liminary training should be initiated long before in order to inhibit their later development. The adolescent boy or girl should be helped to make a wholesome adjustment to the demands of his instinctive nature in the first place, for by the time he reaches a hospital for the insane, he has commonly departed so far from normal habits of thought and conduct that attempts to reeducate him are of very little use. There must be psychiatrists in the upper grades of the public schools and in the high schools, for frequently it is there that incipient mental disorder first shows itself. There must be more mental hygiene clinics and education of the public in regard to the subject of mental hygiene.

1

It may be interesting to note at this point that the mental hygiene division of the Free Synagogue, of which mention has already been made, has established and maintains a country home or camp to which are sent adolescent girls recommended by physicians, nurses, teachers, social service agencies and others. The girls are examined by a psychiatrist and if found to be cases of mental maladjustment in danger of developing some mental or nervous disorder, they are sent to the camp for a period of several weeks or even months. While there they are under the constant and direct supervision of a nurse specially trained in work with this type of girl. They are followed-up after discharge, hold reunions throughout the fall and winter, and in case of further need of country care are permitted to return to the camp until their condition has shown marked improvement. The experiment has well justified the expense involved and raises the hope that similar camps or convalescent homes for other groups will prove to be a very effective means of preventing mental and nervous breakdowns in later life.

1 Harrington, Milton A., "Mental Disorder in Adolescence," Mental Hygiene, Apr., 1920, p. 379.

V. MENTAL HYGIENE NEEDS OF A COMMUNITY

The object of this study having been largely limited to a consideration of the social aspects of the treatment of the insane, it may be worth while to point out in closing, the fundamental items of a mental hygiene program for a community, taking for granted that the thoughts already expressed, particularly upon the problem of the child and the adolescent, do not need reiteration.

Mental hygiene activities, as will be remembered, aimed first of all to educate the mass of people regarding the essentials of proper nervous and mental life. Following this came the establishment of mental hygiene clinics with their psychiatrists and specially trained social workers. The plan of activities of certain mental hygiene clinics operating in New York City was presented in the preceding chapter and it was implied that the equipment of the mental hygiene agency operating these clinics is by no means adequate to meet the pressing needs. It is not merely a question of inadequate financial resources to establish more clinics in different parts of the city; other fundamentals are lacking to round out the activities and power for service to the community. A presentation of these will go a considerable way toward indicating what the minimum facilities should be in every large community in order to meet the mental hygiene requirements.

First of all we can proceed on the assumption that in any given community the mental hygiene facilities are not adequate to serve those in pressing need of this kind of medical attention. There is not a city of any size where sufficient emphasis is being placed upon the mental health of the population, either through the activities of the public institutions and their officers, by private agencies, or a combination of both. The fact of the matter is that the mental hygiene idea is only beginning to take root in various sec

tions of the country. It will be some time before an awakened and aroused public conscience takes recognition of its needs, spurred, perhaps, by the propaganda and stimulation of local societies for mental hygiene or by the National Committee for Mental Hygiene.

It should again be made plain that, as at present organized, state hospitals are not prepared to meet the mental hygiene needs of a community without the active assistance and financial support of private organizations. By this is meant that the private agencies should cooperate with and supplement the work of the state hospitals by various activities, some of which will be explained in the following section.

VI. MENTAL HYGIENE AGENCIES

At least four elements are necessary to the proper organization of a mental hygiene agency. These are (a) clinics; (b) convalescent homes; (c) a model factory or workshop; and (d) a psychiatric institute functioning in conjunction with the other items in the program.

(a) Clinics. Clinic organization and plan of service have already been discussed and will be passed over at this point, except to note the further suggestion that before the estab lishment of any clinics in a community a survey should be made of the distribution of the population that is most likely to come to these mental hygiene clinics. Moreover, whenever possible, such clinics should be established within the buildings of a general hospital. With the development of hospitals as health centers, it seems most advisable that mental hygiene clinics should also become part of the community health program.

(b) Convalescent Homes. Those engaged in psychiatric social work often feel themselves at a loss as to where to send a mental case in need of convalescent care. It may be of interest to note that there is hardly a con

valescent home or institution in or near New York City at present that will accept as an inmate one who has been discharged from a state hospital and is in need of a temporary change of environment or convalescent care. The only institution approximating such a place which receives mental cases is the camp already mentioned, and to which, because of lack of room, only adolescent girls are admitted. As a result of this state of affairs, early mental cases and those verging upon a breakdown must be committed to state hospitals from which they might otherwise be saved, or they must be sent to private sanatoria, where the standard of care and attention is often inferior. In the case of single persons without any immediate relatives or friends in the community, the attempt has to be made at an early stage to board them in selected private homes. None of these expedients has as yet been found satisfactory. The only solution that seems at all feasible is the establishment of one or more convalescent homes specializing in the care of mental cases. These might be similar to the institutions already in existence to which are sent persons in danger of a physical breakdown, or those recuperating from surgical operations and severe physical ailments.

(c) Workshop for Mental Hygiene Patients. From a reading of the cases cited in the preceding chapter it must have been realized that one of the main difficulties faced in trying to assist patients to readjust themselves was the inability to provide suitable employment for them under favorable working conditions. It is not very difficult to find some kind of work when there is a labor shortage, but the problem is so to place mental hygiene patients that for one reason or another they will not feel compelled to leave the job found for them within a few hours or days after beginning work. The difficulty is that these persons cannot fit into what we to-day call, whether rightly or wrongly, the

normal industrial life. They must have working conditions specially planned to meet their particular needs. Thus, the recovered and improved cases of manic depressive insanity find it well-nigh impossible to return to former sweatshop and high-speed industrial life without exposing themselves to a relapse and readmission to the state hospital. The numerous early cases of dementia praecox and others lose one position after another because the employer does not understand and refuses to sympathize with their condition and discharges them when they repeatedly come late in the morning, when they feel indisposed and remain away from work, and otherwise fail to measure up to the standard and pace set by their healthy fellow-workers.

Suitable occupation under favorable conditions is an established and recognized therapeutic agent for mental cases. To prevent the numerous relapses and hospital readmissions. as well as to stave off, in the first place, the need for commitment because of social maladjustment arising from industrial and occupational difficulties, model workshops for mental hygiene patients should be established. A workshop for Jewish men and women afflicted with tuberculosis has for several years been in operation in New York City under the direction of a social agency. The project long ago outgrew the experimental stage and has from its inception been a successful venture from the social, medical, occupational and economic viewpoints. The same kind of workshop, with certain necessary modifications, should be established for mental hygiene patients. It would then not be necessary for patients discharged from state hospitals to reenter at once the industry which in the first place contributed to their mental or nervous breakdown. Those suffering from the milder forms of mental disease could find gainful occupation where they would work under the supervision of those who understood their condition,