The Relative Functions of the Occupation Centre and the Mental Deficiency Colony in the Training of Defectives
- Author:
EARL, F.R.C.P., D.P.M.
(Asst. Medical Officer, Caterham L.C.C. Mental Hospital)
It has always been the tradition in this country, as in all civilised countries, to do something to help the helpless?and amongst the helpless, the Mentally Defective,?and this custom has arisen because of the traditions of our culture, rather than in any purely logical fashion. But our social tradition has taught us to regard the defective as something other than a merely helpless, or semihelpless creature. We tend to feel that he is different from ourselves; in some way a danger as well as an economic burden. Our national attitude to the defective is a sort of compromise between the spirit of Christian charity, and the tribal spirit of ” here’s a stranger, heave half a brick at him Until the first decade of the present century the problem had not assumed serious proportions, but, following the introduction of modern mental testing methods, when it became clear that mental subnormality was very much more common than had been previously supposed, the problem has grown steadily more difficult and more complex. Previous to that time, only those of imbecile Paper read at Public Health Services Congress, London, November, 1938. and idiot grade had been recognised to be mentally defective at all. And society, when it became alarmed, tried to deal with the new conditions as it had dealt with the old, in the old traditional way of providing institutions in which the mental defective might live, relieving his normal fellow men of the difficulty and danger of his presence among them. It is to be noted that we did not pause to be sure exactly what was the degree of this danger, nor even whether it existed at all; nor did we ask whether anything could be done to relieve these unfortunate people; we just said ” lock ‘em up”.
Since then the problem has become steadily greater, for we have come to realise that you cannot lock up all the subnormals in the country and that it is not only unfair to the defective, but grossly wasteful of public money, to lock up anybody all his life unless we are very sure that it is necessary. And even to-day, when the institutional accommodation for the defective is greater than ever before, there is not a single institution in England which is not packed, while the problem which faces every public authority to-day is ” How are we to deal with our defectives, and how are we to keep down the expense?” The answer to both questions seems to be ” By keeping as many defectives as possible out of the Institutions “. From the point of view of that tiresome breed against whom I wage constant war on behalf of my defectives?I refer to the ratepayer?this would be an admirable idea if it could be done. What about the point of view?in my eyes more important?of the welfare of the defective? What is the evidence? Well, much of the evidence is purely traditional belief. It is the tradition in this country?not in all countries mark you, but in this country?to keep defectives in institutions. All our laws have been framed with that ideal in mind?lawyers, I need hardly tell you, are the most hidebound traditionalists; they much prefer a good, well-ripened act of King John to any of these new-fangled twentieth century affairs. From a more practical point of view, however, we have accumulated a lot of evidence in the last few years to show that it is not by any means always the best thing to do with a defective, and that in some respects it is quite certainly the ivorst thing?from the patients’ point of view.
And the contribution which I want to make to this afternoon’s discussion? based on a good many years’ experience of institution work?is to try to differentiate between those cases which should be dealt with in institutions and those which should not; and, though here 1 speak with considerably less authority than the other speakers, to say something of the training which can be obtained for the defective who remains in the community.
The mentally defective, it must be remembered, are not a single homogenous class?not even a series of distinct classes. There is 110 real dividing line between the best of the defectives and the worst of the non-defectives. Mental deficiency, in so far as it is a valid category at all, is a social and not a psychological one. We may start then by dividing defectives from the social point of view, into those who fail in society because society is too much for them, and those who fail because they are too much for society! These latter, the socially dangerous, the criminal, the wildly unstable, the sex-offender, and the like, we may at once label as institution cases; obviously they must be segregated?until or unless their anti-social tendencies can be cured, which they quite often can. Of those who are not actual dangers to society, we may safely say that the very low grade and the severely crippled must also be institutionalised ?those, in other words, who are so helpless as to require constant and skilled attention if they are to be kept alive.
We arc left with the more stable feebleminded and with the imbecile. The feebleminded, of course, are dealt with as children largely in Special Schools and under the Education Act; only if they are really difficult, or if the home circumstances are extremely bad, do they come to institutions and even in such cases many of them go to residential special schools. Those over 16 years, if they are certified under the Mental Deficiency Acts, usually come to the institution, and quite rightly so. The institution is not a purely custodial centre; its main function is?or should be?training. And there is no more sutiable place for the boy or girl who, having attended a special school, is still a social problem. One is constantly amazed at the improvement these cases make in early adult life, and at the number of them who can be made to adjust in society. Still more essentially the institution is the only place for the higher grade case who has failed in society itself?as apart from school failure. These cases are analogous in many ways to the problem children one sees in child guidance clinic practice. Their difficulties can be cleared up with suitable treatment, and they can live normal lives enough. But the only chance of such treatment lies in the institution. It is true that we are by no means perfect; we are still greatly handicapped by shortage of skilled staff, and by lack of educational departments, but taking it all round we can do and do do a lot for such patients. Essentially, our function in these cases is educational rather than custodial. You do not make a boy fit for society by shutting him out of it. The more liberty we can give, the more elastic our method of admission, of licence, and of discharge, the better for the patient. Once that is firmly established?and only when it is?we may expect to see many of these youngsters sent to us before they have become hopelessly impossible in a Special School, and before they have fallen into police hands. At present many Special School masters, and many other responsible people hesitate too long. They hate to see a boy sent into what they fear will be permanent custody, especially if he is really high grade; so they keep on trying to cope with temperamental and emotional disorders which are not the province of the schoolmaster but of the psychiatrist. Given that a boy or girl is a social or Special School failure, then the higher grade he or she is, the more likely he is to be suffering from an emotional disorder, and the more necessary it is for him or her to be sent where he can have proper treatment.
Now we come to the imbecile category?accepting as imbecile, roughly, those patients who cannot be taught to read or write. What are we to say about them? They cannot become self-supporting. Must they not be sent to institutions ? And ought they not to be sent there at the earliest possible moment ? Well, twenty years ago almost any institution medical man would have said “yes” unhesitatingly to both those questions. In the light of present day knowledge the answer is ” No, you cannot generalise; every case must be treated on its merits; and institutionalisation per se is not a good thing at all.” Now, in saying that, I am not thinking primarily of the public purse but of the benefit of the patient. In medicine and surgery of to-day we have got far beyond the stage of a magical belief in the bottle and the knife. The mere fact that a man is ill, or physically subnormal, is not taken to mean that he must choose between being dosed and being carved up. If it is at all possible we try to make him live a healthier life?to eat and drink less perhaps, to smoke less and sleep more, to avoid overwork and so forth?in other words to try to live within his physical limitations. Now exactly the same thing applies in mental medicine, and especially in the case of inherent lacks which no treatment can replace. We want, alike in physical and mental medicine, to avoid more interference than is absolutely necessary. And sending a patient to an Institution is a gross interference?it is sending your patient into an artificial environment.
If we are to take such a step, we should have a pretty clear idea of our reasons for doing it. We should weigh the pros and cons carefully, for we are committing both the child and the community. There are a number of reasons why a child might be sent to an Institution. First, of course, he might be sent there (usually is sent there)?faut de mieiur-?simply because he is impossible in the home and there is nowhere else to send him. Or he might be sent there with the idea of training him, either to be self-supporting (as in the case of the feebleminded), or at least to live in a normal home. The institution of to-day does try to train the children who are committed to its care, and the institution can provide much that the home cannot. For one thing, it is a tremendous burden on the mother of a working class family to have an imbecile child added to her other difficulties. There is so much that the ordinary child learns without being taught?learns without knowing that he is learning it?all sorts of personal habits, knowledge of what is dangerous and what is not, knowledge of how to play and who to play with, knowledge of what is taboo in the home and what is not?all perfectly simple and obvious things which the defective child has to be taught with infinite care and patience, to say nothing of skilled and experienced handling. The only way in which he can be taught these things is by routine, by living a routine life, by doing the same thing over and over again at the same time and in the same way. Such training is quite out of the question in the average home. In the institution it is a matter of course. In addition there is, of course, training in more formal accomplishments; learning to do useful work, simple household tasks, handicrafts and the like. Here again, the Institution caters for the child, giving it a training which is out of the question in the home itself. So far, the institution accomplishes valuable and essential work, and in so far it may be called a successful method of treatment of the imbecile child.
I believe myself that institutional training is essential for a great many patients of imbecile grade, particularly those from urban or slum areas. But I am bound to say that I do not know for how many of them. I do not know how much can be done outside. On general grounds T should think that the majority of imbecile children will always have to pass at least some of their lives in an institution. But I do not think it necessary to assume that all of them will have to spend all their lives there; I think it very well worth trying to see how far our present methods of dealing with them in the community can be extended. I say this largely in the interests of the patient and of his parents, rather than in the interests of economy, though such a method would probably effect a fairly considerable saving of public money. The reason I say it is, that however skilled the staff of an institution, and however good the training which is provided therein, there are certain disadvantages in institutional life which, at any rate in some cases, form a very serious objection to institution training. I think these cases are mainly the higher grade imbecile and lower grade feebleminded, the children who are just the doubtful bets in a Special School and who tend to be excluded and then institutionalised.
The disadvantages of institutional life apply, of course, to all institution children?to the normal orphanage child, and to the feebleminded, as well as to the imbecile. In the case of the normal or feebleminded child, however, the disadvantages do not operate so heavily, and are more than set off by the advantages of training which they obtain. We must remember that, in the case of the imbecile no training can make him self-supporting; we are confined to making him fit for life in a sympathetic home or a very simple community? even then it is life as a passenger, so to speak.
The objections to institutional life are mainly two. The first is that the very routine, through which the child is trained, is in itself an artificial routine from the social point of view, and that the child is very apt, if an attempt is made to re-socialise him later, to feel the difficulties of society all over again. Especially he feels them in so far as he has been accustomed to have his time filled in for him instead of being expected to find something to do for himself. The routine of institution life is a two-edged weapon, especially for the imbecile, who is more subjected to routine than any other institution child, and while I feel that it is very necessary in the circumstances, I constantly wish that it did not have to go on for twenty-four hours a day.
The second point is, in some respects, even more important. The normal environment for a young child is the family. The family is, after all, the normal unit of human society. In the family the child finds the emotional stimuli and the emotional satisfactions which are so essential for normal development. The emotional relationship between the child and his parents, between the child and his brothers and sisters, are most important factors in his development. They are factors which cannot be adequately reproduced outside the home. Most especially they are difficult to reproduce in a big institution. The institutionalised child is always handicapped in the emotional field. The normal child in the orphanage tends to be emotionally starved; and neurosis and emotional problems are far commoner among orphanage children than amongst children reared in their own homes?however bad the economic circumstances of the home may be. This is not really the fault of the institution or orphanage staffs. We are not hard-hearted monsters, nor are we as incompetent as we might be. It is simply that artificial emotional relationships are like artificial milk?the natural product is always better. Moreover, the quality and quantity of the artificial emotional relationship available is not by any means always adequate. Here we find ourselves up against the public purse. Institutions are large?they have to be for economy’s sake,?and the larger they are the more rigid and impersonal they tend to be. The larger the institution the more powerful becomes the purely mechanical administrative factor, and the more difficult becomes the supply of sufficient skilled staff. You have to remember that the staff of a mental deficiency institution have a very responsible task, and if that task is to be properly carried out, we need plenty of really skilled and experienced people. And that means paying them. In other words the amount of personal liking or affection which the institution child gets is not only artificial but it is governed largely by the public purse, which, in its turn, is governed by the attitude of the man-in-thestreet, who can always think of something more important to do with public money than to spend it on the defective.
The child who lives at home?on the other hand?has his fate governed by the private purse and the personal attitude of his parents. With regard to the first, one has to admit that in the majority of cases the purse is not deep enough. The imbecile child is too heavy a burden and can only be kept at home?too often is kept there?by sacrificing the rest of the family. The parental attitude is usually good, though ignorant. Of course, one does find parents who are so unable to bear the thought that they have brought a defective child into the world that it is quite impossible for them to treat him naturally. In the majority of cases, however, the parental attitude is quite good, while in some cases at any rate, the economic situation is good enough to allow the child to be kept at home. But the question of training has to be faced and it is just for this purpose that the Occupation Centre exists.
I would say that there are three main classes of case which should, par excellence, be sent to occupation centres. First are those younger children who are not good enough for elementary schools, and whose eventual acceptance at a special school is still doubtful. It seems a tragedy to let such children drift, and to allow them to do so may just weigh the balance against them. On the other hand, it is foolish to push them into institutions until one has to. In many of these cases the problem can be solved by Occupation Centre training. The second class of case is that group of children who come from the more fortunate homes, from the socio-economic standpoint, where the parents are both willing and able to keep the child, but not able to afford special training in the home. If such a child can be taken off his mother’s hands for part of the day, and if, in addition, he can receive skilled training during that time, then the burden is lessened, both on the child and on the mother, and it may be possible for him to remain at home.
The third class of case -is one in which both institution and Occupation Centre can play their part. In quite a number of cases the family circumstances which forced a child into an institution, change. The other children grow older, and get jobs; the family income increases while the mother’s responsibilities decrease. In the meantime the patient has grown older, and he has had the advantages?alas, also the disadvantages?of institution training. From being a helpless and difficult individual he has now learnt to look after himself and has acquired a certain sense of discipline. He is now much less of a burden, and his family is much better able to carry a burden. He will be happier at home and his parents may be glad to have him?both provided that he has some proper occupation and recreation during part of the day?in other words, provided that he can attend an Occupation Centre. He may, in the end, have to return to an institution, when his parents grow old or die, for instance; but why should he not go home for as long as possible if he is temperamentally suitable? This last class is, perhaps, the most important of all, and it is the one which has been least exploited.
Well, this is my concept of the functions of Occupation Centres, I dislike the word, by the way, because it suggests that these places do nothing but keep the defective out of mischief, whereas they provide admirable training for the patients and excellent centres from which the mothers may obtain skilled advice on those problems which arise in the home. Now, I am not going to say anything more about the Occupation Centre as it exists to-day. But I would like to say a word about the Occupation Centre as it may be?as I would like it to be? to-morrow. I would like to see first of all a much closer co-operation between training centre, special school, and institution. At present these three main branches of our mental deficiency service are separate and independent, their efforts are not co-ordinated, and their staffs rarely, if ever, meet. That is all wrong, of course, and for real efficiency there must be a much freer exchange of ideas between us all. Whether this is necessary to centralise our administration further, I cannot say; possibly such a step would lead to too much red tape.
Secondly, I would like to see very much more elasticity in the whole system of dealing with the defective child, in his transfer from one type of handling to another if this is thought to be more suitable. At the moment we have rarely any guarantee, in sending a child home on trial, that anything at all will be done for him in the nature of training. We are naturally hesitant?knowing that he will likely be allowed to drift, and that his mother will find the burden too heavy for her, and that the chances are that he will come back to us?unhappy and unmanageable?in a very few months.
Thirdly, I would like to see a more systematic and a much more skilled psychological service for defectives all round; in School, Special School, Occupation Centre, and Institution, and I would like a very much more efficient record system, so that a child transferred from Special School to Occupation Centre, Occupation Centre to Institution, or the other way round, would take with him an adequate record of his previous history and of the results of his examination by really competent specialists.
Fourthly, I would like to see the Occupation Centre system extended far more widely and exploited more fully. I would like to see it used for some of the lower grade children in the Special Schools and especially I would like to see it used for more adults. True there is even now some more attempt to do something for the adult defective in this way, but with a stronger organisation, and better co-ordination of the services, I feel sure that quite an appreciable number of adult imbeciles, at present in institutions, could be adequately cared for in the community.
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