaps.

SUMMARYA group of twenty male schizophrenics, aged

25-45, who had been in hospital over 2 years,attended routine courses at a Ministry of LabourIndustrial Rehabilitation Unit. Ten equivalentpatients who remained in hospital acted as controls.The two groups were initially similar in respect of anumber of relevant variables. The experimentalgroup showed a clear superiority in discharge andemployment status one year after leaving the Unit.Severity of illness was an important factor in deter-mining future success. Various aspects of behaviourand attitudes were measured and an attempt hasbeen made to relate the changes recorded to theoutcome. The question of how far the results can begeneralized is discussed.

I am deeply indebted to Dr. A. B. Monro, PhysicianSuperintendent of Long Grove Hospital, and to MrR. G. T. Giddens, Rehabilitation Officer of WaddonIndustrial Rehabilitation Unit, and to their staffs, fortheir willing co-operation. Dr. A. E. Maxwell, of theInstitute of Psychiatry, kindly advised on the particularmethod of analysis of variance to be used. My colleague,Dr. G. M. Carstairs, undertook the ratings of mentalstate.

REFERENCESBrown, G. W., Carstairs, G. M., and Topping, G. (1958). Lancet, 2'

685.Cross, K. W., Harrington, J. A., and Mayer-Gross, W. (1957).

J. ment. Sci., 103, 146.Garratt, F. N., Lowe, C. R., and McKeown, T. (1957). Brit. J. prev.

soc. Med., 11, 165.Jones, Maxwell (1956). Lancet., 2, 985.Ministry of Labour (1958). Gazette, 66, 289.Report of the Committee of Inquiry on the Rehabilitation. Training,and Resettlement of Disabled Persons (1956). "Piercy Report".Cmd. 9883, H.M.S.O., London.

Wing, J. K. (1959). "Experimental and Clinical Studies of Rehabilita-tion in Chronic Schizophrenia." Ph.D. Thesis, University ofLondon.

(1960a). Acta psychiat. neurol. scand., 35, 245.(1960b). "The Problem of 'Institutionalism' in Mental Hos-

pitals." (To be published).

180 J. K. WING

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