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ignorances, its financial difficulties, its pressure for quick decisions, its inevitable compromises, its deep and sound common sense. We talk little and write less of just how we, as practicing case workers, are working out these pratical applications. We say we are too busy, that we lack the necessary perspective; we allege that we long for the time when we can get away from the pressure of our office and "think things out." And yet every day we individually arrive at diagnoses and make plans, see the immediate results of these plans, and have to bear the onus of the community reaction to their success or failure. Is it not absolutely necessary for us to take the time to record our experiences, to state our convictions, and thereby to help standardize our new profession?

In no field is this truer perhaps than in case work, which involves the problem of so-called high grade feebleminded individuals. There is a very definite, very ¡ractical, very human contribution that we, as case workers, have to make to this 、roblem, and yet it is one in which we have been markedly content to leave the whole iscussion to the eugenist, the psychologist, and the institutional superintendent. [any thoughtful case workers who meet other family problems with elasticity and he originality that is born of wide background and much practical experience seem › stop thinking when they approach this problem, to assume a hopeless attitude, ad to take it for granted that good case work is impossible in this field, that the one ing which can be done is to work for better custodial provision for such subnormal

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It is of course the popularization of the psychological tests that was partly brought out through the war, together with the published results of the army tests, that has rced us into a different attitude. As it became routine to test our families, we began realize that what the army tests had shown for the country at large was true for ir own communities-that a surprising proportion of our families contained subormal persons, and that these subnormal clients differed as much among themselves so-called normal people do, and that many of them had a definite share in the world's ork. The increased work opportunities also brought about by war conditions, the illingness of employers to utilize uncritically any sort of labor power, made possible ich experiments as Miss Bigelow's in the rubber factories in New Haven; and the ›nviction grew on us that many of our failures with the feebleminded had not only ɔme from our generally unintelligent and prejudiced attitude toward these people, ut especially from the poor work we had been doing with them vocationally. And long with these convictions came an understanding of how unintelligent is it to deal with these clients on the basis of intelligence alone, how important it is to reckon with he equally important factors of emotional quality and will power.

Then, on one hand, the extension of the machinery of social work in the form of a great increase in the number of out-patient clinics, both in connection with state institutions for the feebleminded and in connection with general clinics, was a tremendous stimulus and help to home supervision of this group. (It may be noted here that a wilder interest in psychiatric problems has tended to emphasize problems of mental instability rather than problems of feeblemindedness, and that clinics not only willing to give psychological tests and general recommendations based on them, but with facilities for re-examination and continuing expert advice, are still all too rare.) And on the other hand, the carrying of case work into rural communities, so splendidly pushed by the Red Cross, put case workers on their mettle not to depend on machinery

for the solution of their problems but, where no such machinery existed, to try out instead novel and individualized kinds of personal adjustment.

I happen to be working in the heart of New York City, and we metropolitan workers have this bond in common with the county workers in a so-called backward community, that it is practically impossible to obtain custodial care for a feebleminded woman, particularly if she is married, if she has a fair measure of health, can earn money from time to time, and is not a proved lawbreaker. Her children may be taken from her on the same grounds on which children may be taken from a normal mother, but she herself is left to go on being a community problem. It is waste of time, therefore, to seek commitment for most of our feebleminded women. Carefully supervised employment in the suitable institution on a regular pay basis is the nearest approximation we can secure to segregation, and the instances of home supervision that I would like to discuss with you this morning are instances where we have been forced to undertake supervision because there was no other course open to us.

Before taking up the problems that are definitely problems of subnormality let us remind ourselves that there are many of our clients who, without due consideration on the part of the psychologist to the full history that a thorough case worker can give, might be given a very low I.Q. indeed. There are so many factors that, singly or together, may cause a deterioration similar to feeblemindedness, such as long continued physical abuse of any sort, years of fear and anxious dread, even when due to imaginary causes, long continued underfeeding, syphilis, alcoholism, and endocrine conditions. We are always hoping, with these borderline women, that fuller inquiry will show that there is some such definite cause for the low grading, that originally our client was a normal woman, and that patient treatment will make her at least approximately a normal woman again.

But this hope eliminated, there are certain great principles that every worker with the feebleminded knows by heart. These subnormal people are creatures of habit. Like a street car, they go fairly easily and smoothly and without too many jolts and jars on their accustomed track. Once off the track, they flounder wildly about and probably run into something and smash. There is very little power of initiative and no elasticity. The problem is to find what simple things they have been trained or can be trained to do, and then seek no further. To be successfully supervised while living freely in the community, these clients must be of docile temperament, with no complication of insanity. More than that, they must have a certain readiness to meet the worker half way, be willing to "co-operate," as our somewhat hackneyed phrase goes. Their immediate environment must be favorable for treatment. The most important factors in such a favorable environment are (taking for granted adequate shelter, food, and medical attention) first, opportunity to do enough routine work which does not require planning to keep them busy and out of mischief-by using up their surplus energy, and, second, kindly people in their personal environment, people who have the character to command the respect of these clients, and who will give steady encouragement to weak-willed, suggestible women who are only too accustomed to discouraging and unfavorable criticism. It goes without saying that the feebleminded woman who is markedly promiscuous sexually cannot be given successful extra-institutional treatment. But as we arrange for psychological tests, not because of the anti-social behavior of the individual, but as routine, we find many feebleminded individuals becoming dependent from time to time whose sex

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behavior approximates the normal. Others have had a poor sex record in adolescence, but have "settled down" after marriage.

The visitor who undertakes the supervision must be one who is on the staff on a long time basis, who is not carrying a heavy case load, and who is by temperament interested in problems involving time and patience. To be successful this visitor should be a person of truly democratic and friendly ways, who knows how to combine a gentle and kindly attitude with an occasional stiff dogmatism, who will try to win the simple affection of her subnormal client, and who will not grow weary in hammering upon a few specific points that especially need to be stressed, and which, early in the plan, it has been decided to stress. The old Wordsworthian phrase "We live by admiration, faith and love" is just as true for our subnormal clients as for our normal ones. Once a personal loyalty is secured, it is very lasting.

If the emotional factor is tremendously important in the lives of these people, their physical well-being is equally so. that makes it seem impossible to fit the poor client into any groove, may again The uneven temper, the general "contrariness" be due to syphilis, to an endocrine condition, to a pelvic irritation, to ulcerated teeth or tonsils, and adequate treatment may make the difficult woman comparatively co-operative and docile, to an even greater degree than in higher grade people. These physical difficulties corrected, the supervising of a feebleminded woman is twofold: it is a problem of the focusing of suggestion, by case work methods, and it is a vocational problem. The visitor of strong personality who relies on her own ability to influence her subnormal client will sooner or later lose out. In some way or other the co-operation of the client's group must be obtained in suggesting the same ideas that the visitor is trying to put over, or the individual social worker's work will be of no permanent value.

A successful handling of the vocational problem goes back very definitely to an exact knowledge of the early history of the client. How often Dr. Pearce Bailey's words come home to us: "An individual with a mental age of eight years who has definitely acquired habits of industry, obedience and regularity, is a far more useful member of society than a high grade moron who has never acquired such habits."

How often the case worker has taken a subnormal client away from a job which she has held for eight or ten years, as, for instance, that of a "shaker" in a laundry, because it seemed to the case worker so deadly monotonous, and because there was not opportunity for advancement, and placed her in a pleasing position at, say, wrapping and packing fine china, and later was bitterly disappointed because the client wended her way back to the old job in the steaming laundry. It is just the sort of work whose monotony would drive more highly organized women insane that appeals most strongly to these women, and it is on this basis, the possibility of lessening of labor turn-over for monotonous jobs, that we can best get the co-operation of the employer in these vocational experiments. And yet we must not forget that this type of client frequently manifests special abilities, the opportunity to exercise which is always important to her general happiness and contentment, and may be economically important as well. The subnormal man with a mechanical gift, the subnormal woman who is a good dressmaker, or a fine ironer or a gifted cakemaker, are known to every case worker.

Miss Bigelow's experience in New Haven and the experience of other people who have worked along similar lines, has been that some very anti-social behavior tends to disappear when the right vocational adjustment is made, along with a general

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environmental adjustment. The workers have simply not the surplus energy or time to get into mischief. That vocational guidance of this sort involves a friendly and honest understanding with the available employers and their foremen goes without saying.

Better state provision for segregation must remain the only satisfactory solution for the difficulties presented by many of these people. But are not our psychiatrist friends, indifferent though they are inclined to be to this particular problem, always reminding us what bad mental hygiene a wishful attitude is, how necessary for our minds' health it is to sturdily face life as we find it. And so, since custodial care is not to be had, and we are, frankly, opportunists, we rejoice that with these cases of moron women an adjustment can be made that is socially useful; that in the actual world which these handicapped families and we have to face they, to paraphrase Louis Blanc's old saying, have received according to their need, and are now contributing according to their ability.

C. EXTRA MEDICAL SERVICE IN THE MANAGEMENT OF THE MISCONDUCT PROBLEMS IN CHILDREN

M. E. Kenworthy, M.D., School of Social Work, New York

It is my purpose to present to you some of the outstanding opportunities through which extra medical service may be of indispensable use in the management of conduct problems in children.

For two years we have had a mental hygiene unit in connection with the Vanderbilt Clinic, under the able leadership of Dr. Bernard Glueck, the primary aim of which has been to furnish a practical teaching center for the training of psychiatric social workers engaged in study at the New York School of Social Work. The results of this work are gratifying from two points of view.

First, through this clinic medium the workers have received adequate experience in handling cases of maladjustment and misconduct. The facilities of a clinic of this kind furnished a varied type of cases with all gradations of maladjustment, ranging from the very simple problem of faulty parental understanding to the more serious grades of mental disease. You will readily see then why a field of training presenting such a rich variety of problems supplies the student worker with a more comprehensive understanding in the field of mental hygiene than could be supplied by a state hospital which deals largely with the end results of mental disease rather than maladjustment in its incipiency. In the pursuit of these studies in adjustments of cases, we often have found that the situations met with were not only germain to psychiatric practi as such, but the conditions existing paralleled those found in all case work deali with human problems-those of the family, child placing, etc. Thus we were led appreciate that in all case work one must recognize the presence of the mental hygie problems.

Second, we found that in the adjustment of the patient the continuous and co-operative assistance of the social worker became a forceful therapeutic agent in carrying the case to a satisfactory conclusion.

It might be well to ask ourselves, then, before entering concrete situations, "What are the aims and tasks of the

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this term I mean all social workers, for I feel more and more strongly convinced that this field of psychiatric inquiry, containing a wealth of mental hygiene principles applicable to every branch of case work, should become a basic foundation in the training of all social workers. It is to be hoped that before many years we will no longer divide social workers into specialized groups, accepting the psychiatric branch as an entity apart, but that included in every social worker's training there may be furnished a thorough understanding of the problems in the field of mental hygiene, in order that every case worker through the medium of her mental hygiene equipment may be able to understand and adjust the problems which she meets in actual practice.

What then shall we conceive as the fundamental task of the social worker engaged in the handling of cases of maladjustment? The first principle in the consideration of this problem of human endeavor is the necessity of determining the motive behind every act, that is to say, we must seek to find the key to each problem of misconduct. In order to do this, it is the purpose of the worker to discover and interpret with the aid of the psychiatrist all the data.

The first step towards this goal is the collection of all available material, in order to furnish a complete knowledge of the elements in the child's life which tend to shape and influence his development. By means of this the worker will be enabled to gain some insight into the concrete forces making for success and failure in every case.

In view of this consideration it would seem pertinent to ask what are the requisites needed for the successful understanding and management of cases of maladjustment. In order that we may be enabled to satisfactorily direct the progress of any given problem to the best advantage we must have a complete understanding of the situation through the study of the personality of the patient, so that we may estimate human values aright. This involves a knowledge of the individual's native and acquired equipment, an understanding of his inherited traits, an evaluation of his special aptitudes and handicaps, and a carefully made estimate of his family.

If we are to attempt to modify or reshape the original desires and strivings of the patient through our efforts at education we must perforce recognize some of the possible sources of conflict or failure in his attempts at adjustment to life. Thus we are early led to recognize that dissatisfaction which becomes reflected in the patient's attitude may be a result of a specific reaction to his surroundings.

In the consideration of the possible sources of these dissatisfactions let us first discuss those which may emanate from the home. Here it would seem that the social worker has a unique opportunity to gain a better knowledge and insight into this side of the problem than the psychiatrist himself, through her many possible contacts in the home.

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