Towards
a
Unified Mental Health Service* By
SIR LAURENCE BROCK, C.B.
Chairman, The essential
unity
Board
of
Control
of all mental health services has been obscured
by entanglement was inevitable because certain mental states necessitate the patient's segregation, and all restrictions on liberty demand, and rightly demand, legal safeguards against their abuse. But, while it was inevitable that mental medicine should be entangled with the law, the results of this entanglement are in many ways unfortunate. The law proceeds on the assumption that people are either sane or insane. Such a division sounds simple and logical and, to be fair to the lawyers, it is not to see how easy they could have proceeded on any other basis. But logical as the classification sounds, it has Insanity very little relation to the facts. is purely a legal concept. Medically, the term is almost meaningless. It does not describe a pathological condition; it is not a diagnosis; it is at best merely a convenient way of describing the condition of persons whose mental state necessitates some restriction on their liberty. Unhappily the use of what is entanglement
with the law.
This
"
*
"
a speech to the North Eastern Council for Mental Welfare on the 26th May, 1939. The introductory sentences and nearly all personal references have been omitted. The transcript represents the substance of the speech, and does not purport to be an
Transcript of exact
reproduction.
94
MENTAL WELFARE
legal and not a medical term has led the public to believe that all forms of mental disorder are one and the same, and that they differ merely in the degree of the severity of the attack. This is far from being the case. really
a
There are many different forms of mental disorder, as some of you know and as all of you can see if you look at the list in any mental hospital report. Diagnosis is exceedingly difficult in some cases, because similar aberrations of behaviour may be due to different disorders. Even now, there is no general agreement as to classification and nomenclature. Our classification differs from that used abroad, and the same term may have a somewhat different content in different countries. Let
me
disorders
try and illustrate this point by
are
due
to
physical
causes.
a few examples. Some mental example, general paralysis of the all admissions, is now known to be
For
insane, which accounts for about 8% of due to venereal disease, and to the presence in the blood vessels of the brain of minute organisms called spirochetes. This is now treated by induced malaria which kills the spirochetes and, if the case has not gone too far, the will recover sufficiently to return to ordinary life. Then there are the toxic cases due to some poison in the system. The focus of infection may be in the sinuses, may be intestinal, or due to septic teeth. The problem is to find the source of the infection and to clean it up. Here again, if too
patient
damage has not been done, the patient has a good chance of recovery. These are examples of mental disorders due to a specific physical cause, which have to be treated by physical methods. But there are other forms of disorder which are purely psychological, and need to be treated by psychological methods. There is no discoverable physical cause, and the whole method of approach has to be different. But the problem of diagnosis is not the whole of the difficulty. There is no sharp line between certifiable patients and others who exhibit some degree of mental abnormality. You cannot divide people into sheep and goats, sane and insane. In reality there are endless degrees of mental abnormality or instability; nor is there any exact test by which to determine the degree of instability which constitutes much
unsoundness of mind for purposes of the law. Between the extremes of pure white and absolute black there are endless shades of grey. Unconsciously we recognise this in common speech. We call people eccentric, nervy, or, if we like them, temperamental. All these are euphemisms; they are all terms intended to describe
some
degree talk
of mental of
these
instability. borderline
If
we
want to be
as being impressively technical, we all indicate are and there many more, psychopaths," but all these terms, a recognition that there are many people in the community who are mentally not quite normal. But the difficulties resulting from entanglement with the law are far from ending here. Unfortunately, different forms of mental abnormality are dealt with by different Acts administered by different bodies. Let me illustrate "
cases
MENTAL WELFARE this in
by concrete examples. public mental hospitals or
95
Mental disorders, so far as they can be treated in out-patient centres, are dealt with by visiting
committees.
Cases of mental disorder which are treated in public assistance institutions, are dealt with by the public assistance committee. But, if instead of a public assistance institution there is a municipal general hospital, that hospital falls within the ambit of the public health committee. The same haphazard division of duties is found in the case of mental deficiency. Children who are defective for the purposes of the Education Act are the responsibility of the local education authority. Ineducable children and adult defectives are dealt with by the mental deficiency committee. Child guidance, so far as it is undertaken at all by local authorities, is a matter for the local education authority. Elsewhere it is left to voluntary organisations. Borderline cases, neuroses or psycho-neuroses, may go either to general or special hospitals, or to outpatient centres or as voluntary patients to mental hospitals. Mentally abnormal delinquents are dealt with by the prison authorities. This
voluntary
of statutory bodies has its parallel on the side of The After-Care Association deals with discharged patients
multiplicity effort.
limited extent, with what is called pre-care. The Central Association for Mental Welfare is primarily concerned with mental defect, but in many areas acts as agent for the After-Care Association, besides dealing with
and,
to a
boarding out and organising training courses. Boarding out is also dealt by guardianship societies such as The Guardianship Society, Brighton. Child guidance is organised by the Child Guidance Council, but the problem of the difficult child also comes within the province of the Home and School Council. Borderline mental cases are dealt with by organisations such as the Tavistock Clinic, and the mentally abnormal delinquent is dealt with by the Association for the Scientific Study of Delinquency. All these organisations are concerned with separate bits of work in the field of mental hygiene, It is not and all are competing against one another for public support. which and the that are that the confused, support they give public surprising is generally quite inadequate. But the point I want to stress is that there is no co-ordinating authority. There is no statutory body able to survey the whole field and frame a comprehensive programme.
with
that the different classes I have mentioned need to be handled in different ways. Mental disorders, for example, call for active remedial treatment. Mental defect calls for training and occupation. But the difference in the methods applicable to different classes should not be allowed to obscure I
recognise
the fact that all
are
forms of mental
abnormality.
Imagine the result of principle, to physical
same principle, or rather absence of Suppose there were different committees of local authorities, or different voluntary organisations dealing with rheumatism, tuberculosis, heart diseases and surgical cases. The absurdity of such a position does not need We need to look at mental abnormality as a whole. All to be emphasised.
applying
disorders.
the
96
MENTAL WELFARE
these different sections form part of the general problem of mental hygiene. The essential unity of the problem has been obscured in the past by too much concentration on end results. This has led to the apportionment of duties on the basis of the type of institution suited for cases demanding institutional care.
the
We
cannot
neglect
end results, but
we
ought
to pay
more
attention
to
beginnings.
If we are to unify control, there must be a simplification of administrative machinery. There should, in my view, be a mental health committee charged with the general oversight of all forms of mental health work. Such a committee would be able to define the provinces of municipal and voluntary effort. There is ample scope for voluntary work in mental hygiene, but voluntary organisations need to be linked up by some co-ordinating authority if overlapping and competition are to be avoided. I hope that the Feversham Committee's long-awaited report, which I understand is soon to be issued, will show how this
can
best be done.
One obvious
advantage of such a co-ordinating committee would be that of institutional accommodation could be viewed as a whole. At present it is far too common to find mental defectives, many of them children, who because they happen to be certifiable under the Lunacy Acts are allowed the
problem
to occupy valuable mental
hospital
which would of
beds.
This is not because of any superjustify their treatment in mental
vening psychosis, hospitals, but simply because the mental deficiency committee has failed to provide proper accommodation of its own either in colonies or in adapted public assistance institutions. This is a waste of hospital beds and it is unfair to the other patients; it is unfair to the nurses who have not been trained in mental deficiency work, and it is unfair to the defectives themselves because they cannot get the training which they need. This is merely one illustration of possible improvement in administration. But a far more important result will be to focus public attention on mental health. At present, because the work is sectionalised, no one is concerned with prevention. The visiting committee concentrates on mental hospital management, which is after all its statutory responsibility. The mental deficiency committee concentrates on ascertainment and on the provision of institutional care for defectives. The local education authority may, or may not, have a special school. Each committee thinks in terms of its own job, naturally and inevitably, since their duties and responsibilities are defined by It is no one's duty to ask whether anything can be done to save statute. cases from reaching a stage at which institutional care becomes inevitable. Child guidance, for example, or the problem of the so-called difficult child, is simply non-existent in many places and where, as in London, something is being done, the work owes its initiation to American philanthropy. But if a mental health committee is to function effectively, it will need a specially trained executive officer and adviser: in other words, a medical course
MENTAL WELFARE officer of mental health. for this officer, because
I want to
the need for
special training as it is, is hospital, not enough by itself. I have the greatest regard for mental hospital doctors, but they necessarily think in terms of the major psychoses and their tendency, naturally enough, is to want to bring the cases into hospital rather than to keep them out of hospital. An adequate training in mental hospital work experience
emphasise
97
in
a
mental
essential
is essential because the medical officer of mental health must have a sound clinical background. But he needs much more than this. He ought to be familiar with modern methods of psychotherapy. We want to develop out-
patient centres, and to do much more in the way of treatment there instead of making the sessions so few and so short that little can be attempted beyond diagnosis. He ought also to have experience of child guidance, and he should co-operate with the school medical officer and with the teachers, who
can
signs of mental abnormality far sooner than anyone else. It is equally important that he should have had some experience in mental deficiency work, and a knowledge of modern methods of training. I admit that this is asking a great deal. These Admirable Crichtons do not exist to-day, but they can be trained when the need for them is more generally recognised. After all, the training of the M.O.H. has only developed gradually. Now in the bigger cities and counties we have a body of men with an all round training in public health and preventive medicine unsurpassed anywhere in the world. But this is not the task of a day or of a year. I am not talking of what is immediately practicable, but of the goal at which we ought to aim.
detect
If only committee, the
vast
measures.
It
will
we
can
concentrate all aspects of mental health work in
one
the public conscience and make people realise may social importance of the problem and the need for preventive It will cost money, of course it will, but think what it might save. we
take
arouse
time; amending legislations will be needed; long-standing
professional rivalry and vested would be too depressing if we mine, job, limited our thoughts and aspirations simply to our day-to-day tasks. Nothing of what I have outlined is impossible. It may be difficult, indeed I know it is, but it is in no way impossible. Is it just a dream? I think not, but even if it is a dream, I make no apology on that score. If it is a dream, surely it is one worth dreaming. In mental health, perhaps more than in any other sphere, it is true, literally and terribly true, without a vision the people perish."
prejudices
will have
interests faced.
But
to
our
be
overcome
and
yours and
"
a
Unified Mental Health Service* By
SIR LAURENCE BROCK, C.B.
Chairman, The essential
unity
Board
of
Control
of all mental health services has been obscured
by entanglement was inevitable because certain mental states necessitate the patient's segregation, and all restrictions on liberty demand, and rightly demand, legal safeguards against their abuse. But, while it was inevitable that mental medicine should be entangled with the law, the results of this entanglement are in many ways unfortunate. The law proceeds on the assumption that people are either sane or insane. Such a division sounds simple and logical and, to be fair to the lawyers, it is not to see how easy they could have proceeded on any other basis. But logical as the classification sounds, it has Insanity very little relation to the facts. is purely a legal concept. Medically, the term is almost meaningless. It does not describe a pathological condition; it is not a diagnosis; it is at best merely a convenient way of describing the condition of persons whose mental state necessitates some restriction on their liberty. Unhappily the use of what is entanglement
with the law.
This
"
*
"
a speech to the North Eastern Council for Mental Welfare on the 26th May, 1939. The introductory sentences and nearly all personal references have been omitted. The transcript represents the substance of the speech, and does not purport to be an
Transcript of exact
reproduction.
94
MENTAL WELFARE
legal and not a medical term has led the public to believe that all forms of mental disorder are one and the same, and that they differ merely in the degree of the severity of the attack. This is far from being the case. really
a
There are many different forms of mental disorder, as some of you know and as all of you can see if you look at the list in any mental hospital report. Diagnosis is exceedingly difficult in some cases, because similar aberrations of behaviour may be due to different disorders. Even now, there is no general agreement as to classification and nomenclature. Our classification differs from that used abroad, and the same term may have a somewhat different content in different countries. Let
me
disorders
try and illustrate this point by
are
due
to
physical
causes.
a few examples. Some mental example, general paralysis of the all admissions, is now known to be
For
insane, which accounts for about 8% of due to venereal disease, and to the presence in the blood vessels of the brain of minute organisms called spirochetes. This is now treated by induced malaria which kills the spirochetes and, if the case has not gone too far, the will recover sufficiently to return to ordinary life. Then there are the toxic cases due to some poison in the system. The focus of infection may be in the sinuses, may be intestinal, or due to septic teeth. The problem is to find the source of the infection and to clean it up. Here again, if too
patient
damage has not been done, the patient has a good chance of recovery. These are examples of mental disorders due to a specific physical cause, which have to be treated by physical methods. But there are other forms of disorder which are purely psychological, and need to be treated by psychological methods. There is no discoverable physical cause, and the whole method of approach has to be different. But the problem of diagnosis is not the whole of the difficulty. There is no sharp line between certifiable patients and others who exhibit some degree of mental abnormality. You cannot divide people into sheep and goats, sane and insane. In reality there are endless degrees of mental abnormality or instability; nor is there any exact test by which to determine the degree of instability which constitutes much
unsoundness of mind for purposes of the law. Between the extremes of pure white and absolute black there are endless shades of grey. Unconsciously we recognise this in common speech. We call people eccentric, nervy, or, if we like them, temperamental. All these are euphemisms; they are all terms intended to describe
some
degree talk
of mental of
these
instability. borderline
If
we
want to be
as being impressively technical, we all indicate are and there many more, psychopaths," but all these terms, a recognition that there are many people in the community who are mentally not quite normal. But the difficulties resulting from entanglement with the law are far from ending here. Unfortunately, different forms of mental abnormality are dealt with by different Acts administered by different bodies. Let me illustrate "
cases
MENTAL WELFARE this in
by concrete examples. public mental hospitals or
95
Mental disorders, so far as they can be treated in out-patient centres, are dealt with by visiting
committees.
Cases of mental disorder which are treated in public assistance institutions, are dealt with by the public assistance committee. But, if instead of a public assistance institution there is a municipal general hospital, that hospital falls within the ambit of the public health committee. The same haphazard division of duties is found in the case of mental deficiency. Children who are defective for the purposes of the Education Act are the responsibility of the local education authority. Ineducable children and adult defectives are dealt with by the mental deficiency committee. Child guidance, so far as it is undertaken at all by local authorities, is a matter for the local education authority. Elsewhere it is left to voluntary organisations. Borderline cases, neuroses or psycho-neuroses, may go either to general or special hospitals, or to outpatient centres or as voluntary patients to mental hospitals. Mentally abnormal delinquents are dealt with by the prison authorities. This
voluntary
of statutory bodies has its parallel on the side of The After-Care Association deals with discharged patients
multiplicity effort.
limited extent, with what is called pre-care. The Central Association for Mental Welfare is primarily concerned with mental defect, but in many areas acts as agent for the After-Care Association, besides dealing with
and,
to a
boarding out and organising training courses. Boarding out is also dealt by guardianship societies such as The Guardianship Society, Brighton. Child guidance is organised by the Child Guidance Council, but the problem of the difficult child also comes within the province of the Home and School Council. Borderline mental cases are dealt with by organisations such as the Tavistock Clinic, and the mentally abnormal delinquent is dealt with by the Association for the Scientific Study of Delinquency. All these organisations are concerned with separate bits of work in the field of mental hygiene, It is not and all are competing against one another for public support. which and the that are that the confused, support they give public surprising is generally quite inadequate. But the point I want to stress is that there is no co-ordinating authority. There is no statutory body able to survey the whole field and frame a comprehensive programme.
with
that the different classes I have mentioned need to be handled in different ways. Mental disorders, for example, call for active remedial treatment. Mental defect calls for training and occupation. But the difference in the methods applicable to different classes should not be allowed to obscure I
recognise
the fact that all
are
forms of mental
abnormality.
Imagine the result of principle, to physical
same principle, or rather absence of Suppose there were different committees of local authorities, or different voluntary organisations dealing with rheumatism, tuberculosis, heart diseases and surgical cases. The absurdity of such a position does not need We need to look at mental abnormality as a whole. All to be emphasised.
applying
disorders.
the
96
MENTAL WELFARE
these different sections form part of the general problem of mental hygiene. The essential unity of the problem has been obscured in the past by too much concentration on end results. This has led to the apportionment of duties on the basis of the type of institution suited for cases demanding institutional care.
the
We
cannot
neglect
end results, but
we
ought
to pay
more
attention
to
beginnings.
If we are to unify control, there must be a simplification of administrative machinery. There should, in my view, be a mental health committee charged with the general oversight of all forms of mental health work. Such a committee would be able to define the provinces of municipal and voluntary effort. There is ample scope for voluntary work in mental hygiene, but voluntary organisations need to be linked up by some co-ordinating authority if overlapping and competition are to be avoided. I hope that the Feversham Committee's long-awaited report, which I understand is soon to be issued, will show how this
can
best be done.
One obvious
advantage of such a co-ordinating committee would be that of institutional accommodation could be viewed as a whole. At present it is far too common to find mental defectives, many of them children, who because they happen to be certifiable under the Lunacy Acts are allowed the
problem
to occupy valuable mental
hospital
which would of
beds.
This is not because of any superjustify their treatment in mental
vening psychosis, hospitals, but simply because the mental deficiency committee has failed to provide proper accommodation of its own either in colonies or in adapted public assistance institutions. This is a waste of hospital beds and it is unfair to the other patients; it is unfair to the nurses who have not been trained in mental deficiency work, and it is unfair to the defectives themselves because they cannot get the training which they need. This is merely one illustration of possible improvement in administration. But a far more important result will be to focus public attention on mental health. At present, because the work is sectionalised, no one is concerned with prevention. The visiting committee concentrates on mental hospital management, which is after all its statutory responsibility. The mental deficiency committee concentrates on ascertainment and on the provision of institutional care for defectives. The local education authority may, or may not, have a special school. Each committee thinks in terms of its own job, naturally and inevitably, since their duties and responsibilities are defined by It is no one's duty to ask whether anything can be done to save statute. cases from reaching a stage at which institutional care becomes inevitable. Child guidance, for example, or the problem of the so-called difficult child, is simply non-existent in many places and where, as in London, something is being done, the work owes its initiation to American philanthropy. But if a mental health committee is to function effectively, it will need a specially trained executive officer and adviser: in other words, a medical course
MENTAL WELFARE officer of mental health. for this officer, because
I want to
the need for
special training as it is, is hospital, not enough by itself. I have the greatest regard for mental hospital doctors, but they necessarily think in terms of the major psychoses and their tendency, naturally enough, is to want to bring the cases into hospital rather than to keep them out of hospital. An adequate training in mental hospital work experience
emphasise
97
in
a
mental
essential
is essential because the medical officer of mental health must have a sound clinical background. But he needs much more than this. He ought to be familiar with modern methods of psychotherapy. We want to develop out-
patient centres, and to do much more in the way of treatment there instead of making the sessions so few and so short that little can be attempted beyond diagnosis. He ought also to have experience of child guidance, and he should co-operate with the school medical officer and with the teachers, who
can
signs of mental abnormality far sooner than anyone else. It is equally important that he should have had some experience in mental deficiency work, and a knowledge of modern methods of training. I admit that this is asking a great deal. These Admirable Crichtons do not exist to-day, but they can be trained when the need for them is more generally recognised. After all, the training of the M.O.H. has only developed gradually. Now in the bigger cities and counties we have a body of men with an all round training in public health and preventive medicine unsurpassed anywhere in the world. But this is not the task of a day or of a year. I am not talking of what is immediately practicable, but of the goal at which we ought to aim.
detect
If only committee, the
vast
measures.
It
will
we
can
concentrate all aspects of mental health work in
one
the public conscience and make people realise may social importance of the problem and the need for preventive It will cost money, of course it will, but think what it might save. we
take
arouse
time; amending legislations will be needed; long-standing
professional rivalry and vested would be too depressing if we mine, job, limited our thoughts and aspirations simply to our day-to-day tasks. Nothing of what I have outlined is impossible. It may be difficult, indeed I know it is, but it is in no way impossible. Is it just a dream? I think not, but even if it is a dream, I make no apology on that score. If it is a dream, surely it is one worth dreaming. In mental health, perhaps more than in any other sphere, it is true, literally and terribly true, without a vision the people perish."
prejudices
will have
interests faced.
But
to
our
be
overcome
and
yours and
"
