CHAPTER VIITHE MENTAL HYGIENE MOVEMENT
As the result of an intimate personal knowledge of the subject, acquired during an extended hospital residence as a patient in both public and private institutions, Clifford W. Beers, having recovered his health, resumed his place in the world profoundly impressed with the feeling that the question of mental diseases as a public health problem was one which demanded immediate consideration. In no position financially to institute a campaign for the purpose of interesting the public in the importance of topics which had not been made the subject of general discussion in the past, he was confronted with the necessity of securing the cooperation and support of persons who had the means to launch such an undertaking. With this object in view he wrote his book—"A Mind That Found Itself,"[38]now in its fourth edition and destined, to use the words of the "American Journal of Insanity,"[39]"to become one of the classics of psychological literature." There is some question as to the accuracy with which Mr. Beers analyzed the experiences through which he had passed. Although there is no reason for questioning his mental condition when the book was written, his conclusions were apparently formulated when he had not as yet had sufficient time in which to readjust himself and recover his perspective. Some of his viewpoints certainly reflect a morbid coloring of which he was probably unconscious, although at the time he recognized in himself "symptoms hardlydistinguishable from those which had obtained eight months earlier when it had been deemed expedient temporarily to restrict my freedom." His work was referred to as an "autopathography" by Farrar,[40]who made a detailed study of the various psychological trends manifested. These are more or less immaterial. The interesting feature of his book is the elaborate description of a common but exceedingly important psychosis written by a well educated observer with a collegiate training. Its greatest value, however, lies in the fact that he brings home to us so graphically the overwhelming importance of the personal element so often overlooked by those who are accustomed to dealing with mental cases in large numbers. "It carries the reader away from the technical dissertations, and brings him face to face with the feelings and reactions of a distorted mind, showing him the patient as a human being with a sentient soul and not as a case."[41]
That the plan which Mr. Beers had formulated for an organized mental hygiene movement had a practical application was recognized at once by Dr. Adolf Meyer,[42]who expressed the following views on the subject as early as 1907:—"It will be a difficult task to find the not very common level-headed and well-informed persons in various parts of the country capable of organizing the public conscience of the people. Neglected by physicians and dreaded by the fiscal authorities, the facts are not available today, except in fragments, mixed up with innumerable extraneous considerations; the hospitals are closed corporations, the press injudicious in inquiry and reform, and those capable of judgment unable to get the facts. The crying needs persist in themeantime. Instead of a land fund (the 12,225,000 acres bill and ideal of Dorothea Dix) we must have a permanent survey of the facts and efficient handling of what is not prevented. The experience with what remains as inevitable experiments of nature, as well as with people who should know better, must be put into practical form for communication and teaching, and brought home where it will tell; in opportunities of work and education for physicians, and cooperation between our educational forces and those who labor for physical hygiene and prophylaxis. Most of us are already under too definite obligations to meet the call for devoted work for the maintenance of an organization as well as can Mr. Beers. In my judgment, he deserves the assistance which will make it possible for others to join in the work which will be one of the greatest achievements of this country and of this century,—less sensational than the breaking of chains but more far-reaching and also more exacting in labor. A Society for Mental Hygiene with a capable and devoted and judicious agent of organization will put an end to the work of makeshift and short-sighted opportunism, and initiate work of prevention and of helping the existing hospitals to attain what they should attain, and further of adding those links which are needed to put an end to conditions almost unfit for publication. What officialism will never do alone must be helped along by an organized body of persons who have set their hearts on serious devotion to the cause. If Mr. Beers gets the means to pursue his aim he will secure the body which will guarantee proper judgment in a cause which has been a mere foster-child in the field of charitable donations merely because it seemed too difficult. Here is a man who is not afraid of the task. May he get the help to enable him to surround himself with the best wisdom of our nation!"
Encouraged by this and many other such expressionsof opinion, Mr. Beers proceeded to the organization of the first state mental hygiene society, that of Connecticut, which began its activities in 1908. The National Committee for Mental Hygiene was formally organized on February 19, 1909. The first few years were devoted to raising funds and making comprehensive preparations for further activities which did not start until 1912. In the meanwhile the cooperation of many prominent philanthropists, educators, physicians, etc., was assured. The importance of this movement is illustrated by the prominence of the persons who were willing to associate themselves with an undertaking of this nature. The membership of the committee has included, in addition to many others, Professor William James, Dr. Lewellys F. Barker, Dr. Rupert Blue, Dr. George Blumer, Dr. G. Alder Blumer, Professor Russell H. Chittenden, Ex-President Charles W. Eliot, President W. H. P. Faunce, President John H. Finley, Professor Irving Fisher, Dr. Charles H. Frazier, Cardinal Gibbons, President Arthur T. Hadley, Chancellor David Starr Jordan, President Cyrus Northrop, Dr. Stewart Paton, Dr. Frederick Peterson, Professor Gifford Pinchot, President Jacob G. Sherman, Rev. Anson Phelps Stokes, Mrs. William K. Vanderbilt, Professor Henry VanDyke, Dr. William H. Welch and Ex-President Benjamin Ide Wheeler. Important financial contributions were made by Professor William James, Mr. Jacob A. Riis, Mr. Henry Phipps, Mrs. Elizabeth M. Anderson, Mrs. William K. Vanderbilt, Mrs. E. H. Harriman, Mrs. Willard Straight, the Rockefeller Foundation, etc. With the appointment of Dr. Thomas W. Salmon as Medical Director in 1912 the committee commenced active operations with its future success assured in every way.
The objects and purposes of the National Committee have been very adequately summarized in the following language used in one of its publications:—"The NationalCommittee for Mental Hygiene and its affiliated state societies and committees are organized to work for the conservation of mental health; to help prevent nervous and mental disorders and mental defect; to help raise the standards of care and treatment for those suffering from any of these disorders or mental defect; to secure and disseminate reliable information on these subjects and also on mental factors involved in problems related to industry, education, delinquency, dependency, and the like; to aid ex-service men disabled in the war; to cooperate with the federal, state, and local agencies and with officials and with public and private agencies whose work is in any way related to that of a society or committee for mental hygiene. Though methods vary, these organizations seek to accomplish their purposes by means of education, encouraging psychiatric social service, conducting surveys, promoting legislation, and through cooperation with the many agencies whose work touches at one point or another the field of mental hygiene. When one considers the large groups of people who may be benefited by organized work in mental hygiene, the importance of the movement at once becomes apparent. Such work is not only for the mentally disordered and those suffering from mental defect, but for all those who, through mental causes, are unable so to adjust themselves to their environment as to live happy and efficient lives." The first few years of the committee's existence have demonstrated conclusively that it is the most powerful factor in promoting the welfare and interests of the insane in this country since the time of Dorothea Dix. The elaborate surveys which it has made of conditions existing in various states have resulted in beneficial legislation which had been needed for years. Surveys have been completed in California, Tennessee, Louisiana, Pennsylvania, Texas, Connecticut, Georgia, Wisconsin and South Carolina, and othersare under way. It has brought about an interest in mental diseases and mental defects such as has never been manifested before in this country. Its activities during the early part of the war were responsible largely, if not entirely, for the attention given by the Army and Navy to matters relating to psychiatry. The National Committee has taken a very active part in encouraging the establishment of psychiatric clinics in connection with the state hospitals. It has been largely responsible for the psychological and psychiatric examination of defectives in penal institutions and reformatories now generally recognized as being of vital importance. Its activities have emphasized the importance of a preliminary mental examination of obviously defective individuals brought before the courts. One of its accomplishments has been the publication of a very successful quarterly magazine, "Mental Hygiene," which was undertaken in 1917 and has long since passed the experimental stage. A summary of its activities would not be complete without a reference to the valuable work which the committee has done in standardizing the reports made of institutions and compiling accurate statistics relating to mental diseases and defects which will be of inestimable value to all who are interested in the progress of psychiatry in this country.
State mental hygiene societies now exist in Alabama, California, Connecticut, the District of Columbia, Georgia, Illinois, Indiana, Iowa, Kansas, Louisiana, Maryland, Massachusetts, Maine, Mississippi, Missouri, North Carolina, Oregon, Pennsylvania, Rhode Island, Tennessee and Virginia. The committee on mental hygiene in New York is a department of the State Charities Aid Association, which has been actively interested in matters relating to the care and treatment of the insane for many years. The chief purposes of the state organizationshave been officially described as follows:—[43]"To work for the conservation of mental health; for the prevention of mental diseases and mental deficiency and for improvement in the care and treatment of those suffering from nervous or mental diseases or mental deficiency." The interest of the public is stimulated by pamphlets, reports and publications of various kinds, mental hygiene exhibits of an educational nature, public lectures, mental hygiene conferences, etc. The local societies have as a definite object, moreover, the encouragement of[44]"(a) Out-patient departments for mental cases in connection with hospitals for mental diseases and general hospitals, and independent of either of these agencies, such, for instance, as dispensaries and mental hygiene clinics, (b) Systematic psychiatric as well as psychological examination of school children, (e) Provision for incipient and emergency cases in psychopathic wards of general hospitals, (d) Psychopathic hospitals in which cases of mental disorder may be treated in their earliest and most curable stages and where practical work in prevention and social service may be done, (e) Increased institutional provision for the feebleminded and epileptic." One of their most important objects is the enactment of laws in the various states which will take care of the insane pending commitment out of the hands of the poor authorities and delegate it to health officers or physicians. As Dr. William L. Russell[45]has pointed out, the mere provision of institutional care for the mental diseases of a community is not the only thing to be considered, "Unless the vital issuesoccasioned by mental disorders in the homes, the schools, the industries, and in social relations are intelligently grasped and dealt with by means of the state system, state institutions are liable to be looked upon as a resource which is only to be appealed to when complete separation of the patient from his usual environment has become imperative. They will still be regarded as asylums. In such case, their development is likely to be in the direction of great custodial centers, and economic and so-called business consideration in their management are likely to prevail over those dictated by science and humanity. This has happened in more than one state in which state care has been adopted under conditions of great promise. A system of state care must, to be effective, not only be adopted, but it must be planned and developed with reference to the known needs of the sufferers from mental disorder."
The Canadian National Committee for Mental Hygiene, the second national organization of this type, was established at Ottawa on April 26, 1918, largely as a result of the activities of Dr. Clarence M. Hincks of Toronto University. Arrangements were at once effected for an active participation in war work, a comprehensive study of immigration, elaborate statistical institutional studies, the establishment of a library, special investigation of delinquency and a series of lectures to be given in various parts of the Dominion. This organization has been an exceedingly active one from the beginning. The first number of the "Canadian Journal of Mental Hygiene" appeared early in 1919. A survey was made of Manitoba and its needs during the first year. The University of Toronto announced an extension course beginning April, 1919, for the special training of social workers desiring to enter the mental hygiene field. Instruction was given in psychiatry, social and economic problems, neurology, mental tests, case work, social institutions,occupational therapy, child welfare, home economics and recreation. In 1919 a mental hygiene survey was made of British Columbia. Alberta, New Brunswick and Nova Scotia have already requested similar surveys with the intention of improving the methods of caring for mental diseases and defects in those provinces. Psychiatric clinics have been established in connection with the Toronto University and the Royal Victoria Hospital in Quebec. New institutions have been planned in British Columbia and a psychopathic hospital is to be built in Toronto. In 1920 a mental hygiene committee was instituted in France[46]by the Minister of Hygiene, Assistance and Social Providence. The committee is made up of about forty members, psychiatrists, pathologists, physiologists, managers and magistrates. Dr. Dron, Senator and Mayor of Tourcoing, was elected chairman. The committee is to make a study of all questions relating to mental hygiene and psychiatry. It will consider particularly methods of coordinating the activities of various organizations already at work, the creation of new interests and spreading broadcast information on mental hygiene topics. A representative of this society has already made a visit to this country to study methods employed here. The mental hygiene movement has even reached South Africa. "Mental Hygiene"[47]has called attention to the fact that the Cape Province Society for Mental Hygiene has actively interested itself in the provisions discussed by the government for the care, education and training of the feebleminded. Two institutions are to be opened for this purpose. The Cape Province Society has already instituted a campaign for the purpose of organizing other local societies as well as a national council.
When Mr. Beers wrote his well-known book he evidentlyhad in mind more particularly the amelioration of material conditions existing in institutions. He was looking forward to provision for the more humane and scientific care of mental diseases. This is unquestionably a consideration of vital importance and these objects have not been neglected in the practical operation of the mental hygiene organizations. Mental hygiene in its broadest sense, however, has come to mean much more than that. The foundation of the present-day conception of mental hygiene may be said to have been laid by Adolf Meyer in 1906, when he described the fundamental principles which he believed to be concerned in the development of dementia praecox. He saw in this disease a disorder of the personality due to a deterioration of mental habits, in other words, to faulty mental hygiene. While his views as to the etiology of dementia praecox have not been generally accepted, they suggested an entirely new avenue of approach to the problem of mental diseases in general. Hoch's "shut in" personality and Bleuler's "autismus" were more or less comparable hypotheses which do warrant to a certain extent the tenability of such theories as were advanced by Meyer. The same may be said of some of the mental mechanisms advocated by Freud and others of the more purely psychological school of psychiatrists. This viewpoint is reflected somewhat by White[48]in his conception of childhood as the golden period for mental hygiene. "The outstanding fact that present-day psychiatry emphasizes is that mental illness is a type of reaction of the individual to his problems of adjustment which is conditioned by two factors—the nature of those problems and the character equipment with which they are met.... Mental illnesses, defects of adjustment at the psychological level, are therefore dependent upondefects in the personality make-up, and as this personality make-up is what it is as a result of its development from infancy onward, it follows that the foundation of those defects which later issue in mental illness are to be found in the past history of that development." He protests very properly against accepting the theory that the characteristics of the personality are entirely the products of germ-plasm determiners moulded in strict accordance with the laws of heredity and therefore immutable.
Copp[49]has called attention to the fact that the dominant figure in mental hygiene activities must eventually be the family physician, who has an opportunity to see the beginnings of mental disorders when they first manifest themselves. He must, therefore, be qualified to intelligently understand such conditions and be prepared to suggest a remedy. His is inevitably the first point of contact. Mental hygienists have found a fertile and almost untouched field in our public school system. As Professor Burnham[50]suggests, "It is a grave reflection upon the schools that so many of their graduates have to be reeducated in the sanitarium or the hospital." The hygiene movement in the school population, as suggested by Professor Gesell,[51]means something more than psychological examinations and mental tests, important as they are. It means a study of the individual. He would have a new type of school nurse or social worker, one interested particularly in "the child with the night terrors, the nail biter, the over-tearful child, the over-silent child, the stammering child, the extremely indifferent child, the pervert, the infantile child, theunstable choreic, and a whole host of suffering, frustrated and unhealthily constituted growing minds, that we are barely aware of in a quantitative sense, because we do not have the agencies to bring them to our attention as problems of public hygiene and prophylaxis." They require highly specialized supervision and training if they are not to become future residents of our hospitals for mental diseases or possibly of institutions of a reformatory type. If such reforms as these are to be brought about in our public school system it is hardly necessary to suggest that the teacher herself must have very clear conceptions as to the significance and importance of mental training in youth.
If these matters are important in the public schools they must be even more serious factors in higher education. Campbell[52]has raised the question as to how far the universities "fulfill their responsibilities with regard to the mental hygiene of the community? It is doubtful whether they have attained a clear recognition of the fact that a man's mind may be richly supplied with a great variety of special information, that he may have attained a high intellectual level, and yet the man's life may be rendered inefficient because it rests upon insecure foundations. An education may enable a man to solve abstruse intellectual problems, and yet leave him so hopelessly unable to cope with a bereavement, an unsuccessful love affair, difficult marriage relations, or even simple instructive impulses that he may lose control of the direction of his life and for a period be dominated by factors which have been almost entirely repressed in his conscious life; the disorder may be so marked as to be included under the wide term "insanity." To rear a superb intellectual structure on such a foundation is surely not an ideal education; it is like building a houseon the sand, or, to speak more hygienically, it is like building a superb mansion without paying any attention to the plumbing." Deplorable as it may seem that such important elements in the education of the individual have been overlooked, it is not nearly so surprising as the fact that no instruction of any consequence is given in psychiatry in the great majority of our medical schools. This is a matter which is well worthy of attention and is fortunately beginning to receive some consideration. A rather systematic campaign has been instituted by the mental hygiene organizations to bring about some instruction in these topics in our schools and universities,—a campaign which promises to be productive of results sooner or later.
An interesting phase of the mental hygiene movement is the relation which it has been shown to hold to the field of industry. It must be admitted that this is an intensely practical question. We even have a Journal of Industrial Hygiene, which has been published successfully now for some time. The mere taking of intelligence tests for industrial purposes is only an incident. The important thing, as shown by Cobb,[53]is the prevention of mental disorder by bringing about a proper relation of the worker to his environment and the elimination of causes of discontent. Beyond this there is, of course, the early treatment of individuals before the opportunity of bringing about a proper adjustment has been lost for all time. Cobb[54]suggests that, above all, the physician must "forget orthodox psychiatry (as the economist seems to be forgetting cut-and-dried political economy) and interest himself in a dynamic, individual psychology which recognizes the essentials ofhuman nature and at last begins to analyze for us the elements of which human nature really consists, looking on each case as a human experiment in reaction to environment."
There would appear to be no limit to the possibilities of the mental hygiene movement. Perhaps no more comprehensive summary of its objects and purposes can be given at this time than that contained in a definition recently formulated by Southard:[55]"To stem the tide of syphilis, to wage war on alcohol, to counsel against marriage of defectives, to generalize the insane hospitals, to specialize the general hospitals, to weed defects out of general school classes, to open out the shut-in personality, to ventilate sex questions, to perturb and at the same time reassure the interested public—these are infinitives that belong perhaps in a rational movement for mental hygiene. They are things the past has taught us more or less clearly to do and in that sense the movement for mental hygiene is surely not much more than the elaboration of the obvious."
It may be suggested that these are functions which properly belong to the medical profession exclusively. A little reflection will, however, be sufficient to show that this is not the case. Efforts have been made for years to prevent the spread of venereal disease. Attempts were made to accomplish this by legislative enactment. That these methods of control have been ineffectual is now well known to everyone. Continental governments have for a long while been trying to regulate prostitution by police supervision and frequent medical inspections. The percentage of venereal disease has, however, not been appreciably reduced by this plan and it has been repeatedly condemned by vice commissions as a result of official investigations. It may be stated now, Ithink, without fear of contradiction that this is a matter which must be regulated by educating the public and which can be handled in no other way. It is a well known fact that no law can be enforced unless it meets with public approval. The will of the majority rules. When the effects of venereal disease are generally recognized there will no longer be a necessity for much legislation on the subject. This is a question of far-reaching importance. When it is recalled that twelve per cent of the cases admitted to our hospitals for mental diseases are suffering from general paresis or cerebral syphilis, the necessity of a more general understanding of these conditions is readily apparent. The percentage is much higher in the densely populated metropolitan districts.
Legislative restrictions in the past were never very successful in limiting the use of alcoholic beverages. It is true that the Eighteenth Amendment to the Constitution of the United States and the Volstead Act have had a very material effect on the number of cases of alcoholism admitted to our institutions. The influences which resulted in alcoholism, however, will find an outlet in some other direction unless they are modified in some way. This again is largely a matter of education. There never was a time in the history of the country when a knowledge of the effect of drugs of various kinds on the nervous system was as important as it is today.
The history of the movement to prevent the marriage of mental defectives is more or less familiar to all. The sentiment of the community is apparently not such at this time as to encourage the regulation of the marriage of the mentally or physically unfit by legislative restrictions. Attempts to do so have been almost a flat failure. Various states have passed laws providing for the sterilization of defective delinquents. These laws, generally speaking, have accomplished nothing becausepublic sentiment was not behind them. All of these matters have been brought to the attention of the public by prominent speakers on numerous occasions. Frequent articles have been printed in medical journals, well-known periodicals, and even in the daily papers. Attention has been called to the mental clinics established here and there and repeated reference has been made to the fact that physicians at our state hospitals may be consulted at any time on questions pertaining to mental diseases or mental defects.
Something has been accomplished along these lines. It is unfortunate that, as a rule, people look with more or less suspicion upon institutions which are even now generally referred to as asylums. There are many who still believe that every hospital for mental diseases has its padded cells and underground dungeons. There is a rather widespread idea that the most common causes of insanity are cigarette smoking, religion and self abuse. Even in our most progressive communities it has been difficult, if not impossible, to entirely prevent the temporary detention, at least, of mental cases in jails and police stations. Very few general hospitals have psychopathic wards or any realization as to the necessity of establishing them. It is not to be denied that in many states the care of the mentally ill in our public institutions is far from being what it should be in this enlightened day. These are conditions that cannot be remedied by the medical profession without the active assistance of leaders of public sentiment. The fact that the importance of these questions is recognized by prominent educators, business men, lawyers, and other persons active in the affairs of the community, and well known to the public, will accomplish more than articles in the medical journals by physicians. This constitutes the great field of the mental hygiene organizations. They will mould public sentiment as nothing else ever has, in matterswhich relate to the mental health of the country. They will influence legislation where it is needed in a way that no medical society can hope to do. Above all, they can in time bring the public face to face with the fact that mental diseases should be discussed, generally understood and prevented, instead of being merely concealed and misrepresented. Possibly it would not be looking too far into the future to express the hope that an organization composed largely of laymen may be able eventually to accomplish something that the medical profession has never been able to do,—induce those who frame our laws to provide medical treatment for defective delinquents instead of merely locking them up for the protection of society. It would seem, moreover, that the time has come when the public should insist that the mental condition of persons accused of crime be made a medical rather than a legal question exclusively.