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› not believe it is necessary or desirable to define or limit the respective fields of cor and social worker. Just as the treatment of typhoid fever is very largely one nursing, so the treatment of most of the problems of maladjustment is dependefficient social service. If, however, the social worker is to contribute more ood intentions, human interests, neighborly visits, and advice, she cannot depend personality alone. It is quite essential that she have training and experience will permit her to take her place along with those working in other professions, r responsibilities are of no less importance than those of the doctor, lawyer, or Her technique should be carefully developed along scientific lines, and methods ld be studied with the idea of keeping pace with the other professions. Research ld go hand in hand with routine.

The psychiatric personnel in this country, as in every other, is quite inadequate to et the demands. There is, therefore, a grave necessity to conserve the time of the 'chiatrist in so far as possible, and there is no doubt but that the well-trained psychiic social worker can assume more responsibility than we have heretofore permitted rselves to believe.

Since the tendency is to broaden the scope of the social worker's functions and crease her responsibilities, it will become more and more necessary for her to have not nly a thorough knowledge of the community and all its resources together with its langers and pitfalls, but she also must have an insight into the mental make-up of the patient as well as his social environment in order to evaluate properly what factors are to be accepted and what rejected.

If out-patient clinics and the parole system are to have an opportunity of demonstrating their practical value, the community must be educated and made to understand that there are certain responsibilities which it must assume. I know of no better example of what I mean by community responsibility than that which is exemplified at the little village of Gheel in Belgium. Many of you, I am sure, are familiar with this colony. Since the end of the sixth century it has been a refuge for those mentally disturbed. First those near by came to the tomb of the Virgin simply to pray. Later pilgrimages were made from distant parts to seek a cure. The pilgrims procured board and room in the homes near the church, and from then on until the colony was reorganized by the Belgium State in 1852, much unorganized though sympathetic work was done by those whose social heritage gave them more than ordinary insight in caring for the insane. In 1852 the colony was taken over by the state and has since achieved a world-wide reputation. After thirteen centuries of contact with the insane, the family care of the sick has become a habit almost necessary for the life of the population of this little village. But all who wish may not care for the sick. Before being accepted, the aspirants must prove to be of good character and possess certain surroundings of comfort. The choice of a family is the most important and delicate question to solve. An attempt is made to retain for the patient, bis natural habits of life. The artisans are placed in a family pursuing the same line of work. Patients coming from cities are placed in the families of citizens living in the center of the town and peasants are lodged with farmers.

During the German invasion into France, the villages of Gheel opened up their doors to the insane refugees from the inmates of one of the hospitals on the border. I was told by Dr. Sano, director of the Gheel Colony, that he never witnessed a more pathetic scene than when these insane refugees departed from their Belgium hosts in the

spring of 1919. These villages are as interested in their patients as they could possibly be in a member of their own family. I have visited these homes personally and have seen the true spirit of community responsibility demonstrated.

It is too much, of course, to ask or expect a duplication of the Gheel system, but it is not too much to ask or demand more community co-operation than we are getting at the present time.

There are many ways in which the problems presented to an out-patient clinic might be divided, but for the purpose of convenience and brevity, I will use a very simple clinical grouping; that is, the psychotic, the incipient psychotic, and the psychoneurotic groups. Of the psychotic group, naturally a large proportion are referred directly to a state hospital. There are, however, many of these frankly psychotic cases presenting no particular asocial traits, who can be cared for quite satisfactorily in the community if adequate social service supervision can be provided. Not only can many of these cases be given the proper care in their homes, but they can be made economically independent or at least partially so.

The second group, so-called incipient psychoses, are perhaps of more practical interest, inasmuch as it is here we hope to do something in the way of genuine preventive medicine. It is our aim and purpose in dealing with these cases, to forestall the mental breakdown by the application of the principles of mental hygiene. The following case is a good example of this group.

A young girl aged nineteen was brought to the clinic by her father who stated that for the past three or four months she had been telling most unusual and fantastic tales to the girls at the normal school which she was attending. She made it generally understood at the school that her mother had left her husband, remarried, and was living in France. She showed her companions letters supposed to have been written to her by her mother. She discussed rather intelligently, the economic, social, and educational conditions in France, and told of her plans to go there after finishing her course. Later on she came to school and told of the death of her father which created a great deal of sympathy among her friends and immediately contributions were taken up to send flowers. It happened that this story became more generally known than the others and someone who knew the facts of her case, communicated with the teacher. It was at this time her fabrications for some months past were revealed and she was advised by one of her instructors to come to the hospital. She was a girl of more than average intelligence, had succeeded well in her studies but had fallen down entirely in making friends and getting enjoyment out of the more ordinary things in life. She was inclined to view life rather seriously and had never made but one confidant, a woman who was her teacher when she was in the sixth grade. She had no intimate companion felt that she had never been understood. She stated, "Mother half underst father not at all." It was only very recently that she had slumped in her scho spite of the fact that she was staying up until four o'clock to get her lessons. cussing the situation with the father, it was quite obvious that he had no under: whatsoever of the girl's condition. He said, "Instead of bringing her here, I o put her up against the wall and smash her face." He felt that the fabrications purely voluntary things on her part and that she was ashamed of the rest of the fan. The mother seemed to be a rather sensible hard-working woman who, like the rest the family, had been very subservient to the father. She was making a great effort t assume the responsibilities of the household, not only caring for the house and for the

ree children's physical needs, but always having in mind it was her duty to keep them ppy and contented. She was one of those individuals who expected little and got less om her husband. From her story and the interview with the father there was no ubt that he was the dominant member of the family. Everything revolved around n and he was most exacting in his demands for obedience. When he entered the house e mental atmosphere changed immediately, everything must quiet down, meals must served exactly on time, children must be put to bed at the proper moment, conversaon must cease or be initiated by him. The wife stated, "He is a hard worker and a od provider, but the job of police inspector is extremely trying and nerve racking" d it is quite obvious that much of the irritability developed over his work was exended in the household.

It seems quite apparent from the analysis of this case that the romancing and fabriting, for which, by the way, there are certain definite amnesia periods, represent the fort on the part of the patient to emancipate herself from the tyrannical autocracy of er father. The only road to happiness seemed to necessitate the withdrawal from ality, and the refusal to meet the problems of her everyday life as they were presented. further necessitated a building up of a little dream world of her own in which many of er desires, hopes, and ambitions could be realized. After going over the situation carelly with the mother and the father, it seemed advisable to change the environment of e patient temporarily at least. Fortunately a position was secured for her in a ome as governess for two children, under conditions which were very favorable and at e same time opportunities of adjusting her life in a way more compatible to her pernality were offered. Improvement was immediate and marked.

The psychoneurotic group makes up a very large percentage of all cases receiving erapy in the out-patient clinics, and it is with this group we can best hope to be of al service. It is perhaps of interest to note that of all the patients seen at the Outatient Clinic carried on by the United States Veterans' Bureau in Boston, less than 5 er cent are sent to hospitals for treatment, while in a Middle Western city handling resumably the same group of cases, they find it necessary to hospitalize over 70 per ent of the cases. The reason for the wide discrepancy in hospitalizing patients in these vo cities lies in the fact that in one city there is a well-organized out-patient clinic and n efficient social service, while in the other these facilities are not available. This is a ood example en masse of the value of clinics and social workers. Permit me, however, › present one individual case with its ramifications to illustrate how intricate and volved some apparently simple situations may become if intensively studied.

C. D., a woman fifty-six years of age entered the Out-Patient Clinic of the Boston 'sychopathic Hospital complaining of weakness on the left side of the body confined ery closely to an extensive area which had been burned seven years ago, involving the eft arm, breast, abdomen, and leg. There were also rather vague subjective sensations hich were not constant or characteristic of any nerve lesion. Careful physical and eurological examination revealed no organic cause for her complaints. In taking the istory of the case it was observed that the patient was depressed, extremely sensitive, nd reluctant about going into the details of her early life. It was finally ascertained, owever, that thirty-one years ago she had had an illegitimate daughter by the man vhose name she bears. Notwithstanding the fact that this man was a moral degenerte, socially her inferior, and abusive, she was extremely fond of him, and although not iving with him, was at his command at all times over a period of twenty years. When

their illegitimate daughter was seventeen years of age, her father had immoral relations with her which the mother knew nothing about until some years later. At present the patient is living with this daughter, in fact she thinks she is entirely dependent upon her and her son-in-law, and it is made quite plain to the patient that she is not wanted. This woman has converted many of her mental conflicts into physical symptoms. After going over this situation with the mother a plan of living was outlined and one of its most important features was that she have a home of her own. The patient then requested that she be allowed to bring in her daughter to the clinic and this she did.

The daughter was a well-developed and well-nourished young woman thirty-two years of age who was extremely depressed at the time of the examination. She gave a history of spells of excitement when her thoughts seemed accelerated and prevented her from sleeping. Her married life had been extremely disappointing as there was no real affection between her and her husband. She found life a very solitary affair, and could not meet people as she was unable to appreciate any interest outside of herself. She was constantly seeking sympathy, attention, and romance. She had been extremely disappointed in not having children and had made no effort to fill in the vacuum by outside interests. Her husband was a hard-working man who had but little understanding of his wife's condition. He was extremely co-operative and wanted to do everything that he could to help out. He resented somewhat the presence of the mother-in-law feeling that much of their trouble was due to her interference.

The case was referred to the Social Service Department and it was arranged for the mother-in-law to establish her own apartment, and an effort was made to develop the daughter's interest in some of the social activities in the community. She took up gymnasium work and developed an interest in birds and flowers, and through constant attention and effort on the part of the Social Service Department, much improvement was made in the situation to the satisfaction of all concerned. After a few months, however, the patient again became depressed and at the present time is just getting established again. The whole setting is quite obviously one for very intensive social work. The skill and ingenuity of any worker will be taxed to the limit to develop plans to solve this problem and it is too much to hope that success will be achieved without one or more failures.

One of the chief rôles that the psychiatrist is called upon to play, is that of arbiter. Someone has wisely said "that neuroses, like charity, begin at home" and the paraphrase of this trite saying is well borne out by one's experience in out-patient work. The cases where the solution of the problem depends in a large measure upon the proper adjustment of family situations outnumber any other group, and this is not surprising when one considers the intimacy necessitated by close personal contacts and the innumerable sources of irritation which are ever present. Many of the problems which are presented for solution are frequently complicated and involved, but in general it is not so much the problem as the method by which it is handled that produces at first an unhappy mental atmosphere, later disputes, and quarreling, and finally a situation in which more abnormal methods are utilized in an effort to bridge over the difficulty. These abnormal methods may be drugs, alcohol, convulsions, fainting spells, and not infrequently homicides and suicides.

I can only mention briefly a new phase of work started in connection with the Baby Hygiene Association which the psychiatrist and social worker will co-operate in carrying out. This is the establishment of habit clinics for children of the pre-school age.

cudy of children and the influences which modify habits is what might be called a culture of mental hygiene. The heredity, personality, and environment of these .ture children all need careful investigation. The instincts and emotions are ed in relation to the various personality defects or undesirable habits which usually e up the presenting symptoms. The opportunity for the application of high-grade ■l technique in this group of cases is unlimited, and the time is not far distant when field will be receiving the attention which it so richly deserves.

My effort has been directed toward emphasizing what appears to me to be fundatal points in the organization of efficient out-patient clinics and the rôle that social ice should play in the development of these clinics. To many of you I am sure it been simply an elaboration of the obvious. Yet your profession is young and in y fields not too well established but little appreciated and frequently tolerated as cessary evil. The idea is still prevalent that the highest aims and purposes of social ice are to dispense advice to the patient and to make recommendations to the social acy interested in him. These ends are important and cannot be minimized or lost t of, yet the constructive work that can be done for the patient in striving to meet demands of the immediate situation is what requires personality, judgment, training, experience. The recognized future development of social work and the fact that achievements must ever be closely interwoven with those of the other professions industry demands ideals and standards which will not only assure its success but mit medicine, law, education, and industry to profit by its endeavors.

THE COMMUNITY'S RESPONSIBILITY IN PROMOTING
THE MENTAL HYGIENE MOVEMENT

Arthur H. Ruggles, Superintendent, Butler Hospital, Providence

It seems obvious that every community must desire to take an active and intellit part in the mental hygiene movement in its own locality, and I shall therefore not le the point as to how much of the mental hygiene movement shall be sponsored by a ral committee, by a national committee, or by a state organization. All of these icies must necessarily take a vital interest in the mental hygiene movement and > their own work to do, which again must, in order to be constructive, be closely in h with the community movements. Each community has its own problems of raphy, type of population, local institutions, local laws, and local personnel of ters. Therefore, each community must work on its own problems with those facts ind. And no society or individual at a desk in New York or Washington can guide lestinies of the city of Providence regarding the work for mental hygiene as well e community itself with the help and co-operation of the larger units. In the great ram of the future activities of mental hygiene the community must co-operate with contribute to the state movement and the national movement, but it must also be vital factor in shaping its own destinies in this most necessary work. How, then, is the community to meet its own problems? First, each community take account of stock, in order to find out how great the need is, what agencies eady to help in the work, and what the future developments should be. This work be kept free from political influence, from any party strife or local schisms.