Report of the Feversham Committee
98 MENTAL WELFARE
- Author:
Henry Herd, M.A., M.B., Ch.B., D.P.H.
Formerly School Medical Officer, Manchester Education Committee. The publication of this Report is an event of no small importance in the sphere of Mental Health.
The Committee responsible for the Report was formed as the result of a movement for the co-ordination of the existing voluntary Mental Health Services. For several years there have been in existence a number of separate organisations dealing with various aspects of Mental Health work, the chief of these being the Central Association for Mental Welfare, the Mental AfterCare Association, the National Council for Mental Hygiene, the Child Guidance Council and the Home and School Council. It has gradually been realised that while, for a time, such separation may give scope for initiative and exploration in a variety of directions, there comes the stage when overlapping with consequent waste of effort, makes it desirable, even imperative, to co-ordinate activities.
The terms of reference of the Committee were :? ” To consider the scope and activities of the law affecting existing voluntary organisations rendering Mental Health Services, and to report on the possibility of increasing their usefulness to the community, particularly in relation to:
(1) Their co-operation with Government Departments, Local Authorities and other bodies interested in Mental Health work. (2) The co-ordination of their activities. (3) The extension of the services rendered by them.” The Committee carried out its task in a very thorough manner. A comprehensive and searching questionnaire was issued to Government Departments, Local Authorities, Voluntary Associations and private persons connected in any way, however slight, with Mental Health work in its varied aspects. The task of arranging, analysing and summarising the replies was undertaken by a member of the Committee, Dr J. M. Mackintosh, now Chief Medical Officer of the Scottish Health Department. In this way, there has been collected a large amount of valuable information relating to the treatment of mental disorders (in the widest sense) in different parts of the country ?information which has enabled the Committee to discover the many existing gaps and weaknesses, and to make concrete suggestions for the improvement * Obtainable from IV. H. Barrell Ltd., 112/116 High St., Portsmouth. Price, 2/10 post free. of the service. The Report, therefore, apart altogether from the specific recommendations it makes on its terms of reference, is an extraordinarilyuseful compendium, showing the position of Mental Health activity all over the country at the present time.
In a short article it would be impossible to attempt to give anything like an adequate summary of the Report. It is, in any case, one to be read in full by every one interested in Mental Health. Here it is possible only to take a very general survey and to refer more particularly to certain points, the selection of which may be dictated by the writer’s own interests as a past School Medical Officer.
There may be said to be two outstanding propositions maintained by the Feversham Committee.
The first is their insistence as an indispensable preliminary to a progressive policy, that Mental Health should be recognised as a single concept. Mental defect, mental disorder, organic or functional, and delinquency should, i.e., be regarded not so much as separate pathological conditions as being all of them, in different ways, departures from a normal condition of Mental Health. This conception pervades the whole Report and is fundamental. It is, of course, not a new idea to mental workers and it has already received partial statutory recognition. As the Report points out, ” the Board of Control is a supervising and co-ordinating authority for all branches of mental Welfare recognised by statute,” and the Mental Treatment Act of 1930 extends the Board’s controlling powers to voluntary and temporary patients and even to encouragement of community care.
Throughout the country, however, there is far from general recognition of this unity, and for this reason, the Committee has not been content with a general statement of its view, but applies it in detail. Mental Health Clinics, it is contended, should deal with ” patients of all ages likely to benefit by psychiatric treatment.” This would only exclude the ineducable defective, and the educable defective who requires ” training” and not ” treatment,” but would include the defective who has psycho-neurotic symptoms or shows problems of conduct. Staffs also should be unified.
” We do not think it necessary or desirable for the average Local Authority to appoint one trained staff for Mental Disorders, one for Neuroses and P.sychoneuroses, and one for Mental Defectives”
though separate examination or treatment sessions may be required. The second main proposition of the Report is really only a natural corollary of the first. As a concrete application of the idea of the unity of Mental Health, it proposes that every Local Authority responsible for it should appoint a single Mental Health Committee which would deal with all matters relating to mental welfare?control of institutions, treatment of early mental and nervous disorders, establishment of clinics, community care and education of the public. Such an arrangement would provide a unity of control of Mental Health and mental disorder in its manifold aspects, similar to that exercised to-day as regards physical health by Public Health Committees, although even here there is not complete unity, as part of the physical health control is in the hands of Education Committees.
In this connection, the Report refers to two contributions made in this century to psychological medicine ; viz :
” The growth of the idea of prevention and the recognition of personal care as a more weighty consideration than mere protection of the community.” In these points there is a close parallelism with the Public Health service in which the idea of prevention is dominant and in which also the care of the child has now largely taken the place of earlier concern for the improvement of the environment.
At present, control of Mental Health is in the hands of several Committees, working for the most part independently. The proposal now made is that the Mental Health Committee should be on the ” same footing as other Committees of the Local Authority which are responsible for public health and social welfare.” For the particular case of patients in Public Assistance Institutions, a joint Sub-Committee of the two Committees is suggested, but even here unity could be achieved by ensuring that clinical supervision of all cases should be in the hands of a Medical Officer who is an expert in Psychiatry and Psychotherapy?a medical officer who might or might not be equal in status to the Medical Officer of Health. In practice a difficult situation might be created if the Mental Health Medical Officer was a subordinate of the Medical Officer of another Committee (Public Health) but close co-operation between the two officers would be necessary. One is tempted at this point to wonder why the Feversham Committee has not carried its zeal for unity still further and recognised that the “physical ” and the ” mental” cannot be dissevered. Physical health and mental health are not completely separate conceptions. Health is affected by both physical and mental factors, and while ” Public Health ” has up to the present been generally understood to cover only physical health, there is no reason why that narrow conception of its function should be perpetuated.
In relation to the functions of Education Committees, special problems arise. These have statutory duties relating to education and notification of mentally defective children, and some have established Child Guidance Clinics for the treatment of ” problem ” children. As a rule, on the staffs of the larger authorities, there are one or more School Doctors who have taken the special Course in Mental Defect which qualifies them?theoretically at least?to be Certifying Officers. Child Guidance work, on the other hand, when undertaken, is usually controlled by a part-time psychiatrist, holding the Diploma in Psychological Medicine. Sometimes the psychiatrist is responsible for the M.D. work but there are areas where the two sections function separately, co-ordination being secured bv the Chief School Medical Officer himself. The Feversham Committee recognises this differentiation in the practice of Education Authorities and suggests the need for greater co-ordination. The care of ” mentally retarded ” children should, in the opinion of the Committee, remain a matter for Education Committees and these should also appoint psychologists and psychiatrists, the Local Authority either itself maintaining, or giving grants to, a Child Guidance Clinic. Co-ordination is apparently intended to be secured by referring to the Child Psychiatrist ” special cases of mental defect or behaviour disorder.”
The Committee is justifiably critical of the employment in Child Guidance Clinics of Assistant School Medical Officers with no special training in Mental Health. ” A course on Mental Deficiency is utterly inadequate training for Child Guidance.” The writer, however, has been convinced for a long time that it has become necessary now for any doctor engaged in the Child Welfare or School Medical Service to acquire some knowledge of the science of Mental Health as its affects children. Such knowledge would enable these officers to recognise factors other than the physical affecting the children they examine, and also to do a certain amount of educative work among parents. It is very questionable whether the Diploma in Child Health is a guarantee of the possession of adequate knowledge: some may even doubt whether the Diploma in Psychological Medicine is sufficient. Post-graduate courses on this very specialised line of study are required, and should be part of the equipment of every Medical Officer examining children. The status of the School Medical Service in particular, would be greatly enhanced by such an additional qualification. Psychiatric treatment would be in the hands of the trained psychiatrist, but a preliminary selection of cases by School Medical Officers would save much valuable time in the Child Guidance Clinic. Selection of children on grounds of mental and educational retardation for ” special ” education might remain as at present to be the responsibility?probably shared with the psychologist?of School Medical Officers who have taken the special course, but the psychiatrist might well share responsibility for final notification under the M.D. Act.
The Feversham Committee has given careful consideration to the present statutory provisions relating to defectives in the Education and Mental Deficiency Acts, a subject recently under consideration by the Special Committee representative of many medical and educational bodies appointed by the C.A.M.W. The conclusions of the two Committees are very similar, though not alike in every detail. The term ” mentally defective,” it is suggested, should be reserved for those who have to be dealt with under the Mental Deficiency Acts and the Feversham Report favours the omission of all references to educational incapacity in the definitions in those Acts. Certification as defective should not be a preliminary to giving a child Special School education and the Feversham Committee goes further in the. recommendation that it should be possible for defectives to be admitted to institutions as voluntary cases without certification, just as in the case of persons suffering from mental disorder. Notification of children to the Mental Deficiency Authority should, in the opinion of both Committees, apply to all socially defective children whether in Special Schools or not.
Most School Medical Officers will heartily welcome every one of these recommendations, and have difficulty in understanding why, from any quarter, there should be opposition. The whole purpose of the Special Schools has been to prevent as many as possible of their children from becoming social misfits, yet it has been necessary to certify them as mentally defective in order, if possible, to prevent their becoming mentally defective! The double use of the term has been a source of much confusion and the necessity of certification for educational purposes has deprived many subnormal children of the ” special ” education they required.
An Education Committee as such, is not really concerned with the question whether any child in its schools is defective or not. Its whole concern is with educability. Children not educable can be notified under present legislation as ” idiots” or ” imbeciles.” If educable, but not so by ordinary school methods, then a Special School or Class can be provided for these children with limited possibilities. The question whether they are mentally defective in the true sense (i.e., socially defective) can be determined later, and notification then resorted to if necessary.
The Committee’s enquiries into the provision for skilled observation and treatment of delinquents, have convinced them of its entire inadequacy. There is no organised service of this kind throughout the country. Courts make comparatively little use of the services of psychiatrists, and their advice when given is not always acceptable to the magistrates. Skilled help is too often not available in Remand Homes and there is a great dearth of facilities for in-patient observation and treatment of the delinquent.
School Medical Officers are only too well aware of each and all of these deficiencies. They have welcomed the Child Guidance Clinic, but even then their difficulties in regard to delinquent children are only partially cleared, because of the fact that in so many cases removal, temporarily at least, from the home environment is required. Even when this is secured and the child is removed to an institution, there is no guarantee of adequate supervision and treatment. As the Report says, “the environment must be supervised by a psychiatrist: mere residence and vocational training are not enough ” and only too often, in fact usually, this is all that is available, even in Approved Schools. In any case, admission to an Approved School is generally the last resort of the magistrate, and reserved for persistent delinquents. It is the early delinquent for whom workers in this service wish to make provision. The Report therefore suggests that Local Education Authorities should establish residential homes or schools for maladjusted children or maintain these children in homes provided by other bodies. Such provision is just as important as that of Residential Homes for the Mentally Defective.
” There is every reason to hope,” the Report continues, ” that increased concentration on psychological care within the school system will reduce the sum of mental ill-health requiring treatment at a later period of life.” Much emphasis is laid upon the provision of public education in mental health, with the object of inculcating the principles of normal psychology and mental hygiene, of fostering a healthy attitude towards mental illness, and of identifying early signs of mental instability. Teaching to children?widening the scope of the present biological education?to parents, teachers and social workers, is contemplated. ” The foundations of mental health are laid at home in the family,” and it is to the home, therefore, that the teaching must chiefly be directed. The benefits of education in physical health are gradually becoming more apparent, and the Feversham Committee is confident of the benefit to be derived from education in mental health.
” We believe,” they say, ” that mental ill-health in childhood could be reduced to a very small proportion of its present figure by ordinary educational methods, including patient education in the home by Health Visitors during infancy and pre-school age, and a wise co-operation between home and school.” As already hinted, Child Welfare and School Medical Officers might play a useful part here, and there is also much scope for work by voluntary organisations.
A complete scheme for the amalgamation of existing voluntary mental health organisations is submitted in detail in the Report, with a draft constitution of the proposed National Council for Mental Health, with Articles of Association. These will, in due course, doubtless be discussed by the bodies concerned and the scheme, let us hope, put into operation.
This is a Report of great importance and it is sincerely to be desired that its recommendations will not be neglected when the world of nations has recovered from its own instability and maladjustments. The science of Mental Health may mean much to the future peace of the world, for the great principles of prevention and early treatment are as applicable to national as to individual mental aberrations.
The individual may present himself to the school teacher or attendance officers as a backward scholar or a truant; to the probation officer or diocesan worker as a persistent pilferer or sexual offender; to the relieving officer or institution authorities as a quite unmanageable rebel or a case of acute depression …. but the apparently various problems are in reality a single one, that of helping the sufferer to a better adjustment of life, in short, in restoring to him mental health. W. J. T. KIMBER.
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