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REALITY
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VISION I
A Report of the First Asian Seminar on
MENTAL HEALTH AND FAMIty LIFE Baguio, Philippines, 8-20 December 1958 ~' . f·
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Pro/888OT TSUNG-YI LIN. MD Edited by MARGAIIETHE STEPAN TStJRC-YI Lm AND THE
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Sponsored Jointly by
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OVERNMENT OF THE REPUBIJC OF THE . PffiIJPPINES
e Family Life Workshop of the Philippines d the Philippine Mental Health Association
THE ASIA FOUNDATION THE WORLD FEDERATION OF MENTAL HEALTH THE WORLD HEALTH ORGANIZATION
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MANILA BUREAU OF PRINTING 1960
FOREWORD by KENNETH SODDY, M,D. Directcw of the Seminar It was a signal honour to be invited to be the Director of the First Asian Seminar on Mental Health and Family Life, and I have great pleasure in introducing this report, in the writing of which Dr. Tsung-yi Lin has set out to interpret as well as to describe the happenings at the Seminar. Readers will find that the narrative is much leavened by the wisdom and understanding of Dr. Lin's comment. The staff of the Seminar have decided not to report the names of the individuals who have made contributions to the discussions. It was felt that the Seminar was a team effort of staff and participants alike, a mutual learning experience in which it would be invidious to give prominence to some of us who happened to have more opportunity than others to make contributions. This may mean that much good work will get less recognition than it deserves from those who were not at Baguio, but it will not be forgotten by those who were present. The thanks of the participants and staff to all our benefactors were very warmly expressed at the last session of the Seminar and again, later, by correspondence. Here I would like to record publicly our gratitude to all those who helped to make the Seminar possible. We are deeply grateful to our sponsors, the Philippine Govern-' ment, for much financial and organizational help; to His Excellency, Carlos P. Garcia, President of the Philippines, our Honorary Chairman; to the members of our Executive Committee, the Honorable Elpidio I. Valencia, M.D., Secretary, Department of Health, co-chairman; Miss Helena Z. Benitez, Family Life Workshop of the Philippines, co-chairman; and Dr. Jose A. Villegas, Department of Health, Dr. Domingo C. Bascara, Philippine Mental Health Association, and Dr. Andres Angara, Operational Officer . of WHO for the Seminar. We gratefully acknowledge the support
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iv given to us by the members and staff of the Family Life Workshop of the Philippines and the Philippine Mental Health Association in administration and organization. To the Asia Foundation we are most grateful for their most generous financial assistance, without which the Seminar would not have been possible. The Asia Foundation carried the main burden of the costs of travel and maintenance of the participants and also made a big contribution to central organizational expenses. The Western Pacific Regional Office of the World Health Organization helped us in many vital ways and we are extremely grateful to Dr. I. C. Fang and his staff. The World Health Organization contributed towards travel of participants and administrative costs and helped with administrative services. An even more important contribution made by the Regional Office was the services of the three regional staff members; Dr. Manuel Escudero, Miss Lorna Horwood and Mr. Lynford Keyes; and three consultants who were given special short-term contracts by WHO: Dr. Estefania Aldaba-Lim, Dr. Tsung-yi Lin and Dr. Margarethe Stepan. Mrs. Juana S. Silverio attended through the cour-
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tesy of the United Nations, and in association with WHO, the Food and Agriculture Organization made available to us the services of Dr. Margaret Hockin-Harrington. Our thanks are due to the Regional Office of WHO, also, for a magnificant send-off in their new conference hall in Manila, and both before and after the Seminar, members of the staff gave us every assistance in their power. We are indebted to the World Federation for Mental Health for its pioneer efforts in showing how such seminars can be set up and for encouraging our advance planning and seeking of support. The Federation, in co-operation with the Philippine Mental Health Association, made it possible for Dr. Margaret Mead and myself to attend the Seminar. Perhaps a special debt of gratitude is owning to the Reverend F. C. Madigan, S. J., who responded to our invitation and made many valuable contributions. We are grateful also to UNESCO for making it possible, through the good offices of Dr. Mead to provide background briefing papers on each country represented at the Seminar. • We received much hospitality during our stay in the Philippines. Early arrivals spent a memorable evening in the home of Miss Helena Benitez; we were entertained lavishly by the Executive
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Committee on the opening night; and during the course of the Seminar by Dr. Elpidio 1. Valencia, Secretary, Department of Health; by Mr. and Mrs. Wilson and the Asia Foundation; and by the Mayor of the City of Baguio. It is my pleasant duty to acknowledge also the help of those
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who worked hard both at planning and subsequent to the Seminar. Dr. J. R. Rees, Director of the World Federation fur Mental Health, was largely responsible for planting the idea and for guiding our early plans. Miss Helena Z. Benitez and Dr. Estefania Aldaba Lim carried between them the main burden of organizational responsibility and gave the Seminar its form. They were supported by a devoted administrative and secretarial staff. Dr. Margaret Mead contributed the lion's share of both long-term and detailed planning, out of her unique cross-cultural experience. Dr. Margarethe Stepan contributed to the design of content and undertook the difficult task of collation and organization of the records, in which' she was helped by several members of both the Seminar and WHO staffs. Finally, our thanks are due, most warmly, to Dr. Tsung-yi Lin himself. As for the Seminar itself, we appear to have been fortunate in being able to supply much of what the participants needed, in an appropriate form, and at a suitable time. Speaking for myself, I found that the forthnight I spent in Baguio was an enthralling leiuning experience, particularly in the broadening of horizons, the establishment of links of common interest and mutual appreciation. I believe that everyone who attended found there great enrichment for our common work for mental health in the future. I have thanked every member of the staff, personally, for their understanding and support, and I would like to repeat this in public. People experienced in the conduct of international meeti.ng;!\ will realize from reading the short historical account given in Chapter I that we came to Baguio with a great number of unsolved problems. We had to feel our way forward, but in spite of many inaugural anxieties, our improvised system of two-way . communication on the spot did not fail us. For its ultimate and undoubted success, the participants should be held fully as responsible as the members of the staff. In short, the First Asian Seminar on Mental Health and Family Life was unequalled as a lesson in mutual adaptation and the development of mutual understanding; and unequalled also, I am convinced, as a timely development in mental health understanding in Asia.
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vi Through the medium of this report I am happy to convey a warm greeting to all my friends who were at the Baguio Seminar. I hope to have many opportunities in the future for renewing my co-operation with each one of you. I would also like to commend the study of this report to all who are concerned with mental health but who were, unfortunately, not at Baguio. There is much that is interesting and noteworthy between the covers of this slim volume. WORLD FEDERATION FOR MENTAL HEALTH
19, Manchester Street, London, W. I September 1959
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PREFACE The writing of this report of the Baguio Sef!linar-using the common abbreviated term which has been bestowed with some emotional attachment-turned out to be a most worthwhile and gratifying work. It gave me the rare pleasure of re-experiencing this meaningful meeting through the faithful reconstruction of the Seminar materials and records. Quite frequently during the writing I experienced the real joy of discovering valuable information, stimulating ideas and constructive suggestions which had somehow skipped my perception during the meeting or disappeared from my memory after the meeting. On several occasions I had to modify my personal views or impressions on certain subJects discussed in the Seminar. It was through this process of learning and unlearning that the present "report" was prepared. After going through the reconstructed records of the Seminar, which was done through the laborious work of the secretarial staff under the supervision of Dr. Margarethe Stepan, the following guiding principles were set for writing this report. (a) The report should be written primarily for the benefit of the participants of the Seminar and their colleagues in Asia. ( b ) The report should be arranged in accordance with the development of the Seminar, based on the faithful use of seminar material and records and of the observations made by the staff. (c) No name of any single person-participants and staff alike--should be mentioned in the text, except in the the first two chapters; in order that the Seminar be everybody's responsibility and its success to everyone's credit. (d) The post-seminar developments such as the radical revision of the content of speeches and discussions, and sundry organizational activities such as the establishment of new mental health societies or seminar reports of individual countries should not be the concern of the present report. I was asked to take an active part in the preparation of the report of the "Baguio Seminar" one day before the close of the meeting and when I hastened to review the Seminar to vii
grasp its achievements as well as its full meaning in relation to the future of the field of mental health· in Asia, two words, "reality" and "vision" came to my mind. Strangely enough, thes~ two w!>rds have persistently come to me throughout the course of writing this report whenever I tried to assess the significance of the Seminar. This is the reason why the title "Reality and Vision" was chosen for this report. "Reality" referred to the fact that the "Baguio Seminar" provided the first opportunity for realistically assessing the field of mental health in Asia today. Problems in mental health and family life constitute a major concern of and threat to rapidly changing Asia, although various unfounded reports 'as;. sert that Asian societies enjoy better mental health and family life than some others. It became increasingly and painfully evident to everyone at the Seminar that the knowledge and data from which mental health work should evolve are most inadequate. It was this inadequacy which caused the discussions to center more upon general issues of mental health than upon specific problems related to family life. Everyone shared also the observation that the most serious problem in this field is the critical shortage of trained personnel to cope with the increasing problems and needs. Communication and co-ordination among Asian countries for pooling effort and personnel were felt to be shamefully lagging. The aspiration and visions which participants and staff brought with them to the Seminar remained unimpaired, and in the case of many people were heightened, by this discouraging, if realistic, picture. More objective assessment and understanding of the problems stimulated the participants to think constructively about research. Knowledge of the ~imited. number of personnel available spurred them to serious discussions on the subject of training. Clear realization of the lack of universally applicable theories or blue-prints in mental health work created an atmosphere of more independent search for \ workable knowledge and tools. These positive responses to the problems were further enhanced and strengthened by the establishment of friendly and earnest relationships among the participants from different countries. The sharing of similar problems and similar visions led to the conscious determination to plan and work together for common ends. It was this sort of feeling and enthusiasln that prevailed at the end of the Seminar.
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ix In short, it was felt that the "Baguio Seminar" has accomplished the historical task of being the "First" Asian Seminar indicating, as it did, the directions of future development in the field of mental health based on the clear understanding and acceptance of the reality, with all its problems and limitations. The distances, however, between this reality and the envisaged goals are still great so great that most of us at one time or another had some question as to where we were really going in this particular Seminar. The success of future undertakings will however be determined by how far the impact of this Seminar can be translated into action by each participant and also how much each one of us will grow in knowledge and skill through action and how many more people will be involved in similar ways with similar aspirations and visions to those which marked the "Baguio Seminar". In the preparation of this report I have been furtunate in receiving valuable help from a large number of colleagues and friends: Dr. Manuel Escudero, Miss Lorna Horwood, Dr. Margaret Hockin-Harrington, Mr. and Mrs. Lynford Keyes, Dr. Es, tefania Aldaba-Lim and Dr. Margarethe Stepan. I would also like to express my indebtedness to Miss Helen Z. Benitez and Dr. Andres Angara and the secretarial staff of the Family Life Workshop of the Philippines and the Western Pacific Regional Office of the World Health Organization. Special thanks are due to Dr. Margaret Mead and Dr. Kenneth Soddy, not only for their invaluable collaboration in the writing of the report, but also for their able leadership in all phases of the Seminar. To all of them, and to my wife, who collaborated at every stage, it is a pleasure to express my hearty thanks. September, 1959
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Tsung-yi Lin, M. D. Taipei, Taiwan, China
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CONTENTS Page
CHAPTI!lR CHAPTER CHAPTER CHAPTER CHAPTER CHAPTER
I. III. IV.
Introduction .............................. _...................................... Family Life and Mental Health Problems in Asia Today ............................................................................ Socio-Cultural Changes in Asia and their Effects on Family Life and Mental Health ................. .
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II. Programme and Structure of the Seminar ................
V. Concept of Mental Health ................. . VI. Research on Mental Health and Family Life ........... .
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CHAPTER VII. The Survey as a Basis for Mental Health Planning CHAPTER VIII. Planning for Action ...................................................... CHAPTI!lR EPILOGUE
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IX.
Evaluation of the Development of the Seminar .... List of Participants, Staff and Observers xi
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APPENDIX
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CHAPTER
I
INTRODUCTION
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This is an account of the First Asian Seminar on Mental Health and Family Life held in Baguio, Philippines, 6-20 December 1958, under the sponsorship of the Philippine Government through the Family Life Workshop of the Philippines and the Philippine Mental Health Association, the Asia Foundation, the Western Pacific Regional Office of the World Health Organization, and the World Federation for Mental Health. The place of this Seminar in the global mental health scene was brought out in the opening address by Dr. Kenneth Soddy, the Director: "The First Asian Seminar is one of a looselyconnected chain of multidisciplinary activities in the mental health field that have been springing up in many parts of the world. These activities have in common the fact that they are international and interdisciplinary and they vary from teaching seminars and study courses to working groups and expert exchanges of information. But they are all part of a . tremendous resurgence of international activity that has characterized the years since the close of World War II. It seems that the responsibly-minded people in many countries have felt at the same time that they personally have a responsibility to do something about the aftermath of international suspicion and hostile competition that has followed the two disastrous world wars of this century, and in most fields of human endeavour there has been a great revival of international contact. "In the mental health field specifically this found its first big expression in the Congress on Mental Health which was held in London in 1948 at which the principal theme was Mental Health and World Citizenship. At this Congress the International Mental Hygiene Movement reconstituted itself as the World Federation for Mental Health. "Early in its planning the World Federation for Mental Health foresaw the need for getting together small groups of people in order to undergo mutual learning and teaching processes on important subjects in the mental health field. In 1950 the Federation planned the Chichester Seminar on Mental Health and Infant Development which was held in August 1952. This, like the present Seminar, was a joint effort of a number of organizations, notably the European Regional Office of the World Health Organization, the United States Public Health Service and 1
2 the Grant F01l'Jldation of New York, and it brought together participants from sixteen European countries together with a few representatives from each of the other continents. It was always hoped that this seminar would be followed by others in the other parts of the world, but as anybody can see, the financing of a seminar of this type is an extremely costly business and plans necessarily move slowly. In 1954 the World Health Organization was mainly responsible for a rather similar seminar in Sydney for Australia and nearby countries. And now we come to Baguio. "In choosing subjects for these seminars we have always been concerned with what is developing and what is currently in an important state of change in the regions represented. It has appeared to us that in Asia generally the current focus is very much on family life, and therefore we have decided to pass on from the infancy period that was studied at Chichester and the toddler period that was the main focus at Sydney, to consider the range of family life while children are still mainly dependent on their parents. . . We have come here in order to study s0mething that everybody concedes is in a state of change, to learn about what is going on and to try to find out whether the change is, in the main, 'healthy' or 'unhealthy'.!'
Planning of the Seminar and the Objectives In August 1957, at the Executive Board meeting of the World Federation for Mental Health (WFMH) in Copenhagen, the Philippine Mental Health Association through Dr. Estefania Aldaba-Lim, presented an invitation made jointly with the Family Life Workshop of the Philippines, to the World Federation for Mental Health to support a proposed Asian Seminar on Mental Health and Family Life. Consequently during the ensuing Annual Meeting of the World Federation for Mental Health, a group of interested people met and discussed this project. Those present included: Dr. Estefania Aldaba-Lim, of the Philippine Mental Health Association; Dr. Irene Cheng, Senior Woman Education Officer, Hong Kong;, Dr. Tsung-yi Lin, Professor of Psychiatry, National Taiwan University, Taipei, Taiwan; Dr. Margaret Mead, President of the World Federation for Mental Health; Dr. J. R. Rees, Director of the W orId Federation for Mental Health; Dr. Phon Sangsingkeo, Director of Division of Hospitals for Mental Disorders, Bangkok; Dr. Kenneth Soddy, Assistant Director of the World Federation for Mental Health. Due to financial uncertainty at the time only the aims and objectives in general terms and possible key personnel were discussed by this unofficial preparatory committee. However, it was strongly felt by all concerned that every effort should be made to implement this long-entertained and worthwhile project.
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Meanwhile, much of the subsequent preparatory work was done by the Philippine Organizing Committee in Manila headed by Dr. Paulino J. Garcia, then Secretary of Health and later by his successor, Dr. Elpidio 1. Valencia, Secretary of Health, Philippine Government, and Miss Helena Z. Benitez, the Chair-. man of the Family Life Workshop as co-chairman. The technical and financial assistance of the Western Pacific Regional Office of the World Health Organization and financial assistance ·of the Asia Foundation offices in a number of Asian countries were secured in the spring of 1958. In September 1958, four members-Drs. Soddy, Mead, AldabaLim, and Stepan-of the present Seminar staff took the opportunity afforded by the Annual Meeting of the World Federation for Mental Health to form a steering committee in Vienna. This committee developed a tentative programme based on knowledge available at that time of the likely staff and participants. Three months later most of the staff members met one week prior to the Seminar, during which time the objectives were reformulated and the programme redesigned.
Objectives The general objectives of the Seminar were reformulated thus: (1) To provide an opportunity for participants to exchange. information and ideas about mental health in family life; (2) (a) To identify common practices and problems of family life and the pattern of change in family life in various countries in Asia today. ( b ) To exchange views and information on methods of approach to these problems and to their solution. ,\
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These objectives reflected the desire on the part of the staff that the meeting should be a working seminar where all the members would participate-both participants and staff -to share and pool their knowledge, experiences, anxieties and . aspirations. The main purpose of the Seminar was thus to make this shared knowledged really meaningful and constructive for each participant. It would also provide an atmosphere for the development of mutual understanding and friendship which could lead to a deep sense of a common bond for common goals. Dr. Mead, in the Opening Ceremony made a
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4 statement, "We came here to find people", and Dr. Soddy said, earnestly, "We wanted to involve more people more deeply in working for their fellow human beings". Being the first seminar on mental health and family life in Asia which Asians took an active part in planning, organizing and conducting, this broader objective of involving participants through intense interaction in working groups rather than having the staff attempt to teach the participants seemed to be the appropriate way of setting the tone for the two weeks' period of this hardworking Seminar.
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II
PROGRAMME AND STRUCTURE OF THE SEMINAR ,"
Out of the general objectives, the following four study topics were developed and approximately three days were given to each one.
Topic 1.
Family life and men.tal health problems in Asia today (a) Concept, structure and function of the family
Role of the family in the community Mental health problems in relation to family life (d) Speculation on problems of child development. (b) (c)
Topic 2.
Patterns of chang,e: Socio-cultural changes in relation to family life (a) Identification of such major changes as: increase of population universal education technical change cultural change urbanization resettlement and migration mass communication status of women (b) Implication of these changes for mental health in the family. Methods of approach (a) Need for research in programme planning in a given society (b) Interdisciplinary research methods in the human sciences (c) Application of research in mental health planning. Applications (a) Planning for action (b) Education and training in mental health (c) Mental health and social action 5
Topic 3.
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Topic 4.
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The seminar programme was largely developed through group discussions in the form of four permanently constituted groups, each consisting of 12-14 members including two staff members. The number of study group sessions allotted for each topic varied from three to six. Discussion guides were prepared for each topic by a staff committee. It was made clear that these guides were only suggestive and as the meeting progressed they became less detailed. Each topic was introduced to the Seminar at a plenary session and different methods such as panel discussions, Tole playing, film showings and lectures were used. Likewise, each topic was summarized at a plenary session, again using methods similar to those of the introductory plenaries. At these sessions the findings of the study groups were reported and synthesized. Commentaries as well as papers conceptualizing common problems were given by staff members to assist in the crystallization of the thoughts of the whole Seminar membership. A few plenary sessions were introduced into the programme, mostly during the second week, whenever the need for giving information or stimulating thinking was seen. In the middle of the first week the dynamics of small group operation were presented at a plenary session by means of a role playing scene of group discussion. The purpose of this session was to assist the members of the Seminar to gain insight into the group dynamics essential for the success of a working seminar that was using group discussion as the main method. At other plenaries, two films were shown, "First Five Days in the Life of aNew Guinea Baby" and "Trance and Dance in Bali" to illustrate the use of anthropological research for the understanding of human personality development in relation to culture. Evaluation of progress was made twice, once in a session at the end of the first week, and again at the end, each time by filing out prepared unsigned questionnaires. Each day was divi9,ed into four periods: two periods in the morning of one-and-a-half hours and two hOUTS respectively, with a half-an-hour coffee break in between, and two-hour sessions in the afternoon and in the evening. In principle, only three of the four periods were used in anyone day; or if aU four periods were used in one particular day, two free periods were provided for the following day. There was a small exhibition of pictures and house models illustrating aspects of family life in various Asian countries.
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7 A small library of books related to the topics of the Seminar was also made available, and, in addition, some participants kindly provided informative material about conditions in their respective countries. There were two major characteristic features about the structure and programme of the Seminar. The first was the absence of a rigid structure, which resulted in flexibility of programming. In other words, the programme was continuously revised and adjusted by the staff with participant assistance as the Seminar unfolded. The second important feature was that the whole programme was built around the small group discussions with plenary sessions used to introduce topics or to highlight and conceptualize the group discussions during or at the end of each study topic. Since few participants were familiar with this method of learning in a seminar, a great deal of anxiety was developed at the beginning. Also, the composition of the study groups based on maximum spread or discipline and nationality contributed fm·ther to this initial anxiety. From previous experience, the staff anticipated this reaction and prepared to accept and deal with it, knowing that only through such intense interaction among all seminar members could the maximum of interdisciplinary and international communication take place, which would make the Seminar a living and growing process for the maximum number of members. The staff continued to meet frequently throughout the Seminar as a group or in small working committees to assess progress, plan and prepare for the plenary sessions and to attend to the numerous administrative matters. A Steering Committee was created which was composed of a representative from each study group and four staff members. This Committee served as a two-way channel of communication between the staff and participants. SCHEDULE OF THE SEMINAR
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Saturday, 6 December Opening Ceremony and Reception at the Conference Hall, WHO/WRPO, Manila ....................................... . Sunday, 7 December Introductory Session to the Seminar: Dr. Kenneth Soddy ................................................... . Plenary ....................................................................•...........
(17.00-21.00)
(15.00-17.00) (19.30-21.30)
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8 Address, Film and Discussion: Dr. Margaret Mead "Birth of a Baby in New Guinea"
Monday, 8 December Plenary .............................................................................. . Introduction to Topic One: Dr. Margaret Mead "Family Life and Mental Health Problems" Group Discussion 1 on Topic One Group Discussion 2 on Topic One ............................. Tuesday, 9 December Group Discussion 3 on Topic One ................... . Group Discussion 4 on Topic One ...................... . Group Discussion 5 on Toplc One ............................... . Wednesday, 10 December Group Discussion 6 on Topic One Plenary ..... . Presentation of Group Process: Mr. Lyn Keyes
(08.30-10.00)
(10.30-12.30) (14.30-16.30 ) (08.30-10.00) (10.30-12.30 ) (14.30-16.30)
(08.30-10.30) (08.30-10.00)
Thursday, 11 December Plenary... . ....................... . Summary of Topic One: Dr. Margarethe Stepan Plenary...... ............................................ . Introduction to Topic Two: Dr. Manuel Escudero, Dr. Margaret Hockin-Harrington, Father Fl·ancis Madigan, Dr. Margaret Mead Group Discussion 1 on Topic Two Group.Discussion 2 on Topic Two Group Discussion 3 on Topic Two (08.30-10.00)
(10.30-11.30)
(11.30-12.30) (14.30-16.30) ( 17.30-21.30)
Friday, 12 December Group Discussion 4 on Topic Two Group Discussion 5 on Topic Two (08.30-10.00 ) (10.30-12.30)
Saturday, 18 Deeember Plenary ...................... . Summary of Topic Two: Dr. Manuel Escudero, Dr. Margaret Hockin-Harrington, Father Francis Madigan, Dr. Tsung-yi Lin Plenary..... ...................... . Evaluation of the First Seminar Week: Dr. Margaret Mead (08.30-10.30 )
.. (10.30-12.30 )
, 9 Sunday, V. December Free Monday, 15 Decembe,· Plenary ............... . "The Concept of Mental Health": Dr. Kenneth Soddy Group Discussion 1 on Topic Three Plenary ...................................... . "Approaches to a Mental Health ProgramJuvenile Delinquency" Role play by Mr. Lyn Keyes and group of participants Panel Discussion: Dr. Manuel Escudero, Father Francis Madigan, Dr. Margaret Mead, Dr. Margarethe Stepan Special Session Film and Discussion .. ' .................................................. . "Trance and Dance in Bali" Dr. Margaret Mead
(08.30-10.00)
( 10.30-12.30) (14.30-16.30)
(19.30-21.30)
Tuesday, 16 December Plenary "The Survey as a Basis for Mental Health Planning": Dr. Tsung-yi Lin, Dr. Margaret Hockin-Harrington Group Discussion 2 on Topic Three Special Interest Groups (a) Clinical Child Psychology (b) Education and Community Programmes (c) Psychiatry (d) Social Work
(08.30-10.00 )
(10.30-12.30) (14.30--16.30)
Wednesday, 17 Decembe?' Plenary ......... . Summary of Topic Three: Dr. Margaret Hockin-Harrington, Dr. Tsung-yi Lin, Father Francis Madigan, Dr. Margaret Mead, Dr. Kenneth Soddy Plenary Panel Diseussion of Final Report (I) • Plenary. . ............. . Introduction to Topic Four: Lorna Horwood, Lyn Keyes, Mrs. Juana Silverio Group Discussion 1 on Topic Four ........................... . 006396--2
(08.30-10.00)
(10.30-12.00) (14.30-15.00)
( 15.00-16.30)
10 Thursday, 18 Detember Grou p Discussion on "Skeleton Plots" ....................... . Plenary ............................................................................... Report on "Problem Situation": Mrs. Juana Silverio, Dr. Margaret Mead Friday, 19 December Plenary .................................................................................. Planning for action and training: Dr. Manuel Escudero, Lyn Keyes, Mrs. Juana Silverio Plenary ................................................................................ . Education and training in mental health: Lorna Horwood, Dr. Tsung-yi Lin Plenary Discussion of Final Report (II): Dr. Margarethe Stepan, Dr. Tsung-yi Lin, Dr. Kenneth Soddy Saturday, 20 December Plenary "Mental Health and Social Action". Dr. Estefania Aldaba-Lim, Dr. Manuel Escudero, Dr. Margaret Hockin-Harrington Plenary ................................................................................. . Clor.ing Session: Miss Helena Z. Benitez Dr. Margaret Mead and Dr. Kenneth Soddy (08.30-10.00) (10.30-12.30)
(08.30-10.30)
(10.30-12.30)
(08.30-10.30)
(10.30-12.30)
CHAPTER
In
FAMILY LIFE AND MENTAL HEALm PROBLEMS IN ASIA TODAY
The period for the first study topic was so planned that members of the Seminar would spend ample time in small group discussions to identify family life practices and mental health problems in Asia today, through free exchange of information and experiences, while developing an atmosphere of working and learning together in a group. The topic was introduced to the Seminar in a plenary session by a member of the staff with a prepared study guide. Altogether 11 hours, in six periods were devoted to study group discussions on this topic. The introductory paper included the following:
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"People learned many thousand years ago that different people had different kinds of families, and that family structures could be thought about and changed. Almost every great religious and political movement that we know anything about has had some theory about what the family should be and of whom it should consist. "But for a long time people did not reach a &tage at which they could think scientifically and objectively about the family. Each form of the family, even though it was very new, was still regarded by the people concerned as the only right form. However, in the last 100 years, students of human behaviour-anthropologists, sociologists, social psycho-_ logists, psychiatrists-have begun to think scientifically about the family and have developed a set of categories. Because these categories have been developed by Western scientists, they are still likely to be biased by Western cultural points of view. It will be important for Asians not to let Western categorieS' dominate their thinking too much. "There is a danger that terms like "extended family", 'nuclear family', 'joint family', originally devised by social scientists for purposes of objective description, will become loaded with value judgments such as, for instance, what is Western, what is Eastern, what is old-fashioned, what is modern, and what is good and what is bad. As we use SOme of these descriptive words for the purpose of communicating with each other about the changing family in our societies, I hope we shall be able to avoid making these value judgmentS'. "There will be a tendency to think of the extended family as the older, more traditional form, and the nuclear family as something 'new and modern, so it will be important to recognize that the nuclear family is found among some very primitive peoples, and that in some countries 'where the nuclear family has been a very common form-as in the United States-there is a tendency today once more to include more relatives within the circle of obligations. 11
12 "There is no doubt that the shrinking of the large family to the nuclear family is likely to occur in population movements, and under circumstances of rapid social change when often older and younger members of the family tind it more difficult to live harmoniously together. "We may want to discuss the effect on mental health if the culture should have an ideal family form which is more or less difficult to attain because of the accidents of birth and the events of life. In these conditions most people would have a subjective picture of what is the typical family in their society, which may actually not be the most usual type of family, statistically speaking. "It is also worthwhile recognizing that so far the human race has !lever invented a family form, or even a cluster of family forms, Which has suited every human being born into a given society. Individuals differ so much, one from another, that no single family form can give complete satisfaction to all. But one of our goals may be to develop forms of the family which will give a place to each type of human being. "We want to talk here, from the standpoint of mental health, of the meaning of different kinds of family to the welfare of each individual. What are the family strengths and what are the weaknesses?"
The foregoing remarks served to clarify the directions of the ensuing group discussions. The need for objectivity in discussion without value judgment was repeatedly advocated, because it was clearly noticed in both the information papers prepared by participants and in the statements of the participants early in the Seminar, that considerable anxiety exists about the rapid changes in family and social structure, and about the apparent increase of mental ill health in the countries represented here which appears to be regarded, rightly or wrongly, as'caused by the changes. The following main points emerged from the study group discussions. (1) The focus of discussion in all the study groups centred around the nature of the problem in the extended family system as compared with the nuclear family system. It was felt that the emergence of the nuclear family in Asian countries varies only in tempo and extent in different countries, but that the extended family still prevails generally. In general the extended family system seems to be regarded as the ideal. (2) In the discussions, the initial, nostalgic attachment to and generalization regarding the positive aspects of the extended family system gradually gave way to more critical, analytical and specific statements. The characteristic positive and advantageous aspects of the extended family system reported by the groups were: (a) The provision of continuous security and affection for the child and available alternative care and support
13 which facilitates the'development of a sense of belonging in the child. (b) Less opportunities for exposure of the children to the parental concentration of anxieties and tension upon one or two children. (c) The facilitation of the child's social relationship formation through continuous and diffused companionship. The negative and disadvantageous aspects of the extended family system given were: (a) The tendency to foster over-dependence of children on elders. ( b) Inconsistencies in the training of children by different adults are apt to give rise to confused sense of values, with resulting emotional disturbances. (c) The development of individuals may be limited or retarded, due to the clearly defined and structured roles assigned to each individual which discourage initiative and reduce incentive. (3) The following specific problems were mentioned as having significant effects on individuals in family life: (a) The adjustment of in-laws, particularly of daughtersin-law seemed to be particularly difficult. In most countries the wife's status rises with the birth of the first son and as she advances in age. Conflict between mothersin-law and daughters-in-law seems to be quite prevalent and intense. Also men are often caught between reverence for their mothers and affection for their wives, as well as in the struggle for power of these two important figures in their lives. (b) A child's sibling order apparently has some special psychological meaning to the child, though this varies in different cultures. In countries where oldest sons are treasured, the rates of neuroses were observed to be higher, though not conclusively so, among eldest sons than among the rest of the siblings. Parental over-protection and high expectation were advanced speculatively as the causes of this phenomenon. In other Asian countries contrary to the above observation, younger children seem to be subjected to greater stresses because of parental rejection. (c) The position of women inside the family is generally inferior to that of men in most countries. With age, however, women gain more status and power, though this may
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14 nO't be revealed in public. The cemmO'n preferential treatment O'f h-,ys and discriminatiO'n against girls likewise cO'nstitute ~eriO'us psychO'lO'gical as well as sO'cial prO'blems. (4) It was generally O'bserved that cO'mmunity participatiO'n by Asian family members has usually been an O'ffshO'O't O'f the extended family's help O'f and cO'O'peratiO'n with its many members rather than as a mO're abstract fO'rm O'f cO'ncern fur the welfare O'f unknO'wn fellO'w citizens. The lack O'f initiative in Asia fO'r vO'luntary welfare O'rganizatiO'ns seems to' be largely due to' this basic philO'SO'phy. The welfare wO'rk O'f "psuedO'relatives", such as the "cO'mpadre" system in the Philippines, the clan assO'ciatiO'n in Chinese cultures, shO'WS that Asian peO'ples have cO'nsiderable interest in sO'cial welfare wO'rk, but that such wO'rk is mO'stly dO'ne thrO'ugh the prescribed channels revO'lving arO'und the extended family. Value O'f small study grO'ups
The study grO'up periO'ds given to' this topic withO'ut any intervening plenary sessiO'ns fO'r infO'rmatiO'n or interim summarizatiO'n seem to' have given the Seminar a gO'O'd start, fO'r the fO'IlO'wing reasO'ns: (1) They prO'vided sufficient O'PpO'rtunity fO'r the participants, including the staff members, to' becO'me mutually acquainted and to' recO'ver frO'm the initial cO'nfusiO'n and anxiety O'ften encO'untered in internatiO'nal seminars. (2) They prO'vided O'PPO'rtunities fO'r finding cO'mmO'n grO'und and a cO'mmO'n language. This is essential in interdisciplinary seminars. (3) They prevented rigidity and infO'rmatiO'n-giving in the prO'gramme, because the intrO'ductO'ry speeches, study guides and able leadership encO'uraged creativity, initiative, and active participatiO'n O'f all the participants in the Seminar. (4) This SO'rt of free discussiO'n method enabled the participants to realize hO'W much O'r hO'W little they knew abO'ut their O'wn country, let alO'ne O'ther countries. This furthered their eagerness fO'r an exchange of informatiO'n and especially fO'r mO're factual and research data. It shO'uld be nO'ted that at the end O'f this discussiO'n, there was still cO'nsiderable anxiety among thO'se participants whO' were used O'nly to' didactic teaching situatiO'ns O'r thO'se whO' fO'und it difficult to' mingle with O'r express themselves in the presence of others.
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CHAPTER IV SOCIO-CULTURAL CHANGES IN ASIA AND THEIR EFFECTS ON FAMILY LIFE AND MENTAL HEALTH
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Lively discussicns and exchange of information took place on this study topic, particularly about those changes which seemed to have captured the interest and concern of the members of the Semina-r. The following ideas, observations, and items of information were taken from the study group discussions and plenaries and appear to be representative of the attitudes and concepts expressed. People in Asia now live in the greatest era of social change in the whole span of human history. The only times at which this has previously happened have been when men have ceased to be nomadic hunters and become agriculturalists. Today men a:re moving from a simple, stable life on the land to a highly mechanized, complex and materialistic life in modern towns and cities. The changes that Asians are experiencing today are causing a tremendous upheaval. The great majority of Asians have been confronted with the task of undergoing these changessocial, cultural and technological-in less than two decades, changes which the Westerners underwent over a period of far more than one hundred years. They have been caught unprepared to face, accept and struggle· to adapt to these changeR that are by nature mostly foreign to Asian culture. Some of the more .important are to be found in the area of new ideas and values-ideas of nationalism, of democracy, of social welfare, and of the welfare state. Another enormous area of change can be found in the adoption on a vast scale of whole complexes of new technologies and material devices. Power dams, floods control and irrigation projects, steel mills automobile factories, and fertilizer plants are just a few of the sign!:. of the emergence of a new, but material, cultural change. The exposure of Asians to Western ideas and influence has been multiplied beyond measurement in the last fifteen years through a tremendous expansion of the ideal of universal education and through communication by means of mass media.
Increase of population Another significant phenomenon in relation to and also contributing to social change is the tremendous increase of 15
16 population. Due to the introduction of medical facilities and public health practices, death rates in most Asian countries have declined considerably while the birth-rates still maintain their past high level. In most Asian countries the popUlation is expected to be doubled in the next 25-35 yeaTS and many countries are already over-populated. This serious problem is a true demog'faphic revolution, since it has almost entirely changed the situation of mankind upon the earth. An example can be taken from a country which is in process of industrialization to illustrate the serious effect that population increase can have on the socio-economic welfare of the nation. In that particular country industrial output has risen over 200 per cent in the last decade, but the per capita income remains the same, because the entire increase of production has been absorbed by the newly added popUlation.
Migration and resettlement Coupled with a great increase of population, the problem of migration and resettlement increases the uneasiness of the Asian situation. Extreme poverty constitutes a serious threat to the physical, mental and social well-being of the people. The film from Hong Kong vividly illustrated the incredible inhumanity of the conditions under which the mass of refugees are living there, in strong contrast to the prosperity of the modern and beautiful shops, streets and seaport admired by tourists as the Jewel of the Orient. The sad observation of the Seminar was that this was not an isolated instance. One participant in particular stressed how the anxieties and worries of his countrymen with rega'rd to the uncertainties of the future have aroused in the g'feat mass of the people such a mentally unquiet state that they constantly seek escape from oppressive fears. They tend to live for the day, and by immersing themselves as far as possible in superficial amusements and recreational activities, strive to divert their attention, even for a few hours, from the threat of what the morrow may bring. This is a facet of life with all its mental health implications with which displaced people must live in Asia at present.
Universal education Throughout Asia a great thrist for education is now being seen in many ways, among individuals" families and govern-
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ments. This has resulted in an increase in national budgets for education with the aim to provide education for all children at all levels: in rural as well as urban ai'eas, for backward as well as normal and gifted children, and for the poor as well as the rich. Illiteracy is gradually disappearing, In many countries, illiteracy is considered to be almost a national disgrace, as shown by a tendency not to talk about the percentage of illiterate people in one's country. Many governments can be justifiably proud of their accomplishments. This movement toward universal education has received a certain amount of international aid. UNESCO has encouraged governments to set up national committees on education and has provided specialists in fundamental education, literacy, adult education, textbook preparation, and so on, Certainly, education has been a great liberating force throughout this region as in many other parts of the world. Up to the present the rapid increase in the provision of schools that is characteristic of many countries has tended to follow existing class and caste systems; but increasingly one finds a mixture of economic and social classes and of the sexes in the schools, a trend that has become particularly marked since the war. The reports of discussion groups, however, are full of concern about current· problems of education and the impression is that while universal education may bring many benefits, it also creates many problems. For example, modern education is said to have weakened filial piety. The use of a different language at home and at school causes conflict and misunderstanding between the parents and the children and between parents and teachers. Where paTents do not speak the language used at school, they can have little or no knowledge of the content of the curriculum or of what their children are learning. The present emphasis on examinations also arouses great concern. The passing of grades and keen competition in school inevitably result in long hours of study, often in unhealthy conditions. At the other end of the scale, the overcrowding of schoolrooms has resulted in the widespread practice of automatic promotion from one grade to another regardless of whether the child is adequately prepared or not. Such situations give rise to cheating and other forms of unethical conduct, which are said to be on the increase. The general impression is that there are too few schools almost everywhere, too many overcrowded, classrooms, with
~;~''''"'i=~~~~:'t~nooa:~: paid ~" ~a~ of w:o~"~~' 'l " have to work outside school hours as well, in order to supplement their income. There is also an increase in the numbers of institutions for higher education in the region; but widespread concern was expressed about the poor standard of education to be found therein. In some countries their aims and purposes have not been clearly defined and certainly not geared to the needs of the country. Also educational institutions in some instances are controlled by private families and by corporations with profit as their main motive, so that nepotism and other forms of abuse are rampant. It is very encouraging, however, to find also some evidence that governments are becoming increasingly aware of needs and are taking steps to establish educational standards and to improve both public and private educational institutions. The importance of relating education to the problems and needs of life in each particular country was recognized and stressed. An outstanding example can be taken from the rapid rural development in Puerto Rico, as described in the execellent study of "Patterns of living of Puerto Rican families". This example shows what rural education can accomplish to improve the life of the people if it is carefully related to the needs of the community and objectively assessed by research.
Urbanization Urbanization and its effect on mental health in Asian countries constituted a major concern of the Seminar. Summarizing this subject, one of the members of the staff stated that it had been clearly expressed in the reports of study groups that many Asian countries are already "over-urbanized" and this trend is rapidly increasing. "Over-urbanization" signifies a state in which the growth of cities is disproportionate to economic development, so that the cities cannot perform one of their original positive functions, which is that of facilitating economic progress. Thus their capacity for setting the pace of national development and relieving rural under-employment will be overstrained. "Over-urbanization" has a further implication in Asia where the structure, organization, pattern of life and standard of living in cities have been mostly copied from those of the
19 West, with the result that the differences of culture between urban and rural life can be enormous. This difference will often even reach the point when the cities are regarded by the country people as alien. According to Burgess 1 modern society has four main characteristics: (a) enormous complexity of its economic and social organizations, (b) increasing mechanization and standardization, (c) increasing secularization of life in parallel with mechanized services and standardized goods and (b) substitution of impersonal human relations for personal ones. The above list will show how remote Asian rural communities are from the modern cities and will demonstrate the difficulties that peasants must have in making their adjustment to city life. These very people, who are making great efforts to adjust themselves or Who have failed to live up to their own expectations or those of others, constitute an increasingly large part of the population of the cities of Asia. It was emphasized in discussion that not only do these 'newoomers' to the cities experience conflicts over cultural differences, but the 'old dwellers' in the cities are also often or constantly exposed to cultural changes or confusion of old values. For it is mainly through the cities that outside influences make their initial impact upon a particular country and all kinds of new and strange ideas, gadgets and habits from abroad are first displayed. Just as the urban-rural economic balance is of vital concern to the economic development of a nation, so is the urban-rural cultural balance vital to its cultural life, so that the latter should equally be a basic consideration for city planning. To build a city too advanced in technology and too remote from traditional culture and standards of life may not only overstrain the resources but also defeat the purposes of the endeavour through the alienation of the city from the rest of the country. While the difference of the urban culture may set the pace and provide incentives for a progressive change in the direction of modernization of the whole, due consideration should be given to conservation of traditional culture and also to making the desired changes more acceptable. To do this will ensure a two-way flow of cultural influences, which is essential for the sound and dynamic growth of the individual as well as of his society. 1 Burgess, E. W. (1955) Mental health in modern 8ociety. A. ed. Mental health and mental disorders, New York, p. 3
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Common problems of aajustment in relation to urbanization in Asia It was found that there are two common ways in which village people are introduced to cities: (a) migration through the influence of friends or relatives to an area where a pattern of village life still prevails, and (b) migration independently as unskilled labourers or domestic workers to live scattered in the city but with a considerable concentration in slum areas.
In the former case, the newcomer will pass through the initial stage of adjustment more easily and with less anxiety or feeling of insecurity, for he does not have to break his old habits abruptly and is able to have a somewhat gradual transition. He will be identified from the start as a member of the group and can enjoy its support, an experience which will be similar to that of the village community life to which he has been used. This seems to be an advantage to the individual. There is, however, a serious disadvantage in many instances, in that the migrants may tend to form an isolated community, neither an integrated and constructive part of the modernized and progressive urban community, nor a part of the original, rural community. Such people will usually remain as a group of unskilled labourers, uprooted from their own village community hut showing little sign of advancing in technology. The under-developed industries of Asian cities will aggravate this situation, because the lack of demand for large numbers of skilled labourers or technicians results in a lack of incentive to strive for advanced skill and knowledge. The second category of migrants faces a more serious situation. Confronted with sudden disruption of old habits and forced to learn new ones quickly and with poor living conditions resulting from lack of skill, the unskilled solitary migrant will find himself in the midst of a vastly complicated modern society with its impersonal atmosphere and to which he does not belong. The feeling of loneliness and incompatibility will often overwhelm him and make him confused, insecure and depressed. Some will emerge from this to a successful adjustment, some will find it too difficult and return at once to their former homes, a third group will stay on for some time, and it is these last who are likely to show increasing signs of mental iII health.
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Changes and problems of family life in relation to urbanization and modernization Family life in modern society is undergoing universally a ma:rked transition from the extended family to the nuclear family unit, from the authoritarian institutional family to the democratic companionship family, and from the economic family unit to the economic independence of each family member. These changes seem to vary only in degree and tempo in different places and different countries. Much can be said both for and against the mental health value of the extended family. It is an important subject for careful objective investigation to assess how a large family, in which the members may experience more security but may also be exposed to a mOre complicated pattern of interpersonal relationship, compares in respect of mental health with a small-sized family. The transition from the authoritarian institutional family to the democratic companionship family, and from the economic family unit to the economic independence of each family member involves a change of values. It appears that the change of values involved plays a highly significant role in causing instability of family life and feelings of insecurity. Traditionai authoritarian institutional family life is characteristically regulated by the concepts of status; respect, and duty, whereas the democratic compansionship farm has its foundation in the giving and receiving of affection and in the happiness to be derived from satisfying interpersonal relationships. Even in those 'advanced' countries in the West in which the transition from the former to the latter has taken place slowly in the past few centuries, signs of mstability of family are present, in terms of broken homes and juvenile delinquency. It was stressed that the democratic companionship form of family life should not necessarily be held responsible for this phenomenon, but that a transition without a clear sense of direction and appropriate new system of values might be responsible for confusion of values and instability. Reports on all sides of the Tapid increase of broken homes and juvenile delinquency in the 'under-developed' countries, if they are true, can be regarded as reflecting this transitional instability of family life and confusion of values. An abrupt rise in the status of women and undue emphasis on the social and economic independence of the younger generation, without proper preparation, may also contTibute to the instability of family life.
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22 Children are most susceptible to the kind of anxiety-producing situations caused by unstable family life, with its lack of models for identification. In addition, the conflicting cultural values and the impersonal human relations that exist in the cities have effects which are aggravated by the harsh and competitive struggle for survival. It is likely that the anxiety generated among children in a culture in which the family patterns are in a state of rapid change from an extended to a more nuclear form will be at its greatest among the children of the first generation. Parents brought up themselves in a different kind of world will not have experience to guide them in the formation of the types of relationships that are best able to contribute the life of the new type of family. Care of the aged appears not to constitute a serious problem for Asian countries at present. The fact that the current transition to a smaller family unit will increase the difficulty of taking care of an expanding elderly population indicates that this will, sooner or later, become an important problem in Eastern countries. Though there have been a few reports that urban societies in Japan and Mexico have somehow managed to solve this problem along traditional lines, it is impossible to say how long this will continue. It is well recognized that elderly people find it very difficult, if not painful, to disrupt their old habits. The social and cultural distance between the older and the younger generations, the mobility of younger people and the increasingly impersonal quality of human relationships in the modern Asian world are apt to create undue anxiety among old people, particularly in places where the old culture is Tapidly being washed away by new tides. The effect of urbanization on mental health
Does urbanization constitute a threat to mental health? This question was regarded as a part of a more generally common question: Is modern civilization responsible for the alleged increase of mental ill health of the world today? Many attempts have been made to clarify this problem by workers in the various human sciences-psychiatrists, sociologists, anthropologists, and social psychologists-for it is a question of paramount importance for the appraisal of the future of mankind. Although the answer remains inconclusive, owing to the extreme difficulty involved in the analysis, understanding and measurement of the intricate relationships of the human psyche to
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the environment, some light has been thrown on the problem by recent researches in social psychiatry. According to the staff member who presented the study topic, there are two schools of thought about this question. First, that 'pTimitive' or 'under-developed' societies have no problem of mental disorder and enjoy better mental health than more complex societies was the view of such workers as E. Faris (Bantu), Carothers (Kenya), recently by Maloney (Okinawa) and Forster (Ghana). Secondly, Kraepelin and others claimed that states of mental health do not differ greatly between various cultures and societies. Several careful studies in recent years, both in "Western" and "Eastern" countries have furthered our knowledge of the relationship between civilization and mental disorder. Goldhamer & Marshall 1 made a careful analysis of mental hospital statistics in Massachusetts in the past 100 years (from 1840 to 1940) and found that the frequency of psychoses one hundred years ago was not less than it is today. This is particularly true for the population up to the age of fifty. The apparent increase of mental patients in Massachusetts, and by inference in other modern societies with comparable facilities as well, has mainly been due to the group of patients over fifty years of age, the increase in size of which is related to the longer expectation of life of modern man. Two possible conclusions can be drawn from this study: (a) the e:tiology of psychoses may be independent of environmental factors, or (b) the social changes in Massachusetts in the last hundred years may have been insufficient to produce an increase of psychoses. Eaton & Weil 2 conducted a survey of Hutterites in the United States to evaluate the mental health of this "16th century peasant culture in the heart of the most 20th century minded continent". The Hutterites at one time used to enjoy the reputation of being a mentality healthy society. The investigation found that Hutterite society was not free from mental disorder, and the overall frequency of psychoses was about the same as in the other populations studied elsewhere. In an intensive investigation of three Chinese communities in Taiwan (Formosa), rural, small town and urban, respec1 Goldhamer, H. & Marshal, A. (1953) Psychose8 and civilization., Glencoe • Eaton, J. W. & Weil, R. J. (1955) Th$ mental /walth of the HutteriteB. In: Rose, A. ed. Mental health and mental disorders, New York p. 223.
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24 tively, Lin 1 found that the overall frequency of psychoses among the Chinese roughly corresponded with that of our communities. Similar findings were obtained by Uchimura and his co-workers in Japan. It would probably be too hasty to conclude from the above evidence that the etiology of psychoses, and mental disorder in general, is independent of the socio-cultural environment and that hereditary, constitutional factors play the key causative role. There is good evidence that certain types of mental disorders are related to certain environmental (socio-cultural) factors and this evidence deserved careful attention if the effect of urbanization on mental health is to be understood. Hollingshead & Redlich" were able to show that in an area of the United States of America a significant correlation existed between the type of mental disorder and social class. In their study the neuroses were concentrated at the higher levels of the class stratification and the psychoses, schizophrenia in particular, at the lower levels. In Lin's study of the Chinese population in Taiwan (Formosa), the lowest of the three defined classes in the population showed the highest rate of mental disorder, in general; schizophrenia, other psychoses, senile psychoses, psychopathic personality and mental deficiency, in particular. The highest class ranked second but with the highest rate of manic-depressive psychoses and psycho neuroses. The middle-class popUlation showed the lowest rate in all items. These findings seem to agree with the studies just cited and strongly suggest that social stress has an important role in the etiology of schizophrenia and psychoses generally. In their studies in Chicago, Faris and Dunham also observed higher rates of mental diSQ'rder among immigrants or minority groups. Oedegaard in Norway, and Malzberg in the United States reported similar findings. Alarming reports have been circulated both in medical and in non-medical circles about the magnitude of the problem of neuroses in modern society. Though precise quantitative studies are still lacking, there is good evidence that the rate of neuroses rises in parallel with the extent and tempo of industrialization 'Lin, T. (1953) A study of the incidence of mental disorders in Chinese and other culture, Psycil iatry, 16, 313. 'Hollingshead, A. B. & Redlich, F. C. (1953) Social stratification and psychiatric disorders, Amer, soc. Rev. 18, 163.
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25 and urbanization. According to available reports, the same is true of psychosomatic disorders, juvenile delinquency and mental disorders other than psychoses. In concluding this report in plenary session, the staff member quoted a statement by L. K. Frank: 1 "Our so-called social problems are to be viewed as arising from the frantic efforts of individuals, lacking any sure direction and sanctions or guiding conception of life, to find some way of protecting themselves or merely existing on any terms they can manage in a society being remade by technology. Having no strong loyalties and no consistent values or realizable ideals to cherish, the individual's conduct is naturally conflicting, confused, neurotic and antisocial Today we must face the task of reconstructing our culture and creating our own design for living, in which the age-old cruelties, frustration, and deprivations may, we must hope, be mitigated, if not eliminated. For the task we have need of more understanding of personality and culture and, above all, of faith in the value of human life which the new culture must serve." This statement was originally addressed to the American people in the 1930s. How far it is true of the people of Asia today was clear to everyone at the session.
The development of the Seminar During the course of discussions on the socio-cultural changes in Asia and their effect on family life and mental health, which continued through two plenary sessions and five periods (9 hours) of group discussions, the following observations on the development of. the Seminar were made: (1) A freer and more informal atmosphere continued to grow in all the discussion groups and this helped further to reduce initial anxieties about the methods used in the Seminar. (2) Discussion of sociocultural in Asia enabled participants to recognize through their active participation the common denominator that existed among them, in terms of their sociocultural background and their social and community psychological problems. One participant said, "I was struck by the similarity of our problems". This feeling of common experience contributed to the atmosphere of learning in the groups and to the sharing of experiences. 1
Frank, L. K. (1936) Society as the patient, A mer. J. Sociol. 42, 335.
26 (3) The enormously complicated picture of social changes and their implications that was built up disturbed the concept of mental health that many of the participants had brought with them, and led to considerable confusion in the minds of some. A large majority, however, became more aware of the wide scope of the mental health field and appreciated more the need for interdisciplinary team work. One participant remarked, "Everything seems to have mental health implications, but what can you do?" Another participant said, "If I had not been here (Baguio), I would not have come to an appreciation of the profession of home economics and of community extension workers as colleagues working toward the same end (mental health)". (4) "Changes" constituted the central theme of most of the discussions and concerns of the Seminar. Desires for a more dynamic concept of mental health were clearly felt and frequently expressed, such as "It will be noted that all these factors (causative factors of mental ill health) concern changes, and the problem would appear to be that of how to 'build-in' a sound adaptative mechanism into the child".
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CHAPTER V CONCEPT OF MENTAL HEALm
During the first few days the Seminar opened up new vistas, for most of the members, of the possible scope of the concept of mental health. A general demand grew for more clarification of the dynamic concept of mental health, and to meet this the Director prepared a paper to serve as a point of departure for further discussion. The following quotations illustrate the more important points of his paper:
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Mental keaUk concepts in a changing wo".ld "The crucial issue in regard to mental health and family life allover the world is now, it seems, that of change: widespread social change that, in Asia, is most strikingly revealed in the splitting of the extended family into nuclear families but which, in other parts of the world, no less, is throwing stress up on family life. "One might suspect that intolerance of change, with its nostalgia for a past age of security and innocence, is as old as humanity itself. Certainly this is a recurrent theme in the 'Golden Age' myths of many cultures. Dreams of the lost paradise, as exemplified by the story of the Garden of Eden in Hebrew mythology, or of the Hellenic Golden Age at the time of the opening of Pandora's box, are almost universal. They seem to represent something quite fundamental in human dreaming, something that suggestively resembles nostalgia for the universal experience of life in the mother's womb; just as the legends of the loss of this paradise suggestively resemble those universal implacable forces that drive the human young from a state of dependency into the worldly life of moral responsibility. "But one need not go back to the Ancients in order to find evidence of anxiety about change. Literature, and especially poetry, in many languages has constantly been preoccupied with change. An example of this can be taken from the works of the English poet Matthew Arnold who, in the years 1853 and 1861, respectively, wrote two poems-'The Scholar Gypsy' and Thyrsis', both of which are largely concerned with change. In the earlier poem the following remarkable lines occur: 'Before this strange disease of modern life, With its sick hurry, its divided aims Its heads o'er taxed, its palsied hearts, was rife--' To the mid-twentieth century reader this nineteenth century outburst reads strangely. What can Matthew Arnold have known about the 'sick hurry' of modem life? It appears still more strange when it is realized that the poet was referring to a story of a poor scholar who left the University of Oxford 200 years earlier, in 1661, because he, the scholar, 27
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28 felt unable to cope with seventeenth century life. He went to live with the gypsies, so Matthew Arnold tells us, in order to find peace. "The poet revealed the core of his anxiety in an emotional passage of complaint about the vagueness of belief, shallowness of feeling, halfheartedness of will, weakness of resolve, hesitations, and lack of success that, he felt characterized the 'modern' life of 1853. Such anxieties are typical of a sense of loss of basic security in old values, and of loss of perception of the purpose of life; feelings that may arise, almost inevitably, when, after a childhood spent in a family environment where a single way of life is accepted and unquestioned, the individual passes on to a life of change, of fl'agmentation of family relationships, without having had 'built in', as it were, a capacity to adapt harmoniously to change, "The outstanding preoccupation of the seminar, and of people in the mental health field all over the world, is with the phenomena of change. It follows that our concept of mental health will need to be dynamic, relative, and capable of being changed, too, No entirely satisfactory definition of mental health has yet been made, but a number of descriptions have been attempted. One of the best of the earlier attempts can be found in 'Mental Health and World Citizenship', the published report of the International Preparatory Commission cf the International Congress on Mental Health, London 1948. This description included, among other points: (i) Mental health is a condition which permits the optimal development-physical, intellectual and emotional-Of the individual, so far as this is compatible with that of other individuals. (ii) A good society is one that allows this development to its members while at the same time ensuring its own development and being tolerant towards other societies. (iii) World citizenship implies good society on a world scale. Eric Fromm, in The Fear of Freedom., introduced the idea of the satisfaction of tendencies, including those of growth and the realization of all the individual's potentialities, and of doing this in common with others. H. C. Riinke has added the dimension of a value system that transcends the individual. In the course of an extended description of mental health, and with Western Europe in mind, in a paper written for the International Health Bulletin of the League of Red Cross Societies 19.50, the present speaker included a wider generalization which took up the idea of harmonious adaptation, that appears in the Constitution of the World Health Organization. He wrote on the capacity to live harmoniously in a changing environment as an essential ingredient of mental health; and, among other points, drew the analogy that the healthy mind like the healthy body can meet without signs of strain all normal environmental situations. "The difficulty in defining mental health, hitherto insUl'mountable, has been that descriptions of mental health necessarily include behaviour which, as a study of different cultural patterns will show, will largely be determined by the cultural setting. When we consider the concept of mental health as it applies to Asia, we haye to take cultural diversity
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29 as ane of the fixed conditions of our study and, obviously, We shall not get much further if we turn our attention first to what is diverse. Instead, we must consider the great common denominators and need to study their different manifestations in different cultures. As we have seen, one great common denominator is that of change and, more specifically, the change from an extended family pattern into a more nuclear type of family organization . "The furtherance of mental health involves bringing change to people; it involves securing the alteration of living customs and ways of life in order to move towards an ideal concept of mental health. Therefore, it is very relevant to our work to inquire whether a climate of change can be created, both in the individual and in the community. By a climate of change we mean an atmosphere in which change is not only accepted and tolerated but actively welcomed and is satisfaction giving. "When we consider how a climate of change may be created in the individual we must open our minds to the possibility that different types of family relationship may engender different kinds of reaction to changing circumstances. But whatever the family structure, the spectrum of change during childhood is enormous. It ranges frdm the egocentric dependency of a tiny baby to the adaptation and differentiation achieved by the mature adult. "It is noteworthy that, in general, those societies that have pioneered change over generations have been characterized by a nuclear type of family organization, whether from the start or by development into a nuclear family society early in the process of change; whereas those societies that have not gune into major change spontaneously or have, at first, resisted change conling from without have usually been characterized by an extended family organization. We have seen, in discussion, how an extended family organization cannot survive extensive popUlation movements and, particularly, the type of social change that accompanies rapid industrialization. This is partly an automatic result of the separation of young workers from their ancestral families; and partly due to the fact that a newly industrializing district is a young person's habitat in which there is little place for the aging. It is interesting that in late eighteenth century England, where the industrial revolution appeared first, the family structure had, for some generations been what ~ight be described as rather loosely extended. In many parts of the country it included elements verging towards a more nuclear type of structure. It is possible that a major contribution to the beginning of the industrial revolution in England was that the comparative looseness of the family structure enabled young people to move and transplant. This situation was of course different fl'Om that which often occurred later, in which whole populations of extended families tended to migrate more or less en bloc."
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The attitude of children trom different family paUerns to changing circufn.8tances
"To discuss the question of change in the standard nuclear family situation, first, where mother, father and child form a closely knit unit: the adoption of change by a tiny baby will depend largely upon the skill
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of parental handling. For example, the skilful mother will enable the child to transfer the satisfaction which he has previously gained from sucking at the breast to new attainments, such as feeding himself and keeping himself clean. In doing so the child will build up a warm and secure relationship with the mother, in which mutual appreciation and respect will qualify the instinctual bonds between them. To such a child the greatest pleasures in life will come from the acceptance and performance of neW things introduced by the parents; and as the child matures the world will become for him a place of pleasurable change. His satisfaction in change will be on a warm affective basis, his attitude of positive acceptance towards new things wiJI be, for him, the source of considerable stimulation and fulfilment. As this child begins to identify himself and to identify the surrounding environment, he will go on to incorporate within himself what he can appreciate of the parental value system. While the infant win get satisfaction out of doing new things for mother's sake, the todler will develop a 'built-in' satisfaction in doing things for the sake of doing new things. This will be a truly positive attitude to change, and the fortunate child who develops this will be able to pass through childhood embracing the neW life of each succeeding developmental stage unhampered by relics of old attitudes, and in a frame of mind in marked contrast to the conflict that will beset the child who finds it hard to accept new things. "In the typical nuclear family, conditions are such that relationships between children and their parents are likely to be intense in quality; mere proximity and the exclusiveness of the relationship will do much to bring this about. Of course, we must recognize that this does not happen in every case, that many parents are cool and distant. In the nuclear family parental coolness will be disastrous when, as most often happens, there is no alternative adult available with whom the child can develop a loving relationship. However, coolness is the exception rather than the rule, and the potential intensity of inter-personal relationships within the nuclear family constitutes at the same time its main strength and its main danger. The dangers inherent in the nuclear family system have been rather freely discussed in the seminar. In addition to the plight of the child whose sole mother figure is cold, there is that of the child with an ambivalent or even hostile parent. We have discussed at length the hazards to the child whose parents canalize al\ their anxiety into his future. and pin their hopes and fears on him alone. This picture of the nuclear family, which has concentrated on the disadvantages, needs to be balanced by more recognition of the strength that may be derived from the creation in the child of an attitude of positive enjoyment of change. "In comparison with the foregoing, in a typical extended family the child may be brought up in intimate contact with perhaps half a dozen adults in the family circle and many siblings and collaterals. Thus the child will usually have the opportunity of forming emotional rela~ tionships with a larger number of adults than the child in a nuclear family, who may have only his mother. Since each one of these adults in the extended family cannot have an exclusive relationship with the child, it is a fair inference that. in an extended family, although cir-
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31 cllmstances wiII favour the formation of a greater number of inter-personal relationships, they wiII possibly be of a less emotionally intense character than where the mother-child relationship is more mutually exclusive. This inference is very far from a generalization that all mother-child relationships in nuclear families are intense, and all mother-child relationships in extended families are cool. Provided that the mother is in close contact with her child, there is nothing in the extended family to prevent the development of intense emotional relationships between mother and child. However, the standard conditions of life in an extended family do not necessarily promote this close contact, unlike the situation in a typical nuclear family. In addition, it should be recognized that there are a number of cultural habita and religious attitudes associated with certain examples of extended family systems that may influence the quality of relationship formation within families. For example, the question may be asked: if, in a given culture, a high value is set on non-attachment, might not this discourage intensity of relationship formation in the family? This is an important question that would well repay more careful study. "If we examine more closely the position of the child in a typical extended family, we shall see that he is likely to undergo his early experience of change during infancy at the hands of perhaps half a dozen people. This must necessarily make each experience of change a little less specific for the child than if he was in the care of one adult. Different people vary slightly in the way they will perform intimate services for the child, and not only will the child's experiences be less well-defined and less repetitive, but also the effect built up by successive experiences will tend to be distributed among the people with whom he shares them. The child's pleasure in change will be less specific in character if his experience comes from the common denominator of the behaviour of half a dozen people. Therefore, his experience will be rather more institutionalized, as it were, and his pleasure is likely to be comparatively leBS intense. Furthermore, it is a legitimate inference that in those cases where a child's satisfaction in changing derives from the common denominator of several people's behaviour, the family will show some tendency to maintain the structure of its organization and the forms of its customary behaviour. Where several people are involved, the relationships formed can scarcely have the subtlety and special character of interpersonal relationships formed between only two or, at the most, three individuals. "The foregoing is a frankly theoretical construction on an abstract generalization made from the concept of typical nuclear and extended families, respectively; a speculation that needs a great deal more work before it can be admitted into the canon of knowledge. It would be of the utmost significance to mental health work if it could be established that a child brought up in one kind of family would tend to derive his major emotional satisfactions from the intensity of individual relationships and from the embracing of change for its own Bake; while a child brought up in a different kind of family would tend to derive his major satisfactions from his relationship to the small community of the family and from response to what has been called the 'common denominator'
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32 or institutional form, of home behaviour. In the former case the child would get satisfaction in novelty aDd change and, in the latter would get satisfaction in collective relationships and the maintenance of known forms. Neither of these satisfactions is likely to be absolute or exclusive. Many individuals in both kinds of family will have had personal experience of emotional relationships which may make them belong, in spirit at least, to the other camp. Still more individuals will have had an intermediate type of experience that will blur the differences between the two; but even a superficial glance at the differences between the 'West' and the 'East' will show that these distinctions have some manifestations in broad social phenomena, also."
Socia-cultural rigidity and mental health "Mental health people need to consider the question of how to induce change in a community and to study how the lessons to be learned from the observation of individual changing can be applied to a community. The broad diffel'ences manifested might indicate that behaviour considered to be mentally healthy in one culture might be very different from that considered mentally healthy in another. Nowhere is this more striking than in the differing emphases or trends that can be seen among the great religions of the world, For example, one trend is to emphasize the personal adaptation of the individual to external circumstances, while an opposing trend is to emphasize the conquest or control of circumstances, though no individual can be free from the necessity to adapt what he cannot control. Among the great Eastern religions, as far as I am aware, external circumstances tend to be accepted as they are and the control of the environment is not regarded as of the highest value. There is, perhaps, more concern with the harmonization of the individual's own inner life and, pari passu, adapting to the external environment. In Buddhism, for example, human desire is not only to be controlled but often eliminated, and Buddhist ethical values emphasize taking a 'right view' of circumstances. Taoism emphasizes withdrawal from competition, the negation of personal effort, the glorification of 'non-being', Confucianism emphasizes collective organization and the maintenance of rigidly prescribed systems of family and other social relationship. Hinduism, in some ways, has carried rigid social organization further still, but within the strongly defined form of the Hindu caste system there is a fluidity that is contributed by belief in reincarnation, which tends to diminish the significance of current 'reality'. "At the other pole, the ancient Hebrews emphasized conquest or control of circumstances, an aggressive attitude towards the environment. This attitude has been largely adopted in Christianity, in which there is a general agreement that earthly life is a period of trial or of perfecting, during which Man has an unique opportunity to fit himself for the eternal or heavenly life. This attitude lays upon the individual the moral responsibility both of improving external circumstances and of not adapting to circumstances considered to be imperfect. Islam is on the side of its fellow 'revealed' religions in its attitude towards conquest or control of circumstances, in its teaching that life is a progression through this world towards a more complete understanding of the nature of Godtowards illumination.
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33 "The above illustrations of differing attitudes found among major religions will indicate the possibility of enormous variation in the conceptualization of mental health. But our concern here is to consider the element of change which can affect all these system indifferently. It might be justifiable to generalize that a society which has an aggressive attitude towards circumstances might be forward in the induction of change spontaneously, but, perhaps, resistant to change originating in an outside or alien source. On the other hand, societies in which the harmonization of the individual's internal drives and instincts are more highly valued than the control of outside circumstances are likely to show less spontaneous development of change and to show resistance through inertia to such changes as do arise. However, when external change impinges on such a society to a degree sufficient to break through the society's inertia, patterns will tend to disintegrate and break down without the spontaneous evolution of new forms. This potentially dangerous development has been seen more than once, wben such societies have been overtaken by externally induced change. "Adverting to our more specific task, which is the induction of change in the community in the interests of mental healtb, we may find that a society will react towards such change in the same way as to other forms of change. Let us take a hypothetical example of a society with a very rigid, unchangmg social and family structure, hypothetical because no such society exists in strict fact, but many societies have shown sufficient rigidity for the example to have some relevance. In our hypothetical society a highly formalized life will be handed down through the generations as each new generation identifies with its predecessors. Prescribed forms of behaviour will regulate even the most intimate details of family life. It will be possible to achieve social harmony and adjustment there only by conformity. When the individual is out of step with the group, the society will have prescribed forms for dealing with this situation, whether by exclusion or by reformation and rehabilitation. Individuality will not be highly valued by such a society. "From the point of· view of the practical mental health worker a ,ociety that is rigid in this way is exceedingly unpropitious, because the changes which he. advocates will be received by the society like any other change. In other words, it may be argued from theory, as above, that acceptance of change can only be brought about at the expense of some breakdown of existing patterns. The prescribed forms of behaviour of a strictly rigid society will regulate what changes are permissible, and the people will hardly conceptualize any aspiration other than conformity with the group's way of life. The more that a given society approximates to this rigid form, the greater the difficulties that are going to be encountered by a practical mental health worker."
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Some practical ccmsiderations in the introduction of mental health w01'k to a community "However, nowadays changes are taking place in nearly every society under the sun, and opportunities for practical mental health work wiIl be correspondingly more widespread and more favourable. There are a number of guiding points to be considered here, too. We need to ask 006896--3
34 ourselves, for example, what can be used as guides so that the rate of adaptation to which the society will be exposed in embracing change in the interests of mental health will not outstrip the capacity of its members for adaptation to change? Then, again, how much do we need to know before we can attempt to bring about mental health change in a community? Do we need to know all the facts? At what stage can we begin to get active? "We can learn here from the history of public health. In 1854 there was an outbreak of cholera in London, limited to the parish of Bloomsbury and grouped around a certain community well from which all but the wealthy drew their water supply. A certain local medical practitioner, Dr. John Snow, persuaded the parish council to remove the handle from the parish pump, and this simple measure was enough to control the outbreak of cholera. However, this instance of public health action, two generations before the cholera vibrio was isolated, was not quite as simple as it looks. Dr. Snow was not merely guessing, for he had been studying the epidemiology of cholera for a number of years, and through empirical observation had developed his hypothesis that cholera is carried by the contamination of drinking water by human feces. Dr. Snow applied his scientific mind and his limited scientific knowledge to the careful consideration of the facts elicited by observation, but he needed more than this in order to persuade the parish council to take action. In fact, he nsed his personal prestige as a well-respected local practitioner. His recommendation was accepted on the basis of his personal relationships and the trust that he had inspired, and not on what he could demonstrate. Fortunately for all parties his method worked. "This important historical event needs to be taken to heart by people working in the field of mental health. First, we need to have very much more, careful, well regulated observation of what is going on around us; and secondly, knowledge is not even half the battle, for the mental health worker must occupy a position of trust and enjoy a good reputation in his own community before he is likely to meet with much success. His relationship with the community needs to be very good before people will come to trust his recommendations which, like that of Dr. Snow, must often appear strange to those in authority. "It will be advantageous to apply some of the principles of the introduction of change to the individual to the promotion of mental health changes in the community in a state of evolution. First, it is important that the impulse to change should arise spontaneously from within the community. Change that is identifiable with an alien origin tends to attract the emotional reaction appropriate to the alien origin rather than to itself. Change should not be forced upon people more quickly than they can adapt to it; their speed of adaptation is itself dependent upon factor~ in the cultural pattern and the history of the community; and too rapId change tends to result in social disorganization. We have discussed certain reasons why a more rigid type of culture may prove
resistant to change. Adaptability to change may itself be an important index to mental health in the case of an evolving society, but does not have the same significance in a more rigid society.
35 "The concept of mental health which is widely held in the community will be closely related to ideals of behaviour, to the concept of the 'good man' in the community and to the value system. It is essential for the success of any project to improve the mental health of a community that the important values of that community should be first identified and then fostered. "Generally speaking, a community will allow and encourage change which obviously will lead in the direction of the community ideal; and conversely, change leading away from the ideal will engender anxiety. Examples of this latter can be found in the effect on other countries of showing films depicting changing patterns of adolescent behaviour in the United States of America. Such films which demonstrate patterns of behaviour which are foreign to the ideals of the country in which they are shown, almost always cause anxiety about adolescent behaviour in that country, anxiety which may be totally irrelevant to the reality situation. "
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In his conclusion, the speaker re-emphasized that the great need for mental health work all over the world is for flexibility and adaptability, and not merely for an artificially induced average or normality. Our object is to see how things in this field are interrelated; that family patterns are interdependent with individual attitudes; that the prevailing religion in a society both derives from and contributes to family patterns, and that both religion and family patterns tend to maintain each other; that successful living requires of the individual both adaptation to circumstances and some degree of rigidity. We are not here to advocate or promote one particular form of life or family organization at the expense of another. We want to create a human society that will satisfy human aspirations and not merely the immediate needs of the ordinary man or woman. Our society must be active in the extension, stimulation and promotion of higher human aspirations, but always in a way that can be fulfilled within the life of the society. Our object is not less than to extend the range of potentialities of mankind.
",_'-K_'
CHAPTER
VI
RESEARCH ON MENTAL HEALTH AND FAMILY LIFE
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The great majority (over 95 per cent.) of the Seminar participants were "action people" in the field, mainly concerned with translating the "theories" and "principles" of mental health into practice. The interim evaluation at the end of the first week showed clearly that many had come to the Seminar with the expectation that they would be able to take back home "something definite to show to our Government" or "a blue print by which the family life and mental health of Asian countries can be designed and expanded". Requests for "concrete recommendations to our Government for implementing mental health services" and "exchanges of constitutions and operating methods for National Mental Health Associations in order that the mental health movement can be initiated", were brought forward by participants from a number of countries. This kind of expectations was soon replaced by the development of a growing awareness of the limitations of the present knowledge of mental health, of the scarcity of studies and objective data about people and society and other basic prerequisites for mental health work. The anxieties and sense of confusion caused by this growing awareness were augmented in the case of some members by the realization that commonly advocated "theories" and "principles" were perhaps rather limited in their value for application in Asia. In the case of a large number of the participants, however, these experiences led to sound and constructive rethinking about their own work at home and also their expectations from the Seminar. A senior institutional psychiatrist remarked, "At this conference I admit that I have been bitten by the mental health bug and I am now looking around to find ways and means of tackling this important problem". Another participant said, "Ever since I have been attending the Seminar, I have been getting ideas concerning research practically every hour, from staff members and fellow participants, and have been made aware of the many limitations of workers in my field of education". The shift in emphasis towards the need for research in Asian countries brought about through the Seminar experiences pro36
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37 duced a suitable atmosphere for the discussion of possible research work. The programme far this topic was differently structured from those of the first week. First, the session reported in Chapter V on the concept of mental health had been planned to help conceptualize as well as to stimulate critical thinking on the basic problem. Secondly. there was a plenary session at which a role play of a community problem of juvenile delinquency was watched by a panel of social scientists who then discussed the implication of the role play. The formation which had been needed by the role playing group served as an illustration of how research can be applied to the solution of a mental health problem of a community. A film on "Dance and Trance in Bali" 1 was shown to illustrate the value of anthropological observation and research to the understanding of human behaviour. This was followed by a presentation of a research project as an illustration of how mental health programmes for a country can be based on objective data obtained through surveys of carefully chosen sample populations. This presentation also served to encourage the research-minded members of the seminar by showing that reliable and valuable data can be obtained even with limited trained personnel and financial means if the project be designed and planned carefully and carried out by qualified people with determination. Two permanent study group periods and one period of discussion in special interest groups devoted respectively to the consideration of clinical child psychology, education and community programmes, psychiatry and social work further sharpened and amplified the thinking of participants and staff alike.
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Asia as a field for human science research It was generally felt that opportunities for human science research in Asian countries are exceedingly rich but the accomplishment so far has been embarrassingly minimal. Opportunities are rich because:
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(1) Asia has such diversity of cultures. Even in one country one can find a great cultural variety at different levels of civilization. 1 Mead M. & Bateson G. Dance and trance in Bali, American Museum of Natural History. New York.
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(2) There are also a few places and countries, like Thailand, that are compact and homogeneous, which provide an excellent field for research for that reason. (3) There are a great number of areas in which the density of population is suitable for field research, enabling a large sample of -rural population to be studied within a small area. (4) Socio-cultural changes are taking place so rapidly in Asia that an excellent setting is presented for serial stUdies, within a short span of time, of the relationship of human behaviour with changing social environmental factors. (5) The fact that most Asian countries in some respects are newly developing countries may be an advantage, for there will be better chances for properly obtained results of research and surveys to be put into practice during the process of community development. One participant's view which was shared by many other delegates was that the attitude towaTds research was not favourable in her country. A number of reasons were thought to be responsible for this lack of interest in research, particularly in the field of mental health. (1) Governments are so occupied with the day-to-day struggle for socio-economic survival that they aTe searching for remedies by routine measures rather than looking for what can be brought out only by research. (2) Physical health problems, such as the control of infectious diseases and malnutl'ition, still constitute the major problem in most Asian countries and naturally take priority. (3) In the case of research in the human sciences, which includes the field of mental health, the situation is worse, because such research is time-consuming and not likely to produce visible spectacular results like some natural science research. (4) Research in the mental health field requires multidisciplinaTY personnel and team work for which a certain degree of development of the related human sciences is a prerequisite. In the majority of Asian countries, however, these sciences are relatively undeveloped, and personnel are very few, if any.
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39 (5) The few available mental health pesonnel are already greatly overworked in trying to meet the overwhelming demand for clinical, as well as educational work, and thus have little time for research. Against this general background, the seminar discussions on research covered such topics as: objectives of research, types of research, research techniques, training of research personnel, assessment and use of existing resources for research, the uses of foreign research personnel, suggested programmes of research, national and international cO-Qrdination in the sharing of Tesearch activities and data, and research attitudes. The need for practical research
It was emphasized that practical or action research was needed more in Asia today than more theoretical and academic forms. Several participants and members of the staff stressed the need for collecting objective data about family life practices, mental health problems and educational situations, so that planning could be based on the factual assessment of the type and magnitude of the problems. Another practical research area suggested was that of the continuous objective evaluation of work projects in order to improve the planning of subsequent action. One should not, of course, lose sight of the theoretical aspect of mental health problems while the actual practical research is being carried out. The advantages of smalL scale res'earch projects
Emphasis was repeatedly placed upon "starting in a small way" when undertaking research. The common conception, or rather misconception, about research, that it should be done on a large scale (national or international) by highly organized teams of experts was discussed several times by different people in the Seminar. Under present conditions in Asia, small scale research plans should receive priority, and offer the following advantages: (a) The relatively low cost of a small scale research project will make it more easily support8lble locally, which will be of a high intrinsic value in this field of work. (b) The few available personnel can be more easily brought to undertake small scale research projects.
40 (c) Limited plans provide opportunities for action research in which the ground work for future large scale research programmes can also be simultaneously carried out. (d) After a successful outcome and with a more adequate number of research personnel available, governmental and non-governmental support for subsequent large scale research plans may be more easily sought. Co-o-rdination of national and international research projects As for more complicated or large scale research, the major responsibility should be borne by research institutes in the universities or research centres of international agencies, such as UNESCO. It was stressed that in planning these research activities the local situations should be seriously taken into account, in order to avoid duplication of work, conflict with local programmes, disruption of local projects through depriving them of their staff, or complete isolation from local research circles. There were reports from a number of countries about a lack of co-ordination in this regard; e.g. in one country, an international research institute for child development which had been in operation for years was not known until quite recently to a key professional person in the same city, whose subsequent request to visit the institute was refused on the grounds that the final computation of the data was not yet available to the public. Sharing of information and data Several members advocated the establishment of a clea'ring house of information and research data in the field of mental health and family life and allied social sciences. Even within one country, information and data on research in different disciplines or in different centres were usually not known about, let alone those of other countries. Before the establishment of such a clearing house or Social Science Institute, which seems to be rather a remote possibility, the members of the Seminar strongly felt the need for more individual effort to keep closer contact and communication in this regard. FO'reign 1·esearch personnel Questions were raised about the contribution of foreign "experts" to research in this field. Several disadvantages were brought out which deserve careful consideration and remedy.
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41 ( a) It is often difficult to distinguish between research undertaken by experienced personnel with the full co-operation of the community concerned and that of foreign postgraduate students engaged in collecting material for a thesis er seme other persenal reason. The preblem here is that of identifying which is the "expert" and of finding what use can be made ef the results. (b) In the case of research undertaken by genuinf' experts, often there is no route by which findings can be communicated to the peeple most concerned. (c) Findings and conclusions are occasionally based on hasty or one-sided ebservations without proper understanding ef the people, language and culture. (d) The frames of reference er research designs used for these studies are, mere eften than not, derived or cepied frem some prototype of research done in the West, without proper validation for its new use; possibly a mere serious factor than the ethers mentioned abeve. Ce-O'rdinated and integrated research werk by both national and international (foreign) workers, made possible by the timely use of experts with appropriate qualificatiens, was regarded by the Seminar as essential fer future research in the field of mental health in Asia.
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Interdisdplinary team research The need for interdisciplinary team research in mental health was recognized and stressed in the Seminar. Over-emphasis upon and a superficial attitude to' team research were also adversely commented en. A staff member said: "In eur enthusiasm fer team research we might make a fetish of it". Two' suggestions about interdisciplinary research were made fer consideration: (a) Do not build up a research team on the basis of representation of disciplines in the hope that it will automatically form a team; (b) Continual ever-emphasis en a particular discipline, e.g. by saying, "speaking as a psychologist . . ." will tend to reduce the effectiveness of the team. A participant put this point very beautifully in her repert, "If we could meet on level terms of expressing what each discipline can dO' and if we forget eur particular discipline, thinking only in terms of the end results-the welfare of the people--then, the result weuld be that of working towards mental health and geed family life". This, ef ceurse, applies
42 not only to research, but also to other kinds of interdisciplinary team approach in the field.
Research personnel The Seminar was clearly aware that the most serious weakness in research potential, particularly in the field of human science, is the shortage of available trained research personnel in every country of the region. Since facility with language, understanding of the culture and sufficient time are prerequisites for human science research it was emphatically expressed in the Seminar that the best and, logically, the only recruits for this work will be those who can be obtained from local resources. To find the "right" young people and give them sufficient training in basic principles and techniques of research, both at home and abroad, should be the first and most urgent task. By "right" people are meant people with a sense of dedication, with a talent for enquiring, creative thinking and with imagination and vision. Rare though they may be, they can be found and people of this sort should be the core of research teams. It was also emphasized that every effort should be made to protect people with these talents and to provide them with the necessary facilities and security for their work. Suggested topics for future research Several topics were brought out in the course of deliberations, as being probably most urgent problems for future research: (1) Surveys of communities in order to assess the needs objectively, and to enable an action programme geared to the needs to be set up. (2) The developmental pattern of children in different Asian countries. (3) The effect UpOl. the child's personality development of prolonged physical contact between child and mother. (4) The relationship between child rearing practices (such as exposure of children to the responsibility for making choices between alternatives) and the incidence of anxiety and emotional disturbances in adult life. (5) Ways in which tensions are manifested by children in Asia, and their difference in these respects from the West. (6) The question whether eldest sons are more vulnerable to stresses than their siblings; and the differences in different cultures.
43
(7) The effects on children of sex preferences and discriminations in family life. The above topics are some of the many formulations of the concern which was felt by the Seminar for the objective assessment of the mental health values of extended and nuclear families, respectively. A staff member commented: "We may not be research people by profession and inclination, but we can make contributions in the research field by finding people with research talent, by building them up, and by providing them with sufficient means for living. We can also contribute to research by the collection of objective, unbiased material in our daily work. Furthermore, we have the responsibility of translating the findings, data and conclusions of research properly into practice, for the good of people in our community. If we can do these three tasks well, we have done our job well as members of the research team." The whole period of discussion of this topic on research seemed to be a climax of the Seminar. Members of the Seminar all felt that the responsibility of solving the immense problem is their own and that it can be done by starting in a small way, and by looking forward constructively to a long-range programme.
•
CHAPTER
VII
THE SURVEY AS A BASIS FOR MENTAL HEALTH PLANNING
As stated in the preceding chapter, the presentation of an actual research project 1 was made to the Seminar, as an illustration of the value of a careful survey in the planning of mental health programmes in a developing country.
Objectives This study was done in Taiwan from 1946 to 1948 at a time when modern psychiatry was being introduced to the country, which had minimal mental health facilities and few trained personnel. The objectives were: (a) to assess the mental health and ill-health situation in the community in order to establish a basis for a mental health programme; (b) to collect objective data on mental disorder and the socio-cultural (ecological) factors in the community in order to gain an understanding of their relationship; (c) to provide reliable data comparable with that from other cultures, in order to make a comparative psychiatric investigation. Methods A census investigation was made of the 19-931 inhabitants of three communities chosen as sample populations-a rural area, a small town, and a section of a large city, respectively. The reasons for the use of such a laborious method were as follows: (a) Hospital statistics which have often been used in studies of the prevalence of mental disorder have not been considered reliable even in countries with adequate mental hospital facilities, let alone in Taiwan where at that time there was only one mental hospital with 150 beds serving the seven million population. 1 Lin, T. (1953) A study of the incidence of mental disorder in Chinese and other Cultures, Psychi",try, 16, 313.
44
45 (b) Even if hospital facilities had been sufficient, a large proportion of the cases of mental disorder would have remained living in the community because among Chinese families the threshold of tolerance of deviant behaviour is rather high. (c) The census method provides an opportunity to gather demographic and ecological data at the same time as data on mental disorders. (d) The population of Taiwan has been static, on the whole, for the last half century, people are well acquianted with all the members of their family and their neighbours, and this fact would greatly facilitate the field study. As described in detail in the original paper, the survey of each area consisted of three stages: (1) consulting the official census register, examining reports of town officials, elders, teachers, and physicians in the community; (2) inquiring of members of the family and neighbours about the reported cases of psychiatric disorder; and (3) a personal interview with every inhabitant of the area conducted by a member of the research team and confirmation of the diagnosis by the team leader on each suspected case of phychiatric disorder. At the same time, demographic data were gathered for the population surveyed. Major findings relating to ecological factors
A total of 214 cases were diagnosed as mental illness after psychiatric examination. (1) There was little significant difference among the three population areas in the rates found of all cases of mental disorder or of all cases of psychoses. A slightly higher rate of schizophrenic reaction was seen in the small town and in the city area. The rates of mental deficiency and senile psychosis were slightly higher among the rural population, while psychotic personality and psychoneurosis were higher among city population (Table 1). (2) A striking difference in the prevalence of certain types of mental disorder was noticed between the central and peripheral parts of each population area. In the central parts, a higher concentration of schizophrenic reaction and neuroses was found, while in the peripheral parts epilepsy and mental deficiency were prevalent. Manic depressive psychosis was evenly distributed (Table 2).
46 TABLE
I.-Mental D'worders Grouped According to Type Baksa (Rural area) Simpo (Small town) Ampeng (City)
Total
Total num-
berof casea S('hizophren1c reaction. ________
Rate per 1,000 1." 0,7 0 O,g
Total num-
--- --- --- --- --- --- --17 G
her of cascs
Rate pe, 1,000 2,5 0.7 0 0 0,7 1.5 3,2 0,7 O,S
Total num~
bel' of
cases
Rate pe, 1,000
Total numbel' of
cases
pe, 1,000
Rate
10 4 0 5 3 9 23 3 4
16 4
2,1 0,5 0 0,1 O,S O,g 3,0
43 13 0 6 14 26
2,1 0,7 0 0,3 0,7 1.3 3"
Manic depressive psychosis. ____ General par8Sis. ______________
0 0 5 10 22 5 6 0
0 1
Senile psychoses ______________ Other psychoses _______________ Epilepsy ______ • ______________
0,5 1.6 4,1 0,5 0,7
6 7 23
Mental deCid.ency _____________
68 18 24 2
Psychopathic personality _______ Psychoneuroses _______________ Alcoholism ______ • _______ • ____
10
1.3 1." 0,1
0,9 1.2 0,1
14 1
1 0,2 ----,--TotaL _________________ 11. 1 62
I
------------70 10.3 82 10.9 214 10,8
0
TABLE
2.-Spatial Distribution of Mental Diso·rders Within Areas Baksa Simpo Ampeng
Total p,
---------\--- - - - Schizophrenic reaction ________ _ Manic depressive psychosis ____ _ General paresis _______________ _ Senile psychoses • ____________ _ Othpr psyehoaes•• ____________ _ Epilepsy ____________________ _ 6
c,-
P.**
C.
_P_._ _ c_,_l_p_.___c_,_
11
6
12
4
29 6
14 7
2
2
3
2
3
o 2
o 2
o
o 9 19 3
o o 4
o
o
o 2
o 4
o 2
10 6 4
o 4 2
7
22 51 11
Mental deficien<'y ____________ _ Psychopathic personality ______ _ Psychoneuroses. _____________ _ Alcoholism __________________ _ fotaL. _______________ _ TotalpopUlatlOD ________
17 2
8 2
15
17 7
8 6
4
o o o 31 3,213
17 2
7
o 39 3.587
o 35 3,056
o 126 11,739
22 1,923 11.5
40 3,662
47 4,490
88 8,192
Rate ofment81 disorder per I, 000 popuIat~on ~ _
10,9
9,6
10,9
11.1
10,5
10,7
10,8
• Indicates (!pntral part of the area. •• Indicates peripheral part of the area.
(3) Females had higher rates of schizophrenic reaction, manic depressive psychoses and neUToses, while males were predominant in psychopathic personality and mental deficiency.
47 (4) The rate of mental disorders per 100 population showed a higher prevalence of mental disorders in the middle age groups, a lower prevalence in the older groups and the lowest prevalence in the youngest groups (Table 3) . TABLE
•
3.-Age Distribution of Mental Disorders 0.-9 10-19 20-29 30-39 40-49 50-59 60-69 70-up
- - - - - - - - - --- - Schizophrenic reaction ____ • _____ Manic depressi ve psychosis ______ General paresilL. __ . ____________ Senile psychoses. _______________ Other psychoses. _______________ Epilepsy ___________ • ____ - _____ 0 0 0 0 0 4 0
--- --- --4 1
Total
6 3 0 0 2 6 12 7 7
14 3 0 0
7
8
0 0
43 13 0
3 0 0 4 2 4 3
3 0 0 4 2 8 3
0 0 0 8
0 5 2 0 3 1 0
0 1 0 0 0 1 0
6 14 26
2 3
5 2 0
Mental deficiency ____________ ._ Psychopathic personality ____ • ___ Psychoneuroses. _____________ Alcoholism. ___
31 1
8 2 7
68 18 24
0
0
6
4
0 0 0 0 2 0 0 0 2 - - - - - --- --- - - - - 45 - - 42 -39 31 16 7 32 2 214 - - - - - - - - - - - - - - - - --- --Total population _________ 6,045 4 •.647 2,953 2,288 1,768 1,117 773 340 19.931 ---- --- ----Rate of mental disorder
-- -- --- - - -- - ---
Total ___ --- ---.-------
per 1,000 population. ___
1.1
9.7
14.2
17.1
17.5
28.5
20.7
5.9
10.8
TABLE
4.-Education and Mental Disorders p,<,Publirschool Sehool l
Schizophrenic reaction _________ Manie depressive psychosis _____ General paresis. _______ -----Senile psychosis ____ .~ v ______
--- --- --- --- --- --- --8 5 0
Junior High I
Senior College ll IIlit- Others! Hight eracy 3
'I'otal
0 0 0 0
3
1
28 4
0 1 0 0
43 13
2 0 0 2 0 0
1 0
0 0
0
0 6
__
2 4 15 25 5
0 0 0
0 0 0 0 0 0 0
4 8 8 42 9 9 1
Other psychose8 __________ .• ___ Epilepsy ______ . __________ - ___ Mental deficiency ______ . . ______ Psychopathic personality _______ Psychoneuroses • __________ • __ Alcoholism ___________ -
0 2 1 0 0 0
0 1 0 3 0
14 26 68 18
0 0
1 2 0
11 1
2 0
24
• 1
------------------113 3 76 10 6 1 214 5 - - - - --- --- --- --- ------Total population ________ 4,674 7,162 231 522 55 6,819 468 19,931 --- --- --- --- --- --- ---Total _______ • _________ ~
- - ----
0
2
Rate of mental disorder per 1(>00 population ~ __
0.6
10.6
19.1
26.0
18.2
16.6
10.7
10.8
These categories include both undersrraduatel aDd ,graduatel. In this categories are people who did not receive formal education but had training in old Chinese literature. ~
- '. -·I,'.
~,.
"::- .. ~.:., \,\,
_~"',r'~~\''''11:1~4~~i!l'i#W¥''II \
-
"/'"
48 (5) Mental deficiency, epilepsy, psychopathic personality, senile psychoses were more highly concentrated among illiterates and people of elementary education, while schizophrenic reaction, manic depressive psychosis and psychoneurosis showed a fairly even distribution (Table 4). (6) The percentage of all mental disorders among merchants, farmers and labourers was about the average for the total population. Relatively higher rates were found among professional groups and the unemployed; and a low rate among the salaried workers. The distribution of schizophrenic reaction, senile psychosis, epilepsy, mental deficiency and alcoholics showed a high concentration among merchants, farmers, labourers and the unemployed; whereas manic depressive psychosis, psychopathic personality and psychoneurosis showed a random distribution in all occupations (Table 5). TABLE
5.-Occupation and Mental Di80rders Liberal Salaried prpfes- workers ~nons elags 0 Merchants Farmers Labo~
Unem-
------- -- -Schizophrenic reaction ________ _ Manic depressive psychOBi8 ____ _ General paresis ______________ _ Senile psychoses • ____________ _ Other psychoses ______________ _ Epilep,3y ____________________ _ Mental deficiency _______ ~ ____ _ Paychopathic personality _____ ~ _ Psychoneuroses _________ ~ __ ~ __ Aleoholi8m~
rers
ployed
Others
Total
14 5
13 3 0 4
10 2 0 0 0 4
0 0 0
43 13 0
•
0 0 0
0 0
0
0 0 0 0 0 0
6 14
3 6
4 7
2 4
7
26 68 18
0
5 2
81 3 7
19 9
12
2 0 0
2 Q Q
8 2
24 2
TotaL ____________ ~____
-------------41 72 62 26 1 214 --------- - - 86 --Totalpopula.tion________ 156 1,138 3,912 7,512 5.813 1,314 19,931 -~----
_____ ~_______ _____
0
0
5
7
Rate of mental disorder perl,OOOpopuJation __
-~- - 32.0 6.1
---1----------- ---1-10.5 9.6 10.7 19.7 11.6 10.8
• This category includes fishermen in Ampeng.
(7) A relatively high prevalence of all mental disorders was noted in the lowest class of three main social groupings. The different types of mental disorder had a varied pattern of distribution. The highest class had a comparatively high rate of paranoid schizophrenia, manic depressive psychosis and psychoneuroses. The middle class
, .. '
49
.... •
showed a fairly even distribution of almost every type of mental disorder. The lowest class had a very high rate of schizophrenic reaction, senile psychosis, mental deficiency, and psychopathic personality (Table 6) . TABLE
6.-Socio-Economic Stutus and Mental Disorders ()pppr (':8_;_"'
i
:hl(lU~" (:'ass TO(a! nurnRate per 1 000 '
I
L~,.\, r C_"1 T,?tal n ... m-
Tui.&:
Total' Rat(' numper ber of 1 000 cases •
I
ita:f' ~.wr
-- -- -- -- -- -- -3.;>
ber of ('ases
ber of J 000 cases'
I Tvla, I num-
Rate
bc~r of
lJer . 000 C:l!,ws'
Schizophrenic- reaction _________ Manic depreseive psychosis ____ General paresis _______________ Senne psychoees ______________ Other psychoses ______________ Epilepsy _____________________ Mental deficiency _____________ Psychopathic personality ______ Psychoneuroses _______________ Alcoholism ___________________
6
16 8 0 2 7 14 35 9 12 0
, .2 0.6 0 0.1 0.5 1.0 2.6 0.7 0.9 0
21 3
4 .. )
4' 1:\
2.1
2 0
1.1 0 0 0.6
0.6
0.7
0 4 6 8 31 7 7
0 0.9 1.3 1.7
0 6 14 26 68 18
0 0.3 0.7 1.3 3.4 0.9 1.2 0.1 -.(
0
4 2 2 6
2.3 1.1 1.1 2.9 0
6.6 1.5 1.5 0.4
24 2
-----------12.7 103 7.6 89 18.9 214 22 ------ ---10.8 Total population ________ 1,727 4,703 19,931 13,501 TotaL _________________
0
2
----
•
Comparative studies in variOtl8 C'Ultures of the prevalence of mental disorders
.
Following the survey which has been summarized above, an extensive review was made of mental disorder in other cultures. It was found that the comparison of the figures reported was misleading and often meaningless. It became apparent that primary consideration should be given to such matters as the method of selection of the sample population, the method and intensity of investigation, the method of computation of data, and the criteria of diagnosis (classification) of mental disorder that were employed, before it was possible to derive either general or specific ideas about the prevalence of mental disorder in a particular culture (Table 7). This table presents information and data regarding the nature of surveys made in various countries with the rates found therein of mental disorders and Table 8 gives the rates of each type of mental disorder. Even a superficial examination of these two tables will reveal that there was a wide range in the pre-
TABLE
7.-Summary of Psychiatric Data in Various Countries -
Mental Disorder!!
Psychoses Totul nllmhC'i or eURPS
Investigator
Date of inveRtigation
Type of area
Intensity of investigation ...
Population studied
Total number of easa€
Rat.~
Rate pf'T
per 1000
1000
China Formosa (F) ___________ - __ Lin Germany_ ThUringia rT) ___________ Brugger Bavaria (Ba) ____________ Brugger Denmark Bornholm (Bo) __________ Stromgren Sweden A:bo (A) ________________ Sjoegren Norway West Coast Village (WC) __ Bremer Finland S.F.B. (SFB) ___________ Kaila United States of America Baltimore (B) ___________ Lemkau Tennessee (Te) __________ Roth Japan Hachijo Island (H) _______ Uchimurd Komoro (~) _______ . ____ I Akimoto Tokyo (To) _____________ Tsugawa
1946-48 1929 1930-31 1935 1944 1944 1936 1936 1938 1940 1941 1941
Rural Small town Urban Rural Rural Rural Rural Rural Rural Urban Urban Rural Rural Small town Urban
III II III II (II!)"
19,931 37,561 8,628 45,930 8,736 1,325 418,472 55,129
214 479 517 716 397 259 3,026 3,337 1,721 65 138 82
10.8 12.8 59.9 15.6 45.4 195.5 7.2 60.5 69.4 6.8 26.5 30.8
76 143 48 409 84 19 2,510 171 156 52 44 25
3.8 3.8 5.6 10.9 9.8 14.3 6.0 6.7 6.3 6.2 8.5 9.2 --
II
o
c:n
III II
1 II II III III
24,804 8,330 5,207 2,712
• The investigations have been divided into three ChUOSCf' of intensitv: I. The method of investigation consists of perusal of written records from institutions and agencies. II. The method consistlJ of perusal of written recorw, r~ports from the people, and psychiatric interviews of the metal cases. UI. This method, the most intensive, consists of I and II, plw. census investigation of the whole population . •• In this study, one of tb.~ villages waa investigated inten~ively by home visits.
,.
•
~
•
•
•
,J'
TABLE
S.-Rate of Each Type of Mental DiIlord",," per 1,000 Population * .-----
---
Area investigated
F
T
Schizophrenic reaction ____________________ Manic depressive psychosis _________________ General paresis ___________________________ Senile psychoses" ________________________ Other psychoses'" _______________________ Epilepsy ________________________________ . Mental deficiency _____________ . __ . _____ . _' Psychopathic person.ality _______ . _. _______ . Psychoneuroses __________________________ . Alcoholism ____________________ . _______ ... - .
- - ---- - - - - - - -- - - - - - A
Ba
Bo
we
SFB
B
T.
H
K
To
2.1 0.7 0 0.3 0.7 1.3 3.4 0.5 1.2 0.1
1.9 0.5 0.2 0.5 0.7 0.7 5.4 0.7 1.3 0.4
2.5 1.4 0 0.6 1.0 1.0 34.2 2.8 0.8 2.5 ...
3.3 2.7 0.1 0.2 4.6 1.0 4.2 ?
1.5 0.2 ---
4.6 2.9 0 0.6 1.7 0.2 5.7 2.4 0.5 0.2
4.5 1.5 0 2.3 6.0 0.9 45.3 76.2 45.3 ?
4.2 0.3 ? ?
1.7 1.0 4.4 ? ? ?
2.9 0.7 0.5 0.7 1.9 1.4 6.8 4.5 3.1 ? -
1.7 1.7 0.2 1.0 2.0 ?
8.2 24.2 4.0 ? -
3.8 1.0 0.4 0.2 0.8 0.6 0.6 0.4 ? ?
2.1 2.5 0.2 2.3 1.0 2.5 10.0 2.5 2.5 0.6 - -
2.2 0.7 0.7 0.4 5.2 2.6 9.6 8.5 ?
0.4 ._0.
_ - - - _ . _ - _ .- - - - - _
• Only active cw!cs were included in the Baltimore (B) atudy. All other studies included both active and inactive cases. •• Senile dementia and arteriosclerotic psych08ee are included in this category. *** In this category. all psychotic cases are included except schizophrenic reaction, manic depressive psychosis, general paresis and senile ps.'Ychooea. TABLE --
....
9.-Corrected Incidence (AcC<Jrding to Weinberg's Method) of Major Psychoses and Epilepsy * ---
Arpa investigated
F
T
B.
Bo
A
we
SFB --
H
K
To
Schizophrenic reaction _____________ . Manic depressive psychosis _________ Gener..l paresis ____________________ Senile psychoSB!' ••_________________ Epilepsy __________________________ .--
5.9 2.3 0 10.7 2.1
3.8 1.1 0.5 9.3 0.8
4.8 2.8 0 10.9 1.4
6.3 6.4 0.3 2.8 1.5
8.3 6.0 0 3.4 0.3
10.0 3.8 0 25.2 0.9 ----
9.1 ? ? ? ?
9.1 2.8 1.3 2.2 1.0
5.0 8.7 0.7 6.3 4.0
4.9 2.3 3.3 14.7 3.5 ---
mentia and
• The author was unable to obtain the corresponding data from the American autbors--Lemkau'& studY in Baltimore and Roth's study in Tennessee. ** These figurea were calculated by the present author from the Original data when the corre.iponding figures were not given. Senile de.. arterio8cl~rotio PSychOfoes
are inclluded in this category.
J
F ••
, I
.... ~
... ,
52 valence of all mental disorders, whereas the psychosis rates fell within a narrow range (Table 8). The most likely explanation of this difference is that at the present stage of development of psychiatry, the diagnosis of non-psychotic mental disorder is still not uniform and subject to personal variations among the investigators, as well as to cultural influences, in terms of the attitude of the community towards mental illness. The rates of non-psychotic mental disorder may be less of an indication of the actual number of cases of mental illness in the community than of a reflection of the scope, intensity, and criteria of diagnosis used in the investigation. Though a similar consideration will still apply to the case of psychotic mental disorder, the diagnostic criteria used and the attitude of the community are relatively uniform. Therefore, data in the case of the latter can be compared more meaningfully (Table 9). It may be said from the studies of the three communities of the Taiwan inquiry that the incidence of major psychoses and of epilepsy there did not differ appreciably from those of other countries. As for non-psychotic mental disorder, the incidence of psychopathic personality, obsessive compulsive neurosis and alcoholism are fairly low in Taiwan. However, a more satisfactory comparative evaluation still awaits further cross-cultural studies.
What this survey contributed to the development of mental health programmes in Taiwan (1) The community mental health programme (a) The quantitative and objective presentation of data regarding the large number of cases of mental disorder in the community, a number that is comparable with that of other societies, make it possible to correct the misconception, perhaps due to false pride, that Chinese society is free from mental iIIness because of its philosophy and "glorious" culture. (b) It provided convincing evidence of the needs for mental health planning in order to alleviate the existing conditions, because the majority (over 95 per cent.) of the cases were untreated. (c) This survey provided an excellent opportunity for studying the attitude of the community towards deviant behaviour and it confirmed the pre-survey impression that Chinese society in general has a high threshold of tolerance
.,
,.",;:;, .
~
. ,
53 to deviant behaviour. This observation has led to a basic and important query about the wisdom of developing a mental health programme which follows the path of building mental hospitals as can be seen in "advanced" countries. The proper use of the existing resources in the community, such as the strength of extended family relationships as expressed in the responsibility assumed by the family for the welfare of each member and in tolerance of deviant behaviour, should be the central theme in the formulation of mental health programmes. (d) The establishment of intensive treatment centres in general hospitals, with all facilities and with well-trained personnel should be given the highest priority of the entire programme. These centres should also serve as teaching centres for medical, public health nursing, social work and psychological personnel and students. (2) Programmes for psychiatric education wnd training The whole programme of psychiatric education and training of specialists was developed around the above philosophy. Efforts have been concentrated on the integration of psychiatry and mental health into the basic undergraduate medical and nursing teaching, so that doctors and nurses will be able to understand and utilize psychiatric principles in their everyday activities, both in government service and private practice. The teaching of medical students is being undertaken in the outpatient clinic and by means of intensive case studies and conferences. Emphasis is laid on the "common" psychiatric problems such as neuroses, psychosomatic diseases, major psychotic disorders, and character behaviour disorder that ordinary medical practitioners are likely to encounter in their daily practice. The training of well-qualified specialists is of primary importance in the total mental healh programme. Along with the training in a sound orientation to and skill in psychodynamic methods, special consideration is given in the four-year training programme of psychiatrists to the development of insight into the social background of the patients and of skill in finding and utilizing community resources for the treatment and rehabilitation of patients . (3) Research programmes The wealth of material collected in the course of the survey about socio-environmental factors in relation to mental health
• '.
1 r
I
J
..
t, ..•",;..,
.
54 has focused the research interest of the mental health team on sodal psychiatry, as follows:
(a) Comparative psychiatric studies of four mountain tribes at different levels of acculturation Four tribes among the original Malayo-Polynesian inhabitants of Taiwan, representing respectively the most primitive, the most acculturated, and two intermediate tribes, were studied between 1949 and 1953. The research technique used was similar to that used for comparative purposes with the three Chinese communities. (The data of this study have been collected and analysed and will shortly be published.) It is hoped that the carefully validated data of this kind of survey will shed light on the question that is both of major theoretical interest and practical importance, whether acculturation processes produce strains and stresses that result in the increase of mental ill health. (b) Because clinical impressions indicate that proportionately more eldest sons than other silblings are being seen in clinics and that they seem to have some common clinical and personality features, a study of the personality development of Chinese eldest sons is in progress. The kind of privileges enjoyed by eldest sons in Chinese families seems to have some untoward effects on them in terms of engendering over-dependency and passivity. This inquiry may lead to greater understanding of which part of the family structure in a given society is most vulnerable to certain stresses. This is a problem of paramount importance in the study of family life. (c) Follow-up surveys of the same three communities of the Taiwan project are being planned to start in 1961, i.e. 15 years after the original work, in which the prevalence of mental disorder in relation to social change will be studied. This sort of longitudinal study should yield valuable data for the understanding of the environmental factors affecting mental health.
CHAPTER
VIII
PLANNING FOR ACTION
•
The development of the Seminar, the accumulation of knowledge, the clearer definition of ideas, the sharpning of thoughts and the growing eagerness of members for the constructive use of learning experiences, was brought to something of a climax by the last topic on "Applications". Bearing in mind the participants' diversity of disciplines, a hypothetical problem situation was constructed to stimulate thought and discussion about the need to plan and organize in order to resolve problems created by social change. Approximately two study group periods were used, followed by a plenary reporting session for summarizing the discussion of the problem situation, after which a member of the staff discussed the principles involved in planning for action. (1) The hypothetical problem situa,tion related to cultural
change "A government sponsored textile factory, employing a thousand workers from outside the community is introduced into a small Asian town of 20,000 people. This is part of a government scheme to bring workers and their families from congested urban areas into rural areas. In this case 5,000 people including workers and their families are brought to the town. "This Asian town has a population of 20,000 people and lies in a farming area, in which there are also cottage industries (weaving and basket making). The town is 60 miles from the nearest large city. There is a bus once a day to and from the city. The roads, which are unpaved, are cleaned by local labour. There is limited electricity, avail. able only at night. Water is obtained from artesian wells. There is no sewerage system. "On the twice-weekly market days, kitchen utensils, ready-made clothes, shoes, and cloth may be obtained in the town in addition to food. There are small shops, including smali cafes selling soft drinks, a few patent medicines, and coffins. There is no inn, and no place for the sale of alcohol, no bank, no telegraph office. There is a movie house which plays three times a week. The use of radio is limited by the electric supply. "In addition to a number of one-room elementary schools, with only one teacher, there is only one primary school. Another primary school and a small orphanage are operated by a foreign missionary society. 55
1',*,. h\,~,\ m:;.e· ~yP3;" ·-:;W}4'.4,;;t!>~?ii'i,}C 'If¥' ~:
j
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56 "The health services are limited to one district health officer, one general clinic, one district nurse, two sanitarians and a hospital of 25 beds. There is no operating theatre. There are three private doctors and 10 nurses in the town. Infant vaccination is routine, but there is no ether immunization available except in case of epidemics. Animals of all kinds may be kept in the town. "There is a mayor and a municipal council and the following services are located in the municipal building: police chief and 26 policemen; a registry of births, marriages and deaths; a real estate office; an electoral list; a post office; an old-fashioned fire department with a fire chief and two paid firemen; a small one-room jail, and a department of public works that deals with roads and bridges. "There is a women's club. "Harmless mental defectives are permitted to wander about the streets. It is not customary to lock houses. There are 10 wealthy families of the landlord class, who maintain homes in the nearby city. There are five "bad women". There are a number of money-lenders who, like the shopkeepers, are foreigners. All the other inhabitants belong to the region and speak the same dialect. "The one meeting place is in the primary school and it will not accommodate more than 300 people."
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The four permanent study groups were each given one of the following questions to discuss: If it is known a year in advance that the factory is to be built, what steps could be taken to prepare for the arrival of the 5,000 people? If the factory has just been built and the 5,000 new people are arriving, what steps can be taken to deal with the situation? If the factory was built five years ago with the migration of 5,000 new people and nothing has been done to deal with the resulting conditions, what can be done? If the factory will be built 10 years from now, as part of a large national plan announced years in advance, what steps can be taken? Each study group was expected to answer the following question in relation to the topic it was given: What plans could be made, and by whom, to meet the situation, in terms of local organization, requests for outside help, training and personnel, and co-ordination of effort? The reports of each group revealed that their approach had been quite comprehensive and pertinent. In making plans to meet the pressing needs of a migrating popUlation, in terms of
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,, 57 housing, health measures, food, education of children, price control, communication, social problems; in the mobilization of community resources; in the long-term planning for community development, all the members of the study groUPS seemed to have pooled their professional skills and what they learned in the Seminar. This was a very outstanding feature; i.e. each member of the Seminar appeared to have forgotten his (or her) own national identity and professional discipline. One member of the staff pointed out that an important common oversight in the groups' thinking had been that little was said as to how to develop local incentive in such communities, to do something about the conditions--how to stimulate responsible local people to become aware of problems caused by change. In other words, how to find out what are the sources of incentive and how these can be mobilized actively in tackling such problems. The above point is probably a facet of a problem of basic importance in all projects of the type under discussion. This is the attitude of an established community to the implantation of a relatively large minority. Such problems of attitude will be especially acute when the implantation is imposed from without and not primarily designed for the benefit of the host community. The effects of the problem are likely to be seen in irrational resistances and other social disturbances. Another important aspect mentioned by a staff member, which deserves attention, was the question of community organization, making use of existing neighbourhood organizations. This important tradition of Asian social structure should be made more use of, as the basis of mobilization for meeting new situations and for community development. By way of a corrective, it was felt that the kind of approach and action-planning of members of the Seminar to meet the problem situations of the hypothetical town had been "very Western", as termed by a member of the staff. The Western training which most of the members of the Seminar had received was thought to have had a great deal to do with this. Also the fact that most of the Seminar members themselves came from cities might have been a significant factor. The very fact that these problem situations were hypothetical and necessarily incomplete might have stripped something of the feeling of reality from the discussions of the groups and caused some dissociation from the actuality of the situations depicted.
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58 (2) Some necessary considerations for planning and implement-
ing activities and programmes Planning for mental health programmes in different countries or communities should vary according to the needs and sociocultural background of the people. However, there are some basic principles and necessary steps for planning and the implementation of programmes that are common to all cultures. (u) Assesb"ing the situation in order to detennine problems and needs A clear understanding of the kind and extent of needs and problem of a community is a prerequisite for effective planning and designing of a programme. The collection of information about what has been done before and what the people of the community want done in a given instance should precede any practical consideration as to what needs to be done from a professional, or technical point of view. In other words, high priority should be given to relating the past experiences and the progress made by the people concerned as well as their specific desires in these matters to what professional and technical workers are interested in achieving. While for success a programme needs to g1'O\\T out of the capacities and interests of the professional workers, it is equally important that whatever is done should be an integral part of the life of the people themselves.
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(b) UnderstuncZin.q the community and its resou'rce8 First-hand knowledge and appreciation of the people for whom the programme is being planned is of primary importance. The way of life of the people, their goals, values, aspirations, beliefs, customs, traditions with respect not only to the specific problem concerned but also in terms of their total life needs and expectations, should be carefully considered and built into the programme so that the latter can be accepted by the people and community without the feeling that it is being imposed from without. Frequently local workers with long years of experience may assume that they have an adequate knowledge of the people, but upon close examination they will realize that, on the whole, they have little systematic understanding. It was stressed that the skills of social scientists, inadequate as they may be, should be called upon to help in this important aspect of the
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work. This does not imply that only-fully-trained social scientists are able to provide a systematic understanding of people in a community. Other people who are properly oriented to and willing to make a sociological approach can acquire sufficient knowledge and understanding of the people through observation, contacts, conversation, working and living with the people to enable them to carry out successful programmes and bring about desirable changes. It was recognized that though this may be a slow and long process, it is a sure, worthwhile and meaningful approach. Another point of importance in the practical planning of an action programme is to have an understanding of the social structure, particularly the power structure of the community. The enlistment and co-operation of the right leadership and the effective use of adequate ch:;lllnels of communication and propagation of ideas are essential for success. The importance of identifying the real leaders of the community and of involving them in planning and action cannot be emphasized too much. A detailed assessment of· community resources in terms of financial support for the programme, personnel at all levels and in all related areas of activity and agencies, should be carried out. Attention should be given to a rather neglected area in this connexion; i.e. to discover the liabilities as well as the assets among the community resources, such as identifying the most resistant groups of people, in terms of profession, social class, or age, etc. To do this may greatly facilitate planning and action, the avoidance of unnecessary resistance or enable a more specific educational programme to be built into the general programme. The attitude of workers toward the people, to value systems, traditions and beliefs, customs and practices is as important as their technical competency. Without due respect for the people and their culture, without an attitude of acceptance on the part of the workers, the whole programme is unlikely to yield the hoped-for results.
(c) The setting of goals and the establishment of priorities The choice of goals by professional people must be tempered with an understanding of what is acceptable to the people concerned, and whatever goals are adopted should be clearly and concretely defined with the full comprehension of the people.
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60 Goals are best divided into immediate and long range. It seems desirable to select some that can be achieved with relative ease and speed, so that the group or groups working together can experience a feeling of success and satisfaction before tackling more difficult problems. To do this will also be useful in providing opportunities for training the necessary personnel and for the development of skills for the assumption of larger and more difficult tasks later. On many occasions the Seminar was reminded of the importance of starting programmes, both of research and of action, in a small way.
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(d) Continuous evaluation, restatement of goals, assessment Of results and research. If programmes and projects are to be sound they should be subjected to continuous reassessment and readjustment. It is best first to plan, then work a while, appraise a while, replan, work again, appraise again; thus repeating the cycle over and over. Evaluation should be built into every programme as early as possible, to encourage the systematic accumulation and assessment of facts and opinions which can be used in further planning and in making decisions about every phase of a programme. To gain the maximum benefits from continuous evaluation during the development and operation of a programme, it is essential during planning to ensure that: (i) the objectives of the programme are clearly defined; (ii) the criteria for success and failure are decided upon; (iii) evaluation procedures are selected and developed; (iv) a base-line from which to measl1re progress is estabtiveness. (v) work methods are chosen and pre-tested for their effectiveness. (3) Learnilng and action The value of Western training for practical work in the field of mental health and family life was a matter of considerable concern to a large number of the participants. Remarks like "We were indoctrinated in Western centres" or "The things I learned in the States were not applicable because of the cultural differences" were frequently made during the Seminar. A plenary session was used for consideration of this subject: a staff member interviewed a participant who had been abroad both for undergraduate and graduate stUdies, which served as
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the point of departure for buzz group discUBBions. important points emerged:
Several
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(a) A person should have an adequate understanding of his own culture before going abroad for training. ( b) "Personal readiness", in terms of emotional and intellectual maturity, is a prerequisite of primary importance. (c) A clear understanding of the objectives and purposes of study will make the experience more valuable and meaningful. (d) Too high expectations on the part of the sponsoring organization or community can create too much pressure on candidates, and frequently result in feelings of inadequacy during the study or after return. Over-expectations may also lead to a hasty and inappropriate, blind application of the knowledge and techniques gained abroad. (e) Upon their return it is advisable to give the Westerntrained people enough time for reorientation, readjustment, reflection and experimentation before they take up responsible positions or actual work. However, it must not be forgotten that a mature person can learn through action under almost any circumstances.
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Education in Asia Following this session, a member of the staff discussed the problem of education in Asia in its historical perspective and in relation to the principles of learning. The following are excerpts of the discussion. For centuries, there has been a gulf between privileged scholars and non-privileged illiterates in most Asian countries. As a result the idea has developed that education automatically leads to status, prestige and economic gains. At an early stage of contact with the West this gulf between literates and illiterates became more marked and the gap increased, because the economic advancement of the former group was accelerated by trade with the West and by mass production. With the introduction of universal education, to which nationalistic ideology and movements have greatly contributed, the mass of people have eargerly seized the opportunity for education mainly, and understandably, to advance their own personal and financial status.
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62 Despite the positive gains, evidence was produced in the Seminar of serious adverse effects also, which have resulted from universal education in Asia (see Chapter IV). The main reasons for adverse effects appear to be: (i) The countries undergoing rapid change have not been able to produce a sufficient number of qualified teachers and adequate facilities for a rapidly increasing population in a short period, because of extremely limited financial resources. (ii) The socio-economic conditions are such that the educated people are unable to secure jobs that bring them privilege and status, which was their primary objective in seeking education. The results are that anxieties, frustration and confusion are generally to be observed in relation to education both among people who have been or are unable to get into schools and among school graduates. The lack of integrated objectives, guiding principles and clear sense of direction is probably the main defect of contemporary education in Asia. In the Seminar it was regarded as essential that the attitude to and concept of education should change, that it should not be sought merely to improve status and to achieve financial gain. It is equally important that time should be allowed for the steady and gradual development of educational facilities, the training of teachers, and most of aU for the integration of principles of education, that are adapted to the needs, culture and development of the particular Asian country. The success of education and training depends on the combination of four factors: proper motivation, the clarification of goals, suitability of the learning situation, and the recognition of the personality and capacity of students. In any educational activity none of these factors should be lost sight of. The motivation to get education should come mainly from within the individual student rather than from outside. Motivation can best be aroused in students (people) by someone who has an intimate knowledge of and feeling for them. The way in which the motivation is aroused is as important as, or even more important than, the actual stimulus itself. For a clear understanding of goals it should be borne in mind that goals are multiple and complex and there will always be
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a dynamic interaction between the goals of different stages of a learning situation. Because of this there wiII be freedom, choice, individuality and growth in the learning process. A learning situation is both historical and dynamic; it has a past, a present, and a future, and its components wiII be physiological, social and geophysical. The recognition of the dynamic complexity of the learning situation (field) should enable a teacher humbly to realize more the need to understand the history of personality development, of the culture and of the complicated interpersonal relationship of home, anxiety and aspirations which each student will bring with him into the classroom or into any place of learning. To impose an artificial set of conditions on learning, to enforce very severe regulations and attempt regimentation, to evaluate the student's achievements only through marks gained in examination, and to treat students as if they were no more than numbers, and so on, wiII do injustice both to the individuals and the society. The proper assessment of the individual's capacity to learn is important for finding the basis as well as the goals of education. The current methods of psychological measurement stilI lack precision and at present can serve only as a rough estimate of the capacity, but they can also be used as the point of departure for further efforts in the refining of methods. It was stressed that learning can be a very slow process depending on the readiness of the individual to learn; and the effect of learning, as seen in changes in concept and action, may also become apparent very slowly. Since the most effective learning is that which takes place through experience-an active rather than a passive process-the experiences which the present working Seminar has undoubtedly afforded its members have provided a suitable atmosphere and much opportunity for learning effectively. As a result, our concept of mental health wiII change, sooner or later, and this wm in turn affect our action. ( 4) Mental health and social action
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One session was given to the consideration of the formation of health associations, both national and international. A detailed history of the development of the Philippine Mental Health Association, which has the largest membership (25,000) of any mental health association in Asia and which was also one of the sponsoring organizations of the Seminar, was presented
by a member of the staff. (It was reported that there were only five countries in Asia in which there was a national mental health association but that several other countries were contemplating the establishment of one.) The foIlowing points are taken from the presentation. "The Association was organized in 1950 by a group of 67 interested people. Its formation was prompted by the need to improve the National Mental Hospital, to solve increasing educational problems after the war .and the problems of juvenile delinquency, eta. "In establishing program priorities for the Association which was faced with many problems such as limited funds and trained personnel, it was quickly decided that the Association should be first identified with men and women of status in the community . . . "In order to avoid the stigma attached to the tenn 'mental health', which in the public's mind connoted insanity and mental hospitals, the Association identified itself with educators and social workers rather than with psychiatrists and psychologists. Through this means it was hoped to create an attitude in the public mind that mental health is everybody's business. "The President of the Republic proclaimed an annual 'Mental Health Week' and appointed a mental health technical assistant to the office of the President. Government financial support was sought through the Senate or House Committee, particularly by working with the wives of members. Use was made of current social problems to arouse the interest of legislators and of the public through mass communication methods and public meetings. Particular efforts were made to arouse public opinion and to put pressure on the Government to institute a refonn of the National Mental Hospital, and also to create a Division of Mental Health in the Department of Health. A WHO consultant has been helping to ameliorate the conditions of the mental hospital and has accomplished much in a 'Short period. Various voluntary organizations have also started contributing money and services to the patients of the hospital. "Mental health education of the public has constituted the main bulk of the work of the Association and this has been promoted by public speeches, radio, drama, newspaper articles, seminars for in-service training, particularly for teachers on counselling, and by recent establishment of a demonstration child guidance centre. This mushrooming of activities has been paralleled by the increase of membership from 67 to 25,000 in eight years."
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The Speaker went on to evaluate the development of the Philippine Mental Health Association, and this was followed by comments and constructive suggestions by various Semjnar members. The following main points emerged: (a) The identification of the Association with people of high status may be a valuable aid in the establishment
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65 of an association, but this should not be done at the expense of the identification with the mental health movement of the people who have the technical knOWledge. (b) The above point leads on to the question of the wisdom of a mental health association, identifying itself but little with or even shying away from, the clinical side, particularly during the early stage of its 'development. Failure to involve psychiatrists and psychologists actively,the very people who are generally regarded as key professional personnel in the mental health field, might well lead to their feeling left out and to a lack of their support which, in the long run, could seriously handicap the sound development of a mental health association. It was also felt that an apparent neglect of the professional group was not entirely justified by the reason given, "to avoid the stigma of insanity being connected with the Mental Health Association". As was pointed out, it is impossible to avoid this stigma in any society, and to attempt to avoid it conflicts with the stated objectives of the Mental Health Association. The balanced and co-ordinated participation of "clinical" and "lay" groups should form the basis of the work. ( c) The speaker expressed her fear of over-development of the Association. This problem was put in another way by another member of the staff in the question: "Do you have enough trained people to meet the demands which you have created through the mental health campaign?". It was suggested that the present state of knowledge and skills in. the mental health field does not warrant the employment of the kind of mass education methods used by public health in certain fields. It was felt that the steps to be taken in mental health work must be very sure, especially in the early stages of development, in order that understanding, skill and enthusiasm may be properly propagated; and that this can be done only by adequately trained people. (d) One member of the staff raised another important issue regarding the whole scheme of activities of the said Association on the grounds that it was too urban-oriented and "Western". In addition, consideration should be given to the special needs of rural communities and the working classes. \ 00689&---5
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66 (e) Earlier in the Seminar a staff member had cited experiences in other parts of the world regarding the establishment of voluntary agencies. He pointed out that it was usually not difficult to stimulate the formation of such organizations using modern mass media of communication, campaign methods and similar techniques. Experience has shown, however, that where and when these programmes and activities did _not develop from the felt needs of the people and were not planned by the people concerned, such organizations were often short-lived and might rapidly become increasingly less effective after, perhaps, a spectacular beginning.
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CHAPTER
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EVALUATION OF THE DEVELOPMENT OF THE SEMINAR
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The feelings of exhaustion and accomplishment, and enthusiasm for future work, which prevailed at the end of the Seminar were expressed clearly in the speeches at the closing session. One member of the staff attributed the exhaustion to the intensity of the learning process: "We have condensed into two weeks a growing and learning process that otherwise would have taken a long time. A condensation is expensive; it tends to bring out our most human emotions, speaking in a derogatory sense, and also our most human potentialities, in a complimentary sense." This statement was in accord with the feeling of almost every member, that each had learned a great deal, changed and grown considerably during the two weeks of the Semina'r. Another member of the Staff emphatically underscored this statement by saying, "There is not a single person in this room now who is not different, in several ways, from when he came here a fortnight ago". Though change took place in different ways among different individuals of the Seminar, one development that !'leemed to be common to all members was the feeling of mutual identification; one member of the Staff remarked on, "the enormous common interest, field of common experience, and span of common humanity of which we have been so conscious here, and an intense emotional investment in what has been happening". This feeling of a common bond and concern for humanity, with more identification with Asia, constituted the basis of the enthusiasm for their future work which the Seminar participants were undoubtedly feeling. The atmosphere at the end of the Seminar was quite different from that at the beginning when members had first come together with different concepts and anxieties about the meeting. These initial anxieties and differences of anticipation had been unduly, ma'rked, because of the inadequate information that had been available in advance to the participants and staff members alike, about the objectives, structure and programme of the Seminar. Enormous practical administrative difficulties had been responsible for the fact that many of the participants 67
68 received the news bulletin of the Seminar less than one month before the Seminar, some within one week and a number of them not at all; and the majority of the staff members had not been consulted on the programme or their own assignments before the very tentative programme had been announced three months prior to the Seminar. Another factor which added to anxiety and a feeling of uncertainty was the complete revision that had been undertaken at the last moment of the tentative structure and programme of the Seminar. During the staff planning week immediately prior to the Seminar, which seven of the eleven members were able to attend, the objectives of the Seminar were Tevised to suit the anticipated needs of the participants more closely, as well as the present state of development of the field of mental health and family life in Asia. Alterations were made in the programme in order to promote more active participation and more intense interaction of the participants and staff members, so that the Seminar could be a living and growing process for the maximum number of members. More important than listening to prepared lectures was the encouragement given to the participants to share knowledge, experiences, ideas, anxieties and aspirations. All members were involved as much as possible in the various activities of the Seminar and an atmosphere de·veloped that was conducive to a constructive attitude towards working together both during the Seminar and in future work in the field of mental health and family life after the meeting. The programme and structure of the Seminar was built around the study groups, and plenary sessions were fitted in by way of introducing topics, summarizing group reports, imparting information and' conceptualizing the thoughts. Th~ principles of working seminars were observed by the staff members, not only out of the conviction that this was the best way to make the Seminar successful, but also to provide flexibility and fluidity.
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Methods used in the Seminar Various methods were used in the plenary sessions and the study groups to ensure the maximum participation of both participants and the staff, to maintain the interest of the members and to stimulate the continuous growth of the Seminar. In summary these methods were: (a) Introductory plenary sessions. Study topics were introduced by a paper read by a staff member or by a panel
69 of staff members discussing the topic. Study guides were provided for the study group discussions. At one plenary session, an interview of a participant was used as a stimulus to further discussion. Following every presentation in plenary session time was given for discussion or questions. (b) Summary plenary sessions. Q'he presentation Df the reports of study groups consisted, variously, of summaries by each individual study group rapporteur, by staff members who had condensed the group reports, by a panel discussion of certain staff members on reports presented by a panel of participant rapporteurs, and by the reports of individual study groups followed by comments made by a staff member. ( c) Lecture sessions. In response to the expressed wishes of the participants, three lectures were given by different staff members to provide information, to stimulate thinking and to help organize the complex facts and (lonceptualize the ideas emerging from the Seminar. These sessions were each followed by general discussion, either in plenary session or in buzz groups. It is to be noted that these three lectures were all given in the second week, when the specific needs of the participants had heome clear. (d) Study groups. Study Group discussions constituted the live core of the meeting and a large proportion of the total time was used for this purpose, e.g., almost two-thirds of the first week's programme was allotted to study group work. The initial anxiety of participants, as mentioned previously, was increased by their unfamiliarity with this method. However, the skillful use of group techniques and the permissive atmosphere which was developed soon eased the original tensions. This spirit of working together' transcended both nationality and professional discipline. The offices of study group chairmen and rapporteurs were rotated among the participants, by their own decision, in order to ensure the maximum participation of each member. (In only one group a permanent rapporteur served throughout the whole Seminar, but equally by the decision of the group itself.) Several participants requested that staff members should visit each study group in rotation, and some suggested a re-grouping of the study groups. after an intermediate stage. 4 few staff members actually visited other groups as resource personnel at the group's request, but nearly all members quickly identified
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70 themselves highly with their own study groups. Each study group participated in the overall operation of the Seminar through one of its members elected to the Steering Committee. (e) Session on group process. In order to help the participants to gain a better understanding of the dynamics of working and living together at a seminar, to foster a constructive attitude towards study group discussions, and to secure the maximum benefit from a working Seminar, a session on "group process" was presented on the third day of the first week. This session was so timed to make use of the participants' experience of the first two days of the Seminar. The team which made the presentation included participants, observers and staff. They planned and staged a role-playing scene showing various different kinds of behaviour in groups which can help or hinder the group's progress towards goals. While the scene was in progress, the rest of the members of the Seminar were asked to identify the positive (contributing) and negative (inhibiting) behaviour exhibited by each role-playing member. (f) Other sessions. Fil1n8': Two films, "First Days in the Life of a New Guinea Baby" 1 and "Dance and Trance in Bali", were shown, with a narrator, in order to illustrate anthropological techniques for the observation and understanding of human personality development in relation to family life and culture. Several participants showed films made in their countries, of habits and customs, folklore and present social conditions. These film showings, at which attendance was optional, promoted mutual understanding and also provided recreation. Role playing session on "Approaches to a Mental Health problem--JuveniZe Delinquency". A group of participants ;and staff planned a session at which they took various assigned roles as community leaders, and discussed the solution of a problem of juvenile delinquency in a hypothetical town. Following this discussion, a panel of staff members commented on the various approaches to and the proposals made, and in particular on the need for reliable informa1 First Days in the Life of a New Guinea Baby, Bateson, G. & Mead, M. American Museum of Natural History, New York.
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71 tion which must be available before a group can solve a problem of this kind. This session served to stimulate a critical attitude and some constructive thinking about the place of research in the solution of mental health problems. SpecWJ, interest group. Toward the end of the Seminar one session was used for a meeting of groups concerned respectively with psychiatry, clinical child psychology, education and social work. Discussions were held about specialized problems and approaches in various limited professional fields and the possibilities of future co-operation were greately emphasized. Group discussion on "skeleton plots". Each study group selected one of a list of so-called "skeleton plots" for discussion, at one session. These "skeleton plots" were outlines of social situations commonly seen in almost any culture, and they were introduced with the intention of stimulating and promoting discussion by people of different nationalities and professions. Two examples of the "skeleton plots" used in the Seminar are: "A teen-age boy living in the city is caught stealing from a shop. What will happen?; "A well established family has a marriageable daughter and the prospective husband's family discovers familial taint in the bride's heredity. What will happen?" It will be seen from the above brief account that the Seminar members were kept busy and hard at work throughout the two weeks. Frequent staff meetings, small committees for preparation of panel discussions, topic introductions, summary sessions, role playing periods, and study guides, and the writing of study group reports took up almost all of the unscheduled time between 7 :30 a.m. and 11 :00 p.m. and frequently ran beyond midnight. Such time as remained was filled up by social evenings which provided a friendly and relaxing time for the members. One staff member with an extensive experience of international meetings said, "It was one of the hardest working seminars I have ever known". This opinion was echoed by almost all the members.
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Final evaluation by the participants and staff The following representative views taken from· the final (unsigned) evaluation questionnaires regarding the Seminar
72 seem to support the attitudes expressed by all the speakers at the closing session about the success of the Seminar.
(a) On the working reULt:ionship and atmosphere This was generll.lly described to be "friendly", "pleasant", "free", "informal", "enjoyable", "stimulating", or "extraordinarily gentle." No comment was made to the contrary. A staff member remarked on this point, "I think we have had a magnificent demonstration of what mental health is. We do not simply cure mental diseases and run guidance clinics or such specific things. This is mental health as I see it: "Mental Health is the name for the aspirations within which all of us with a professional commitment to the welfare of human beings can work together . . . .''' Specific mention was made by the same staff member of the Filipino delegation, that they made magnificent efforts to introduce discipline and mutual understanding in their especially large and complex group.
(b) On the Programme amd methods of the Seminar As stated in Chapter IV, the Seminar programme and methods had been fully accepted and appreciated by the majority of participants and staff by the end of the first week of the Seminar. The members' appreciation of the value of a working seminar was increased by the role playing session on "group process". Appreciation of the value of the study groups was expressed in such remarks as "excellent learning situations", "hearing it (social and cultural changes in different Asian countries) first hand from the delegates made it more impressive and real", and "the thinking together and exchanging ideas have been the best experience for me". The use of a variety of methods in plenary sessions was greatly appreciated as effective teaching methods which could also be used in the respective countries of members. The desires expressed in the first week to have more lectures, more information on research, more participant participation, etc., seemed to have been well met during the second week. Such a statement as "I was mildly disappointed in the beginning that we participants did not really come to grips with the subject of the Seminar, but I was impresed by the way things [picked up towards the end of the first week", represented the view of the majority of participants. With a few exceptions, the participants felt that they had par-
ticipated fully in the Seminar activities, more fully than they had expected. (c) In relation to participants' pre-seminar expectations
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Though no inquiries were made before the Seminar regarding the participants' expectations of the Seminar, both the interim and the final evaluation indicated clearly that the majority had expected lectures from "experts" and "world-famous authorities" and that they had wanted to be able to bring back "prescriptions" or "blue-prints" for their future work in the imProvement of the mental health of families. These expectations were legitimate in view of the fact that the :tentative programme of the Seminar had indicated that there would be twelve lectures, but had left the remainder of the programme open. Even among those who had not received the pre-Seminar news bulletin, such expectations would have been legitimate, because Seminars on any subject in Asia have frequently consisted solely of lectures. As stated in Chapters III and VI, participants were at first disappointed and confused to find that theIr expectations were not likely to be fulfilled; but with the gradual recognition of the nature and objectives of the Seminar, the majority became more interested in working on their problems through discussion under able leadership. This general change of expectations of the Seminar was also clearly indicated in the final evaluation questionnaires, e.g., "Certainly I can't go away with a 'blueprint' of what and how to do in mental health work. I don't mind now." "We gained insight instead of the unrealistic "alluseful prescription" which some of us might erroneously have wanted to have."
(b) Organizatiorn and operation of the Seminar The efforts, thoughts, and generosity put into orgamzmg the Seminar by the Philippine Organizing Committee and the various sponsoring organIzations which together set up the Seminar were greatly appreciated and the gratitude of all members was clearly expressed, knowing the enormous difficulty and complexity of this sort of international, interdisciplinary and interorganizational undertaking. The Filipino hospitality was another important factor in the creation of such a friendly atmosphere which contributed to the success of the Seminar.
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74 As stated previously in this Chapter, there was unanimous agreement among the participants and staff that no matter what administrative and practical obstacles may have to be overcome, an international seminar should not be undertaken in Asia unless the following conditions can be fulfilled: (1) Staff members should be recruited at least one year before the Seminar. (2) All the staff members should be consulted on the specific objectives, nature and preparation of the content of the Seminar; so that the Seminar programme will meet the needs of the participants of the region. (3) The tentative objectives and outline of the programmes of the Seminar should be distributed to the countries to enable proper selection of the participants to be made at least six months before the Seminar opens. (4) Great care must be given to secure adequate representation from every country to which invitations are extended. In principle, individuals should not attend on their own, but should always be accompanied by at least one compatriot. (5) Working papers, background papers and other necessary preparatory material should be sent to the participants at least three months prior to the Seminar. (6) Pre-Seminar staff meetings should take place at least one week prior to the Seminar and all the members attend. It is most desirable for the staff members to have intimate knowledge of the countries of the participants. (7) The recruitment, as far as possible, of Asians as staff members is advocated. These conditions are advanced as constructive suggestions for the organization of future seminars rather than as critieisms of the present Seminar. The quality of participants and the calibre of staff members were, in general, quite appropriate and well appreciated.
The significance of the First Asian Seminar on and Family Life, in historical perspective.
Menta~
Health
The co-Chairman of the Philippine Organizing Committee, at the closing session, congratulated the members of the Seminar
75 on "having really made the Seminar an opportunity and having answered the challenge". This statement can be interpreted that the Seminar has a historical significance because it has accomplished its task of being the "First" Asian seminar in this field of mental health and family life. This Seminar was the "First" of its kind in Asia in the sense that it was the first at which mental health and family life were linked together as the focus of concern and study. It was also the first in the sense that Asians took an active part in planning, organizing and conducting an international seminar of this sort. The term "Asians" should not be interpreted as implying a narrow regionalism. This word refers to the people of countries in the region represented by the participants. The First Asian Seminar signified a historical phenomenon making the fact that people of this part of the world had become aware of the needs in this field, and had come together to think about and work on problems that concern their own well-being and and also to take a proper share of responsibility in the common undertaking of working for the good of mankind. This Seminar having beep called the "First", it follows logically that a "Second" and "Third" and so forth are expected. Obviously, the "First" indicates the beginning, and the Seminar has answered the challenge to lay the foundations of an enormously difficult and complicated undertaking. It was clear from the discussions and presentation in the Seminar (see Chapter VIII, (2) and (3) that proper motivation is the first prerequisite for action. In this respect, the Seminar has succeeded in having motivated and "involved" its members. Such statements in the evaluation sheets as, "more time for more discussion", "more data as basis for concrete action", and "more Seminars on the same subjects, for following up our efforts", indicated well the consensus of opinion that "The Seminar has answered the challenge and made it an opportunity".
•
Tasks for the immediate future
,
"
In the evaluation questionnaires as well as at the closing session, interest and concern were shown as to how to maintain enthusiasm, how to utilize the network of friendly working relationship of the participants which has been established during the Seminar for future international work; and how to continue improving the quality of the work in the field of mental
76 health and family life in Asia. The following suggestions were made: (1) To plan for a similar seminar in the near future (1961 or 1962) at which more research data should be presented, in order to facilitate the study and solution of the problems concerned. (2) To have a follow-up study by a suitable consultant of the effect of the Seminar on the participants in their actual work. This would enable the planning for the next Seminar to be focused more closely on the actual needs. (3) To study the possibility of organizing an "Asian Federation for Mental Health" (tentative name) to promote the mental health movement in the region, in close association with the World Federation for Mental Health. (4) To study the possibility of establishing a training centre in this region to meet the critical shortages of personnel. (5) To study the possibility of establishing an institute for research in mental health and family life, which will also assist in training research personnel and serve as clearing house of research information and data.
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EPILOGUE By Dr. MARGARET MEAD
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I still see before me the faces of all of the members of the Seminar as we sat together on that last morning. I realize, even more keenly than I did then, how each participant can be seen as one in a million, or sometimes even one in several million -the single member of a particular discipline in a particular country, who is ready and willing to take the next necessary step towards the fulfilment of our common aspiration. For that is how I see mental health, as the shared world-wide aspiration of all of us who are professionally trained to work with human beings, as educators, as physicians, as clinicians, etc., in the fields of public health and community development. In separate professional associations, our interests become narrowed; working together for mental health, our goals are both wide and shared. But we work also in many different frameworks of time and space. Some of the peoples represented here have common cultural roots going back thousands of years; for others the closest contact came only very recently in a shared contact with the West. Some of us come from cultures where purposive change has been part of experience for many generations; for others a tradition of timelessness has only recently been relinquished. But for those who come from either tradition, time is needed either for the absorption of new details of living, or for the systematic transformation of individuals who ar~ members of societies which have chosen more drastic and complete change. So, the Seminar brought to the fore a whole series of important issues about how and how fast human beings can change. The focus on the family as the place where the young child learns about change, learns to change in a form which we call growth, proved particularly valuable also in keeping our eyes on the human aspects of change. Here contributions came from Asia, urging us to recognize that human beings must grow into new ways of life, and from Europe and America, reporting on ways in which we had seen individuals change very rapidly. These two emphases are not contradictory: rather they com77
78 plement each other in producing a new sense of how fast beings can change, if they change together, all the generations at once, which in itself is a kind of condensed growth process, just as this Seminar itself was a condensed growth process. Because we were so different one from another, in age, in experience, in background, in professional skills, we were able to create a small piece of evolution, a microcosm within which an evolutionary step could be taken. But if each of us is to have a hand in the process of change which has been initiated alI over the world by men's new vision of what mankind can be, this will involve the continued purposive cultivation of trust in each other, including trust in that which is different and that which often seems alien and incomprehensible. This has been an Asian Seminar, and it has, been a revelation to those who came of how much they had in common, whether in discussions of the changes in the extended family, in the subtle rhythms of music and dance, or in the shared intensities of their aspirations. Yet, to one who, like myself, is not an Asian, there has been an equal revelation of the great number of ways in which a sense of common humanity can be built. As I watched-with an anthropologically disciplined eye-the interplays among the peoples represented here at the Seminar, I was newly impressed with how many other combinations of peoples each group here could have fitted in because of religion, or history, or size, or type of government, or even styles of gentleness and laughter. It was heartening to Asians to find how much they had in common with other Asians who live thousands of miles away. It was exciting to be able to draw on peoples as far apart and yet rely on a sense of neighbourhood. But it was also exciting to think that we were finding, among the members of the Seminar, individuals who would be growing points of change not only within their own countries and within Asia but within the whole world. No report, even one as skillfully woven as this one, can adequately catch all of the nuances of new knowledge and new understandings that we as participants took home with us. For each one, some special pieces of insights must stand out as one, in particular, stands out for me: my new understanding of how easy it is to build upon skilled hands. Here the example is the old village midwife, with hands wise from bringing babies into the world, who knows, however, nothing of antiseptic procedures. She can learn, as an old woman, to boil her mid-
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wifery scissors; and when she learns a practice based upon the whole background of modern medical science she does not lose her former skill, she can simply exercise it more safely. But I realized it is different with the herbalist who handles a traditional magical pharmacopoeia. He cannot graft antibiotics into his magical kit as easily as the midwife. Here there is a greater distance to be traversed before there will be those, necessarily from the young, who have been trained in modern scientific skill. As was so eloquently pointed out, this scientific knowledge that is needed is neither eastern nor western-simply which all the peoples of the world can learn and use. So, in every part of the world we need devices for the identification of future young scientists who will be skilled in research, in the arts of healing, and in the understanding of human behaviour. Regional seminars permit us to experience a sense of growth in each section of the world where one is held. They bring together those who, in their own professional groups in their own countries, sometimes feel and think so differently from their fellows that they feel isolated and lonely. At a Seminar like this one, each participant learns what it is like to be one of those who live on the growing edge of change. Here, on the edge, there are never enough people, and there is always too much work to do. There is never enough money, and never enough time. And here, on the growing edge, are the people who have chosen to work there, who, once the point of view they now strive for is accepted, will move on-to a new frontier post, as understaffed as this. But, understaffed as such frontier positions are, still those who man them have never had at their disposal such enormous opportunities as we have today. In the vast network of communications of which this seminar was a part, each new idea can echo round the world. Each advance in methods of work can be made immediately available to peoples on the other side of the world. The centres of innovation and inspiration can shift-from Geneva to Calcutta, Rome to Manila, Paris to Bangkok and back again, within a season. Never has the individual counted for so much, had so vast a world to listen, or so vast a world-wide process within which to act to make the future more fulfilling for human beings.
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APPENDIX FIRST ASIAN SEMINAR ON MENTAL HEALTH AND FAMILY LIFE
List of Participants, Staff and Observers (.-Staff ··-Observers)
•• Dr. Cesaria Goducl>-Agular Clinical Director, National Mental Hospital Mandaluyong, Rizal Philippines •• Miss Helena Z. Benitez Chairman, Family Life Workshop of the Philippines; Executive Vice-President, Philippine Women's University; Council Member, Int'!. Union of Family Organizations; Board Member, Int'\. Federation of Home Economics; Vice-President, Int'!. Council of Women 1743 Taft Avenue, Manila Philippines Mrs. Elpidia E. Bonanza Chief, Home Economics Division Bureau of Public Schools Manila Philippines Dr. Eufronio Carrasco Professor and Head, Department of Physiological Hygiene and Nutrition Institute of Hygiene, University of the Philippines H erran Street, Manila Philippines Professor Valentin G. Cedillo Research Coordinator and Assistant Training Officer, Presidential Assistant on Community Development 00889fr--6
522-524 Isaac Peral Manila Philippines Miss Anita King-Fun Chen Lecturer in Child Development and Psychologist University of Hong Kong Hong Kong Mrs. Kyung Choon (Sohn) Choi Associate Professor of Nursing University of Ewha, Korea 1-298 Puk a Hym Dong Seoul, KOTea Miss Hsin-Hsin Chung Teaching Supervisor Department of Neurology and Psychiatry Taiwan University Hospital Taipei, Taiwan Republic of China •• Dr. Marcia Cooper Lecturer, WHO Institute of Hygiene, University of the Philippines 625 Herran Street, Manila Philippines Miss Daviras Dhanagom Head of Home Economics Section The College of Education 36 Pradit R<lad, Soriwongse Bangkok, Thailand Dr. Kalika-Charon Dube Superintendent, Mental Hospital Agra India
81
82 • Dr. Manuel Escudero Consultant for Mental Health WHO-WPRO Taft Avenue, Corner Isaac Peral Manila Philippines Dr. Jose A. Fernandez Acting Chief, Division of Mental Hygiene Department of Health Manila Philippines Vialdelle Terme di Caracalle Rome Italy
* Miss
Lorna Horwood WHO Nurse Educator WHO-WPRO Liaison Office 5 Chungshan South Road Taipei, Taiwan Republic of China Miss Tsui-Ping Huang Probation Officer Social Welfare Department Fire Brigade Bldg. Hong Kong
.* Mrs.
Lucille Foster Member of the Board of Governors Philippine National Red Cross Lepanto, Mountain Province Pldlippines
•• Miss Lourdes Gal'abato Technical Assistant, Philippine National FAO Committee Department of Agriculture Manila Philippines Mrs. Maria Dayoan-Garcia Director, Department of Home and Family Philippine Federation of Christian Churches 1648 Taft Avenue, Manila Philippines Miss Eva Beatriz Gonzales Assistant Professor in Home Economics University of the Philippines Diliman, Quezon City Philippines Miss Daphne Ho Assistant Director of Social Welfare (Special Welfare Services) Social Welfare Department Hong Kong
Mr. Chien-hou Hwang Associate Professor, Department of Education Taiwan Provincial Normal University 190 Chow St., Taipei Taiwan, China
"'* Mrs. Adela A. Kabigting Principal, Manila Sanitarium and Hospital School of Nursing Manila Sanitarium and Hospital P. O. Box 1592, Manila Philippines Mr. Chamnean Kantasewi Chief, Intake Section, Child Welfare Division Department of Public Welfare Ministry of Interior Bangkok, Thailand Mrs. Kaniz Sakina Wajid-Khan Secretary General, Pakistan Council for Child Welfare No.1, Bath Island Road Karachi, Pakistan
* Mr.
* Dr.
Margaret Hockin Harrington Chief, Home Economics Branch, FAO Food and Agriculture Organization of the United Nations
Lynford Keyes Health Educator Adviser, WHOWPRO Corner Taft Avenue and Isaac Peral St. Manila Philippines
83 Miss Whang-Kyung (Evelyn) Koh Professor of Sociology; Head of Sociology Department Ewha University, Seoul Korea
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Estefania Aldaba-Lim Director, Institute for HUman Relations; 'Professor of Psychology and Mental Hygiene, Philippine Women's University Taft Avenue, Manila Philippines Mrs. Mei-Chen Lin Consultant, Taipei Children's Mental Health Center 19 Chung-shan Road, South Taipei
Fernando D. Manalo Head, Medical Dept., Benguet Consolidated Inc., Baguio City; Clinical Director, Notre Dame de Lourdes Hospital, Baguio City 7 Navy Road, Baguio City Philippines Mrs. Edita Gonzales MartiIIano Chief, Social Service, Veteran's Memorial Hospital, Quezon City 20 Arayat Cubao, Quezon City Philippines
*. Dr.
* Dr.
Taiwan
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Tsung-Yi Lin Professor of Psychiatry and Chairman of the Department of Neurology and Psychiatry, National Taiwan University, Taipei; Director, Taipei Children's Mental Health Center, Taipei -National Taiwan University Hospital, Taipei
K. R. Masani Director, Indian Institute of Mental Health and Human Relations Silver Oaks Warden Road Bombay India
•• Miss Rita McEwan Nurse Educator, Mental Health (WHO) Woodbridge Hospital, Yio Chu Kang Road Singapore 19 Singapore
Taiwan
* Dr.
.* Miss
Delfina S. Maceda Professor of Home Economics, Philippine Women's University 1841 Colorado, Malate, Manila Philippines Fr. Francis C. Madigan, S.J. Director, Social Science Research Institute; Dean, The Graduate School 'Xavier University Cagayan de Oro City Philippines Dr. Subha Malakul Head, Mental Hygiene Section Somdej, Chaopyo Hospital Dhonburi
Margaret Mead Curator, American Associate Museum of National History 15 W. 77th Street New York 24, New York U.S.A. Dr. Ambhorn J. Meesook Director, Division of Educational Information, Ministry of Education I 85 Ekamai Road, Bangkok Thailand Mr. Mohammad Modabbir Vice-President, Pakistan Child Welfare Council, East Pakistan Chairman, Junior Red Cross and of Handicapped Rehabilitation Board, East Pakistan
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84 Editor, Pakistan; President, East Pakistan Editor's Association 32 Old MogultuIi Dacca Pakistan Dr. R. Natarajan Professor of Psychiatry and Superintendent Mental Hospital, Hyderabad India Mrs. Tane Ohata Professor and Dean of Women, St. Paul's University, Tokyo, Japan Tokyo 543 Seijo-Machi, Setagaya-ku Japan Professor Waldo S. Perfecto Professor, De La Salle College, Manila Catholic Educational Association of the Philippines 2474 Taft Avenue, Manila Philippines Dr. Hsien Rin Instructor in Psychiatry, National Taiwan University, College of Medicine; Staff Psychiatrist, Department of Neurology and Psychiatry, National Taiwan University Hospital, Taipei No. 19, Lane 23, Yung-Kang St., Taipei, Taiwan China Dr. Salekan Director, Mental Hospital Services Ministry of Health, Djakarta R.S.D. Grogol, Djakarta Indonesia Dr. I. A. Senanayake Psychiatrist 51 Gregory's Road, Colombo 7 Ce'llUm Dr. Kusumanto Setyonegoro Psychiatrist, Department of Psychiatry and Psychotherapy, University of Indonesia Djalan Tjokroaminoto 97, Djakarta II/18 I ndonesia .~
* Mrs.
Juana S. Silverio Regional SOOal Services om~. United Nations Economic Commission for Asia and the Far East (ECAFE) Sala Santitham, Bangkok Thailanct Consultant for Mental Health. WHO-WPRO Vienna XVII, Kochlespasse 18 Austria
* Dr. Margarethe Stepan
* Dr.
Kenneth Soddy Scientific Director of the World Federation for Mental Health; Physician In-Charge of the Child Guidance Department, University College Hospital World Federation for Mental Health 19 Manchester Street London W 1, England
Mr. B. H. Tan President, Central Welfare Council Federation of Malaya P.O. Box 60, Seremban, N.S. Federation of Malaya Malaya Mrs. B. H. Tan Voluntary Social Worker representing various Voluntary Organization in the State .of. Negri Sembilan, Federation of. Malaya P. O. Box 60, Seremban, N. S., Federation of Malaya Malaya,
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Miss Wilhelmina Tan Health Sister % Health Center, Kuching Sarawak Miss Duong Thi Thuong Chief of Home Economics Divi"'" sion, Ministry of Agriculture 12 Rue Massiges, Saigon Vietnam ...... Dr. Alberto Tupas ... Honorary President, Philippine Pediatrics Society 1734 M. H. del Pilar, Malate, Manila Philippines Mrs. Chindabha Sayanha-Vikasit Associate Professor and Head of the Maternal and Child Health Department, Faculty of Public Health, University of Medical Sciences, Ministry of Public Health Faculty of Public Health, 420/1 Rajvithi Road, Bangkok Thailand
** Mrs.
Alicia Feria Winn Executive Secretary, World Brotherhood, Philippines; Writer, Editor, Publisher 2504 Pennsylvania St., Manila Philippines
Dr. Petrus Suckjin Yoo Director, Petrus Neuropsychiatric Hospital; Chairman, Professional Team and Meeting, Seoul Child Guidance Clinic; Lecturer of Neuropsychiatry, Caththolic Medical Center; Lecturer, Graduate School of Psychology Department, Ewha Women's University;
Vice-President, Korean N europsychiatric Association; Member of the Morale Education Committee, Ministry of Education 59, 4Ka, Myong-Ryung Dong, Chong-ReKu, Seoul Republic of Korea
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