WELFARE STATE
Mind—your own business
Jef Smith
Some years ago it was a favourite gimmick Of advertising agents to boost a campaign on a product by mounting a special ' week ' when the saleable item in question was pushed for multimedia coverage. This tiresome trick seemed to be discontinued, as I recall, soon after Michael Frayn wrote a piece on the thankfully mythical Dried Pea Week. Charitable organisations, however, who were just clambering aboard the bandwagon when their commercial colleagues dropped off have kept the tradition alive. Within the last few months we have had National Dependants Week, Friendship Week (for handicapped children) and Help The Disabled Week, and in case you haven't noticed it you have just lived through MIND Week. Like the church's calendar in their recurrence, this sequence of campaigns by voluntary organisations serves at least to remind us, fleetingly and Just once a year, of the depth and variety Of problems faced by the neighbours to Whose fate but for the grace of God go I. Perhaps in an increasingly secular society, it would do us good to fill out the diary With a few of the even less fashionably disabled groups. For the next few years at least, the National Association for Mental Health, MIND's sponsor, intends to upset us regularly between about Harvest Vestival and Michaelmas with the uncomfortable reminder, to quote one statistic, that one in seven of today's schoolgirls Will suffer a mental breakdown at some stage of her career.
Since the 1959 Mental Health Act, attitudes to people we call "mentally ill ” -I quarrel with the terminology but will return to this point — have changed Progressively if not as rapidly as would have been desirable. The trend has been away from compulsory admissions to hospital, away from the Victorian asylums that circle London and other major cities O n top of the ring of hills beyond the nineteenth century town boundaries, away as far as possible from the institutionalising routine of hospitals altogether. It has been less clear what the trend has been towards except that the sacred catchPhrase has been 'community care.' Sometimes community care has seemed to Mean minimal domiciliary attention — keeping the sick person in his own home, hopefully in his own family, accepted. (even more hopefully) by his own neighbours and workmates. At its worst
this has been mere callous money-saving, thrusting the possible patient straight back into the situation that provoked his disorder with only an occasional visit from a social worker or GP and a bottleful of drugs to keep him steady. At its best of course, it has prevented the terrible process by which moderately disturbed people become increasingly and eventually incurably disturbed through the very process of being incarcerated in an establishment as basically abnormal as a mental hospital.
Ideally, community care has involved not a retreat from the use of all institutions but the development of a flexible programme in which the available range of care includes hostels, half-way houses, recuperative units and theropeutically run hospitals as well as support services to patients in their own homes. There was, however, one major organisational problem which arose, like so many of our ills, from the tripartite structure of the health service. A psychiatric patient would probably take his initial troubles to his own family doctor and most GPs operate in effect as one-man businesses. If admissions to hospital or out-patient treatment was indicated, care passed to a separate branch of the health service. Compulsory admission and follow-up aftercare fell to yet another group, the health departments of the local authorities. It required a very sane and level-headed patient to find his way through this maze of apparently unrelated helpers.
As far as services for the mentally ill are concerned the Seebohm Report made the picture even more complicated,. The problem of a mentally disturbed person in a family, Seebohm argued, requires the same sort of measures as those needed to help clients handicapped in other ways; mental health in the community should be the responsibility of the social services department. Personally I am far from inclined to argue with that conclusion, but it is difficult to deny that over the short term the development of interdisciplinary teamwork which is vital to a comprehensive service has received another setback. Mental health was easily the smallest of the three departments which were brought together to form social services and as a result there are few people in senior posts, and almost no directors of social services, with recent professional experience of providing psychiatric services.
By and large the doctors, particularly those in public health, opposed the transfer of mental health facilities to the new social services departments. After licking their wounds for a year or two, the medical officers have lately been in full cry again. This year's BMA conference heard some strange atrocity stories from north London, the Royal College of Psychiatrists sponsored a critical working party report which came out in June, and just a few weeks ago the superintendent of a Yorkshire hospital delivered the sharpest broadside of all at a meeting of the Royal Society of Health. Many of the problems complained of, however, can properly be traced to the mere problems of transition; the longer term worries like the shortage of residential hostels for both mentally ill and mentally handicapped patients date from underinvestment during the period in which the services were medically run. And if the average social worker is less than fully expert in mental welfare problems he is at least as well briefed as most GPs.
" How ", asked Dr Bickford of Hull at the RSH meeting I mentioned, "does an illness become a non-illness?" He was meaning to place doubt on the competence of a mere social worker trained in psychology, sociology and administration to deal with areas regarded until recently as the preserve of the medically qualified, but he touched on a basic philosophical question. It does not require adherence to the thorough-going analysis of the anti-psychiatrists to recognise that there is a great deal in the conventional practice of medicine that is at best irrelevant and at worst positively misleading to a true understanding of mental disorder. The white coats worn in hospitals lose any physical function but serve insidiously to mark off the sane from the mad. The exhortations to trust the therapist and relax to await cure may be precisely wrong for a psychiatric patient who needs above all to be motivated to help himself to recover. The very strangeness of institutional routine, tolerable perhaps over a short period of physical illness, can overlay a psychiatric condition with a maladaptation worse than the original disturbance. To many of the problems of those we perforce still call " mentally ill," medicine has little to offer other than merely repressive medication. It may be that in due course we will recognise the social work model as equally irrelevant, but for the moment it gives us a vital chance to see conditions through a new perspective. In various periods of history the mentally non-conforming have been regarded as wicked, as devilpossessed, as objects of ridicule, as divine; one day we may feel it just as unhelpful to have thought of them as sick.
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