Lunacy Law and Institutional and Home Treatment the Insane
Being the Final of a Course of Lectures on Psychiatry for Local Secretaries of Mental Welfare Associations delivered at Horton Mental Hospital, Epsom,
- Author:
Lt.Col. J. R. Lord, C.B.E., M.B. (Edin.)
(The Lecturer after having briefly epitomised the provisions of the Lunacy Act of 1890 continued as follows):
It will thus be readily seen that the chief aims of this Act are to secure: (1) That no person is received as a patient into a mental hospital or other approved place unless of a certainty he is a lunatic within the meaning of the Lunacy Act., i.e., an idiot or a person of unsound mind,
(2) That a person so admitted shall be discharged immediately he is no longer certifiable as a person of unsound mind, and a proper person to be detained under care and treatment.
That he is not illtreated or neglected while under detention.
(4) That in case of his death in the mental hospital, the cause and circumstances thereof are the subject of special report and possibly searching enquiry.
It assumes the possibility of moral turpitude, in carrying out its provisions, on the part, of the judicial authority, the patient’s relatives and friends, the doctor, the nurses, the Managers and even the Commissioners. Its attitude is that of suspicion throughout , and threats and penalties are plentiful?quite enough I should imagine to satisfy the most rabid reformer.
The Lunacy Act of 1890 has been much criticized of late, in fact it has become almost fashionable to abuse it. As a legal measure it undoubtedly was most carefully and conscientiously framed. Personally I have a real healthy respect for it in more senses than one and underlying it are many great principles and ideals. It must be remembered, however, that it is a consolidating act and represents, with but few innovations, the English lunacy law as it has evolved since the time of Edward II.
As a measure designed to secure the best treatment of the mentally unsound, it is, however, singularly incomplete. It portrays almost entirely the legal attitude of mind to the insane. The “patient” it deals with means every person received or detained as a lunatic or taken care or charge of as a lunatic (Section 114 of the Lunacy Act, 1845). Pie is not the “patient” in the medical sense. It is not the onset of disease which makes him a “patient” but an act under the law. It is not the cessation of disease which occasions his ceasing to be a ‘ ‘patient” but the failure to find sufficient cause for detention. The medical view of insanity is secondary. Respect for the liberty of the subject Is accounted of more importance than that those who are afflicted with mental disease should have every opportunity of obtaining the best treatment at the earliest possible moment and under the most favourable circumstances for their recovery. There is undoubtedly a legal aspect, and an important one too; the liberty of the subject cannot lightly be tampered with, but the medical aspect of insanity, its prevention, its cure, should be the basis of the law on lunacy.
In effect the attitude the law takes to a person suffering from mental disease is that he shall not enter an asylum for care and treatment unless circumstances force it, nor shall he remain there if it is possible for him to be outside. Nowhere does it urge upon citizens the duty of taking prompt steps for the proper care and treatment of the mentally afflicted; on the contrary, it treats such steps with suspicion and imposes restrictions; so much so that those primarily concerned, i.e., the patient, his medical attendants, and the patient’s friends and relatives, avoid invoking the law’s aid. Lunacy is a contamination and anathema to many medical men and they decline utterly to have anything to do with it.
The Lunacy Act gives only a meagre recognition of the onset or early stages of mental disease and of the stage of convalescence. The “Urgency Order” machinery which is meant to “secure the speediest possible treatment of the first symptom of derangement” is either a seven-day measure or a prelude to full certification, and this procedure is limited to patients with means. A poor person who can be certified as of unsound mind, but who is sufficiently cognisant of the state of his mind to enable him to seek admission into one of the 97 county or borough mental hospitals, cannot, without infringement of the law, be received there until he has been duly certified as of unsound mind, and, until a justice’s order has been ontained for not only his reception and retention, but for his detention too. (Vide Dr Bond’s Presidential Address to the Medico-Psychological Association, 1921). Only those registered hospitals and licensed houses with provided accommodation can admit him as a voluntary boarder. The “urgency machinery” in the case of a pauper or poor patient is admission to the workhouse through the kindly intervention of a constable or relieving officer or overseer of a parish, and subsequent certification.
As regards convalescence the “absence on trial” the Lunacy Act permits depends upon the patient being still certifiable, i.e., still of unsound mind and a proper person to be detained under care and treatment. Time does not permit of my discussing this subject more exhaustively, but briefly the I junacjr Act wants “completing,” as it were, at both ends, in order to cover more appropriately and effectively the early stages of mental disease and the convalescent period. Much of it needs also recasting to bring it more within the spirit of the times. Why a hitherto respectable citizen, immediately he has to handle a lunacy matter in any capacity, should at once be regarded by the law as being capable of the deepest villainy I cannot conceive. To-day such an attitude to the practice of psychiatry is surely an anachronism, at least, let us hope so.
My own views put shortly are:
(1) That all institutions, hospitals, homes, etc., treating mental patients free or for profit should be licensed, registered, and subject to periodic inspection by some central authority. (2) That all admissions thereto which arc not voluntary should be notified to some central authority with discretionary power to investigate and act. (3) That no person who objects to indoor mental treatment and loss of liberty for the purpose should be sequestered without the sanction of the law. Let us hope that the future evolution of the lunacy law will be along these lines.
You will no doubt, in the course of your labours, often meet cases of slight mental breakdown or even cases of definite insanity in its early stages. I have already discussed with you five types of borderland cases. I have also pointed out that such cases can readily be confused with the types of cases you as Voluntary Associations are designed to deal with under the Mental Deficiency Act of 1913. Indeed, in many instances there is no clear distinction to be drawn between them except the previous history?which maybe imperfect. Thus you may be asked to express an opinion as to whether the case is one for home or mental hospital treatment.
Now the universal experience in mental hospitals is that the cases which recover are those of short duration prior to admission. The longer the patiert who is ultimately admitted is kept away from us the fewer the prospects of recovery. At the same time there is undoubtedly a “stigma” attached to an ex-mental hospital patient.
By avoiding mental hospital treatment, the case may become a hopeless one; by adopting it, a life may be partially wrecked. Thus the real difficulty is this ‘stigma” which seems ingrained in the minds of the people. Only a bold attempt to teach the rising generation better ideas regarding insanity will remove it. The educational code of our national schools should decree a course on both mental and physical hygiene for senior pupils, and children should all be taught that:
Mental disorders are as common and as natural as common colds;
(2) That mental and physical hygiene are one and the same problem and that such terms as “general debility,” “run down,” “fed up,” “need a change” are descriptive of mental exhaustion and that insanity is only mental breakdown of a more severe character ; (3) That mental hospitals are merely special hospitals for the treatment of severer forms of mental complaints and the physical disorders which accompany them; (4) That superstitious views regarding insanity or mental disorders belong to the past and that the adopting of a superior, a scornful, a ridiculing, or humorous attitude to an insane person or one who has been mentally unsound is both unkind and foolish, prevents the early treatment and recovery of such cases and favours the accumulation of incurable insanity which is a burden to the community.
Now, if these notions were to prevail generally among the community most of he troubles regarding the treatment of mental diseases would disappear. It would not matter a button where a patient was treated or what the institution was called so long as the most effective treatment was secured.
Another point you should bear in mind when considering institutional v. home treatment is that a depressed state of mind carries with it possibilities of suicide. In other words all melancholies are potential suicides. If the risk is taken in such cases and the patient remains at home for treatment certain precautions are wise. They must be tactfully carried out. A ground floor bedroom should be selected, suggestive weapons and all keys should be removed and the bolts on the inside of doors rendered non-effective. Continuous observation is essential, but it is difficult to carry out in a private house. As regards a deluded patient, should he show any tendency to take action as an outcome of his delusions, confinement in a mental hospital is absolutely necessary.
Remember that when a hitherto respectable and orderly citizen becomes a “wrong ‘un,” begins to speculate and develop extravagant habits, becomes a devotee at the shrines of Venus and Bacchus, and coquettes with the bankruptcy or divorce courts, these may be the early symptoms of mental disorder and something more serious than ‘ ‘wickedness.’’ Urge in such cases a medical examination if only for the sake of his wife, children and other relatives.
Again, it is often necessary and in many cases imperative that marital relationship should cease when signs of mental breakdown appear. It is a difficult matter to separate the sexes in a private house and home treatment may entirely fail for this reason.
If in grave doubt, the case might be referred to the special outpatient department for nervous and mental disorders attached to several of the general hospitals or to the Maudsley Hospital for advice.
There is really very little to say in favour of home treatment, especially in the case of the poor. It is often quite impracticable, because working class families look askance at any cessation of work on the part of the bread winner for any reason other than physical. Home treatment, in fact, would never be even dreamt of if people had confidence in the mental hospitals.
To combat this want of confidence:? (1) Mental hospitals should, as far as practicable, be thrown open in the same spirit as are the general hospitals and the cleansing and stimulating influence of a correctly informed public opinion brought constantly to bear upon mental hospital care and treatment. Mental hospitals should be part and parcel of the everyday life of the community and not an excrescence hidden away and remote from the public eye;
(2) The welfare of every mental hospital patient should be considered as a communal responsibility. Broadly speaking, the influences which cause mental breakdown are cosmic in addition to being individual. The insane, as a class, are people broken on the wheel of the fierce struggle for existence and each of us by our survival contributes to the slaughter. About no section of the community can we less dare the query “Am I my brother’s keeper?” Under the Common Law, the King, the Head of the Nation, is the general conservator of his people and Guardian of the Insane. What title can he be more proud of? Yet many of his subjects, howbeit kindly treated, languish in our mental hospitals absolutely friendless. It should not be; no patient should be friendless. Can any worse calamity be imagined than being afflicted with unsoundness of mind? It cuts at the root of everything life stands for. When those so afflicted have no relatives or friends other than professional custodians to take a kindh interest in their welfare, a spirit of thankfulness that this terrible fate has not fallen to our lot should bear fruit in the form of practical altruism. What better direction could this take than the “adoption” of these mental derelicts by kindly disposed and charitable individuals ?
(3) In addition every mental hospital ward or convenient group of wards should have its social visitor. I am not advocating the advent of a crowd of fussy, unbalanced men and women, but of level headed, discreet and kindly women, and in some cases men, with some idea of mental disorders, who would bring into our wards regularly a breath of fresh air from the outside world to combat institution conventionality and narrowmindedness. These social workers, failing others, would pay particular attention to friendless patients. They would act as a communicating link between the patients and their homes. They would gather reliable information regarding the patients’ home environment of great value to the Medical Officer and thus help him materially as regards causation, treatment, and subsequent disposal of the patients on recovery. They would interest themselves in the social life of the wards, the entertainment and recreation of the patients, and be a consolation and comfort especially to those confined to bed for physical reasons. I am glad to say that with the permission of the London County Council Mental Hospitals Committee, we have made a move in this direction at this hospital by the appointment of Miss V. M. Dale as Hospital Visitor. She is gathering experience and exploring the directions in which she can be useful and will train others in due course. I hope this movement will spread. One of the reasons why I so readily welcomed you here was that you should hear of this good work and help it forward. It is another way in which the public can be brought into closer touch with the mental hospitals. Such social workers in our wards, when they spoke?say in annual conference?the public would listen to and have confidence in what they said. How can the public rely upon what many of the so-called reformers say, many of whom know not the insane, and have never been in a mental hospital except perhaps when handicapped by a disordered mind.
Now a few final remarks before we separate. —————————————–The establishment of a new group of institutions for the treatment of incipient insanity is advocated?asylums really but with camouflaged names. I am not in the least opposed to them?rather the contrary?but this step will not settle the problem In a few years they will be tainted places just as the present mental hospitals are m the public estimation. Other and still more camouflaged institutions will then be called for. No, the questions first to be answered are “What is wrong with our public mental hospitals?” “Have they failed, and if so why?”
Obviously in a measure they have, for there is a vast held of mental work they scarcely touch. Why do they fail ?
(1) Because of the continuance of public ignorance as to what insanity really is and the prejudiced attitude the public adopts to the insane and the ex-mental hospital patient.
(2) Because the mental hospitals are too much bound by law and rule. They are not free to experiment, expand, evolve, and progress with the general advancement of medicine like general hospitals. Liberty and money are necessary for progress.
Wliat is required to make the public mental hospitals really efficient ?
(1) They need public sympathy and support. They want the public with them and not against them. They work too much in isolation and secrecy and are thus easy victims to misrepresentation and abuse. There should be more opportunities for public co-operation with and for public criticism of and public appreciation of, the work of the mental hospitals.
(2) Old and out of date mental institutions should be abolished and replaced by smaller mental hospitals of modern type.
(3) There should be better provision in all mental hospitals, preferably in detached buildings, for the treatment of voluntary boarders and incipient insanity, and the law altered to permit of this. (4) Propaganda against public prejudice and superstition as regards mental disorders and the insane.
(5) More freedom for districts to adopt their own measures for the care and treatment of the insane, measures best suited to district requirements, and subject only to national control on broad lines (vide ” General Improvement in Lunacy Administration including the Grouping of Areas for certain Purposes.” Proceedings of Lunacy Conference, 1922.
This brings our course to a conclusion. You have been very welcome and your visit has given the hospital the greatest pleasure. There is no doubt in my mind as to the essential unity of problems of mental deficiency and mental disorder, and there is everything to be gained by a unity of forces. They have both the same object in view that the mental hygiene of the community should progress pari passu with the progress of science, education, and political economy in order that these may be made the best use of to promote happiness and human efficiency and not become destructive of human character and instruments of mental regression.
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