CONDITIONS IN MENTAL HOSPITALS
LETTERS TO THE EDITOR
[Correspondents are requested to keep their letters as brief as is reasonably possible. The most suitable length is that of one of our " News of the.Week" paragraphs. Signed letters are given a preference over those bean( ig a pseudonym, and the latter must be accompanied by the name and address of the author, which will be treated as confidential.—Ed. THE SPECTATOR.] [To the Editor of THE SPECTATOR.] SIR,—I am glad that Miss Sturges has written to point out the overcrowding and other abuses which prevail in the mental hospitals. It is sad enough that some unfortunates have to be shut away from the outside world, but that they should be crowded and deprived from many of the elementary decencies is deplorable.
The abuses are not the fault of the medical officers who have officially about 400 patients each to control, but actually have to treat many more since illness, holidays and so on cause extra work, and the Superintendent and Assistant Superintendent in some hospitals have charge of no wards, but are concerned with the endless administration which fritters away so much time. It is incredible that the Superintendent should have to concern himself with the quantity of cow-cakes ordered on the farm, and have to investigate why one ward uses a cake of soap more than another one, but such things actually occur. The injuries of patients are correlated very exactly with the number of nurses on duty—in crowded under-staffed wards the patients fight and injure themselves, in spacious well-staffed wards they can keep away from each other and fights are stopped by the nurses before they become serious. Although there may be exceptions the average mental hospital physician and nurse are conscientious men trying to work under difficult conditions and only too often rewarded by abuse.
The remedy for the undoubted crowding is to certify as few patients as possible. Only those who are definitely suicidal or homicidal and who refuse to enter a hospital as a voluntary patient should be certified. The person who enters a mental hospital as a voluntary patient has his remedy for unsuitable conditions or treatment by refusing to stay (he can leave after three days' notice if he wishes and, moreover, has more oppor- tunity of making his complaints heard by the Superintendent). I find in -practice that patients rarely refuse to enter as a volun- tary patient if the matter is explained to them properly, and although I have seen a large number of insane patients (some of whom I persuaded to enter hospitals for treatment) I have not found it necessary to certify a patient during the last two years.
The tragedy of the 193o Act is not that patients are ill-treated, but that there is so little treatment for the insane when they do enter hospitals. The available treatment is (a) drug therapy —sedatives or continuous narcosis ; (b) occupational therapy— the making of rugs, mats and carpentry, &c. ; (c) physio- therapy—sunlight, exercises, and so on ; (d) psychotherapy. The use of drugs has, unfortunately, been disappointing. Occupational therapy may divert the patient's thoughts from his superficial worries, but does not attack the basic causes of his illness. Physiotherapy improves the physique, and so gives the mind a better chance, but it is only in psychotherapy that the basic causes of insanity are attacked. It is too little understood that in all functional psychoses we are facing the difficulty of a mind which has been damaged in childhood, trying to adjust itself to an • environmental problem at the present time. Too often the environmental problem is dis-; regarded, so that a patient is-discharged after the isolation from his environment has caused improvement, but owing to the lack of social workers and psychiatric investigation nothing has been discovered of the environment which made him ill. He returns to the drunken wife, the hated occupation, or what not, and as a result breaks down again. This environmental problem has been better attacked recently, but the psychiatric social worker is still a rara avis in many mental hospitals, and where there is one her help is too often disregarded.
The basic problem is how to cure or prevent the damage to the mind. This can best be done in early childhood, and if more attention were paid to the presence of personality- defects in childhood the occurrence of insanity in later life would be lessened. For instance, Kasanin and Veo in America found that 5o per cent. of the patients suffering from insanity, in a series investigated by them, showed either a " shy with- drawn " personality or else an " odd, queer " one. This was marked enough to notice when at school.
Those who show the early signs of mental illness will often respond to psychotherapy—this partictilarly applies to de- pressives. Too often, however, the relatives look on such cases as being worthy of contempt and nothing is done until frank insanity appears. Very often a psychosis appears, first, as a perversion or " sexual crime " such as exposure. If, instead of giving these sufferers a prison sentence, they were given the rhanre of treatment they would have an opportunity of ridding themselves of their anti-social behaviour and, also, of safeguarding themselves against insanity. The absurdity of the law in such cases is shown by a case which I was investi- gating with a colleague. Before I had a chance to examine this man (who was suffering from homosexuality) I heard that he was in the hands of the police. My colleague and I wrote long reports and, instead of the judge sentencing him to prison, he (quite illegally) sent him to a mental hospital for treatment. The man went there under protest, but was dis- charged after some months' detention, during which the only curative measures taken were "custodial treatment." He is now under the care of the Institute for the Scientific Treatment of Delinquency. I have seen a man in a mental hospital who had six attacks of mania, five following homosexual affairs and one following an heterosexual one, but no one had taken the trouble to find out why he had had these attacks before I did so.
Let us be observant to prevent mental illness in its earliest stages in the personality-defects of children, let us treat the first signs of " queerness " in the young man or woman, and let us give every psychotic we can the benefit of psychotherapy, and we shall have few that we must certify and shut up forcibly. Those unfortunates who must be put away frequently improve, and if they could be returned to a more fortunate environment there would be fewer relapses. Above all, let the authorities encourage and subsidise research and we shall have emptier mental hospitals and a happier nation.—I am, Sir,
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