A NEW MINISTER TO MINDS DISEASED

MICHAEL M. DAVIS, Jr.

DIRECTOR BOSTON DISPENSARY

AND

MABEL R. WILSON

SOCIAL WORKER, MENTAL CLINIC, BOSTON DISPENSARY

Early last June Mrs. R., a rosy-cheeked, attractive Irish-American woman of thirty years, came to the mental clinic of the Boston Dispensary in a depressed and emotional condition. She was obsessed by the idea that every one in the world had syphilis, and that she in particular was a menace to her husband and their three young children. So firm was this conviction that she had seriously contemplated suicide.

Four years previously Mrs. R. had shown distinct manifestations of syphilis, and had received medical treatment. The infection the physicians believed was accidental, and the husband and children had proved, upon examination, to be free from any symptoms. For over a year in Mrs. R.'s case Wassermann tests had indicated that the disease had been cured; but the doctor's assurances were of no avail.

The blackness of this patient's depression had almost wrecked her home. For months she had not prepared a single meal. The patience of her relatives and friends and of the priest of her church—who considered her what she looked, the picture of health—was entirely exhausted.

Ordinarily the income of the family was sufficient for self-support. Mr. R., a bright, clean-looking young bar-tender, who was well thought of by his employers, earned $18 a week. He had been making a desperate effort to meet the extra expenses due to his wife's illness. The strain was beginning to tell upon him, however, and the health of the children was also falling below normal. The family lived in a five-room tenement in a congested and undesirable neighborhood. Mrs. R. for this reason worried constantly about the possible bad influences upon her two elder children, who were just beginning to go to school.

Thus the mental clinic faced an acute situation. If it were not effectively dealt with it would, at worst, terminate in suicide, and, at best, in breaking up a promising family.

The facts just recited were, of course, not secured at the physician's first interview with Mrs. R., but were in part gained by the social worker in the clinic and at the home. It was apparent that the home situation must be considered as well as the medical problem. There was clearly a joint task for the social worker and the mental specialist. Consultation led to the conclusion that the home arrangements would have to be changed until Mrs. R. was able to undertake housekeeping again. A long month of explanation and persuasion passed before the family, friends, and priest were converted to a plan which involved the temporary dissolution of the home. Consent was finally obtained, and the children were placed by a children's agency. Probably most important of all, the earnest co-operation of the patient herself was won. For four months she reported at the clinic two or three times a week. After the many interviews held with her by doctor and social worker, her depression gradually cleared up, and she became ready to take up the battle of life again.

As improvement grew more marked, the doctor advised that she should work three hours each day outside her home. Three hours' work every day in a good restaurant was secured. The benefit was so marked that after a month the doctor suggested that the working time be doubled.

Mrs. R. now reports weekly to the clinic, but her depression has disappeared. She is cheerful, interested in life, and is looking forward to the re-establishment of her home this spring.

Recent conferences on mental hygiene have emphasized the fact that the traditional conception of mental disease, raving insanity, is far behind the times. We recognize today that there are in the community all classes of mental disorders, from the maniac or imbecile to persons who are "just a little queer," or who, like Mrs. R., have a definite and curable obsession.

The time has also gone by when we associated the treatment of mental disease with the straight-jacket. The hopelessly defective and insane must indeed be segregated in institutions. But it is public economy to diagnose and treat the great mass of incipient and curable cases of mental disorder, since these, if uncared for, mean the wrecking of lives, the breaking up of families, and material loss to the community. The psychopathic clinic, or clinic for mental diseases, is an agency the importance of which is now recognized by all who have given attention to this field. Such clinics have usually been conducted in hospitals or institutions which specialized in mental disorders. They have rarely been managed as adjuncts of general hospitals or dispensaries. There is a distinct place for them in this connection, however, for in this way they catch patients who do not know that their troubles are really symptoms of mental disease.

Mrs. R.'s case illustrates not only the service of such a mental clinic, but also the two chief agents in achieving the service, the physician—specialist in mental diseases—and his aide, the social worker. Mrs. R.'s case belongs to one of three classes of mental disease which such a clinic can benefit—the incipient type. The second class comprises cases of mental defect which require diagnosis and institutional care.

For example. Mrs. B., a middle-aged Irish woman, came to the clinic much excited, fancying that people were locking her into her rooms. Among other delusions she feared that she might injure her two children.

The doctor diagnosed her case as involutional insanity, and thought that immediate arrangements were desirable for her entrance into an insane hospital as a voluntary patient. Mrs. B. did not remember her street number, and undoubtedly she would have been a "lost" patient if the social worker had not taken her home. Arrangements were made and carried out for a transfer to the insane hospital that same afternoon, and a children's agency agreed to assume supervision of the children during Mrs. B.'s absence. The help of a friendly landlady was also enlisted.

Within three months Mrs. B. was discharged from the insane hospital in excellent condition, with the understanding that she should report regularly at the clinic. Her improvement continues. She is at present earning good wages as a housekeeper and looks forward in the future to a little store and the re-establishment of a home for her children.

Another illustration of this type is Mr. D., a German forty-eight years old, who has been in the United States twenty years.

Mr. D. became known at the dispensary through his wife, who had been a patient. The man went on periodic "sprees" at this time, apparently because his work as an order clerk had occasioned considerable nervous strain. Temporary financial assistance and a new job outside of Boston, seemed to put the man on his feet again; and, with a happier home life, his wife's health improved.

In a short time, however, distinct symptoms of mental disorder began to manifest themselves. Mr. D. talked much to himself, and was haunted by doubt in everything that he did. If he put on his hat he was forced to step in front of the mirror several times to be sure that the hat was really on his head. After completing a piece of work, he returned many times to make sure that it was really done. Occasionally he remained at home in bed, because his fellow workmen, noting his peculiar actions, had laughed at him. Upon this basis a fear of meeting people grew up, and he shunned every one. Once or twice he approached his wife threateningly. The superintendent feared to keep him at the factory any longer, and discharged him. After a careful medical examination, the prognosis for the patient was not very favorable. A possible outcome was an active and incurable form of insanity. It seemed necessary, in order to have a reasonable hope of cure, that a radical change of life be made.

Therefore, Mr. D. was induced to go as a volunteer patient to a hospital for the insane. There he remained six months, during which time, with the assistance of the Associated Charities, suitable quarters and light work were found for his wife. Mr. D. was allowed to visit her weekly, until she became ill with an attack of Bright's disease, which, complicated by cardiac symptoms, occasioned her death. This loss retarded Mr. D's. recovery; but, at the end of six months the hospital considered him sufficiently improved to be discharged to the dispensary for continued observation.

At present, six months after his discharge, the situation is very encouraging. Mr. D. is working most satisfactorily as a porter for a large department store. He has secured an excellent room with some old friends, has given up drinking, and, from his twelve dollars a week, is paying back the advances made by the Associated Charities. His "insanity of doubt" seems to have vanished, and his outlook upon life is once more interested and hopeful.

Still another case is that of R., a boy of eleven years. He was born in Russia, of Russian Jewish parentage and has been in the United States six years:—

R.'s own story of his first visit to the mental clinic, was in a manic condition and talked incoherently. A week before his appearance at the dispensary the child had returned from school in a much disturbed state. Since that day he had not been able to sleep, and had manifested great nervous depression with hallucinations and had attempted several times to jump from the window.

R.'s own story to the physician was broken and confused. He talked much of having been forced by his teacher to go down on his knees, and insisted that his hair was on fire. He appeared a sensitive and intelligent child.

Investigation revealed no history of mental disease throughout the families of both father and mother. A home visit by the social worker showed that the family of seven lived in a four room tenement in a congested and noisy Jewish section. The father was a tailor with an irregular income.

The boy was immediately sent to the psychopathic ward of the Boston State Hospital, where the diagnosis of acute insanity was confirmed and a week later R. was committed to the Danvers State Hospital. A co-operative connection was established between the social worker and the hospital physicians at Danvers who were in charge of the case. After he had sufficiently recovered, the plan was made that R. was to be placed in the country under the supervision of one of the children's societies for a period of at least six months. Dr. Mitchell, superintendent of the Danvers State Hospital, wrote in approval of this arrangement.

The plan was carried out with most successful results. At the end of six months he was released from the parole of Danvers State Hospital and returned to his home to report once a month to the mental clinic at the dispensary.

The social work in this case was not confined entirely to arrangements for the boy, but extended to the preparation of the family for his return, which involved moving to a less congested neighborhood in a Jewish section of a Boston suburb. It was also necessary to arrange for his attendance in an open air class, win his teacher's interest and co-operation, and educate the father to a realization of the need of discipline, the value of regular hours for eating and sleeping, the desirability that the boy should sleep alone, and the danger of exciting recreations.

R. has now been at his own home for twelve months. A recent entry on the medical record states: "Patient in excellent physical and mental condition."

The third class includes patients who have been discharged from insane hospitals as cured, or as so much improved that they should be able to maintain themselves and take part in family life again.

This work of after-care is extremely important. Many cases of mental disease can be safely discharged from an insane hospital if there is assurance that they will be properly followed up in their homes. Such supervision requires the joint efforts of the physician and the social worker.

Miss C., for instance, a woman of thirty-three years, was sent to the clinic for after-care, by arrangement with the superintendent of the insane hospital to which she had twice been sent for maniac-depressive insanity. Her mother had also been a patient for years in the same hospital. During the first weeks of her treatment at the clinic, she was still nervous, complained of gnawing sensations in the back of her head, and dreaded to ride in the street cars. When sitting, she constantly pulled and twitched different parts of her clothing, beat upon the floor with one foot, and kept one hand on her head, using the other one alone. She lived with a married sister who was in comfortable circumstances, and worked for her brother in an unprofitable little plumber's shop, which he apparently kept mainly to afford employment for Miss C. and a younger brother.

With this history it was plain that careful oversight and regular clinical visits were necessary to prevent future attacks. Advice and encouragement were given with the object of stimulating Miss C.'s normal interests and of persuading her to return to wholesome companionship. During the summer of 1912 it was decided to remove Miss C. entirely from home associations, and a desirable position as housekeeper was secured in the country. There she gained in weight and spirits, and acquired valuable experience. She still comes regularly to the clinic, and the medical and social prognosis seems favorable.

The value of organized social service in connection with the clinic for mental diseases has been strikingly shown since its recent establishment at the Boston Dispensary. In the department for mental diseases in this institution, which is a large and long-established dispensary taking all classes of diseases, a trained social worker was set at work in January, 1912. At the expiration of a year an efficiency test was made, comparing the clinic during 1911, when the medical staff had no social worker to assist them, with 1912, when she was at their service. The following table summarizes this test:

19111912Increase Per Cent

New Patients12521370

Old Patientsno record100—

Visits by New Patients388909134

Visits by All Patients5161568203

Cured or Substantially Improved19%22%16

Cases Pending at End of Year[8]2%22%1000

Transferred to Other Agencies16%49%206

Patients Lost27%5.6%90[9]

Relative Efficiency43%94%118

The gist of these statistics is that, with the aid of a trained social worker, it is possible to treat certain forms of mental disease effectively in an out-patient clinic. The physician becomes able to keep a grip upon all patients that he wants to hold. There is practically a closed circle, and the results of treatment bear favorable comparison with private work. It is not too much to say that such a clinic, provided with a staff of interested mental specialists and with trained social workers, can perform an important function in treating mental disease and preventing its spread in the community.[10]

The social worker at the Boston Dispensary works actually in the clinic. Here she meets each new patient and takes a careful social history, usually before the patient sees the physician. Often she is present when the doctor interviews the patient, and always, after this interview, the physician consults with the social worker. Then a plan of treatment is made which includes the social as well as the medical factors of the case. In a certain proportion of cases, home visits are not necessary. The efforts of the social worker in the clinic itself are sufficient to secure adequate treatment. Thus there appears a very important classification of the kinds of social work required:

1. Patients presenting acute family problems of poverty, ignorance, or undesirable home conditions and associations. These patients require home visits and intensive social work. In the mental clinic of the dispensary they constituted 48 per cent of the 141 patients.

2. Patients requiring a home visit simply for the purpose of insuring the patient's return to the clinic—that is, cases in which there were no complex home problems but in which it was necessary to go to the home once in order to persuade the patient to come back for treatment. This class at the Dispensary constituted 20 per cent.

3. Patients to whom it was possible to give effective treatment by clinical interviews only, without home visits. This class constituted 32 per cent.

Inasmuch as the cost of the service per patient (estimating the time taken by the social worker) is enormously greater in class one than it is in class three, it is highly important to make this classification, and to keep a close watch upon the proportion of the different types, so that the cost of the work as a whole, with reference to its efficiency, can be accurately estimated.

An efficiency study from this standpoint during 1912 leads to the conclusion that the average cost per patient (the complete treatment of a case) in class three is sixty cents; in class two, a dollar; in class one, four dollars. The medical service is given gratuitously by the physician. More extended studies in this and in other mental clinics should be made in order to work out the cost figures more accurately.

There can be no doubt, however, that even if the cost of medical service were added, it is cheaper to treat mental diseases in the early stages, when patients can retain their places in the community, wholly or partly self-supporting, than to let the disease reach a point where permanent damage is done, and the insane hospital is the only resource.

That out-patient clinics should fill an important place in the new nation-wide campaign for mental hygiene, there can be no doubt in the mind of any one who has given attention to the matter. That organized social service is not only a desirable accompaniment of such clinics, but an essential condition of their efficiency, is a demonstrable and measurable fact.