for the pediatrician, psychologist, and psychiatrist a social history which includes data on health, intellectual ability, and emotional adaption to life, and it should fit the recommendations of these three consultants as far as possible to the daily life of the child. This seems to be the first principle in organization of clinic service for a children's agency to which our reasoning has thus far led us.

But it will be said, It is impossible, for two reasons, for many children's agencies to do this: first, because their understanding of health and personality problems is too limited to enable them to gather data which the clinic needs, second, because they are carrying so many cases that even if they had adequate knowledge of physical and mental health, they still would not be able to put clinic advice into effect because they can give too little time to individual cases. If a clinic has developed in a community where this is true of the majority of the social agencies, we can sympathize with it and hope that it will see, as some clinics have seen, that its function is primarily education as to the meaning and time-consuming nature of all case work. For such a clinic it is of utmost importance that the psychiatrist and the chief of social service be good teachers even more than good technicians; that they be tolerant, patient, and willing temporarily to sacrifice ideal clinic practice to gradual education of the social agencies. If the clinic makes common cause with the agencies, explaining that success with cases handled by its own social service staff is dependent not only on insight and good technique, but also on a low case load, and if it succeeds in so interpreting case work that the agencies, in time, will be willing to secure workers with adequate equipment and enough of them to make it humanly possible to do their work well, then the clinic will have given to its community in that stage of its development the kind of service needed. If, on the other hand, in its disappointment over the low standards of the agencies, the clinic withdraws from their sad plight and devotes itself to the diagnosis and treatment of cases referred from sources not associated with the agencies, it may derive great personal satisfaction from the skilled workmanship of its staff, but it will be missing an opportunity to reach indirectly numbers of cases which it cannot hope to handle itself, and, because of the wide gap between its interpretation of case work and that of the rest of the community, and between its case load and that of the rest of the community, it may be in danger of being thought ornamental rather than useful, and, perhaps, of suffering even more severely because of the jealousy and inferiority feeling of the overworked and understaffed agencies. We question whether any one social organization, especially one as technical and expensive as a child guidance clinic, can survive long in a community whose general social standards remain very much below its own. Certainly it cannot operate as effectively as it wants to and as it should. For self-preservation therefore, as well as to safeguard its own ideals of work, it would seem to be the part of wisdom for clinics in communities whose case work standards are low to devote themselves to pioneer educational work. Would they not be assisted in leveling the difference between their point of view and that of the agencies if national organiza

tions, particularly in the child welfare and family welfare fields, could send a teacher of case work into the agencies to assist from the inside in raising standards? Do not the clinics fighting the battle of all case work deserve this help from other fields?

But what shall we say to communities and agencies that have not already set up clinic service, and that now wish to have it? Let us take an imaginary case. Here is a city of 250,000 population whose buildings and business projects indicate local pride, prosperity, and a spirit of progressiveness. Its case working agencies include a family welfare society, subsidized by public funds, which hands out doles the amount of which is determined, not by a budget based on the cost of living, but on the guesses of a committee of wealthy women and a staff of débutantes whose ages do not exceed twenty-five. There is a protective society which construes its work to be so confidential that for some cases it keeps no records at all, and for those whose identity it is willing to intrust to paper, its records are in such a jumble that only luck and a good memory emable the worker to locate any given record when she wants it. This confusion in the filing system is accompanied by equal confusion in the case work. There is a child placing agency which accepts babies with a minimum number of questions and places them for adoption in foster families whose histories remain as mysterious as those of the babies they so trustfully accept. There is an institution for children whose board of forty women is dominated by a sentimental autocrat who derives most of her emotional satisfaction in life from her control of this institution and the destinies of its hapless children. Although the institution boasts a staff member whom it euphemistically calls a case worker, her duties are chiefly clerical, and her judgment, such as it is, is constantly overridden by the dominant member of the board. There is a juvenile court whose judge has blocked progressive legislation, and whose probation officer, thrilling over the sensational episodes in her work, finds time to record only the information called for on the police docket. The public schools are headed by a man who believes in corporal punishment, humiliation, and other tortures for the unlucky youngsters who cannot conform to its rigid system. There is no visiting teaching. The attendance work is carried on by an officer whose pace is retarded by his lumbago and the (for him) lucky fact that the law permits a child to be absent three days before it requires him to look into the matter. The health work among those not able to pay for private practice centers in a clinic whose medical staff attends so rarely that hospital internes, without supervision, are not only permitted, but obliged, to treat patients in all departments. The city is not yet in the birth registration area. Infant mortality, especially among the foreign group, is high, and respiratory, infectious, and nutritional diseases, even among children of wealthy families, are prevalent to a shocking degree. The whole scene is dominated by a community chest which has successfully raised enough money to carry on the limited programs with which the agencies are satisfied. Measured by even lenient standards, there is not one agency practicing creditable case work.

Should this community be encouraged to organize a child guidance clinic, even though, having heard the magic words, it is anxious to taste this latest novelty in social work? Assuming that for the next two years it can raise $25,000 to $50,000 above its present budget, will greater benefit be derived from investing this sum in the already existing agencies, strengthening their staffs, both in quality and quantity, and broadening their programs so that the fundamental social needs of the community may be more adequately met? Just as a cautious pediatrician withholds sweet potatoes and pork chops from the diet of a six-months-old baby, should we withhold full-fledged child guidance clinic service from some agencies and communities until their social digestive system is mature enough to assimilate it? This is not merely an academic question. Though the community we have described is a hypothetical one, it is similar to real communities that we have known and that have wanted a child guidance clinic and have been willing and able to pay for one. Does not the mental hygiene field deserve the sympathy and backing of the other case working fields when it urges caution in such a situation?

Let us return to our first concept as to the relationship that should prevail between case work and psychiatry. If it is true that case work, being concerned with personality, needs to use knowledge of physical and mental health day in and day out, not on special cases, but on all cases; if it is also true that a mental hygiene clinic wishing to serve a community must offer its resources to the children's and other social agencies and use them as channels of education to large numbers of cases whom it cannot treat directly, then it seems clear that the interests of the two fields are interrelated so closely that one cannot fully advance without the other. Case workers cannot practice with full effectiveness without consultant service from a mental hygiene clinic, nor can a clinic function except lamely without case workers with sufficient grasp of their own fields and sufficient knowledge of physical and mental health to assist in getting its message into the life of the community. These workers must not be merely those on its own staff, but on the staffs of all the agencies dealing with people in trouble. Therefore if we tell a community with a poor social program and low standards of case work that the kind of clinic service it needs is a limited service or none at all at present; that, rather it should spend a year or two cleaning house, raising its agencies to at least a minimum level of effectiveness, so that they can use a clinic intelligently and with a minimum of waste, are we merely delaying the spread of these valuable adjuncts to case work? Are we not, rather, paving the way for the clinic so that when it comes it will not find itself set down in an uncomprehending world? In general, will not the spread of effective clinic service be in proportion to the spread of effective case work? Therefore is not a mental hygiene program advanced by every effort made in other fields to educate case workers, to raise the level of their practice, to lower case load to the feasible carrying point? Should we not be looking forward to the day when there will be no distinction between psychiatric and non-psychiatric case work; when the

lessons of psychiatry will be absorbed by all case workers; when the conditions of practice will be favorable to high standards; and when, therefore, clinic service, limited, so far as the agencies are concerned, to primarily consultant service, may become like the hub of a wheel, using social agencies like spokes to carry its help to the large number of people who constitute its circumference?

PROGRAM FOR MEETING PSYCHIATRIC NEEDS

IN THE STATE: AIMS AND PROBLEMS

OF THE ILLINOIS PLAN

Herman M. Adler, M.D., Criminologist, State of Illinois; Director,
Illinois Institute for Juvenile Research, Chicago

Since one can never really start anew even with so relatively new a subject as the psychiatric problems of a state, it will be necessary to state briefly the historical developments of the work in Illinois in order to understand the present situation and the reason for the plans we are carrying out.

History of the work in Illinois.—Briefly, the first application of psychiatry and psychology to behavior problems in this country was at the Juvenile Psychopathic Institute, founded in Chicago in March, 1909. The idea was the conception of Mrs. William F. Dummer, and the tremendous progress that has been made, not only in this community itself, but in the development of other clinics throughout the country, bears testimony to Mrs. Dummer's wisdom. Dr. William Healy was appointed the first director, and for five years the Institute functioned under private support from Mrs. Dummer. This five-year period was a demonstration, the avowed object of which was to convince the officials and the general public of Cook County of the value of the work, with the intention that when this was accomplished the support of the Institute would be officially undertaken by the county.

This method of demonstration was not new, and similar demonstrations have been carried out since. The work of the child guidance clinics of the Commonwealth Fund and the National Committee for Mental Hygiene has been organized on this same basis. This method of creative work is perhaps the outcome of a previous less constructive method, namely, the social survey. The survey method is one which has proved very useful in the past, and is still of value today under certain conditions. For reasons which will appear later, however, I hazard the statement that unless a survey or a demonstration such as the first five years of the Juvenile Psychopathic Institute is applied under unusually favorable conditions, permanent success is very doubtful. The survey, as employed in public service, is usually conducted as the result of dissatisfaction with existing conditions on the part of a group in the community, or as a result of a scandal. The survey usually results in a report in which constructive suggestions are made. While some surveys have been eminently successful in estab

lishing permanent improvements, too frequently the opposite has occurred. By the time the report is rendered the original excitement has died down, and the report is filed and nothing done. Furthermore, survey officials are usually handicapped by having only a brief time in which to get acquainted with the field that is being studied, and by ignorance of details which, in themselves unimportant, may nevertheless be decisive as to the practicability of the final recommendation made. Many a scheme which appears satisfactory and logical on paper has failed of adaptation or of practical effectiveness when adopted because of the neglect of some of these smaller details. Demonstrations, on the other hand, have the advantage of actually carrying out work under the conditions which any permanent organization will have to meet. There is therefore the possibility of actually doing the work intended, and thereby silencing any objection that the plan is visionary.

Transfer of Juvenile Psychopathic Institute from private to county and to state auspices in turn.-The Juvenile Psychopathic Institute during its first five years overwhelmingly demonstrated not only the practicability of the project, but also its great value. Not only Chicago and Cook County, but the entire country, was inspired by what Dr. Healy and his associates accomplished. As a result, at the end of the demonstration period the commissioners of Cook County accepted the Institute as an official obligation of the county.

With Dr. Healy's departure, in 1917, to his present position with the Judge Baker Foundation in Boston, it was natural that, because of his very remarkable record at the Institute, the public should lose some of its interest. This loss of interest was soon made manifest on the part of the commissioners of the county, and it was not long before word came to Judge Arnold of the Juvenile Court that the commissioners of the county were pressed for funds, that economy was the watchword, and that they would have to retrench. It was natural that in looking around for some place to save money they would select the Institute as something without which the county could continue to exist. Judge Arnold, therefore, informed me that at the termination of the fiscal year there would be no funds for continuing the work.

In the meantime Governor Lowden had completed the draft of the Civil Administrative Code, which organized the administration of the state. This included, among other departments, a Department of Public Welfare, with a director who had charge of all the charitable, penal, and correctional institutions of the state. In the Department of Public Welfare was a Division of Criminology, to be in charge of a criminologist, a specialist who was to apply scientific methods of research to the problem of criminal behavior. When Mr. Charles H. Thorne, director of the Department of Public Welfare, invited me to take this position of criminologist, I agreed, and it was determined to continue the work of the Juvenile Psychopathic Institute as the preventive work of the Division of Criminology, under state support. The work has been thus continued from 1919 to the present time.