Some Lessons of Wartime Psychiatry. II
- Author:
Kenneth Soddy, M.D., D.P.M.
Medical Director, National Association for Mental Health In the previous issue the work of psychiatrists in the services was described in order to apply the lessons learnt there to the problems of peacetime reconstruction.
Psychiatrists made a distinctive contribution to the work and life of the armed services in addition to the traditional role of treatment of mental illness by furthering a positive mental health policy, by selection, elimination of the unfit and by advice on leadership, on the handling of men and on morale. It was quickly realized that psychiatry would not do its duty by the service if it merely provided treatment for the mentally ill. Even if successful, soldiers so treated are of limited use subsequently and the time consumed in treatment is uneconomic. These considerations placed prevention of maladjustment at the top priority for psychiatrists, and although this is a break with the tradition that the patient must take the initiative in consulting the doctor, it does but follow the precedent so successfully established by the Public Health Authorities. The aim of prevention of mental ill health led straight to the investigation of the factors producing it, to study of the raw material of the army and the way in which the service treated this material. The most important objects for study were the fitness by personality and past experience of the individual for the role in which he was cast, the quality of training, the leadership, the indoctrination of the soldier and the foundation of good morale. These studies represented a very practical application of the principles of preventive psychiatry. In order to undertake the above studies and practical duties psychiatrists became much more closely identified with army life than would have been the case by the mere provision of psychiatric hospitals and special clinics.
They were established as officers within the military hierarchy, and were concerned with anything affecting private or public mental well-being. These officers were not attached to hospitals, but had their main linkages with the various military formations in their sphere of operations, where by the use of the appropriate channels of command much could be achieved in an authoritarian society. Some Differences between the Military and the Civil Social Orders
What worked well in the army may not necessarily work as well in civil life, for the army is a closely knit authoritarian hierarchy which exists (in time of war) only for the specific purpose of destroying the enemies of its own society. It is, therefore, a group within a group, charged with particular functions, and apt to be narrowly intolerant of the larger issues confronting the community proper, because of the peculiar psychological strains of its own function.
This authoritarianism does not rest only on traditions handed down from an earlier social order, it is also the dynamic result of at least two strong psychological forces. First, entering the army involves the recruit in a clean break with his civilian past. Henceforth the army is his life, his emotional ties with his past life are largely severed and those with his family considerably modified. That this is interpreted by the individual as a dangerous threat to the continuity of his personality is suggested by the boredom, the emotional emptiness of the recruit’s early days in spite of the novelty of his life. It is remarkable, however, how quickly this disinterested and rudderless phase is followed by one of identification with an idealized father figure, in this case the authoritarian society ; and so the mutilated personality finds itself again. Secondly, when the recruit embarks on the career of licensed homicide for which he is trained, not only is he exposed to danger, injury and death, but also to blood guiltiness. A strong father figure now becomes doubly necessary, the organization which punishes him as severely as this must also protect him not only from destruction, but also from his own guilt. Hence the preoccupation of the army with welfare and day-to-day care of the soldier, the development of the strong fraternal spirit of comradeship, and the deep dependence of the soldier on his organization.
The authoritarian character of military life is therefore a natural development mainly growing out of the dynamics of the situation, and being all pervading affects the military psychiatrist equally with other officers. He is inevitably invested to some extent with the attributes of the fathersubstitute, independently of any individual transference. In other words, the soldier expects, needs and looks for the type of ” directive psychiatry ” which the army provides.
On the other hand civilian society normally has none of this special mission and, with an intimate personal tradition handed down the generations, it is more stable and can survive with a far less degree of rigid organization. The civilian is & the same time more individualistic, more matur6 emotionally, and more firmly embedded in tradi’ tion than is the soldier. Being a member civilian society for his whole life he is also more deeply affected by changes therein. Love and hate are not organized and directed on to specif^ objects as they must be in the fighting servicesThe adult civilian must deal with his emotion3’ problems himself and cannot pass them up for solution by higher authority.
Father-substitutes in civilian life are many and varied, there is no over-riding intimate homogeneous personal loyalty except at the remote distance of the state itself. So that with civilian society a man can be in it but not of it, and the community will not feel menaced ; eccentricity and exclusiveness can be tolerated. It is not so in service life where a soldier who fails to identify himself with the group becomes a menace to the Security of the whole, and, as stated in the previous article, has to be disposed of. By discharging maladjusted soldiers to civil life, with severed ties and with no alternative attachments formed during service life, the services have contributed, though unwittingly, to the psychological problems of the post-war period. In addition to this emotional dislocation, such men have to re-establish their ties, only to find that they, their families and the environment have altered meanwhile. Moreover there can be no future discharge from civil life into some other body, this easy solution of the problem of the misfit is denied to a permanent society, which must absorb and carry its own misfits.
Some segregation is in fact attempted in civil life, mental defectives go to colonies, psychotics to mental hospitals, neurotics to various private homes and communities, psychopaths when delinquent go to prison, but only a very small proportion can be permanently excluded from society. That segregation is not the final answer to mental ill health is obvious because the discharge rate of Psychotics from mental hospitals is now 70 per cent. of the current admission rate ; nearly all neurotics and criminal psychopaths return to circulation sooner or later, and 80 per cent, of mental defectives are never effectively segregated. Common responsibility for these human beings must be recognized whether they are segregated ?.r at large. The future life of the misfit in the civilian community constitutes one of the main challenges to mental health work.
The Place of the Psychiatrist in Society It has been claimed that when a service psychiatrist }as effective it was mainly attributable to his identification with the organization in which he served. He shared the life, fitted into the autocracy and adapted his methods to those of an authoritarian paternalistic society. Surely the same Principle holds good for civil life, a psychiatrist ?ust adopt protective colouring and fit easily into me general structure.
. It is undoubtedly true that the psychiatrist in civil life is still thought of by the community as a J^an apart. He has the reputation of sitting in Judgement on his fellow men and of being preoccupied exclusively with morbid reactions. It is now being proved that this can be overcome by adapting the psychiatric service to the structure of society, but civilian society is so vast and so complex that it is difficult to know where to start. The mere establishment of a large number of regional psychiatrists at a fairly high level in the public health services, will not necessarily provide the answer, unless the officers concerned manage to establish the closest possible relations with nonofficial society. The creation of a race of psychiatric super civil servants enjoying wide administrative powers would doubtless do well enough in a bureaucratic society, but British society is not entirely bureaucratic, at least not yet; Regional Commissioners of this and District Controllers of the other have not up till now been noted for their close contact with the community which they serve.
The Shape of the Future?a Social Service ? A psychiatric service, if based on wartime experience, would need strengthening on the social side ; it is possible that it should even be based on social service and that the clinical and curative measures should be regarded as ancillary. An eminent trans-Atlantic psychiatrist lately remarked that even if there were 200,000 more psychiatrists all engaged on treatment in the United States they would still be unable to cope with neurotics and misfits as quickly as the combined forces of heredity and environment were producing them. The same holds true in proportion for Britain, and if the main answer is psychiatrically based social work (as many believe) it can no longer be the prerogative of a few charitably minded people, but must be a wide activity demanding a team comprising all those interested in humanitarian and social issues. In Dr Blacker’s Neurosis and the Mental Health Services, a list is given of eleven functions of the proposed Medical Officer of Mental Health. If he fulfils all these functions this official will have contributed greatly to the well-being of the community by dealing with psychiatric illness, ascertainment, community care of mental defectives, criminal psychiatry and delinquency, industrial psychiatry, special schools, mental health propaganda, surveys and follow-up. This is an enormous sphere of action in all conscience, and it is difficult to see how a member of the Public Health hierarchy can adequately combine all these functions in his own person, and especially the last three on the list. The Charter of the World Health Organization agreed to by 61 nations defines health as “a condition of complete physical, mental and social well-being, and not merely an absence of disease This wide definition demands a broad view?the establishment of well being and not, primarily, the tackling of disease. As with the army at the outbreak of war the problems of mental ill health in civil life are too vast and pressing, the resources too limited, to admit of a laisser faire policy. The atomic bomb bogey hangs over us, the urgent need is to improve the state of mental health of mankind before it is too 68 MENTAL HEALTH late. Can there be any higher priority than this ? Our chief contribution naturally lies with our own people. Are we right in attempting to build up our clinical and treatment facilities and allowing social provisions to grow out of them ? Or should we concentrate on social work based on sound psychiatric foundations and build our hospital services and treatment facilities thereon ? Provision of the latter depends largely on sense of public urgency and there could be no creator of public consciousness more effective than a good social service of the type projected. It is submitted that a case can be made out for concentrating on the social aspects of a proposed psychiatric service, and by this is meant a comprehensive service of which psychiatrists will be the clinical directors and the main work carried out in the community by psychiatric social workers and their assistants. As remarked above psychiatry is already greatly oversold, and the claims made for it, now conceded by the public, cannot be met adequately for many years. But in the building up period, a strong psychiatric social service would make a positive contribution to health while acting as a stimulant to complete evolution. The Social Effects of Psychiatric Illness The provision of psychiatric hospitals and outpatients clinics is certainly of very great importance but it does not go to the root of the matter. Psychiatric illness when it occurs in a home strikes a more intimate and deeper blow than can be parried by giving only the patient special treatment. It undermines security, creates tensions, and arouses fears in the minds of all who have an emotional relation with the sick person whose cure, even if achieved, will not automatically dispel the unrest and disquiet which has been aroused. This is now recognized by very many people and has led to the appointment of psychiatric social workers at many clinics. These workers do an invaluable job in attempting to deal with the family and domestic problems arising out of psychiatric illness, but it seems doubtful if the fullest potentialities of psychiatric social work can be achieved in close identification with the clinic and all that means in terms association for the patient and his relatives. The Services’ After-Care Scheme Arising directly out of war experience the Services’ After-Care Scheme has built up a nation-wide system of intimate social work available to all those discharged from the Services with psychiatric illness. Lately this scheme which has now accepted 10,000 cases and operates from 15 different centres has become progressively more civilian in character. This is partly due to the fact that the erst-while soldier is now a civilian, and partly to the number of referrals and enquiries coming in from purely civilian sources, as people begin to realize what such a Service offers. This After-Care Service has had the usual difficulties in securing staff with adequate previous experience and also suffers from the general shortage of social and clinical facilities. The great burden of responsibility has fallen on to the psychiatric social workers, and it has not been possible hitherto to provide the everyday close co-operation with psychiatrists which a medical project of this sort requires. The appointment of psychiatrists regionally as consultants to this organization would immediately transform its whole scope and enable it to make a striking contribution to Mental Health. The position of these psychiatric social workers in the After-Care Scheme is in some ways analogous to that of the Area Psychiatrists in the army. The latter found that their main attention inevitably became attracted to attacking social and psychological causes rather than attempted patchwork on individuals. Similarly the psychiatric social worker finds herself or himself enquiring more and more into causes, which itself involves (as in the army experience) closer and closer identification with the community in all its daily ramifications. A Social or a Clinical Service ? In the proposals for a National Health Service there is some danger that in the interests of organization, opportunities may be missed of creating the most effective instrument possible for the furtherance of Mental Health, by regarding social work as merely an adjunct to clinical treatment. It is a natural stage in medical organization that the central point should be conceived of as the clinic or hospital, from which all other services radiate? a conception inherent in the current practice of controlling all medical education from hospitals. The question to be asked is whether this should apply also to Mental Health Services, or whether it is possible to devise a method whereby those in need of help can consult a community service which can take responsibility for the case before special treatment is necessary (if this be possible) and retain contact until assistance is no longer required. Special hospital and clinic treatment under such a system would be a derivative of the organization and not its central point. If this idea were accepted we should need to face certain differences of emphasis discernible between the needs of an organized clinical service and those of community care. The former must be integrated into the general hospital system of the community. It is not desirable to have psychiatric clinics divorced from surgical, orthopaedic, medical, children’s and tuberculosis clinics or any others. Medicine has been all too prone to accept arbitrary divisions based on textbook pathology which make for ease of hospital organization and economy of equipment but have the weakness of sending the patient from clinic to clinic. Such a system is confusing to patient and doctor alike, and the Mental Health Service must avoid this error. ? MENTAL HEALTH 69 A Suggested Form of Psychiatric Service Plans so far made public indicate that the National Health Service in the mental field is designed to provide a nation-wide clinical system of special hospitals, out-patients clinics and their derivatives. Community care is to be the responsibility of the local Health Authority as part of its general welfare functions with due provision for the co-operation ?f social workers based on clinics in suitable cases. It is argued here that it would be a better arrangement to make the division of responsibility in a different place ; to take a much broader view of the social or community aspects and to organize a nation-wide social psychiatric service under the general supervision of psychiatrists which will take wide responsibilities for mental health. This service active in health and disease will send patients to its sister Clinical and Treatment Service (which ?f course is no less important), and then later in the history of each case, take it back for after-care and prevention of recurrence. But whereas the Treatment Service is more within the traditional Medical field, the Social Service is somewhat of an innovation. The Clinical and Treatment Service The special administrative requirements of the elinical service must not be under-estimated. Psychiatric hospitals need a certain scale of equipment and premises, only understood by specialists. ^.Uch an organization lends itself to the creation of a hierarchy. It will not be difficult to introduce at an appropriate level in the National health Service administrative medical officers Responsible for the organization of psychiatric ‘eatment facilities. In parenthesis it is observed that no large ^ganized medical service has yet solved the proems raised by the fact that the more senior appointments inevitably become administrative ; t is very rare for a doctor in public service to attain a senior position and yet retain active clinical 0rk. Such a system puts a premium on unnthusiastic doctoring, encouraging a flight into oministration?a less disturbing, worrying and ^acting task than the care of patients. This endency does not lead to high morale within the ervice. It is a problem which must be solved ejore the National Health Service will be a success. The creation of a chain of command within the Psychiatric treatment service presents no special ‘hiculties. Professional staffs need control, ?spital property must be administered, patients ,e bound by the terms of treatment to conform rules, and provided the essential doctor-patient tationship is safeguarded, there seems no reason % an organized service on a normal service Pattern should not function smoothly. But if t stops there and treats the social aspects of its Vn f-as secondary to the treatment of disease it 111 fall far short of what is required. (b) The Psychiatric Social Service The National Health Service includes Mental Health. It is suggested that top priority be given to the creation of a really adequate psychiatric social service for the community in the homes, factories and schools. Such a service, although not undertaking remedial treatment itself, will be in close touch with the therapists, and will act at all times as a social agent to implement recommendations made in the clinics. It should provide a medium of stable friendship available to all who need it; neurotics, psychotics and psychopaths are essentially lonely people whose contact with their social environment is poor. Armed with its knowledge of the patient and of local conditions, such a service could participate actively and indirectly in negotiations with employers, Government departments and with other social agencies, with the object of explaining both sides to each other. Maladjusted people have peculiar difficulty in making themselves understood, and the education of officials and employers alike in the particular needs of this class of person is an important function. In the role of adviser and mediator this service will make the positive contribution of finding suitable places in the social system for many who are a social problem at present. Secondly, such a service will have an unrivalled opportunity for undertaking public education in the interests of mental health. Just as the Health Visitors and District Nurses in their different ways exert a powerful influence through their personal contacts; so the psychiatric social worker will have equally good chances of being a real power for good. This will supplement present propaganda methods of lectures and meetings which never have more than a superficial effect. There are also challenging possibilities of research into social causative factors of mental ill health which these workers will be able to take up. Thirdly, this Service can make a direct contribution to the morale of the community, both by solving the problem of the misfit and by its ability through its close links with the neighbourhood to discover causes of friction and unrest and of making concrete suggestions. It should command the confidence of dissatisfied elements in the community as well as the respect of the majority, and will be in an unrivalled position to carry out surveys, enquiries and social experiments into the causes and effects of diseases, disabilities, popular movements, prejudices and cults; many and varied problems of interest to physician, sociologist and politician alike. Rehabilitation is a fashionable term at present. Eradication of the last effects of illness and reestablishment of health must include attention to the mental attitudes which have arisen during illness, not only in the patient but in all his human contacts. Industrialists are all too prone to think of a man as so much production; doctors see him as a background to a disease; social workers as the possessor of an economic or domestic problem. 70 MENTAL HEALTH The army has known for many years that when the soldier enlists the entire family enlists too?or does so in effect. Similarly the entire family is involved in illness; so that the modern conception of psychiatric social work must be far wider than the present orthodox practices in follow-up, aftercare or convalescence; it recognizes the necessity to mobilize the entire family in the active pursuit of health, the finest form of insurance against future breakdown. The Type of Organization Required Arguing from experience, the officers of the future psychiatric service will need to be more intimately concerned with the daily life of the ordinary man than is likely in a service with a hospital or a centralized type of organization. It will not be sufficient to give the Medical Officer of Mental Health an office in the local County Hall or Regional Board Headquarters, and to identify him completely with the Government. He will not do his best work by controlling his patients. If he is doing his work properly they will consult him as free agents at a stage when there are still many alternative courses of action to be considered?not at the last moment when hospital treatment is the only possible course left. He must not represent the government ?or any other institution. He will measure his success by his degree of identification with the people. For similar reasons it would be wise to avoid too close identification with hospitals and clinics, because it will take some years yet for the public to accept mental illness without nervousness. The present reaction of the public is still mingled with fear and hostility, the wish to segregate, or in other words to deny its existence in ordinary life. Whatever may be the ultimate ideal, at present close association with hospitals will hamper the psychiatric service in gaining the complete confidence of the public. While the treatment service can be organized on a normal pattern within the general provisions this should not form the main pre-occupation of the Medical Officer of Mental Health. To be sure he will need to work in closely with it and exert an influential advisory function, but he should have ample responsibilities in the social field to extend him. Since from the very nature of his work he can rarely issue orders and has no legitimate means of enforcing compliance (except extreme legal sanctions) there seems little point in granting him a high place in the direct chain of command of the total Health Service. This argument does not constitute a plea for an entirely independent status because he must obviously be very closely responsible to the community he serves. According to this view his main task is the organization of a community psychiatric service, in which psychiatrists, psychologists, psychiatric social workers, sociologists, and teachers would co-operate with general practitioners and with psychiatric clinics. The aim is to provide as a permanent feature a service able to accept responsibility for the well-being of all who need psychiatric help. It should be able to ” take on a case ” and keep in touch with it, and with the family during the whole of its career until a settlement of the problem is reached. At different phases, clinic or hospital treatment can be arranged, or the Ministry of Labour contacted or many other services given designed to aid recovery, but the Community Psychiatric Service should be, as it were, the sheet anchor of the case. This does not deny the right of the general practitioner to deal direct with the psychiatric clinic, or of the latter to conduct its own social work on its active cases as the clinical situation demands ; obviously close co-operation would be essential and in many areas interchange or even sharing of part-time personnel would occur. But if it is accepted that in any case of psychiatric illness not only the individual but also the family and the social group is affected, it is logical to provide the main service to give over-all cover and to have clinics and hospitals as a special technique ancillary to the social service. Naturally, a central organization will be necessary as it it will not be possible for local bodies, especially in the early stages independently to judge quality of work or policy. Supervision of standards of employment of personnel and co-ordination between districts will be unavoidable. But the Medical Officer of Mental Health should be directly responsible to the community which he serves, which could be represented by a Mental Health Committee. The possible advantages of making these committees voluntary rather than administrative bodies are for consideration. The finest organization would be defeated if it is not accepted by the public and it is therefore important to make the greatest use of all available assets and to build on existing goodwill, rather than attempt to organize a new scheme from scratch. In the present services’ after-care scheme there is a nucleus readily capable of expansion, and it is to be hoped that full advantage will be taken of this in the immediate future. Later on the work can be transferred to the appropriate local bodies as the latter become ready to undertake it, if desired. In this way sturdy growth and continuity can be assured. This projected Mental Health Service, to be a success, must stand on its own feet and be built up by the community as an organization belonging to them, whose services they can command and whose activity they can control. It must avoid the label of too great officialdom, it is not there to serve the interests of the National Health Service as a whole, nor to foster the cause of psychiatric hospitals and clinics. It has no concern with the efficiency of either of these for their own sakes, but it is deeply concerned with the complete physical mental and social well-being of individual human beings and of the families to which they belongOnly on such a basis will the community psychiatric service of the future reach its full stature.
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