Neurosis and the Mental Health Services

The text was completed by December 1944

page 39

Preventive Psychiatry a Mainly Sociological Question.

The first aim of a comprehensive and free medical service should be to prevent disease. Disease is caused by the interaction of factors inside and outside the individual, by the interplay of genetic pre­dispositions with influences exerted by the environment. It is the joint product of nature and nurture. Genetic factors play a more obvious part in psychiatry than in most other fields of medicine. They contribute much to mental deficiency, especially the higher grades, and to mental subnormality ; to many forms of psychosis ; and together with adverse influences beginning in infancy, to various manifestations of neurosis. But these genetic factors are complex and difficult to assess. Compared with them, causes arising in the patient's environment are easy both to recognize and to control. It is easier to improve the conditions in which a people live than to change that people's inborn qualities ; yet both are tasks for the sociologist. From a recognition of the influence upon health of how people are reared, work, behave and live in their homes, has developed what is now called social medicine, which is an aspect—the medical aspect—of sociology. Preventive psychiatry together with preventive medicine as a whole has its roots in sociology.

The following are among the sociological changes which have a bearing upon preventive psychiatry :

Better education of adults in the sensible handling of children— in what habits of mind to instil and what emotional situations to avoid. There is a psychological as well as a physical aspect of infant and child welfare. Useful work has been done by voluntary societies in preaching and teaching what is called mental hygiene or mental health.

Better educational services, with facilities for the early detection of mental defects or disorders ; the provision of appropriate training from the earliest age for handicapped children. Early recognition of, and provision for, children with abilities above average. Innovations valuable from the psychiatric standpoint are embodied in the Education Act.

Better social standards of nutrition, housing and town-planning, such as will promote fullest physical development and health at all ages. Corresponding psychological benefits would follow from improved social services designed to encourage family life and minimize the fears and consequences of illness, unemployment and destitution.

Improved working conditions and leisure facilities.

Better industrial, occupational and social psychiatry, including vocational guidance, all designed to secure good occupational adjustment.

Limitation of fertility of prolific and at the same time constitu­tionally inferior types. Arising from an inquiry into the causes of mental deficiency, the Wood Committee (1929) drew attention to the existence of a "Social Problem Group" consisting of persons who exhibited multiple social problems. Among the persons in the group, a high fertility—the product mostly of unwanted and haphazard pregnancies—is associated with a high incidence of mentally defective (mostly high-grade) and mentally subnormal persons, insane persons, epileptics, psychopaths, paupers, criminals (especially recidivists), unem-ployables, habitual slum-dwellers, prostitutes, inebriates and other social inefficients. Social and genetic factors contribute jointly to this picture ; but in the measure that the former are improved, the latter will be brought into prominence. These reforms would do much to prevent psychiatric illnesses. Though all belong to the province of sociology rather than of medicine, the voice of the doctor—and especially that of the psychiatrist—should be heard with the voices of other advocates of social reform.