31 MAY 1957, Page 4


SINCE the Royal Commission on Mental Health was appointed three years ago the climate of opinion on the subject has been gradually chang- ing. The public is now prepared to examine it with much more interest and sympathy. But the fundamental problems remain : and the Commis- sion's report must be judged on how shrewdly it has examined thein. On balance, the verdict must be that it has done well.

Its recommendations may err on the side of caution; but they are on the right track. In par- ticular it is satisfactory to see the importance attached to the need to make admission to mental hospitals not merely voluntary, whenever humanly possible, but, also informal—as informal as admission to general hospitals. The Commission also urges the abandonment of the attitude that a psychopath is not mentally ill—a relic of the old belief that he was suffering merely from a moral defect. In the light of recent psychological re- search this view is no longer tenable; psychopaths ought to be considered just as much in need of care and treatment as any other sick persons.

The initial problem is a legacy from history. Until recently it was assumed that there was a state of madness, in the same sense that there is a state of pneumonia; that it could not be treated; and that the only remedy was banishment from society. Lunacy was thought of as something it was best to forget : unmentionable. This attitude is still sufficiently widespread to make the task of the mental health authorities difficult. They find the public resistant to the now well-established fact that there is no such thing as madness in the old sense of the word : there are a few diseases of the brain and an enormous variety of neuroses. Most mental illnesses are curable if caught in time; only a tiny fraction of them require re- straint. On the contrary : restraint, it is now realised, actually creates mental illness; the aban- don mcnt of lock and key, of straitjacket and padded cell, has been shown to have an immense therapeutic effect.

The problem now is to persuade the public that madness is no longer a serious threat to their safety. And this is largely, as the Commission makes clear, a question of money. The old-style lunatic asylums are utterly unsuited to provide mental treatment, because of their grim institu- tional air. The whole aim of mental treatment, in the great majority of cases, is to bring the patient back to terms with his environment—not to with- draw him from it. Ideally the patient should be kept in his normal surroundings. It is best, if possible, that he should not have to go to hospital at all; that he should visit a psychiatric clinic as often as is felt necessary, and that he should not be any more worried about visiting it than he would about visiting his family doctor. But an enormous amount of money is required to make this conversion possible; and one of the first legis- lative steps needed is to make some of it available. There need not, however, be too great an in- crease in expenditure, if the possibility is followed up that grants be made to help keep people who are mentally ill, but not seriously ill, at home. True, this might lead to some 'fiddling' to get grants, but the saving, by keeping such people—particularly old people—out of mental hospitals, could be very great. And it would also much improve the patients' chances of recovery.

There is, however, another problem, with which the report hardly comes to grips. The medi- cal profession is sharply divided on the subject of mental health treatment. One school advocates physical treatment, by drugs, electric shock, and brain operations; the other insists that treatment should be psychological. The psychological school is itself divided into warring factions, and at present the physical-treatment school has the upper hand. It has also most of the funds. The result has been the growth of what can be an extremely dangerous attitude of mind to mental illness : that the important thing is to get the mentally ill person into hospital and there deal with him by whatever treatment happens to be fashionable.

This is not so : and the reason it is not so can be judged from the case histories in The Plea for the Silent, by Dr. Donald Johnson, MP, and Norman Dodds, MP '(Christopher Johnson, 12s. 6d.), and in Dr. Johnson's article in this issue. There is a depressing tendency for psychiatrists to justify indefensible interference with individual liberty with the help of such words as `disturbed' or 'uncooperative' about patients who, often for perfectly sound reasons, are reluctant to accept treatment. Certification has been widely abused as a means of getting rid of old people who are nuisances.

It is now often easier to get people locked up in a mental hospital than it is to get them locked up in jail. All that is required for certification is the signature of a doctor (who may have no know- ledge of the patient's background, and who may know nothing about psychiatry—very few doctors 41o) and a magistrate (who may know nothing). Instead of trying to find out what stresses have afflicted the patient to unbalance him, doctors are too often tempted to take the easy way out by certifying him, and so shifting the responsi to the nearest mental hospital superintende such circumstances the patient would no human if he did not resist; and it is the indignity that if he does resist, this is u evidence against him should he later try to an action in the courts. But of course such a are rarely'brought, because every solicitor that they never succeed; the courts always gi doctor the benefit of the doubt.

The chief weakness of the report is that it' not seem fully to recognise this danger. It that `compulsory powers should be used in f only when they are positively necessary to ride the patient's own unwillingness or th willingness of his relatives, for the patient's welfare or the protection of others.' But the guard it suggests to make sure this ruling obeyed—that two doctors, one a spec should be consulted 'except in emergenc hardly sufficient. All too frequently psychic have virtually no trailing in psychotherapY; are inclined to think that it could `be good patient to get him into hospital where ht receive treatment—not realising that the fa patient is being taken there by force again will may destroy, at least temporarily, the of treating him successfully, by confirmil belief that he is being persecuted.

And what constitutes an `emergency'/ recent case a horde of police, called ourst° with a deranged man, succeeded only in him to violence—yet he was eventually by a single social worker. Emergencies are often created than prevented by the of powers to arrest and detain mentally people. The Commission would have done: stress this point, because so long as at powers remain in anything resemblin6 present form (no matter what politer 1, substituted), the old stigmas attached to will remain, too.