An Approach to Community Mental Health

Gerald Caplan

• Publisher: Taylor & Francis
• Year: 2013
• eBook ISBN: 9781136435164
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Tavistock Press was established as a co-operative venture between the Tavistock Institute and Routledge & Kegan Paul (RKP) in the 1950s to produce a series of major contributions across the social sciences.
This volume is part of a 2001 reissue of a selection of those important works which have since gone out of print, or are difficult to locate. Published by Routledge, 112 volumes in total are being brought together under the name The International Behavioural and Social Sciences Library: Classics from the Tavistock Press.
Reproduced here in facsimile, this volume was originally published in 1961 and is available individually. The collection is also available in a number of themed mini-sets of between 5 and 13 volumes, or as a complete collection.

CHAPTER 1

A Community Approach to Preventive
Psychiatry – a Conceptual Framework

DURING the last few years a number of psychiatrists in different parts of the world have been exploring a new approach to the problem of preventing psychiatric illness. Instead of basing themselves solely, as in the past, on the concept of early case-finding, diagnosis, and treatment with the goal of ‘nipping in the bud’ by radical and rapid methods of therapy cases of incipient disease, these workers have set themselves the additional goal of dealing on a community-wide basis with factors that are thought to be pathogenic, in the hope that this will lead to a reduction in the incidence of psychiatric illness in the population. This approach is complicated by the fact that we have as yet no sure knowledge of the factors that lead to psychiatric pathology. We do not really know what causes mental disorder. At least we only know that in any individual case, not one, but many, complicated interrelated factors are responsible for the psychopathological resolution – factors based on constitution, early childhood experiences, vicissitudes of instinctual development, and later socio-cultural pressures.

Our lack of knowledge in regard to the significance of the different factors has to be remedied by a continuation of existing research into aetiology. But, meanwhile, preventive psychiatrists have been able to learn a lesson from their public health colleagues in regard to the handling of the problem of the multifactorial nature of the picture.

The incidence of cases of clinical tuberculosis, for example, in any community is no longer conceived of in public health circles as being merely dependent upon the single factor of the presence or absence of the tubercle bacillus. It is recognized that there are many complicated issues that will determine whether a particular person exposed to the germ will contract the clinical disease: issues involving virulence of the germ, host susceptibility, and various environmental factors. Many of these factors are either unknown or not easily ascertainable in a community, but this does not prevent the public health man from being able to plan and carry out very effective control programmes to reduce clinical tuberculosis in his area; and a good proportion of his programme is not focused at all on the attempt to eradicate the tubercle bacillus itself. The fundamental principle upon which he operates is to conceive of the human community as living in an ecological equilibrium with the community of tubercle bacilli; and then to attempt to move this equilibrium in a healthy direction, as far as the people are concerned, by dealing with those forces which are accessible to his manipulation. The important point is that by altering a significant proportion of the forces he swings the whole equilibrium over to the healthy side. A similar approach governs some of the recent attempts in community-oriented preventive psychiatry. Whether it will have as happy an outcome in the field of mental health as has been achieved by our public health colleagues in the field of physical health remains to be seen. At the moment we are still in the stages of the earliest fumbling attempts. I shall describe some of these so that the reader may judge whether we are moving in the right direction, or whether other approaches might prove fruitful.

In pursuit of the goal of altering what we think are unhealthy forces in a community from the point of view of the mental health, either present or future, of the population, we have been operating in two main ways, which I have called, on the one hand, Administrative Action, and, on the other hand, Personal Interaction. I shall describe a few examples of each of these to indicate what I have in mind.

ADMINISTRATIVE ACTION

The goal here is to reduce preventable stress, or to provide services to assist people facing stress to healthier problem-solving, by means of governmental or other administrative action. The object is to influence laws, statutes, regulations, and customs, in order to achieve these ends. It is recognized that what is involved is specific culture change; and since all cultures are to be conceived of as systems of interdependent forces, we realize we must move cautiously lest a favourable change in one area of the system may lead to unexpected unfavourable side-effects in other parts. The system is interdependent – alteration of any one part affects the whole. It may be thought desirable to alter some particular aspect in order to achieve some mental health goal, but something else may happen that was entirely unforeseen and may leave things worse off in the end than they were in the beginning.

Despite this danger, which has not always been clearly borne in mind by those of us who have engaged in this type of work, we have, during the past few years, built up a body of experience which indicates that this may be a promising avenue for exploration.

The role of the mental health specialist in this type of work is to act as the consultant and adviser to administrative and governmental bodies. He seeks to introduce a point of view to the administrators that is dependent upon his own specialized knowledge of interpersonal forces and, in particular, upon his knowledge of the psychological needs of individuals and groups. His goal is that the emerging plan or regulation will take account of the mental health needs of the total community, and that at least it will not add to the mental health burdens.

In England

One example of this work, from England, is John Bowlby’s studies on the pathogenic influence of prolonged mother-child separation in early childhood on the child’s personality development. Although Bowlby has not yet proved his case, and, indeed, some of his latest research results are far from conclusive, many of us with clinical experience in this field agree that, other things being equal, prolonged separation of mother and child is not a good thing. The interesting point is that even before Bowlby has proved his case and certainly before he has teased out more than a small proportion of the interrelated forces involved, he has been able to influence the policy of the Ministry of Health so that one source of mother-child separation has been radically reduced over the whole country. In 1952 a directive was issued by the Ministry to all hospitals with children’s wards to the effect that wherever possible daily visiting of children by their parents was to be permitted and encouraged. Recent figures show that by 1960 about 80 to 90 per cent of the children’s wards and institutions were carrying out this directive. A revolutionary and powerful blow for the cause of mental health in childhood was struck by that regulation. It is too early to see what the side-effects have been in regard to compensatory forces set up among the nurses and the administrators of children’s institutions. These will certainly have to be carefully watched. What is involved here is a major change in the culture of the child-caring institutions. But already in the past eight years, the incidence of mother-child separation in England has been drastically reduced.

In Israel

Another example comes from Israel. When I first went there in 1948 there began a tremendous wave of immigration into the country. In the twelve years since the establishment of the State in 1948, the population of the country has more than doubled. For a number of reasons the immigrants were originally housed on arrival in huge camps in large army-style barrack huts. Each hut housed 30 to 50 people. There was no provision for privacy, no segregation of family units, and minimal facilities for work. Food was provided in communal dining-halls. The immigrants stayed in these camps for many months until arrangements could be made to transfer them to permanent settlements. By that time many of them had sunk into an apathetic dependent state, and when the opportunity for independent and self-respecting work arrived many could not grasp it.

I remember very vividly the complaints and. the grumbles of the government administrators responsible for this immigrant programme when they said, ‘We do all that we can for these people, and then when we give them a chance to settle on the land and do some useful work, the lazy good-for-nothings won’t do it; they just want to sit around and twiddle their thumbs and ask to be fed, and do nothing.’

Later on, as a result partly of mental health consultation in which I was involved, as well as of various other complicated factors, the style of the reception camps was radically changed. Newcomers were sent straight from the boat to small temporary encampments dotted about the countryside. They were housed as family units, at first only in canvas tents and later in crude tin huts. These were not as cool in summer or as water-tight in winter as the big army barrack huts, but they did protect the integrity of the family and its strength. Communal kitchens were not provided; each family had to fend for itself; and from the first they were given work to do, mostly difficult work, clearing rocky hillsides or draining swamps, but productive work which fostered their feelings of independence, and gave them immediately the feeling of being involved in a collaborative endeavour to build a homeland. Naturally, there have been many grumbles on the part of new immigrants who have been frightened by the isolation, the hard work, and the physical danger of exposure to marauding Arab attacks, but the former apathy and over-dependence have disappeared. On a recent visit to Israel I was very interested to find that there were still people living in the dirty, ramshackle remains of the big camps. The government had closed the camps down, but could do nothing with these inmates who had fallen into a completely dependent, apathetic state; and that is where they stay. Of course, the number of such die-hards is now quite small.

In Boston

Another example comes from Boston, Massachusetts; an example not, unfortunately, of successful action of the type that I have mentioned, but of the possibility for action. Across the street from the Whittier Street Health Center where I work in Roxbury, a rather poor suburb of Boston, there is a large new housing project. Nowadays it does not look very new; but about nine or ten years ago it was new and it looked new. Since it has been set up, there has been a steady drain on the budget of the City of Boston Health Department for the repair of broken windows in the Health Center building. The children used to spend much of their free time throwing stones through the windows; and it hardly ever happened that we would come to work in the morning without having to brush glass off the floor of our rooms before going near the window. There have been many other indications in the neighbourhood of an increase in destructive and delinquent acts by children of various ages. Now, the topic of juvenile delinquency is very complicated, and I do not wish to discuss it in the present context, but there are one or two factors in relation to the housing project which I believe are not insignificant.

First, we discovered when we looked at these housing projects that about 50 to 60 per cent of the families in them were broken families of one sort or another; that is, the mother had never had a husband, or he had left her, or it was a common-law marriage in uneasy equilibrium. The project population contains many other examples of social pathology. There appears to be a diffusion of culture from the unhealthy families to the previously healthy ones. A healthy family comes in and gets infected, as it were, like putting a new apple in a barrel where there are a lot of rotten ones. Some non-delinquent children after living a short time in the project join the delinquent gangs, the core of which appears to be made up of children from the disordered families.

There is nothing new in this, indeed it is quite usual; but if one asks how it happens that so high a proportion of the inhabitants of the housing projects are social deviants, one finds that to get into such a project a family has to be on a priority list, position on which depends upon a point system; and the point system is determined largely by the social need, so that the greater the social pathology, the more likely the family is to get to the top of the list. Moreover, in Boston as in other places, administrative difficulties are involved in getting into housing projects. No doubt this does not apply in Denver or in Manchester, but in Boston in order to get into housing projects it is better if you have ‘pull’. Once upon a time with the political boss system, and the ward system, the healthiest families were the ones that had the most ‘pull’. They could get around and manipulate the politicians, but nowadays we have done away with that. Instead, the people who have the ‘pull’ are the social agencies. It is the social workers who apply pressure on behalf of their clients, and they can apply more pressure than an individual family can do on its own.

The reader may agree with me that it was a pity that a mental health worker was not present while that priority system was being worked out, in order to try to influence the administrators to plan some kind of balanced population for the project. Of course, research is needed to determine what is the critical proportion above which a housing project population cannot accept broken families without endangering its total morale. Given a housing project population, what proportion of disordered families can be introduced so that the disordered ones will be made healthier by the healthy ones, rather than the healthy ones be influenced by the unhealthy ones?

I have chosen these three examples to illustrate one type of Administrative Action for preventive psychiatry, the goal being the reduction of the incidence of stress situations, or the increase of the provision for the satisfaction of psychological needs. We have to realize, however, that we can never aim at removing all problems from the world, by ensuring that all people are satisfied. Suffering is going to be with us; illness and death are going to be with us for ever. We can, however, assist community leaders to arrange facilities so that people who are facing inevitable stress situations may be helped to solve their problems in a healthy way. There is a good deal of justification for thinking that the capacity for reality-based problem-solving is an excellent measure of the mental health of an individual or a group, and also for thinking that the way people handle any significant stress situation in a crisis will have far-reaching effects on their future mental health. Indeed, a good deal of the structure of society can be understood in terms of its purpose in supporting individual members in their solution of life’s problems. All communities have specialized agencies and individuals who can be conceived of as ‘caretaking agents’, whose function it is to help people in various predicaments. These predicaments, such as birth, death, change of marital and other status, illness, change of occupation, and so on, are normally not conceived of by administrators as mental health crises; and, of course, primarily they are not. But community arrangements, such as agency structure and policy, will often affect in no small measure how individuals in these predicaments handle their problems and what the mental health consequences will be. How a given community deploys its limited care-taking resources may depend on all kinds of social and political forces. There is room in such planning for a mental health consultant who will advise on the effects of policies on the mental health of the population.

Prenatal and Postnatal Services

Let us take as an example the crisis of a woman having a baby. In the United States most communities provide prenatal clinics for checking the pregnant woman’s physical state, obstetric hospitals for helping her give birth, and well-baby clinics for continued supervision of mother and infant. There is often a domiciliary nursing service such as a Visiting Nurse Association, which visits the home a few times during pregnancy and once or twice after delivery to supervise the woman’s health. Many localities have a municipal health department which provides nurses who make one visit after the mother returns home from the lying-in hospital to check the baby’s condition and to invite the mother to the well-baby clinic. But, in most localities, all or most of these agencies operate separately, with little or no relationship with each other. This may not be ideal policy from the point of view of the physical health of the mother and baby, but from the point of view of helping the mother handle the mental health crises of this crucial period it could not be worse.

A recent experiment conducted by the Harvard School of Public Health, the Boston Lying-In Hospital, and the Boston Children’s Hospital has shown the tremendous benefits to the developing mother-child and general family relationships of continuity of agency service throughout this period; based upon the fact that there is continuous support to the mother through the building up of a stable relationship, as well as the possibility, and this is very important, of predicting problems during pregnancy which can be nipped in the bud at that time or immediately afterwards, rather than allowed to run on until they become serious. I shall discuss this more fully in Chapters 3 and 4.

There is one other point that I should like to emphasize here. We found that one of the most difficult times for the mother is during the three to four weeks after she leaves the lying-in hospital. In most places this is a relative hiatus as far as agency service is concerned. The mother is usually expected to make her first visit to the well-baby clinic when the infant is about one month old. During that month she is left largely to her own resources unless she is lucky enough to have a supportive family around her. And I would point out that in a country like the United States the two sides of the family may come from different cultural backgrounds. This may be productive of much insecurity, because there may be the advocacy of two sets of differing ways of taking care of the baby. Furthermore, husband and wife may be of another culture from their parents (a subject I shall consider in Chapter 5) and so a three- or four-way conflict is possible in a significant proportion of cases. Everyone in the family, not to mention the neighbours, will be telling the mother something different.

A change of agency pattern suggested by the above work is intensive domiciliary supervision in certain cases during that particular period, and earlier contact with the well-baby clinic. This matter has been found to be of even more importance if there is something wrong with the baby, such as prematurity or a congenital abnormality, and these are not uncommon happenings. I have not been able to obtain from my paediatric and obstetric colleagues any certain estimate of the incidence of congenital abnormality, but the figure of 2 per cent is often quoted. Anyway, it is not a small figure, if all the degrees of congenital abnormali ties are included, so that we are here discussing a significant proportion of mothers who have babies. The baby may be very adequately cared for as regards his physical condition in the hospital; and in the case of prematurity many hospitals arrange for a nurse to visit the mother at home before the baby is discharged to make sure there are proper facilities to receive it. If she is a public health nurse who has plenty of time and a rather small case-load, she can in fact do more than just make a routine visit. Crippled children’s services, however, do not come into action for many months or longer after the parents have had to deal unaided with the complicated emotional burden of adapting to the child’s abnormality. How much time and wasted professional energy would be saved, not to mention avoidable unhappiness and personality distortions for family and child, if community leaders were to realize that a baby with a congenital abnormality is a situation requiring emergency agency attention concentrated and deployed at the critical period; that is, within the first two months after birth.

The type of caretaking personnel available to various agencies is also a matter with preventive psychiatric implications. If a community can afford a certain number of psychiatrists, psychiatric social workers, and public health mental health nurses, should these all be operating in remedial institutions, or should some of them be made available to work in agencies which deal, for example, with the ordinary woman having a baby? What are the needs for psychiatric assistance...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Acknowledgments
• Introduction
• 1. A Community Approach to Preventive Psychiatry a Conceptual Framework
• 2. Relevant Aspects of Ego Psychology and their Relation to Preventive Intervention
• 3. The Psychology of Pregnancy, and the Origins of Mother-Child Relationships
• 4. Early Mother-Child Relationships and the Effects of Mother-Child Separation
• 5. Mental Health Aspects of Family Life
• 6. The Role of the Nurse in Maternal and Child Care
• 7. The Role of the Social Worker in the Public Health Setting
• 8. The Role of the Family Doctor in the Prevention of Emotional Disorder
• 9. Comprehensive Community Psychiatry
• Index