V- A Salutiferous Society
The family is the basic organism in society. As a constituent of society it contributes to society. Equally, society contributes to it. Each family relates to all the other families that make up the psychic environment outside itself; it can equally suffer. The more health-promoting, salutiferous, is society, the more will its families benefit.
Thus it is essential to examine society for its health-promoting potential. Should the functioning be inveterate, set and permanent, this would be a wasteful exercise. Its malignant permanence would have to be accepted. Fortunately, society, like the family and the individuals, is endowed with the capacity to change. Its infinite pattern of functioning can be restyled; herein is society’s capacity for health. In the final hierarchy of phenomena, the pneumococucus is as significant as a person. In some circumstances, it might even have greater importance than a person. In our set of circumstances, the pattern has to be moulded against the pneumococcus and in favour of man. Man has the capacity to develop awareness to the point when he can, within the limits allowed him, reshape the pattern of functioning to his advantage. Hitherto, his predominant endeavour has been concentrated on adjusting his material environment. With this task largely accomplished in developed countries, there should now be resources to re-pattern the psychic sphere of living.
The author sees society as a vast field of forces in which elements are loosely defined – culture, community, neighbourhood, family, individual; essentially each element has equal significance. The emotional forces within the life space produce degrees of well-being or harm and they can be re-patterned to promote either. Understanding of this potential for change in either direction allows the conscious selection of patterns of emotional forces toward bringing well-being to society and to the elements within it. Thus, through generations, a reshaping of the emotional self-improvement.
Much thought and print has been expended in attempting to define health. It is easier to feel it than to define it. Its correlates are easy to delimit and describe – emotional and physical well-being, the capacity to adjust to life’s stresses, the ability to co-operate with others, unselfish actions born of security, efficiency, and productivity. All these indicate harmonious functioning in the individual – what he feels is the comfortable state of “being well”.
Most definitions of health are in terms of the individual; it may be more realistic to attempt it in terms of society, which ultimately dictates the state of its elements, families and individuals within it. It might be thought that society is sick only in the sense that it contains a number of sick people. It is more correct to say that society itself is sick and therefore must contain a number of sick individuals. At the moment, forces within society are arranged in a pattern that provokes emotional ill-health, which flows from one generation to the next. Society carries within it the capacity for health because its fields of force carry the potential for rearrangement. This fact makes clinical endeavour worth while. Health and “normal” behaviour of course must not be confused. The normal, usual, statistically average state of emotional functioning in society is far from “health”. With each succeeding generation it is hoped that the emotional norm will increasingly approximate to health – a state of affairs being achieved slowly and with difficulty in the field of physical health.
The clinician’s endeavour is the production of health. In family psychiatry the goal is a healthy family, with, of course, healthy individuals, a task always limited by the fact that social ill-health pulls the family towards conformity to its norms. Over the generations, small gains in the rearrangement of the vectors will have a cumulative effect on society. Gains can be made at individual, family and social levels, and the process is indivisible. For the present, the family is the vantage point. Progress can be made only at the speed with which knowledge develops. But clinical effort carries the prospect of new insight; research and clinical work go hand in hand.
It is one of the central themes of this writing that discernment must come before change, diagnosis before therapy. So it is with an effort to make society health-promoting, or salutiferous. It is necessary to know what is required for healthy human functioning – bit it individual, familial or social. The lessons of health often emerge from a study of ill-health. Thus, the first step is a massive assessment of dysfunctioning in society. It can operate at three levels: (i) what accounts for the dysfunctioning in society as an organism (where do its harmful leaders, movements, collective aggressive acts, etc, spring from); (ii) what accounts for the contribution of society to the dysfunctioning of the family (what harmful values, habits, restrictions, etc does it impose on the family); and (iii) what accounts for the involvement of society in the dysfunctioning of the individual (what harmful psychic noci-vectors spring from its institutions – schools, industry, neighbourhoods, etc).
Central to any evaluation is to establish standards. Paradoxically, standards of health often emerge only after an examination of ill-health. The absence of ill-health is easier to ascertain than the presence of health. Over time, sometimes as the result of trial and error, the pattern of optimum functioning for a salutiferous society will emerge. A further complication is added by the fact that what is optimum functioning at one moment in history is not optimum functioning at another. Fortunately, change takes place in collective human functioning at such a slow rate that this is unlikely to be a serious complication. It might be supposed that change in society takes place very rapidly today. But this would only be true of material change; the level of general psychic well-being in the most materially developed of societies is often not only very low, but lower than in materially poorly endowed societies.
It may be useful to contrast briefly what is being said about the creation of a salutiferous society with what is termed “social psychiatry”. This latter has been the subject of much confusion, especially concerning such aspects as “therapeutic communities”, “therapeutic milieu”, “community psychiatry”, etc. The first two are concerned with the climate of psychiatric institutions, a humanising movement that allows of more patient involvement, greater freedom, and a constructive group feeling; they are a reaction to the rigid institutionalisation of the last two hundred years, and only partly ameliorated, here and there, by the efforts of Pinel, Chiarugi, Conolly, and Tuke in the 19th century. Community psychiatry has affinity with social psychiatry and the terms are often used synonymously. It is a movement that wishes society to take a larger share of the care of the mentally ill, who, according to it, should remain in the community. Thus, it emphasises the need for day hospitals, hostels, etc, to keep patients in the community rather than in hospitals and the need for “after care” agencies to facilitate their discharge from hospitals. All the above are elements, but only a few, within a health-promoting society, a salutiferous society. The salutiferous society is concerned not only with the management of the identified ill, but much more with identifying influences that encourage dysfunctioning, and then re-patterning social living so that the level of emotional, and not “mental”, functioning improves. It has to do not only with the management of the alcoholic, for instance, but with all the adverse practices in society that set up the particular combination of psychic noci-vectors that precipitate alcoholism.
The salutiferous society has affinity with the preventive movement in the physical field that has made such a significant contribution to the improvement in the standard of physical health. It is more useful to talk of the promotion of health, than the prevention of ill-health. It is easier to persuade a person to win a race than persuade him not to lose it. Hence, health promotion and the term “salutiferous”. The salutiferous society could be said to embrace both psychic and physical health; here it will be employed as it relates to the former. Indeed the two are indivisible, as change for the better in one encourages an improvement in the other. In preventive organic medicine there has been a systematic analysis of those elements in life which are antagonistic to physical health. The tubercle bacillus was isolated, it was shown to have a bovine form, the bovine form was transferred by the milk of affected cows to children and hence bovine tuberculosis that was responsible for such deformities in children in the past. The understanding of this process led to large-scale preventive procedures largely by promoting the health of cows. (As in physical medicine, so in psychic medicine, the understanding of pathology is the key to health promotion.) It will be noticed that curative and health-promoting medicine go hand in hand. Clinical work led ultimately to the isolation of the tubercle bacillus; preventive measures then took over. Curative medicine is both a palliative and a research endeavour. Similarly, there is no contradiction between curative and preventive psychic medicine. They complement each other. Psychic medicine has its palliative and research functions and leads to large-scale health promotion efforts.
Satisfaction of material needs to a large degree, together with the recognition of emotional phenomena, makes it now within our grasp to enter this new phase of social action. A perceptible improvement may be all that can be achieved by community action in one generation, but this will have a cumulative effect over the generations. Individuals are most susceptible to emotional influences in their early, formative years, and special attention should be paid to this fact when planning community measures. Thus the psychiatric service for children has a duty to make its findings on the emotional life of the child known to those agencies able to effect improvements in community living.
To conclude, the concept of the salutiferous (health-promoting) community is based on the idea that the whole emotional stratum of society should promote healthy emotional living. Thus, following an examination of the field of forces, a re-patterning of the forces takes place, which will encourage optimum conditions for emotional health. The programme calls for an examination of every aspect of social functioning, its standards, roles, institutions, organisation and aims. Every one of its multitudinous facets should be examined to assess its value in promoting emotional health. Those which are conducive to health should be retained; those that are antagonistic to health should be changed. The concentration is not on a sick person, the patient, but on the emotional self-improvement of the whole society. Over the generations, increasing self-improvement will result in a salutiferous society that supplies optimum conditions for emotional health in itself and its elements – culture, community, neighbourhood, family and individual.