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Suburban Neurosis Up to Date
146
Suburban Neurosis
Date IT is now nearly twenty years since TAYLOR1 described in our columns a condition which he called suburban neurosis". He was writing about life in the new housing estates which had sprung up round our great cities. In these estates-sometimes jerry-built and almost always devoid of social amenities-it was considered correct to keep oneself to oneself. The one-child family and the baby car represented the height of ambition; and, though physical health was compara-
Up
to
"
tively good, many of the people had anxiety states, often with hysterical features and reactive depression, which TAYLOR attributed to boredom, loneliness, and a false set of values. One of the happier results of the 1939-45 war, and particularly the continuing threat of air-raids, was to build a new community life in such places. Firewatching, the Women’s Voluntary Services, evacuation, and many forms of mutual help broke down the previous social isolation, and the prevalence of neurotic illness declined spectacularly. Afterwards there was some the but social isolation of the inter-war back, slipping not been has restored. years fully Since the war, the emphasis of building development has changed. Green belts of a sort have been established around the cities, and instead of the speculative hirepurchase estates we have had huge blocks of municipal flats, large out-county municipal estates, and the new towns. (Only within the past three years has speculative building recommenced, and its scale is much smaller than before.) Though redevelopment in municipal flats has had its social difficulties, old ties of friendship and kinship have not been broken, as must happen when a family moves right out of the city. In the new towns, industry and homes have moved out together, and imaginative social provision has done much to reduce the risk of neurotic reactions in a new environment-though the combination of high rents, hire-purchase payments for furniture, and rapidly increasing families often leads to justifiable financial anxiety.2 The out-county municipal estates, however, have long been suspected of partly repeating the story of the pre-war speculative estates. Great working-class populations were translated to new homes in country suburbs; and, though the standards of housing were admirable, social provision was at first very meagre: the great majority of the wage-earners continued to earn their living in London, while the women tended to follow the obsolescent middle-class pattern of social isolation as a standard of respectability. Hence it was good that a team from what was then Prof. J. M. MACKINTOSH’s department at the London School of
Hygiene should decide to make a detailed study of what going on in one of these out-county estates to the
was
north of London. Two reports of this team’s work appeared last year,34 and a third, by MARTIN, BROTHERSTON, and CHAVE,5 deals with the incidence of neurotic and psychotic illness. 1. Taylor, S. Lancet, 1938, i, 759. 2. Taylor, C., et al. Lancet, 1955, ii, 863. 3. Brotherston, J. H. F., Chave, S. P. W. Brit. J. prev. soc. Med. 1956, 10, 200. 4. Maule, H. G., Martin, F. M. Advanc. Sci. 1956, 12, 443, 448. 5. Martin, F. M., Brotherston, J. H. F., Chave, S. P. W. Brit. J. prev. soc. Med. 1957, 11, 196.
Four
of information admissions, referrals to
sources
hospital
tapped-mentalpsychiatric outpatient
were
general-practitioner consultations, and the results of a direct-interview survey. Between 1949 and 1954, there were 129 admissions to mental hospitals from the estate, giving a rate slightly more than 50% above what would be expected from national figures. Admissions for neuroses were twice the national rate, with neurotic reactive depression among females predominating. On the other hand, the discharge-rate was high, and the average period in hospital short. Psychiatric outpatient referrals did not differ markedly from the national average, but were twice as numerous as in neighbouring areas served by the same hospitals. During 1953, all the doctors in general practice on the estate maintained records of all their consultations, and the following table shows the number of patients consulting them for various complaints (per 1000 registered populaclinics,
tion)
set
alongside " expected " figures:
The direct-interview survey showed that the selfestimate of " nerves " on the estate was 223 per 1000 adults, compared with the national figure of 126 obtained by the Social Survey of Sickness.6 Complaints of neurotic symptoms were higher among those who had lived on the estate for two years or less than among those who had been there for three to six years; but even the oldest inhabitants had rates far above the national
figures. Admittedly, rehousing on an out-county estate is partly determined by medical certificate; but a psychiatric or quasipsychiatric diagnosis had been submitted for only 2% of men and 8% of women, and these can account for only a small part of the excess of neurotic illness encountered. Here, then, is the suburban neurosis presenting itself again, and probably for much the same reasons. As Professor BROTHERSTON and his colleagues remark, each family " keeping itself to itself " generates a degree of loneliness and social isolation inconsistent with good mental health. The findings at direct interview and the statistics for juvenile delinquency suggest that, with time, there is a slow improvement; but the picture remains a sad one. Physical planning on the out-county estates appears to be out of step with social planning, and rehousing has improved physical environment at the cost of mental wellbeing. There is reason to think that in the new towns the lessons of the past have been learnt and applied. Precise statistical evidence has yet to be collected, but we agree that " comparable studies of mental health problems in New Towns ... would be especially 6. Stocks, P.
Studies of Medical and Population Subjects, no. 2. H.M.
Stationery Office,
1949.
147
The present study supports the view that social environment affects the prevalence not only of neurotic but also of psychotic illness; and, if this is so,
illuminating".
preventive psychiatry will lie as much in planning as in early diagnosis and treatment. A few thousands of pounds spent on social amenities and social development may save hundreds of thousands used on therapeutic services or wasted in labour lost. the future of
social
Artificial Insemination ARTIFICIAL insemination of livestock is practised, and its techniques are both
widely simple and reliable. There are few practical difficulties in carrying out the same process in human beings; and most of what has been written on this subject turns on the desirability of doing so. In a new review1 of the human applications of the method, a Dutch obstetrician and gynaecologist now
deals with both types of insemination now in use-from the husband and from a donor or donors. He discusses techniques, but he is more closely concerned with far more contentious matters. Few biological discoveries on so sensitive areas of human belief, trespass many and the body of resulting comment-legal, religious, and ethical-is the main topic of Dr. SCHELLEN’S review. For some commentators every stage of the process, from the manner of collecting semen and the desirability of paying the donor to the risk of inadvertent marriage between siblings, is of immediate and serious moral importance. Others are more preoccupied with the effects on parents, child, and doctor of granting or refusing a request for donor insemination. In the discussion of these possible effects, rationalisation often plays a recognisable part. SCHELLEN does not wholly escape the charge of special pleading in his chairmanship of the debate, and his parti pris, although evident, is overtly declared only in his last few pages. But his book is a fascinating study of the social anthropology of human opinion. Such an alarming battery of theological, moral,
magical, psychological, and admonitory comment is likely, thus presented, to deter any cautious doctor from involving himself, at least in donor insemination; and the deterrent action was perhaps SCHELLEN’s aim. Many whose ethics are based on similar religious belief may well agree with his assessment and emphasis. To others, it may seem that patients seeking medical help in their desire for children are less agitated by scruple over details of procedure than are their spiritual mentors. At the same time, the possibility of all kinds of trouble arising from donor insemination must be evident to all but the blindly sanguine. SCHELLEN quotes many such forebodings; the actual failures he mentions are largely anecdotal. But his book poses once more one of the central questions of medical ethics-how the moral and religious opinions of the doctor and his patient should determine the advice given in matters of conduct. 1. Artificial Insemination in the Human. By A. M. C. H. SCHELLEN, M.D., resident at the department of obstetrics and gynæcology, University Hospital, Groningen. New York: Elsevier. London: Cleaver-Hume. 1957. Pp. 420. 72s.
He offers
on the motives which lead donor insemination. These are patients request be and diverse: it would important probably possible to take the extreme position that well-adjusted patients will not require donor insemination, and the ill-adjusted may be harmed by it; such a view leads, at least, to dignified inactivity. Some doctors believe that donor insemination has a valid place in medical practice, and meets both a demand and a right. There are those who would no doubt agree with GUTTMACHER,2 both in his summary handling of the theologians and in his general advice-that the doctor should act on his judgment and knowledge of the patient, with privacy and without formality of any kind, avoiding the formidable legal instruments prepared by some authorities bent on selfprotection, refusing high fees, and " putting the name of the husband as father on the appropriate forms-a white lie here is a humane, friendly deed ". At the opposite extreme, there is anxious debate whether a donor who accepts payment is morally fit for fatherhood, or whether he is entitled to demand it for " a service more distasteful than that of a blood donor". Even the use of the husband’s semen gives rise to heartsearching in some places. Every approach, from an ingenuity of scruple worthy of Hudibras to frank commercialism, is cited in SCHELLEN’S collection: the only criticism of its scope is that this citation of extremes leads to an under-representation of more moderate judgments.
only conjecture
to
Since many critics of artificial insemination base their objection, at least in part, on genetic and psychological risks, it is unfortunate that we have here no follow-up studies of couples who have borne a child in this way, and no serious discussion of the biological implications in terms of modern genetics. Evidence of this kind might form a more manageable basis for advice than appeals to general, or even infallible, moralities. The genetic comment is uncritical, both in exaggerating by implication the physical consequences of accidental endogamy, and in accepting anecdote-about supposed man-ape hybridisation, for example. There are those who will read Dr. SCHELLEN with irritation; but the human anxieties he writes of are real and deepseated, even when unspoken. Mountains of this kind have to be scaled by the patient, even when they have been made from what, to the unconvinced sceptic, appear to be ethical molehills. Some of the instances of medical insensitivity to which SCHELLEN_ refers are warnings against overconfidence and undue persuasion. Eradication of Malaria MALARIA eradication, though known to be feasible, might have been pursued only exceptionally but for the fear that, owing to the growth of anopheline resistance, control by means of residual insecticides could not be maintained permanently. The W.H.O. Expert Committee on Malaria, in recommending eradication,S points to its social and economic advantages, and remarks that it needs special finance for a limited time only. Moreover, in achieving eradication a government gains an asset in well-trained staff available for other services. 2. 2nd American Congress of the Society for the 3. Wld Hlth Org. techn. Rep. Ser. 1957, no. 123,
Study of Sterility, 1942. p. 5.
Suburban Neurosis
Date IT is now nearly twenty years since TAYLOR1 described in our columns a condition which he called suburban neurosis". He was writing about life in the new housing estates which had sprung up round our great cities. In these estates-sometimes jerry-built and almost always devoid of social amenities-it was considered correct to keep oneself to oneself. The one-child family and the baby car represented the height of ambition; and, though physical health was compara-
Up
to
"
tively good, many of the people had anxiety states, often with hysterical features and reactive depression, which TAYLOR attributed to boredom, loneliness, and a false set of values. One of the happier results of the 1939-45 war, and particularly the continuing threat of air-raids, was to build a new community life in such places. Firewatching, the Women’s Voluntary Services, evacuation, and many forms of mutual help broke down the previous social isolation, and the prevalence of neurotic illness declined spectacularly. Afterwards there was some the but social isolation of the inter-war back, slipping not been has restored. years fully Since the war, the emphasis of building development has changed. Green belts of a sort have been established around the cities, and instead of the speculative hirepurchase estates we have had huge blocks of municipal flats, large out-county municipal estates, and the new towns. (Only within the past three years has speculative building recommenced, and its scale is much smaller than before.) Though redevelopment in municipal flats has had its social difficulties, old ties of friendship and kinship have not been broken, as must happen when a family moves right out of the city. In the new towns, industry and homes have moved out together, and imaginative social provision has done much to reduce the risk of neurotic reactions in a new environment-though the combination of high rents, hire-purchase payments for furniture, and rapidly increasing families often leads to justifiable financial anxiety.2 The out-county municipal estates, however, have long been suspected of partly repeating the story of the pre-war speculative estates. Great working-class populations were translated to new homes in country suburbs; and, though the standards of housing were admirable, social provision was at first very meagre: the great majority of the wage-earners continued to earn their living in London, while the women tended to follow the obsolescent middle-class pattern of social isolation as a standard of respectability. Hence it was good that a team from what was then Prof. J. M. MACKINTOSH’s department at the London School of
Hygiene should decide to make a detailed study of what going on in one of these out-county estates to the
was
north of London. Two reports of this team’s work appeared last year,34 and a third, by MARTIN, BROTHERSTON, and CHAVE,5 deals with the incidence of neurotic and psychotic illness. 1. Taylor, S. Lancet, 1938, i, 759. 2. Taylor, C., et al. Lancet, 1955, ii, 863. 3. Brotherston, J. H. F., Chave, S. P. W. Brit. J. prev. soc. Med. 1956, 10, 200. 4. Maule, H. G., Martin, F. M. Advanc. Sci. 1956, 12, 443, 448. 5. Martin, F. M., Brotherston, J. H. F., Chave, S. P. W. Brit. J. prev. soc. Med. 1957, 11, 196.
Four
of information admissions, referrals to
sources
hospital
tapped-mentalpsychiatric outpatient
were
general-practitioner consultations, and the results of a direct-interview survey. Between 1949 and 1954, there were 129 admissions to mental hospitals from the estate, giving a rate slightly more than 50% above what would be expected from national figures. Admissions for neuroses were twice the national rate, with neurotic reactive depression among females predominating. On the other hand, the discharge-rate was high, and the average period in hospital short. Psychiatric outpatient referrals did not differ markedly from the national average, but were twice as numerous as in neighbouring areas served by the same hospitals. During 1953, all the doctors in general practice on the estate maintained records of all their consultations, and the following table shows the number of patients consulting them for various complaints (per 1000 registered populaclinics,
tion)
set
alongside " expected " figures:
The direct-interview survey showed that the selfestimate of " nerves " on the estate was 223 per 1000 adults, compared with the national figure of 126 obtained by the Social Survey of Sickness.6 Complaints of neurotic symptoms were higher among those who had lived on the estate for two years or less than among those who had been there for three to six years; but even the oldest inhabitants had rates far above the national
figures. Admittedly, rehousing on an out-county estate is partly determined by medical certificate; but a psychiatric or quasipsychiatric diagnosis had been submitted for only 2% of men and 8% of women, and these can account for only a small part of the excess of neurotic illness encountered. Here, then, is the suburban neurosis presenting itself again, and probably for much the same reasons. As Professor BROTHERSTON and his colleagues remark, each family " keeping itself to itself " generates a degree of loneliness and social isolation inconsistent with good mental health. The findings at direct interview and the statistics for juvenile delinquency suggest that, with time, there is a slow improvement; but the picture remains a sad one. Physical planning on the out-county estates appears to be out of step with social planning, and rehousing has improved physical environment at the cost of mental wellbeing. There is reason to think that in the new towns the lessons of the past have been learnt and applied. Precise statistical evidence has yet to be collected, but we agree that " comparable studies of mental health problems in New Towns ... would be especially 6. Stocks, P.
Studies of Medical and Population Subjects, no. 2. H.M.
Stationery Office,
1949.
147
The present study supports the view that social environment affects the prevalence not only of neurotic but also of psychotic illness; and, if this is so,
illuminating".
preventive psychiatry will lie as much in planning as in early diagnosis and treatment. A few thousands of pounds spent on social amenities and social development may save hundreds of thousands used on therapeutic services or wasted in labour lost. the future of
social
Artificial Insemination ARTIFICIAL insemination of livestock is practised, and its techniques are both
widely simple and reliable. There are few practical difficulties in carrying out the same process in human beings; and most of what has been written on this subject turns on the desirability of doing so. In a new review1 of the human applications of the method, a Dutch obstetrician and gynaecologist now
deals with both types of insemination now in use-from the husband and from a donor or donors. He discusses techniques, but he is more closely concerned with far more contentious matters. Few biological discoveries on so sensitive areas of human belief, trespass many and the body of resulting comment-legal, religious, and ethical-is the main topic of Dr. SCHELLEN’S review. For some commentators every stage of the process, from the manner of collecting semen and the desirability of paying the donor to the risk of inadvertent marriage between siblings, is of immediate and serious moral importance. Others are more preoccupied with the effects on parents, child, and doctor of granting or refusing a request for donor insemination. In the discussion of these possible effects, rationalisation often plays a recognisable part. SCHELLEN does not wholly escape the charge of special pleading in his chairmanship of the debate, and his parti pris, although evident, is overtly declared only in his last few pages. But his book is a fascinating study of the social anthropology of human opinion. Such an alarming battery of theological, moral,
magical, psychological, and admonitory comment is likely, thus presented, to deter any cautious doctor from involving himself, at least in donor insemination; and the deterrent action was perhaps SCHELLEN’s aim. Many whose ethics are based on similar religious belief may well agree with his assessment and emphasis. To others, it may seem that patients seeking medical help in their desire for children are less agitated by scruple over details of procedure than are their spiritual mentors. At the same time, the possibility of all kinds of trouble arising from donor insemination must be evident to all but the blindly sanguine. SCHELLEN quotes many such forebodings; the actual failures he mentions are largely anecdotal. But his book poses once more one of the central questions of medical ethics-how the moral and religious opinions of the doctor and his patient should determine the advice given in matters of conduct. 1. Artificial Insemination in the Human. By A. M. C. H. SCHELLEN, M.D., resident at the department of obstetrics and gynæcology, University Hospital, Groningen. New York: Elsevier. London: Cleaver-Hume. 1957. Pp. 420. 72s.
He offers
on the motives which lead donor insemination. These are patients request be and diverse: it would important probably possible to take the extreme position that well-adjusted patients will not require donor insemination, and the ill-adjusted may be harmed by it; such a view leads, at least, to dignified inactivity. Some doctors believe that donor insemination has a valid place in medical practice, and meets both a demand and a right. There are those who would no doubt agree with GUTTMACHER,2 both in his summary handling of the theologians and in his general advice-that the doctor should act on his judgment and knowledge of the patient, with privacy and without formality of any kind, avoiding the formidable legal instruments prepared by some authorities bent on selfprotection, refusing high fees, and " putting the name of the husband as father on the appropriate forms-a white lie here is a humane, friendly deed ". At the opposite extreme, there is anxious debate whether a donor who accepts payment is morally fit for fatherhood, or whether he is entitled to demand it for " a service more distasteful than that of a blood donor". Even the use of the husband’s semen gives rise to heartsearching in some places. Every approach, from an ingenuity of scruple worthy of Hudibras to frank commercialism, is cited in SCHELLEN’S collection: the only criticism of its scope is that this citation of extremes leads to an under-representation of more moderate judgments.
only conjecture
to
Since many critics of artificial insemination base their objection, at least in part, on genetic and psychological risks, it is unfortunate that we have here no follow-up studies of couples who have borne a child in this way, and no serious discussion of the biological implications in terms of modern genetics. Evidence of this kind might form a more manageable basis for advice than appeals to general, or even infallible, moralities. The genetic comment is uncritical, both in exaggerating by implication the physical consequences of accidental endogamy, and in accepting anecdote-about supposed man-ape hybridisation, for example. There are those who will read Dr. SCHELLEN with irritation; but the human anxieties he writes of are real and deepseated, even when unspoken. Mountains of this kind have to be scaled by the patient, even when they have been made from what, to the unconvinced sceptic, appear to be ethical molehills. Some of the instances of medical insensitivity to which SCHELLEN_ refers are warnings against overconfidence and undue persuasion. Eradication of Malaria MALARIA eradication, though known to be feasible, might have been pursued only exceptionally but for the fear that, owing to the growth of anopheline resistance, control by means of residual insecticides could not be maintained permanently. The W.H.O. Expert Committee on Malaria, in recommending eradication,S points to its social and economic advantages, and remarks that it needs special finance for a limited time only. Moreover, in achieving eradication a government gains an asset in well-trained staff available for other services. 2. 2nd American Congress of the Society for the 3. Wld Hlth Org. techn. Rep. Ser. 1957, no. 123,
Study of Sterility, 1942. p. 5.