The Canadian Journal of Psychiatry

In recent years a method of conducting mental health surveys has been developed which relies mainly on interviewing individuals according to a questionnaire. Subjects for the surveys are chosen by statistical techniques so that they will be representative of designated populations regardless of whether or not they have ever had psychiatric treatment. The questionnaires are administered by trained interviewers who as a rule are not psychiatrists; the data are later evaluated by psychiatrists who make a series of ratings on each individual in the survey. Inasmuch as surveys of this type show a very high prevalence of psychiatric disorder in many populations (from 10% to 60%), the question of validity becomes a matter of major importance.

In the present study 123 individuals were examined and rated independently by both the survey technique and by a psychiatrist employing his usual clinical approach. After the psychiatrist had made his independent rating he was allowed to see the survey data and also to re-examine the subject again if he wished. He then made a final rating constituting his best judgment based on all information available.

The degree of agreement is indicated in Tables I to IV. Table I deals with symptom patterns considered without regard to diagnostic implications. Thus, a given individual may have more than one of these symptom patterns. Table II concerns impairment by reason of psychiatric symptoms. Table III deals with a rating as to whether or not the subject is a psychiatric case: ‘A’ means almost certainly a psychiatric disorder of some sort; ‘B’ means probably; ‘C’ means doubtful; and ‘D’ means almost certainly not a psychiatric case. (Note that the group here studied was deliberately weighted with ‘A’ and ‘D’ ratings and hence is not representative of any population.) Table IV summarizes the agreements.

While more work is needed, and studies of this kind should be repeated, the results so far show considerable agreement between the survey and clinical methods. This suggests that the large percentage figures obtained by surveys are properly matters of serious concern and that they have far-reaching implications for the teaching and practice of psychiatry.

This paper reviews the methodology employed in assessing the extent and characteristics of persons needing psychiatric care. Surveys of the need for physicians' care for any type of disorder (as well as psychiatric) are characterized by problems associated with:

a) Diagnostic process

b) Social factors in attending physicians

c) The natural history of the disorder

d) Definitions of impairment, disability and handicap

e) Clinical insignificance of some statistically significant factors.

Case-finding in psychiatry has additional problems associated with the use of symptom questionnaires; the criterion of work limitation; and the question of past versus present disability. Determination of the type of psychiatrists' care required is also of paramount importance.

One should not equate symptoms with illness; nor symptoms with a need for psychiatrists' care. Community surveys have not yet been able to provide valid estimates of the nature or extent of psychiatrists' care required.

This work deals with the problem of paternal incest occurring with young daughters at puberty. Only those incestuous relations which lasted at least one year have been the subject of the present research.

1) As far as the family structure is concerned, this study has revealed the incestuous father as a weak, masochistic, passive person who is dominated by his wife. The incestuous seductions of the daughter are experienced by her as making her party to his humiliation by his wife. It is under cover of pity that he turns his erotic desires to his daughter. He either beseeches her understanding and compassion or he uses violence.

He has no control over his home and above all he has no control over himself. The wife holds the reins. The father is incapable of saying no to his incestuous desires.

The mothers of these adolescent girls were described as essentially rejecting, and we noted that there is a parallel between the ego-disorganization of the adolescent girl and the intensity of the mother's rejection.

2) We have found that for the duration of the incestuous relationship, these adolescent girls had not suffered any behavioural or personality disorganization which would have alarmed their environment.

3) It was at the time, and very often on the very day, of the father's departure that these girls broke down.

4) Their disorganization was characterized by a very violent, compulsive acting out, which was for the most part erotic-heterosexual behaviour. Other acting out was observed, such as suicidal attempts, running away from home, auto-mutilation and destructive behaviour. We have given the name of compulsive-masochistic reaction to this type of disorganization.

Two adolescent girls eventually had a more severe reaction. They evolved a frank psychosis.

5) Our main hypothesis, which was confirmed by the analysis of the clinical material, was that the compulsive-masochistic reaction is due to a masochistic father-fixation. In other words, these young girls seek at all costs to perpetuate the incestuous liaison to which they are henceforth irremediably attached. Moreover this father-fixation protects them from a much more radical regression; namely an oral and murderous invasion by the mother.

The psychosis occurs when this father-fixation is no longer possible, that is when the father is annihilated, as much in the mother's eyes as in the daughter's. (“He no longer exists for me”, Lise told us). Then the adolescent girl cannot seek any help in her struggle against the oral, devastating and totally destructive mother with whom she is at grips. The effect is therefore fatal: a collapse of the ego's structure; it is psychosis.

The establishment of realistic read-mission rates has always been a problem for the Mental Hospital Administrator. A cohort of discharges from Brandon Hospital for Mental Diseases, discharged in the years 1953–57 inclusive, of 1,113 patients, was followed in the community for five years to establish time specific readmission rates. The results reported indicate the following:

1) Most of the patients lost to the study were lost during the first year of the follow-up.

2) The readmission rate for males during the full five-year period was slightly lower than for females. First admission discharges had lower read-mission rates than readmission discharges.

3) Schizophrenic patients exhibit the highest readmission rates.

4) Almost half the readmissions for the whole five-year period occurred during the first year following discharge.

5) In general, readmission rates declined the longer patients stayed out of hospital.

An effort has been made to review the changes taking place in the administration of psychiatric services across Canada. There can be little doubt that the general recommendations of More for the Mind, Action for Mental Health and many other such reports are gaining increasing acceptance.

It is indeed unfortunate that the federal government has not taken the lead in creating the necessary climate for more rapid implementation of the major recommendations of More for the Mind. The federal government could and should take the lead in seeing that all discrimination against the mentally ill and the services being provided for them are removed from all federal legislation. Such action would have an impact out of all proportion to the federal funds involved. It would surely give leadership to the provinces in their efforts to improve the administration of psychiatric services in Canada and would help to ensure to all Canadians the psychiatric services to which they should be entitled.

There have been encouraging changes in administrative practices during recent years but no province has yet taken the major steps necessary to bring about a full integration, regionalization and decentralization of mental health services. While there have been improvements in the legislation in force in various provinces, these have been in the main in the direction of modifying existing legislation rather than the introduction of completely new concepts.

It is difficult to recommend and seek major changes in the organization and administration of mental health services when the professional groups involved in the provision of such services do not seem to have fully clarified for themselves the major recommendations made during recent years. Psychiatrists and the other professional groups involved must clarify their responsibilities and roles in our society. Until this is done, it is difficult to believe that political and governmental authorities can accept responsibilities for many of the extensive changes which have been recommended.

While recent developments have been encouraging it is also true that some of the major changes which appear to be desirable, particularly in relation to the provision of patient care are being impeded and delayed by many existing attitudes towards mental illness and the mentally ill. It would appear that much more will have to be done to change the attitudes of those responsible for major legislation and administration. There has not been time in this paper to deal with this matter in any detail, but it does seem apparent that the public at large and many community groups are ahead of the professions and governmental authorities in their attitude towards mental illness and in their desire to see improvements in the services provided. We must find ways of mobilizing this general public support and using it to bring about necessary changes.

We along with our neighbours to the south are much concerned about the pockets of poverty which exist in our affluent society. Are we as concerned about the pockets in our society which produce delinquents, misfits and others who cannot function adequately? Have we noted the findings of Crestwood Heights and Sterling County? Are we as concerned as we should be about de-socialization and the repetitive patterns of anti-social, destructive behaviour in generation after generation? Do we really think we will solve the problems of our older people, of our adolescents, of the unemployed, by dealing with these on a materialistic basis? The answer is clearly negative—the universal old age pension of 1945 did not reduce the flow of older patients to mental hospitals, family allowances have not improved our child-rearing practices and the presently proposed Canada Pension Plan and other welfare programs will not be effective unless we concurrently find ways of ensuring for every Canadian a useful, satisfying place in our society as a contributing citizen. This and not the meeting of material needs is the real challenge of our modern society.