Care of the mentally ill Acceptance
of the concept that human behaviour is understandable and modifiable is basic to the care of the men¬ tally ill today. Evidence from the preChristian era indicates that the treat¬ ment of psyche and soma were on an equal footing. Up to the 18th century AD undesirable or unacceptable be¬ haviour was viewed as a matter of good or bad, of visitation by the devil rather than illness, so that care of the mentally ill passed from those con¬ cerned with health to those concerned with morality and antisocial be¬ haviour. Then, when Pinel, Tuke and others demonstrated that the mentally ill responded positively to recognition of their individual worth, living space, good food, fresh air and work, "moral treatment" of the insane developed. Freud and his followers (including the neo-Freudians and those of other schools of psychology) believed that hu¬ man behaviour could be understood and, subject to our increasing but often inadequate skills in all forms of ther¬ apy, could be changed. From 1945 to the present, a resurgence of interest in the treatment of psychiatric patients in "open" mental hospitals has been apparent throughout the Western world. But progress has been slow, as illustrated by Voineskos in this issue of the Journal (page 689). More important, perhaps, there has been a concurrent revival of interest in custody and protection custody in protecting the public, and protection "in the best interests" of the patient. A number of coroners' inquests and other legal activities have indicated a new concern with custody, restraint, seclusion and protection, rather than treatment and rehabilitation of the mentally ill. The history of the treatment of insanity can be divided according to its practice into three epochs the barbaric, the humane and the remedial1 though both in Egypt and in Greece, the insane took refuge in the temples .
of Saturn and the asclepia, respectively, where the treatment was, in principle, identical to that of the present. More¬ over, the advice of the classical medical authors, and especially Hippocrates and Galen, was quite sound. In the Middle Ages, and up to the middle of the last century, however, the care or cure of the mentally ill was neglected. In a few instances they were looked after in common prisons or monastic houses for example, the original Bethlehem Hospital, or Bedlam, cared for 50 lunatics but such bedlams, or houses of detention for lunatics, were excep¬ tions, and the insane were permitted to stray at will, without special care. By the middle of the 18th century the condition of the insane had attracted the attention of the public in part because the public was concerned about its own safety and comfort. As a result, many asylums contained more mentally ill persons than formerly. Even so, this still did not terminate the barbaric
period.
Nor was the situation any better in France when Pinel took charge, in 1792, of the Bicetre, the famous Paris hospital. Pinel's great contribution was to free of restraints those under his care. About the same time, Tuke, a Quaker, took similar steps in the York Retreat in England, an institution car¬ ing for Quakers. The names of Pinel and Tuke thus are the great names in the history of the humane treatment of the mentally ill; to Pinel and Tuke are due the realization by not only the public but also the medical profession of the basic principles of treatment of the mentally ill though it was years before their principles were widely ac¬ cepted. It was not until 1815 that a committee of the House of Commons revealed many gross abuses in Bethle¬ hem Hospital, and not until 1836 that mechanical restraint was totally re¬ moved from an English public asylum. The principles of Pinel and Tuke and others have proved to be sound, for
experience has demonstrated
that the of the insane is facilitated by removal of all forms of restraint. Today mental illness perhaps differs in type from that of former years, but one could also take the view that the type of treatment is now different. True, today we see little of the violent madness that was described in earlier days, but equally the lack of restraint allied to more humane care has led to greater tranquillity among the men¬ tally ill. A confusion of objectives in the care of the mentally ill is at present one of the most disconcerting aspects of the mental health movement con¬ fusion between treatment and the need for custody and protection, to ensure adequate treatment of those who are ill and to provide adequate protection for the public and for the patient against his self-destructive impulses. This confusion has also been noticeable among staff, who wish to give up the symbols of their professional roles typified by the nurse giving up her uniform. While there is no conclusive evidence to indicate that treatment is either better or worse when nurses are in or out of uniform, there are strong, widely held beliefs that both staff and patients feel more at ease and more comfortable when the staff are out of uniform. It is interesting to watch nurses out of uniform working in psy¬ chiatric hospitals so often they wear, attached to their ordinary clothes, a key or keys, the real symbol of their authority. Although the number of locked wards and the frequency of seclusion and restraint have decreased during the past 30 years, there are still many situations in which the staff holds the option to apply such measures on an emergency basis, and the visibility of the key is often sufficient to show the patient who has the real authority, whether the nurse is in or out of uni¬ care
form, or a
or
playing
a
highly permissive
constructive structured role.
CMA JOURNAL/APRIL 17, 1976/VOL. 114 661
One can only hope that interest in the comprehensive treatment of the mentally ill, with all that it implies, will be revived and that there will not be, as one fears, a return to custody and restraint, which would circumvent society's responsibility to ensure that the mentally ill are adequately treated. In his paper Voineskos attempts to dispel the myth that open wards and related manifestations of effective treatment programs require greater concentrations of staff than do closed wards
and more regressive forms of treatment. If treatment is to be effective it must result in self-control and the development within the patient of the ability to obtain gratification and satisfaction from living without indulging in socially undesirable behaviour. In terms of human behaviour we should always remember Thoreau's statement that there is "no rule which holds so true as that we are always paid for suspicions by finding what we suspect"2 that is, patients are often able to pick
up the cues and double messages around them and tend to respond to their perceptions of what others expect of them, with respect to their behaviour. C.A. ROBERTS, MD
Department of psychiatry Royal Ottawa Hospital Ottawa, ON
References 1. Insanity, in Encyclopaedia Britannica, rev 9th ed, Hall, New York, 1895, p 95 2. THOREAU HD: Journal, 1837-1847, Dover, New York, 1962
Home testing of fitness of Canadians At a national conference on fitness and Canadians to become aware of the dehealth in 1972 various aspects of the sirability of evaluating their own derelation between these two determi- gree of physical fitness by preparing nants of personal well-being were dis- the Fit-Kit. cussed,1 and out of it came the recomThe Fit-Kit contains eight items. The mendation that a self-administered fit- basic one is a phonograph record that ness test for Canadians be developed. permits anyone between 15 and 69 The result is the Fit-Kit. Recently pro- years of age to conduct a test of cardioduced for the Canadian public, the pulmonary fitness in their own home Fit-Kit is a package designed to enable without supervision. Entitled "The Caany Canadian to evaluate his or her nadian Home Fitness Test: 1, 2, 3... own degree of physical fitness and to Steps to Better Health", the record promotivate emergence from the state of vides instructions on how to perform sloth to which each of us too readily a two-step exercise test and then how is attracted. to relate the ensuing pulse rate to three It is a general opinion that Cana- levels of fitness - "undesirable", "mindians are unfit: less than one half of imum and "recommended". Based on the population can be classified as work of Bailey, Shephard and Mirmanifesting a degree of fitness that is wald (see page 675 of this issue of the fair or low. Precisely what the conse- Journal), the test is adjusted for sex and quences of a poor level of fitness are age. A person is instructed to step to is not clear, though today, as long music at a certain speed for 3 minutes, ago, it is believed that fitness, like to count the radial pulse rate for 10 virtue, brings its own rewards, intan- seconds and then, if the pulse rate does gible though these may be. Long ago, not exceed a given rate, to proceed to in Plato's Dialogues, Timaeus told So- a second 3-minute test, after which the crates that "moderate exercise reduces 10-second pulse rate is again deterto order, according to their own af- mined. Take the example of a man in finities, the particles and affections his 40s: he is allowed to take the secwhich are wandering about the body";2 ond exercise test if his 10-second pulse and, more recently, Fox and his col- rate is 25 or less, but he is warned not leagues3 summarized the modern view to take it if the rate is 26 or more, by stating that "there is an ever-increas- for he has an undesirable level of fiting body of knowledge suggesting... ness; the fitter 40-year-old, however, is that increased habitual physical activity permitted to proceed to the second can be helpful in enhancing health, im- 3-minute test and at the end of this proving the quality of life and prob- he can determine whether he has a ably contributing to the prevention of minimum level of fitness (pulse rate, coronary heart disease for many if not 24 or more) or the recommended level most persons." Much more research is of fitness (pulse rate, 23 or less). required so that a body of hard data The instructions accompanying the concerning the relation of fitness to record make it clear that seven simple health can be built up, but meanwhile questions (based on the PAR-Q quesit is prudent to follow the assumption tionnaire4) concerning one's medical that fitness is a prerequisite for health. history must be answered appropriately It is for this reason that the fitness and before a person decides whether it is amateur sport branch of Health and safe for him to take the test. If a perWelfare Canada has seen fit, so to son answers Yes to the question, Has speak, to lead the way in encouraging your doctor ever said you have heart 662 CMA JOURNAL/APRIL 17, 1976/VOL. 114
trouble?, for example, he is directed to consult his physician before going further. Studies of the Canadian Home Fitness Test (CHFT) indicate that the test is safe: among 14 794 persons screened before taking the test some 3% were not permitted to take it for medical reasons, and among the 14312 persons analytically tested through January 1976 only three minor incidents were recorded (one man fainted after incorrectly performing carotid [rather than radial] palpation - the radial pulse is now counted; one man became distressed during the second stage of the test but he, it was found, had falsified answers in the preliminary questionnaire; and one man who was tired slipped and sprained his ankle) (S. Keir: personal communication, 1976). The test is therefore now freely prescribed. Also contained in the Fit-Kit are seven items designed to motivate persons to participate in individual or group physical activity programs. One, labelled "R. for Physical Activity", provides a good guide to basic needs for physical activity with respect to weight control, flexibility, muscular endurance, cardiopulmonary fitness and physical recreation. Another, dubbed "FitTips", is a series of rhythmic exercises to improve strength, endurance and flexibility in all major muscle groups. The third item is a "Fit-Kit Progress Chart", which enables a person to monitor his progress in a physical fitness program. The next item is a "Walk-Run Distance Calculator", constructed to help individuals calculate how far they should walk or run in 15 minutes to improve their level of fitness, and based on the work of Jett.,5 another aspect of which is to be found in the paper by Jett. and colleagues on page 680 of this issue of the Journal. The sixth item is an advanced test of fitness for those who have attained and wish
of the concept that human behaviour is understandable and modifiable is basic to the care of the men¬ tally ill today. Evidence from the preChristian era indicates that the treat¬ ment of psyche and soma were on an equal footing. Up to the 18th century AD undesirable or unacceptable be¬ haviour was viewed as a matter of good or bad, of visitation by the devil rather than illness, so that care of the mentally ill passed from those con¬ cerned with health to those concerned with morality and antisocial be¬ haviour. Then, when Pinel, Tuke and others demonstrated that the mentally ill responded positively to recognition of their individual worth, living space, good food, fresh air and work, "moral treatment" of the insane developed. Freud and his followers (including the neo-Freudians and those of other schools of psychology) believed that hu¬ man behaviour could be understood and, subject to our increasing but often inadequate skills in all forms of ther¬ apy, could be changed. From 1945 to the present, a resurgence of interest in the treatment of psychiatric patients in "open" mental hospitals has been apparent throughout the Western world. But progress has been slow, as illustrated by Voineskos in this issue of the Journal (page 689). More important, perhaps, there has been a concurrent revival of interest in custody and protection custody in protecting the public, and protection "in the best interests" of the patient. A number of coroners' inquests and other legal activities have indicated a new concern with custody, restraint, seclusion and protection, rather than treatment and rehabilitation of the mentally ill. The history of the treatment of insanity can be divided according to its practice into three epochs the barbaric, the humane and the remedial1 though both in Egypt and in Greece, the insane took refuge in the temples .
of Saturn and the asclepia, respectively, where the treatment was, in principle, identical to that of the present. More¬ over, the advice of the classical medical authors, and especially Hippocrates and Galen, was quite sound. In the Middle Ages, and up to the middle of the last century, however, the care or cure of the mentally ill was neglected. In a few instances they were looked after in common prisons or monastic houses for example, the original Bethlehem Hospital, or Bedlam, cared for 50 lunatics but such bedlams, or houses of detention for lunatics, were excep¬ tions, and the insane were permitted to stray at will, without special care. By the middle of the 18th century the condition of the insane had attracted the attention of the public in part because the public was concerned about its own safety and comfort. As a result, many asylums contained more mentally ill persons than formerly. Even so, this still did not terminate the barbaric
period.
Nor was the situation any better in France when Pinel took charge, in 1792, of the Bicetre, the famous Paris hospital. Pinel's great contribution was to free of restraints those under his care. About the same time, Tuke, a Quaker, took similar steps in the York Retreat in England, an institution car¬ ing for Quakers. The names of Pinel and Tuke thus are the great names in the history of the humane treatment of the mentally ill; to Pinel and Tuke are due the realization by not only the public but also the medical profession of the basic principles of treatment of the mentally ill though it was years before their principles were widely ac¬ cepted. It was not until 1815 that a committee of the House of Commons revealed many gross abuses in Bethle¬ hem Hospital, and not until 1836 that mechanical restraint was totally re¬ moved from an English public asylum. The principles of Pinel and Tuke and others have proved to be sound, for
experience has demonstrated
that the of the insane is facilitated by removal of all forms of restraint. Today mental illness perhaps differs in type from that of former years, but one could also take the view that the type of treatment is now different. True, today we see little of the violent madness that was described in earlier days, but equally the lack of restraint allied to more humane care has led to greater tranquillity among the men¬ tally ill. A confusion of objectives in the care of the mentally ill is at present one of the most disconcerting aspects of the mental health movement con¬ fusion between treatment and the need for custody and protection, to ensure adequate treatment of those who are ill and to provide adequate protection for the public and for the patient against his self-destructive impulses. This confusion has also been noticeable among staff, who wish to give up the symbols of their professional roles typified by the nurse giving up her uniform. While there is no conclusive evidence to indicate that treatment is either better or worse when nurses are in or out of uniform, there are strong, widely held beliefs that both staff and patients feel more at ease and more comfortable when the staff are out of uniform. It is interesting to watch nurses out of uniform working in psy¬ chiatric hospitals so often they wear, attached to their ordinary clothes, a key or keys, the real symbol of their authority. Although the number of locked wards and the frequency of seclusion and restraint have decreased during the past 30 years, there are still many situations in which the staff holds the option to apply such measures on an emergency basis, and the visibility of the key is often sufficient to show the patient who has the real authority, whether the nurse is in or out of uni¬ care
form, or a
or
playing
a
highly permissive
constructive structured role.
CMA JOURNAL/APRIL 17, 1976/VOL. 114 661
One can only hope that interest in the comprehensive treatment of the mentally ill, with all that it implies, will be revived and that there will not be, as one fears, a return to custody and restraint, which would circumvent society's responsibility to ensure that the mentally ill are adequately treated. In his paper Voineskos attempts to dispel the myth that open wards and related manifestations of effective treatment programs require greater concentrations of staff than do closed wards
and more regressive forms of treatment. If treatment is to be effective it must result in self-control and the development within the patient of the ability to obtain gratification and satisfaction from living without indulging in socially undesirable behaviour. In terms of human behaviour we should always remember Thoreau's statement that there is "no rule which holds so true as that we are always paid for suspicions by finding what we suspect"2 that is, patients are often able to pick
up the cues and double messages around them and tend to respond to their perceptions of what others expect of them, with respect to their behaviour. C.A. ROBERTS, MD
Department of psychiatry Royal Ottawa Hospital Ottawa, ON
References 1. Insanity, in Encyclopaedia Britannica, rev 9th ed, Hall, New York, 1895, p 95 2. THOREAU HD: Journal, 1837-1847, Dover, New York, 1962
Home testing of fitness of Canadians At a national conference on fitness and Canadians to become aware of the dehealth in 1972 various aspects of the sirability of evaluating their own derelation between these two determi- gree of physical fitness by preparing nants of personal well-being were dis- the Fit-Kit. cussed,1 and out of it came the recomThe Fit-Kit contains eight items. The mendation that a self-administered fit- basic one is a phonograph record that ness test for Canadians be developed. permits anyone between 15 and 69 The result is the Fit-Kit. Recently pro- years of age to conduct a test of cardioduced for the Canadian public, the pulmonary fitness in their own home Fit-Kit is a package designed to enable without supervision. Entitled "The Caany Canadian to evaluate his or her nadian Home Fitness Test: 1, 2, 3... own degree of physical fitness and to Steps to Better Health", the record promotivate emergence from the state of vides instructions on how to perform sloth to which each of us too readily a two-step exercise test and then how is attracted. to relate the ensuing pulse rate to three It is a general opinion that Cana- levels of fitness - "undesirable", "mindians are unfit: less than one half of imum and "recommended". Based on the population can be classified as work of Bailey, Shephard and Mirmanifesting a degree of fitness that is wald (see page 675 of this issue of the fair or low. Precisely what the conse- Journal), the test is adjusted for sex and quences of a poor level of fitness are age. A person is instructed to step to is not clear, though today, as long music at a certain speed for 3 minutes, ago, it is believed that fitness, like to count the radial pulse rate for 10 virtue, brings its own rewards, intan- seconds and then, if the pulse rate does gible though these may be. Long ago, not exceed a given rate, to proceed to in Plato's Dialogues, Timaeus told So- a second 3-minute test, after which the crates that "moderate exercise reduces 10-second pulse rate is again deterto order, according to their own af- mined. Take the example of a man in finities, the particles and affections his 40s: he is allowed to take the secwhich are wandering about the body";2 ond exercise test if his 10-second pulse and, more recently, Fox and his col- rate is 25 or less, but he is warned not leagues3 summarized the modern view to take it if the rate is 26 or more, by stating that "there is an ever-increas- for he has an undesirable level of fiting body of knowledge suggesting... ness; the fitter 40-year-old, however, is that increased habitual physical activity permitted to proceed to the second can be helpful in enhancing health, im- 3-minute test and at the end of this proving the quality of life and prob- he can determine whether he has a ably contributing to the prevention of minimum level of fitness (pulse rate, coronary heart disease for many if not 24 or more) or the recommended level most persons." Much more research is of fitness (pulse rate, 23 or less). required so that a body of hard data The instructions accompanying the concerning the relation of fitness to record make it clear that seven simple health can be built up, but meanwhile questions (based on the PAR-Q quesit is prudent to follow the assumption tionnaire4) concerning one's medical that fitness is a prerequisite for health. history must be answered appropriately It is for this reason that the fitness and before a person decides whether it is amateur sport branch of Health and safe for him to take the test. If a perWelfare Canada has seen fit, so to son answers Yes to the question, Has speak, to lead the way in encouraging your doctor ever said you have heart 662 CMA JOURNAL/APRIL 17, 1976/VOL. 114
trouble?, for example, he is directed to consult his physician before going further. Studies of the Canadian Home Fitness Test (CHFT) indicate that the test is safe: among 14 794 persons screened before taking the test some 3% were not permitted to take it for medical reasons, and among the 14312 persons analytically tested through January 1976 only three minor incidents were recorded (one man fainted after incorrectly performing carotid [rather than radial] palpation - the radial pulse is now counted; one man became distressed during the second stage of the test but he, it was found, had falsified answers in the preliminary questionnaire; and one man who was tired slipped and sprained his ankle) (S. Keir: personal communication, 1976). The test is therefore now freely prescribed. Also contained in the Fit-Kit are seven items designed to motivate persons to participate in individual or group physical activity programs. One, labelled "R. for Physical Activity", provides a good guide to basic needs for physical activity with respect to weight control, flexibility, muscular endurance, cardiopulmonary fitness and physical recreation. Another, dubbed "FitTips", is a series of rhythmic exercises to improve strength, endurance and flexibility in all major muscle groups. The third item is a "Fit-Kit Progress Chart", which enables a person to monitor his progress in a physical fitness program. The next item is a "Walk-Run Distance Calculator", constructed to help individuals calculate how far they should walk or run in 15 minutes to improve their level of fitness, and based on the work of Jett.,5 another aspect of which is to be found in the paper by Jett. and colleagues on page 680 of this issue of the Journal. The sixth item is an advanced test of fitness for those who have attained and wish
