Some Reflections on the Report of the Royal Commission on Lunacy and Mental Disorder
By Evelyn Fox.
This Report has been awaited with great eagerness by all those interested in the mental health of the community and’ in the extension of the role of preven- tive medicine to the lield of mental nygiene, as well as by those whose interest has been specially aroused either on personal or general humanitarian grounds by the difficulties and dangers surrounding the compulsory detention of the insane.
Dealing with a subject surrounded by much ignorance and more misappre- hension, tne Commissioners Have produced an admirable Report reflecting the niodern and more enlightened views on mental disease, keeping a sane and balanced judgment between the claims of the individual and the rights of the community, inspired by real feeling for the sultering of the individual and of his relations, yet lull 01 practical suggestions which can be put into operation with comparative ease. Above all they nave emphasised, and in their ‘Recommenda- tions acted on, the basic principle that ” there is no clear line of demarcation between mental illness and physical illness, ihe distinction as commonly diawn is based on a ‘difference in symptoms. In ordinary parlance a disease is described as mental ii its symptoms manifest themselves predominantly in derangement of conduct, and as physical if its symptoms manliest themselves predominantly in derangement of bodily function, inis classitication is manifestly imperfect. A dental illness may have physical concomitants; probably it always has, though they may be difficult of detection. A physical illness, on the other hand, may have, and probably always has, mental concomitants. And there are many cases in which it is a question whether the physical or the mental symptoms pre- dominate ” (p. 15).
As the Report aptly puts it (p. 17): ” The keynote of the past has been detention; the keynote of the future should be prevention and treatment.” Ihe Work of the Chairman and his colleagues, unfamiliar as they probably were with many of the distressing features of mental illness, must often have been of a Painiul nature; the best thanks that we, who see in their Recommendations a Possibility of real progress in the near future, can give them is to help in every way to secure the passing of legislation on the lines suggested.
It is within the recollection of most of us that legislation based on the Recommendations of the Royal Commission on the Care and Control of the Feeble-Minded and the Committee of Inquiry on Venereal Disease would ha/e been seriously delayed if active societies had not been formed to press for legisla- tion and ensure the passing of the appropriate measures, and to assist in the administration of such measures by practical organisations. It may be necessary again to take steps to arouse public opinion to demand that ihe Recommendations ?f the Commission be carried into effect.
I do not propose in this short article to cover the various recommendations included in the Report, as the notices, both in the daily press and in special periodicals, have been very full, but there are certain aspects of the Report which are of great importance to all those engaged in social work.
The problem which faces the social worker and all those whose daily lives bring them constantly into contact with the workers and their homes is the inability to secure early diagnosis and preventive treatment for those whose only hope of mental health lies in proper treatment at the earliest possible moment. Up to the present there has been a great dearth of hospitals and clinics under a skilled staff where such patients could attend. A glance at the very complete list of Clinics, etc., issued by the Board of Control in their Report for 1925 (p. 54), will show how few and how badly distributed geographically such clinics are.
The Recommendations of the Commissioners aim at meeting this long-felt want. The Report recommends a re-classification of cases requiring mental treat- ment into (1) voluntary, and (2) involuntary cases, with the extension of the Voluntary Boarding System on the general principles of the lines laid down in the Mental Treatment Bill. That is, that Voluntary Boarders be received in Mental Hospitals controlled by Public Authorities, and that, in addition, Local Authorities be given power to contract with General or Special Hospitals, Nursing Homes, etc., to receive early cases for treatment at the expense of the Authority.
Such cases would be admitted on their own written application (if under 18 on the application of their parent or guardian) and would be able to leave on giving 72 hours’ notice. If the Boarder should cease to have volition, to be able to express his wishes, he should be dealt with as an involuntary case. The above changes in the law would enable anyone, of whatever means, who was capable of co-operating to place themselves under the right treatment at the first moment that the need of such treatment was indicated. The power given to Local Authorities to pay for such cases, whether in Hospitals, etc., run by the Authori- ties themselves or in Hospitals specially approved by the Board of Control for the purpose, is of the utmost importance for all classes in the community from the point of view of prevention. Once provision has been made for early cases, instead of waiting for treatment till certification has become inevitable, each patient will be able to be sent to whatever type of place his medical man considers will give him the treatment requisite in his case. Involuntary Cases. Under this heading the Report includes both non-volitional and resistive cases where the prospects of early recovery are favourable, and they suggest a new form of certificate?the Provisional Treatment Order. This Order, they re- commend, should be made by a Justice on a Petition presented by a relative or friend, or officer of a public authority, and supported by one Medical Certificate. The Order would last for one month only, and at the end of that period, should the prognosis of recovery still be favourable, the Order could be renewed for a total period of five months, or the person might become a Voluntary Boarder.
If, on the other hand, the prospects of recovery within a short time were very slight, full certification should be resorted to. The patient could be treated under this Order either in a Mental or Registered Hospital, Licensed House, under single care, or in a General Hospital, Nursing Home, etc., approved for the purpose by the Board. In connection with the suggested methods of dealing with both types of cases the Commissioners have indicated that a wider range of institutions than Mental or Registered Hospitals or Licensed Houses is desirable, and they have stressed the need for the approval of the Board of Control of suitable General Hospitals, Clinics with beds, Nursing Homes, etc., for dealing with cases, and it is this possibility of more varied facilities of treatment which is of especial importance ‘n connection with the evidence given by the Central Association for Mental Welfare to the Royal Commission.
As our readers are aware, the Association gave evidence based upon the prac- tical experience both of the Central and of many Local Mental Welfare Associa- tions, ” 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 >et 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 banner to their surroundings, and who consequently are in need of supervision, training and treatment.” (C.A.M.W. Memorandum of Evidence, Paragraph 7.) the majority of such cases would not even come under the new definitions of the Rental Treatment Bill, for though their special form of mental disorder may be a condition of arrested or incomplete development of mind … induced a’ter birth by disease, injury or other cause,” yet it may not be of a permanent character. The Report refers to the cases in the following way:?
” Adolescent Cases.?It is relevant to mention here another class of case which might benefit by the extension of facilities for care and treatment with- out certification. Our attention has been drawn to the peculiar difficulties that arise in the case of young persons who develop symptoms of mental instability in the period of adolescence. Such cases often prove quite intract- able to home discipline and some of them ultimately appear in Court as young offenders. It is not improbable that this kind of case should appropriate!}* be provided for by some extension of the Mental Deficiency Act, but the extension of opportunities for treatment without certification under the Lunacy Act might afford timely assistance to some of these young persons for whom at present there appears to he no suitable provision.”
The concluding words (the italics are ours) give some indication that the onimission thought their recommendations for the treatment of cases without certification might provide help for such cases.
If the law recognised training homes for young people adequately staffed and I?.r the direction of mental experts, approved by the Board of Control, and to jch Local Authorities had the power (as for other Voluntary Boarders) to pay Maintenance grants for cases, we should at least have laid the foundation of an ?ghtened system of dealing with these most tragic borderland cases, the despair e of the medical man and the social worker. At present these cases drift from one unsuitable home to another, with periods of failure in the community toi which ey are temporarily unable to adjust themselves. No constructive effort has 1 nerto been made to give them the prolonged training and occupation in a right environment under medical supervision which they require. Till this has been ried, we can have no definite knowledge of the proportion who will settle down c Ho return to the outside world with every prospect of success. That some will never balance up and that other methods will be needed to assist them is clear, U there are sufficient indications in the desultory and disjointed efforts of the c s to encourage us to concentrate our efforts on securing assistance for these Ung people on the lines suggested by the Recommendations of the Royal n?mmission. No powers of detention are asked for, nor will they probably be tiji?essary in most cases; incidentally it would be unwise to press for such powers Practical experience has demonstrated the real necessity for them.
The Report draws attention to two forms of social service:? (a) the after-care of patients discharged from Mental Hospitals, with special reference to the admirable work of the Mental After Care Society and the necessity for developing the work still further in the provinces, and (b) the activities of friendly social visitors to Mental Hospitals, who serve as a link between the patients and the outside world.
The possibility of grants by authorities for after-care should greatly facilitate the extension of the work. It is to be regretted that no reference is made to the establishment of field-workers or social visitors in connection with all Clinics for mental patients; the link between the home and the Medical Officer which such a service gives and the infinite possibilities of helping the individual back to normal life which the trained and qualified social worker acting under the doctor can offer are not yet sufficiently recognised in this country, but reference to them would have been useful in drawing attention to the need.
The Report contains matter of great interest which has not been alluded to here?recommendations as to the re-organisation of the Board of Control, the simplification of procedure, the removal of the insane from the purview of the Poor Law, etc. It includes also a careful review of the present conditions of Mental Hospitals, and should carry re-assurance to those who have had doubts as to the treatment of patients. Whilst suggesting various improvements the Commissioners pay a tribute to the kindness and humanity of the Staffs in Hospi- tals, and their historical review fully confirms the improvements in the care of the insane. If the new suggestions made can be carried into effect, we should see not only a decrease in the incidence of insanity through preventive measures, but a gradual lessening of the feeling of horror with which insanity has been viewed by the general public.
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