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responsibility; a tendency to compete with others to the degree that ordinary individuals compete; and a willingness to submit new ideas, if indeed any are conceived, to public opinion. Obviously no attempt can be made here to define a “complex situation," but perhaps one is justified in saying that the characteristics mentioned in the preceding sentence are some of the earmarks and they may be in evidence not only in industrial activities but also in the family and social life of an individual.
If it may be assumed that the recovered patient should refrain from undertaking great responsibilities and from attempting to compete with the most active the question is presented: What then may he do? Idleness is certainly not advisable, as it would favor reactions not censored by reality. From consideration of the inclinations of the dementia præcox case one lears not only to refrain from placing him in the most complex situations but also that if not roused and stimulated to some extent, progressive disinterest in the environment is very apt to result.
It would be useless to try to specify the type of work all cases should do, hours of employment, home conditions, recreation, etc., which are most favorable for all paroled cases. Each case must be treated as a problem distinct from all others, but the general principles outlined should be kept in mind. The criterion to be used in the estimation of the suitability of a given situation is whether the accomplishments of the individual keep pace with his aims. In so far as can be done by the prescription of certain occupation and recreation and by regulation of stimuli in the matter of home conditions one should try to make the aims of the patient as broad as seems consistent with his continued welfare. This done, he should be watched closely to see if the aims are realized, and if not steps should be taken to simplify them. By "aim" is meant here not simply desire, but the actual assumption of responsibility for certain definite results. A homely illustration may make this somewhat abstract thought clear. If a man desires a fortune but feels no obligation in obtaining it, failure to gratify the desire is not apt to result in mental upset. If he feels obliged to gain a fortune and succeeds, the aim leads to no difficulties; but if instead of success he meets with failure the inability to react adequately to the aim necessitates a readjustment. In one given to subterfuge or in whom unusual oscillations of mood are apt to occur in ordinary
situations such readjustments as those just mentioned are likely to lead to mental disorder. They are the especial stresses of life.
The rehabilitation of patients who have passed through the more acute manifestations of mental disorder must begin in the hospital. From the time the case is received at the institution efforts should be made to obtain information in regard to the make-up of the individual, especially as to the character of the situations faced which led to disturbances of behavior. After the acute disturbance has subsided the work of re-education must be instituted. There is no justification for delay in rehabilitation until the patient is paroled from the institution. It is the duty of the hospital to fit the patient for life outside the institution so far as this is possible by advice, instruction and habit formation. When it has been decided that a patient may be released from the hospital there should be available some organization which properly may be termed an out-patient department to carry out supervision begun in the hospital. This department may quite well be a part of the state hospital, but its scope will differ widely in certain respects from the ordinary work of the institution. It may be said that while the patient himself constitutes the field of endeavor of the hospital, it is the environment of the patient in the world at large which the out-patient department attempts to control and shape. Instead of being the custodian the out-patient department becomes the mentor; and while compromise with the activities of the ordinary citizen still must be considered, the broadened outlook of the patient with consequent multiplications of the reactions changes greatly the aspect of the problem of his welfare. In place of stage-settings entirely subject to the desire of the hospital physician, the out-patient department must make use of the activities and interests of the world at large. The difficulty is not that the activities are too few, but that the capabilities of the patient most frequently precludes anything but the cautious assumption of the ordinary responsibilities of citizenship; and lest the patient attempt too much, the scope of the out-patient department must be such as makes it possible to reach out and keep pace with the patient's activities, even to anticipate them, to mold and to limit the situation to which he must react.
The number of workers which is necessary to carry out the work outlined depends altogether upon the number of paroled
patients in a given district and the size of the area to be covered by the visitors. An organization may be sketched, however, which will cover the necessary activities. There should be included a medical director, an examining division and a social service department, and if desired an occupation bureau may be added as a special branch of the last named.
The medical director shall coordinate and direct the work of the department. Under his guidance each subdivision shall carry on its particular task.
The workers in the examining division must be trained in medicine, especially in psychiatry. It is the business of this department to consult with the paroled patients when the latter make their regular visits to the department. The physician should make the necessary progress notes, advise the patient in regard to his activities and watch closely for evidences that he is finding difficulty in adjusting to the situation. Such evidences might be irritability, abstraction, depression, insomnia, the complaint of pain or distress not founded on organic change, etc. If unusual problems in the life of the patient arise special attention should be given him in an attempt to aid him to weather the storm. There is need for care that acute somatic illness shall not remain undetected and that the progress of chronic disorders, neurological or otherwise, be gauged.
The work of the social service department should include investigation of the home before the patient is paroled, to judge of its fitness as a habitation and of the probabilities of the patient being supplied with ordinary needs of life. The attitude of the others in the home should be learned, and where indicated an attempt should be made to educate the members of the family in regard to an understanding of the disorder through which the patient has passed and of the factors which might cause future attacks. Occasionally it may seem unwise to return the patient to his former home. The social life, recreations and avocations should be scrutinized; in a word, all the interests should be considered with the aim of directing so far as is possible the activities of the patient. This will necessitate talks with the patient and occasional consultation with relatives or friends.
If desired, a special bureau can be formed to obtain employment for the patients and whether this is done or not the occupations followed need consideration. The experience and preference of the patient must be weighed in the choice of employment, but at times new fields will seem advisable and the preference of the patient may seem unwise. Here the problem is difficult and must be left to the discretion of the department.
Unfortunately the wages are frequently a necessary item and the actual needs for financial aid makes unavoidable occupation which is undesirable. Even in such case there is room for endeavor on the part of the out-patient department. In certain instances it may be advisable to take the employer into confidence and enlist his aid. If the latter knew the condition of the patient he would at least, in many cases, be more willing to transfer the patient to more desirable work when opportunity arose.
Of course the problem of prevention of future attacks is very closely allied to the one of rehabilitation, although it is not embraced by the title of this paper. Perhaps the statement may be
. made here that the data in regard to onset of past mental disorders and the out-patient department as an organization would be applicable to the problem of prevention as well as to rehabilitation.
Finally there is the question of control of the patient. The solution of this problem will be aided by an understanding between the staff members of the state hospital and the patient, that the parole of the latter will be granted with the understanding that he will visit the out-patient department and abide by the advice tendered there in regard to occupation, etc. This understanding will give the out-patient department a lever with which to gain access into the life of the patient. Such hold is a very poor substitute for real understanding which should be established as rapidly as may be. It is only when a sympathetic contact is accomplished that the stage is reached where advice may be given and accepted which actually results in alteration of viewpoint on the part of the patient. And this is the highest goal of therapy of most of our recoverable insane cases: to aid the patient in arriving at an understanding of his limitations so that he will attempt only the activities to which he may react safely and continuously.
Notes and Comment.
THE WAR AND PSYCHIATRY.—With an abruptness which astounded the careless observer, the world war has come to a pause, let us hope to an end.
From the outset psychiatrists recognized the fact that problems were involved to which in past conflicts too little attention had been given.
So little attention indeed had been paid to the mental examination of the prospective soldier, and so little notice taken of the effects of military drill, campaigning, and fighting upon the nervous system that in many instances the suggestions which were made for a more careful mental examination of men about to be inducted into service were received with marked disfavor.
This country had the advantage of the experience gained in nearly three years of actual warfare, by its allies, before it began to raise and equip an army, and in many things profited thereby. There were nevertheless many officers in the army, particularly in the line, and a few in the medical corps, who looked askance upon the introduction of specialists and special examination, particularly psychiatric, into the routine of army medical work.
The elimination of men from the ranks for mental disorders or defects unless they were so manifest that they were at once recognizable, was, particularly when the authorities were working at a feverish rate to rapidly raise, train and equip a large army, looked upon as a waste of material, and as the result of too great dependence upon the special viewpoint of the examiner.
In a short time, however, a change took place. Officers who complained that too large a percentage of men were rejected, became the advocates of still more rigid examinations when squads of men were returned from over seas, as unfit for even limited service, by reason of mental defect or disorder.
It took time necessarily to select the men to make and formulate methods of making mental examinations. The number of