AND THE WORK OF THE PSYCHIATRIC

THE MENTAL HEALTH OF THE COIiL,.uNITY

AND THE WORK OF THE PSYCHIATRIC DISPENSARY

By

C.

MACFIE CAMPBELL, ^M.

^D.

Johns Hopkins Hospital

THE NATIONAL COMMITTEE FOR MENTAL

_HYGIENE, Inc.

50

Union

_Square

New

York_City

REPRINTNo. 21

Wyt ^{Rational Committee for JHental}

FOUNDED 1909 INCOBPOBATED 1916

50

UNION SQUARE, NEW YORK CITY

President

DB. LEWELLYSF. BARKER

CHARLES W. ELIOT

Vice^Presidenta

Treasurer

OTTO T. BANKAHD

DR. WILLIAM H. WELCH

Executive Committee DB. WILLIAM L. RUSSELL, Chairman DR. LEWELLTS F. BARKER DB. WALTER E. FEBNALD

Da. GEORGE BLUMER MATTHEW C. FLEMING

STEPHEN ^P. DUGGAN DR. GEORGE H. KIBBT

Committee on Mental_Deficiency DR. WALTER E. FERNALD, Chairman

DR. L. PIERCE CLARK

DR. CHARLES S. LITTLE Finance Committee RUSSELL H. CHITTENDEN, Chairman

OTTO T. BANNARD

DR. WILLIAM B. COLET WILLIAM ^J. HOGGSON

WarWorkCommittee

MAJOR PEARCE _BAILET, Chairman

DR.FRANKWOODE. WILLIAMS, Vice-Chairman

Executive_Officers DR.THOMASW.SALMON,Medical Director

DR.FRANKWOODE. WILLIAMS,Associate MedicalDirector

CLIFFORDW.BEEBS, Secretary

MEMBERS

MBS.MILOM.ACKER,Hornell,N.Y.

JANE ADDAUS,Chicago

EDWINA.ALDEBMAN,Charlottesville,Va.

MBS.A. A.ANDEBSON,Greenwich, Conn.

DR.PEABCEBAILEY,NewYork

DB.CHARLESP.BANCROFT,Concord, N.H.

OTTOT.BANNABD,NewYork DB.LEWELLYSF.BARKER,Baltimore DR.ALBERTM.BABBETT,AnnArbor, Mich.

DB.FBANKBILLINGS, Chicago SUBG.GEN.RUPEBTBLUE,Washington DR.GEORGEBLUMEB,NewHaven DR.G.ALDER BLUMER,Providence WILLIAM H. BURNHAM,^Worcester DR.C.MACFIE CAMPBELL,^Baltimore RUSSELLH.CHITTENDEN,NewHaven DR.L.PIERCE CLARK,NewYork DR.WILLIAMB. COLBY,NewYork DB.OWENCOPP,Philadelphia DR.CHARLESL.DANA,New^York

C. B.DAVENPOBT,Cold Spring Harbor, N. Y.

STEPHENP.DUGGAN, NewYork CHARLESW.ELIOT,Cambridge DB.CHABLESP.EMERSON,Indianapolis ELIZABETHE. FABRELL,NewYork W.H.P.FAUNCE,Providence KATHEBINES.FELTON,SanFrancisco DR.WALTERE.FERNALD,Waverley, Mass.

JOHNH. FINLEY,Albany IRVING FISHER, NewHaven MATTHEWC. FLEMING,NewYork HORACEFLETCHER,NewYork HOMERFOLKS, NewYork

DR.CHARLESH. FRAZIER,Philadelphia JAMES,CARDINALGIBBONS, Baltimore ABTHUBT.HADLEY,NewHaven DR. WILLIAM HEALY,^Boston DR.ARTHURP.HERRING,Baltimore HENRYL.HIGGINSON, Boston DR.AUGUST HOCH,Santa Barbara,Cal.

WILLIAMJ.HOGGSON,Greenwich, Conn.

DR.WALTER_{B. JAMES,}NewYork MBS. WILLIAMJAMES,Cambridge DAVID STARRJORDAN, PaloAlto, Cal.

HARRYPRATTJUDSON, Chicago

DR.CHARLESG.KEBLEY,NewYork DR.GEORGE_{H. KIRBY,}NewYork FRANKLINB. KIRKBRIDE,NewYork DR.GEORGE M.KLINE, Boston JOHN KOBEN,Boston JULIAC.LATHBOP,Washington ADOLPH LEWISOHN,NewYork SAMUELMcCuNELINDSAY,NewYork DB.CHABLESS.LITTLE,Thiells,N. Y.

GEOBGEP.McLEAN,Simsbury, Conn.

V.EVERIT MACY,Scarborough, N. Y.

MARCUS M._MARKS,NewYork LEEMEBrwETHER,^St.Louis MRS. WILLIAMS.MONROE,Chicago DR.J. MONTGOMERY_MOSHER,Albany DR.FRANKP.NORBURY,Jacksonville,^111.

CYRUS NORTHROP,Minneapolis WILLIAMCHUBCHOSBORN,NewYork DB.STEWARTPATON, Princeton DB. FBEDEBICKPETERSON,NewYork HENBYPHIPPS, NewYork

GIFFORDPINCHOT,Washington FLOBENCEM. RHETT,New^York DB.ROBERTL.RICHARDS,Talmage,Cal.

MRS.CHAS.C.RUMSEY,WheatleyHills,N. Y.

DR. WILLIAML.RUSSELL,WhitePlains,N. Y.

JACOBGOULDSCHURMAN,Ithaca DR.ELMERE. SOUTHARD, Boston DB.M.ALLEN_STARR,New^York DR.HENRYR.STEDMAN,Brookline,Mass.

ANSONPHELPS_STOKES,NewHaven DR. CHARLESF.STOKES,Briarcliff,N. Y.

SHERMAND.THACHER,Nordhoff, Cal.

VICTORMOBBISTYLER,NewHaven MRS. WILLIAMK. VANDEBBILT,New^York HENRYVAN DYKE,Princeton

DR.HENRYP.WALCOTT, Cambridge LILLIAN D.WALD, NewYork DR. WILLIAMH.WELCH,^Baltimore BENJAMINIDEWHEELER,Berkeley, Cal.

DR.WILLIAMA.WHITE,Washington DR.HENRYSMITH WILLIAMS,NewYork ROBEBTA.WOODS,^Boston

ROBEBTM.YERKES,Minneapolis

CHIEFPURPOSES: Towork_fortheconservation of mentalhealth; topromotethestudyofmentaldisordersand mentalg defectsinalltheirforms andrelations; toobtainanddisseminatereliabledata concerning them;tohelp^{raise thest} of careandtreatment;tohelp co-ordinateexisting agencies.Federal, Stateandlocal,andtoorganize in euery ^State affiliatedSociety forMentalHygiene.

,,^ ^..,,.,

-

[ReprintedfromMENTALHYGIENE,Vol.I,No._4,October, _1917]

THE MENTAL HEALTH OF THE COMMUNITY AND THE WORK ^{OF THE} PSYCHIATRIC

DISPENSARY*

C.

MACFIE

_CAMPBELL, M.D.

JohnsHopkinsHospital

THE

unfortunate _patient,

who

suffers

from

oneofthecountless

ills to which

human

^flesh is heir, as a rule has insight into his condition

and knows

in a_general

way

^whereto gethelp; even though unable^to

pay

special^feeshe can go^to a_specialclinicsuch as the eye clinic, or can consult the dispensary ^of the general hospital, where he is referred to the suitable special department.

The

nature of the

work

of each _special department ^isfamiliar in its general ^{outline to} the

man

in the street.

The

situation is

somewhat

differentwith _regard to the depart-

ment

that deals with mental disorders; the public

and

even the medical profession are here not so well informed.

The

_patient

suffering from a mental disorder

may ^{have no}

inkling of his sickness; the family

and

social agencies frequently ^{fail to realize} that the situation isone

demanding

expert medical ^{advice. Itis} important, ^{therefore, to diffuse}

more

_{widely the knowledge} of

what

_help is offered

by

^a psychiatric dispensary,

and

of

what

type ^{of cases should} be brought ^there.

To many

^the

^name

"psychiatric dispensary" suggests ^little or nothing; the term

"mental

clinic" or

"mental

out-patient ^de- partment" sounds

more

_familiar,

and

_yet even so simple a

term may

^call

up

^{in the}

minds

of

many

a very misleading picture.

Althoughliving inthe twentieth century,

we

arenotfreefromthe trammels of medieval _thought.

We

^are _apt ^{to deal} with words the symbols ^{of reality, rather} than with the facts of experience.

So the term mental _disorder, like the _legal

term

_insanity, has a certainominous_ringaboutitwhich

makes

_peopletendto.avoidit.

It is well, therefore, to begin

by

freeing our

minds from some

general misconceptions before passing

on

to the presentation ^of concretefacts.

Mental

disorders are disorders of

human

_adjust-

ment, maladaptations, unhygienic compromises,

immature

or distorted

methods

ofmeeting^the complexsituations oflife.

The

mentalout-patient^clinicor psychiatricdispensary^dealswithsuch

*Readbefore theMental Hygiene^{section of}the National Conferenceof Charitiesand Correction, Pittsburg,June12,1917.

1

disorders ofadjustment;^itdealswiththefailuresoftheindividual to

meet

life's problems. Unlike internal medicine, psychiatry cannot limit itself to the failure of single organs ^or groups ^of organs ^{to deal}with theirproblems; ^ithasto deal with the malad- justments ^of thepersonality as a whole. Psychiatry

may

^there-

forebeconsidered aspersonal medicine, ^asopposed^toimpersonal medicine; while in other departments ^the personality

may

^be

ignored, although not always withimpunity, ⁱⁿ the mental clinic the personality ^is the organic unit with which

we

work. It is

true that disorders of the individual organs

and

of groups ^of organs

may

cause modifications of the personality.

The

_per-

sonality^isnot something ^outsideof

and

_apart

from

the constituent organs ^of the body; ^{it is the} total activity of these organs

more

adequately conceived.

The

_study of the personality

and

its disorders involves the study ^{of all} the bodily organs, but in a

more

_{completesetting}thanisnecessary ^{in internal}medicine.

In the mental clinic, therefore,

we

deal with _patients

whose symptoms

require for their understanding a study ^{of the} per- sonality

and

of its problems.

Mental

disorders are notdisorders

whose symptoms

necessarily are mental, but

whose

roots are mental, that ^is

whose

roots cannot be understood without_study- ingthe patient ^{in his}complete

human

relations.

The symptoms may

^{be insomnia,orheadache,or}vomiting;they

may

^{consist ofa}

paralysis or a_tremor; they

may

^{be limited to}

^an

apparent^blind- ness or deafness or dumbness;

and

_{yet the} disorder

may

^{be a}

mental disorder because its roots lie in the _difficulty the person- ality has in its adjustment ^{to the situation.}

The

personality, in the face of difficulties,

may

^find refuge in phantasies, ^deliria or hallucinations,butalso in aches

and

_pains

and

_palsies,

and

the latter

may

^{beas trulyevidenceofmental}disorder asthe former.

Symptoms

^suchas paralysis orblindness

may

^bethesignal ofa complex

human

_difficulty while the individual organs ^are sound;

on

the other

hand

_changes of personality, moods, hallucinations

and

delusions

may

^{be the} sign ofthe disorder of

some

individual organ ^or group ^{of organs.}

The

organs involved

may

^{be the}

central nervous system, the glands which are at the very ^basis oftheemotionallife, or

some

other organ such^asthestomach,^or lungs.

Where

the personality ^is involved in this secondary

way

the mental

symptoms

^are merely

symptomatic

of disorders, the study

and

treatment of which can be carried on _{along the} nar- rower lines of internal medicine.

MENTAL HEALTH OF THE COMMUNITY

3

A

_survey of the actual

work

done in the psychiatricdispensary

may

begin properly with the^children; these

may

^be divided con- veniently ^into the subnormal

and

the neurotic group.

With

_regard to the former _{group, the} early recognition

and

complete study ^of

any

constitutional defect is extremely im- portant;^this enablesthe physician ^toadvisethe_teacher,to guide the mother, ^to safeguard the ^child

from

deleterious influences,

from

drifting intounhealthy ^or delinquent habits,from

becoming

the tool of the unscrupulous.

Pronounced

backwardness at school without obvious cause is a sufficient indication that a psychiatric examination is required.

The

neuroticgroup^is

composed

^{ofthosechildren}

who show

such

symptoms

^as night-terrors, bed-wetting, tantrums of temper, excessively fidgety behavior, poor ^{sexual habits,} pilfering, ro- mancing, unexplained moods,

marked

_{cruelty or}other anomalous

traits of character.

Inevery case the physician aimsfirstata thorough study^ofthe child from _{the point} of view of his physique, ^his intelligence, his emotionallife

and

general balance;

and

thenata study ^{of thein-} fluence of the environment

on

the formation of habits of the child.

With

the teacher he discusses the school _situation; with the parent he has to review _carefully the

home

behavior of the child, the development ^of the neurotic traits,

and

the conditions which

may

^{influence them.}

^The

individual child thus

may

get help,

symptoms

^{be relieved,} improper habits checked; but

an

important by-product ^is that the teacher gains a broader con- ception^ofthenatureofeducation, the parenta_deeperinsight into the problem of training thechild atask oftensohonestlytaken

up and

^so inefficiently carried out.

Inorder that the teacher

may

furnish essentialdatato thedis-

pensaryphysician,thelatter should supplysimple formsinwhich the important^facts can be _briefly entered; the teacher

may

^then

learn tofillin such aform, notas a

burdensome

routineduty but with the

same

interest withwhich the physician

makes

hisnotes.

Similar co-operation should be obtained

from

all social workers dealing with the problems ^of childhood,

when

_{they bring} one of their wards to the dispensary ^for examination. This of course applies equally where the

ward

is a child, a

wayward

^{adult, or}

delinquent, or drug ^addict.

The

social worker should realize theimportance^of apsychiatric opinion

on

such _cases,

and

should prepare the ^available data with

some

insight into the _require-

ments

of the physician; while the^{latter, in} the_lightof these data

and

the examination oftheindividual, should be prepared ^tofur- nish the worker

an

_opinion, which will

make

the actual

manage- ment

of the case

more

efficient.

Such work

will be a source of instruction to the individual worker; ^itwill

make

less haphazard

and more

_firmly based

on

rational principles the

work

of

many

organizations dealingwith _prisoners, unmarried_{mothers, juvenile} delinquents,

and

_dependents of other _types.

Work

of this type

will do

much

to instruct the whole

community

^{as to the under-}

lying causes of these disorders of conduct

and

the necessity of dealingwith

them

at

an

early stage,thatis,inthe school_period.

The

adult patients of the dispensary present a great variety of practical problems.

Sometimes

theproblems ^{are those of the} general dispensary; that ^isespeciallytruewherethemental

symp- toms

_point to

some

_underlying disease, either ofthecentralnerv- ous system (e. g.,braintumor) ^orof

some

other organ^orgroup ^of organs (e. g., exophthalmic goitre).

But

in a _largegroup ^{of cases} the

symptoms

^areintimately ^associated with _personal difficulties of adjustment,

and

a thorough study has^tobe

made

of the whole attitude

and

balance of the _patient,

and

of the life-situation in which he finds himself.

A

painstaking review

and

discussion of those _factors, which

make

for happiness or unhappiness ^{in life, is often} a relief

and

revelation to patients,

whose

ailments

have

hitherto beentreated inthetraditionalimpersonal

way by

drugs,rest-cures,

and

_opera-

tive measures.

Thus

a

young man came

_preparedto enterthehospital for the treatment of persistent headache; ^the headache

was

associated with worry ^{over faulty sexual habits.}

A

frank discussion of the whole situation relieved his

mind

considerably; he

was

en- couraged ^to improve ^his adaptation outside rather than to take refuge ⁱⁿthe_hospital. Accordingly,a

somewhat

uncongenial ^en- vironment

was

_given

up

^for residence in town, ^suitable employ-

ment was

found, the patienttook

up

^theregular

gymnasium ^work

of the Y.

M.

C. A. _along with other recreation in the evening.

Sincethenthepatient's attitude

toward

lifehasbeen transformed from one of sensitive seclusiveness toa

much more

healthy out- look; instinctive control is satisfactory; headache is no _longer spontaneously ^{referred to,} while his

improvement

^{has been}

an

enormous

relief to his family.

Encouraged by

^the improve-

ment

of the_patient, abrother has also sought ^advice.

MENTAL HEALTH OF THE COMMUNITY

5

While the

aim

of the treatment is the readjustment ^{of the} patient^to theenvironment, ^the

method

^islargely re-educational;

atthe

same

time,such_generalmeasuresas drugs, diet

and

bathsare not_neglected. Re-educationofthe patient

means

thathestudies his

own

_personaldifficultiesinaratherintensive

way

(assuminghe has the _requisite intelligence); he traces out the factors which

have

influenced his habits

and

_attitudes; he learns to face the facts ofhislifeintheir biologicalcrudityas well as in their ethical

and

aesthetic setting; he _{gains courage} to discard mental

make-

shifts

and

_disguises.

But

thisgainⁱⁿhonestinsight intotheproblems^oflife

must

not be a barren intellectual _exercise; it

must

_go

hand

in

hand

with asearch for thosepractical aidstotheformation of betterhabits whichthe

community may

^offer,

^{and must}

be accompanied

by

^the

actualutilizationof theseaids. Inthe_daily

and

_weekly

program

the variedneedsof

human

nature

must

_get sufficientrecognition;

work

should _yield its

own

return, opportunities ^{for recreation} shouldbe_available, thesocial, intellectual, aesthetic

and

_religious

aspects of^life

must

not be _{ignored; balancing} factors in the

way

ofhobbiesare tobeencouraged,

and

thefundamentalrelations of the patient ^{to his}

own

_familyare of cardinal importance. While the physician with his special knowledge helps the patient to unravel his tangles, the trained social service worker _plays

an

essential role in directing thefirst steps of the_patient. It is the

aim

ofthis

communication

to outlinethis

work and

illustrateit.

A

girl of twenty-one with a slight physical deformity took it

very seriously to heart,

saw

her life as without

any

promise,

and

harped

on

a

number

ofphysical complaints which

seemed

to

have no

_adequate cause.

A

review of her case

showed

that, partly owing^to personal difficulties, partly owing to faulty training

and

difficultcircumstances, she

had

developed her invalidism^asa_pro- tection, while her trueinterestsfound

no

outlet. Frequent^inter- viewswiththe physician enabled her^toadopt^{thelatter'sattitude} toward her

symptoms. At

the

same

time the social service worker* _got in touch with the _{patient's sister,}

and

did

much

to correct the attitude of the latter,

who had

fostered the _patient's invalidism. She put the patient ⁱⁿ the

way

^of developing her artistic talents

by

arranging ^for an exceptional educational op-

*Itakethisopportunityto expressmyindebtednesstoMissS.L.Lyons,ⁱⁿcharge^of theSocial ServiceDepartment^ofthePsychiatric Dispensary,^forher assistance in the preparation^ofthispaper.

portunity.

The

_patient

was

soon able to discard her _protective invalidism; she has

made

_{a good}start ontheroadtoeconomicin-

dependence; ^{her attitude} toward life is one of cheerfulness

and hope

^{instead of} discouragement

and

resignation, while the _slight physical deformity hasshrunkinher perspective

from

a

mountain

to a molehill,

and

as a matter of fact is not noticed

by

^her

com-

rades.

The

fact that the patient

was

referred to the dispensary

by

the physician

who was

consulted for the physical deformity, illustrates the benefit of the medical profession in general being trained torecognizesuch _disorders, whichare so apt ^to masquer- ade in _disguise.

The

_general social worker, too,does well to respond with

some

sensitiveness to anomalies of personality,

and

to

know when

to invite a psychiatric opinion before planning the ^{life of} the indi- vidual.

A young woman

of eighteen, with

some

artistic talent

and

superficiallybright, enlistedthe

sympathy

^{of adistrict social}

service worker through ^her story of ill-treatment at

home. The

latter obtained for the _girl the opportunity ^of going ^to

town

to take

up

^the study ^{of art.}

The

_girl soon attracted the attention of hercompanions

by

her phantastic ^stories

and

lack of respon- sibility

and

she

was

_brought to the psychiatric dispensary ^for examination.

A

_thorough review of her condition

and

of her early development

showed

that she

was

constitutionally ^in- ferior, not inthesense ofbeing intellectually defective,butin her response ^{to ethical} standards. This condition of constitutional psychopathic inferiority, which _gives rise to so

many

legal

and

otherdifficulties,

made

^it_necessaryin viewof heractual behavior to

have

_{her placed} in astate hospital.

The

well-meantendeavor of the social workerto help the patient

went

_astray, because the former

was

_guided rather

by

sentimental considerations than

by

trained insight into the personality ^of the _patient.

The

contact of the general ^social worker with the psychiatric dispensary should broaden the basis of

much

social

work and

be one

more

step in diffusing knowledge ^of mental hygiene throughout ^the

community.

The

consistent

and

conscientious treatment of the patient

means

that whatever necessary conditions ^are indicated for the readjustment ^of the patient ^{should, if} possible, be _placed at the patient's disposal, although ^{the search for}

them

takes one from the hospital into the school, the labor market,

and

the church.

The

concrete needs of the individual patient

have

to be defined

MENTAL HEALTH ^OP THE COMMUNITY

⁷

and

_.supplied;

by

^that

we

do not

mean

thatthe situation is

made

too easy ^for the _patient, nor that the patient ^is encouraged ^to

become

_dependent

on

the support^of the clinic.

But

the patient

must

be _given

more

than _general directions,

must

at first be

led, perhaps, ^until the

way

^is

^more

^familiar.

To make

the _steps

and

nature of the treatment clear, further individual cases

may

^be quoted.

A woman

of twenty-six ^for severalyears

had

_complainedofsevere headache,dizziness,vomit-

ing, burning pains, insomnia

and

nervous _feelings; the physician

who had

treated her

by

^{the usual medical measures for a} long period without result, recognized the true nature ^of the case

and

transferred herto the psychiatric dispensary.

The

mental roots of the disorder were not difficult to discover,

and

the mental hygiene ^of the patient

was

_placed

on

a better basis. She

was

sensitiveabout her ignorance^ofEnglish; shegot^littlesatisfaction

from

her few household duties; she squandered

much

time

and

energy ⁱⁿ day-dreaming.

Under

the stimulus of the social worker, she

was

_encouraged to take systematic^{lessons in} English; she

became

a

member

of a

gymnasium

^{class at the Public Athletic} League; she joined the

swimming

^class; she learned to develop her

home

responsibilities, attended the weekly occupation ^{class at} the psychiatric dispen- sary,

and

did

some

volunteer social service work.

When

the patient ^first

came

under observation her condition

was

such that admission to a state hospital

was

_seriously considered

and would have

been

welcomed by

^{the husband.}

With

_{the help} of the measures outlined above the patient improved greatly, although leaning frequently

on

the social service worker.

The husband was much

encouraged

by

^theimprovement; ^his hearty co-opera- tion in the treatment

was

the result of the support

by

^theclinic,

and

_replaced his previous resignation to the prospect ^of having her leave

home

for a long residence ina_hospital.

Itisoftenso;with the dispensary^tofall

back on

intimeofneed, the

husband

or _wife, parent ^{or child, is often}

much more

_willing

to undertake the task of looking ^afterthe patient ^at home.

The

treatment of the patient ^is the treatment of the whole situation

and

the other

members

of the family

must

often receive psychiatric attention, as in the _following case.

A man

of forty-seven, with epileptiform convulsions,

was

sus- pected ^of malingering

by

^{the social} organization which _helped to support ^his family. Examination at the psychiatric dispensary

determinedthe organic nature^ofthe_disorder;he

was

_operated

on

in the _hospital, unfortunately without _relief; after leaving the hospital hecontinuedto visitthepsychiatric dispensary wherehe attended the weekly occupation class, his sole recreation. His wifepreferred to care^for

him

at

home

thanto

have him

admitted toastate hospital. It

was

foundthat

two

ofhis children

showed

neurotic

symptoms

^;they wereaccordinglyexamined,^their

mother was

advised as to the necessary

home

_hygiene, their school teachers were interviewed

and

informed of the medical _opinion,

gymnasium

privileges were _arranged for

and

the necessary shoes provided.

The

_range of the

work

done

by

the dispensary in treatingade- quately the ^situation presented

by

^a patient ^is

shown

in the fol-

lowing ^case.

A

_foreigner, cultured but_eccentric,

was

referred to the dispensary

from

the tuberculosis clinic

on

account of his depressed condition; his funds were low, there

had

been friction

with the church authorities, thefault not being altogether

on

his side. Inviewof hisprejudices

and somewhat

difficultpersonality, the problem ^of readjustment

was

rather complicated.

The

frictionwiththechurchauthorities

was smoothed

over, asuitable position

was

obtained forthe_patient, debts were _paidin orderto let

him move from

a _quite uncongenial environment to one

more

suitable for

him and

for his children, clothing

was

_providedforthe family, ^artificialteethfor the_wife,

some

literature

was

_putatthe patient's disposal,

and

thebasis for

some

_congenialfriendships

was

laid.

Such

a series of steps

may ^seem

^{to stretch rather far the}

functionofthe dispensary,butsolong^asthe therapeuticproblem^is taken _seriously they are as essential as the individual _{steps in} surgical or ordinary medical treatment.

From

theeconomicstandpoint the outlay ⁱⁿ such acase

comes up

for scrutiny.

The

serious probability

was

that this eccentric

man,

^{with his} cultural interests starved in a drab environment, unable toearn_{his living}owing^tothechurch_friction,

would show

progressive embitterment

and

_develop definite delusions.

The

result

would

then have been his admission to a state hospital, perhaps^to remainfor life, while his children

became

a _charge

on

the

community. By

^{the measures taken, which involved an}

expenditure ^{of less} than

two hundred

dollars, he _promisesto be-

come

a _productiveeconomicunit, the support ^of thefamily, get- ting satisfaction out of life,

an

asset to the culture of the

com-

munity.

Not

_only ishe himselfhappy, but the prospects^forthe

MENTAL HEALTH OF THE COMMUNITY

9

healthy development^ofhis children are_infinitelybetter. Thisis

preventive medicine.

Even

in cases where theseriousness of the disorder allowsonly palliativetreatment, the dispensarycan

do much

to outlinemeas- ures to reduce friction with the _patient; the_physician,

by

giving the family an insight into the medical view of the _disorder,

may

rob it of

much

of itsbitterness.

One

_important practical decision has frequently ^to be

made,

namely, whether the patient should be _placed in a _hospital even withouthisco-operation.

The

relativesareapt^{totake the}

symp- toms

_merely at their face value; the _physician, however, ^realizes that a _patient with _{incipient paresis}

may

seriously

compromise

his

name and

_fortune, that apatient with a mild _depression

may

commit

suicide, that a seclusive

and

embittered patient

may

suddenly

commit

a homicide. Impressed with these dangers

he

may

urge the ^{friends of} the patient ^to take the necessary steps to

have

the latter admitted to a state hospital or private sana- torium. In the popular

mind

old associations still cling to the hospital formentaldisorders;the

man

inthestreethardly ^realizes that they are hospitals in the true sense of the word, _specially staffed

and

_equippedfor the curative

and

_palliative treatment of disease.

One

need not

blame

the

man

in the street, for physicians

and

social workers often require enlightenment on ^this topic. In

illustration, I

may

quote an ^extract from the letter of a social worker, protesting against the advice ^to send a

young woman

to a state hospital:

"From

a physician's point ^of view, would

you

advise further hospital treatment outsideof an insane asylum? So _long as she

isperfectlyharmless,

would

shestand abetterchanceinamedical hospital foralittle while_longer, if

we

could soplace her?" This referenceto a state hospital asaninsane asylum, a_placewhich is

not_regarded as a medical _hospital but where _patients should

be

sent only

when

_they cease tobeharmless

and

can notbebenefited

by

^further treatment, illustrates a medieval trend from which contemporary thought

must

be _purged.

Where

the medieval attitude still dominates theinstitutions of the state, ^{it is} an im- perative duty ^{of the}

community

^{to see that the} hospitals are brought

up

^{to a}

modern

level.

Itisnotsufficienttogive^tothe family the

summary

^advicethat

commitment

to a state hospital ^is necessary; the nature ^of the

advice

must

be

made

clear,

any

prejudices

removed

so far aspos- sible, the actual steps ^for the admission of the patient arranged with the utmost consideration for the attitude of the _patient.

The

relation between the patient

and

the physician ⁱⁿ the state hospital

may

^be seriously

compromised by

injudicious

manage- ment

of the patient before admission; there should be no _deceit;

non-medical interference, such as the co-operation ^of the _police, shouldbe avoided_exceptinaseriousemergency,

and

then a_plain- clothes

man

should be employed.

A

frank attitude towards the patient

may

gain co-operation, even where the outlook is not promising.

Thus

a

woman

of forty-two at first rejected indignantly the advice ^to go ^to a state hospital; she

had

ideas of persecution, thought ^{that she}

was

fol-

lowed

by

detectives, threatened to shoot her persecutor,

and was

incensed at the physician's guarded suggestion that her whole attitude required a detailed examination such as could only be adequately ^carried out in a _{special hospital.} After

two

months' contact with the dispensary, she ^herself asked the physician ^to

make

the necessary arrangements ^{for her admission to the state} hospital. After a _stay of over a _year in the _hospital she left it

and

visitedthe dispensary; she^still clung^to herold ideas

and

did not _{accept the} physician's view of her sickness, but she

had no

resentment _against

him

for having ^{sent her for} treatment to a mental _hospital.

Some months

_later, unable to establish herself inthe

community,

she returned voluntarily to the state hospital.

The

detailed treatment of the individual case, so far as the analysis of the

symptoms ^and

^the readjustment ^{of the} patient's attitude areconcerned, belongs

more

to a technical medical dis- cussion than to the present review, which aims

more

at adiscus- sion of the _objective

methods

_involving social co-operation. It

may

^be helpful to mention _brieflythose socialorganizations with which thepsychiatricdispensary

must

_keep in touch, through ^its social service department.

To

^a _large extent they supply ^the machinery^forthereadjustment^ofthepatient,

and

theproblem^of the psychiatric ^social service worker is largely to co-ordinate theirindividual ^services. Contact withthese organizations^to be

efficient

must

be _personal

and

_intimate, not formal

and

_perfunc-

tory.

The

_dispensary

must

be in close touch with the school system

and

_co-operatewith_principals

and

teachers, sothattheirproblems arefreely referred tothe dispensary,

and

itsadviceactually carried

MENTAL HEALTH OF THE COMMUNITY

11

into practice. Similar relations should exist with the _juvenile court, with reform

and

_{parental schools,}

and

with all official

charity organizations, for no organization can deal adequately with the problems ^of dependency which ^{does not realizethe r6le} played

by

^{mental defect} or disorder.

These

organizations can not _{only bring} their problems ^{to the} dispensary, but

make

a valuable social apparatus available for the readjustment ^{of the} psychiatric patient.

Such

readjustment ^{is often} facilitated

when

the psychiatric worker ^is in touch with the _large employers ^{of labor}

and

with

employment

^{bureaus, such as the}

new

Federal

Employment

Bureau; ^the economic readjustment ^{is often} an essential part ^of the total task.

For

the development ^{of those}

human

interests which are such importantbalancing^{factors inlife,} one

must

bein touch withthe local opportunities ^for promoting ^self-culture, with organizations such as the night schools, the Jewish Educational _Alliance, the Y.

M.

C. A.

and

theY.

W.

C. A.

The

_patient

may

^alsobegrate- ful for

some

_help in _utilizing the other cultural opportunities ^of the

community,

^the

museums,

libraries, picture-galleries

and

concerts. Simple ^recreative opportunities ^are sometimes to be found in well-run municipal dance-halls, while the

humble

"movies" may

^be

recommended

as an invaluable diversion in a

community

^{wherethe only}alternativeisthesaloon.

For

_physical culture, the development ^of the corpus

sanum

as afittemple^{forthe ideal}

mens

sana,one

must

be able toutilize the

gymnasia

^{associatedwiththeabove}organizations,withseveral churches,withthe PublicAthleticLeague, whileⁱⁿ

summer

_healthy

exercise

and

recreative diversion are

combined

in

summer

_camps, perhaps under the auspices ^of the

Boy

^{Scouts or the}

Camp

^Fire

Girls.

Where

the patient has not cut himself adrift from his organic church affiliations, ^{it is} important ^thatthis

most

_potentinfluence in

human

^life should play^{its r6lein} the readjustment^orhygienic resurrection oftheindividual. Thisistobe donenot

by

referring the patient ^to

some

_hybrid organization, a blend of church

and

medicine, but

by

^restoring the patient ^to the fellowship of that church of which he

was

an _organic

member;

^{with his fellow-}

members

he ^is entitled to get

from

his spiritual guide

some

_prac-

ticalhelpⁱⁿharmonizing^hishighest needs with the other^insistent

demands

of

human

nature. Co-operation ^{of this} type ^will be

more

generally available

when

those preparing^to be the_spiritual leaders in the

community

^are offered, during their training,

a

psychology ^{that deals with the actual conflicts of the}

home and

the market,

and

not a sterilized laboratory psychology.

Here may

^{well end our brief sketch of} the organic connections ofthepsychiatric dispensary withthelifeof the

community, and

of the task of those

who

_{help us} in building

up

again the ^struc- ture of

human

^lives which

have

_{been badly}shaken.

"And

difficultasit

may

^betotransform theinstinctsthat dwell in the soul, ^{it is} well that those

who

build not should be

made

aware of the joy that the ^others experience ^as they incessantly pile stone

upon

^stone. Their thoughts

and

attachments,

and

love; their convictions, deceptions

and

even their doubts all

standingood^service;

and when

the passingstorm has demolished their mansion, they ^build once _again with the _ruins, a little dis- tance away, something ^less stately perhaps, but better adapted to all the requirements ^{of life."}

SUMMARY

Indigestion

and

headache

may

^{be mental} disorders just as truly as are

morbid

_phantasies

and

distorted attitudes; ^it depends on their _origin.

The

mental out-patient department or psychiatric dispensary of a hospital deals with

symptoms

^{of mental} origin, whether the

symptoms

^{are called} physical or mental.

The

psychiatric dispensary ^will be of the _greatest value to the

community when

_physicians

and

socialworkers

who come

into contact withcases of mental disorder or defect

know

thetype ^of

work

done there.

The

teacher

who

_promptly ^securesapsychiatric opinion

on

her subnormal

and

neurotic _pupils, develops deeper insight into her

own

_special educational task.

The

basis of

much

philanthropic

work

can be broadened if the psychiatricdispensary^isfreelyconsulted

by

^workersdealingwith thedependents

on

_society, delinquents, prisoners, vagrants, drug addicts, unmarried mothers, ^etc.

Many

patients with mental

symptoms ^have

^{somatic disorders}

and

_present

no

different problems

from

those

met

in the general dispensary. Other_patients do not react to the ordinary medical treatment(drugs, baths, exercise, rest,operation,etc.)becausethe

symptoms

^{are interwoven} with the personal difficulties of the

MENTAL HEALTH OF THE COMMUNITY

¹³

patient.

The

psychiatric dispensary, receiving these patients

from

the general dispensary ^or from outside physicians, helps to keep ^before the medical _profession the importance ^{of certain} factors of health too often _neglected,

namely

^{those factors which} arethe_specialprovince^ofmental_hygiene.

The

treatment of a patient often

means

his re-education, his revaluationof the variousfactors in_life,his progressfrom

an

im-

mature

attitude to one

more mature and

honest. Difficulties in the life-situation of the patientwhich are

open

^to modification

must

notbe _neglected.

At

the

same

_time,

more

_{hygienicadapta-}

tion to the complex

demands

of life, the formation of better social habits, are complex ^tasks where supervision

by

^{an intelli-} gent^{social service}worker is invaluable.

The

socialserviceworker, ^tobeof practicaluse tothe _patients,

must

_keep in intimate personal touch with

many

aspects ^of the

community

^{life, economic,} educational, philanthropic, religious

and

recreative.

The

treatment of a patient frequently

means

thetreatment of his whole domestic

and

economic situation; the thorough per- formanceofthistaskistobeconsidered preventive medicine.

A

000

494

970 7

MENTAL HYGIENE

QUARTERLY MAGAZINEOF

THE NATIONAL COMMITTEE FOR MENTAL _HYGIENE,

INC.

EDITOBIAL OFFICE: 50 UNION SQUARE.

NEW YORK

CITY

EDITORIAL BOARD

THOMAS W.

SALMON,

M.D.

MedicalDirector,TheNationalCommittee_forMental Hygiene

FRANKWOOD

E. WILLIAMS,

M.D.

AssociateMedicalDirector,TheNationalCommittee_forMental Hygiene

GEORGE

_BLUMER,

M.D. WALTER

E. FERNALD,

M.D.

Deanof^theYaleMedicalSchool Superintendent, Massachusetts School for Feebleminded

C.

MACFIE

CAMPBELL,

M.D. AUGUST

_HOCH,

M.D.

AnociateProfessor of Psychiatry,Johns HopkinsUniversity FormerDirector,PsychiatricInstitute,N.Y.StateHospital

STEPHEN ^P. DUGGAN, ^PH.D.

STEWART

_PATON,

M.D.

Professor of Education,Collegeof^theCity ofNewYork Lecturer inNeuro-biology,Princeton University

VOL. II, No. 1

INDEX

_JANUARY, 1918 The Management^ofWarNeurosesandAlliedDisordersintheArmy [Col.]SirJohnCollie 1

MentalHealthforNormalChildren WilliamH.Burnham 19

AConsiderationofConductDisordersintheFeebleminded L.PierceClark 23

FeeblemindednessandIndustrialRelations C. S.Rossy 84

ThePracticalFunctionofthePsychiatric Clinic JohnT.MacCurdy ⁵³ TheFamilyof the Neurosyphilitic Harry^C.Solomon,MaidaH.Solomon 71

BetterStatisticsofMentalDiseases HoratioM.Pollock 81

Special Article

A_Studyof608 AdmissionstoSing Sing Prison BernardGlueck 85

Notes andComments 152

BookReviews 162

Current Bibliography MabelW.^Brown 168

Directory ^{of Societies}and CommitteesforMental Hygiene ¹⁷³

MENTAL HYGIENE

will aim to bring dependable information to everyone whose interest or whose work _brings him into contact with mental _problems.

Writers of authority ^will present original communications and reviews of impor- tantbooks;noteworthyarticles inperiodicalsoutofconvenient reachofthe_general public ^will be republished; reports of surveys, special investigations, and

new

methodsof prevention^ortreatmentinthe broadfield of mental_hygiene and_psy- chopathology^willbe_presentedanddiscussed in asnon-technicala

way

^aspossible.

It is our aim to

make MENTAL HYGIENE

indispensable to all thoughtful readers. Physicians, lawyers, educators, clergymen, public officials, and students ofsocialproblems ^willfindthemagazineof especial ^interest.

The

National Committee for Mental Hygiene ^{does not} necessarily endorseor assume responsibility for opinions expressed or statements made. Articles pre- sentedare printed uponthe authority ^{of their writers.}

The

_reviewingof a book does not imply ^its recommendation by

The

National Committee for Mental Hygiene. Though^all articles in this magazineare copyrighted, others

may

quote from them_freelyprovided appropriate^creditbe given^to

MENTAL

HYGIENE.

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York_City.

Copyright, ^1917, by

The

National Committee forMental _Hygiene, Inc.