to be recognized as such by their own profession, who have a most inadequate conception of social treatment. The real social psychiatrist is a scarce article. The clinic imports several ready-made-saves the social workers of the town all the trouble of training one. The clinic, in fact, bridges the gulf between psychiatry and case work.

The fifth contribution of the clinic is that, on the average, it does more intensive work than other case work agencies and, incidentally, induces the other agencies to go more intensively into the problems which they bring to the clinic. Here is an instance:

A boy of fifteen refused to do anything in school, even to taking off his overshoes and coat. He had been obliged to repeat several grades, having been a chronic truant. At home he had stolen money repeatedly. Finally he was brought into court on charge of being incorrigible and a runaway. Today his attitude at school and in the home has completely changed. He has become fond of his teacher-the same teacher he hated—and he seems willing, even anxious, to please. For the first time he is trying hard with his school work, has been advanced a grade, and is doing the work well. This improvement has continued for several months now without one lapse. At home also he is now happy. For the first time in his life he has even offered to help his sister with the dishes. This conversion was affected by the clinic on the basis of the following diagnosis and treatment:

Handicapped early in life by the death of his mother, this boy had longed in vain for someone who would show him affection. His stealing was for the purpose of getting money to buy the affection of his comrades by treating them. He was lying as a defense, not to get anyone into difficulties. The clinic recommended that the teachers and social workers should not stress the incident when he was caught stealing, but simply make him return what he had stolen, and that his lying should also be overlooked. Other interests were supplied, instead, to occupy the center of his emotional life, replacing the scoldings and whippings. John's teacher was told of his longing for attention and affection. And the teacher, seeing the point, made him feel that there was a place for him in school, praising him whenever possible. John has mechanical ability, and is now being given a chance to express it. A "Big Brother" has taken him auto riding and is showing a real interest in him. John's older sister, after having the situation explained to her, has ceased to nag him, and is paying him more attention. Thus the affection and attention which he craved have been substituted for censure, and his delinquency has ceased.

Before the clinic, six social agencies were interested in this boy, including the attendance department, the juvenile court, and the Associated Charities. The clinic brought in the element which, in this particular case, made their work for the first time really effective.

Thus does the clinic help with a most difficult part of case work, namely, the establishment of a relationship between social findings. For example, here we knew that John stole, and we also may have observed that he had an in

feriority feeling and a longing for affection. But we might not have connected these two facts, nor thought out the solution. The clinic helped us to see that stealing was simply the expression of his inferiority feeling and yearning for affection. And when the boy was given a chance to achieve in other ways he did not think of stealing thereafter.

Clearly such adjustments are a joint product. The clinic helps the agencies, and the agencies greatly facilitate the effectiveness of the clinic by placing at its disposal their great bulk of accumulated information and by applying in many other families the principle suggested in a few instances.

The social agencies are looking to the clinic to demonstrate results in case work. Even the most progressive general case work agency cannot practice so thorough a study of more than a small percentage of its cases. The clinic, with its very limited case load per worker, its comparative freedom from the exigency of a time limit, and its well-nigh ideal set-up is a strategic position to be a standard-maker.

In addition to the stimulation it gives in individual cases, the clinic is peculiarly equipped for research as to the effectiveness of various lines of treatment.

Even when it fails, we may learn from the experiment. For instance, I am most interested right now to learn whether heredity or environment will triumph in a case where the clinic is endeavoring, through environment, to change the character of a problem child of eleven with an Intelligence Quotient of 146, almost in the genius class, whose mother was epileptic and feebleminded, and whose father was psychoneurotic and unstable. This girl is sexually precocious, and is manifesting other behavior difficulties. Such a struggle between heredity and the best case work, if recorded in many such instances, should indicate the future direction of our efforts towards prevention.

In instances where the clinic's case work succeeds in effecting a social adjustment where our case work has failed, we derive the tremendously valuable opportunity of studying our own previous failure. Here we can hold up a mirror before us. We can study wherein our unsuccessful treatment deviated from their more successful plan. Thus can we discern our weaknesses, and can at the same time absorb their more successful technique to be applied in other similar cases; of course, with the advice of such specialists as the psychiatrist and the physician.

We would not convey the entirely false impression that the clinic always suggests a more effective plan. Often its plan does not prove more effective than our own. Such double failure of both the local agency and the clinic reveals the even yet undeveloped stage of our case work technique, and demonstrates the need for a cooperative effort on the part of us both to delve more deeply into motivation and study more painstakingly our technique, until each group can reach its highest achievements with the aid of the other, until we are able to touch springs of human action now hidden, and assemble social forces not now known.

THE PROBLEMS OF A PERMANENT CHILD
GUIDANCE CLINIC

Hester B. Crutcher, Chief Psychiatric Social Worker, Child

Guidance Clinic, Minneapolis

The problems which daily confront a permanent child guidance clinic are so many and so complex that even to attempt an enumeration of them within the brief time which is allotted me becomes out of the question. It is, therefore, my task to select, from the many issues which present themselves, a few of those which have been most forcibly brought to our attention during the first year of our work in Minneapolis. These problems may be considered under the following heads: first, what is the permanent clinic? second, the financing of the clinic, involving question of personnel and intake; third, type of servicepreventive or curative, complete or partial study; fourth, educational and preventive work; fifth, research work; sixth, unification of the efforts of the social agencies for a mental hygiene program.

The first question—just what is a permanent clinic? Is it a diagnostic and consultant service for the problem cases of social agencies and parents? Or is it an interesting experimental frill maintained so as to give an air of progressiveness to the public board which sees fit to maintain it? In either case, how can the community be convinced of the necessity for its continued maintenance? If such a clinic is supported by a community chest, then the probability is that its value would be recognized by the social agencies, its bearing on the solution of their problems appreciated, and its permanence not so vague. Its continuance would, no doubt, be assured as long as the community chest was adequately financed. Furthermore, its type of service and nature of intake would be chiefly indicated by the agencies which it serves. If, however, the clinic is maintained by a publicly financed board it must, in addition, have some results evident to the public at large to justify its existence; otherwise it becomes a matter of enlisting the power of the erudite and influential to keep the clinic in the public graces.

Aside from the necessity of obtaining visible results there are other difficulties which invade the realms of the publicly financed clinic, such as the question of maintaining satisfactorily trained personnel, and the exclusion of those desirable from a political standpoint; to avoid having the clinic used as a parking place for time-honored employees who need comfortable salaries and whose chief qualifications are age and life experience.

The problem of intake of a clinic so financed is also a paramount one, both as to number and selection. How much consideration should be given to the children in whom strategic people such as doctors, influential parents, etc., are interested? Often these children are referred to the clinic with some imagined behavior disorder or personality difficulty. This may cause the clinic to be surfeited with cases for whom, from a psychiatric standpoint, the real value of its

services is relatively small. On the other hand, is it not a valuable service to reassure parents, who feature minor difficulties, of the assets and possibilities of their children?

Though I hold no brief for the clinic financed by the public budget, there are many factors in favor of the clinic so supported. There seems to be a certain prestige which accompanies a public movement, and its right to make certain demands for the cooperation of other public agencies is recognized. Thus, when the clinic is under the direction of the school board, as ours is, the teachers seem to take a proprietary interest and, on the whole, are most willing to do any extra work incumbent upon clinic examination, treatment, or a research project initiated by the clinic.

Likewise, would not other public agencies, such as the juvenile court, child welfare boards, etc., have a certain fraternal feeling toward a clinic which, like themselves, has the public backing, with the perplexities which this entails? Our Minneapolis experience has led us to believe that they feel more free to discuss their problems, make requests as to the types of service most feasible for them, and offer constructive suggestions.

It would seem that if a clinic can be adequately financed by public boards without dogmatic restrictions as to service and type of work, and with the assurance that it is relatively permanent, not the hobby of some passing politician, then such maintenance would seem highly desirable.

A question that confronts all permanent clinics is the type of work which should be undertaken. In the first place, should the main efforts of the clinic be directed toward cases where the difficulties are apparently in their incipiency and may or may not become fixed and undesirable? Or should its main efforts be directed toward curative work where undesirable patterns of reaction seem fairly well fixed? In our present state of knowledge, are we able to distinguish definitely cases for which preventive work is needed, provided there is no asocial reaction and no overt behavior? If we cannot differentiate such cases, is it not better to concentrate upon an attempt to "cure," and from these data, eventually, can we not work out a technique of prevention?

Should the clinic have various types of service, or should a thorough and exhaustive study be made of every case, so that errors of treatment can be reduced to a minimum? Take, for instance, the case of a child who is exceedingly low-grade intellectually, yet both parents and teachers have expected the standards of the average child of him and he has been pushed and pressed at every hand. His behavior may be decidedly asocial. Is it fair to assume that his undesirable reactions are the result of this pressure and that, when his mental inferiority is understood and his environment simplified, desirable reactions can be substituted for his undesirable ones? If so, then would not partial study (a social history, a psychological examination, with perhaps a physical examination) be adequate? (Psychological facilities outside of clinics still do not seem easily available in many cities.) Similarly, in certain cases a brief social history

and a psychiatric examination may frequently serve the purpose. Is it feasible, as another rather extensive type of work, for the social service department to maintain an advisory or consultant service for parents? Is it possible for a wise selection of problem cases to be made by the social worker in this way? If it seems legitimate for the clinic to render such types of service rather than the thorough study of every case, its services thus can be greatly extended, which is most desirable in a publicly financed clinic, as numbers seem to talk. Is the risk involved great enough to justify the curtailing of this service? The Minneapolis clinic does not feel that it is, and, so far, followup on such partial service cases has not shown this practice to be undesirable.

What of the educational phase of clinic work? Certainly this is a most important phase, and how can a program of preventive education best be carried out?

All clinics seem to agree that staff meetings offer the logical means of giving the social agencies an insight into clinic methods and procedure. The question is how to make these staff meetings both alluring and educational. Unless the discussion is carefully guarded it is apt to drift into reminiscences and comparisons on the part of the social workers. If the discussion is too carefully guided, spontaneity may be lost, and an atmosphere of restraint prevail, which makes the meeting unpopular, dry, and boresome. People in general, and social workers especially, take it as a personal affront if they are not allowed to express their opinions freely. Just how to stimulate this free expression and at the same time secure intelligent discussion is indeed a problem.

The group which can be reached by staffs is relatively small; hence, if possible, a consistent system of preventive education should be worked out with parents and teachers. Can courses in mental hygiene be made available, interesting, and practical for parents and teachers, or is a little knowledge a dangerous thing? The problem would seem to be to make the limited amount of information so acquired sufficiently intriguing that more would be eagerly sought for. The wisdom of Solomon might be necessary to achieve great success in this way; yet does not a fair amount of success, with the maximum precaution to prevent undesirable results, make the experiment worth while?

Since the Minneapolis clinic is working with the schools, an attempt was made to initiate preventive work by a study and advisory treatment of kindergarten children. These children will be followed as they progress through the grades, and it is hoped that some definite results of preventive work can be observed and further plans for this type of work formulated.

As a preventive, and also a constructive, measure in mental health, a course in mental hygiene was given to one hundred high school seniors. Results cannot be measured, but apparently there has been little adverse criticism, either from parents or pupils. Optimists would interpret this favorably.

Since clinical work is as yet largely in the experimental phase, the fund of material which is acquired should be made available to those working in similar