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Physical and psychological aspects of Borstal Training
PUBLIC
HEALTH,
July,
~955
of succeeding generations, a n d this in itself m a y have h a d a r e t a r d i n g effect t h r o u g h o u t . I t h i n k it is necessary for m e to offer a w o r d of e x p l a n a t i o n a b o u t t h e title of the paper. I have, of course, b e e n talking essentially f r o m facts collected i n Bolton, a n d a l t h o u g h I have w i d e n e d t h e title to i n c l u d e L a n c a s h i r e , I feel t h a t I a m largely justified in so d o i n g b e c a u s e of t h e similarity in d e v e l o p m e n t of so m a n y of o u r i n d u s t r i a l towns. As a n e w c o m e r a m o n g s t you, y o u m a y t h i n k it strange t h a t I s h o u l d choose this s u b j e c t r a t h e r t h a n wait u n t i l I h a d m o r e experience of t h e area. I c a n o n l y reply t h a t t h e p r o b l e m is one w h i c h has fascinated m e since I arrived a m o n g s t you, a n d t h e m a t t e r s w h i c h I have discussed are those w h i c h c a n n o t escape notice in t h e course o f a n y day. One final note o n t h e q u e s t i o n of staff. W e have a considerable a m o u n t of work yet to b e d o n e in all b r a n c h e s of t h e p u b l i c h e a l t h field. Our mortality and morbidity figures alone s h o w o u r greater n e e d t h a n elsewhere, a n d yet m a n y of us are c o n s t a n t l y suffering st~ff shortages. I refer particularly to h e a l t h visitors a n d s a n i t a r y inspectors. A recent r e p o r t to t h e N o r t h - W e s t e r n F e d e r a t i o n of M e m b e r s of the Q u e e n ' s I n s t i t u t e of District N u r s i n g shows quite clearly t h e t e n d e n c y of the drift of n u r s i n g staff f r o m n o r t h to south, t h a t is to say, away f r o m m u c h of t h e work w h i c h still r e m a i n s t o b e d o n e i n p u b l i c health. I t w o u l d s e e m logical t h a t posts in certain areas s h o u l d b e m a d e m o r e attractive. I a m aware t h a t t h e r e are national shortages, b u t s o m e h o w a m o r e e v e n d i s t r i b u t i o n s h o u l d b e assured. I a m also aware t h a t certain authorities have recently t a k e n i n d e p e n d e n t action to raise salaries a b o v e usually a c c e p t e d national scales. D e s p e r a t e c i r c u m s t a n c e s certainly n e e d drastic m e a s u r e s to deal w i t h t h e m , b u t I a m n o t sure a n y of the m e t h o d s so far t r i e d are t h e r i g h t ones. Nevertheless, somehow t h e staff m u s t b e m a d e available if t h e back log o f work is to b e overcome. PHYSICAL A N D PSYCHOLOGICAL ASPECTS OF BORSTAL T R A I N I N G * By D. A. OGDEN, L.M.S.S.A.,
Medical Officer, H.M. Borstal Institution, Portland W h i l e Medical Officers of H e a l t h are n o t so m u c h i n v o l v e d in m a t t e r s w h i c h t o u c h o n Borstal T r a i n i n g as colleagues in t h e H o s p i t a l Service, n e v e r t h e l e s s occasions d o arise w h e n t h e I n s t i t u t i o n M e d i c a l Officers n e e d y o u r advice a n d assistance, a n d I a m gl~td of t h e o p p o r t u n i t y of t h a n k i n g your h o n o r a r y secretary , D r . G o r d o n Wallace, for his help o n various occasions w h e n I have n e e d e d to a p p r o a c h h i m . Before I refer to the specific p r o b l e m s ' of Borstal T r a i n i n g it m i g h t b e h e l p f u l to give a b r i e f r6sum6 o f the d e v e l o p m e n t of the Service. I n 1894 t h e P r i s o n C o m m i t t e e r e c o m m e n d e d t h e experim e n t of s e t t i n g u p a P e n a l R e f o r m a t o r y a n d t h a t t h e C o u r t s s h o u l d have p o w e r to c o m m i t to t h e s e e s t a b l i s h m e n t s offenders u n d e r t h e age of 23 for periods of n o t less t h a n one year a n d n o t m o r e t h a n t h r e e w i t h liberal exercise of a s y s t e m o f licence. As a result a pilot e x p e r i m e n t was s t a r t e d at B e d f o r d Prison, and, following e n c o u r a g i n g reports, i n 1900 p a r t of Borstal C o n v i c t P r i s o n was set aside for this e x p e r i m e n t to b e e x t e n d e d . I n 1907 t h e C o u r t s were i n f o r m e d t h a t the s y s t e m i n Borstal was ready, a n d in t h e following year t h e n e w Borstal T r a i n i n g received s t a t u t o r y r e c o g n i t i o n in the P r e v e n t i o n o f C r i m e Act. I n 1914 the c o n d i t i o n s were modified b y f u r t h e r A c t of P a r l i a m e n t to r e m o v e t h e previous restriction t h a t a s e n t e n c e of Borstal T r a i n i n g could only follow conviction for an indictable offence, a n d to raise t h e m i n i m u m t o two years. Since t h e n c o n s t a n t d e v e l o p m e n t has t a k e n place u n t i l the p r e s e n t stage has b e e n reached, a l t h o u g h t h e last w a r caused v e r y serious d i s i n t e g r a t i o n a n d loss of g r o u n d which h a d to b e m a d e up b y gradual stages. **Address to the Southern Branch, Society of M.O.H.
I57
S i m u l t a n e o u s l y the n u m b e r of o t h e r u n i t s in the s y s t e m increased, taking the n a m e Borstal f r o m the original. By 1934 seven Borstals were in use, a n d b y 1951 the n u m b e r h a d risen to 18 for boys a n d two for girls. T h e s e institutiorrs m a k e u p a system in w h i c h each u n i t plays a p a r t - - o f t e n widely different. T h u s , two are Allocation Centres, two are of full security, t h r e e are of closed type a n d t h e r e m a i n d e r open. Briefly a closed Borstal is o n e in w h i c h an o u t e r b o u n d a r y can b e sealed off, b u t is n o r m a l l y only done so at n i g h t , whereas a n open Borstal is s i t u a t e d in a n estate w i t h n o o u t e r wall.
T h e Borstal S y s t e m T o - d a y T h i s , t h e n , is t h e size to w h i c h Borstal has grown, a n d I t u r n n o w to a d e s c r i p t i o n of the training, giving as I go t h e various levels at w h i c h t h e M e d i c a l Officer is c o n c e r n e d . Before sentence, reports are p r e p a r e d for the g u i d a n c e of t h e C o u r t s c o n c e r n i n g fitness for a y o u t h to u n d e r g o Borstal T r a i n i n g . I t is the responsibility of the Medical Officer to d e t e r m i n e w h e t h e r t h e r e are any physical or m e n t a l reasons w h y s u c h t r a i n i n g s h o u l d b e unlikely to b e effective. A f t e r s e n t e n c e a y o u t h is sent to a n Allocation C e n t r e a n d it is here t h a t t h e s y s t e m really begins. T h e f u n c t i o n of t h e Allocation C e n t r e is to decide w h i c h of t h e various Borstal I n s t i t u t i o n s is t h e m o s t suitable for a n individual youth. O n e I n s t i t u t i o n provides work reclaiming land f r o m t h e sea, a n o t h e r is p r e d o m i n a n t l y agricultural in training, a n o t h e r has a r o u t i n e a d a p t e d to y o u t h s of lower t h a n average intelligence rating, a n d several i n s t i t u t i o n s have industrial t r a i n i n g shops. T h e Allocation C e n t r e has to balance these possible lines of t r a i n i n g against t h e likelihood of a particular y o u t h staying at a n o p e n Borstal or a b s c o n d i n g , his degree of m a t u r i t y a n d t h e extent to w h i c h his c r i m i n a l activities have progressed. A very full investigation is carried out at the Centres, a n d m u c h material is g a t h e r e d c o n c e r n i n g past h i s t o r y - - f a m i l y h i s t o r y a n d h o m e conditions. T h e f u n c t i o n of the M e d i c a l Officer is to r e p o r t firstly a n y physical defects w h i c h will n e e d to be c o n s i d e r e d w h e n allocation is decided, a n d a n y m e n t a l or psychological features w h i c h will n e e d to b e investigated or treated. A r e s i d e n t psychologist p u t s t h e y o u t h s t h r o u g h a b a t t e r y of tests d e s i g n e d to give a n assessm e n t of intelligence level a n d m e c h a n i c a l aptitude, a n d a n y y o u t h s h o w i n g m e n t a l a b n o r m a l i t y is referred for p s y c h i a t r i c opinion. A small p r o p o r t i o n are w i t h d r a w n for p s y c h o t h e r a p y b e f o r e allocation. T h e great majority, however, are sent o n to the T r a i n i n g Borstal c h o s e n for t h e m w i t h full reports on personality, e d u c a t i o n level, intelligence level a n d expected ability. A t the actual t r a i n i n g e s t a b l i s h m e n t s t h e p r o b l e m s f r o m t h e medical p o i n t of view vary greatly f r o m i n s t i t u t i o n to institution. T h u s at the o p e n Borstals, to w h i c h are allocated t h e y o u t h s w h o seem the best prospects, the work involves m a i n l y t h e d a y - t o - d a y medical care of t h e population, a n d this is usually t a k e n o n b y a local general practitioner. A t a large closed I n s t i t u t i o n s u c h as t h e one at w h i c h I a m in post the position is very different. Y o u t h s are allocated to s u c h an e s t a b l i s h m e n t becaus~e either physical or p s y c h i a tric a t t e n t i o n m a y b e required. T h e y m a y also b e t r a n s ferred f r o m o p e n Borstals w h e r e theii" b e h a v i o u r has b e e n a b n o r m a l . I do n o t wish to give the i m p r e s s i o n t h a t all allocations to closed Borstals are o n medical g r o u n d s - - b u t a fair p e r c e n t a g e a r e - - a n d as a result a full Medical Officer is i n post to deal w i t h the m a n y p r o b l e m s w h i c h arise. T h e r e is n o t time to d e s c r i b e in detail the process o f t r a i n i n g - - b u t briefly t h e objects are to instil t h e h a b i t of work, develop t h e ability to accept responsibility a n d o b e y a c o m m u n i t y ' s rules, while at t h e same t i m e tackling i n d i vidual m o r a l weaknesses. T h e Work o f t h e M e d i c a l O f f i c e r T h e work of t h e M e d i c a l Officer comes u n d e r t h r e e h e a d ings, a n d I will discuss t h e m in t u r n .
158
(1) The Care of the Sick T h i s follows very m u c h the lines of practice in the A r m e d Services. It m i g h t be thought that malingerers a b o u n d - but such is not m y experience. T h e r e is the inevitable minority of s u c h - - b u t minor neurotic mad hysterical manifestations are m o r e e v i d e n t - - a n d are indeed a c o m m o n feature of the delinquent personality. (2) Physical Rehabilitation M a n y youths coming to Borstal have been the subject of parental n e g l e c t - - a n d this certainly applies to medical matters. Only occasionally is serious malnutrition met with, but m a n y physical defects are f o u n d which can be corrected. It is highly important that this should be done, firstly because it is essential that physical limitations of ability to work on release should be removed to improve a youth's prospects in the difficult world he re-enters, and secondly because the psychological effect on the youth that society has bothered to do something for him is most useful in modifying antisocial feelings. It is therefore m y practice to draw the Specialist's attention to m y hope that surgical attention may well produce this two-fold result in suitable cases and I would like to pay tribute to the most valuable assistance given b y the Hospitals Staffs in this way. F o r the Medical Officer to complete physical rehabilitation it is necessary to call on the specialist services a great d e a l - and indeed the whole resources of the medical services of the area are called upon at various t i m e s - - a n d freely given. T h e m o s t c o m m o n disabilities met with are ear, nose and orthopaedic faults. Chronic nasal obstruction or sinus infections are sufficiently lowering to aggravate moral failings and m a n y S.M.R. operations are carried out. M a n y orthopaedic conditions are corrected or i m p r o v e d by operation or physiotherapy. As an example I quote a very severe case of genu v a r u m awaiting correction by ostectomy and post-poliomyelitis cases fitted with correct supports or special boots. In particular I find that squints are very well worth attention. Operative correction almost invariably has a marked effect on personality as the sense of inferiority engendered by the squint lifts. O n the medical side glandular dysfunction cases occur and even in this age-group peptic ulceration is found. Looking at more unusual cases, plastic surgery is called into action from time to time and last year a youth from m y Institution was submitted for cardiac surgery, closure of a serious fault in the aorta being successfully carried out. T h e results in this latter case have been most encouraging. T h e youth is earning a living and behaving well. (3) Psychiatric Rehabilitation I have m e n t i o n e d that youths noted at Allocation to be psychiatrically unsound are sent where a full-time Medical Officer is in post but in addition others m a y begin to show abnormalities during training. Consequently a great deal of psychiatric investigation becomes necessary, and is of a type for which little precedence in other fields of psychiatry can be found. T h i s work in delinquency is constantly under the handicap that the therapist can never really be certain whether the patient is genuinely seeking help, and indeed it is m y experience that in m o s t cases it is first necessary to develop the insight that such help is needed, before any t h e r a p y can be started. T h i s would seem to be a serious barrier, but there are compensatory features. M o s t i m p o r t a n t is the fact that the Medical Officer who proposes to analyse emotional difficulties is also the one a youth will see for treatment of a corn, constipation or other trivial complaint. As a result he is n o t subjected to ridicule by the other inmates and tends to accept psychiatric exploration as just another bit of
PUBLIC HEALTH,
July,
I955
doctoring. T h i s is of great value, as in contrast a visiting therapist immediately meets a barrier of suspicion. Psychotherapy can be divided into minor and major forms. I n m y experience about 25% of the intake to a Borstal with a full-time Medical Officer need m i n o r psychotherapy involving analysis of emotional difficulties, and follow-up interviews. T h e treatment of such cases involves close consultation with the administrative staff. One of the greatest problems is the arranging of leniency at certain times, without upsetting the discipline of the Institution. An emotionally unstable youth who offends occasionally may be putting forth a greater effort than a youth w!th no problems who quietly cruises a l o n g - - y e t u n d u e leniency can menace the whole discipline of an institution. T h e correct balance between therapy and administration is very delicate. Major psychotherapy involving such matters as deep analysis, narcotherapy, residential group therapy and psychodrama are not carried out at training institutions. F o r the fewer cases considered suitable facilities are available in the Service when required. Such is the work of the Medical Officer at the training u n i t - - b u t Borstal training does not end with release of the inmate. H e then passes on to licence to behave well u n d e r supervision of a local officer, and m u c h trouble and time are taken by t h e Borstal After-care Association to guide him in resettlement. Should his conduct be unsatisfactory he can be recalled to a special centre set aside for the p u r p o s e - where the whole circumstances of the failure are considered. Once again a psychological assessment is made and any case thought to show unusual features is referred to the visiting Medical Officer, which at present happens to be myself. A Board then considers all aspects and decides how soon the youth may once m o r e be tried on licence. T h a t briefly is the pattern .of Borstal Training, but before closing I should refer briefly to some of what may be t e r m e d the thorny points. The Psychopathic Personality.--This is no time to discuss exactly what the term means. I w o u l d only say that conduct which seems to indicate clearly psychopathic tendencies is c o m m o n in Borstal but for every one who goes on to become a true psychopath there are others showing just as typical behaviour who learn control and stabilise. I am therefore of the opinion that the diagnosis psychopathic personality should not be used in the Borstal age g r o u p - - a n d that apparently psychopathic conduct is not necessarily a sign of an untrainable youth. The Homosexual.-~As m a y be imagined, the presence of the homosexual in an all-male society provides m a n y serious problems for the administration, b u t f r o m the point of view of the Medical Officer this often provides t h e opportunity to make an approach re psychiatric t r e a t m e n t - - a n d since personalities are not yet set, there is always the possibility of successful modification of the condition. The Epileptic.--It will be appreciated that if attacks are severe and frequent the prospects of training are seriously a f f e c t e d - - b u t fortunately most cases can be reasonably controlled. Simultaneously a m i n o r psychotherapeutical approach can be m a d e on the almost invariable emotional overlay and it is m y experience that most epileptics can be stabilised by time of release on far less drugs than at the start. Conclusion T o conclude this survey of Borstal Training, which has of necessity passed lightly over m a n y important points, I should like to give m y personal opinion that the medical profession m u s t and should play an increasing part in dealing with delinquency, not by replacing tried methods of character training, but by concentrating on the removal of physical and psychological barriers which m a y prevent such training taking effect.
HEALTH,
July,
~955
of succeeding generations, a n d this in itself m a y have h a d a r e t a r d i n g effect t h r o u g h o u t . I t h i n k it is necessary for m e to offer a w o r d of e x p l a n a t i o n a b o u t t h e title of the paper. I have, of course, b e e n talking essentially f r o m facts collected i n Bolton, a n d a l t h o u g h I have w i d e n e d t h e title to i n c l u d e L a n c a s h i r e , I feel t h a t I a m largely justified in so d o i n g b e c a u s e of t h e similarity in d e v e l o p m e n t of so m a n y of o u r i n d u s t r i a l towns. As a n e w c o m e r a m o n g s t you, y o u m a y t h i n k it strange t h a t I s h o u l d choose this s u b j e c t r a t h e r t h a n wait u n t i l I h a d m o r e experience of t h e area. I c a n o n l y reply t h a t t h e p r o b l e m is one w h i c h has fascinated m e since I arrived a m o n g s t you, a n d t h e m a t t e r s w h i c h I have discussed are those w h i c h c a n n o t escape notice in t h e course o f a n y day. One final note o n t h e q u e s t i o n of staff. W e have a considerable a m o u n t of work yet to b e d o n e in all b r a n c h e s of t h e p u b l i c h e a l t h field. Our mortality and morbidity figures alone s h o w o u r greater n e e d t h a n elsewhere, a n d yet m a n y of us are c o n s t a n t l y suffering st~ff shortages. I refer particularly to h e a l t h visitors a n d s a n i t a r y inspectors. A recent r e p o r t to t h e N o r t h - W e s t e r n F e d e r a t i o n of M e m b e r s of the Q u e e n ' s I n s t i t u t e of District N u r s i n g shows quite clearly t h e t e n d e n c y of the drift of n u r s i n g staff f r o m n o r t h to south, t h a t is to say, away f r o m m u c h of t h e work w h i c h still r e m a i n s t o b e d o n e i n p u b l i c health. I t w o u l d s e e m logical t h a t posts in certain areas s h o u l d b e m a d e m o r e attractive. I a m aware t h a t t h e r e are national shortages, b u t s o m e h o w a m o r e e v e n d i s t r i b u t i o n s h o u l d b e assured. I a m also aware t h a t certain authorities have recently t a k e n i n d e p e n d e n t action to raise salaries a b o v e usually a c c e p t e d national scales. D e s p e r a t e c i r c u m s t a n c e s certainly n e e d drastic m e a s u r e s to deal w i t h t h e m , b u t I a m n o t sure a n y of the m e t h o d s so far t r i e d are t h e r i g h t ones. Nevertheless, somehow t h e staff m u s t b e m a d e available if t h e back log o f work is to b e overcome. PHYSICAL A N D PSYCHOLOGICAL ASPECTS OF BORSTAL T R A I N I N G * By D. A. OGDEN, L.M.S.S.A.,
Medical Officer, H.M. Borstal Institution, Portland W h i l e Medical Officers of H e a l t h are n o t so m u c h i n v o l v e d in m a t t e r s w h i c h t o u c h o n Borstal T r a i n i n g as colleagues in t h e H o s p i t a l Service, n e v e r t h e l e s s occasions d o arise w h e n t h e I n s t i t u t i o n M e d i c a l Officers n e e d y o u r advice a n d assistance, a n d I a m gl~td of t h e o p p o r t u n i t y of t h a n k i n g your h o n o r a r y secretary , D r . G o r d o n Wallace, for his help o n various occasions w h e n I have n e e d e d to a p p r o a c h h i m . Before I refer to the specific p r o b l e m s ' of Borstal T r a i n i n g it m i g h t b e h e l p f u l to give a b r i e f r6sum6 o f the d e v e l o p m e n t of the Service. I n 1894 t h e P r i s o n C o m m i t t e e r e c o m m e n d e d t h e experim e n t of s e t t i n g u p a P e n a l R e f o r m a t o r y a n d t h a t t h e C o u r t s s h o u l d have p o w e r to c o m m i t to t h e s e e s t a b l i s h m e n t s offenders u n d e r t h e age of 23 for periods of n o t less t h a n one year a n d n o t m o r e t h a n t h r e e w i t h liberal exercise of a s y s t e m o f licence. As a result a pilot e x p e r i m e n t was s t a r t e d at B e d f o r d Prison, and, following e n c o u r a g i n g reports, i n 1900 p a r t of Borstal C o n v i c t P r i s o n was set aside for this e x p e r i m e n t to b e e x t e n d e d . I n 1907 t h e C o u r t s were i n f o r m e d t h a t the s y s t e m i n Borstal was ready, a n d in t h e following year t h e n e w Borstal T r a i n i n g received s t a t u t o r y r e c o g n i t i o n in the P r e v e n t i o n o f C r i m e Act. I n 1914 the c o n d i t i o n s were modified b y f u r t h e r A c t of P a r l i a m e n t to r e m o v e t h e previous restriction t h a t a s e n t e n c e of Borstal T r a i n i n g could only follow conviction for an indictable offence, a n d to raise t h e m i n i m u m t o two years. Since t h e n c o n s t a n t d e v e l o p m e n t has t a k e n place u n t i l the p r e s e n t stage has b e e n reached, a l t h o u g h t h e last w a r caused v e r y serious d i s i n t e g r a t i o n a n d loss of g r o u n d which h a d to b e m a d e up b y gradual stages. **Address to the Southern Branch, Society of M.O.H.
I57
S i m u l t a n e o u s l y the n u m b e r of o t h e r u n i t s in the s y s t e m increased, taking the n a m e Borstal f r o m the original. By 1934 seven Borstals were in use, a n d b y 1951 the n u m b e r h a d risen to 18 for boys a n d two for girls. T h e s e institutiorrs m a k e u p a system in w h i c h each u n i t plays a p a r t - - o f t e n widely different. T h u s , two are Allocation Centres, two are of full security, t h r e e are of closed type a n d t h e r e m a i n d e r open. Briefly a closed Borstal is o n e in w h i c h an o u t e r b o u n d a r y can b e sealed off, b u t is n o r m a l l y only done so at n i g h t , whereas a n open Borstal is s i t u a t e d in a n estate w i t h n o o u t e r wall.
T h e Borstal S y s t e m T o - d a y T h i s , t h e n , is t h e size to w h i c h Borstal has grown, a n d I t u r n n o w to a d e s c r i p t i o n of the training, giving as I go t h e various levels at w h i c h t h e M e d i c a l Officer is c o n c e r n e d . Before sentence, reports are p r e p a r e d for the g u i d a n c e of t h e C o u r t s c o n c e r n i n g fitness for a y o u t h to u n d e r g o Borstal T r a i n i n g . I t is the responsibility of the Medical Officer to d e t e r m i n e w h e t h e r t h e r e are any physical or m e n t a l reasons w h y s u c h t r a i n i n g s h o u l d b e unlikely to b e effective. A f t e r s e n t e n c e a y o u t h is sent to a n Allocation C e n t r e a n d it is here t h a t t h e s y s t e m really begins. T h e f u n c t i o n of t h e Allocation C e n t r e is to decide w h i c h of t h e various Borstal I n s t i t u t i o n s is t h e m o s t suitable for a n individual youth. O n e I n s t i t u t i o n provides work reclaiming land f r o m t h e sea, a n o t h e r is p r e d o m i n a n t l y agricultural in training, a n o t h e r has a r o u t i n e a d a p t e d to y o u t h s of lower t h a n average intelligence rating, a n d several i n s t i t u t i o n s have industrial t r a i n i n g shops. T h e Allocation C e n t r e has to balance these possible lines of t r a i n i n g against t h e likelihood of a particular y o u t h staying at a n o p e n Borstal or a b s c o n d i n g , his degree of m a t u r i t y a n d t h e extent to w h i c h his c r i m i n a l activities have progressed. A very full investigation is carried out at the Centres, a n d m u c h material is g a t h e r e d c o n c e r n i n g past h i s t o r y - - f a m i l y h i s t o r y a n d h o m e conditions. T h e f u n c t i o n of the M e d i c a l Officer is to r e p o r t firstly a n y physical defects w h i c h will n e e d to be c o n s i d e r e d w h e n allocation is decided, a n d a n y m e n t a l or psychological features w h i c h will n e e d to b e investigated or treated. A r e s i d e n t psychologist p u t s t h e y o u t h s t h r o u g h a b a t t e r y of tests d e s i g n e d to give a n assessm e n t of intelligence level a n d m e c h a n i c a l aptitude, a n d a n y y o u t h s h o w i n g m e n t a l a b n o r m a l i t y is referred for p s y c h i a t r i c opinion. A small p r o p o r t i o n are w i t h d r a w n for p s y c h o t h e r a p y b e f o r e allocation. T h e great majority, however, are sent o n to the T r a i n i n g Borstal c h o s e n for t h e m w i t h full reports on personality, e d u c a t i o n level, intelligence level a n d expected ability. A t the actual t r a i n i n g e s t a b l i s h m e n t s t h e p r o b l e m s f r o m t h e medical p o i n t of view vary greatly f r o m i n s t i t u t i o n to institution. T h u s at the o p e n Borstals, to w h i c h are allocated t h e y o u t h s w h o seem the best prospects, the work involves m a i n l y t h e d a y - t o - d a y medical care of t h e population, a n d this is usually t a k e n o n b y a local general practitioner. A t a large closed I n s t i t u t i o n s u c h as t h e one at w h i c h I a m in post the position is very different. Y o u t h s are allocated to s u c h an e s t a b l i s h m e n t becaus~e either physical or p s y c h i a tric a t t e n t i o n m a y b e required. T h e y m a y also b e t r a n s ferred f r o m o p e n Borstals w h e r e theii" b e h a v i o u r has b e e n a b n o r m a l . I do n o t wish to give the i m p r e s s i o n t h a t all allocations to closed Borstals are o n medical g r o u n d s - - b u t a fair p e r c e n t a g e a r e - - a n d as a result a full Medical Officer is i n post to deal w i t h the m a n y p r o b l e m s w h i c h arise. T h e r e is n o t time to d e s c r i b e in detail the process o f t r a i n i n g - - b u t briefly t h e objects are to instil t h e h a b i t of work, develop t h e ability to accept responsibility a n d o b e y a c o m m u n i t y ' s rules, while at t h e same t i m e tackling i n d i vidual m o r a l weaknesses. T h e Work o f t h e M e d i c a l O f f i c e r T h e work of t h e M e d i c a l Officer comes u n d e r t h r e e h e a d ings, a n d I will discuss t h e m in t u r n .
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(1) The Care of the Sick T h i s follows very m u c h the lines of practice in the A r m e d Services. It m i g h t be thought that malingerers a b o u n d - but such is not m y experience. T h e r e is the inevitable minority of s u c h - - b u t minor neurotic mad hysterical manifestations are m o r e e v i d e n t - - a n d are indeed a c o m m o n feature of the delinquent personality. (2) Physical Rehabilitation M a n y youths coming to Borstal have been the subject of parental n e g l e c t - - a n d this certainly applies to medical matters. Only occasionally is serious malnutrition met with, but m a n y physical defects are f o u n d which can be corrected. It is highly important that this should be done, firstly because it is essential that physical limitations of ability to work on release should be removed to improve a youth's prospects in the difficult world he re-enters, and secondly because the psychological effect on the youth that society has bothered to do something for him is most useful in modifying antisocial feelings. It is therefore m y practice to draw the Specialist's attention to m y hope that surgical attention may well produce this two-fold result in suitable cases and I would like to pay tribute to the most valuable assistance given b y the Hospitals Staffs in this way. F o r the Medical Officer to complete physical rehabilitation it is necessary to call on the specialist services a great d e a l - and indeed the whole resources of the medical services of the area are called upon at various t i m e s - - a n d freely given. T h e m o s t c o m m o n disabilities met with are ear, nose and orthopaedic faults. Chronic nasal obstruction or sinus infections are sufficiently lowering to aggravate moral failings and m a n y S.M.R. operations are carried out. M a n y orthopaedic conditions are corrected or i m p r o v e d by operation or physiotherapy. As an example I quote a very severe case of genu v a r u m awaiting correction by ostectomy and post-poliomyelitis cases fitted with correct supports or special boots. In particular I find that squints are very well worth attention. Operative correction almost invariably has a marked effect on personality as the sense of inferiority engendered by the squint lifts. O n the medical side glandular dysfunction cases occur and even in this age-group peptic ulceration is found. Looking at more unusual cases, plastic surgery is called into action from time to time and last year a youth from m y Institution was submitted for cardiac surgery, closure of a serious fault in the aorta being successfully carried out. T h e results in this latter case have been most encouraging. T h e youth is earning a living and behaving well. (3) Psychiatric Rehabilitation I have m e n t i o n e d that youths noted at Allocation to be psychiatrically unsound are sent where a full-time Medical Officer is in post but in addition others m a y begin to show abnormalities during training. Consequently a great deal of psychiatric investigation becomes necessary, and is of a type for which little precedence in other fields of psychiatry can be found. T h i s work in delinquency is constantly under the handicap that the therapist can never really be certain whether the patient is genuinely seeking help, and indeed it is m y experience that in m o s t cases it is first necessary to develop the insight that such help is needed, before any t h e r a p y can be started. T h i s would seem to be a serious barrier, but there are compensatory features. M o s t i m p o r t a n t is the fact that the Medical Officer who proposes to analyse emotional difficulties is also the one a youth will see for treatment of a corn, constipation or other trivial complaint. As a result he is n o t subjected to ridicule by the other inmates and tends to accept psychiatric exploration as just another bit of
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doctoring. T h i s is of great value, as in contrast a visiting therapist immediately meets a barrier of suspicion. Psychotherapy can be divided into minor and major forms. I n m y experience about 25% of the intake to a Borstal with a full-time Medical Officer need m i n o r psychotherapy involving analysis of emotional difficulties, and follow-up interviews. T h e treatment of such cases involves close consultation with the administrative staff. One of the greatest problems is the arranging of leniency at certain times, without upsetting the discipline of the Institution. An emotionally unstable youth who offends occasionally may be putting forth a greater effort than a youth w!th no problems who quietly cruises a l o n g - - y e t u n d u e leniency can menace the whole discipline of an institution. T h e correct balance between therapy and administration is very delicate. Major psychotherapy involving such matters as deep analysis, narcotherapy, residential group therapy and psychodrama are not carried out at training institutions. F o r the fewer cases considered suitable facilities are available in the Service when required. Such is the work of the Medical Officer at the training u n i t - - b u t Borstal training does not end with release of the inmate. H e then passes on to licence to behave well u n d e r supervision of a local officer, and m u c h trouble and time are taken by t h e Borstal After-care Association to guide him in resettlement. Should his conduct be unsatisfactory he can be recalled to a special centre set aside for the p u r p o s e - where the whole circumstances of the failure are considered. Once again a psychological assessment is made and any case thought to show unusual features is referred to the visiting Medical Officer, which at present happens to be myself. A Board then considers all aspects and decides how soon the youth may once m o r e be tried on licence. T h a t briefly is the pattern .of Borstal Training, but before closing I should refer briefly to some of what may be t e r m e d the thorny points. The Psychopathic Personality.--This is no time to discuss exactly what the term means. I w o u l d only say that conduct which seems to indicate clearly psychopathic tendencies is c o m m o n in Borstal but for every one who goes on to become a true psychopath there are others showing just as typical behaviour who learn control and stabilise. I am therefore of the opinion that the diagnosis psychopathic personality should not be used in the Borstal age g r o u p - - a n d that apparently psychopathic conduct is not necessarily a sign of an untrainable youth. The Homosexual.-~As m a y be imagined, the presence of the homosexual in an all-male society provides m a n y serious problems for the administration, b u t f r o m the point of view of the Medical Officer this often provides t h e opportunity to make an approach re psychiatric t r e a t m e n t - - a n d since personalities are not yet set, there is always the possibility of successful modification of the condition. The Epileptic.--It will be appreciated that if attacks are severe and frequent the prospects of training are seriously a f f e c t e d - - b u t fortunately most cases can be reasonably controlled. Simultaneously a m i n o r psychotherapeutical approach can be m a d e on the almost invariable emotional overlay and it is m y experience that most epileptics can be stabilised by time of release on far less drugs than at the start. Conclusion T o conclude this survey of Borstal Training, which has of necessity passed lightly over m a n y important points, I should like to give m y personal opinion that the medical profession m u s t and should play an increasing part in dealing with delinquency, not by replacing tried methods of character training, but by concentrating on the removal of physical and psychological barriers which m a y prevent such training taking effect.