Archer, B. Crowhurst

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B. CROWHURST ARCHER, M.D., DurbanPROGRESSIVE TRENDS IN PSYCHIATRIC THOUGHTSuid-Afrikaanse Tydskrif vir GeneeskundeKaapstad, 27 Februarie 1960Deel 34THE SOVIET noWith the recent increase in cultural and scientific exchangebetween Russia ami the Western World, there has occurreda corresponding interest in Soviet psychiatry. Wortis3 saidearly in his book that Soviet psychiatry could best be under-stood if it were related to three basic sources of influence:its socialistic setting in a broad framework of public healthservices; its conformity with the general principles of dialecti-cal materialism; and the teaching of Pavlov.Lebensohn4, after his recent visit to Moscow and Leningrad,confirmed these observations and said that the Sovietapproach to psychiatry was ultra-conservative. To cite onlyone example: the two treatments which lie at extreme oppo itepoles in American psychiatry, namely prefrontal lobotomyWESTER EUROPEScience cannot be limited by geographical or politicalboundaries. But psychiatry, as a branch of medicine, is anart as well as a science. It is not surprising, therefore, tofind that the philosophic approach of psychiatrists to person-ality problems differed on the Continent from that of theircolleagues practising in Britain and America.On the Continent psychiatrists have been nurtured in theintellectual traditions of Leibnitz and Descartes, whereas inBritain and America they have been dominated by theempiricism of Locke. Continental theories tend to focus onthe 'whole' man whilst Anglo-American concepts, by contrast,are more often concerned with traits, attitudes, syndromesand performance. Speaking generally it may be said thatthe Anglo-American approach is more concerned with socialrelationships and expresses itself in an optimistic and vigorouspositivism.The emphasis in European psychiatry, however, is stillfocused on diagnostic categories. In Germany this trendfollows the Kraepelinian tradition and the pathology of thelast century. In France a similar approach is found based onthe brilliant clinical school of descriptive medicine of thesame period. In the Scandinavian countries the emphasis is.on genetics and constitutional classifications, with greaterattention to detailed statistics.In Europe, as distinct from Britain, psychiatrists stillspeak of mental diseases, whereas in Britain and Americathey usually speak of 'reactive states', a concept which impliea more dynamic approach and a greater consideration for theindividual.In Britain and America today the principles of the psycho-dynamic school are fairly generally accepted. On the Conti-nent, on the other hand, a variety of approaches is found-phenomenological and existential psychiatry, logotherapyand the conditioned reflex therapy of the Russian school.No. 9Volume 34south African Medical JournalOlpe Town, 27 February 1960THE UNITED STATESIt has always been difficult to determine the trends of thoughtwhich are truly representative of American psychiatry. Forthis reason the recent publication of the American Handbookof Psychiatry2 is both welcome and timely, and the editorsare to be congratulated on the thoroughness and objectivitywith which they have carried out their onerous task.For many years the field of psychiatry in A.n1erica hadbeen divided into two main schools of thought, the organicand the psychobiological.· The first school reduced psychicphenomena to organic causes, and the second: representedby Adolf Meyer, emphasized the importance of environmentas well as biological factors in the causation of mentaldisturbances.Late in the third decade of the present century the initialtrend towards a better integration of psychiatry into thesocial structure of American culture became evident. Theadministration and the training of the personnel of mentalhospitals rapidly improved and, as a result of a vigorousprogramme of after-care and rehabilitation, the institutionsthemselves were readily accepted by the community. Researchalso entered a new phase with the development of psycho-somatic medicine, the introduction of the newer methods ofphysical treatment, including psychopharmacology andelectro-encephalography. Oinical research was also stimulatedin the fields of mental deficiency, child psychiatry, industrialpsychiatry, military psychiatry, space psychiatry, criminology,alcoholism and geriatrics.After the second world war the basic principles of mentalhygiene were firmly establisl;1ed, including extensive pro-grammes for the prevention of mental illness and the rehabili-tation of veterans. Finally, the Federal Government officiallyrecognized the importance of training a sufficient number ofpsychiatrists to meet the growing needs of the community.psychiatry is on the march and it is fitting, in 'World MentalHealth Year 1960', that a serious attempt should be made todetermine the direction of its progress. It may well be thatthe next great advance will come, not in the form of furtherdiscoyeries in the treatment of specific diseases, but, asThomson1 said, from a study of the precise relation of medicalpractice to society.The trends in psychiatric thought in the world todayare not easy to assess because of the many schools and thediversity of outlook. It should be remembered that psychiatryis a social as well as a biological science and that it willalways be influenced by'the cultural setting in which it hasdeveloped. Moreover, the volume of literature publishedsince the second world war has added to the confusion andmade it difficult to ootain a clear picture of the contemporaryscene.1693170 S.A. MEDICAL JOURNAL 27 February 1960and psychoanalysis, were either officially banned or un-officially condemned, leaving only the large middle ground,with its emphasis on physiology.Soviet psychiatry, unlike European psychiatry, is not'hospital orientated'. There is much more emphasis on out-patient treatment and prophylaxis than on hospital-buildingprogrammes, and the average Soviet psychiatrist is more'research minded' than his American counterpart.BRITAINThe unity of British and American psychiatry began in 1927with the publication of Henderson and Gillespie's textbook,5which was not a full exposition of the psychobiologicaldoctrine of Adolf Meyer, but reflected a dynamic approachto psychiatric case-taking and treatmentThe acceptance of this essentially dynamic viewpoint, asRogerS said, created a soil more favourable to psychoanalysisthan to phenomenology. It is against this background thatthe significance of the publication of a textbook, ClinicalPsychiatry by Mayer-Gross et af.? in 1954, should be judged.Although the book puzzled American reviewers, who saw itas a retrogressive trend in psychiatry, there are manypsychiatrists in Britain and elsewhere who regard it as asalutary return to careful clinical appraisal on a sympto-matological level.The general psychiatric trend in Britain today is perhapsindicated by the approach of the mental hospital psychiatrists.In the selection of their cases for physical treatment theirapproach is phenomenological, whereas in their out-patienttreatment of the psychoneuroses they are interested inpsychoanalysis.Under the "National Health Service in Britain it has beenrecommended that part-time appointments of all gradesbe made to the mental hospitals. It is felt that thiswill attract doctors with keen clinical and research intereststo the mental hospital service and establish close associationswith the general hospitals. Thus strengthened, it is anticipatedthat the mental hospital service will undertake diverse extra-mural activities which will include comprehensive out-patientservices, child psychiatry, and industrial forensic and criminalpsychiatry.The social rehabilitation unit established by MaxwellJones8 at Belmont in Sussex is of particular interest. Thepatients consist of the misfits in industry and are admittedfrom the employment exchanges, but others are referred bypsychiatrists and by the courts. Their stay in hospital is upto a period of 12 months. It is stated that in this atmosphereof group endeavour the psychopath develops concern abouthis antisocial behaviour and, as his feelings of guilt increase,begins to identify himself with the aims of the unit.Roger' has remarked on the increased attention which isbeing given to recreation and occupational activities inhospitals and pointed out that at Banstead Mental Hospitala Medical Research Council team has been supervising anexperiment to create a factory within the hospital providingpaid employment for patients. According to the first reports,the results are encouraging. Carse and his co-workers1odescribed a district mental hospital service which providedout-patient and domiciliary treatment for the South Coasttown of Worthing. The effect of this pilot experimentalservice has so reduced the number of admissions to theneighbouring mental hospital that the writers believe thatthe present problem of overcrowding would be completelyresolved if similar services were provided in the rest of themental-hospital 'catchment area'. Perhaps this is whyQuarido's experimentsll in the domiciliary care of psychiatricpatients in Amsterdam are being followed with such interest.McKeown12 recently made a study of the whole hospitalpopulation, except mental defectives, in the Birminghamarea. He suggested that, in future, differentiation betweenthe actual symptoms of illness should be ignored, and thatpatients who needed hospital care should be grouped in onehospital centre with four divisions. The first should have allthe facilities of a hospital, with surgical, medical and skillednursing care; the second should be for those patients whochiefly require simple nursing without medical supervision;the third should be for those who need limited facilities butsome degree of supervision or simple nursing because ot: theirmental state; and the fourth should be for those who mustremain in hospital, chiefly for social reasons-these wouldmainly be geriatric, psychiatric and arthritic patients.This plan would obviate the present difficulties of obtainingadequate medical and nursing staff for long-term chronicpatients, whether physical, psychiatr;ic or geriatric, since thestaff would rotate between long-stay and acute patients.It would centralize both surgical and "laboratory facilities.If the number of patients in one division of the hospitaldiminished, the buildings would beavailable for otherpurposes.This scheme would also simplify the organization of pro-fessional education and encourage research in psychiatry andmany other neglected fields of medicine.SOUTH AiRICAPsychiatry in South Mrica is in a state of active transition.In 1956 a Faculty of Neurology and Psychiatry wasestablished within the College of Physicians, Surgeons andGynaecologists of South Mrica and the first travelling Fellow-ship in Psychiatric Medicine has been awarded for 1960.A scholarship valued at £500 has also been offered to assista suitable postgraduate student to prepare for the higherqualification of Fellow of the College of Physicians withpsychiatry as an additional special subject. In 1959 thefirst full-time Professor of Psychiatry was appointed t6 theUniversity of the Witwatersrand in Johannesburg, and it isanticipated that similar chairs will soon be established at theother medical schools.The South African Medical and Dental Council, which isa statutory body in this country, has recommended thatpsychiatry should be better integrated into the undergraduatemedical curriculum and that a mental health service shouldbe established in the Union of South Africa.It is now generally agreed that the mental hospitals shouldretain their key position in the proposed mental healthservice, and that they should, wherever possible, be raisedto the status of teaching hospitals with university affiliation.The mental health service13• 14 should be organized on a region-al basis around the mental hospitals and the medical schools.The importance of specialized mental hospitals will in noway interfere with the growing facilities provided by thegeneral hospitals for the treatment of mental illness, whichhas done so much to make, not only the public, but alsomedical and nursing students and even the doctors awareof psychiatry as an essential branch of medicine.It"is anticipated that the present overcrowding in our mentalhospitals, as elsewhere in the world, will be reduced by theestablishment of early treatment centres, run on similar lines'Z7 Februarie 1960 S.A. TYDSKRIF VIR GENEESKUNDE 171to the AntwerplS and Worthingl6 experiments. These centresare likely to be gradually established throughout the Unionill the 'catchment areas' of the mental hospitals, and willprovide a small number of beds, a day hospital out-patientservice, and full facilities for domiciliary treatment.Consideration is also being given to the establi hrnent ofinstitutes of psychiatry in Johannesburg, Cape Town andDurban. These institutes will be part of the mental hospitalservice and, with the assistance of the universities and theCollege, they will provide the neces·sary teaching facilitiesfor the psychiatric training of doctors, nurses and auxiliaryworkers, including public health nurses and probation officers.The psychopathic hospital which I have discussed else-where17 has also been approved in principle and will beestablished as soon as the necessary funds are available.This will do much to resolve the social problem created by thecriminal psychopath and provide an opportunity for researchinto the problem of offenders who do not respond to theordinary methods of correction.It is anticipated, too, that regional medical officers ofmental health will be appointed under the Commissioner forMental Hygiene to work outside the mental hospitals and tocoordinate the services of other government departmentsand the numerous voluntary organizations at· presentindependently concerned with various aspects of mentalhealth.Medical education in South .Mrica is undergoing radicalchanges and there is a steady recognition that humane medicinemust be taught. Better integration of psychiatry into theundergraduate medical curriculum will do something torestore the physician-patient relationship which is the key toevery health activity and the basis of the art of healing. For,as Reesl8 has said, just as most general medical and surgicalprocedures are carried out by family doctors, the specialistsdealing mainly with the rarer and more serious conditions, sowith the development of psychiatric insights; the majorresponsibility for applying them, both for prevention andtreatment, will in the future rest with the family doctor andthe public health nurse.It would be a catastrophe, however, if the e tabli hmentof a mental health service were to create the feeling in theminds of general practitioners that mental illness i theresponsibility of others. The practitioner is the man whofirst sees the ick person and knows his environment; thereforethe psychiatrically-minded general practitioner will remainthe mainstay in the fight for mental health.co CLUSIOLooking back into the past we see, as Blackerl9 aid, thatinstitutional psychiatry developed as a segregated specialitycut off from general medicine. The diagno is and treatmentof neurosis developed as an offshoot of neurology. Childguidance began as an independent movement, insufficientlylinked to general medicine and paediatrics and little relatedto institutional psychiatry. Testing procedures and vocationalguidance have been partly derived from non-medicalpsychology. It is now vital that these various approachesto the problem of increasing mental ill-health should beintegrated into general medicine and combined into a multi-disciplined mental health service.REFERE 'CESI. Thomson, A. (1959): Brit. Med. J., 2,130.2. Arieti, S. (1959): American Handbook of Psychiarry. ew York: Basic Books.3. Worti., J. (1950): Soviet Psychiatry. Baltimore: WiUiams & Wilkins.4. Lehensohn, Z. M. (195 ): Arch. euro\. P ychiat. (Chicago), 80, 725.5. Henderson, D. and Gillespie, R. D. (1956): Texrboak ofPsychiatry, th 00.London: Oxford University Press.6. Roger, T. F. (1957): Amer. J.Psychiat., 114,97.7. Mayer-Gross, W., Slater, E. and Roth, R. (1954): Clinical Psychiatry.London: Cas.e!.8. Jone-, M. (1954): Proc. Ray. Soc. Med., 47, 636.9. Roger, T. F. (1957): Amer. J. Psychiat., 114, 101.10. Carse, J., Panton, N. E. and Wall, A. (1958): Lance., J, 39.J I. Quarido, A. (1954): Brit. Med. J., 2, 1043.12. McKeown, T. (1958): Lancet, 1,701. _13. Archer, B. C. (1958): S. Air. Med. J., 32, 1004.14. Idem (1958): Trans. CaU. ofPhycns. Surg. Gynaec. (S.A.), 2,49.15. Quarido, A. (1954): Brit. Med. J., 2,1043. _16. Carse, .l., Panton, . E. and \ all, A. (1958): Lancet, J, 39.17. Archer,'B. C. (1958): S. AIr. Med. J., 32, 411.18. Rees, J. R. (1959): Trans. CoU. of Phyens. Surg. Gynaec. (S.A.). 3, 44.19. Blacker, C. P. (1946): Neurosis and the Mental Health Service, p. 39. London:Oxford University Press.THOUGHTS ON THE PLANNING OF MENTAL HEALTH SERVICES FOR SOUTH AFRICAH. MORoss, M.B., B.S. (DUNELM), D.P.H. (RA D)Medical Superintendent, Tara Hospital, Johannesburg, and Member of the Executive Board of World Federation for Matal HealrhThere have been great advances in psychiatry during the past 30years. Better facilities for care, modern methods of treatment (bothpsychological and physical), and the transition from custodial careto a therapeutic approach have revolutionized psychiatry. In manycountries there is a tendency to arrange for the care of the mentallyill in the community rather than in large isolated hospitals. Thereis an increasing emphasis on prevention and early detection ofmental illness; on early-treatment centres situated in the com-munity, on after-care and rehabilitation and the maintenance ofthe chronic patient in the community, on day and night hospitals,and on dotniciliary services. These developments are proving ofeconotnic and therapeutic advantage.South Africa faces special mental heallh problems in its multi-racial and multi-cultural community. The complexity of Iheseproblems is heightened by urbanization of the non-White races ina time of changing values-especially by the effects of urbanizationon tribal laws, customs and taboos.Matters are further complicated by the shortage of trainedpersonnel and by the size of the country-the uneven distributionof its population and the lack of any psychiatric services over vastareas, such as from Kimberley to the South West Coast and fromthe Cape Peninsula to the b.orders ofAngola.These are some of the features which call for a review of thecountry's mental health services, for bringing them into line withpresent-day needs, and for coordinaled planning for the future,allowing for flexibility and adaptation to changing needs.PRESENT SERVlCESOver 20,000 cases of mentally disordered patients are treatedannually in the mental hospitals of the Union. 1t is e limated Ihatthere are 100,000 mental defectives in South Africa. At the Johan-nesburg General Hospital alone over 8,000 attendances areregistered annually at the p ychialric out-patient clinics. Tenmental health societies have a patient attendance of some 8,000 perannum.These figures only partially reflect the incidence and range ofmental ill-health in tbe country. The actual ize of tbe problem iinfinitely greater and its cost to the State is enormous.MENTAL HOSPITAL SERVlCESOn 31 December 1957 the rated bed-capacity of the 13 mentalhospitals in the Union for White and non-White mentally di orderedand mentally defective patients was 14,943 for 18,561 patients.s

Progressive trends in psychiatric thought

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Progressive trends in psychiatric thought

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