Consideration of state support and civil service restrictions.—Summing up the work to this time, then, it is seen that even with so successful a demonstration as Dr. Healy's five-year period, after two and a half years under public auspices the work broke down and could no longer be supported by the county. It would seem, moreover, that although a state is a better projection than a smaller organization such as a county or a city, nevertheless even here a really thorough scientific work cannot be carried on with complete security. There are some very important, if not fundamental, considerations at the basis of this. In the first place, all state enterprises depend on appropriations from the legislature. While in practice there is frequently no great risk of the state's abandoning any worthwhile undertaking once it has successfully established itself, the dependence on appropriations has certain serious disadvantages. The first of these is the uncertainty as to the possibility of expansion commensurate with the development of public opinion and demands. In the second place, it is difficult to secure for the public service the kinds of personnel that are required for the work. Security of office is essential for obtaining good personnel. The civil service is no help here, but rather a disadvantage at times, since in the first place civil service is not an absolute guaranty, and furthermore, as operative in this country, it tends to standardize so that it is not possible to create individual positions which may fit a particular person.

There is a final point in connection with this method which has been pressed upon our attention. Surveys and demonstrations are for the purpose of arousing a sense of obligation on the part of public officials. However much it may be minimized, there is always a flavor of antagonism in such a procedure. Social workers are generally regarded as "reformers" by public officials. New things are started by attacking public administrators and threatening them with the revealing of their incompetency. Of course there are many instances where public officials have taken the lead and have a conscientious attitude toward obligations. Those states are fortunate in which this has had continuity, but in no state has such a condition been continuous enough really to accomplish what should be accomplished, and in some states progressive and conscientious administrations have been short-lived. Ultimately, of course, such conditions must and will be changed, and it is to be hoped that some day we shall be able to separate public service from the peculiarly political functions, so that we shall have a civil service here comparable to the British civil service, which offers careers for individuals competent to do the work.

But whatever may come in the future, we are faced with the present situation, and, under the democratic form of government which we have, in which service is a part of policy, and therefore subject to political control, even if to no greater extent than that the appropriations are dependent on opinion in the legislature, we must acknowledge the facts. I say this in no critical sense. I believe that even under the present system of conducting public business we can establish work of the kind in which we are interested on a firm basis. The history of

such states as Pennsylvania, New Jersey, Ohio, Michigan, Indiana, Iowa, and Illinois is ample evidence that this is true. It is perhaps just as well that this is so, because it requires on the part of everyone an attitude of tolerance toward others. I doubt very much whether, if the National Conference of Social Work were given the authority to conduct all the welfare of all the states represented here, we should be successful. We should probably be less so than we have been with the help of the legislators and public officials trained in politics and the administration of public affairs.

The problem of personnel.-Since the founding of the Juvenile Psychopathic Institute in Illinois seventeen years ago the idea has developed and spread so that the demand for this type of service has become far greater than could be met by the supply of trained workers. Until recently the plan has been for every institution dealing with behavior problems, every school or school department, every philanthropic organization, to equip itself with a mental hygiene clinic. The recommendations of the National Committee for Mental Hygiene for this purpose have been very specific and fit in well with the procedure in Illinois and elsewhere. According to this a minimum unit staff consists of one director (a psychiatrist), one psychologist, one chief psychiatric social worker, two assistant psychiatric social workers, one secretary, and two stenographers. As the demand increases, however, and the problem becomes one of meeting the needs of an entire state, as in the state of Illinois, the amount of personnel needed is greatly increased and is difficult to find. The National Committee for Mental Hygiene, the Commonwealth Fund, and other organizations have the same experience. There are not enough clinical psychologists, psychiatric social workers, or psychiatrists experienced in the behavior field to meet the needs of the clinics that are even now established. Accordingly, in Illinois we are increasing our training facilities so as to provide more trained personnel. The Commonwealth Fund is similarly planning a program for training personnel. It is apparent, however, on careful consideration, that no matter how much the training facilities may be increased, and no matter how many more workers will become available, there are certain inherent facts which will prevent our meeting the situation on this basis. We believe that the work done in these clinics has something to offer to every individual in the community, old and young. At the present time, and probably for some time to come, to do thorough work in this field requires a great deal of time in each individual case. Therefore it is clear that it is an impossibility ever to secure enough qualified personnel to meet the needs of the entire population on the basis of individual service by a minimum staff such as that set up by the National Committee for Mental Hygiene. It is clear that some division of labor is required, and this must be recognized in planning for any community. Workers of various degrees of competence and responsibility are needed. Large numbers of lower grades of workers can be used, and, because the requirements are not too high, these can be secured in sufficient numbers to deal with the problem. They must have a definite understanding of what their function is, and beyond that point they cannot go. When

they reach that point there must be more advanced and highly trained workers to whom they can refer their cases for more information or for transfer. Finally, the center of the entire system must be a consulting staff of highly qualified experts who can set up policies. This central staff should constitute the headquarters and should combine all of the three functions of such an organization: service, training, and research. These three functions are intimately bound up with each other. Thus the service function offers opportunities for practical training and for research, and the research, in turn, adds to the effectiveness of the service performed.

The Illinois plan. Based on these considerations, the plan for the state of Illinois as at present outlined includes two main divisions of service. The first consists of the institution service, which concerns itself with the study and treatment of individual cases in the state penal and correctional institutions. According to the organization of the Department of Public Welfare, there are also certain institutions which utilize the services of the mental health organization under the Division of Criminology without being officially assigned to that division. These are the two institutions for the feebleminded and the schools for the deaf and the blind, as well as the Soldiers' Orphans' Home The other division of the work is designed to be preventive and extramural. This part of the work consists of the service given at the headquarters and its out-patient clinic, the branch at the Juvenile Detention Home of Cook County, the pre-school and nursery school work at Hull House and at the LaSalle-Peru Township High School, and the Glenwood Manual Training School. In addition to this there are traveling clinics which visit periodically the various cities of the state.

This plan calls for a permanent unit at each of the institutions, two traveling clinics on permanent duty, two units at headquarters, and one unit at the Juvenile Court. At the present time this plan is by no means complete in its operation, because of the scarcity of personnel, and particularly because of the difficulty in obtaining clinical psychologists and psychiatrists not only competent to do the work, but willing to go out into the field and be stationed at the penal and correctional institutions, but it is gradually being put into effect. At present we have, at the penitentiary at Joliet, a psychiatrist, a part-time psychologist, a clerk, and are about to add a psychiatric social worker. The Reformatory for Boys at Pontiac and the Southern Illinois Penitentiary at Menard are covered by visiting clinics at monthly intervals. We are about to put in a permanent staff at the reformatory, and a clerk is assigned to each institution. At present there is a psychologist at the Training School for Boys at St. Charles and at the School for Girls at Geneva.

The headquarters, that is, the Institute for Juvenile Research itself, has recently been moved to a modern fireproof structure which affords better facilities for the development of the work. This, however, is still a temporary building for us, and we expect in the near future to have a permanent building designed for our needs. At the headquarters there is a chief psychiatrist, a chief psychologist, and a chief psychiatric social worker, each of whom is responsible for the

entire service of his division of the work. In addition to this service staff, there will be attached to the headquarters a body of research workers of different grades, from graduate students to recognized authorities in the various lines of work. Research in the past has been conducted under difficulties because of ininadequate funds and space and because of the immense pressure of the service work. Recently, however, a committee of citizens of Chicago, realizing the importance of the work which is done at the Institute for Juvenile Research and the opportunities for research which the clinical material offers, undertook to raise a sum of money to be used for independent research in problems of human behavior. This fund, which is called the Behavior Research Fund, is now complete, and the organization of the work is being planned, to begin officially October 1, 1926. The fund amounts to $55,000 a year and is guaranteed for five years, and there is every indication that it will be made permanent before the end of the five-year period. Thus it will be possible to attract to the work scientists who would not have been willing to consider the risk involved in accepting a position under state appropriation, with the potential danger of the support being withdrawn at any time. The security and continuity guaranteed by this arrangement is seen to be comparable to that of a university. Moreover, the opportunities for conducting research in human behavior problems is far better at the Institute for Juvenile Research than at any university at present, because of the close knitting of the public service with the research, the tremendous facilities and clinical material of the state being made accessible to the scientist with the least possible effort involved. Nor will the research workers have to interrupt their work to fulfil service obligations or demands. The service staff will attend to all of that, and the scientific workers in research will be protected against any interference.

With this arrangement, moreover, it is obvious that there is an ideal opportunity for training students and workers in the various specialties represented. In order to facilitate the use of these opportunities for graduate students, the Institute for Juvenile Research will effect an affiliation with various universities, so that the work done by students at the Institute under the supervision of the senior staff will be counted for credit at their respective universities.

PROGRAM FOR MEETING PSYCHIATRIC NEEDS IN
THE CITY: AIMS AND PROBLEMS OF
THE CLEVELAND PLAN

Lawson G. Lowrey, M.D., Director, Demonstration Child
Guidance Clinic, Cleveland

It is not intended in this paper to try to present a program for meeting all the psychiatric needs of a city, but to present a program for meeting some of those needs not now commonly met. A basic need in any program is, of course,

facilities for the recognition and care of the legally feebleminded and insane. This involves adequate diagnostic service, to be had in Cleveland in a variety of ways: from practicing psychiatrists, hospital dispensary services, and the psychopathic hospital. Care and treatment must also be provided, either in special institutions, private or public, or in the community. All of this work centers around the treatment of disease and defect states, while our interest today is in prevention rather than cure. For that reason we shall not discuss this important phase of the work, but will devote attention to the problems involved in a preventive program.

By common agreement a preventive program must be focused primarily upon the problems of children. The main reason for this is that we know that work with children when attitudes and personality trends are developing and before modes of response have become fixed will prevent a great many difficulties either in personality adjustment or in behavior, and will therefore contribute to a happy and healthy life. It is clear, however, that working with the problems of children involves also working with the problems of the adults, who control in so many ways the life and development of children. We have, then, actually a double approach in our preventive work, through working with both the child and the adult to achieve for each new levels of adjustment which shall be reflected in the adjustments between the two.

There are many known groups of children presenting problems for mental hygiene work. There is the group of dependent children who, because of some disaster in the home, are becoming social charges and will, during the period of childhood, have their lives ordered by the social agencies, institutions, and foster homes which assume the responsibility for them. For these a mental health study seems needed in order that actually adequate plans may be made for their care. The mere fact of the breaking up of a home and the necessary assumption by some extra-home agency of the care and training of these children presents a mental hygiene problem in the individual child of no small proportions. There is also a group of children showing retardation in intellectual development such that they are unable to compete in the ordinary types of intellectual work required of them. The need here is for adequate diagnostic facilities in the schools, and, over and above that, adequate facilities for the proper education of those children who are unable to keep up in normal competition, and also for the superior child. It is today recognized as a basic principle in mass education that classification of pupils according to intellectual ability and the provision of special types of education is an essential, not only in training for economic productivity, but in procuring an adequate degree of stabilization for the individual child. As is true in any section of our work, the facilities for diagnosis are not enough. It is much more important to have developed methods of dealing with the diagnosed cases than it is merely to make the diagnosis. I should plead here for a complete obliteration of the notion that just because a diagnosis has been made the situation has been in some way helped. To be sure, adequate planning and