In the prevention of social disorder the personnel worker equipped with the point view of mental hygiene has a large opportunity both to preserve happiness and romote efficiency. Temperamental difficulties, peculiarities, unfulfilled longings, isappointed ambitions leading to conduct that makes trouble in the shop and creates avolved situations at home, when properly understood and dealt with from the sychiatric standpoint may often be rendered quite harmless. The promotion of nental hygiene of industry would do a great deal toward the prevention of social

disorder.

The general public is at the present time highly receptive to ideas of mental hygiene, to such an extent that any practitioner or panacea advertised with assurance as a mental help readily gets a following. At the same time there are comparatively few persons who regard mental disease with the same objectivity with which they regard physical disease. And most persons still think of mental hygiene only as a means of avoiding mental disease. The social worker is probably the best agency there is for spreading better information concerning mental health and mental disease. In every case she deals with she interviews numbers of persons-anywhere from five to twenty-five possibly. Both by her attitude toward the patient in question and by what she tells about him, she leaves behind in every interview an impression that the trouble is a disease to be regarded as other diseases. Moreover she has countless opportunities to talk with family relatives and friends of patients about mental hygiene as a means of increasing happiness and efficiency. This responsibility for public education should be consciously part of the duty of the psychiatric social worker in particular.

In considering the educational value of psychiatric social work to the community, I have spoken only briefly of its influence upon psychiatry and upon public education and have discussed almost entirely the influence it is exerting upon social work because the benefit to the community of this latter influence will, I believe, outweigh in extent and importance all other effects of psychiatric social work.

C. MENTAL HEALTH CLINICS

H. Douglas Singer, M.D., Professor of Psychiatry, University of Illinois; Alienist, State Department of Public Welfare, Springfield, Ill.

While it may not be quite true to say that every case in need of social service is a psychiatric one, the reverse that every psychiatric case is a problem in social adjustment is unquestionably true. Social existence with the necessary control of individual desires, which this implies, is impossible without corresponding mental development in which is included not merely intelligence but also the manner in which this is used. In other words psychiatry is the science of behavior.

Mental health must be the most important factor both for the welfare of the social group and the happiness of the individual. Its province extends far beyond the realms of insanity, which represents only certain forms of mental ill health which require segregation from society because of the dangers which result from this behavior to the patient or his surroundings. It enters into the immense fields of dependency, delinquency, and crime, and furthermore it is concerned with untold numbers of chronic invalids, usually grouped as nervous or neurotic, who form such a large proportion of the clientele of the general physician and the specialist as well as of irregular practitioners, fakers, and the various cults. Clinics (the word implies the presence of beds but this true meaning is now practically eliminated by usage) for the study and treatment of diseases of various parts of the body have long been in existence and it seems but logical that others devoted to the study and treatment of the man as a whole, his behavior, are at least equally important and equally medical. Yet the number in existence is extremely small and those largely of recent development. The problems are as yet but poorly defined and it is probable that experience will bring in the near future many modifications and developments.

Before discussing the needs in general terms it seems wise to illustrate by actual experience. For this purpose I will quote some figures derived from one hundred consecutive cases seen at a clinic maintained in Chicago at the dispensary of the College of Medicine of the University of Illinois with the co-operation and assistance of the Illinois State Department of Public Welfare. Under this plan which is as yet only partly in operation, there are maintained two separate clinics: one for the study of children, known as the Institute for Juvenile Research, is under the direction of Dr. H. M. Adler who is also criminologist to the department; while the other, for adults, is under my own direction. It is from the latter that these figures are taken. This clinic has been developed in the department of the general dispensary devoted to nervous diseases and for that reason possibly receives more strictly neurological cases than might be true in a clinic developed primarily for mental health. The combination, however, seems to be an excellent one, for the reasons that it helps to diminish any objection there might be upon the part of patients to a clinic bearing the title "psychiatric" or "psychopathic" and that a large proportion of the patients of any neurologic clinic are strictly mental cases. At the present time the clinic is handicapped by the absence of beds and wards for the special observation and study of suitable cases, though a hospital for this purpose is now in course of erection. There is also an absence of some desirable facilities for treatment, the lack of which is felt continuously; these also will be provided in the new quarters.

In Table I have been grouped the reasons which led the patient to come to the clinic. It must be understood that many of the cases might well be included in several

different groups but it was thought best to indicate only the problem which seemed to stand out most prominently in each case.

Under the heading of bodily complaints have been placed not only the more strictly neurologic difficulties such as paralysis, blindness, etc., but also many psychoneurotic complaints such as nervousness, insomnia, headache, etc., which have led the patient to seek assistance on his own initiative or on the advice of friends or

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physicians. Such cases often have not as yet become definitely social problems to the general public but they are inefficient, more or less dependent and, where money is scarce, liable to become burdens upon society, very probably dragging others with them. Under the heading "Special reasons" have been grouped cases referred for Wassermann or other tests or for examination as to fitness for mother's pensions, etc.

It will be noted that 38 per cent were referred because of definite difficulties in social adjustment and an additional 8 per cent because of mental symptoms which caused upsets in the social environment. Thus approximately one-half the cases have already been recognized as social problems.

The diagnoses reached are shown in Table II from which it will be noted that mental deficiency combined with the related groups of defective delinquent and inadequate personality constitute about one-third of the cases. The psychoneuroses come second and it is of interest to note further that many of the cases placed in the group of mental defectives also presented psychoneurotic symptoms. This is undoubtedly due to the fact that the struggle for existence and self-expression under social regulation is rendered much more difficult by reason of the lack of intelligence.

In Table III is given a list of the agencies concerned in bringing these one hundred patients to the clinic. It is not a complete list of those which have referred cases. It is a sufficient indication, however, of the widespread relations concerned.

beds, which will permit detailed observation of the behavior under the controlled conditions and also permit the performance of some of the laboratory tests, are also essential for thorough work.

But since the problems with which the clinic is concerned are essentially social it is obvious that trained social workers to investigate conditions in the home, at work, and at play, are absolutely necessary. Such assistance under favorable circumstances may often be secured by co-operation with the agencies referring patients to the clinic, but it is to be remembered that many times success in treatment and the avoidance of more serious difficulties will depend more upon the quality of the social worker than upon any other factor.

The treatment may be considered under two headings: first, that which attempts to correct the deficiencies or faults in the patient; and second, that which is designed to modify the conditions under which he must live. The former concerns (a) the remedying or minimizing of handicaps due to disease or defect in which assistance is often necessary from other medical or surgical departments of a general dispensary service; and (b) the application of psychotherapy which means the education of the patient in the nature of his difficulties and their mode of origin, with advice and assistance in adopting more satisfactory methods of meeting them. Valuable assistance in this procedure can be secured from hydrotherapy, electrotherapy, occupational therapy (used, not as a means for vocational training but, as an education in habits of application and the development of outlets for self-expression in the form of hobbies, artistic interests, etc.), and employment and recreational agencies.

In the modification of the environment, trained social workers are again essential if the patient is to be kept in the community and does not need to be removed temporarily or permanently to the simplified conditions of a hospital or colony.

In some cases it may be permissible for the clinic to secure some legal authority over a patient which will be respected by him. This can be brought about by means of probation from juvenile, domestic relations, or other courts, or by preliminary commitment to and parole from a state hospital. Such steps, however, must be taken only with the most careful consideration as it is absolutely essential that the patient realize that the clinic is working for and not against him. For this reason it is preferable such steps be taken by some other agency.

The location of the clinic need not detain us; it should be as easy of access to its patients as possible and, as already pointed out, in close proximity to, preferably a part of, a general medical and surgical dispensary. The hours of operation are, however, important, in view of the fact that the difficulties to be remedied are those of social adjustment. For this reason it is especially desirable to disorganize the hours of employment of the patient as little as possible. Hence evening hours should be arranged for those who cannot come during work hours.

For securing contact with patients, affiliations must be established with all organized public welfare agencies-schools, churches, courts, police, charitable, etc.with the medical profession, and by popular lectures and demonstrations with the people of the community.

The source of supply of the psychiatrists to take charge of these clinics will probably vary with the conditions. In large cities it may be possible to secure the services of trained neuro-psychiatrists in private practice but in many instances, especially in the smaller communities, this service should be provided by the state hospitals. The