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The mental treatment act, 1930
2,~o
PUBLIC HEALTH.
MAy,
T h e M e n t a l T r e a t m e n t A c t , 1930. By- Sir [[UBERT BOND, K.B.E., D.SC., M.D., F.R.C.P., Commissioner of the Board of Control; and P. K. McCowAN, M.D., M.R.C.P., D.P.M., Medical Superintendent, City Mental Hospital, Cardiff. The Mental Treatment Act is another added to the increasing number in the administration of which the medical officer of health may be given concern, and the following contributio~Ts, submitled at the December meeting of the Society by two distinguished alienists, will be read with interest as casting light on some points of difficulty. SIR HUB:ERT BOND. ~HILE psychological medicine must, Sir Hubert said, perhaps always be a specialty, any water-tight compartment was not in its best interests or in those of the patients under its care. The enthusiasm for prevention must not be pursued at the expense of ti'eatment; he or she who. was ill cared nothing for prevention. Measures primarily and essentially preventive sometimes involved controversial sociological considerations, and impatience, although perhaps laudable, was apt to urge trial of what seemed to be short cuts to prevention. The speaker admitted that he shrank from this method of approach. There were other methods which, tho.ugh less spectacular, were to be preferred because of their essential soundness--e.g., treatment of disease in an incipient and inchoate early phase, Legislative freedom and medical facilities fo.r this early treatment constituted the cardinal features of the Mental Treatment Act, 1980. Prevention was confined to a small paragraph. The Act as a who,~e, when brought into full force, would, however, prove to be a preventive measure of-the highest potency. The Act was an amending Act to the previous Lunacy and Mental Deficiency Acts. It widened the scope of voluntary treatment, thereby avoiding certification and giving a great incentive to early treatment. It created a new s t a t u s - - - t e m p o r a r y treatment without certification. It considerably widened the scope of the local authorities, and gave statutory recognition to out-patient treatment, after-care, social services, and research. It was disappointing to notice how slowly advantage was being taken of the revised U r g e n c y Order. The battle in mental treatment was more than half won when the patient's voluntary co-operation was obtained. It was important not to jump to the conclusion that certification connoted absence of recoverability, although manifestly the greatest pro-
W
portion o.f recoveries would be found among the voluntary and tile temporary classes. If the percentage of recoveries in the three classes were compared, however, the certified would not show up at all badly. Indeed, the very act of certification, cutting the Gordian knot o.f family complications and enforcing firm medical control, was a very valuable form of treatment. In some alcoholic patients it brought about lifelong total abstinence. Nevertheless, in most cases certification was a great handicap to treatment in the first months of the illness. H e believed that out-patient treatment in properly organised centres was the greatest factor in preventive rnental treatment. DR. McCOWAN. Menlal Out-patient Clinics.--The passing of the Mental Treatment Act has undoubtedly commenced a new era in the treatment of mental disease. It is probably no exaggeration to say that it is the greatest advance since the days, one hundred years ago, when Pinet in Paris and Tuke in York removed the chains from their insane patients. Past legislation has been under the domination of the lawyer with his pre-occupation with the liberty of the subject; but the present Act reflects rather the dynamic approach of the physician, with the consequence that the primary object of the psychiatrist is no longer the custodial care, but, instead, active treatment of his patients. I feel certain that mental out-patient clinics will play a very important part in this treatment. Apart from the very great benefit which the patients attending will receive, these clinics should prove important co-ordinating links between our mental hospitals on the one hand and the various mental hygiene movements in the general community on the other. Properly administered, they should prove a great influence for good in educating not only the public but also the medical profession to
1932.
PUBLIC HEALTH.
the importance of mental hygiene in general, and the early treatment of mental disease in particular. T h e subject could be approached from many angles; but, in the short time at m y disposal, I thought it would be as well if I confined myself to two aspects o.f it, namely : L - T h e patients dealt with as regards their (a) type; (b) source; and (c) disposal. I I . ~ T h e preliminary organisation of a mental out-patient clinic on a small scale. I.
(a) T y p e . - - T h e type of patient dealt with at an out-patient clinic can be divided roughly into two classes--psychotics and neurotics. At present, with the psychotic or po.tentially psychotic class, what happens is that if the patient is a man o.f small means he cannot afford skilled attention in the early stages of his mental breakdown; and, as his physical health is not necessarily impaired, he carries on until his disease is well advanced. The final result, as we know, is inevitable remm~aI to a mental hospital. The early treatment of this type of person has two advantages. In the first place, it may lead to cure, rendering institutional care ~unnecessary. In the second place, even if removal to a mental hospital should ultimately become necessary, he has been under skilled o.bservation at a stage when he is often most dangerous to himself or to others, such danger including" not only physical violence but also such things as financial ruin or domestic upheavals. That the state of affairs is serious and calls for active measures is strongly suggested by the knowledge that there are 6,000 cases of actual or attempted suicide in England and W a l e s every year, and that nearly one-half of all persons arrested for murder are ultimately found to be insane. This, taken in conjunction with the fact that the vast majority of these people make such suicidal or homicidal attempts before any question of mental treatment has arisen, shows the importance of trying to institute something which aims at encouraging early treatment of these conditions. Here, coroners could render a real service. In the evidence given in their courts in cases of suicide, it is usually abundantly clear that the deceased had sho.wn definite signs of mental abnormality prior to the suicidal act.
231
If coroners would enquire as to what steps had been taken to have the person treated, and point out that out-patient clinics were available for such purposes, the press reports of the cases could not .fail to impress the lesson both on tile public and on the members of the medical profession who meet such cases. Our second group of patients form the majority of the clinics' clientele. T h e y are sufferers from what may be called minor mental ailments, such as hysteria, neurasthenia, various anxiety states and mild depressions. Next to common colds, these comprise the commonest diseases to which man is heir, and are the cause of incalculable human misery, largely preventable. At present they have practically no treatment, and, even from their medical attendants, not much s y m p a t h y or understanding. (b) Source.--Patients come mainly from one or other of the following sources : - (1) Majority from local general practitioners. (2) Other clinics, e.g., child guidance, school clinics, social welfare societies. (3) Cases referred from the courts. (4) Other departments of the hospital where out-patients are being seen. (5) Patients on trial or discharged from the local mental hospital. This last is a very important function of tlie clinic, and has a definite bearing on the question of the clinic's personnel. Apart from the more important humanitarian point of view of benefit to the patient, I think I might justifiably emphasise here the economic aspect of the clinic, as this group lends itself to easy demonstration of this point. In the first place, cases can be sent out on trial from the hospital at an earlier date, as they can still be kept under observation at the clinic; and, in the case of those numerous patients subject to recurrent attacks of excitement and depression, they can take advantage of the clinics to seek advice whenever they feel an attack impending. T h e y are advised to do so when at the mental hospital; and, as they and their relatives usually know from bitter experience the symptoms premonitory to a full-blown attack, one has little d i ~ c u l t v in convincing such patients of the advantage of attendance at the clinic; and now that we can admit such patients on a voluntary basis into our mental hospitals, such attendance is even more important. (c) Disposal. - - This, naturally, depends
232
PUBLIC HEALTH.
chiefly on the type of case; but other factors - - s u c h as distance of patient's home from the clinic, the views of tile practitioner sending the case---enter into the disposal question. R o u g h l y , five chief methods are available . - (1) Return to practitioner for treatment, with a report. Some clinics confine themselves to this, which, in my opinion, is unfortunate if the clinic is willing to do more. (2) Treatment at the out-patient clinic, with consent of general practitioner. (3) Transfer to mental deficiency authority in case of mental deficients. I did not deal with group (3) in describing the type of case dealt with at the clinic. The straightforward mental deficients cannot be treated at the clinic, but they appear there in fairly large numbers. In (1) and (2) we have anxiety cases, obsessions, phobim, mild depressions and certain other psychotics best so treated. (4) In-patient at general hospital. Unfortunately, the beds of an ordinary general hospital, as at present administered, are neither freely available nor very suitable for the nursing of our class of patient, although they are undoubtedly useful in organic cases, e.g., for laboratory tests or the malarial treatment of cases of general paresis ; but this, of course, depends on local conditions, and, if a few beds are available, they should undoubtedly be accepted. (5) In-patient at mental hospital. This last depends partly on the type of case and equally on the reputation of the mental hospital. At Cardiff 1 have found no difficulty in persuading ordinary neurotics to enter the mental hospital as voluntary patients; and I may say that no mental hospital will enjoy such a reputation uniess by contact with the public and general practitioners through extramural clinics. This category includes not only psychotics requiring in-patient treatment, but also neurotics who require change of environment, regulated occupational therapy, or deeper mental analysis than is possible at an trot-patient clinic. II. I now pass on to the question of organisalion of the mental out-patient clinic. Such a clinic may be of four kinds, namely, in connection with a general hospital ; in connection with a municipal hospital; in connection with a mental hospital; or in connection with a special psychiatric hospital, such as
MAY,
the Jordanburn in Edinburgh or the Tavistock Clinic and the Maudsley Hospital in London. All have their relative advantages and disadvantages, but there is little doubt that the chief development will be in connection with our big general hospitals. The advantages of the latter are that patients will more readily attend a general hospital, and also that here other specialists and laboratory facilities are readily available. Failing the general hospital, the local municipal hospital could be used ; but, without entering into this controversial subject, I would state that, in my opinion, the clinic would be more likely to prove a success at the general hospital. Again, however, I make this statement in a general way, and agree that special local conditions may well make the municipal hospital preferable. The question of payment for medical services comes in here. Personally, I see no reason why the staff should be on any different basis from other members of the honorary consulting staff of the general hospital. This, of course, means that the medical officer of health would have no control over tile clinic; but then, there is no reason why he should. Presumably, all he is interested in is the provision of a means of improving the mental hygiene of the community he serves, and if he is satisfied that an efficient clinic is operative, his responsibility ends. Of course, if tile clinic is at the municipal hospital, the staff would naturaIly be paid, on the grounds that here no work is carried out on a voluntary basis. tf it is decided to run the out-patient clinic in connection with the mental hospital, then it would probably be advisable to obtain a room outside the mental hospital, on the lines of an ordinary surgery, as there is no doubt that it would be much more difficult to get patients to attend at the mental hospital itself. As regards the fourth kind of out-patient clinic, viz., that in connection with a special psychiatric hospital, this, of course, is the ideal arrangement; but, unfortunately, the question of expense makes this prohibitive in most areas at present. W e hoge to start one such clinic with twenty-odd beds in Cardiff in the near future. Clinic personnel can be dealt with under two heads--(1) medical; (2) social worker. (1) Medical.--I have already stated that the medical superintendent of the local mental hospital should be in charge of the clinic; and
1932.
PUBLIC HEALTH.
I r e p e a t t h a t this s h o u l d be so u n l e s s t h e r e a r e special local conditions, s u c h as t h e availability of p r i v a t e c o n s u l t i n g p s y c h i a t r i s t s . E v e n then, the medical s u p e r i n t e n d e n t s h o u l d b e r e p r e s e n t e d on the staff, as a liaison b e t w e e n the clinic a n d the m e n t a l hospital is essential if the full benefit of the clinic is to be f o r t h c o m i n g . O f course, the medical officer of health will o n l y h a v e a d v i s o r y p o w e r s a s r e g a r d s p e r s o n n e l if the clinic is r u n on a v o l u n t a r y b a s i s ; b u t he s h o u l d be insistent on the a d v a n t a g e s of c o n t i n u i t y of t r e a t m e n t u n d e r the s a m e medical m a n , b o t h for the p a t i e n t e n t e r i n g the m e n t a l hospital f r o m t h e clinic, a n d for the p a t i e n t d i s c h a r g e d f r o m the m e n t a l h o s p i t a l to the clinic. T h e o u t - p a t i e n t clinic is the c a t c h m e n t a r e a for the v o l u n t a r y p a t i e n t u n d e r the new M e n t a l T r e a t m e n t A c t ; a n d a p a t i e n t will m o r e readily g o to t h e m e n t a l h o s p i t a l if he k n o w s he will b e u n d e r the care of the doctor w h o h a s p r e s u m a b l y g a i n e d his confidence at the clinic. A n o t h e r p o i n t in f a v o u r of the clinic b e i n g r u n f r o m the m e n t a l hospital is that, except at the v e r y b e g i n n i n g , it will not be p o s s i b l e for one a s s i s t a n t medical officer to d o the w o r k ; a n d I s h o u l d i m a g i n e it would be v e r y difficult in m o s t a r e a s to find m a n y medical m e n with the n e c e s s a r y e x p e r i e n c e outside the m e n t a l h o s p i t a l s . F o r e x a m p l e , at Cardiff I h a v e t h r e e a s s i s t a n t s . I see all new cases myself, g i v i n g on a n a v e r a g e a n h o u r to each, a n d decide w h a t I c o n s i d e r to b e the b e s t line of t r e a t m e n t . T h u s , p a t i e n t s w h o al-e to continue a t t e n d a n c e at tile clinic are h a n d e d o v e r - - m a l e s to the m a l e medical officer, a n d f e m a l e s to a f e m a l e medical officer. W e h a v e t w o sessions w e e k l y . (2) Social Worker.~A social w o r k e r is really essential if full benefit is to be d e r i v e d f r o m the clinic. H e r visits to the p a t i e n t s ' h o m e s e n s u r e m u c h essential i n f o r m a t i o n a b o u t f a c t o r s w h o s e correction m a y be necess a r y for the p r o p e r m a n a g e m e n t of the c a s e ; for e x a m p l e , the q u e s t i o n of t r o u b l e s o m e n e i g h b o u r s m a y h a v e to be dealt with, or d o m e s t i c t r o u b l e s with h u s b a n d a n d children. S h e s h o u l d be in a t t e n d a n c e at the clinic p r i o r to the arrival of the psychiatrist, so t h a t she can take histories of new cases. S h e s h o u l d b e m a d e r e s p o n s i b l e for the k e e p i n g of records, which, of course, need not be at all e l a b o r a t e . I c a n n o t e m p h a s i s e too s t r o n g l y t h a t n o e l a b o r a t e a r r a n g e m e n t s are n e c e s s a r y for s e t t i n g u p a m e n t a l o u t - p a t i e n t clinic, a n d the a b s e n c e of b e d s a n d social w o r k e r s n e e d b e
2aa
no b a r . T h e s e can well be left until after the clinic is e s t a b l i s h e d a n d h a s p r o v e d its utility. F i n a l l y , m i g h t I s a y that, in m y opinion, the m o s t fruitful line o f a t t a c k for the f u t u r e will be a l o n g the lines of p r e v e n t i o n ; a n d this even m o r e so t h a n with p h y s i c a l diseases such as tuberculosis, cancer, etc. T h e r e is little h o p e of m u c h s a v i n g in the e i g h t or nine million p o u n d s s p e n t a n n u a l l y in l o o k i n g after those s u f f e r i n g f r o m m e n t a l disease if we confine o u r m a i n a t t a c k to the c o m p a r a t i v e l y a d v a n c e d cases a d m i t t e d to o u r m e n t a l hospitals. T h e w o r k of the future m u s t be l a r g e l y e x t r a - m u r a l a n d m u c h of it will require the closest liaison b e t w e e n t h e p r a c t i s i n g p s y c h i a t r i s t a n d the medical officer of health. DISCUSSION. The President (Dr. C. Killick Millard) said that the
subject of mental disease had not hitherto concerned the medical officer of health very closely, but in the future, he would have to take more interest in it. Lieut.-CoI0nel F. E. Fremantle, M.P., explained that the main difficulty in passing the measure-the great possibilities of which had been expounded in principle by Sir Hubert Bond, and in practice by Dr. McCowan--had been the idea of treating the matter as an illness instead of as a problem of protection of the community from a dangerous individual and a dangerous individual from himself--the original basis of lunacy treatment. Speaking from the point of view of the ordinary medical officer of health, he rejoiced to see that there was a reality in the treatment, and the hope of prevention of serious mental trouble in many cases. He imagined that the future would see a great increase in nervous breakdown and the need for some kind of rest-home or medical monastery to which people could retire to recover from the surfeit of intellectual activity. Out-patient departments were most valuable units in the scheme of mental treatment, and the extension of the work in that direction should make a strong appeal, more particularly as they were relatively inexpensive. Dr. E. H. T. gash (Heston and Isleworth) asked how far the general medical practitioner could be used in the treatment of mental disease. Sir Hubert Bond, in reply, said that the question of the general practitioner was one of enormous importance : the treatment of the mental case could not be denied him if he could do it, but fellow practitioners would not appreciate a man claiming special knowledge of mental disease and at the same time carrying on general practice. He was extremely glad to learn that the bulk of D r . McCowan's clinic cases came from general practitioners. Dr. McCowan added that in 1931, actually 40 per cent. of the patients admitted to the Cardiff City Mental Hospital came as voluntary patients, thus showing that the Act was a live force. A vote of thanks to the principal speakers, proposed by the President, and seconded by Dr. Nash, was carried by acclamation.
PUBLIC HEALTH.
MAy,
T h e M e n t a l T r e a t m e n t A c t , 1930. By- Sir [[UBERT BOND, K.B.E., D.SC., M.D., F.R.C.P., Commissioner of the Board of Control; and P. K. McCowAN, M.D., M.R.C.P., D.P.M., Medical Superintendent, City Mental Hospital, Cardiff. The Mental Treatment Act is another added to the increasing number in the administration of which the medical officer of health may be given concern, and the following contributio~Ts, submitled at the December meeting of the Society by two distinguished alienists, will be read with interest as casting light on some points of difficulty. SIR HUB:ERT BOND. ~HILE psychological medicine must, Sir Hubert said, perhaps always be a specialty, any water-tight compartment was not in its best interests or in those of the patients under its care. The enthusiasm for prevention must not be pursued at the expense of ti'eatment; he or she who. was ill cared nothing for prevention. Measures primarily and essentially preventive sometimes involved controversial sociological considerations, and impatience, although perhaps laudable, was apt to urge trial of what seemed to be short cuts to prevention. The speaker admitted that he shrank from this method of approach. There were other methods which, tho.ugh less spectacular, were to be preferred because of their essential soundness--e.g., treatment of disease in an incipient and inchoate early phase, Legislative freedom and medical facilities fo.r this early treatment constituted the cardinal features of the Mental Treatment Act, 1980. Prevention was confined to a small paragraph. The Act as a who,~e, when brought into full force, would, however, prove to be a preventive measure of-the highest potency. The Act was an amending Act to the previous Lunacy and Mental Deficiency Acts. It widened the scope of voluntary treatment, thereby avoiding certification and giving a great incentive to early treatment. It created a new s t a t u s - - - t e m p o r a r y treatment without certification. It considerably widened the scope of the local authorities, and gave statutory recognition to out-patient treatment, after-care, social services, and research. It was disappointing to notice how slowly advantage was being taken of the revised U r g e n c y Order. The battle in mental treatment was more than half won when the patient's voluntary co-operation was obtained. It was important not to jump to the conclusion that certification connoted absence of recoverability, although manifestly the greatest pro-
W
portion o.f recoveries would be found among the voluntary and tile temporary classes. If the percentage of recoveries in the three classes were compared, however, the certified would not show up at all badly. Indeed, the very act of certification, cutting the Gordian knot o.f family complications and enforcing firm medical control, was a very valuable form of treatment. In some alcoholic patients it brought about lifelong total abstinence. Nevertheless, in most cases certification was a great handicap to treatment in the first months of the illness. H e believed that out-patient treatment in properly organised centres was the greatest factor in preventive rnental treatment. DR. McCOWAN. Menlal Out-patient Clinics.--The passing of the Mental Treatment Act has undoubtedly commenced a new era in the treatment of mental disease. It is probably no exaggeration to say that it is the greatest advance since the days, one hundred years ago, when Pinet in Paris and Tuke in York removed the chains from their insane patients. Past legislation has been under the domination of the lawyer with his pre-occupation with the liberty of the subject; but the present Act reflects rather the dynamic approach of the physician, with the consequence that the primary object of the psychiatrist is no longer the custodial care, but, instead, active treatment of his patients. I feel certain that mental out-patient clinics will play a very important part in this treatment. Apart from the very great benefit which the patients attending will receive, these clinics should prove important co-ordinating links between our mental hospitals on the one hand and the various mental hygiene movements in the general community on the other. Properly administered, they should prove a great influence for good in educating not only the public but also the medical profession to
1932.
PUBLIC HEALTH.
the importance of mental hygiene in general, and the early treatment of mental disease in particular. T h e subject could be approached from many angles; but, in the short time at m y disposal, I thought it would be as well if I confined myself to two aspects o.f it, namely : L - T h e patients dealt with as regards their (a) type; (b) source; and (c) disposal. I I . ~ T h e preliminary organisation of a mental out-patient clinic on a small scale. I.
(a) T y p e . - - T h e type of patient dealt with at an out-patient clinic can be divided roughly into two classes--psychotics and neurotics. At present, with the psychotic or po.tentially psychotic class, what happens is that if the patient is a man o.f small means he cannot afford skilled attention in the early stages of his mental breakdown; and, as his physical health is not necessarily impaired, he carries on until his disease is well advanced. The final result, as we know, is inevitable remm~aI to a mental hospital. The early treatment of this type of person has two advantages. In the first place, it may lead to cure, rendering institutional care ~unnecessary. In the second place, even if removal to a mental hospital should ultimately become necessary, he has been under skilled o.bservation at a stage when he is often most dangerous to himself or to others, such danger including" not only physical violence but also such things as financial ruin or domestic upheavals. That the state of affairs is serious and calls for active measures is strongly suggested by the knowledge that there are 6,000 cases of actual or attempted suicide in England and W a l e s every year, and that nearly one-half of all persons arrested for murder are ultimately found to be insane. This, taken in conjunction with the fact that the vast majority of these people make such suicidal or homicidal attempts before any question of mental treatment has arisen, shows the importance of trying to institute something which aims at encouraging early treatment of these conditions. Here, coroners could render a real service. In the evidence given in their courts in cases of suicide, it is usually abundantly clear that the deceased had sho.wn definite signs of mental abnormality prior to the suicidal act.
231
If coroners would enquire as to what steps had been taken to have the person treated, and point out that out-patient clinics were available for such purposes, the press reports of the cases could not .fail to impress the lesson both on tile public and on the members of the medical profession who meet such cases. Our second group of patients form the majority of the clinics' clientele. T h e y are sufferers from what may be called minor mental ailments, such as hysteria, neurasthenia, various anxiety states and mild depressions. Next to common colds, these comprise the commonest diseases to which man is heir, and are the cause of incalculable human misery, largely preventable. At present they have practically no treatment, and, even from their medical attendants, not much s y m p a t h y or understanding. (b) Source.--Patients come mainly from one or other of the following sources : - (1) Majority from local general practitioners. (2) Other clinics, e.g., child guidance, school clinics, social welfare societies. (3) Cases referred from the courts. (4) Other departments of the hospital where out-patients are being seen. (5) Patients on trial or discharged from the local mental hospital. This last is a very important function of tlie clinic, and has a definite bearing on the question of the clinic's personnel. Apart from the more important humanitarian point of view of benefit to the patient, I think I might justifiably emphasise here the economic aspect of the clinic, as this group lends itself to easy demonstration of this point. In the first place, cases can be sent out on trial from the hospital at an earlier date, as they can still be kept under observation at the clinic; and, in the case of those numerous patients subject to recurrent attacks of excitement and depression, they can take advantage of the clinics to seek advice whenever they feel an attack impending. T h e y are advised to do so when at the mental hospital; and, as they and their relatives usually know from bitter experience the symptoms premonitory to a full-blown attack, one has little d i ~ c u l t v in convincing such patients of the advantage of attendance at the clinic; and now that we can admit such patients on a voluntary basis into our mental hospitals, such attendance is even more important. (c) Disposal. - - This, naturally, depends
232
PUBLIC HEALTH.
chiefly on the type of case; but other factors - - s u c h as distance of patient's home from the clinic, the views of tile practitioner sending the case---enter into the disposal question. R o u g h l y , five chief methods are available . - (1) Return to practitioner for treatment, with a report. Some clinics confine themselves to this, which, in my opinion, is unfortunate if the clinic is willing to do more. (2) Treatment at the out-patient clinic, with consent of general practitioner. (3) Transfer to mental deficiency authority in case of mental deficients. I did not deal with group (3) in describing the type of case dealt with at the clinic. The straightforward mental deficients cannot be treated at the clinic, but they appear there in fairly large numbers. In (1) and (2) we have anxiety cases, obsessions, phobim, mild depressions and certain other psychotics best so treated. (4) In-patient at general hospital. Unfortunately, the beds of an ordinary general hospital, as at present administered, are neither freely available nor very suitable for the nursing of our class of patient, although they are undoubtedly useful in organic cases, e.g., for laboratory tests or the malarial treatment of cases of general paresis ; but this, of course, depends on local conditions, and, if a few beds are available, they should undoubtedly be accepted. (5) In-patient at mental hospital. This last depends partly on the type of case and equally on the reputation of the mental hospital. At Cardiff 1 have found no difficulty in persuading ordinary neurotics to enter the mental hospital as voluntary patients; and I may say that no mental hospital will enjoy such a reputation uniess by contact with the public and general practitioners through extramural clinics. This category includes not only psychotics requiring in-patient treatment, but also neurotics who require change of environment, regulated occupational therapy, or deeper mental analysis than is possible at an trot-patient clinic. II. I now pass on to the question of organisalion of the mental out-patient clinic. Such a clinic may be of four kinds, namely, in connection with a general hospital ; in connection with a municipal hospital; in connection with a mental hospital; or in connection with a special psychiatric hospital, such as
MAY,
the Jordanburn in Edinburgh or the Tavistock Clinic and the Maudsley Hospital in London. All have their relative advantages and disadvantages, but there is little doubt that the chief development will be in connection with our big general hospitals. The advantages of the latter are that patients will more readily attend a general hospital, and also that here other specialists and laboratory facilities are readily available. Failing the general hospital, the local municipal hospital could be used ; but, without entering into this controversial subject, I would state that, in my opinion, the clinic would be more likely to prove a success at the general hospital. Again, however, I make this statement in a general way, and agree that special local conditions may well make the municipal hospital preferable. The question of payment for medical services comes in here. Personally, I see no reason why the staff should be on any different basis from other members of the honorary consulting staff of the general hospital. This, of course, means that the medical officer of health would have no control over tile clinic; but then, there is no reason why he should. Presumably, all he is interested in is the provision of a means of improving the mental hygiene of the community he serves, and if he is satisfied that an efficient clinic is operative, his responsibility ends. Of course, if tile clinic is at the municipal hospital, the staff would naturaIly be paid, on the grounds that here no work is carried out on a voluntary basis. tf it is decided to run the out-patient clinic in connection with the mental hospital, then it would probably be advisable to obtain a room outside the mental hospital, on the lines of an ordinary surgery, as there is no doubt that it would be much more difficult to get patients to attend at the mental hospital itself. As regards the fourth kind of out-patient clinic, viz., that in connection with a special psychiatric hospital, this, of course, is the ideal arrangement; but, unfortunately, the question of expense makes this prohibitive in most areas at present. W e hoge to start one such clinic with twenty-odd beds in Cardiff in the near future. Clinic personnel can be dealt with under two heads--(1) medical; (2) social worker. (1) Medical.--I have already stated that the medical superintendent of the local mental hospital should be in charge of the clinic; and
1932.
PUBLIC HEALTH.
I r e p e a t t h a t this s h o u l d be so u n l e s s t h e r e a r e special local conditions, s u c h as t h e availability of p r i v a t e c o n s u l t i n g p s y c h i a t r i s t s . E v e n then, the medical s u p e r i n t e n d e n t s h o u l d b e r e p r e s e n t e d on the staff, as a liaison b e t w e e n the clinic a n d the m e n t a l hospital is essential if the full benefit of the clinic is to be f o r t h c o m i n g . O f course, the medical officer of health will o n l y h a v e a d v i s o r y p o w e r s a s r e g a r d s p e r s o n n e l if the clinic is r u n on a v o l u n t a r y b a s i s ; b u t he s h o u l d be insistent on the a d v a n t a g e s of c o n t i n u i t y of t r e a t m e n t u n d e r the s a m e medical m a n , b o t h for the p a t i e n t e n t e r i n g the m e n t a l hospital f r o m t h e clinic, a n d for the p a t i e n t d i s c h a r g e d f r o m the m e n t a l h o s p i t a l to the clinic. T h e o u t - p a t i e n t clinic is the c a t c h m e n t a r e a for the v o l u n t a r y p a t i e n t u n d e r the new M e n t a l T r e a t m e n t A c t ; a n d a p a t i e n t will m o r e readily g o to t h e m e n t a l h o s p i t a l if he k n o w s he will b e u n d e r the care of the doctor w h o h a s p r e s u m a b l y g a i n e d his confidence at the clinic. A n o t h e r p o i n t in f a v o u r of the clinic b e i n g r u n f r o m the m e n t a l hospital is that, except at the v e r y b e g i n n i n g , it will not be p o s s i b l e for one a s s i s t a n t medical officer to d o the w o r k ; a n d I s h o u l d i m a g i n e it would be v e r y difficult in m o s t a r e a s to find m a n y medical m e n with the n e c e s s a r y e x p e r i e n c e outside the m e n t a l h o s p i t a l s . F o r e x a m p l e , at Cardiff I h a v e t h r e e a s s i s t a n t s . I see all new cases myself, g i v i n g on a n a v e r a g e a n h o u r to each, a n d decide w h a t I c o n s i d e r to b e the b e s t line of t r e a t m e n t . T h u s , p a t i e n t s w h o al-e to continue a t t e n d a n c e at tile clinic are h a n d e d o v e r - - m a l e s to the m a l e medical officer, a n d f e m a l e s to a f e m a l e medical officer. W e h a v e t w o sessions w e e k l y . (2) Social Worker.~A social w o r k e r is really essential if full benefit is to be d e r i v e d f r o m the clinic. H e r visits to the p a t i e n t s ' h o m e s e n s u r e m u c h essential i n f o r m a t i o n a b o u t f a c t o r s w h o s e correction m a y be necess a r y for the p r o p e r m a n a g e m e n t of the c a s e ; for e x a m p l e , the q u e s t i o n of t r o u b l e s o m e n e i g h b o u r s m a y h a v e to be dealt with, or d o m e s t i c t r o u b l e s with h u s b a n d a n d children. S h e s h o u l d be in a t t e n d a n c e at the clinic p r i o r to the arrival of the psychiatrist, so t h a t she can take histories of new cases. S h e s h o u l d b e m a d e r e s p o n s i b l e for the k e e p i n g of records, which, of course, need not be at all e l a b o r a t e . I c a n n o t e m p h a s i s e too s t r o n g l y t h a t n o e l a b o r a t e a r r a n g e m e n t s are n e c e s s a r y for s e t t i n g u p a m e n t a l o u t - p a t i e n t clinic, a n d the a b s e n c e of b e d s a n d social w o r k e r s n e e d b e
2aa
no b a r . T h e s e can well be left until after the clinic is e s t a b l i s h e d a n d h a s p r o v e d its utility. F i n a l l y , m i g h t I s a y that, in m y opinion, the m o s t fruitful line o f a t t a c k for the f u t u r e will be a l o n g the lines of p r e v e n t i o n ; a n d this even m o r e so t h a n with p h y s i c a l diseases such as tuberculosis, cancer, etc. T h e r e is little h o p e of m u c h s a v i n g in the e i g h t or nine million p o u n d s s p e n t a n n u a l l y in l o o k i n g after those s u f f e r i n g f r o m m e n t a l disease if we confine o u r m a i n a t t a c k to the c o m p a r a t i v e l y a d v a n c e d cases a d m i t t e d to o u r m e n t a l hospitals. T h e w o r k of the future m u s t be l a r g e l y e x t r a - m u r a l a n d m u c h of it will require the closest liaison b e t w e e n t h e p r a c t i s i n g p s y c h i a t r i s t a n d the medical officer of health. DISCUSSION. The President (Dr. C. Killick Millard) said that the
subject of mental disease had not hitherto concerned the medical officer of health very closely, but in the future, he would have to take more interest in it. Lieut.-CoI0nel F. E. Fremantle, M.P., explained that the main difficulty in passing the measure-the great possibilities of which had been expounded in principle by Sir Hubert Bond, and in practice by Dr. McCowan--had been the idea of treating the matter as an illness instead of as a problem of protection of the community from a dangerous individual and a dangerous individual from himself--the original basis of lunacy treatment. Speaking from the point of view of the ordinary medical officer of health, he rejoiced to see that there was a reality in the treatment, and the hope of prevention of serious mental trouble in many cases. He imagined that the future would see a great increase in nervous breakdown and the need for some kind of rest-home or medical monastery to which people could retire to recover from the surfeit of intellectual activity. Out-patient departments were most valuable units in the scheme of mental treatment, and the extension of the work in that direction should make a strong appeal, more particularly as they were relatively inexpensive. Dr. E. H. T. gash (Heston and Isleworth) asked how far the general medical practitioner could be used in the treatment of mental disease. Sir Hubert Bond, in reply, said that the question of the general practitioner was one of enormous importance : the treatment of the mental case could not be denied him if he could do it, but fellow practitioners would not appreciate a man claiming special knowledge of mental disease and at the same time carrying on general practice. He was extremely glad to learn that the bulk of D r . McCowan's clinic cases came from general practitioners. Dr. McCowan added that in 1931, actually 40 per cent. of the patients admitted to the Cardiff City Mental Hospital came as voluntary patients, thus showing that the Act was a live force. A vote of thanks to the principal speakers, proposed by the President, and seconded by Dr. Nash, was carried by acclamation.