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The second need-that of research-was fostered in varying degree in the older hospitals. Laboratories were equipped and supported in some, but a broad research program was very difficult to maintain in the state hospitals, largely for financial reasons. The proper care and housing alone of the large number of patients in such hospitals represents a considerable expenditure of public funds, and because of this economic pressure, institutions were more apt to be compared by legislators on the basis of their per capita cost than on their scientific standing or productivity. Moreover, the field of research in mental diseases, because of the innate intricacy of its problems, has not been one in which advance is possible except by tedious effort and costly experiment.

The third chief function-teaching-was likewise carried out as far as facilities would permit by the state hospitals. Training of medical graduates as assistant physicians was one of their regular functions, and those so situated as to be able offered didactic and clinical work to the students of nearby medical colleges. In most cases, however, the state hospitals were located in the country or in small communities, and while the hospital physicians gave generously of their time and experience, the opportunities for clinical observation were small, and probably few, if any, of them offered courses which could be considered adequate for a well-rounded medical curriculum.

The mental hygiene movement is more difficult to define. Perhaps for a working basis it will suffice to outline it as an attempt to apply the psychiatric viewpoint of an intensively individualized study of behavior problems to the amelioration of minor mental disturbances and toward the prevention of more serious ones. It is obvious from this that psychiatry has a very intimate relation to this movement. Mental hygiene, however, because of its very wide scope, has drawn many workers to its aid who have not been trained in mental medicine. This border zone of service is far too large to be manned by those trained in general medicine, particularly as the subject of mental diseases has never been one to attract recruits in large numbers.

Psychiatry is, however, a branch of medicine. Its roots lie deep in brain anatomy, brain physiology, general and special pathology, internal medicine, serology, and other technical subjects. Take for example, general paresis, which constitutes about 10 per cent of mental diseases. When I first entered the field this disease was considered to be a result of syphilis by most workers, but there was still doubt enough so that the Ford-Robertson theory of a chronic intestinal infection with a diphtheroid organism gained considerable credence and cases were actually under treatment in this country with the serum of goats immunized to these organisms.

Because of this fundamental linkage between medicine and psychiatry, the latter must continue to recruit its own ranks from among those trained in general medicine, but because its subject matter forms a very essential part of the mental hygiene movement it must also prepare to work in harmony in this broader field with workers with other training. One great danger threatens

this harmony, and this is a lack of a clear-cut recognition of the technical field which psychiatry occupies on the part of some, at least, of those who work along its borders. Psychiatrists, like all others who have acquired an extensive special training, are jealous of their field, and resent the intrusion of inadequately trained workers from other fields and refuse to work with them. The psychiatric social workers have never been offenders here. Starting as it did in the cooperative work of Dr. Southard and Miss Jarrett in Boston, psychiatric social work has grown to be an important collaborator with psychiatry.

Psychology, on the other hand, has not had this close association, and evidence of friction here is easy to unearth. One of the most frequent sources of this friction deals with the selection of material for study by one or the other group. When a psychiatrist is told, for example, that a certain case is or is not suffering from a mental disease, and therefore does or does not require his services, by one who has never studied mental diseases, he is naturally apt to resent it as an intrusion. To determine the difference between two frank cases of mental disease is usually a much simpler task than to determine whether a definite mental abnormality exists in a borderline case. This is one of the most difficult problems the psychiatrist meets.

I believe that by far the greater number of intrusions of this nature are due to a lack of information as to the scope of psychiatry and the great technical intricacy of these borderline problems, rather than to any intent to overstep, and I therefore feel that it is incumbent on the psychopathic hospitals to offer their material and instructional facilities to those who are to enter the border zone through other avenues than medicine in order not only to give them the psychiatric viewpoint needed in their work, but also, and equally important, to delimit for them the strict psychiatric field, so that they may be prepared not to offend through ignorance.

The Iowa State Psychopathic Hospital was organized with the aid of a coordinated investigative program from the organic standpoint, and included four laboratory groups in addition to its wards. These are, first, the histological laboratory, where routine and research work in neuropathology are carried out, and where courses in this subject are given to the students of the college of medicine. This work is under the immediate supervision of the director, and is carried out by one or two assistants and two technicians. Second, the chemical laboratory for investigative work on individual cases and research work on broader problems. This work is in charge of a full-time chemist. Third, the psychological laboratory, in charge of a full-time worker with several graduate students as part-time assistants. Fourth, the laboratory for bacteriology and serology. This is in charge of a competent clinical microscopist, but as yet this work has not entered the bacteriological field.

The hospital's teaching function is represented in the college of medicine by a course in neuropathology given to the second-year students, a course in psychiatry for junior students, and advanced work in both subjects offered as elec

tives and as graduate courses. A course of lectures and at least eight weeks of practical experience in the wards of the Psychopathic Hospital is required for all pupils of the school of nursing.

The head of the psychological laboratory holds a combined appointment as psychologist to the hospital and as a member of the teaching force of the department of psychology in the university, and offers a course in psychometrics. The director of the hospital also offers a lecture and clinical course in mental diseases open to advanced students of psychology in the graduate college, to certain students of sociology, and to others who have special interests in this work.

The department of social work of the hospital also gives a course in the fundamentals of psychiatric social work to students of sociology.

The clinical staff of the hospital consists of four physicians, two internes, and two psychiatric social workers. The clinical service includes sixty beds, with facilities for handling cases in all degrees of severity. The law under which the hospital was organized is a broad one and permits of the admission of "any person who is suffering from an abnormal mental condition," and our experience in the past has been that that expresses the range of clinical types encountered quite accurately. Cases come from all parts of the state and, conforming to Iowa's policy in the university and children's hospitals, the indigent cases are cared for at the expense of the state. Under the law private patients cannot be charged a rate higher than that paid by the state for the care of an indigent case, and this relieves the hospital of the need of providing special quarters and giving special privileges to private patients. The service, therefore, can be adjusted exactly to the psychiatric needs of the case, with no regard to financial status. The hospital does not offer a clearing-house service for the rapid review of a large number of cases, but rather attempts intensive study and treatment of a relatively small number. It also maintains an out-patient department which, in spite of the long distances in the state, already cares for about as many cases as do the hospital wards. The major part of these out-patient cases are referred by local physicians, and there is among them a growing number of university students, a fact of interest in connection with the movement to establish mental hygiene in the colleges. Others are referred, however, by the courts, the schools, and the various social agencies. Because of the fact that distances in Iowa are great and that Iowa City is rather difficult to reach from certain parts of the state, only the more pressing found their way to the hospital, either as residents or out-patients, and an experiment was considered to test the feasibility of holding a clinic in a small community which could not afford to provide itself with adequate advice on mental problems. An offer was therefore made to the State Conference on Social Work to undertake such a clinic, without charge for the technical service, in any county which would defray the maintenance expense and could assure us of the interest of the physicians, the courts, the schools, and the social agencies. Greene County, Iowa, responded with an invitation, and the experiment was carried out in January, 1925. The unit con

sisted of a psychiatrist, the chief social worker, the hospital psychologist, and two graduate-student assistants, one in psychology and one in social work. During two weeks of intensive work by the group, 173 cases were reviewed. These were distributed as follows: medical, 8; legal, 5; school, 128; social, 25; and 7 who came of their own initiative. Many cases of great interest were encountered, particularly in those referred by the schools, and one group of these— children with a special disability in reading-has formed the subject of an apparently promising study of their difficulty which is to be carried further. The experiment convinced the members of the unit at least, and we hope also the community, that such a mobile extension of the out-patient service to meet the needs of rural and semirural districts is well worth while, and we are hoping that it will be possible to continue this mobile clinic on a more extensive scale in the near future.

PSYCHIATRY, SOCIAL SERVICE, AND SOCIETY

Mrs. H. S. Mallory, Director, Social Service Department,
Michigan State Psychopathic Hospital, Ann Arbor

Psychiatrists in general agree that the laity must be led to appreciate the need for early recognition and expert treatment of mental disorders, and that social rehabilitation of non-institutional cases can be accomplished only with society's willing and continual cooperation. In such a program there is no place for the social worker who has chosen her profession to counteract a personal complex, for only a sane and load-free advocate can convince the community of its responsibilities with respect to the mentally disordered, and only a serene personality can perceive and provide for what is necessary to the rehabilitation of the maladjusted. The psychiatric social worker must have insight, courage, and persistence in order to serve both society and her patients. She must be trained in psychology, social psychiatry, sociology, and biology, and she needs actual experience of life, with a faculty for drawing reserve powers from some stream outside the round of work. She must be able often to reassure herself and others that somehow there is evolving among the whole people a philosophy of life that promises for the future a general mental health far sounder than that of today.

Among the signs of such an ameliorating process are the psychiatrist's comparatively recent interest in preventive measures and conduct problems and his establishment of children's habit and guidance clinics. Also the psychologist is devoting himself to a study of the factors of personality and is opening behavior clinics for both normal and abnormal children. Minor conduct disorders are being successfully handled by the nursery school for the preschool child. Research in these fields has led to the new dynamic methods of public school instruction. Perhaps most significant of all is the recent introduction, into the curricula of various state universities, of extension courses for parental instruc

tion. To this opportunity for studying the physical requirements and the intellectual and emotional reactions of their children parents have enthusiastically responded. As such movements do not spring up until there is a more or less clearly recognized need for them, it appears that the fundamental impulses of the social order are encouragingly right. Also, there is no doubt but that this change in society's attitude toward the mental health of children and adults has been promoted by the psychiatrist and his social worker. Through them people have come to realize the significance of conduct disorders and have undertaken to conserve the mental health of childhood.

The Michigan State Psychopathic Hospital, under the able direction of Dr. Albert M. Barrett, is the oldest of its kind in America, having been opened in 1906. A somewhat cursory survey of its records indicates clearly the change in society's attitude toward mental health during the two decades of the hospital's service. In 1908, in addition to a high percentage of dementia praecox and manic-depressive insanity, we find 9.4 per cent of the patients classified under the diagnosis of psychopathic states, as opposed to a group, in 1923, of psychoneurotics, neurotics, and psychopathic personalities, comprising 22.2 per cent of the hospital population. This indicates that society, awake to the seriousness of gross mental deviations, has begun to concern itself with the psychiatric treatment of human disorders previously regarded as mere peculiarities or physical illnesses.

Since the State Psychopathic Hospital has no facilities for the care of children, its house-patient records do not indicate the social interest in the present-day diagnosis and treatment of child cases, but the outpatient records, available since 1916, afford index to the people's attitude by the following data. Beginning with 1916, out of the first five hundred patients, 9.6 per cent were between sixteen and twenty-one years of age; 8.5 per cent were under sixteenthat is to say, 18.1 per cent of the five hundred were twenty years old or under. Among the last five hundred out-patients, we find 46.8 per cent were twenty years old or under and 32 per cent of these were under sixteen years of age. It is interesting to compare the diagnoses of these two groups of patients. In 1916 we find: hereditary lues, imbecility, feeblemindedness, dementia praecox, feeblemindedness, juvenile paresis, hysteria, feeblemindedness, etc. Among the last five hundred cases are marked retardation, mild reactionary depression, conduct problem, endocrine disturbance, manic depressive psychosis, conduct problem, seclusive type of personality, conduct problem, conduct problem, conduct problem, etc. These data need no comment.

That society is recognizing mental deviations more readily and demanding treatment earlier than formerly is evident. But along with this alertness goes the old demand for permanent hospitalization. The social worker must therefore face the fact that the family and the community of the mental deviate are inclined to shirk their responsibility when confronted with the problem of his social rehabilitation. "Give him work," urges the social worker. "We are afraid

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