Special Difficulties of Mental Welfare Officers with the Aged J. E.

Westmoreland,

M.B.E.

Honorary Secretary of the Society of Mental Welfare Officers it should be made clear that FIRST this article is based purely

positive authority. Cases are still by all and sundry, without regard to his present position no

referred to him

not on

personal experience, but results from

in these matters, and he is subject to pressures from all sides to solve the

directed to branches of the of Mental Welfare Officers in all parts of the country, and many scores of mental welfare officers have contributed to the discussions which have taken place. The results are

enquiries

Society

most

nation-wide

dealing

with the

cases

nature

Welfare

problems,

dealing

compassionately

equipped

referred to them whilst maintaining a professional avoidance of emotional involvement. In the

of

frustration,

anger and bitterness often take possession of the mental welfare officer when all too frequently he is involved in situations for which he no

answer.

No positive authority Many people do not, or will

not, mental welfare officer of today is not the duly authorised officer of the old legislation. Then he had direct responsibility and statutory authority to enable him to solve his problems. Under the Mental Health Act, he has less well defined responsibilities and

appreciate

that

the

fraught

with

the

areas,

services for the

aged

are

care

not

completely adequate, and that in others, they are quite seriously under-provided. A common complaint is that in far

geriatric field, however, their emotions are deeply engaged. Feelings of

has

problem

difficulties everywhere, but it is also apparent that the difficulties differ in detail and in degree in different areas. It is clear that even in the best

revealing.

of their calling, mental officers are accustomed to with difficult and complex

By

insoluble. It is apparent from the correspondence that the care of the aged is a

too many cases where there is the mildest deviation from strictly normal behaviour, other social agencies are quick to label the case "mental", to refer it to the mental welfare officer and to retire precipitately. Conversely, cases which have once had contact with the mental health service, however slight, are regarded with the deepest distrust by other agencies who will only move in the matter with Mental welfare great reluctance. officers generally feel that far too many cases come to them which could, and should, be more satisfactorily dealt with elsewhere. Some mental welfare officers are

211

deeply worried about the numbers of aged people admitted to psychiatric hospital who could be dealt with in other manner if facilities existed. There is a strong feeling that more accommodation should be provided for the care of the mildly disordered whose condition would cause difficulties in existing welfare homes, but which does not really need the full facilities of a psychiatric hospital. It is felt that the Minister should encourage local authorities to provide such accommodation and at the same time realise that the encouragement that would be most appreciated, and acted would be financial upon, some

encouragement. local

Undoubtedly,

some

authorities are deliberately dragging their feet in this matter because of the cost of providing an adequate service, and without help from the National Exchequer, are likely to continue to do so for a long time. The type of hostel required in this connection would need to be staffed by psychiatrically-trained personnel and an additional difficulty is the lack of positive direction as to whether the Health Committee or the Welfare Services Committee should be responsible for providing the accommodation.

Distressing It is distressing to many mental welfare officers, owing to the lack of alternative facilities, to have to persuade both patient and relatives to accept the prospect of admission to a psychiatric hospital, a prospect which even in these enlightened times, is still abhorrent to many people as the last home of a beloved parent. A major difficulty encountered by many mental welfare officers, and one which often results in them being left "holding the baby", is the lack of co-operation between geriatricians and consultant psychiatrists who form and firmly hold to opposing opinions about a case; this results in neither accepting it, leaving the officer victim to mental welfare

mounting pressure of public opinion to "do something" in a matter in

which he

is

There is a need for a "referee", a third and decisive opinion to which disputed cases could be referred. There is no doubt that some old people are left in undesirable conditions whilst the arguments proceed, or families are strained to breaking point with the continued care of a seriously deteriorated old person who has got right beyond care in a private house. It is appreciated that many disputes arise because the numbers of old people needing care are growing much faster than facilities are being provided; a surplus of accommodation could result in competition for cases ! Hospital authorities tend to look at the patient in isolation whilst the mental welfare officer cannot avoid seeing the whole picture of the family and the environment. Psychiatrists and geriatricians decide on acceptvery strong

ance

or

powerless. feeling of a

rejection

by

considering

whether the patient would benefit from admission to their unit; the mental welfare officer is apt to see a situation in which the family must be relieved of an intolerable burden. It is when the two criteria do not give the same answer that the mental welfare officer feels most keenly the lack of other facilities. Admittedly, there are many marginal cases where hospital care is not essential and is sought only because A no other solution is available. strengthening of other local authority services would enable more old people to be maintained in their own homes; if home help could be more freely given, particularly in the case of old people living alone apart from, or without family; if nursing services were strong enough to allow frequent visitation, and if arrangements could be made for the proper administration of medication. Sometimes without hospital admission, and sometimes following treatment in hospital, mildly confused old people, or those disposed towards depressive phases, could be maintained in the community with regular medication, but their own 212

condition

tends to militate against the medicine as directed, or in some cases, in being permitted to have supplies of potentially dangerous drugs; a service which could cope with this quite important aspect would, it is felt, markedly reduce pressure on residential accommodation.

taking

the time when they should have been outside help, and second, those who endeavour to evade all responsibility and begin to shout loudly for help before any really difficult situation has developed. Although the latter by their persistence draw attention to themselves and give rise to generalisations about the modern slackening of filial responsibility, there is no real evidence to show that they are in fact a larger group than those who carry their burden uncomplainingly for far too long. It is suggested that there is need for a more vigorous campaign of public education in the problems of ageing than far has been conducted, which so would lead to a modification of attitudes and a more balanced appreciation of the problems that inevitably arise. Families who are quite genuinely anxious to keep aged relatives with them often meet with one or other of two serious difficulties. The daytime care of a person who cannot be left unattended presents obvious difficulties to a family, of whom there are a great many, where each member is in regular employment. To expect one member of the family to give up work to cope with the aged relative is not always reasonable; in not a few cases it would lead to real economic hardship. In other cases, night care is the great difficulty; reversed sleep habits and a tendency to nocturnal wandering can result in continual disturbed nights for those for whom rest is essential before tackling another day's work. Day hospitals or specially organised full time clubs for old people are found to be a very good answer to the first problem, but do not seem to be as fully developed as necessary anywhere, and in some areas, are non-existent. It is suggested that where and when day hospitals are available, consideration might be given to making the fullest use of the facilities by equipping them also for use as a night nursery for those who can live happily at home in the daytime, but whose night care needs

seeking

Better provision Their insistence on the need for better hospital and hostel provision for the aged should not lead to the thought that mental welfare officers believe that admission to some form of residential care is the ideal to be striven for in all cases. Mental welfare officers are the first to realise the value of keeping family groups together or of enabling independent old people, deeply attached to the homes they have established and maintained for themselves over many years, to retain that independence to the end if need be, and certainly as long as possible, but it is obvious to them that in many cases a tremendous amount of outside support is necessary to enable this to be done, and it is realised that such support might well be as expensive, and quite certainly less spectacular than a proliferation of neatly built Welfare Homes and Hostels in nicely selected

situations. This is perhaps the point to mention that from one quarter comes a very strong plea for more consultation with ageing people as to the provision they would appreciate, as against the volume of proposals coming from other quarters as to what would be good for them. It should be a salutory thought for all to

remember that we who are called upon to cope now, being spared other ills, will in turn become the ones to be coped with. Mental welfare officers in their contacts with families find that the close relatives of aged people fall almost entirely into two well-defined groups. First are those who will struggle with a situation to the detriment of their own health and happiness long past

nursing supervision.

213

Need for "notification" Some mental

welfare officers are the quite serious deterioration which has taken place in some people, particularly those living alone, before the case comes to attention, and an urgent situation revealed which might have been averted had there been earlier knowledge of the case. It is seriously suggested that consideration should be given to some form of "notification" to the local health authority of ageing members of the population, putting on the authority the responsibility of immediate enquiry into the circumstances of each case and maintaining contact through social workers in order that necessary help may be given immediately the need arises in order to avoid the quite disastrous deterioration which can take place in present circumstances. This suggestion is akin to the now discarded "ascertainment" under the old Mental Deficiency Act, but that should not inhibit consideration of a such scheme. It is abundantly clear that in geriatrics a stitch in time is of immense value and the mere fact of being in touch with people before difficulties arise would in itself be a preventive measure of first-class disturbed

by

importance. Frequently it is found most difficult to persuade some aged people to accept the help of which they are so obviously in need; before referral, they have deteriorated to a condition often of complete misery, in which their only wish is to be left alone. If by a system of earlier referral, a relationship could be established before

there is acute need, it is felt that services would be accepted as required and the worst difficulties might never arise. When in their own interests old people must be admitted to some form of residential care, a major difficulty on occasion is their positive refusal to acquiese in the arrangements made for them. Complaint is made that insufficient use is made of Section 47 of the National Assistance

Act, and that perhaps this section requires re-drafting to enable it to be better which

for use in the cases encountered. In the meantime, it is all too frequently found that the only effective compulsory procedures which can be applied are those contained in the Mental Health Act. Compulsion very often is required only to overcome initial reluctance; once admitted the patient settles down quickly and is prepared quite happily to remain. Unfortunthan other establishments ately psychiatric hospitals are in the main most reluctant to receive applications under the Mental Health Act. It is quite strongly felt that if only geriatric and general hospitals would more freely accept these applications, some of the present difficulties in effecting removals to the most appropriate form of care could be overcome.

adapted

are

Throughout

themes

are

the correspondence, two

reiterated; that

too many

late, and that far too many cases are labelled "mental" because of some eccentricity. It is felt, in fact, that too many cases have in the end to be dealt with under the Mental Health Act because failure to provide more appropriate care earlier has allowed deterioration to continue unduly. There is repeated pleading for strengthening of the domiciliary services, and, in addition to those things already mentioned, many suggestions are made which space will not permit to be given in great detail, such as the need for home helps for night sitting, a more effective service of meals on wheels of greater frequency, and the provision of laundry services.

cases come

to attention too

Voluntary effort It is suggested too that effort should be mobilised

voluntary and

co-

ordinated to a greater extent than is at present done. The formation of

"good neighbour" groups to pay social visits to the elderly both to perform small tasks such as shopping for the house-bound, etc., and also to be 214

able

to apprise the appropriate authority as the needs grow. It is impossible, and may always be so, for

official sources to do all that is necessary to ensure that everything possible is done for the comfort and care of the aged in their own homes. Such a scheme would in fact go far to prevent the feeling of unwantedness and lack of a place in society that causes so much unhappiness to solitary old people. It must be realised that to be

successful, community

care

must not

only be seen as care in the community, but to some extent, care by the community.

Mental

welfare officers generally about the situation with regard to the aged. They feel there is an even bigger problem here than has yet been generally realised, that much has and is being written on the subject, but that performance falls badly behind intention. There is need for great expansion of all services, but the mental health service should be the last and not the first to be expanded to cope with the growing army of people who, as a result of age and increasing infirmity, become a burden to themselves and a problem to the community. are not

happy