Charles Davies-Jones
in anvsviumj
Medical Superintendent, County Mental Hospital, Newport, Isle of Wight. The Mental Treatment Act of 1930 differs in the mode of its application and interpretation from many enactments in that it depends very largely upon the initiative and goodwill of those who are able to co-operate in putting it into effect. It is hardly necessary to say that its provisions are of course statutory and it is equally possible to say that within a large measure they can be evaded. This possibility at first sight would appear to nullify the working of the Act but I feel that it is nearer the mark to regard it as a ” mixed blessing ” in that it allows much scope and latitude for individual effort and research. By the Act the law in relation to lunacy was altered and it became incumbent upon the existing ” Asylums ” to adopt and apply it. Its phraseology is concise and at the same time in parts cumbersome and therefore exposed to much destructive and even virulent criticism. It is conversely open to useful interpretation and application and under the latter circumstances brings about the transformation of an “Asylum” into a Mental Hospital in deed rather than in name only. Its application in a Hospital newly built in accordance with modern requirements and the Act’s provisions is comparatively easy as compared with the difficulties attendant upon introducing new methods into an old building hampered with the old-fashioned routine, discipline, and outlook of ” Asylum ” days. The problem is indeed that of ” putting new wine into old bottles”; but is it new wine? 1 venture to suggest that one may regard the vintage as matured but only recently rendered available for consumption, for many of the permissive provisions of the Act, as it stands to-day, had been tried out and not found wanting long before they were placed upon the Statute Book as for example, the out-patient treatment of early mental illness at the Radcliffe Infirmary, Oxford.
One cannot be expected to imagine that the Act is intended either to be incapable of amendment or unlikely to be so dealt with. Accumulated experience and research will render available to our law makers, in process of time, valuable information. As I have said scope is at present allowed not only by its permissive sections but also by the fact that they themselves inculcate the spirit of experiment. I propose in this contribution to outline some of the possibilities and experiments which have been carried out in an ” Asylum” where the desire to encourage any such effort exists. Naturally I am only able to speak from personal experience. There appear to me to be, broadly speaking, three main aims in the Act:?
To afford treatment for mental illness in its earliest stages.
(b) To render such treatment available to the sufferers with the greatest practicable ease. (c) To diminish the use of admission to Mental Hospitals by the process known as ” Certification.”
First of all I feel it would be useful to outline as briefly as possible the foundations of any success and I do so in what I consider the order of importance as follows :?
1. It is essential that the Visiting Committee of the Hospital should be fully desirous of making all sections of the Act available to that section of the community embraced by its activities. 2. The general public require to be made fully aware of the provisions of the Act. 3. The local doctors also require to be conversant with those sections which directly involve themselves. 4. The Mental Hospital Staff and its Superintendent need to be prepared by precept and example constantly to draw attention to the provisions of the Act and in a proper manner to keep in touch with those enumerated above. To fight shy of reasonable methods of propaganda by means of public lectures, circular letters, etc., cannot be expected to be fruitful. My own experience has taught me that no stone should be left unturned to bring before the notice of those concerned, the fact that the County no longer possesses an “Asylum ” and that the Mental Hospital which replaces it is not administered along the lines of the old-fashioned ” Asylum.” Every encouragement is given to the doctors to consult with the Medical Staff of the Hospital over any cases where there is doubt as to the right course of action to adopt.
For a Medical Superintendent to imagine that he can in any way play a lone hand in promoting the use of the Act is nothing short of absurd, co-operation and teamwork are essentials.
The formation of an Out-Patient Clinic is of the greatest importance. On the Island one was formed in 1932. Two sessions were held weekly, namely at the County Hall, Newport, and at the County Hospital, Ryde. During the first year the number of patients attending was 92. Very soon it was found necessary to open another session which was held at the Mental Hospital. Although the attendances at this latter session are not as numerous, they are none-the-less important, for the cases that come to Whitecroft are those requiring longer periods of treatment (analysis, etc.), or who come for reasons of privacy or where some laboratory investigation is required to elucidate the condition. In 1933 the Clinic had established itself to such a degree that a request was received from the Cowes Town Council asking the Committee to make arrangements to provide a session there. I consider this action to be an outstanding instance of the success of the Clinic and was pleased to find that my Committee authorised the opening of a further weekly session at Northwood House, Cowes. The latest figures show that the number of patients attending has risen to 203. The Clinic had not been running long before I became aware of the fact that parents, guardians, teachers and doctors were making use of it in regard to problems arising connected with childhood. Children of all ages were being seen and treated. A certain proportion were naturally found to be mentally retarded while the residue presented the complex problems which we know to be associated with childhood. The need to give definite attention to the problem of child guidance became very obvious and this was increased by the use which was made of the activities of the Clinic to get assistance in regard to cases of delinquency dealt with by the Juvenile Courts. It was not long, therefore, before it became necessary to make known to the departments concerned the real need which existed to provide the easiest possible means to deal with the problems of childhood and as a result of the representations made definite steps are now afoot to form an experimental Child Guidance Clinic. So much for the necessity of Clinics?unless I add that it is my opinion that Clinics should certainly hold sessions at least once a week and that as many Centres as possible should be provided so that access may be rendered the more easy.
Within the Mental Hospital one was immediately faced with the problem of modernising the ” Asylum.” The old system of suspicious vigilance and the tendency to regard cases as ” chronic ” had to be dealt with. I can well remember the awkward feeling experienced by myself when I first came here, at the number of times it was necessary to use a key to gain admission not only to wards but to the very corridors leading thereto. To a person totally untrained in the ways of a ” Locked Asylum ” this was in itself well-nigh unbearable and 1 think that condition in itself assisted me to appreciate how terrible must be the feeling of any patient with sufficient comprehension to have to live under conditions always associated with the jingling of keys and the shooting of locks. The big difficulty was of course to get the staff to relax their ideas. 1 felt, however, that any definite direction upon my part that such and such a ward should be forthwith unlocked would have had very unpleasant consequences. Instead, by dint of discussing the matter with the Heads of the Male and Female Departments, a spirit of competition was induced and it was not long before the Head Male Nurse suggested to me that it might be possible to administer one of the wards upon the “open door” principle. Within a very few months I was in the happy position of finding that out of nine wards only three required keys in order to effect an entrance and the doors from the front door to the corridors to the wards remain open all day. The blocks on numerous windows on the ground floor were also removed and within the first year it was noticed that the number of escapes on the part of patients had fallen below 50 per cent, of what it used to be in the ” locked-up ” days. To-day it is a comparatively rare thing to have a patient deliberately run away. One or two tend at times to overstay their parole but in the true sense of the word we know where they are.
The question of mechanical restraint is beyond my ability from the point of view of discussion as I have never applied it and never shall do, being perfectly convinced, though my experience is by no means large, that it is quite uncalled for. On the question of seclusion, that is to say the locking of patients into single rooms during certain legally prescribed hours of the day, I feel no qualm for in its use is an indication of attention to the individual rather than to the crowd. That is surely an axiom of modern treatment.
Similarily 1 do not find it possible to range myself on the side of those who advocate the abolition of padded rooms. When I came here we possessed four very home-made affairs consisting of canvas which had acquired the hardness almost of stone as a result of repeated applications of coats of enamel. These have now been removed and have been replaced by four of the latest design with special heating arrangements so that they are rendered not only safe but comfortable.
Where all the doors are locked and where the tendency to treat patients along the lines of a herd exists there can be, in my opinion, very little hope of classification of patients to wards. Nor can there be much encouragement, therefore, of recovery. It has been found possible, despite the difficulties of overcrowding, to classify patients and in an area such as this where the Local Authority is unable to make heavy demands upon the public purse, the provision of a separate Admission Hospital was very fortunately solved by classifying the private patients who were accommodated in the private villa. Nor was this move a disadvantageous one for the private patients for their numbers had fallen so low that they no longer had the complete use of the private villa but found that the spare accommodation was filled by ” chronic ” patients. Classification has also improved their lot and the Admission Hospital, which is separate and distinct as a building from the main Hospital, came into being.
There seems to me to be plenty of scope still for improving the lot of the patients and it was not long before one realised that the habit of locking patients of orderly type and habits in single rooms during the long hours of the night and in complete darkness could be revised. I have been able to put the experiment successfully into operation of having through handles fitted to the doors of chosen side rooms and a switch for the electric light fitted within the side room as well as outside it so that the patient using the room could leave it at will and could switch the light on or ofif from the inside (as could any visiting nurse from the outside).
Much can be done apart from classification to improve the sleep function. 1 am quite well aware of the fact that many patients require sedatives and hypnotic drug treatment to ensure the proper period of sleep but I am also very sure that the mattresses supplied have a great deal to do with this. I became the more sure having endeavoured to sleep upon one myself. The Admission Hospital has now been equipped with mattresses of a modern type filled with coil springs and from the moment of their introduction success has indubitably attended their use. These mattresses are made by a firm specialising in providing them for Hospitals. They are easily sterilisable and when necessary the thin layer of padding above the springs can be quite easily replaced. The mattresses also have the added factor that they are light for nurses who have to manipulate them. Feather pillows have also provided a salutary adjunct.
Consequent upon the unlocking of doors and the strong suggestion of freedom which that action implies, comes consideration of the question of parole. This exists in many Hospitals to a large or small degree according to circumstances and in an area such as the Island one would naturally argue that the introduction of any system of parole would be an easy one. 1 at least thought so but it was not long before numerous residents in the neighbourhood protested and although I quite agree there may have been some sound reason in part as a foundation for their protests I also felt that much of it arose because parole was an innovation. It was not long before complaints reached the Board of Control, and a small enquiry was set up under the guidance of one of the Senior Commissioners of the Board. Parole was not abolished and now runs smoothly. I have found it beneficial from all points of view to grant this privilege to patients under the term of “associated parole” whereby two or more patients are allowed outside the Hospital grounds during certain stated periods together, and so far 1 have not been sorry, for it allows me to grant this boon to those who are somewhat deaf and liable therefore to be rendered unable to avoid traffic with the acrobatic agility required to-day.
A further step was taken last summer and is to be repeated on a larger scale this summer, by the institution of a patients’ Holiday Camp. A suitable field by the seaside on the south of the Island was rented from a very accommodating and kindly farmer and ten male patients accompanied by three male nurses and a doctor were accommodated for a week in bell tents and had ” the time of their lives.” I can only claim that the idea was mine, the whole brunt of the work fell upon the shoulders of the Clerk and Steward who in the remarkable way in which, I am happy to say, some Clerks and Stewards seem to be able to meet all emergencies, provided all the necessaries without the slightest hitch even to the inclusion of almost military ” iron rations.” The patients returned from the holiday bronzed and fit. They had of course been chosen with care, partly because it was necessary that the experiment should be a success and also of course from common sense consideration connected with the views of the public. That the experiment was a popular one there can be no doubt and, as T say, it is hoped to repeat it this year on a larger scale. The whole project was from start to finish under the control of the Mental Hospital, that is to say we did not join in with any local Holiday Camp although one was by no means distant. It was not possible to sanction bathing upon the part of the patients but games on the shore, rambles, paddling and all the fun of camp cookery was fully encouraged and to the enthusiasm of the staff concerned must be attributed the success of the venture.
I need hardly comment upon the necessity to provide a properly equipped laboratory for any Hospital hoping to make progress in the application of the new Act. Nor do I consider that the installation of a laboratory should primarily be for the purpose of research but rather for the practical and very necessary investigations which are required in relation to treatment. Where no laboratory previously exists the question of expense will of course be a somewhat acute one. Such was the case here. Nevertheless we now possess an efficiently equipped room which fulfils its purpose including bacteriological examinations and which is under the care of a trained assistant. The number of investigations carried out therein amply justify its existence.
Much has been said about the cumbersome sections of the Act particularly in relation to the Temporary patient but with the passage of time I believe the somewhat involved provisions in regard to this type are being more fully understood by medical practitioners, with consequent beneficial results. Of course only a certain percentage of psychotics can ever be embraced by this section and one should be on one’s guard to make sure that mere enthusiasm does not lead one to tolerate the admission of types not embraced by the provisions. There must be “a reasonable hope of recovery” which at once precludes, in my opinion, cases of senile dementia, and of course the patient must be unable to express willingness or unwillingness. Perhaps one of the most difficult points in relation to the temporary patient is that which relates to the return of volition, namely the existence of this condition for a period of 28 days. Here we have tended to overcome it by employing a system whereby the nurse in charge of the ward commences to complete a form stating that the return of volition has been noted. This form is displayed in the Clinical Room and acts as a constant reminder so that if an unbroken period of 28 days occurs it is not so likely to be overlooked.
With regard to the Voluntary patient much can be said. In many ways this is one of the most important provisions of the Act for it accords to those of small financial means the facilities which have hitherto been only available to persons able to be classed as ” private patients.” I am of the opinion that, providing the patient is able to volunteer, the type of mental illness should offer no barrier to admission. It seems absurd to turn down the application of a person merely because the condition is fraught with the fear of suicide, for example. Nor do 1 feel that it is necessary to refuse to admit cases which are a prey to fugues and agitated panic. I know that the latter are liable to run away but it is the habit here to obtain an undertaking from the patient and the relatives, if necessary, authorising us to bring them back to the Hospital. I feel that many voluntary patients are liable to be refused if one has not the courage to rely upon the provision of immunity from legal action if one has acted in good faith. It has been urged from some quarters that the voluntary patients should be grouped in a ward or building by themselves. I have never been in favour of this, nor does it seem to me to be a common sense arrangement if one adheres to the idea that any cases may be admitted who see fit to volunteer. Voluntary patients here are therefore graded and classified. Prior to admission the patient is given distinctly to understand that no guarantee can be given as to the allocation to wards but that classification is dependent entirely upon mental grounds. The notice intimating the intention to leave the Hospital is kept in the ward and the patient is instructed on admission that this is so and that the legal right to demand it is fully acknowledged. It is also impressed that the medical recommendations as to discharge should naturally be taken into account and where the patient has completed the notice of intention to depart and subsequently intimates the desire to remain for a further period, it is the habit here to have that request written by the patient on the back of the notice, which is then kept in the Hospital files. We have also made it a rule here that no voluntary patient departs from the Hospital without some relative or responsible friend having been previously requested to attend at the hour of departure to accompany the patient outside the Hospital grounds. Fortunately the form of application for admission for treatment as a voluntary patient is not a statutory one and at Whitecroft it has been seen fit to employ one clearly printed and couched in simple plain English. No effort is made to avoid the fact that admission to the Mental Hospital is being sought; that application is made entirely voluntarily upon the part of the patient; that the legal right to give 72 hours’ notice of departure exists; that the forms for this purpose are obtainable on demand from the nurse in charge of the ward and that the Hospital Rules and Regulations will be adhered to.
Before I conclude these remarks attention should be drawn to the great necessity of adequate Medical Staff. There is little doubt in my mind that the old ” Asylum ” spirit tended to call for what I may term ” a routine outlook primarily on the part of doctors and one of practical interest and keenness secondarily. I feel, however, that that order is reversed with the proper application of the Mental Treatment Act. It is, however, not only necessary to afford the latest facilities for treatment but to see to it that an adequate Medical Staff exists for carrying out that treatment. In a similar fashion the unlocking of doors and the reduction of mechanical aids to supervision call for a larger degree of human supervision and place increased burdens upon the Nursing Staff with a demand for its augmentation. Nor must the Clerical Staff be overlooked. The amount of correspondence, statutory and otherwise, entailed by the administration of this Act renders our ideas of the staffing of the Clerical Department quite obsolete. 1 find that the old habit of using ready printed forms is of necessity falling into desuetude. Nearly every letter which 1 receive (and they have increased) requires a personally dictated answer. In any case it is highly desirable that replies should be made in this manner.
This effort to outline modern mental treatment in older institutions has been sketchy and is capable of much enlargement and addition in many directions. It is beyond my power to make it more complete at this moment for the simple reason that we still live in the age of experiment as far as the application of the new Act is concerned. I can only outline some indication of my firm belief that ” where there is a will there is a way ” and that the slogan of the adapted ” Asylum ” should be the motto quoted in our Hospital Rule Book, namely, ” Effort and renewed effort “.
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