lecture-room twice a month, directly after visiting hours, for fifteen-minute talks regarding the causes, treatment, and prevention of mental disorders. Much to our gratification, these meetings have been attended very well. Twenty people attended the first meeting. After a fifteen-minute talk by some member of the staff, relatives are given a five-minute period to ask questions. This has led to a very close association between the hospital and the community, and has helped to break down that feeling prevalent among relatives that mental diseases are a disgrace and develop on a mysterious basis. The experiences in the Colorado Psychopathic Hospital thus far with this type of education have been very pleasing and promise much for the future.

In conclusion, I wish to state the earnest and stimulating hope that the Colorado Psychopathic Hospital will take an active part in the treatment and prevention of mental diseases, and so follow in the steps of the other psychopathic hospitals-the Boston Psychopathic Hospital, Henry Phipps' Psychiatric Clinic, the University of Michigan Psychopathic Hospital, and the University of Iowa Hospital.

3

PSYCHIATRIC SOCIAL WORK IN RELATION TO

A STATE MENTAL HYGIENE PROGRAM

Ruth Lloyd, Colorado Psychopathic Hospital, Denver

Mental hygiene in a community never has a definite beginning-it has (always existed. Physicians, social agencies, schools, and courts every day have been dealing with the disorders of human maladjustment, maladaptation, unhygienic compromises, immature or distorted methods of meeting the complex situations of life. How often attempts have been made to formulate principles and prevent unnecessary expenditure of time, energy, and money in the establishment of a state-wide mental hygiene program. If the state will maintain a psychopathic hospital, dispensary, and traveling clinic to serve its citizens in the treatment and study of all types of mental disorders, and will have a centralized organization to form its policies, study its problems, and spread more widely the knowledge of what help is offered and what type of case should be referred, the mental hygiene movement will develop on sound and lasting principles and will become one of the most helpful resources in the community. ་ The average psychopathic hospital has a very limited bed capacity but a large community to serve. The out-patient clinic has not only been established to meet this situation, but its other equally important function of educational work with social organizations, community work, and parents. The psychiatric worker realizes how utterly hopeless it is to carry alone the problems, and were it possible to do so, she would be defeating her rôle in making mental hygiene a necessary development in the curriculum of every case working agency, The social and health workers have read extensively about the movement and are

waiting for the opportunity to carry their problems under the supervision of a psychiatrist and be helped at critical moments by the psychiatric worker. How often their contact with the patient has been over a long period of time. They have facts, feelings, and impressions that only weeks, months, and years of association can develop. Why should the psychiatric worker carry their problems? She already has many patients not known to any agency.

Through well-organized courses of lectures, with clinical demonstrations followed by supervised contact with problems, the social worker soon learns to administer treatment and recognize early symptoms. She is surprised to learn that the psychiatrist does not simply diagnose, but talks to her in simple everyday terms of treatment. She is instructed definitely how to attack her problem, and leaves the clinic feeling that an adjustment is not hopeless. She may be in doubt about the procedure. The psychiatrist is not always available, but the psychiatric worker should be at the community worker's disposal with unlimited time and patience. The aim of treatment is readjustment, but the worker soon learns that the method is largely one of re-education. The patient is taught to study his own personal difficulties in a rather intensive way—to trace out the factors which have influenced his habits and attitudes-to learn how to face the facts of his life in their biological crudity as well as in their ethical and aesthetic setting, and to gain courage to discard mental makeshifts and disguises. This gain in honest insight into the patient's problems must not only be analytical, but it must be part of a search for practical aids in the formulation of better habits. Suitable remunerative work must be found, opportunities for recreation supplied. The social, intellectual, aesthetic, and religious aspects of life must not be ignored. Hobbies are to be encouraged, and the fundamental relations of the patient to his own family are of utmost importance. The X physician, by his skilled analysis, has helped the patient to understand his maladjustment, but the social agencies and community life must supply the facilities for the readjustment. If the community does not recognize these needs and supply them, how can a few scattered psychiatric workers hope for results? If the psychiatric worker complains of lack of resources and cooperation she has failed to interpret mental hygiene. By glancing around she will locate many opportunities to begin the work. She cannot descend upon a community unexplained-parents become alarmed at the word "mental," but when a psychiatric examination is part of a state-wide health program, cooperation is immediately secured. Johnny comes to the clinic, is weighed and measured; eyes and teeth are examined; he is gone over thoroughly by the pediatrician. The teacher has suggested a psychological examination to know why there is so much difficulty with arithmetic, and yet Johnny may know everything about animals, crops, carpentry, or machinery. The psychologist explains that he is always going to have trouble with arithmetic, that his intellectual abilities are limited, but that his manual trainability is good. The parents have recognized this for a long time, but have never known how to express it to themselves or

teacher. Their problem is to understand how to make Johnny sociably competent. Psychology now means more than a word, and when asked to go to even a worse-sounding person-a psychiatrist—it is not such a task if it has been explained that this doctor wants to talk to them about Johnny's temper tantrums or eneuresis, jealousy, night terrors, stealing, lying, running away, destructiveness, fire-setting, sex assaults, cruelty, or simply his inability to get along with his brothers, sisters, or children in the community, the fear of the word "mental" no longer exists. These are ordinary everyday occurrences, and easy to talk over. Johnny has been rather difficult lately. Thus the psychiatrist is enabled to advise the mother, teacher, and community nurse to safeguard the child from bad influences, from drifting into unhealthy or delinquent habits, and becoming the tool of the unscrupulous. The individual child thus gets help, symptoms are relieved, and improper habits checked, but an important result is that the teacher gains a broader conception of the nature of education, the parent a deeper insight into the problem of training children—a task often so honestly taken up but so inefficiently carried out. The ultimate aim of education is the parent. The social worker may understand Johnny's problem, but if she is unable to interpret him to his family, and the family to him, his numerous visits to the clinic have not been constructive. Not until the parent realizes that life is not made richer by emotional conflicts, character not developed, and that the aim of mental hygiene is the early recognition of mental disorders and treatment in childhood, will mental hygiene be constructive. The psychiatric worker, through community contacts, education, and demonstration treatment, is one of mental hygiene's greatest assets.

The erroneous idea that the term "mental" means only the treatment of insanity and feeblemindedness, which are two of the most striking examples of mental ill-health, has been fairly well corrected in city life through the establishment of clinics, but when one stops to consider that the whole system of civilization is built upon intellectual activity, and that intellectual activity depends upon mental health, the subject is so large that it enters into every phase of community life. Little has been done for the rural districts. This can be taken care of through traveling clinics. One encounters the financial problem, as a traveling clinic is expensive. The rural districts have had little contact with mental clinics and naturally are unwilling to invest money. If the psychiatric worker glances around her state and knows her resources, she can find many opportunities to suggest to the mental hygienist where work can be carried on with the expenditure of a small sum of money.

Much can be written on theory, but we are always more interested in actual demonstration. A few years ago the university extension of the University of Colorado began a state health program through exhibitions at state and county fairs. This work has developed, and today Colorado has one of the bestequipped traveling child welfare clinics in the country. The health agencies have founded a health council to discuss and decide where clinics can be most effec

tual. The organizer from the university extension visits the locality and presents the work of the clinic. Simple and explicit directions are given and the responsibility for its success is left with the community. A local chairman has been appointed, and whenever possible the community assumes part of the financial responsibility. It is a big problem, and if it is to be a success everyone must not only know about it but do actual work. The traveling clinic consists of representatives from the state child welfare bureau, state board of health, state tuberculosis association, and state dental association. The clinic is held in a church or school, and an average of one hundred children pass through it in a day. A history card, asking definite questions, has been printed. Responsible members of the community assist the historian, as well as in the departments where the children are undressed, weighed, measured, and teeth and eyes examined. A thorough examination is made by the pediatrician, who is usually assisted by the local physician. The mother has had instruction as the child has passed through the different departments, but in order to assure a thorough understanding, the child's defects are summed up at the end and the parent receives a pamphlet stating what medical care is needed; weight, height, and diet charts are also given. There are health lectures in the afternoon and health movies in the evening. Could mental hygiene ask for a better opportunity than to be a part of such a clinic? Here is the theory of integration, or the study of the individual as a whole. The physical examination has been made. The parent, teacher, minister, and community worker have been an actual part of the clinic and have requested examinations on special problems. They are waiting for the opportunity to carry out treatment. The pediatrician and clinic worker have detected and referred problems, and soon the psychiatrist has more than a day's work.

The staff of the Colorado Psychopathic Hospital was invited, and financed by the child welfare bureau, to be a part of the May conference, and functioned with the clinic two days. Such interesting problems were presented that at the end of the second day it was decided to send a psychiatric worker with the clinic for the purpose of a survey and the beginning of mental hygiene and educational work in the southeast section of Colorado. The communities were not notified that psychiatric histories were to be taken. The results were most instructive, as an average of 10 to 12 per cent of the children reporting to the clinic were referred to the psychiatric division. The clinic was held in one town 50 miles from the nearest railroad and 65 miles to the nearest physician. One found just the same proportion of personality defects, mental deficiency, organic, endocrine, and psychotic problems as in the busy city clinic. Dr. Thom's Habit Formation bulletins have been sent to many mothers. Arrangements are being made for some of the children to be referred to the hospital, and the community workers are doing followup work on other problems.

The staff of the Colorado Psychopathic Hospital feels that it is advisable, instead of organizing a separate traveling clinic, to accept the invitation to participate in this splendid organization.

ORGANIZATION AND TECHNIQUE IN CHILD
GUIDANCE CLINIC WORK

COMMUNITY ORGANIZATION FOR CHILD GUIDANCE
CLINIC WORK

Grace F. Marcus, Supervisor of Case Work Methods, National
Committee for Mental Hygiene, New York

I object to my topic. There is something oppressive and ponderous about it. The term "community organization" represents to most of us an unmanageable abstraction. We have met it but embodied negatively in political and religious antagonisms, in social cross-purposes organized against each other, in unwieldy outworn machinery immovably blocking our way. We know communities that face organization as a necessity and are doing their best to function as social wholes, but if we analyze that best, what can we see in it but the bare bones of a community dream? Certainly so far as child guidance clinics are concerned, we have learned from experience that community organization must be regarded as an experimental process, that plans for it should not be concerned with wholesale solutions and ultimate goals, but with those immediate, troublesome realities to which some adjustment must be made.

We all know that child guidance is a very new, but not necessarily a final, development; that it is not superior to all the sordid realities of budget, case load, and inadequate social resources with which other organizations are struggling; that its welfare is largely determined by the status of other social, medical, and educational agencies, that it too is a creature of environment, and that it neither has nor wants a splendid isolation. Organized to assist in the individual. adjustment of children presenting problems in personality and behavior, employing to this end the techniques of psychiatry, psychology, medicine, and case work, it naturally enters a community as something formidably different from any of the other agencies handling children. This difference is real, valuable, and dangerous. For the very fact that child guidance clinic technique is a composite implies its fundamental dependence on each of the fields from which it derives. It has no final formulations to offer. It starts as an assimilator, an assimilator of many developing techniques into a balanced, coordinated whole which can be socially applied. It waits on further growth in allied fields for material to be placed at the service of case work. It needs the cooperation and understanding of specialized agencies to effect this assimilation, since the treatment which they will help it to carry out is the only laboratory at its disposal. It must begin, then, from the beginning to strip its techniques of strangeness, to make them part of the familiar thinking of other agencies, to submit them to the evaluation other agencies must give them, if the clinic is to discover where its work is of practical value and where it is not. All this entails community organization.

There is, of course, another side to the question. The clinic can only make itself understood in terms of its understanding of the methods, aims, assets, and