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Let us take the case of Providence. The mental hygiene movement is in very much the same position now that the tuberculosis movement was in ten years ago. It is said on good authority that only about twelve years ago, when a tuberculosis nurse was added to the force of the Providence District Nursing Association, it was thought that there would be about sixteen cases of tuberculosis in Providence who would benefit by the visitation of this nurse. There are now seven nurses in this Association doing only tuberculosis work. In the list of cases visited by the district nurses a year ago, the number of nervous and mental cases seen and classified as such could be counted on the fingers of the two hands; and yet those of us who know something of the situation in our own city know personally of hundreds of cases that are being seen by the nurses, by the city physician, and by charitable organizations, in which the true situation is the direct result of nervous or mental disease, which at the present time is receiving no attention whatever.

We must try to search out all these cases in the community in order that we may know how many there are, how many nurses we need, what hospital facilities and what dispensary service. This can be done only with the aid of a specially trained physician, nurse, or psychiatric social worker-or, better still, by the co-operation of all three. There must be some office in the city, or in the village, if we are dealing with a rural community, where those interested in the invalid may go easily to seek advice and help. If the office of the State Society for Mental Hygiene happens to be in the community, as it would naturally be in the community of Providence, this serves admirably as a clearing-house for all the mental hygiene problems of the locality. If there is not an office of the state society, then the local visiting nurse association or Red Cross may serve in a similar capacity. I have no hesitation in saying that in our own community when we have secured the services of a psychiatric nurse it will not be two years before the work has grown to such magnitude that a second must be asked for, and that within five years we should have five nurses devoting themselves to mental hygiene in Providence.

But the nursing side is only one phase of the community's responsibility in this work. There is the need of trained study of many of the cases in our local courts, and this community cannot long shirk the responsibility that faces it in the examination of all offenders coming into the juvenile courts and a careful study of the recidivists in other local courts. Too many defective delinquents are now going to the Work House for thirty days or more, and then returning again to be problems in the community.

In the question of feeblemindedness, the community must see that the cases needing institutional care are able in that institution to get adequate care-which means that they must see that proper financial support is given our existing institutions, so that the cases now there and those that will go there in future years shall be properly treated and properly trained, and those that go out of the institution are properly followed up.

We have a small state, all parts of which are within easy access, and the bulk of population is in our own community. We should have a mental hygiene movement which is the best organized, and a mental hygiene program that is the best conducted of any state and community in the country; and yet we are far behind many other communities whose situation is far more difficult of handling than our own. Political machinations have crept in far too much and expert advice and care have been too little valued for the progress of our community work. There are more beds provided

; and mental cases in this state than for all other diseases combined, and yet interest has this community taken in providing for the future and seeing that t provision is the best that can possibly be made? There are no beds prour general hospitals for mental cases. The city has made no provision for y care and observation of incipient cases of mental disease. Annually hunnental shipwrecks could be prevented if adequate temporary care and observa: provided within the city limits.

need a development of out-patient department facilities for early mental cases. a development of psychiatric social service. Cases leaving the hospitals and >atient departments must be followed up. Homes and families must be studied 1 cases of mental disorder have arisen; and other potential mental cases in milies must be cared for. The study of special children in the schools of Provias begun early and has been splendidly developed, but here again the community rovide increasing financial help for the growth of this work if it wishes to be in çard in the enviable situation that we have been in in regard to fresh-air schools e care of the tubercular. Last year in New York City there was a rate of loss ulmonary tuberculosis of 89 per 100,000 of population; while but fifty years ago, e was 408. A reduction of the death-rate from tuberculosis of 51 per cent in the velve years among the 6,000,000 people of New York City, shows us what can ne with other preventable diseases.

here is no disorder which brings about as much suffering in the home and in the unity as that resulting from mental disorder; and yet for this most serious of diss there is the least done. Each community must awake to its opportunities. community that does not want the opprobrium of being derelict in its duty to the must awake to the fact that there are in its midst thousands of actual sufferers from or advanced mental disorder, and that there are other thousands who are the ntial inmates of the mental hospitals of tomorrow; and that we must educate oures to know the true condition, to study the perfected methods, to provide the necesclinics and their accessories, to furnish an adequate number of hospital beds in itals properly supported, to provide the most modern of care.

To many of us the need is distinctly seen, and yet how inadequately prepared we to meet the tragedy of mental disease when it comes to our own! Let us educate selves and our brothers and sisters in the community. Let us provide adequate ns for the study of mental disorder as seen in the courts. Let us insist upon laws t do not discriminate between the rich and poor afflicted with mental disease. Let ee that there are an adequate number of places where the problem of mental disease ts incipiency can be dealt with, that the segregation of the feebleminded is adequately vided for, both as to numbers and as to modern treatment. Let us see that our ntal hospitals that provide for the care of those in our community are the best mental spitals in the world.

If the community rises to its responsibility we could in the next ten years see a water progress made in the prevention of mental disorder than has ever been made in e struggle of the human race against preventable diseases. We will see the recovery te for mental disorder improved by 50 per cent, and the commitments to our hospitals duced in like proportion.

The responsibility is with you and with me. Are we going to meet it at once, and e we going to meet it in the best possible manner; or are we going to delay our respon

Let us take the case of Providence. The mental hygiene movement is in very much the same position now that the tuberculosis movement was in ten years ago. It is said on good authority that only about twelve years ago, when a tuberculosis nurse was added to the force of the Providence District Nursing Association, it was thought that there would be about sixteen cases of tuberculosis in Providence who would benefit by the visitation of this nurse. There are now seven nurses in this Association doing only tuberculosis work. In the list of cases visited by the district nurses a year ago, the number of nervous and mental cases seen and classified as such could be counted on the fingers of the two hands; and yet those of us who know something of the situation in our own city know personally of hundreds of cases that are being seen by the nurses, by the city physician, and by charitable organizations, in which the true situation is the direct result of nervous or mental disease, which at the present time is receiving no attention whatever.

We must try to search out all these cases in the community in order that we may know how many there are, how many nurses we need, what hospital facilities and what dispensary service. This can be done only with the aid of a specially trained physician, nurse, or psychiatric social worker-or, better still, by the co-operation of all three. There must be some office in the city, or in the village, if we are dealing with a rural community, where those interested in the invalid may go easily to seek advice and help. If the office of the State Society for Mental Hygiene happens to be in the community, as it would naturally be in the community of Providence, this serves admirably as a clearing-house for all the mental hygiene problems of the locality. If there is not an office of the state society, then the local visiting nurse association or Red Cross may serve in a similar capacity. I have no hesitation in saying that in our own community when we have secured the services of a psychiatric nurse it will not be two years before the work has grown to such magnitude that a second must be asked for, and that within five years we should have five nurses devoting themselves to mental hygiene in Providence.

But the nursing side is only one phase of the community's responsibility in this work. There is the need of trained study of many of the cases in our local courts, and this community cannot long shirk the responsibility that faces it in the examination of all offenders coming into the juvenile courts and a careful study of the recidivists in other local courts. Too many defective delinquents are now going to the Work House for thirty days or more, and then returning again to be problems in the community.

In the question of feeblemindedness, the community must see that the cases needing institutional care are able in that institution to get adequate care-which means that they must see that proper financial support is given our existing institutions, so that the cases now there and those that will go there in future years shall be properly treated and properly trained, and those that go out of the institution are properly followed up.

We have a small state, all parts of which are within easy access, and the bulk of population is in our own community. We should have a mental hygiene movement which is the best organized, and a mental hygiene program that is the best conducted of any state and community in the country; and yet we are far behind many other communities whose situation is far more difficult of handling than our own. Political machinations have crept in far too much and expert advice and care have been too little valued for the progress of our community work. There are more beds provided

ch was largely attended and productive of good results. What if the university on hill were to establish a department of mental hygiene? What a rare opportunity be given for developing the problem of Providence about this department of Brown iversity! Think of the high standard that would be established at the inception of work, and realize how effectually our mental hygiene program might be rescued m political entanglements. We must see to it in this community, as I know each one you wishes to do in your own community, that the mental hygiene movement as it is veloped is developed on a truly constructive and honestly conceived plane, and that -ose watching over the destinies of the individuals in our community, both inside the stitutions of the state and outside of them, shall be directed by individuals thoroughly ained, of broad vision, with a true concept of their duty toward humanity, and unemarrassed by any political affiliations.

I want to express my own appreciation of the great good work presented in this ection of the Conference, and to say that although far too few of our community leaders ave attended these meetings much good is sure to result from the seeds that you have own, and Providence owes you a very great debt of gratitude for the presence of such n earnest body of workers, for the words of wisdom that have been pronounced in this ›ld church, and for the outline of a mental hygiene program which is safe, sane, and an mperative need—a program for which I think that we are all very much indebted to the wise leadership of your chairman, Mr. Hastings.

THE COMMUNITY'S PART IN THE CARE OF DEFECTIVES

Charles S. Little, M.D., Superintendent, Letchworth
Village, Thiells, New York

It seems to me that the community's interest in the mental defectives is so interwoven with the institution interest that the two problems should be spoken of together. But before touching on the community's part in the care of the mental defectives, let us very briefly bring ourselves up to date by reviewing what has been the attitude in regard to this problem in the past. Without going into ancient history or alluding to the works of Etard and Seguin in France, I propose to cover only what has been done in this country.

The first teacher of the feebleminded in this country of whom we have any record was Dr. Howe, of Massachusetts, and this work was carried on in connection with the Massachusetts School for the Blind, starting in about 1848. It was his hope and the hope of many others who followed him that by special training the feebleminded could be cured and returned to society as useful members. Although he and others of his contemporaries were encouraged by the improvement manifested, still the cases were not cured. From our latter-day knowledge of mental defect, I suspect that they were working with a much lower grade than many who come under our observation today. From that little special class of Dr. Howe's in connection with the Massachusetts School for the Blind, institutions for the feebleminded were started in Massachusetts, then in New York, and so on state by state until now nearly forty states have institutions for this group, and some have several, New York having four. But more important than the development of the institution for the feebleminded has been the growth of the special or ungraded class, which is intended to supply the defective living at

sibility and when we do meet it, do so in a makeshift way, as the result of political int ference and a niggardly appropriation? There can be but one answer. Each cor munity desires to meet this responsibility, but it will not and cannot do so unless eac one of us constitutes himself and herself as a committee of one to see that the work begun now and that the work is well done.

Having listened to many of the talks before the mental hygiene section of th Conference, I feel that everything contained in my paper as originally written has bee said in a manner better than I should be able to express it; but although my paper his already been presented to you by other speakers, I have nevertheless gotten materi from these other speakers which I shall use today.

I believe that the mental hygiene program has outstripped the workers capable c carrying it out; and the thing most impressed upon me, as a result of the papers of this Conference, is that not only the community of which I am speaking, but also the state, must aim its immediate program to the securing of psychiatrists, of psychiatric nurses, and of psychiatric social service workers in great numbers. I believe that at least double the number now engaged in our work are needed at once and that we must stimulate the individual and all our educational institutions to the training of these workers, and that until this is done we can but continue to scrape the surface of the work already before us. I feel sure that if I asked each one of you whether you felt that the mental hygiene program in our community was adequately covered by psychiatrists, psychiatric nurses, and psychiatric social workers, your answer would be in the negative, and that we would all admit that the program as outlined has far outstripped the personnel to carry out this program. Therefore, it seems to me that the next great need in the mental hygiene movement is the need for personnel to carry out the work already outlined.

I have never attended a conference in which the problems before it were so carefully diagnosed and in which the treatment was so wisely indicated as in the mental hygiene section of the National Conference of Social Work; and yet I have been brought face to face with the fact that we are entirely inadequately staffed for carrying out this program, much less to extend it as it necessarily should be within the next few years. When we realize that it takes approximately ten years from the high-school graduation to produce a psychiatrist, three years from the same period to produce the psychiatric nurse, and two years for the psychiatric social worker, we must realize that we can lose no time in going back to our communities and constituting ourselves a committee of one to see that we enlist some individual to at once train themselves for this most important part of the public health program. There is, and there should be, no short-cut attempted toward obtaining the trained worker for the various branches of this activity. We all of us know the dangers of the inadequately trained and inexperienced worker in our field, and we must never countenance a program which encourages inefficient work.

One of the colleges of this country, situated in a very small college town, has through its trustees voted to establish a professorship of mental hygiene. What a wonderful solution for the community's problem regarding mental hygiene! To be sure, no one has yet been found to take that position, but someone will be found before very long, even though that individual is lost to another community where he may be sadly needed. But when the department is in active operation, what a wonderful center about which the whole community's problem can be organized! For the past two years Brown University has had an extension course in psychiatric social service

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