Isabel G. H. Wilson, M.D., D.P.M
Some men and women keep a marvellous fresh interest through all the fortunes of institution work, whether that ” institution be a solitary small house for four or five imbecile children or a great establishment for two thous- and souls or more. Others, less resilient, sink into discouragement, com- plaining of the monotony of a life which may, like the moon, show the same face through all its phases; of the physical stress of a hundred duties and of the heaviness of ambition blocked or hope deferred. Such are the troubles which may appear; troubles which do raise their heads also in other places, if the truth be known. There are many jobs which are beyond comparison more monotonous, more wearing and more limited than the job of the worker in the institution for those of defective or unsound mind.
The following suggestions on keeping interest alive are offered mainly as gleanings from the active people mentioned above, whose vitality is a per- petual inspiration. I do not refer specifically to interest in the individual because though that is the mainspring of enjoyment in institution work, it can- not be fostered on paper. It is a practical business, to be learned among the patients. What is put forward is a series of rather disiointed remarks upon various angles of approach to the work, in the hope that one or another of them may fire the train of interest for somebody who has begun to feel bored and hampered.
Hospital life for the patient is a big problem; too big to be tackled here, since any discussion of the avoidance of monotony and boredom raises the whole issues of psycho-therapy, physical therapy, occupation therapy, library work, games and entertainments, clubs, debates and the visits of friends. It may be worth while, however, to touch in passing upon three items in the direct effect of institution life upon the patient, referring, for the moment, to the insane patient.
First?How much is the severity and permanence of the illness due to the tendency of the patient himself to turn away from the friendly activities of reality and lose himself in the solitary fastnesses of his own imagination; and in so doing, to welcome the shelter offered to him? An American writer1 remarks: ” It is very striking how much more composed and amenable to explanation and conversation many patients are just on admission than they are only a few hours or a day or so later, especially if there is any tendency to mutism and confusion.” We may take it that the patient who has struggled painfully to maintain something like a conventional response to the goadings of the outside world, seizes firmly, if unconsciously, upon the opportunities offered by a hospital environment in which he may subside unreproached into complete silence or give free rein to any nonsensical whimsy that crosses his mind. We may take it too that this release from the control of convention is often a good thing because it offers a safety valve for the escape of emotion and of repressed tendencies which can no longer be tolerated without breakdown.
Hence the second point arises?Assuming that the turning away from reality is for the moment useful, how long may that moment last? When does the health-giving release of ” acute ” insanity slip over into the morbid habit of ” chronic ” insanity and what can be done to seize the patient at that turning-point and try to draw him back into a world of fact and action? The third question is rather different?What is the effect of group life as such upon a patient who has hitherto lived a family or a lonely life? Getting up in a crowd instead of alone; sleeping in a dormitory instead of in a room; living regular hour after regular hour in a place where group activities go by clock-work, in spite of individual vagaries. What difference do these things make to this patient or to that?
These fascinating topics must be left undiscussed because the discussion of them would burst all reasonable bounds of space. We must return to the worker, whose problem is not so complicated, though it is just as important. The facing and acceptance of the fundamental tragedy of severe mental illness is a first essential. This is a thing which lies very deep, below all the activity and variety of hospital, and below all the contentment of the patient. It is the onlooker rather than the patient who realises the trouble; it is not the imbecile happily marching a clumsy baby march or the manic patient singing lustily who know that there are other folk who hold better cards in the game. But the nurse understands these things, and from the very beginning, she must assimilate that knowledge. That there is pain and trouble in the world must be admitted and that the worker among mental illness has chosen to go and live in the midst of it must also be admitted. No hospital is a fair sample of the world; it is, essentially, a sample of its sorrows, though every patient cared for in hospital means a home freed of a great part of its anxiety and stress. Nevertheless, the nurse here must come to terms with the fact of mental illness, just as her sisters in other work must come to terms with the harsh facts of poverty, unemployment and physical illness.
Fierce war must be waged with these evils by any who can see where to attack and strike home?but the case will not be helped by mere regret, by mere wishing that the world were otherwise, or by sinking into distraught and helpless sympathy. The problem of evil is not confined to hospitals for the sick. There is hardly a poet or philosopher who has not wrestled with it? Goethe2 with his ” Entbehren sollst du,” and Carlyle3 ” What law was there that thou shouldst be happy? ” There is scarcely a thoughtful man or woman who has not plunged into the deep abyss of?Why??Why??and come out again with the question still unanswered, bringing at most a conviction that there is an answer somewhere. I have dwelt at some length on this side of things because the young probationer may be sharply brought up against it for the first time when she takes up work, and must come in the end to the only solution?Here is this world. It is as it is. Let us make the best of it. This is after all the only way, though it may be coming perilously near the attitude of the heroine of an old story told by William James.4 The lady, who was a preacher, said, ” I accept the Universe! ” When Carlyle heard of it he said, ” Gad, she’d better!
Next, an item not so much for the beginner as for the older worker?the avoidance of physical over-strain. It is important that she should live within her reserves of strength. Just as bad headaches after concussion are cured by rest, beginning activity at nil and increasing it gradually, always stopping short of pain; as strength is gained in heart weakness by slow ventures in exertion, always stopping short of fatigue; and as a good sauce is made by drop-by-drop additions, always stopping short of lumps; so the best work in institutions or anywhere else is that which is done with a margin in hand. Every worker, particularly if she is ” not so young,” should find the level at which she can live without exhaustion, and keep within that. She may smile a smile if she reads this and say, ” It can’t be done.” But I say most respectfully, ” It can.” If she had mumps, or a son at school, or a new ward, she would assuredly curtail her present activities to leave space for these others; if she can do that she can now cut down her work so that what she does may be done with a sparkle and enjoyment that will make the results quite different. While on the topic of health I should like to mention a few more aids to energy?relaxa- tion of muscle except where muscular contraction is really useful; lying flat and quiet if possible in the interval between work and play, and putting off working clothes with working hours and wearing instead something not necessarily greater in price or less in extent but different in colour, texture and fit from that of daily wear. Such change is heartening to woman-kind and I cannot but think that if it were the fashion for men to wear crimson plus fours, or trousers of gold and green with coat and waistcoat to tone, they would get joy of their change also, like spring peacocks.
Routine comes next on the list, a dim Angel to whom it should be said, ” I will not let thee.go except thou bless me.” Routine must be mastered? there is no other way. The waste and discouragement begin when there is continued skirmishing and no decisive battle?when the struggle for order and cleanliness, for instance, occupy the whole energy of the worker. Such a shocking state of affairs can only be justified when the worker has inherited some establishment where slackness and neglect have flourished, some Augean stable which must be cleansed. Then indeed there is nothing for her to do but take her seven maids and seven mops and sweep it for half a year?prob- ably to the complete eclipse of the broader view. In most circumstances, however, routine should roll along with a smooth momentum of its own; the running of the under carriage that the whole may rise. School time-tables, planned diets, turned-down beds, weight charts, clothes lists?to choose from the domestic side for our examples?put so much oil in the wheels that it is sad to think of any experienced worker taking routine as the beginner perforce must do?i.e., thinking afresh every day on things which should run almost of themselves, needing guidance only when they threaten to go wrong.
It is convenient here to mention interests outside work. They are valu- able because they are in themselves delightful, and because the worker who acquires a new set of interests and accomplishment becomes to that extent a new person, and more than ever companionable in her job. Moreover, know- ledge of any subject of general interest is a useful coin in social exchange? something to offer to the stockpot of common conversation. I have known two workers who each privately labelled the other as dull, without any thoughts outside the daily round. Both were thirsting to receive stimulus and amusement but neither had thought to spend time in cultivating anything to give; they had not developed any medium of exchange. I would particularly suggest to the worker who has times of leisure short or long spent in the institu- tion, that she should set to work to learn about something or to learn how to do something new. The possibilities are endless. Drawing, painting, beauti- ful and fine embroidery; the learning of a language or of poetry; correspond- ence classes as advertised in any magazine for those who want a lead; music, sport, dramatic work, gardening, or hiking for those who have opportunity. The student should stick to the chosen subject with determination and energy until it has yielded something solid to her.
” There is no time?there is no strength for it,” says the busy one. All the strength that is needed is strength to disregard the recurring reluctance to begin a task that will certainly seem a forlorn weariness to the flesh at first, but before long will be a habitual joy and recreation. All the time that is needed is a few minutes, every day. But it must be every day. Ten minutes every night between getting into bed and putting out the light, with a book of poems, and at the end of the year the worker will have a corner of her mind full of lovely phrases and rich thoughts. Ten minutes every lunch-hour with a pencil and a sheet of drawing paper, and in time she will look at posters with a new eye, realising the skill that goes to suggesting the live curve of a blade of grass or the mild folds of a piece of tape. I do not mean that the drawing of the amateur who draws for ten minutes a day will necessarily be valuable or interesting in itself, though it may be both. What I do maintain is that the thoughts and observation of the sketcher will reach out in new directions and enrich her whole outlook. If the worker can give an hour a day to her ” recreational work,” she is rich in opportunity. The important thing is that the worker should really want to tackle the new study?but it may be sug- gested that if she would like also to find it of use in future holidays, work, or friendship, she should choose something which has some sort of link with one or other of these. The knitting of innumerable identical socks for no particular person or the study of Ogham or mediaeval Dutch may be fascinating occupa- tions in themselves but on the face of it are hardly likely to form the bridge desired between the worker and her acquaintances. Perhaps I might suggest also that a very modest beginning should be made. An ambitious plan is apt to over-reach itself. However, let the worker study something, golf, bees, smocking, Esperanto?but something. In weariness and time of trouble a bit of work of this kind will be a great refuge and comfort.
Within the institution there are a dozen lines of thought which may be pursued. A study may be made of the patient’s point of view, pains taken to learn what the patient thinks of life and to read some of the books written by patients. Or the broad organisation of the profession can be considered in the light of the conditions in that profession in the particular institution in which the worker may be. As far as nursing is concerned, for instance, consider the Final Report of the Lancet Commission ‘ on nursing. In one of the London hospitals each section of that report was studied by a group of nurses, findings were pooled, and opinions quoted by a nurse herself at the Agricultural Hall meeting. Should men and women have equal pay? How should hours be arranged? Is the profession sufficiently interested and articulate about its own needs? Is the training what it should be? These questions may be con- sidered in relation to any branch of institution work, medicine, teaching, occupation work, domestic, social work, mental nursing and mental deficiency nursing. In such a study careful notes should be kept of every detail relating to any points raised and comparison made with other professions and other countries. After a year of this the worker may be overworked but she cannot be bored!
Then there is the national and international point of view. Who really does support the defective who happens to be born in a shiftless family? What is the relation of mental institution work to the health and happiness of the community? If you could sterilise by magic, upon whom, within your own knowledge, would you exercise your gift? If you could sterilise by law, how many of the parents of your patients would or could you sterilise, if your power to do so depended upon your ability to carry local public opinion with you in the case? These things can be thought about in full and careful detail in relation to every patient and patient’s family in the institution. By the end of her study the worker may not have solved the problems raised, but she will begin to grasp the size of them. As to the international point of view, think for instance of the London hospital afore mentioned which is said6 to make a practice of taking one coloured student nurse every year, and to find the plan successful and of our own mental hospital which regularly takes students from Scandinavia. There are endless questions on methods of dealing with defec- tive and insane persons in various countries, the study of which would be of great interest to the worker here.
Other and perhaps less complicated lines of special work may be taken up?the study of Girl Guide movement in all its branches and ramifications as they apply to or differ from the movement as used for defectives, the study of library work, book-binding, cataloguing, selection and care of books them- selves, the study of movement and gesture in the insane?to mention a few at random.
Research cries out for the keen worker. What is the baby-hood, pre- school, school and after-school history of schizophrenics? Are ambivalence, a desire to punish, and other factors suggested by Freud7 true of the melancholic? Can a history of prolonged and anxious attention to a disliked task, followed by a sudden release, be traced in manic patients as it was in Pavlov’s8 dog, who became manic on release from his harness? Is the hyperglycemic index one of the really useful criteria of fitness for discharge, as suggested by Quastel?9 Non-medical readers must please forgive an excursion into the medical field, this time, for primroses along the flowery path to enjoyment of institution life. Let me list one or two aids to the pursuit of the interesting.
1. The letter of enquiry and exchange. Any expert welcomes letters of enquiry provided that they are reasonably brief and come from people who know precisely what they want to know and can ask it clearly. Letters of friendship and exchange of news between workers in different branches are invaluable.
2. The busman’s holiday. An occasional visit to see others at work at home or abroad is most refreshing and worth considerable cost in time and cash.
3. The card index, properly so-called?or a packet of cards in a box for a start. For detailed notes on the subject of special study. For example, the worker is particularly interested in weaving. Then under L will be notes on Looms?looms seen elsewhere. Looms?prices of looms, address of man who makes. Under D?Design?notes of article on; Demonstration?points noted at. Dyeing?information from Miss Snook’s letter on. Such an index is worth its weight in gold. Even ten such cards would be a very considerable help to the enquirer. The worker will soon learn to avoid the vague and badly indexed note?as ” Snooks, Miss?wrote to the vicar’s wife about dyeing. Verv interesting.” In a year the worker may never think of looking under S for her note about dyeing and she may well have forgotten what Miss Snooks wrote to the vicar’s wife.
4. The technical library. Every institution would be the better of a technical library for its staff. This would contain works of reference on lunacy and mental defect for the worker who might want to know some point or another on encephalitis or paranoia and what not; and any other kind of book which a generous committee, a grateful patient, a departing nurse or any one so inclined might give. Nursing, psychology, gardening, manual training, delinquency, alcoholism, community singing?here is another random list of some of the subjects which one or another would wish to read of and find useful. The library could be housed in open shelves if the workers were more than ordinarily angelic in disposition, or there can be safeguards such as a locked cupboard, a keen librarian, a notebook for entry of books borrowed and returned (to be initialled by the borrower)?and if necessary a deposit in cash to be refunded when the worker leaves, but forfeited if and when she loses a book. Books may be lost for all these precautions, but it is better that the workers should lose a book or two now and then than that they should lose heart.
Finally, I should like to say that these notes are offered with respect to those who are in the thick of work; and that I am grateful to many enthusiasts who have not only shown me their methods of work but have told me of all that they would like to do if they could.
Well may we feel that mental work offers unlimited and fascinating op- portunities, as Hokusai felt about drawing when he said: ? ” When I am eighty I shall know more; at ninety I shall have got to the heart of things; at a hundred I shall be a marvel; at a hundred and ten every line, every blot of my brush will be alive! References? 1 KIRBY. Guide for History Taking and Clinical Examination. New York State Hospital Press. 2 GOETHE. Faust, Part I. 3 CARLYLE. Sartor Resartus. 4 WILLIAM JAMES. The varieties of Religious Experience. Longmans Green. 5 LANCET. Report of Commission on Nursing. Lancet Offices, 7, Adam Street, W.C.2. 6 MANCHESTER GUARDIAN WEEKLY. March, 1933. 7 FREUD. Mourning and Melancholic. Collected Papers, Vol. IV. Psychoanalytical Press. 8 PAVLOV. Conditioned Reflexes Tr. Anrep. Pp. 398. University Press. 9 McCOWAN and QUASTEL. Blood sugar studies. Journal Mental Science, 1930. 10BINYON. Painting in the Far East. Arnold.
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