confidant of many families to which another outsider would find but a
coolly polite welcome. The fact that she is a social worker makes her
interest in her cases widen to their families and remain after her
professional duties are no longer needed. Being the head of the house,
she can dictate as to the time of meals and the activities of the house
for the good of the infirmary patients, yet being the social worker, the
interest of the clubs and classes in the house are not needlessly
sacrificed to the whims of her patients. Her training as a nurse and her
experience has made her more executive than the ordinary young social
worker, but her authority as head of a house of so many interests and as
executive for so active and powerful an association, gives her prestige,
and with that prestige a power for self-development which utilizes the
best qualities she possesses. Moreover, in a country district such as
our valley, where sickness is the exception, a nurse who was confined to
her profession would have much idle time on her hands, and a social
worker who was solely a social worker might be discouraged as to the
slowness of the growth of her ideals in the minds of those about her.
For where people live twenty-five miles from the railroad, tomorrow is
always as good as today for beginning a new work. The women are, to say
the least, conservative, and the girls are shy about showing enthusiasm
for a new idea. The audiences for lectures arrive with sublime
dilatoriness, and the boys stay outside until they are quite sure that
what is going on inside is a roaring success.
Of course, the head of the house has a comprehending executive committee
behind her. Of course, too, each department of the Neighborhood House,
infirmary, summer school, exchange, clubs, etc., has its own committee
and chairman. Her responsibilities, also, are only those of a trusted
agent and all her reports are filed for the benefit of the Association,
so that while each department depends practically upon her, she in her
turn depends upon each committee and upon the executive committee and
above all upon the able president of that committee for her inspiration
and encouragement in carrying out her share of the usefulness of the
house. All these good things did not come the first night the house was
open. They are fruits of a happy growth. There have been many minor
difficulties and prejudices and some evils to overcome. The prejudices
died easiest, one of them, the fear that Neighborhood House provided for
needs that did not exist, went most quickly of all.
Last summer when an army officer from West Point lay convalescing in one
room, sharing his nurse with a little blind pauper baby, there was no
doubt as to the need of an infirmary for rich and poor. When the
exchange, which sold impartially the rag rug made by a guide's wife, the
oil painting of an artist, and the home-made candy of a school child,
and turned in $500 profits to its members, there was no doubt as to the
democratic practicability of the exchange. When the women came from the
Adirondack Club, and from the summer cottages to debate with the women
of the village on domestic science, there was no question as to the
success of the Woman's Club. And when the women of the church sewing
society came to count their gains from the country supper, and the
village Glee Club met to rehearse for its great concert, and the boys
invited the girls to their birthday suppers and the girls invited the
boys to their dancing classes, and the young married people of the
village invited last year's debutantes of far away cities to teach them
new figures and steps, and the clergymen who supplied the village church
and the lecturers sent by the government to answer the farmers'
questions about agriculture, all shared the hospitality of the house,
there remained no doubt in any one's mind as to its great usefulness to
the entire community.
As to whether it has made neighbors of us all in the spiritual sense--as
loving one another as we love ourselves--that has not become noticeable
to a degree which has affected the price of eggs! And yet I noticed with
a pleasant thrill at my heart last summer that when a woman, quite two
miles away from my cottage, came down from her porch with a loaf of
bread which she insisted upon my taking as a gift from her baking
because she knew the bakery was shut and that I was in a sudden stress,
she called me: "Neighbor!" "For goodness' sake!" said she. "Don't you
dare to pay me. You'd do the same for me, I just guess! Aren't we
neighbors?"
Yes, surely we are neighbors--we city folk and country folk! But it took
the Neighborhood House to teach us as a community the beginnings of the
art of neighborliness.
[Illustration: THE NEIGHBORHOOD HOUSE IN WINTER]
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:
Increase
1911 1912 Per Cent
New Patients 125 213 70
Old Patients no record 100 --
Visits by New Patients 388 909 134
Visits by All Patients 516 1568 203
Cured or Substantially
Improved 19% 22% 16
Cases Pending at End of
Year[8] 2% 22% 1000
Transferred to Other
Agencies 16% 49% 206
Patients Lost 27% 5.6% 90[9]
Relative Efficiency 43% 94% 118
[8] The increase of "cases pending" is due to the organized medical and
social follow-up work, whereby the patients are held at the clinic until
the physician feels that they may safely be discharged. Without this
service the cases do not "pend" because they are lost.
[9] Decrease.
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]
[10] The preventive work of the clinic takes place in two ways: first, by
diagnosing cases of mental defect that ought to have institutional care,
and in securing this care for them by placing them or inducing their
families to consent to place them in the proper Institution; second, by
the education of patients and their families in habits of life and
principles of mental hygiene which establish a home environment
favorable to the preservation of mental health.
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.
CIVIL WAR IN THE WEST VIRGINIA COAL MINES
HAROLD E. WEST
[_The Survey has not had staff or means to send a special representative
to the West Virginia coal fields to make an intensive investigation of
the conditions in the strike area. That is the sort of social
interpretation we shall hope to perform with the growth of the slender
resources of the Survey Associates. We have done the next best
thing--viz., turned to the most promising newspaper source._
_It has been current gossip among journalists that the press of West
Virginia could not be relied upon to tell the truth about the situation
in the Kanawha Valley. Of the metropolitan newspapers which up to March
had had staff representatives in the field, the accounts of the
Baltimore Sun stood out. They did not mince matters in telling of the
brutal murder by the strikers of the mine guard Stringer; nor did they
hedge in publishing what was done by the Cabin Creek and Paint Creek
Colliery Companies. Mr. West was the representative the Sun had sent
into the field, and from him The Survey requested an article, only
stipulating that it be fair to both sides and tell not only the events
of the strike but the conditions back of them._