126
MENTAL WELFARE
\
ADDRESS ON
Mefatal \| at the
Deficiency as
Given
by
DR. E. O.
Annual Meeting
Community Problem
LEWIS, M.A., M.R.C.S., L.R.C.P.,
of the
held on
a
London Association
Thursday, June
(Printed by kind permission
for
Mental
Welfare,
20th, 1929.
of the London Association for Mental
Welfare.)
I feel that it is necessary at the outset to explain why most of my remarks this afternoon refer to the more general and theoretical aspects of my subject. We had hoped that Part III of the Report of the Joint Committee on Mental Deficiency would have been published by this time. In this part of the Report the Committee deal fairly thoroughly with the subject of mental deficiency as a community problem, but, as this is not yet published, it is obviously impossible for me to discuss the specific recommendations of the Committee this afternoon; and therefore I shall confine my remarks to the more academic and theoretical features of my subject. We shall deal more especially with the problem of the care of the mentally defective living in the general community. In doing so, we do not forget the importance of the other form of care, namely, the institutional care of defectives. The cleavage between these two forms of care has been too marked in the past. This has been due to the fact that most of the institutional cases have required permanent care. Owing to the scarcity of accommodation, only the lower grade cases and the more urgent of the feeble-minded have been admitted to our institutions. As the accommodation increases a much larger proportion of higher grade cases will be admitted and a certain proportion of these will, after a few years' training, return to the general community. Dr. Douglas Turner has expressed this most aptly when he said?" Institutions in the past have been stagnant pools?in the future they will be running lakes." It will thus become one of the chief aims of our institutions to give defectives the type of training that will best fit them to take their place in the ordinary industrial and social world; and the success with which we shall be able to care for the mentally defective thus rehabilitated will depend largely upon the early training they receive in the institutions. The first question we have to decide is the magnitude of the problem of the community care. There are about 300,000 mental defectives in England and Wales. It is estimated that about 120,000 require institutional care of some kind and about 200,000 remain in the general community. Of these, 84,000 are children of school age and are therefore within the jurisdiction of the Local Education Authority. This leaves about 100,000 adult defectives, lower grade children and young feeble-minded children in the general community, that is, approximately 3 per thousand of the population; and most of these will require some form of supervision, statutory or voluntary.
MENTAL WELFARE
I27
These figures naturally lead us to ask whether the incidence of mental deficiency is increasing, but I do not intend to discuss this somewhat contentious subject this afternoon. We shall all agree, however, that mental deficiency as a manifest problem is increasing. It will always be difficult to make a complete ascertainment of the number of persons who are mentally defective in the most strictly scientific and clinical sense of the word; but it is a much easier task to ascertain the number of mental defectives who, on account of their social inefficiency, require some form of care by the community: and it is this figure that indicates the manifest magnitude of the problem. There can be but little doubt that the proportion of the population of this country comprised in the group of persons recognised to be mentally defective because of their economic and social failure is increasing. The
of this increase of manifest mental deficiency form an infor discussion and investigation. From one standpoint, this teresting subject increase need cause no alarm. In fact, it may be regarded as an indication of national progress. The higher the type of organism, the greater the differentiation of its parts; and the more civilised a nation becomes, the more conspicuous become the variations in the mental endowments of its members. This is exemplified by our educational system. We now recognise that about 10 per cent, of the children in our schools are dull or backward and from i to 2 per cent, are mentally defective. If a psychologist had made such a statement 60 years ago, before the days of General Elementary Education, he would have been suspected of trying to bolster up some theological doctrine of election or pre-destination; but our school system has now made manifest that there is a much greater variation of mental endowments than we had hitherto thought to be the case. causes
A parallel sifting process is being applied to adults. The modern trend of events in industry is gradually increasing the handicaps of the section of workers most lowly endowed with intelligence, and thereby increasing the manifest numbers of those economically inefficient. Such Acts as those instituting minimum wages, trades union rates of pay, workmen's compensation and employers' liability?all designed to safeguard the interests of the main group of workers?seem to militate against the assimilation of the mentally defective into the industrial system, and gradually result in a more definite ostracism of this group. One example of this is the application of a minimum wage to agricultural labourers. With the general principle of a minimum wage we are not concerned at present and naturally express no opinion. As you all know, the farmers can secure exemption from paying minimum wages to mentally defective employees. We saw in the course of our investigation a large number of defectives in respect of whom such exemption had been granted. They were practically all persons of the imbecile grade. These exemptions applied to comparatively few men of the feeble-minded grade; and yet farmers recognised that the large majority of this latter group were so inefficient that their services were not worth the minimum wage, with the
MENTAL WELFARE
128
result that they were seldom employed permanently and had to depend upon casual labour. Their economic position was thus often worse than that of the lower grade defectives. There is a great gap between the type of mentally defective person to whom committees will apply the exemption and the person who is really worth the minimum wage. Into this gap fall many thousands of feeble-minded workmen. In one way or another these "become financial burdens to the community and their numbers increase considerably the manifest magnitude of the problem of mental deficiency. Another factor which we will only mention that tends to eliminate larger numbers of persons of poor endowment from our industrial system is the application of scientific methods, especially in the selection of workers. do with this increasing manifest problem P Some people dismiss a always problem with a dictum. That applied to our present is one we have all heard many times?"After all, there must be hewers problem of wood and drawers of water." My only comment on this is that it is a dictum which belongs to a past age and civilisation, and it would have been well if the dictum had been lost with that civilisation. What
are we to
can
After reading the Annual Report of this Association, and after hearing Miss Wallas's speech this afternoon, I feel I should have come here to listen and not to talk. The activities of this Association show that a great deal can be done to socialise the mentally defective. To read what has already been done for them fills us with admiration for the work of your Association. The Annual Report shows that 80 per cent, of the group of mental defectives investigated by this Association were last year usefully employed in the industrial system. These are most remarkable figures, especially in these days of much unemployment. I cannot help contrasting them with some of my estimates for the areas we investigated; and it should be borne in mind that the local authorities and voluntary associations in some of the districts were progressive and very active. These areas were probably fairly representative of the country as a whole in this respect. We concluded that of every 100 defectives living in the general community, only 20 were regularly employed. It must be admitted that these figures and those for the London area are, in some respects, not comparable, but the disparity is significant. Miss Wallas said there is a considerable variation from one district another in regard to the numbers of defectives that can be employed in industry; and the data of our investigation confirm this. We found that in districts where there is a great deal of group work, the mental defectives fare better than in those where the only work available is that which necessitates their working independently. For instance, in the mills of the North-country industrial areas large numbers of mental defectives are employed in group work and are able to earn some kind of living. This feature of industrial cohesiveness is an important factor in the socialisation of defectives, because it enables them to be buoyed up industrially. In other districts we found to
MENTAL WELFARE
129
very different conditions. Previous to this investigation, I shared the idea which is by no means uncommon, that defectives fared much better economically in the rural than in the urban areas. My recent experience, however, has convinced me that this is not the case; and this I attribute chiefly to the fact that there is comparatively little group work on the farm. The defectives require much supervision in their work and many farmers said that they could not give time to supervise them and therefore had to dismiss them. For the same reason, mentally defective girls do badly in domestic service. The proportion of girls receiving remuneration in domestic service, as shown in the last Report of this Association, is only one-seventh of the whole group. So far I have dealt with the industrial aspect of the problem, but there is another aspect, namely, the supervision of the defectives in their homes and during their leisure hours. Here again the question of social cohesiveness is an important one. In certain communities defectives do much better than in others. In this respect the country districts probably provide the more favourable conditions. In large towns there is little social cohesiveness, with the result that families of low mental endowments tend to precipitate out of the general life of the community and live in slums. Our conception of chronic slumdom is that of a community of feeble-minded persons exploited by the morally defective. When we find a family with two or more feeble-minded persons which usually has a poor home environment, the problem of community care of the defectives resolves itself into the supervision of the whole family. There is much discussion of the eugenic aspect of this family problem, but very little is said concerning the way it affects the question of the community care of the defective.
This
brings me to my last point. One fact brought home very forcibly my colleagues and myself in the course of our investigation was that, however serious die problem of mental deficiency may be, a still more serious is the problem marginal problem of mental inefficiency. When we visited many of the homes, we found that possibly two or three of the children were definitely feeble-minded, but four or five others were certainly dull, though not sufficiently low grade to be certified as mentally defective. The mentality of one or both of the parents was also sub-normal, but again not low enough to be regarded as mentally deficient. It is in such families we have a concentration of most of our chronic social problems, such as chronic pauperism and slumdom, habitual crime, high infantile mortality, illegitimacy and mental disorders of to
all kinds. In the past some writers have endeavoured to convince us that mental deficiency is the parent of all these other conditions, but it would be truer to say that it is one of the children. The true parents are (a) the condition of poor mental endowment, scarcely low enough to be regarded as mental deficiency, and (b) unfavourable environmental conditions. These form a vicious circle. One of the great problems of the present day is that presented by this group of social inefficients which comprises about 10 per cent, of the population. Mental in its broad social sense, and not mental deficiency in the narrow
inefficiency
130
MENTAL WELFARE
legal interpretation of this term, is the important and urgent national problem. The service which workers and students in the field of mental deficiency are rendering is the emphasis they place upon the fact that most of the chronic social problems are essentially associated with a condition of low intelligence, and that whatever solutions are proposed, the quality of the human beings forming this subnormal group of the community should always be borne in mind. Many political and social reformers recognise this fact, but they add that their first duty is to legislate for the 90 per cent, normal and not for the 10 per cent, sub-normal persons. Our reply to this is that many of the social reforms designed for the general improvement of the community will not be fruitful until we have dealt with the special problems of the sub-normal group. The doctor in his treatment of a case clears the deck for action by first removing all the septic foci. A similar maxim seems applicable to our national health. Mental deficiency is one of the septic foci, and it calls for treatment at the outset of any attempt to deal comprehensively with the chronic social evils of the
community.
MENTAL WELFARE
\
ADDRESS ON
Mefatal \| at the
Deficiency as
Given
by
DR. E. O.
Annual Meeting
Community Problem
LEWIS, M.A., M.R.C.S., L.R.C.P.,
of the
held on
a
London Association
Thursday, June
(Printed by kind permission
for
Mental
Welfare,
20th, 1929.
of the London Association for Mental
Welfare.)
I feel that it is necessary at the outset to explain why most of my remarks this afternoon refer to the more general and theoretical aspects of my subject. We had hoped that Part III of the Report of the Joint Committee on Mental Deficiency would have been published by this time. In this part of the Report the Committee deal fairly thoroughly with the subject of mental deficiency as a community problem, but, as this is not yet published, it is obviously impossible for me to discuss the specific recommendations of the Committee this afternoon; and therefore I shall confine my remarks to the more academic and theoretical features of my subject. We shall deal more especially with the problem of the care of the mentally defective living in the general community. In doing so, we do not forget the importance of the other form of care, namely, the institutional care of defectives. The cleavage between these two forms of care has been too marked in the past. This has been due to the fact that most of the institutional cases have required permanent care. Owing to the scarcity of accommodation, only the lower grade cases and the more urgent of the feeble-minded have been admitted to our institutions. As the accommodation increases a much larger proportion of higher grade cases will be admitted and a certain proportion of these will, after a few years' training, return to the general community. Dr. Douglas Turner has expressed this most aptly when he said?" Institutions in the past have been stagnant pools?in the future they will be running lakes." It will thus become one of the chief aims of our institutions to give defectives the type of training that will best fit them to take their place in the ordinary industrial and social world; and the success with which we shall be able to care for the mentally defective thus rehabilitated will depend largely upon the early training they receive in the institutions. The first question we have to decide is the magnitude of the problem of the community care. There are about 300,000 mental defectives in England and Wales. It is estimated that about 120,000 require institutional care of some kind and about 200,000 remain in the general community. Of these, 84,000 are children of school age and are therefore within the jurisdiction of the Local Education Authority. This leaves about 100,000 adult defectives, lower grade children and young feeble-minded children in the general community, that is, approximately 3 per thousand of the population; and most of these will require some form of supervision, statutory or voluntary.
MENTAL WELFARE
I27
These figures naturally lead us to ask whether the incidence of mental deficiency is increasing, but I do not intend to discuss this somewhat contentious subject this afternoon. We shall all agree, however, that mental deficiency as a manifest problem is increasing. It will always be difficult to make a complete ascertainment of the number of persons who are mentally defective in the most strictly scientific and clinical sense of the word; but it is a much easier task to ascertain the number of mental defectives who, on account of their social inefficiency, require some form of care by the community: and it is this figure that indicates the manifest magnitude of the problem. There can be but little doubt that the proportion of the population of this country comprised in the group of persons recognised to be mentally defective because of their economic and social failure is increasing. The
of this increase of manifest mental deficiency form an infor discussion and investigation. From one standpoint, this teresting subject increase need cause no alarm. In fact, it may be regarded as an indication of national progress. The higher the type of organism, the greater the differentiation of its parts; and the more civilised a nation becomes, the more conspicuous become the variations in the mental endowments of its members. This is exemplified by our educational system. We now recognise that about 10 per cent, of the children in our schools are dull or backward and from i to 2 per cent, are mentally defective. If a psychologist had made such a statement 60 years ago, before the days of General Elementary Education, he would have been suspected of trying to bolster up some theological doctrine of election or pre-destination; but our school system has now made manifest that there is a much greater variation of mental endowments than we had hitherto thought to be the case. causes
A parallel sifting process is being applied to adults. The modern trend of events in industry is gradually increasing the handicaps of the section of workers most lowly endowed with intelligence, and thereby increasing the manifest numbers of those economically inefficient. Such Acts as those instituting minimum wages, trades union rates of pay, workmen's compensation and employers' liability?all designed to safeguard the interests of the main group of workers?seem to militate against the assimilation of the mentally defective into the industrial system, and gradually result in a more definite ostracism of this group. One example of this is the application of a minimum wage to agricultural labourers. With the general principle of a minimum wage we are not concerned at present and naturally express no opinion. As you all know, the farmers can secure exemption from paying minimum wages to mentally defective employees. We saw in the course of our investigation a large number of defectives in respect of whom such exemption had been granted. They were practically all persons of the imbecile grade. These exemptions applied to comparatively few men of the feeble-minded grade; and yet farmers recognised that the large majority of this latter group were so inefficient that their services were not worth the minimum wage, with the
MENTAL WELFARE
128
result that they were seldom employed permanently and had to depend upon casual labour. Their economic position was thus often worse than that of the lower grade defectives. There is a great gap between the type of mentally defective person to whom committees will apply the exemption and the person who is really worth the minimum wage. Into this gap fall many thousands of feeble-minded workmen. In one way or another these "become financial burdens to the community and their numbers increase considerably the manifest magnitude of the problem of mental deficiency. Another factor which we will only mention that tends to eliminate larger numbers of persons of poor endowment from our industrial system is the application of scientific methods, especially in the selection of workers. do with this increasing manifest problem P Some people dismiss a always problem with a dictum. That applied to our present is one we have all heard many times?"After all, there must be hewers problem of wood and drawers of water." My only comment on this is that it is a dictum which belongs to a past age and civilisation, and it would have been well if the dictum had been lost with that civilisation. What
are we to
can
After reading the Annual Report of this Association, and after hearing Miss Wallas's speech this afternoon, I feel I should have come here to listen and not to talk. The activities of this Association show that a great deal can be done to socialise the mentally defective. To read what has already been done for them fills us with admiration for the work of your Association. The Annual Report shows that 80 per cent, of the group of mental defectives investigated by this Association were last year usefully employed in the industrial system. These are most remarkable figures, especially in these days of much unemployment. I cannot help contrasting them with some of my estimates for the areas we investigated; and it should be borne in mind that the local authorities and voluntary associations in some of the districts were progressive and very active. These areas were probably fairly representative of the country as a whole in this respect. We concluded that of every 100 defectives living in the general community, only 20 were regularly employed. It must be admitted that these figures and those for the London area are, in some respects, not comparable, but the disparity is significant. Miss Wallas said there is a considerable variation from one district another in regard to the numbers of defectives that can be employed in industry; and the data of our investigation confirm this. We found that in districts where there is a great deal of group work, the mental defectives fare better than in those where the only work available is that which necessitates their working independently. For instance, in the mills of the North-country industrial areas large numbers of mental defectives are employed in group work and are able to earn some kind of living. This feature of industrial cohesiveness is an important factor in the socialisation of defectives, because it enables them to be buoyed up industrially. In other districts we found to
MENTAL WELFARE
129
very different conditions. Previous to this investigation, I shared the idea which is by no means uncommon, that defectives fared much better economically in the rural than in the urban areas. My recent experience, however, has convinced me that this is not the case; and this I attribute chiefly to the fact that there is comparatively little group work on the farm. The defectives require much supervision in their work and many farmers said that they could not give time to supervise them and therefore had to dismiss them. For the same reason, mentally defective girls do badly in domestic service. The proportion of girls receiving remuneration in domestic service, as shown in the last Report of this Association, is only one-seventh of the whole group. So far I have dealt with the industrial aspect of the problem, but there is another aspect, namely, the supervision of the defectives in their homes and during their leisure hours. Here again the question of social cohesiveness is an important one. In certain communities defectives do much better than in others. In this respect the country districts probably provide the more favourable conditions. In large towns there is little social cohesiveness, with the result that families of low mental endowments tend to precipitate out of the general life of the community and live in slums. Our conception of chronic slumdom is that of a community of feeble-minded persons exploited by the morally defective. When we find a family with two or more feeble-minded persons which usually has a poor home environment, the problem of community care of the defectives resolves itself into the supervision of the whole family. There is much discussion of the eugenic aspect of this family problem, but very little is said concerning the way it affects the question of the community care of the defective.
This
brings me to my last point. One fact brought home very forcibly my colleagues and myself in the course of our investigation was that, however serious die problem of mental deficiency may be, a still more serious is the problem marginal problem of mental inefficiency. When we visited many of the homes, we found that possibly two or three of the children were definitely feeble-minded, but four or five others were certainly dull, though not sufficiently low grade to be certified as mentally defective. The mentality of one or both of the parents was also sub-normal, but again not low enough to be regarded as mentally deficient. It is in such families we have a concentration of most of our chronic social problems, such as chronic pauperism and slumdom, habitual crime, high infantile mortality, illegitimacy and mental disorders of to
all kinds. In the past some writers have endeavoured to convince us that mental deficiency is the parent of all these other conditions, but it would be truer to say that it is one of the children. The true parents are (a) the condition of poor mental endowment, scarcely low enough to be regarded as mental deficiency, and (b) unfavourable environmental conditions. These form a vicious circle. One of the great problems of the present day is that presented by this group of social inefficients which comprises about 10 per cent, of the population. Mental in its broad social sense, and not mental deficiency in the narrow
inefficiency
130
MENTAL WELFARE
legal interpretation of this term, is the important and urgent national problem. The service which workers and students in the field of mental deficiency are rendering is the emphasis they place upon the fact that most of the chronic social problems are essentially associated with a condition of low intelligence, and that whatever solutions are proposed, the quality of the human beings forming this subnormal group of the community should always be borne in mind. Many political and social reformers recognise this fact, but they add that their first duty is to legislate for the 90 per cent, normal and not for the 10 per cent, sub-normal persons. Our reply to this is that many of the social reforms designed for the general improvement of the community will not be fruitful until we have dealt with the special problems of the sub-normal group. The doctor in his treatment of a case clears the deck for action by first removing all the septic foci. A similar maxim seems applicable to our national health. Mental deficiency is one of the septic foci, and it calls for treatment at the outset of any attempt to deal comprehensively with the chronic social evils of the
community.
