THE PRACTICAL FUNCTION OF THE

PSYCHIATRIC CLINIC

BY JOHN T. MACCURDY, M. D.

The chief object of this paper is the discussion of the relation of social service to psychiatry. When a patient has been committed to an institution, that institution is responsible for his welfare so long as he is within its walls. When released on parole there is no longer a direct contact between the patient and his physician except on occasional visits, and the general mangement of the case must be left to a greater or less extent to the after-care agent. This branch of social service work has been recognized and its value well appreciated for a number of years. There is, however, another branch of this work which is much less known and is probably of vastly greater importance. I refer to the care of the mentally abnormal whose disease has not progressed to the point demanding commitment. This work is essentially prophylactic, and therefore, were it only from an economic standpoint, would demand the attention of the State hospitals; for every patient kept out of an institution for a month represents just that much lightening of the hospital load. This prophylaxis, however, is of the greatest psychiatric and human interest, and it is in this field that social service work is of unique importance. Much could be said in generalities on this side of the question, but I have thought it probably more useful to focus my remarks on actual observations; to give you an idea of just what may be accomplished and of the rôle of the social service worker in these achievements. For this purpose I have made an analysis of 100 consecutive cases seen by myself at the Cornell University Medical School, in the dispensary operated jointly by the Psychopathological Department of the University, and the Mental Hygiene branch of the State Charities Aid Association.

There are others in the dispensary who have had more brilliant results, I know, but I thought it fairer to present

only the cases that I myself had seen, as the same criteria for judging success or failure can be applied to all of them.

The therapeutic results in any dispensary are apt to be far behind those of private practice. This is particularly true of psychiatric work, and it must therefore be borne in mind that the incomplete success or actual failure of the dispensary is no indication of what the trained psychiatrist can do in the treatment of neuroses and psychoses, but is much more a measure of the insurmountable difficulties to be met with in charitable work. In fact, when one considers the physical disabilities under which the clinic at Cornell labors, it is surprising that good results are ever obtained. And in order that you may keep this in mind when hearing the results of our work it may be well to mention what these are.

The clinic is held in a class room about 30 feet by 40 feet in size. In one corner is the desk of the social service worker and the file of histories. In the middle of the room sit the patients who are waiting for examination. At the other side of the room from the social service worker is the examiner's table, separated from the rest of the room merely by a flimsy cotton screen. It will be immediately understood that under these circumstances no complete physical examination can be made when such is required, and that a discussion of the intimate affairs of the patient can never be carried on with any real privacy, since everyone in the room can hear all that is said unless both patient and physician speak in a voice little above a whisper. Another difficulty lies in the fact that the clinic is undermanned, and the physician is frequently forced to give a patient only fifteen or twenty minutes of time when one or two hours would be little enough to devote to the problem in hand. It must be remembered, too, that more than in any other branch of medical work we are dealing with those who are burdened with bad heredity and environmental difficulties which are beyond remedy with the present organization of society. As you all know, a great deal of mental abnormality is engendered or fostered by unhappy human associations, and it is not easy to take the patient

away from the influence of an unsympathetic family or employer, particularly when, as is usually the case, the patient is economically dependent on the maintenance of these relations. For these reasons it is therefore plain that, what psychiatrists have learned in recent years of the psychological factors tending to develop abnormal states, can not be applied to best advantage in the clinic, and that one must be satisfied without a full psychological analysis of the patient's difficulties or the environmental changes which his judgment tells him are imperative.

On the other hand, we have been extremely fortunate in the aid we have received from the Mental Hygiene branch of the State Charities Aid Association, and we have always been able to count on the social service work being carried out as completely as is physically possible. For this we have to thank the intelligence and sympathy of Miss Tucker and her successor, Miss Taft, but most of all are we indebted to Miss Wells who has taken by far the largest share of the work connected directly with the clinic.

Our situation having been explained, I can proceed to outline the practical aims of the clinic. Naturally we hope in every case to produce a cure, but this is a result which is most rarely obtained. In this connection it must of course be remembered that I am speaking of "cure" in a psychiatric sense. In many of the cases which I shall report with the result "improved", the patient himself, his family or friends would say that a cure had been effected, whereas the psychiatrist, who can recognize the persistence of potential difficulties, is more conservative in his claims. Practically speaking, therefore, our aim comes to be an alleviation rather than a cure. The patient who has not been working is brought to be self-supporting. The one who has been in active conflict with his environment is taught to adapt himself. Society is protected from the abnormality of the patient who has been a menace to it. In all these matters it is evident that the results are of social rather than individual value. In this connection it is important to emphasize one of the chief activities of the clinic in its advisory capacity to charity organizations. Of

the 100 cases to be reported, no less than 48 were referred by charitable organizations, and in practically all of these cases the association in question needed advice as to whether aid should be given the patient, and if so, how that aid should be applied. The growing recognition of the value of the clinic to these organizations has been gratifying. The reasons why charitable societies are forced to turn to the psychiatrist for advice may be plainly understood when one remembers that trouble of any kind produces mental disturbances. These troubles may be essentially external or internal in origin, and it is only the psychiatrist who is able to differentiate between the symptoms produced mainly by environmental stress, and those for which inherent abnormality is mainly responsible. These two groups, therefore, which may be superficially alike, require quite different treatment at the hands of those who would give them help.

The methods of treatment adopted are chiefly these. When the patient has sufficient intelligence and insight to justify the attempt, a discussion of his difficulties from the psychological standpoint is essayed. It must be understood at the outset that one could not call this psychoanalysis as one speaks of that method in private practice. The analysis in the clinic is at best superficial. It is important, in understanding the practical function of the clinic, to note that in the 100 cases such analysis was attempted even in the smallest way in only 10 or 12 of the patients. In a much larger number the psychotherapeutic measures would more properly be grouped under the heading "suggestion", using that term in its widest sense. The diagnosis, where possible, is explained to the patient, and he is encouraged to believe that he can take the situation in hand himself and that he should fight against the purely subjective symptoms. In patients whose difficulties have been for a long time. fostered by a belief in some physical ailment, a candid discussion of the diagnosis is often of considerable value. Not infrequently in an unstable individual the factor which may make the difference between a tolerable and an intolerable existence is the presence or absence of some

minor physical trouble. For this reason medical advice, particularly sound directions as to physical hygiene, is not infrequently of great value. Allied to this are measures which, though apparently physical, have a large indirect mental effect, such as the use of baths, exercises and the timely use of sedatives or tonics. Most important of all are the environmental changes which are carried out through the agency of the social service workers. In these cases some particular strain from which the patient suffers may be relieved and the mental balance resumed. A mother whose household duties have become more arduous than her mental capacity will tolerate may have her children taken care of for a few weeks. The wife whose domestic situation has become intolerable can be supported away from home for a short time. The adolescent who is chafing under the restraints of home can be given aid while establishing himself independently. In all such cases it must be borne in mind that we do not consider that the benefit derived is really physical, but that the strain of adaptation is temporarily too great for the patient, and that a brief relaxation of his efforts may make a better adaptation possible when he has gained a little surplus energy. It must be remembered that such relief is never given when it seems likely that the patient is permanently incapable of adaptation, in which case charity becomes pauperization. It is in such situations that the psychiatrist is capable of giving expert help.

We can now proceed to a discussion of the different groups. The largest of these is that of the psychoneuroses, and it is natural, as these represent the mildest type of mental abnormality, that improvement in their condition is most frequently secured. The statistics of this group may be of interest. There were 24 such cases out of the total 100. Of these the etiology was thought to lie preponderantly in the make-up of 13 cases, and of these 13 the condition of 2 remained unchanged; 6 were not heard from after the initial visit; 5 were improved, with 2 of these possibly cured. Of those where the etiology seemed to be preponderantly environmental (that is, where the patient was subject to an