THE ST. JAMES' JOURNAL

'What Matters Most in the Care of the Mentally Ill'
 
By Mrs. M. P. Fogarty
 
MENTAL patients lack the ability to define and solve their own problems, and to restore this ability is the aim of all those who look after them. Everything in their treatment is incidental to this. Patients, relatives and the general public have by now been trained to speak of a 'mental hospital' instead of an asylum, but have not yet absorbed the corresponding attitudes. They are still afraid of the hospital, and need to shed many preconceived ideas and ingrained prejudices. However disturbed patients may be, they are still aware on entering the hospital that they are arriving 'somewhere'; they are uncertain and bewildered.
 
Treatment, therefore, begins from the moment patients enter the door. A great deal depends on the way they are received. They should be treated as people coming home to a community in which they belong; as if they were entering their own home with their armchair waiting by the fireside. It is important to know their name and to have at least a rough idea of where they are coming from and what their problem is; anything to take away their initial sense of bewilderment. When they ask 'Why am I here?' — as every second patient does — there should be a ready and calming explanation, depending on the patient's personality and problems.
 
There is an instinct, or perhaps a skill, for knowing to which group a patient belongs and which answer will serve best.
 
It does not do simply to wave a hand at this and that and tell patients vaguely that there is where such and such a thing is. It is necessary to think in terms of the patient's own immediate felt needs, and to explain to him, if necessary with an almost unlimited amount of repetition, how he can meet them. The point is not to give him a geography of the hospital; it is to see the hospital through his eyes, and to answer the questions which come to his mind even when he cannot formulate them clearly or grasp the answers at once.
 
In all this, and here is something which cannot be emphasised too much, the key is good manners — plain good manners, no condescension. It would be quite wrong to speak in a tone different from that which one would use to someone who was completely sane. One may need to go slower and to repeat and explain more often, but the tone itself must be the same. One should always request, not dictate. Good manners pay dividends all the time; and this means good manners among the staff themselves as well as between staff and patients, for it is this that sets the standard for everyone in the hospital. There is a distinct levelling up of the behaviour of patients to each other when among the staff behaviour is as it should be. There is a level of consciousness, below the often wild surface behaviour of a newly arrived patient, at which he responds to good manners and somehow registers his response for future use. The capacity for good relations with others, which he develops even sub-consciously, as a result, is part of his return to sanity.
 
At this point, or a little later, it is useful to explain to those, whose minds and emotions can take it, the new attitude to mental health treatment and to mental problems among educated people, and what it is that the hospital is trying to do with its meetings, its therapy and its general atmosphere. The aim should be to enlist their co-operation so far as they are capable of understanding what is going on and of giving it. Naturally, not every patient can grasp this kind of explanation. But for those who can it is an effective way of reassuring them, of building up their self-confidence, and of drawing them into the activities of the hospital.
 
By this time the patient is becoming assimilated, a member of his group. Let us assume that patients' purely medical treatment has been dealt with. They have if necessary been tranquilised and brought into a state in which they can usefully join in a group's activities. What is to happen to them next? They are in the hospital to restore their normal functioning as individuals and members of the community. The aim is not simply to protect them (or the community from them), or to keep them occupied, though both these things may be necessary in the last resort. The problem in practice is more often to get them out of the hospital than to force them to stay in. How is it to be done?
 
The first step is to assess the patient as an individual. The problem is to give him back a sense of direction — standards of judgment — and the ability to face problems. The special quality of a human being is that he has reason and free will and can understand and obey a moral law; it is by his own free decision that he chooses his line of development and looks for his own perfection. It is this capacity which the mental patient has lost, at any rate in part, and it is this that the hospital must give him back. But in order to do this patients must be taken on their own terms; it is necessary to build on such foundations as they, personally and individually, may happen to have. Whoever is in charge of them must find what roots they have — their religion, if they have one, but otherwise whatever roots they may possess — and then appeal to and develop from them. The staff member must himself have roots and a firm foundation to work from; but his business is to help the patient to be himself in terms of whatever roots he, the patient, has. To work effectively the staff member must also of course be aware of his own personality and reactions; he must first and foremost know himself.
 
The way back to normal functioning lies partly through individual contacts and partly through contacts with staff and other patients in a group. Drugs, shock treatment and so on help by removing obstacles; but in the end the way back to mental health lies through personal and group contacts. A patient should be given a function in a group as he might in the community outside. Silences can be useful, but with mental patients it is important for staff to take the initiative and keep the group moving. It helps both the individual patient and the group if an appeal is made to the more capable members of the group to help in its leadership; even if, as happens from time to time, they round on a staff member when the suggestion is made. All the time, it matters vitally to keep the level of manners and relationships high; for this, as has been said, is itself part of the process of learning once again to handle relationships such as are found in the community outside.
 
Since the aim is to restore patients' normal functioning in the community, it is important to preserve any links with relatives, work or other outside contacts of which they are capable. Their progress is marked by the step-by-step revival of capacity for contacts like these. From gumming paper in a hospital work group they graduate to at least contemplating an outside job — it may not be easy to get them past contemplation to actually taking one — and thence to working at a job, or perhaps taking week-ends or other spells at home, while still based on the hospital; till finally they can return to full normal relationships outside.
 
In the meantime there is a problem of embarrassment and misunderstanding in contacts with (so far as the hospital is concerned) outsiders such as relatives or prospective employers. This calls for tactful handling, remembering that the sane, like mental patients themselves, retain many of the prejudices of the past about insanity. It is for instance important to greet and to reassure visiting relatives, and to ease them into the group, in essentially the same way as newly arrived patients.
 
The absolutely essential point — to conclude — is to remember that patients are basically ordinary people like ourselves, anxious for friendly and civilised contacts even when their illness prevents them from showing it. Simplicity, sincerity and a polite friendly approach will always pay. It is inevitable that patients should sometimes be violent and abusive. The right approach is not to answer in kind but either to turn abuse aside or, if this is impossible, to keep silence and as nearly as may be ignore it. It is a great mistake, and one which lowers the level of personal contacts, on which the whole success of treatment depends, to deal with the violent and abusive patient on what appears, because of his illness, to be his own level. There is a deeper, less visible, level at which he can respond to civilised treatment in spite of his surface symptoms.
 
Winter 1962/3
 

Table of Journal Contents