The Evidence of the Central Association for Mental Welfare before the Royal Commission on Lunacy and Mental Disorders. On Tuesday, November 10th, the Royal Commission received a deputation from the Central Association for Mental Welfare. Dr. Tredgold, Miss Fox, and Miss Andrew (of the West Lancashire Voluntary Association) represented the Association. The Memorandum of Evidence which had been unanimously approved by the Council on May 26th, 1925, was submitted in advance. The Memorandum runs as follows :? The Central Association for Mental Welfare is an Incorporated Society, for profit, and was established in 1913; it consists of a Central Council and a number of affiliated Local Associations throughout the country. 1.
not
trading
2. The purpose for which the Association was primarily established was that of dealing with cases coming within the scope of the Mental Deficiency Act, 1913. Under its Articles of Incorporation, however, it was also empowered to deal with other forms of mental abnormality and disorder, and from the time of its institution it has been consulted with regard to a large number of borderland cases, of epileptics and of cases of early mental disorder. The number of these non-defective cases has increased year by year and the Association has now come to be regarded as the chief and largest non-official body in the country to which cases of mental abnormality may be referred for advice. The total number of cases so referred to the Central Office and Local Associations during the past ten years is approximately 34,000..
2
MENTAL WELFARE.
The Central Council is a representative body under the Presidency of 3. Sir Leslie Scott, K.C., M.P., and is composed of representatives nominated by various official and public bodies and societies dealing' with the mentally abnormal {e.g., H.M. Prison Commissioners, County Councils Association, Association of Poor Law Unions, Association of Education Committees, Medico-Psychological Association, Church Army, Salvation Army, Charity Organisation Society, Mental After Care Association, etc.), of representatives of Homes and Institutions; of medical experts and of co-opted members having special experience of the mentally abnormal, the official and voluntary elements being approximately balanced. Its main purposes are to act as a co-ordinating link between the various Authorities and Organisations concerned with the mentally abnormal; to act as a Central Enquiry Bureau ; to form Local Mental Welfare Associations; to provide courses of instruction for medical men, teachers, nurses and social workers; and to carry In addion general propaganda and educational work throughout the country. tion to voluntary subscriptions it has, since its inauguration, been in receipt of an annual grant from the Board of Control; but although in this way officially recognised and consulted, the Association desires to point out that it is an entirely independent body whose policy is not in any way controlled by any Government
Department. 4. The affiliated Local Associations consist of 48 Mental Welfare Associations covering 21 Administrative Counties and 43 County Boroughs of England. The purpose of these local Associations is to act as local co-ordinating links and as enquiry bureaux ; to assist, supervise, visit and befriend such defectives and mentally abnormal persons within their areas as are living at home and are in need of advice and assistance, and to bring them, where necessary, into touch with the appropriate Local Authority charged with the administration of the various Acts of Parliament: also, where desired, to carry out the statutory work of visiting and befriending such persons on behalf of the Local Authority. 5. It is necessary to emphasise the point that the assistance rendered by the local Associations, consisting as it does of frequent home visits and advice to parents on general management and methods of training, of the holding of classes in handicrafts, etc., is such as to bring these Associations into very intimate connection with the patients and their families and thus to afford these Associations particularly detailed and valuable knowledge of the characteristics and needs of a very large number of the mentally abnormal population. 6. In submitting evidence to the Royal Commission the Association understands that the subject of Mental Deficiency is outside the scope of the Commission's
it is also cognisant of the fact that evidence regarding the insane has been already given by other bodies. It therefore proposes to restrict its evidence to certain groups of cases of mental abnormality which are not certifiable under either the Mental Deficiency or the Lunacy Acts and regarding which it is believed to have such special and extensive experience as to enable it to arrive at certain definite conclusions and to submit certain recom-
enquiry;
certifiably
mendations. 7. The experience of the Central Association shows conclusively that there exists in the community a considerable body of persons who cannot be certified under either the Mental Deficiency or Lunacy Acts, but who yet suffer from such pronounced forms of mental disorder and instability as to make it impossible for them to adapt themselves in a satisfactory and efficient manner to their surroundings and who consequently are in need of supervision, training and treatment. From the Returns of the Local Associations and from the case records of the Central Office it has been found that about 10 per cent, of the total number
3
MENTAL WELFARE. ?f cases referred to
These persons comprise a concome within this category. siderable proportion of the inmates of charitable institutions such as Rescue and Preventive Homes, of Poor Law Institutions and of Prisons, etc. They are the despair of every relief society and although their mental disorder is well known to
the medical experts, teachers and social workers who
them, it has not hitherto been recognised by any Association submits that such persons come within
come
statute.
into contact with
Nevertheless, the
the scope of that term of of the Royal Commission which specifies " the extent to which provision ?s or should be made in England and Wales for the Treatment without certification of persons suffering from Mental Disorder." These persons may be conveniently divided into several groups which will be dealt with seriatim.
reference
8. The first and most important group to which the Association desires to refer consists of adolescents between the ages of 15 and 21 j'ears. The Central Office has been furnished by the local Associations throughout the country with
a
large number of detailed pxtending over a period of Jt is abundantly clcar that
these persons, many of them and from these particulars the condition of adolescent mental disorder is widely Prevalent and fraught with grave menace to the general well-being of the community. There is also clear evidence that it is a condition for which the provision ?f appropriate treatment is not only quite inadequate but urgently required. In many of these cases there is evidence from teachers that some abnormality of behaviour was present during school age. Upon leaving school the freedom from discipline, the increased responsibility and the competitive conditions of modern fife impose a strain which the individual is unable to meet, with the result that he develops definite signs of mental disorder and instability. He or she becomes "wayward, unruly, irresponsible, unbalanced and incapable of settling down to any steady occupation. At the best such individuals are social inefficients, while a considerable proportion of them develop definite anti-social tendencies and drift into a life of immorality and crime. The experience which the Central Association possesses of persons of this type, and the number of cases about which it is consulted, has convinced it that the problem of this group of persons, in its general bearing upon society, is even graver than those of the mentally defective and insane, and it desires very earnestly to bring this class to the notice of the
Royal
9.
case
histories
regarding
ten years and often
longer,
Commission.
emphasise the fact incipient insanity and that they existing administrative procedure.
that the cases here referred to are cannot be dealt with satisfactorily under any A small proportion, it is true, may subsequently prove to be Dementia Prascox or some other variety of certifiable unsoundness of mind, but this is not so with the majority. Nevertheless, the condition is one of mental disorder of such a degree as to render the individual socially inefficient or anti-social, and to necessitate supervision, training and treatment which cannot be given at home. It is also necessary to point out that the condition is one which frequently lasts for a period of years and that during this time it is not only a great disadvantage for the individual to be deprived ?f some form of in handicraft or industrial work, but that It is necessary to
not cases of
appropriate training
such training constitutes a very important part of his treatment. For these reasons the treatment afforded by an ordinary Mental Hospital as suitable for acute and temporary cases of mental disorder, or by the Hospital establishments suggested in the Mental Treatment Bill, is not applicable to the more prolonged care required by the majority of these persons. The appropriate supervision, treatment and training which are needed can only be afforded by institutions of a special character. The entire social experience of the Association in dealing with these cases bears out the fact recognised by medical men that the home is
MENTAL WELFARE.
4
in many instances the actual cause of the patient's abnormal condition, and that in nearly every case a change of environment is essential to improvement. The Association has made every effort to deal with these cases in a satisfactory and constructive manner. In a few instances the necessary treatment and training- have been forthcoming- in a voluntary home, and in such cases great improvement has resulted and the individual has been restored to a normal condition. Speaking generally, however, the utter inadequacy of any such facilities The Association desires to emphasise has resulted in a failure of these efforts. the fact that whilst a few voluntary homes exist to which such patients may be sent, the number of these is extremely small. It also desires to point out that no Authority (other than Poor Law Guardians who can deal with such persons only as paupers) has the power to pay for treatment for them and that voluntary agencies have not the means to assist them. 10.
A group of cases which has come prominently before the Association 11. consists of persons primarily referred on account of more or less serious misconduct, in many cases of such a nature as to bring the person before the Courts. The Association is satisfied that in a very considerable proportion of these the essential cause for the misconduct is uncertifiable disorder of mind, and that there would be a reasonable prospect of benefit resulting from treatment in special training institutions, did such exist. 12. It is clear, however, that with regard to this group the mere provision of institutions would not suffice to meet the case unless there were some machinery for the systematic medical investigation of persons charged with offences in whom there was privid facie evidence of mental disorder. Although such machinery exists in the case of persons charged with serious crimes, there is, generally speaking, no adequate provision for persons coming before the lower Courts unless remanded to a prison or workhouse, which in many cases would appear to be undesirable. It is felt that the absence of this provision constitutes a serious hindrance to proper diagnosis and treatment. 13. During the increasing number of
past few years the Association has had referred to it an cases of disorder of mind, very frequently accompanied by
misconduct, which have been shown to be the results of lethargic and other forms of encephalitis. Practically all these cases have been children of school age or young adolescents, and, speaking generally, attempts to deal with them have largely failed owing to the absence of any suitable arrangements. A few of these cases are certifiable under the Mental Deficiency and Lunacy Acts and should be dealt with in Certified Institutions or Mental Hospitals, but in the majority this is not so. On the other hand they present characteristics which render them quite unsuited to, and cause their rejection from, any existing institutions, voluntary or otherwise. There is reason to think that, in the case of many, the need would be met by special training institutions of the type already referred to. Also that such institutions would be of particular value for the after treatment and training of many cases discharged from Hospital. 14.
In the
course
of its work the Central Association has been consulted
considerable number of cases of incipient insanity and has been greatly impressed with the lack of adequate facilities for the treatment of these, particularly in the case of persons of limited means. The Association is aware
regarding-
a
that evidence has already been given by other bodies regarding this class of persons, and all that it desires to do is to corroborate and emphasise the views which have already been expressed as to the great need which exists for the means provision of in-patient and out-patient treatment, without certification,
by
MENTAL WELFARE.
?f
Special Hospitals, Special Departments
Clinics
"4
in General Hospitals, and Out-Patient
for persons of this class.
15.
tions
5
The Central
Association desires
to
make the
following
recommenda-
:?
-4s to Provision
(a)
of Special Institutions.
empowered to establish (either alone with other Authorities) Training Homes for persons under the age of 21 years who are suffering from disorder of mind, not certifiable under the Mental Deficiency or Lunacy Acts, and should be empowered to contract with the Managers of any such recognised home for the reception and maintenance of such cases. That the Local Authority empowered to establish or maintain patients in such Homes should be the County or County Borough Council. That the Treasury be empowered to give a grant towards the expenses of Local Authorities establishing such homes, or maintaining patients in such homes as are established by other authorities or bodies. That such homes should provide skilled and adequate medical treatment appropriate to the mental disorder of these persons, as well as industrial and other forms of training. Also, that they should be available as hostels for such patients for a limited time on their first taking up outside employment. That persons should be admitted to such homes on the application of a parent or guardian, or failing these, on the application of the Local Authority, accompanied by the certificate of a qualified medical practitioner stating that the person is suffering from mental disorder not certifiable under the Mental Deficiency or Lunacy Acts, and is in need of care and supervision in a training home. That a patient in such a home should be discharged by the Superintendent or other appointed officer, upon 72 hours' notice being given by the parent or guardian, except in cases sent by the Courts. That such homes should be registered and under the general supervision of the Ministry of Health. That such homes as are suitable for children should be recognised by the " schools of recovery " for children under 16 Board of Education as from of post-Encephalitis. years age suffering That Local Authorities should be or
(b) (c) {d)
(e)
(/) (5-) (h)
B?Ts
(a) (b)
to
the
Psychological Examination of
Persons
charged
with Offences.
machinery should be provided for the adequate investigation of all persons charged with offences against the law in whom there is reason to suspect the presence of mental disorder or abnormality.. That in the case of persons found on such investigation to be suffering from uncertifiable mental disorder and whom a Court is desirous of placing on probation in such homes as are proposed in this memorandum, it should be lawful for a Local Authority to contribute towards the maintenance of such persons in such homes. That
Dr. Tredgold, in his spoken evidence, emphasised that " there is a type of which we call adolescent mental disorder, which is not capable of being dealt with either under the Mental Deficiency Act or the Lunacy Act." The reply of the Chairman is of significance. He said, " You have furnished us with a series of illustrative cases which we have read, and I must say they impressed me as very striking?very trying and difficult cases, for which there is, apparently,
ease
MENTAL WELFARE.
6
adequate provision just now." Dr. Tredgold referred to the recommendations of the Central Association for the establishment of special institutions for such " we realise that possibly some of these cases adolescent cases, and added that would be dealt with under the Mental Treatment Bill if the Bill became an Act, Pressed by the Chairman on the point that but comparatively few of them." the recommendation involved an additional type of institution, Dr. Tredgold " At a very large and very well attended meeting of the Medical Council replied : We realised that the only way of dealing with these we faced this question. cases in a satisfactory manner was to provide a different type of home altogether which should not be an asylum and which should not be an ordinary Clinic." no
Asked whether the charitable institutions already in existence or philanthropic effort in the future could cope with this type of case, Miss Fox replied that the existing homes and institutions were not really suitable owing to the mixed cases received, and the economical lines on which they were run, as they were unable to provide the rather special staffing and surroundings required. She added : "In the case of the homes which we have tried the longest time allowed, I think, is for two years, and in some instances it is obvious that a girl wants rather more than that in a special surrounding" : it may be three or four years. To The period of instability lasts a considerable time in some of these cases." the Chairman's question whether she would require compulsory detention, she " " " Because I could imagine that that The Chairman continued : No. replied or of man young- woman is just the type who might type undisciplined young " I think go into your home and leave again in a few days." Miss Fox replied : there would be a risk of that with some of the cases, but I think that one would be able to have a very large number who would remain, provided the environDr. Tredgold emphasised his agreement ment of the home was of the right sort." with the view that compulsory detention was not desirable. Miss Fox made a the uncertifiable cases point in answer to the Chairman's remark that not all " referred to the Association were children. She replied : They started younger."
Miss Andrew gave evidence of the difficulty she had experienced in finding suitable homes for such cases, and that, in order to obtain vacancies, her Association had raised the money to support four beds in an existing home, but the
Association found that the different type.
cases
could not be
beneficially
associated with
girls
of
A long discussion took place as to whether the cases submitted could be dealt with under the Mental Deficiency Act, and as to how far their conduct was due to mental disorder. : In the illustrations you give us of several cases, are not many which come directly under the Mental Deficiency Act??(Dr. Tredgold) : I think you will find in all those cases, whilst on the face of it it is suggested that they are mentally defective, none of them have been proved to be capable of being dealt with under that Act. I think that applies to all the cases have put forward?that in actual practice they cannot be dealt with under we that Act.
of
(Mr. Micklem)
them
cases
(Mr. Micklem) : It is not easy to follow that. The cases that are given on the face of them look very much as though they were precisely covered by the Act?some of them??(Dr. Tredgold): I quite agree they do, but in actual practice they cannot be dealt with. I think 1 am correct in saying that several of them we tried to put under the Mental Deficiency Act.?(Miss Fox) : We have taken the cases that no one would certify. lake
"
like your case E," there seems to be nothing the what happens to everybody who leads an immoral criminal life. I tendency is due to mental disturbance??(Dr. suppose, any " " E has been seen by various specialists, and though they Tredgold) : This case she was not were said certifiable they quite certain she wanted some treatment.
(Mr. Jowitt)
matter
with
the
:
case
a
case
except
MENTAL WELFARE.
7
you take cases of dementia prascox??(Dr. of dementia precox; I do not think there are any of those cases here. 1 may say that all these cases have been selected from a very large number, and in all of them there has been no doubt as to mental abnormality. It is perhaps rather difficult to express that in the brief notes which we have given you, but the cases have come before the Association because of definite mental abnormality.
(Sir Humphry Rolleston) : Tredgold): We have excluded
Do
cases
view a symptom of mental abnormality that a should go outside the shop??(Miss Fox): This girl has had I don't know how many different places and she has been seen by several specialists, as her conduct was such that nothing could be done with her; she has been seen by a great number of specialists who said that she was not certifiable in any way.
(Mr. Jowitt) girl employed at
it
in
:
Is
a
photographer's
your
(Mr. Micklem) : But so many of these cases seem to me to be cases of what the common person would call vicious or criminal disposition, on which punishment has very little effect, and they want looking after. Prima facie a case of that kind would come under the Mental Deficiency Act??(Dr. Tredgold): In selecting these I cases do not think there was one who was not examined by more than one expert as to the possibility of certification under the Act. Was not that certification under the Lunacy Act??Yes, and the Mental Deficiency Act also. (Chairman)
:
The
four
classes
under
the
Mental
Deficiency
imbeciles, feeble-minded persons and moral imbeciles?in each
?(Dr. Tredgold):
case
Act with
are a
idiots,
definition?
Yes?
" Persons who from an early age display some Imbeciles are defined as with defect mental strong vicious or criminal propensities on coupled permanent Some of these cases are which punishment has had little or no deterrent effect." not unlike that description??(Dr. Tredgold): That may be so, Sir, but, as a matter of fact, I have no hesitation in saying that none of these cases could be dealt with as moral imbeciles, and I go further and say that none of them could I think one has to distinguish very be dealt with under the Mental Deficiency Act. carefully between mental defect and mental disorder. If they could be dealt with under the Mental Deficiency Act we should be only too glad, because our difficulties would be very much lessened ; but it was because we find in actual practice that they are not mentally defective but suffering from mental disorder?in other words because under the existing Act that we venture to place we find they cannot be dealt with them before you as a special class for consideration. It seems to me that with regard to vicious and criminal propensities the position is this : Whilst vicious and criminal propensities one may regard perhaps as the unfettered sway of certain lower instincts ?we will put it that way?when the control is inoperative, then one's natural instincts tend to have unfettered sway and may manifest themselves in vicious or That may arise in the case of the mental defective as a criminal misconduct. result of the non-development of control; he has never acquired control over those But the instincts; he has been mentally defective from birth or an early age. type of case we have in mind here is where conduct at one time has been good and normal and has conformed to the laws of society, but control has broken down as a result of mental disorder or disturbance, and whilst it has broken down then I think one does want very clearly to distinguish between we have this misconduct. those two cases : the type of case in which the person has not only never developed control, but is incapable of developing control, and the person who has at one Wre suggest that these cases, time had control, but whose control has broken down. whilst they are not capable of being certified under the Lunacy Act for practical purposes, nevertheless do come within the terms of your reference in this particular " term : The extent to which provision is or should be made in England and Wales for the treatment without certification of persons suffering from mental disorder." We hold the opinion very definitely that they are suffering from mental disorder. Of course there is a school which regards all vicious propensities as indicative of a certain amount of mental disorder??(Dr. Tredgold): Yes.
Moral
(Mr. Jowitt): Does the doctor accept that view??(Dr. Tredgold): That is rather another question. Do you accept that view??I do not know that I would, because I think that certain vicious and criminal manifestations are due to this: the individual carefully balances the consequences and decides whether it is going to be to his advantage to commit this particular crime or not, and whether he is likely to be found out If he decides that on or not. It is a case of carefully balancing the consequences.
MENTAL WELFARE. the whole he is not likely to be found out, and he will reap a material advantage from committing the crime, then he deliberately takes the risks. (Chairman) : I do not think very many philosophise the situation quite so It is instinctive, I am afraid in a good many cases. (Dr. carefully as that. an accused person Tredgold) : Yes, but on more than one occasion I have heard " " for in the I that he accounting delinquencies. Well," expression said, using and I decided to take the a it what and I think that is risk," over, thought just lot of criminals do. clear, which seems absolutely fundamental to (Mr. Jowitt) : May we get this " E." I go back to case Here I have a case of a girl who is quite your position. unable to stay long in a situation, who goes as a help to somebody and only stays two weeks, and then as a companion to an elderly lady, where she stayed three weeks; she then goes to a photographer's shop and looks out of the window instead of attending to her business, and finally runs away and lives with a man somewhere. Suppose I told you those facts about any girl would you draw the conclusion that that girl was in any way suffering from mental disorder and ought to be placed under restraint??(Dr. Tredgold) : A case where a girl does that, in spite of careful upbringing, may I add? If you like, certainly. In spite of the careful upbringing is unable to stay longer than about a fortnight in any situation, neglects her opportunities when she Would goes into business, and, if you like, is found periodically living with men. you predicate on those facts some type of mental disorder??(Dr. Tredgold): In other words, she is following a line of conduct which is greatly to her disadvantage? Certainly.?(Dr. Tredgold) : I should say, on the face of it, that that implies some mental failing of some kind or other, to my mind. (Chairman) : This is a little difficult class of case to describe. One is quite familiar with the type of child who is obviously dull and unresponsive to stimuli and unreceptive of education ; that is, no doubt, the typical mental defective. Then you may have, of course, the child who is really of unsound mind, but in this of mental infer of case state class from unsatisfactory abnormality you apparently conduct, if one may put it in general terms??(Dr. Tredgold) : Yes. evidenced untruthfulness and of conduct by Unreliability petty thefts, and from that kind of social abnormalities you infer that that person is suffering from some form of mental disorder??(Dr. Tredgold): Yes. That is not the generally accepted view, that that is necessarily mental disorder, It is, in a sense, mental disorder, because it means that the person does is it? not conform to ordinary standards of conduct; but is it disease??(Dr. Tredgold): I think I should certainly take this view, that if you have a child who has been well brought up, whose environment has been satisfactory, where she has been subject to good example and good precept, and yet, in spite of that, she has persistently given trouble, she cannot conform to the standards of the home, she cannot conform to the standards of society, she breaks the law, she has no idea of personal cleanliness, she is dirty in herself, and she embarks upon a course of conduct that is obviously to her disadvantage?in other words, entails some sort of punishment?I should certainly conclude that there was something wrong with that person's mind. One would want to know more details to decide what was wrong, but I think one would certainly conclude that there was something wrong. Miss Fox developed the idea put forward by Sir Humphrey Rolleston and the Chairman that possibly some modification of the recent Mental Treatment Bill might " serve to include the class of persons whom they wish to see treated. She said We did look through the old Mental Treatment Bill, and it seemed to us that with The very small adaptations the Bill could be made to cover what we have in mind. question of time and of hospitals with a training basis seemed to us as if it would meet the need. Very minor alterations as it came out of the House of Lords would make it possible to take in this type of case. Of course, it gives what we suggest should be given, a power and not a duty to authorities to deal with them, two very different things, and it does away with that bureaucratic element which you referred to, Sir, and means generally the use of what is available rather than the creation of new things." Turning to the other point in the Memorandum on the psychological examination of persons charged with offences, in reply to the Chairman, Dr. Tredgold said " The point that we rather wanted to insist upon, as I say, is that at present there is practically a complete absence of any means of finding out whether they are mentally abnormal or not. We think there ought to be some better means of examining these cases which come before the Courts." He said also that if the epidemic of encephalitis lethargica were going to continue the problem would become much more serious.
MENTAL WELFARE.
9
Dr. Ovide
Decroly has been good enoug-h to send us the following- article, extremely fortunate in securing something from his pen, for he has a great European reputation as a pioneer in educational method. He was trained as a Doctor of Medicine, and his interest in psychological problems and the study of the defective child led him to found a school in 1901 for defective and exceptional children. Working on his experience of the results here obtained, and
we
are
he opened a school for normal children in 1907 in Brussels. The name of the school (Ecole pour la vie par la vie) sums up his method, and Mademoiselle Hama'ide, who collaborated with him, has introduced this method into many of the Brussels Elementary Schools. A review of the recent English translation of her book appears on page 26. Dr. Decroly is now head of the Department of School Hygiene in Brussels University Medical School.
not
trading
2. The purpose for which the Association was primarily established was that of dealing with cases coming within the scope of the Mental Deficiency Act, 1913. Under its Articles of Incorporation, however, it was also empowered to deal with other forms of mental abnormality and disorder, and from the time of its institution it has been consulted with regard to a large number of borderland cases, of epileptics and of cases of early mental disorder. The number of these non-defective cases has increased year by year and the Association has now come to be regarded as the chief and largest non-official body in the country to which cases of mental abnormality may be referred for advice. The total number of cases so referred to the Central Office and Local Associations during the past ten years is approximately 34,000..
2
MENTAL WELFARE.
The Central Council is a representative body under the Presidency of 3. Sir Leslie Scott, K.C., M.P., and is composed of representatives nominated by various official and public bodies and societies dealing' with the mentally abnormal {e.g., H.M. Prison Commissioners, County Councils Association, Association of Poor Law Unions, Association of Education Committees, Medico-Psychological Association, Church Army, Salvation Army, Charity Organisation Society, Mental After Care Association, etc.), of representatives of Homes and Institutions; of medical experts and of co-opted members having special experience of the mentally abnormal, the official and voluntary elements being approximately balanced. Its main purposes are to act as a co-ordinating link between the various Authorities and Organisations concerned with the mentally abnormal; to act as a Central Enquiry Bureau ; to form Local Mental Welfare Associations; to provide courses of instruction for medical men, teachers, nurses and social workers; and to carry In addion general propaganda and educational work throughout the country. tion to voluntary subscriptions it has, since its inauguration, been in receipt of an annual grant from the Board of Control; but although in this way officially recognised and consulted, the Association desires to point out that it is an entirely independent body whose policy is not in any way controlled by any Government
Department. 4. The affiliated Local Associations consist of 48 Mental Welfare Associations covering 21 Administrative Counties and 43 County Boroughs of England. The purpose of these local Associations is to act as local co-ordinating links and as enquiry bureaux ; to assist, supervise, visit and befriend such defectives and mentally abnormal persons within their areas as are living at home and are in need of advice and assistance, and to bring them, where necessary, into touch with the appropriate Local Authority charged with the administration of the various Acts of Parliament: also, where desired, to carry out the statutory work of visiting and befriending such persons on behalf of the Local Authority. 5. It is necessary to emphasise the point that the assistance rendered by the local Associations, consisting as it does of frequent home visits and advice to parents on general management and methods of training, of the holding of classes in handicrafts, etc., is such as to bring these Associations into very intimate connection with the patients and their families and thus to afford these Associations particularly detailed and valuable knowledge of the characteristics and needs of a very large number of the mentally abnormal population. 6. In submitting evidence to the Royal Commission the Association understands that the subject of Mental Deficiency is outside the scope of the Commission's
it is also cognisant of the fact that evidence regarding the insane has been already given by other bodies. It therefore proposes to restrict its evidence to certain groups of cases of mental abnormality which are not certifiable under either the Mental Deficiency or the Lunacy Acts and regarding which it is believed to have such special and extensive experience as to enable it to arrive at certain definite conclusions and to submit certain recom-
enquiry;
certifiably
mendations. 7. The experience of the Central Association shows conclusively that there exists in the community a considerable body of persons who cannot be certified under either the Mental Deficiency or Lunacy Acts, but who yet suffer from such pronounced forms of mental disorder and instability as to make it impossible for them to adapt themselves in a satisfactory and efficient manner to their surroundings and who consequently are in need of supervision, training and treatment. From the Returns of the Local Associations and from the case records of the Central Office it has been found that about 10 per cent, of the total number
3
MENTAL WELFARE. ?f cases referred to
These persons comprise a concome within this category. siderable proportion of the inmates of charitable institutions such as Rescue and Preventive Homes, of Poor Law Institutions and of Prisons, etc. They are the despair of every relief society and although their mental disorder is well known to
the medical experts, teachers and social workers who
them, it has not hitherto been recognised by any Association submits that such persons come within
come
statute.
into contact with
Nevertheless, the
the scope of that term of of the Royal Commission which specifies " the extent to which provision ?s or should be made in England and Wales for the Treatment without certification of persons suffering from Mental Disorder." These persons may be conveniently divided into several groups which will be dealt with seriatim.
reference
8. The first and most important group to which the Association desires to refer consists of adolescents between the ages of 15 and 21 j'ears. The Central Office has been furnished by the local Associations throughout the country with
a
large number of detailed pxtending over a period of Jt is abundantly clcar that
these persons, many of them and from these particulars the condition of adolescent mental disorder is widely Prevalent and fraught with grave menace to the general well-being of the community. There is also clear evidence that it is a condition for which the provision ?f appropriate treatment is not only quite inadequate but urgently required. In many of these cases there is evidence from teachers that some abnormality of behaviour was present during school age. Upon leaving school the freedom from discipline, the increased responsibility and the competitive conditions of modern fife impose a strain which the individual is unable to meet, with the result that he develops definite signs of mental disorder and instability. He or she becomes "wayward, unruly, irresponsible, unbalanced and incapable of settling down to any steady occupation. At the best such individuals are social inefficients, while a considerable proportion of them develop definite anti-social tendencies and drift into a life of immorality and crime. The experience which the Central Association possesses of persons of this type, and the number of cases about which it is consulted, has convinced it that the problem of this group of persons, in its general bearing upon society, is even graver than those of the mentally defective and insane, and it desires very earnestly to bring this class to the notice of the
Royal
9.
case
histories
regarding
ten years and often
longer,
Commission.
emphasise the fact incipient insanity and that they existing administrative procedure.
that the cases here referred to are cannot be dealt with satisfactorily under any A small proportion, it is true, may subsequently prove to be Dementia Prascox or some other variety of certifiable unsoundness of mind, but this is not so with the majority. Nevertheless, the condition is one of mental disorder of such a degree as to render the individual socially inefficient or anti-social, and to necessitate supervision, training and treatment which cannot be given at home. It is also necessary to point out that the condition is one which frequently lasts for a period of years and that during this time it is not only a great disadvantage for the individual to be deprived ?f some form of in handicraft or industrial work, but that It is necessary to
not cases of
appropriate training
such training constitutes a very important part of his treatment. For these reasons the treatment afforded by an ordinary Mental Hospital as suitable for acute and temporary cases of mental disorder, or by the Hospital establishments suggested in the Mental Treatment Bill, is not applicable to the more prolonged care required by the majority of these persons. The appropriate supervision, treatment and training which are needed can only be afforded by institutions of a special character. The entire social experience of the Association in dealing with these cases bears out the fact recognised by medical men that the home is
MENTAL WELFARE.
4
in many instances the actual cause of the patient's abnormal condition, and that in nearly every case a change of environment is essential to improvement. The Association has made every effort to deal with these cases in a satisfactory and constructive manner. In a few instances the necessary treatment and training- have been forthcoming- in a voluntary home, and in such cases great improvement has resulted and the individual has been restored to a normal condition. Speaking generally, however, the utter inadequacy of any such facilities The Association desires to emphasise has resulted in a failure of these efforts. the fact that whilst a few voluntary homes exist to which such patients may be sent, the number of these is extremely small. It also desires to point out that no Authority (other than Poor Law Guardians who can deal with such persons only as paupers) has the power to pay for treatment for them and that voluntary agencies have not the means to assist them. 10.
A group of cases which has come prominently before the Association 11. consists of persons primarily referred on account of more or less serious misconduct, in many cases of such a nature as to bring the person before the Courts. The Association is satisfied that in a very considerable proportion of these the essential cause for the misconduct is uncertifiable disorder of mind, and that there would be a reasonable prospect of benefit resulting from treatment in special training institutions, did such exist. 12. It is clear, however, that with regard to this group the mere provision of institutions would not suffice to meet the case unless there were some machinery for the systematic medical investigation of persons charged with offences in whom there was privid facie evidence of mental disorder. Although such machinery exists in the case of persons charged with serious crimes, there is, generally speaking, no adequate provision for persons coming before the lower Courts unless remanded to a prison or workhouse, which in many cases would appear to be undesirable. It is felt that the absence of this provision constitutes a serious hindrance to proper diagnosis and treatment. 13. During the increasing number of
past few years the Association has had referred to it an cases of disorder of mind, very frequently accompanied by
misconduct, which have been shown to be the results of lethargic and other forms of encephalitis. Practically all these cases have been children of school age or young adolescents, and, speaking generally, attempts to deal with them have largely failed owing to the absence of any suitable arrangements. A few of these cases are certifiable under the Mental Deficiency and Lunacy Acts and should be dealt with in Certified Institutions or Mental Hospitals, but in the majority this is not so. On the other hand they present characteristics which render them quite unsuited to, and cause their rejection from, any existing institutions, voluntary or otherwise. There is reason to think that, in the case of many, the need would be met by special training institutions of the type already referred to. Also that such institutions would be of particular value for the after treatment and training of many cases discharged from Hospital. 14.
In the
course
of its work the Central Association has been consulted
considerable number of cases of incipient insanity and has been greatly impressed with the lack of adequate facilities for the treatment of these, particularly in the case of persons of limited means. The Association is aware
regarding-
a
that evidence has already been given by other bodies regarding this class of persons, and all that it desires to do is to corroborate and emphasise the views which have already been expressed as to the great need which exists for the means provision of in-patient and out-patient treatment, without certification,
by
MENTAL WELFARE.
?f
Special Hospitals, Special Departments
Clinics
"4
in General Hospitals, and Out-Patient
for persons of this class.
15.
tions
5
The Central
Association desires
to
make the
following
recommenda-
:?
-4s to Provision
(a)
of Special Institutions.
empowered to establish (either alone with other Authorities) Training Homes for persons under the age of 21 years who are suffering from disorder of mind, not certifiable under the Mental Deficiency or Lunacy Acts, and should be empowered to contract with the Managers of any such recognised home for the reception and maintenance of such cases. That the Local Authority empowered to establish or maintain patients in such Homes should be the County or County Borough Council. That the Treasury be empowered to give a grant towards the expenses of Local Authorities establishing such homes, or maintaining patients in such homes as are established by other authorities or bodies. That such homes should provide skilled and adequate medical treatment appropriate to the mental disorder of these persons, as well as industrial and other forms of training. Also, that they should be available as hostels for such patients for a limited time on their first taking up outside employment. That persons should be admitted to such homes on the application of a parent or guardian, or failing these, on the application of the Local Authority, accompanied by the certificate of a qualified medical practitioner stating that the person is suffering from mental disorder not certifiable under the Mental Deficiency or Lunacy Acts, and is in need of care and supervision in a training home. That a patient in such a home should be discharged by the Superintendent or other appointed officer, upon 72 hours' notice being given by the parent or guardian, except in cases sent by the Courts. That such homes should be registered and under the general supervision of the Ministry of Health. That such homes as are suitable for children should be recognised by the " schools of recovery " for children under 16 Board of Education as from of post-Encephalitis. years age suffering That Local Authorities should be or
(b) (c) {d)
(e)
(/) (5-) (h)
B?Ts
(a) (b)
to
the
Psychological Examination of
Persons
charged
with Offences.
machinery should be provided for the adequate investigation of all persons charged with offences against the law in whom there is reason to suspect the presence of mental disorder or abnormality.. That in the case of persons found on such investigation to be suffering from uncertifiable mental disorder and whom a Court is desirous of placing on probation in such homes as are proposed in this memorandum, it should be lawful for a Local Authority to contribute towards the maintenance of such persons in such homes. That
Dr. Tredgold, in his spoken evidence, emphasised that " there is a type of which we call adolescent mental disorder, which is not capable of being dealt with either under the Mental Deficiency Act or the Lunacy Act." The reply of the Chairman is of significance. He said, " You have furnished us with a series of illustrative cases which we have read, and I must say they impressed me as very striking?very trying and difficult cases, for which there is, apparently,
ease
MENTAL WELFARE.
6
adequate provision just now." Dr. Tredgold referred to the recommendations of the Central Association for the establishment of special institutions for such " we realise that possibly some of these cases adolescent cases, and added that would be dealt with under the Mental Treatment Bill if the Bill became an Act, Pressed by the Chairman on the point that but comparatively few of them." the recommendation involved an additional type of institution, Dr. Tredgold " At a very large and very well attended meeting of the Medical Council replied : We realised that the only way of dealing with these we faced this question. cases in a satisfactory manner was to provide a different type of home altogether which should not be an asylum and which should not be an ordinary Clinic." no
Asked whether the charitable institutions already in existence or philanthropic effort in the future could cope with this type of case, Miss Fox replied that the existing homes and institutions were not really suitable owing to the mixed cases received, and the economical lines on which they were run, as they were unable to provide the rather special staffing and surroundings required. She added : "In the case of the homes which we have tried the longest time allowed, I think, is for two years, and in some instances it is obvious that a girl wants rather more than that in a special surrounding" : it may be three or four years. To The period of instability lasts a considerable time in some of these cases." the Chairman's question whether she would require compulsory detention, she " " " Because I could imagine that that The Chairman continued : No. replied or of man young- woman is just the type who might type undisciplined young " I think go into your home and leave again in a few days." Miss Fox replied : there would be a risk of that with some of the cases, but I think that one would be able to have a very large number who would remain, provided the environDr. Tredgold emphasised his agreement ment of the home was of the right sort." with the view that compulsory detention was not desirable. Miss Fox made a the uncertifiable cases point in answer to the Chairman's remark that not all " referred to the Association were children. She replied : They started younger."
Miss Andrew gave evidence of the difficulty she had experienced in finding suitable homes for such cases, and that, in order to obtain vacancies, her Association had raised the money to support four beds in an existing home, but the
Association found that the different type.
cases
could not be
beneficially
associated with
girls
of
A long discussion took place as to whether the cases submitted could be dealt with under the Mental Deficiency Act, and as to how far their conduct was due to mental disorder. : In the illustrations you give us of several cases, are not many which come directly under the Mental Deficiency Act??(Dr. Tredgold) : I think you will find in all those cases, whilst on the face of it it is suggested that they are mentally defective, none of them have been proved to be capable of being dealt with under that Act. I think that applies to all the cases have put forward?that in actual practice they cannot be dealt with under we that Act.
of
(Mr. Micklem)
them
cases
(Mr. Micklem) : It is not easy to follow that. The cases that are given on the face of them look very much as though they were precisely covered by the Act?some of them??(Dr. Tredgold): I quite agree they do, but in actual practice they cannot be dealt with. I think 1 am correct in saying that several of them we tried to put under the Mental Deficiency Act.?(Miss Fox) : We have taken the cases that no one would certify. lake
"
like your case E," there seems to be nothing the what happens to everybody who leads an immoral criminal life. I tendency is due to mental disturbance??(Dr. suppose, any " " E has been seen by various specialists, and though they Tredgold) : This case she was not were said certifiable they quite certain she wanted some treatment.
(Mr. Jowitt)
matter
with
the
:
case
a
case
except
MENTAL WELFARE.
7
you take cases of dementia prascox??(Dr. of dementia precox; I do not think there are any of those cases here. 1 may say that all these cases have been selected from a very large number, and in all of them there has been no doubt as to mental abnormality. It is perhaps rather difficult to express that in the brief notes which we have given you, but the cases have come before the Association because of definite mental abnormality.
(Sir Humphry Rolleston) : Tredgold): We have excluded
Do
cases
view a symptom of mental abnormality that a should go outside the shop??(Miss Fox): This girl has had I don't know how many different places and she has been seen by several specialists, as her conduct was such that nothing could be done with her; she has been seen by a great number of specialists who said that she was not certifiable in any way.
(Mr. Jowitt) girl employed at
it
in
:
Is
a
photographer's
your
(Mr. Micklem) : But so many of these cases seem to me to be cases of what the common person would call vicious or criminal disposition, on which punishment has very little effect, and they want looking after. Prima facie a case of that kind would come under the Mental Deficiency Act??(Dr. Tredgold): In selecting these I cases do not think there was one who was not examined by more than one expert as to the possibility of certification under the Act. Was not that certification under the Lunacy Act??Yes, and the Mental Deficiency Act also. (Chairman)
:
The
four
classes
under
the
Mental
Deficiency
imbeciles, feeble-minded persons and moral imbeciles?in each
?(Dr. Tredgold):
case
Act with
are a
idiots,
definition?
Yes?
" Persons who from an early age display some Imbeciles are defined as with defect mental strong vicious or criminal propensities on coupled permanent Some of these cases are which punishment has had little or no deterrent effect." not unlike that description??(Dr. Tredgold): That may be so, Sir, but, as a matter of fact, I have no hesitation in saying that none of these cases could be dealt with as moral imbeciles, and I go further and say that none of them could I think one has to distinguish very be dealt with under the Mental Deficiency Act. carefully between mental defect and mental disorder. If they could be dealt with under the Mental Deficiency Act we should be only too glad, because our difficulties would be very much lessened ; but it was because we find in actual practice that they are not mentally defective but suffering from mental disorder?in other words because under the existing Act that we venture to place we find they cannot be dealt with them before you as a special class for consideration. It seems to me that with regard to vicious and criminal propensities the position is this : Whilst vicious and criminal propensities one may regard perhaps as the unfettered sway of certain lower instincts ?we will put it that way?when the control is inoperative, then one's natural instincts tend to have unfettered sway and may manifest themselves in vicious or That may arise in the case of the mental defective as a criminal misconduct. result of the non-development of control; he has never acquired control over those But the instincts; he has been mentally defective from birth or an early age. type of case we have in mind here is where conduct at one time has been good and normal and has conformed to the laws of society, but control has broken down as a result of mental disorder or disturbance, and whilst it has broken down then I think one does want very clearly to distinguish between we have this misconduct. those two cases : the type of case in which the person has not only never developed control, but is incapable of developing control, and the person who has at one Wre suggest that these cases, time had control, but whose control has broken down. whilst they are not capable of being certified under the Lunacy Act for practical purposes, nevertheless do come within the terms of your reference in this particular " term : The extent to which provision is or should be made in England and Wales for the treatment without certification of persons suffering from mental disorder." We hold the opinion very definitely that they are suffering from mental disorder. Of course there is a school which regards all vicious propensities as indicative of a certain amount of mental disorder??(Dr. Tredgold): Yes.
Moral
(Mr. Jowitt): Does the doctor accept that view??(Dr. Tredgold): That is rather another question. Do you accept that view??I do not know that I would, because I think that certain vicious and criminal manifestations are due to this: the individual carefully balances the consequences and decides whether it is going to be to his advantage to commit this particular crime or not, and whether he is likely to be found out If he decides that on or not. It is a case of carefully balancing the consequences.
MENTAL WELFARE. the whole he is not likely to be found out, and he will reap a material advantage from committing the crime, then he deliberately takes the risks. (Chairman) : I do not think very many philosophise the situation quite so It is instinctive, I am afraid in a good many cases. (Dr. carefully as that. an accused person Tredgold) : Yes, but on more than one occasion I have heard " " for in the I that he accounting delinquencies. Well," expression said, using and I decided to take the a it what and I think that is risk," over, thought just lot of criminals do. clear, which seems absolutely fundamental to (Mr. Jowitt) : May we get this " E." I go back to case Here I have a case of a girl who is quite your position. unable to stay long in a situation, who goes as a help to somebody and only stays two weeks, and then as a companion to an elderly lady, where she stayed three weeks; she then goes to a photographer's shop and looks out of the window instead of attending to her business, and finally runs away and lives with a man somewhere. Suppose I told you those facts about any girl would you draw the conclusion that that girl was in any way suffering from mental disorder and ought to be placed under restraint??(Dr. Tredgold) : A case where a girl does that, in spite of careful upbringing, may I add? If you like, certainly. In spite of the careful upbringing is unable to stay longer than about a fortnight in any situation, neglects her opportunities when she Would goes into business, and, if you like, is found periodically living with men. you predicate on those facts some type of mental disorder??(Dr. Tredgold): In other words, she is following a line of conduct which is greatly to her disadvantage? Certainly.?(Dr. Tredgold) : I should say, on the face of it, that that implies some mental failing of some kind or other, to my mind. (Chairman) : This is a little difficult class of case to describe. One is quite familiar with the type of child who is obviously dull and unresponsive to stimuli and unreceptive of education ; that is, no doubt, the typical mental defective. Then you may have, of course, the child who is really of unsound mind, but in this of mental infer of case state class from unsatisfactory abnormality you apparently conduct, if one may put it in general terms??(Dr. Tredgold) : Yes. evidenced untruthfulness and of conduct by Unreliability petty thefts, and from that kind of social abnormalities you infer that that person is suffering from some form of mental disorder??(Dr. Tredgold): Yes. That is not the generally accepted view, that that is necessarily mental disorder, It is, in a sense, mental disorder, because it means that the person does is it? not conform to ordinary standards of conduct; but is it disease??(Dr. Tredgold): I think I should certainly take this view, that if you have a child who has been well brought up, whose environment has been satisfactory, where she has been subject to good example and good precept, and yet, in spite of that, she has persistently given trouble, she cannot conform to the standards of the home, she cannot conform to the standards of society, she breaks the law, she has no idea of personal cleanliness, she is dirty in herself, and she embarks upon a course of conduct that is obviously to her disadvantage?in other words, entails some sort of punishment?I should certainly conclude that there was something wrong with that person's mind. One would want to know more details to decide what was wrong, but I think one would certainly conclude that there was something wrong. Miss Fox developed the idea put forward by Sir Humphrey Rolleston and the Chairman that possibly some modification of the recent Mental Treatment Bill might " serve to include the class of persons whom they wish to see treated. She said We did look through the old Mental Treatment Bill, and it seemed to us that with The very small adaptations the Bill could be made to cover what we have in mind. question of time and of hospitals with a training basis seemed to us as if it would meet the need. Very minor alterations as it came out of the House of Lords would make it possible to take in this type of case. Of course, it gives what we suggest should be given, a power and not a duty to authorities to deal with them, two very different things, and it does away with that bureaucratic element which you referred to, Sir, and means generally the use of what is available rather than the creation of new things." Turning to the other point in the Memorandum on the psychological examination of persons charged with offences, in reply to the Chairman, Dr. Tredgold said " The point that we rather wanted to insist upon, as I say, is that at present there is practically a complete absence of any means of finding out whether they are mentally abnormal or not. We think there ought to be some better means of examining these cases which come before the Courts." He said also that if the epidemic of encephalitis lethargica were going to continue the problem would become much more serious.
MENTAL WELFARE.
9
Dr. Ovide
Decroly has been good enoug-h to send us the following- article, extremely fortunate in securing something from his pen, for he has a great European reputation as a pioneer in educational method. He was trained as a Doctor of Medicine, and his interest in psychological problems and the study of the defective child led him to found a school in 1901 for defective and exceptional children. Working on his experience of the results here obtained, and
we
are
he opened a school for normal children in 1907 in Brussels. The name of the school (Ecole pour la vie par la vie) sums up his method, and Mademoiselle Hama'ide, who collaborated with him, has introduced this method into many of the Brussels Elementary Schools. A review of the recent English translation of her book appears on page 26. Dr. Decroly is now head of the Department of School Hygiene in Brussels University Medical School.
