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mental hospitals or, when this is inadvisable, in encouraging their acceptance of inpatient
treatment and furthering their social readjustment after discharge.
The work, at the stage to which it had developed in 1957, can therefore be discussed
in two main aspects, with an ancillary service arising from them which, in the light of
the Royal Commission's recommendations, is likely to assume increasing importance.
It must be emphasised that these divisions are of more theoretical than practical consequence,
and the ways in which the categories interact will be discussed later. They
are—
(a) preventive, in the sense both of delaying and avoiding the total breakdown of
social life;
(b) after-care ; with
(c) a psychiatric consultative service.
(a) Preventive care—While the importance of physical conditions for public health was
well recognised by the beginning of the century, and this knowledge has been steadily
implemented since, the view that the emotional conditions under which people live
may have an equally important bearing on health has emerged comparatively recently
and gained ground very slowly. Yet illness that is psychosomatic in origin crowds
general practitioners' surgeries, fills waiting lists for consultative and hospital services,
and has a very high cost—indirectly in absenteeism, delinquency or the break-up of
homes and directly in unemployment, national insurance or assistance payments.
Though it is certainly not invariably the case, many nervous disturbances show themselves
in the form of comparatively minor physical symptoms (for example, headaches,
rashes, indigestion or loss of energy) which call for only minor physical remedies and
are not likely to lead to in-patient treatment in a mental hospital. They are, however,
both the sign and the cause of much individual suffering, are socially disruptive and
wasteful, and their underlying disharmony is very infectious in the community. They
have the common characteristic of anxiety, nearly always arising from social pressures
which the patient feels unable to meet. To help him recognise this when he has the
ability to do so, to help in simplifying the social situation when he has not, or to do
both together, in co-operation with general practitioners is a large part of the preventive
side of community care work.
(b) After-care—The rehabilitation of patients after hospital treatment is an especially
important part of community care, because the nature of psychiatric illness and the
general fear of its symptoms add to the difficulties of readjustment. It is not during
treatment or training courses, but when he returns home and has to meet the claims of
his family and employment, that a person's ability to readjust is tested. It may be that
treatment has had to be prolonged—in spite of the present trend to shorten it as much
as possible—involving medical, surgical or psychological investigations carried out
while the patient is deprived of initiative and independent action. On his return to the
community the time comes for him to act as a self-reliant individual, and for those with
residual psychiatric disabilities this may present extraordinary difficulties. It is at this
crucial point that the patient needs to be able to turn for help to someone who will not
only understand the situation as it presents itself to him, but also offer a relationship
through which he may ' grow back ' into the community.
In fact, of course, these two aspects of community care work are closely allied.
What is officially after-care may well become preventive work against another breakdown,
or while after-care is being given to one person, other members of the family
may need help in a preventive sense to deal with the resultant strain.
(c) Consultative help—This is provided for those who, in their private or professional
capacities, are already in contact with the mentally disturbed.
Though it would be a mistake to underestimate the superstitious fear of any form
of mental disorder still existing in the community, with the growing recognition of
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