LIBRARY THE UNIVERSITY OF CALIFORNIA SANTA BARBARA PRESENTED BY DONALD BEEKS Hubert Sauhott Sail MENTAL HYGIENE Two Years' Experience of a Clinical Psychologist I MENTAL HYGIENE Two Years' Experience of a Clinical Psychologist By LILLIEN J. MARTIN, Ph. D. BALTIMORE WARWICK & YORK, Inc. 1920 V" Copyright. 1920 By WARWICK & YORK. Inc. To the Memory of my Friends William James and Oswald Kulpe PREFACE Up to the present time the clinical psychologist has largely confined his work to diagnosis not to the diagnosis of in- dividuals or of all classes of mental irregularities, but par- ticularly to separating out one class of people, the feeble- minded without even here having made any very search- ing individual study. The medical profession has now largely accorded to the clinical psychologist the work of a clearing house as re- gards the feeble-minded, but there is too great a tendency on its part to accept the clinical phychologist's self-imposed limitations as regards the field of work and to expect him to leave therapeutic and preventative mental hygiene fields for the most part untouched. When I opened an office in San Francisco as clinical psychologist, I determined if pos- sible not only to broaden out the work in mental hygiene so as to include the two last mentioned fields, but also to ascer- tain from actual experience whether the clinical psychologist has a place, not alone as simultaneous accompanier and sup- plementor of the work of the general medical practitioner, but as an independent worker, in increasing the health and efficiency of the community. The beneficial results coming from applying general psychological principles and labora- tory experience in a therapeutic way during the last two years, have shown me conclusively that the clinical psychol- ogist ought to have in the future a much wider field than he has previously had. 729 Jones Street, I,, j. M. San Francisco, March, 1920. CONTENTS PAGE Preface vii Introduction , I CHAPTER I. Distribution of Consulters as to Sex, Age, and Place of Con- sultation 7 CHAPTER 2. The Mental and Physical Examination of the Consulters 9 CHAPTER 3. Classification of the Mental Disturbances of the Consulters and Summary of the General Manner of Handling the Various Classes 14 CHAPTER 4. The Psychodiagnostic and Psychotherapeutic Modes of Treatment Employed 36 CHAPTER 5. The Method of Re-Education 44 CHAPTER 6. A Discussion of Some Typical Cases 61 CHAPTER 7- The Part of the Social Worker in Mental Hygiene Diagnosis and Treatment 68 CHAPTER 8. The Effect of the Mental Hygiene Treatment on the Con- suiters 73 CHAPTER 9. Preventative Mental Hygiene 78 Conclusion 85 INTRODUCTION In February, 1917, I opened an office in San Francisco, as consulting psychologist. In view of the newness of the work in applied psychology it has seemed to me that a sum- mary of the number of consumers, the mental difficulties which led them to seek psychological advice, and the diag- nosis and treatment given them, might be of interest and possibly of use to others. Publicity. The first problem that contronts one in open- ing an office of this kind is how to acquaint people with the nature of mental hygiene work. In view of the custom in medical practice and the fact that one wishes to get the support of physicians, it is desirable, of course, to avoid di- rect advertising. The indirect advertising that comes through informing the public what mental hygiene is, by means of interviews with newspapermen seemed to me legit- imate, and I therefore received two reporters who wished to discuss the matter with me. Lectures on the subject were also given and my professional card, and the following circulars were sent to physicians and acquaintances : THE AIM OF A MENTAL HYGIENIC ADVISER IS To decrease the mental disturbances growing out of a severe emotional strain ; to banish abnormal persistent ideas ; to do away with some of the mental disturbances of the stress periods of adolesence, change of life, and old age; to increase a person's power along the lines of observation, attention in- cluding concentration, memory and will; to eliminate injurious mental and physical habits; to get rid of distressing dreams and sleeplessness ; to destroy the painful and paralyzing mental after-effects which sometimes follow a successful operation and the cure of a disease ; and to prevent and overcome the forma- tion of alcohol and drug habits. To assist in the protection, proper care and education of insane and feeble-minded persons. To aid mothers and teachers in educating and managing, not alone their nervous children, but also those who are healthy, through applying the results of recent investigations in psy- chology along the lines of heredity and mental diseases. 2 MENTAL HYGIENE To help in the personal application of some of the more recent studies of unnecessary fatigue. To assist students and others to adjust themselves to their work, and to aid in the selection or change of a vocation; in general, to help people to increase their efficiency and happiness. In order to let any one who thought of consulting me, see that I had had thorough psychological training, I occa- sionally sent out later the biographical sketch below, which has appeared in "Who's Who," and elsewhere, with the above circular. This was done partly also to avoid unnec- essary interruptions, as I found that certain untrained per- sons (mental healers of various sorts, psychopaths, etc.,) "dropped in" my office to discuss "our common work." These persons had had a different preparation for the work of mental hygiene and their ideals were so far removed from mine, that I soon found I had nothing to give them, nor could I get anything of value from them. MARTIN, LILLIEN JANE, born at Clean, N. Y., 1851; A. B. Vassar College, 1880; U. of Gottingen, 1984-1898; Hon. Ph.D. Univ, of Bonn, 1913. The honorary degree was con- ferred upon Dr. Martin, the diploma says, because she had in- troduced into psychology a method through which it is pos- sible to make a comparison between an image and the cor- responding sensation ; for inventing a new psychological method the Projection Method; for introducing into psychol- ogy a method of measuring imageless thought; for putting the Suggestion-Method on a scientific basis ; for testing for the first time experimentally Fechner's aesthetic laws ; for making the first experimental study of the Comic; for investigating experimentally certain current theories in Aesthetics, as those of Gross, Hegel, etc. ; and for testing by experiment the theories of the subconscious, of Binet, Meyer, Freud and Prince ; for her investigation with Miiller on the Analysis of the Sensi- bility to Difference, of which one of the most eminent living American Psychologists says : "There can be no doubt that the work of Martin and Miiller will stand as a landmark in the history of experimental psychology comparable, perhaps, with such books as Hering's Lichtsinn or Ebbinhaus." Science teacher Indianapolis High School, 1880-9; vice principal and head of department of science, Girls' High School, San Francisco, 1889-94; Professor of Psychology, 1899-1916, Leland Stan- INTRODUCTION 3 ford Junior University, when she became Professor Emeritus, and opened an office in San Francisco as consulting psychol- ogist. Wellow of A. A.'A. S. Member of Kongress fiir experi- mentelle Psychologic. American Psychological Association; Sigma XI; Honorary member of Century Club of California; President California Branch of the Association of Colle- giate Alumnas, 1892; President College Equal Suffrage League, 1912; Vice- President Section H, of the American Association for the Advancement of Science, 1914-15; President of the California Society for Mental Hygiene, 1917. The response to the first circular was immediate. The number of consulters has increased from month to month. The total number of persons coming for consultation was 500, and the whole number of visits 1400-1500, that is ap- proximately three visits for each consulter. Among those who came for consultation were persons who felt depressed, anxious, or worried, or had lost their interest in life or their ambition; those who felt they were breaking down mentally ; those who were extremely nervous, irritable and even fretful, or suffering from insomnia ; those who found everything in life against them ; those who knew that something was wrong with them mentally and wished to know what it was; individuals who found their daily work to be a burden and that living was getting to be too great a tax upon them; those who had become doubtful of their own ability to deal with a business situation and were, therefore, afraid to take the initiatory steps necessary; those who sought aid because they realized that they had not the knowledge required to cope adequately with their children and many other family problems. The mother came to ascertain why her child was not doing satisfactory work in school, to get assistance in dealing with the un- stable and stress period of adolescence, in selecting a vocation fitted to the difficult environment in which she found her- self, and in overcoming the confused mental condition and the melancholy feelings accompanying the stress of the 4 MENTAL HYGIENE menapause and old age. Others whom I saw were persons having difficulty in controlling their thoughts or emotions, or who had lost the ability to hold their attention to the work in hand, or had found that their memories were weak- ening ; melancholy persons ; "shut-in" personalities avoiding the society of others and feeling that they were misunder- stood, slighted, or shunned by their family and friends; neurasthenics who lacked the initiative to find and hold a position; those who found that they were not in an em- ployment suited to them and sought advice as to what they were really fitted to do; young people who wanted help in choosing a vocation; excitable, irresponsible, high-strung, uncontrolled persons; psychopathic individuals and insane persons ; the prematurely old ; adolescent boys and girls, sometimes hysterical, who were not understood by them- selves or by those around them, and longed for sympathy and guidance; backward, feeble-minded children who had stolen; children difficult to control at home and at school; parents who not only took too much alcohol themselves, but were even giving it to their children; those whose families were at the point of disruption. All were not ignorant or poor among them were a college professor, an influential business man, a leading newspaper writer, and an editor. In short, people came who wished to increase not alone their happiness, but also their effectiveness. Unfortunately, in- formation giving and advertising in regard to mental hygiene work must be more or less kept up, as the advertis- ing which comes through one consulter's telling another that he has been helped by a given psychologist is very much less than in the case of the patient of a physician, as consulters hesitate to say that they have received benefit from his treatment, fearing that others 'may think they have been mentally affected. INTRODUCTION 5 Fees. What to charge for his services will occasion the clinical psychologist considerable thought on opening his office. Giving professional advice in regard to maintaining or restoring mental action in the case of normal persons in whom the physicians find no physical disturbance requiring a prescription, which is the work of a mental hygiene ad- viser, is something new and apparently so simple to the un- initiated that one foresees that only a few persons will ap- preciate the previous preparation required to carry on such work successfully or the fatigue entailed by it. Moreover, a satisfactory examination takes so much time, usually an hour and occasionally more, that one can receive but a very limited number of consulters in a day. After talking the matter over with a leading psychiatrist in San Francisco, I finally decided to adopt his rates : Ten dol- lars an hour for the first visit and five dollars for the sub- sequent ones. Persons who could not afford to pay this fee were given half rates, or if this was too great a financial burden upon their resources, they were treated free at one of the two clinics which I had opened. It may be of inter- est to those wishing to know something definite regarding the immediate returns from such work to be told that the fees of my private office during the first year amounted to $60 per month, and during the second year $100 per month. Of course, this does not compare in any way with the in- come of a physician, but in view of the fact that there is such a decided increase in the income during the second year, practically double, and as I had been told on all sides that it would be impossible for any one to support him- self, even partially, as a consulting psychologist, I have thought it well to publish these facts. As regards the financial side, it is not to be forgotten that I live in a com- munity where I have many old acquaintances, whom I have 6 MENTAL HYGIENE largely charged nothing. Also that some others who were properly clinic consulters from the financial standpoint, for various reasons have been treated free in my privae office. Moreover, if I had included the amount remaining unpaid on bills which I expect to be paid later, the income this year would have been considerably larger. Psychological versus medical terminology. The term consulter has been substituted for the term patient, which applies to persons seeking medical advice. This has been done with an object, namely, that the person coming for advice might clearly understand that the person whom he was consulting was not a physician. If there was any pos- sibility of his not realizing that he was not getting advice from a physician in coming to the mental hygiene office, he was told this. The title of doctor gives one a cer- tain prestige ; however, and tis it had been previously gen- erally used in addressing me, I decided to allow the consul- ters to employ it or not, as they pleased in addressing me, but I have been careful in writing my name to put Ph.D. after and not Dr. before it. In fact, everything possible has been done to give the impression that I wished it to be clearly understood that I am a psychologist and not a physician. CHAPTER ONE DISTRIBUTION AS TO SEX, AGE, AND PLACE OF THE CONSULTATION In Table I below, the numbers visiting the three different centers where I held office hours, are segregated. Work at the San Francisco Polyclinic was begun at the time my private office was opened; that at Mount Zion Dispensary, where a large per cent, of the consulters were Jewish peo- ple, a year later. To each of the clinics one morning a week and occasionally two have been given. TABLE I. Age Private Office San Francisco Polyclinic Mount Zion Dispensary Total T. M. F. T. M. F. T M F. T. M. F. 6 Yr. 2 2 972 11 6 5 22 13 9 7-13 17 13 4 48 31 17 37 27 10 102 71 31 14-21 21 11 10 21 6 15 46 34 12 88 51 37 22-30 24 16 8 27 4 23 16 1 15 67 21 46 31-40 40 11 29 42 8 34 12 3 9 94 22 72 41-50 26 6 20 39 6 33 15 5 10 80 17 63 51-60 11 3 8 12 1 11 1 1 24 4 20 61-70 3 3 2 2 5 5 71-84 2 2 1 1 2 1 1 5 3 Unclas- sified 826 5 5 13 2 11 Total 146 60 86 209 66 143 145 77 68 500 203 297 T. total M. male F. female The above table shows : i. The number of consulters at Mount Zion has been greatest. This is not only due to the fact that other clinics are larger there, but also, I suspect, from a comparison with the consulters elsewhere, to the racial peculiarities of 8 MENTAL HYGIENE the Jewish people. Without going into too great detail I am not able to bring out these differences in the table. In the way of illustration it may be said that if the table were so arranged as to show the number of individuals belonging to the same family who were treated in the Mental Hygiene Clinic, it would be seen that family group treatment has been much more necessary at Mount Zion Dispensary. 2. Three-fifths of those visiting the mental hygiene offices are females, probably not a greater proportion, however, than in the case of other clinics. 3. After 40 years of age the number of consulters de- creases. 4. Up to 40 the number of consulters increases in the pri- vate office. In the clinic where the influence of the physicians and the teachers is more potent as regards sending persons to the mental hygiene adviser, the highest point as regards number of consulters falls in one case between 7 and 13 years and in the other between 14 and 21. 5. Evidently 31-50 years of age is the stress period as regards the need of mental hygiene aid among females. 6. Among males the stress period is 7-21. This can be explained by the fact that feeble-mindedness, insubordination, and adolescent disturbances attract more attention in boys than in girls. CHAPTER TWO THE MENTAL AND PHYSICAL EXAMINATION OF THE CONSULTERS. Mental examination. In my private office I took the con- suiter's history myself on a card. Each consulter was asked to give a chronological account of his life. He was closely questioned wherever there seemed to be any likelihood of getting more exact and detailed information. An effort was also made to fill in apparent omissions in his recital by questioning. He was asked about his usual dreams and occasionally to keep a written record of them. In some cases the history which is, as far as the consulter's report is concerned, introspective in nature, giving only an account of what is above the threshold of consciousness, was com- pleted through getting what was below the threshold, by applying psychoanalysis, by the giving of the spontaneous arising ideas or the description of spontaneous arising visual images, and occasionally by giving Jung's association test. I have not used hypnotism in the last two years for diag- nostic purposes, but formerly I was able through it to get diagnostic information, in that the person was often not able to keep to himself certain things he had not intended to re- veal. It seemed to me in such cases it was not the particular details which the patient revealed, for I confess I do not place entire confidence in these, but as starting points for examination by other methods, the results that I found were of value. The belief in what is popularly called "the subconscious mind" is so widespread that the consulters are usually quite willing to have psychoanalysis employed. They are not, however, always well pleased when they begin to realize that the subconscious mind is probably merely the If) MENTAL HYGIENE storehouse of forgotten experiences which have come to them in their previous life through the senses, sight, hear- ing, etc. Occasionally the consulter's automatic utterances, also talking to himself, revealed what was going on in his mind. This came out in a striking way in the case of a delinquent feeble-minded boy whose unconscious remarks betrayed his delinquencies along sexual Lines. Once 01 twice a consulter's automatic writing has given a cue as to his mental condition. I have found the automatic writing method in cases where there is an attention disturbance, very useful. This once came out in the case of a Stanford Univer- sity student on the margin of whose English theme and occa- sionally in the body of the paper, the name of a famous foot- ball man was repeatedly written. During the examination any mistake in acting, reading, writing and in forgetting words, as well as any physical manifestations of psychological inter- est, were of course recorded. Mental tests were also fre- quently given, not only to determine whether the person was feeble-minded, but also to get material that might be useful in a diagnostic way. In the clinic the blank given in the appendix was used in taking a child's history and one similar to it with an adult. It will be seen that these blanks encourage a searching ex- amination of the consulter's life, without which it is impos- sible of course to deal adequately with a case. The history blank was filled in by a social worker trained to do this work. In some cases a life chart was later constructed from the history to bring out in relief the origin and source of a mental disturbance, as for example, some delinquency. Where the consulter's deportment during the taking of the history or later suggested feeblemindedness or when it seemed desirable to get more definite information in re- DISTRIBUTION OF SEX AND AGE II gard to his mental calibre or when the person had come for vocational advice and placement, a mental test was also made by the social worker. When the history and test making was completed, the social worker brought the data into my office and the points that were to act in a suggestive way in my own examination of the case were noted. The patient was then shown in. After a provisional diagnosis had been made, such thera- peutic treatment as was possible in view of the examination already made, was given and a date set for the consulter's return to the mental hygiene clinic for further advice and examination. The social worker who was to look after the case was then called in and arrangements made for her visits to the consulter's home. Such visits are indispensable in that they allow opportunity for modifying, supplementing and emphasizing the treatment given at the first visit. Even if no modification of treatment seems necessary, there is still a good reason for frequent visits to the clinic. The director through acting as an audience is a strong stimulus to the complete and persistent carrying out on the part of the consulter of my psychotherapeutic treatment given. One of the many problems confronting one in regard to re-education work is how to give advice effectively. Experi- ence shows that straightforward modes of attack are de- sirable. The consulters feel the need of guidance in their activities. A crisp and business like way, so as not to convey the impression that it is merely a friendly talk without prac- tical significance, is usually most efficacious. As regards making an impression upon the consulter, the mental hygiene adviser must have that cooperation and help of the social worker which comes ^rom his really believing in the effective- ness of the methods tmployed and therefore in the import- ance of getting the patient back to the clinic at frequent intervals, to receive further advice. 12 MENTAL HYGIENE Physical examination. The consulters were closely questioned as to their physical condition and even if there were no complaints along this line they were in general re- quired to take a complete medical examination. In no sense was a physical examination made in the mental hygiene office, though the eyes and ears and speech organs were sometimes tested in a very casual way by the social worker to determine whether the consulter ought to be sent to the eye, ear, nose, throat or dental clinics, as well as to the medical. The posture, gait, and feet were also observed by us both to ascertain whether an orthopedic examination was desirable. If anything in the consulter's deportment sug- gested the need of psychoneurological examination he was also sent to that clinic after I had examined the reflexes in a casual way for the purpose of getting, if possible, further data that might confirm the provisional judgment that such examination ought to be made by a neurologist. If any of the physicians thought immediate treatment was desirable, the consulters were urged and in some cases compelled to take it, if they wished to continue to come to the mental hygiene clinic. As a matter of fact, nearly every con- suiter has been sent to one or more different medical special- ists and I very much doubt whether many other clinicians have sent as many people to physicians as I have during the past two years. To attempt to give proper mental hygiene advice until one has a clear picture of the person's physical conditions seems to me, folly. Of course, physical treatment often improves the mental condition and vice versa. The large number of persons referred to me by physicians, even while they were still treating the cases themselves, shows that many of them also think so. The question may be asked whether the consulting psychologist has a work to do with the individual which is independent of that of the physician. DISTRIBUTION OF SEX AND AGE 13 If one will look over the mental disturbances enumerated in Table II he will see that the medical profession has made no provision for dealing with a large number of them. In fact, it is a question whether many physicians would care to handle such cases. At any rate they have referred a number of them to me for treatment. In view of my experience I am convinced that the work of the clinical psychologist not alone supplements that of the medical profession in many cases, but also is entirely outside of it in some cases. Cibranj of Hubert Jlauhnn *laH CHAPTER CLASSIFICATION OF THE MENTAL DISTURB- ANCES OF THE CONSULTERS AND SUMMARY OF THE GENERAL MANNER OF HAN- DLING THE VARIOUS CLASSES The consulters have been classified in Table II below so as to show the mental disturbances which brought them to the mental hygiene office. Such a classification is more or less arbitrary. As for example, in placing the delinquents in one class, some of the subnormal children had to be taken from class 9, and again most cases of syphilis referred to the mental hygiene clinic by physicains were not put in class 2 but in class 12. That is to say, the consulters were classified under that disturbance which for various reasons appeared best to describe the kind of mental action which brought them to the clinic. 1. Cases of true and incipient forms of insanity. The guardians of those consulters who could not be kept at home were informed as to the institution to which they should be sent and the proper procedure to follow in order to get them into it. Other cases were referred to a neuro- psychiatrist. In the incipient cases, with the consent of the attending physician, re-education or some similar therapeu- tic method was undertaken if it seemed probable that it would be beneficial. 2. Cases of nervous disease, neuritis, chorea, syphilis, tabes, shell shock, etc. These cases were also sent to a psychoneurologist. If it appeared that anything could be done in a psychotherapeutic way in arresting the disease or in ameliorating the present condition, or in hardening the person against future attacks, the mental hygiene adviser 14 L 0\ TABLE II. CASES OF Private Office San Francisco Polyclinic ll N| ^ V So -3 1 1 True or incipient forms of insanity demen- tia praecox (6), paranoia and paranoid pecu- liarities (1), manic depressive psychoses (5), hysteria (4), epilepsy (4), or psychopathic states (16). 16 13 7 36 2 Nervous diseases: Neuritis (1), chorea (3), syphilis (2). tabes (1), shell shock (1), etc. 1 3 4 8 3 Borderline states : Neurasthenia and extreme lassitude (25), psychastenia (phobias, etc.) (12). 19 14 37 4 Sensory disturbances accompanied by those that are mental: of the eye (1), the ear (3), the mouth or nose and throat (speech difficulties) (8). 3 3 12 5 Unhealthy post-operative mental condition. 1 1 6 Habit pains, feelings of suffocation, etc., partly at least having a mental basis. 2 2 7 Alcoholism. 1 3 4 8 Supernormality. 3 3 9 Supernormality exclusive of delinquency (in- cluding feetole-minded, borderline, and dull per- sons) and of school retardation for other rea- sons than low mentality. 15 34 14 63 10 Juvenile delinquency (truancy, insubordina- tion, fighting, lying, pilfering, stealing, etc. (50), and cases disciplinary in character (36). 7 21 58 86 11 Mental disturbances connected with the adoles- cent, menopause, senile, 'and pre^senile periods of life. 11 18 2 31 12 Mental disturbances where "nervousness," "de- pression," or in common parlance an "un- strung" condition is present. 16 64 19 99 13 Insomnia. 14 Lack of emotional control (anger, hatred. 1 2 Jealousy, and other unhealthy emotions pre- dominating). 4 5 3 12 15 Marked weakness of will (1), inability to hold attention, loss of memory, or prevalence of im- ages having; an hallucinatory character (2). 1 1 1 3 16 Failure in adjustment of family and community life. 25 5 30 17 Women needing advice as to parental or infant care. 2 2 4 18 Persons desiring advice as to the most effec- T tive methods to employ in "improving and strengthening their minds." 11 19 Persons desiring advice along the lines of vo- 11 cational selection, training and placement. 7 4 4 15 20 Unclassified mental disturbances. 17 24 41 146 121 143 500 l6 MENTAL HYGIENE gave advice along the lines of avoiding fatigue and too great physical and mental stimulation, and if it was a clinic case, concerning the social service work to be undertaken. The social workers did what they could to carry out any sug- gestions given by other clinics as well as ours. As for ex- ample, in a case diagnosed by the physician as tabes dorsalis, the shoes recommended were provided, exercises advised were arranged for, arrangements made with a charitable organization for proper food, and appropriate work obtained. 3. Cases of borderline states: neurasthenia, and ex- treme lassitude, psych asthenia, (phobias, etc.) In these cases overwork, very protracted periods of persistent work, and uneconomical ways of doing work played a prominent role. Often the condition could be explained also by some of the causes enumerated under classes u and 15. Some of the consulters with difficulties having a neuras- thenic coloring had well marked phobias. These were of two kinds. A general undifferentiated feeling of fear or a fear of some particular thing. There were in the second case certain places that may be termed "fear arousing cen- ters." The Oakland ferry is one of these and a particular street car line another. The growing up of the fear complex is slow and not always easy to trace. One of the common fear instigators is gas in the stomach. The person had come gradually to associate with it some heart disturbance fears, as that he may faint in the street or be unable to get back to his house. The result was that he finally became unwilling to leave it. Such fears are enhanced by unusual fatigue and frequently by the fact that the person rarely goes into unac- customed places, and fails to get the new ideas which would crowd out the old painful ones which have become enor- mously strong through constant attention and repetition CLASSIFICATION OF MENTAL DISTURBANCES 17 The problem of course in such cases is through psychothe- rapy to supplant the injurious and fear producing thoughts by more healthy ones. When such fears are accompanied by visual or strong auditory images or inner speech, such images can often be replaced through appropriate exercises and if this is impossible, they can be broken up or modified or associated so that they will lose their former fear arousing charcater. My own method has been where such fears exist, as they are more common when one has no pressing work on hand, to get the person to undertake some entirely new line of work, and as I have found that they are often present when one is weary, short and frequent rest periods are in- troduced into their daily regime. The treatment of persistent ideas is particularly difficult and it seems to me requires more prolonged effort than almost any other mental diffi- culties which I have attempted to treat. Phobias are also very much more common than I had supposed. I confess I have a theory that some artificial aid, say a phonograph constantly repeating certain appropriate sentences, could be made very useful in a suggestive way along this line. It may sound absurd but I suspect the phonograph method, if I may be allowed to so term it, has great possibilities as regards the replacing of unhealthy ideas by healthy ones. 4. Cases of sensory disturbances accompanied by those that are mental. The person was referred for examination to the proper specialist in such cases for physical treatment ; but where, for example, as was sometimes the case, lack of attention played a decided role in the trouble or some complex lay at its base, the treatment was also taken up in the mental hygiene clinic. In the case of speech disturb- ances where the physical examination showed no need of medical treatment, psychological treatment along re-educa- jg MENTAL HYGIENE tional lines was given while the trainer who made speech defects a specialty and to whom the person had been re- ferred did his work. 5. Cases of unhealthy post-operative mental condition. With the one consulter here classified everything possible was done to arouse him to the necessity of carrying out the ex- ercises prescribed by the physician. With cases classified elsewhere some of the various occupations now used by the reconstruction aids in occupational therapy in army hospitals were employed. 6. Cases of habit pains, feeling of suffocation, etc., partly at least having a mental basis. Treatment by sug- gestion was often used in such cases, also exercises to direct the attention to other parts of the body. 7. Cases of alcoholism. A number of persons who were taking too much alcohol came to the office for some mental difficulty as, for example, frequent auditory hallucinations. In all the cases where the alcoholic drinking was serious, the fundamental cause of it was in no two cases the same. It grew in one case out of the momentary relief it allowed from mental conflicts with which the consulter could not cope ; in another from a failure in adjustment in daily life ; in another from extreme fatigue and discouragement re- sulting from it ; in another from pleasure in a world of fancy which the consulter was not able to create without a stimulant ; in another from imitation of intemperate asso- ciates and suggestions received from them. I have placed but four persons in the alcoholic class because only in these cases was it thought that the taking of alcohol was the pri- mary cause of the mental trouble. The mental disturbances of the other alcoholic persons, as was said, have been clas- sified under other divisions. Alcoholic drinking, for example, in the case of a person who had had a phobia, while doubt- CLASSIFICATION OF MENTAL DISTURBANCES 1Q less increasing the fear-difficulty, had apparently been in- dulged in subsequently as regards the phobia and as a means of escaping from the suffering entailed by it. 8. Cases of super-normality. These were gifted chil- dren who were inattentive or disorderly in school, for the most part because insufficient or uninteresting tasks were being assigned to them, or they became much interested in some particular thing as airships, or wireless telegraphy, about which they spent most of their time in building air castles. 9. Cases of subnormality exclusive of delinquency and of school retardation for other reasons than low mentality. Such consulters were examined by the Stanford Revision of the Binet-Simon or the Yerkes-Bridges tests. If these tests indicated feeble-mindedness, farther examination was made on the points suggested by Fernald physical examination, family history, personal and developmental history, school progress, examination in school work, practical knowledge and general information, social history and reaction, econ- omic history and reactions, economic efficiency, moral reac- tions, mental examination before passing on the mental status of the individual. Such additional examination re- quired of course much social service work. If the con- suiter was found to be feeble-minded, his parent or guardian was directed as to his placement in a special school; and explicit directions were given as to home training. The feeble-minded person was not left here, but his name was put in a card catalogue looking to future official registration and perhaps sterilization. Many children who were suspected of being feeble- minded were sent by their teachers to the office or their parents brought them on account of their poor work or in- ability to do certain things which children of their age can 2O MENTAL HYGIENE usually do. When it was found through examination that they were approximately normal their special difficulties were looked into. In many cases it was not difficult to find the cause. Certain children, for example, who were doing par- ticularly poor work in language work, came from families of foreigners where no English was spoken in the home; again it was found that some children who were unable to take care of themselves properly, as to wash and dress themselves, had always had these things done for them. In the case of several children who wore laced shoes the in- ability to tie a bow knot in the Binet- Simon tests gave a hint of the lack of home training which lay at the root of the school trouble. 1 0. Cases of juvenile delinquency and those disciplin- ary in character. The large number of such cases grew out of the fact that the principal of the Ethan Allen School, a school to which boys guilty of such delinquencies as insub- ordination, truancy, fighting, lying, pilfering, stealing, etc., were sent from the various schools of the city, asked the Mount Zion Dispensary to allow her to send her pupils there for examination and treatment. It was decided to give all of these children a group test in their own school before this was done. Mr. Herbert E. Knollin, who had had much ex- perience with Dr. Terman in mental testing, assisted me in this work. The army tests were used with 50 of the older pupils. Fig. i below, gives the per cent, of the feeble- minded, etc., boys in the school. It will be seen that 28% of these boys were feeble-minded when classified by the Stanford Revision of the Binet-Simon tests. The remain- ing 50 boys who were not sufficiently advanced to use the army tests were given the curtailed form of the Binet- Simon tests proposed by Doll. According to these test? 50% were feeble-minded. CLASSIFICATION OF MENTAL DISTURBANCES 21 Army teete Figure 1. Distribution of "intelligence of the pupils of the Ethan Allen School according to the army tests in terms of the Terraan classification, and the brief Binet-Simon (Doll) tests. Areas, left to right repre- sent percentages of feeble-minded, dull- normal, and average normal, respectively. 4 * Distribution of Intelligence Thirty-five of the boys whom the group and Doll tests given at the school had shown to be feeble-minded or borderline cases were given the Stanford Revision of the Binet-Simon tests at the mental hygiene clinic in Mount Zion Dispensary and wherever there was any physical weakness suspected, they were sent to other clinics. The result of the individual mental tests correlated well with these of the group tests. The teachers in the Ethan Allen School were evidently greatly surprised to find so many of their boys subnormal. Had they previously examined their record books for each child they would have seen that not a child in the school is up to the proper grade, 4% are 6-8 yrs., 29% are 4-5 years., 50% are 2-3.9 y rs -> an d 1 7% are 1-1.9 y rs - be- hind their grade. 22 MENTAI, HYGIENE Not only the scholarship of these boys but their slovenly appearance, their posture, and their movements indicate that many of them belong to an inferior type. In view of the data on the mental status of the boys, the principal was told that many of the methods employed in training backward and feeble-minded children ought to be introduced into her school also that in view of what we know today regarding the in- fluence on the child's mental development of proper posture and good coordination of movement, greater stress should be laid on those matters and that no better single exercise could be given than teaching the boys to "stand at atten- tion" on occasions when it was proper to do so. The handicap under which some of these delinquent boys are working is also seen in the clinical reports on their phy- sical examination. Under nourishment, "flat feet" shod with ill-fitting shoes, adenoids, diseased tonsils, defective eyes with imperfectly adjusted glasses, pains in the stomach produced by eating indigestible food, etc., are reported. The value of a personal mental and physical examination in deal- ing with such boys can be illustrated from the study of a boy who was recently sent to the mental hygiene clinic for advice as to his being allowed to go to work, which he was very anxious to do on account of straightened family cir- cumstances. It was stated that his school work was very poor and that he was not interested in it. Examination showed that his vision was defective and that glasses would not correct it, and that he had a "weak heart." A work per- mit was advised on condition that light work should be selected that would eventually lead to the advancement that was possible in the case of a boy of his mentality. The straightened financial condition of their families and their difficulty in mastering even simple intellectual work make most of these boys long to go to work and strongly CLASSIFICATION OF MENTAL DISTURBANCES 23 supports the principal's desire that some of them be allowed to work half a day (for which they are paid) and attend school the other half day. Such a plan would introduce the boys into the industrial world under proper supervision. Of course at the termination of the school age, most of them could be left to shift for themselves. There are, however, some feeble-minded boys in that school that should be per- manently registered and more or less supervised. I wish the Board of Education of San Francisco might initiate perma- nent registration of feeble-minded children. Where they are not put under custodial care they ought to be safe- guarded to the extent of registration. It ought to be ar- ranged ultimately that at least those children showing strong sex tendencies should also be sterilized for the pro- tection of the next generation. From a social service point of view the Ethan Allen School is very interesting. Through visiting the homes one gets a much more correct and complete idea of the cause of their delinquency and the intensive and very personal care that alone will save them. The social work shows that the stealing, lying, fighting, sex delinquencies, have often a heredity basis of alcoholism, feeble-mindedness, epilepsy, insanity, etc. Social heredity is found to play a highly im- portant role in these delinquencies. The stealing (fruit, junk, etc.) of which they are guilty was often not frowned upon by their families. Racial and family peculiarities and customs explain the cause of the delinquencies, especially the stealing by many of these boys and suggests that if the boys are to be entirely reformed forces must be set to work to train the parents. A large per cent, of these delinquent boys are Italians, one-third of them live in the Italian quarter, a very restricted area of the city, where the close proximity with each other would naturally emphasize racial character- 24 MENTAL HYGIENE istics. Nearly 50% of these Italian children the tests showed to be feeble-minded. The fruit stealing, which is often the beginning of the stealing of other things, is encouraged by the custom of the neighborhood. Observation showed that the children of this district are sent to the markets early in the morning with a bag to collect the discarded fruit the bag gradually coming to be used to collect fruit not dis- carded. This is a danger locality for the delinquent boy and a properly trained policeman could do o good work here. The fighting so common among these boys and so much complained of is often a defensive measure. They have not the intelligence to meet the word attacks of the brighter children, and to ward these off they use the only weapon at their command the fist. Some of their lying is due doubt- less to imperfect powers of observation and weak memory and to the desire to play an important role. Their truancy sometimes comes from lack of interest in their work, growing in some cases out of their inability to hear and see. A lively imagination which had its material from some of the moving pictures they had seen, led to some of their stealing and other escapades. It probably even instigated some of their sex misdemeanors. This was revealed by the content of the automatic talking of one boy as he sat waiting to be brought into the mental hygiene clinic. Abnormal sex delinquencies are also the result of the close family life, the ill fitting cloth- ing, the information imparted by evil companions of the neighborhood, and the lack of proper attention to cleanliness and bodily needs. I have gone into the more intimate life of these boys to give an idea of what was attempted in a social service way in dealing with this and other classes of consulters. CLASSIFICATION OF MENTAL DISTURBANCES 2$ The reasons for sending children for correction and dis- cipline to the mental hygiene office are numerous. One of these is masturbation. Its removal was often accomplished through impressing the parents with the importance of cleanliness and changing the child's sleeping place, some- times by having a doll or something similar taken to bed to direct the attention away from a dangerous field. The work of child correction was not only largely a psychical matter, as in overcoming a slovenly way of speaking, but often a matter of training him in proper physical habits as to keep the mouth shut after adenoids have been removed. Children were often brought to the clinic for pilfering which had its origin in their taking money from the father's pockets. Sometimes it came from the desire for something the child ought to have had. One boy told me about steal- ing money to get a pair of skates which his mother would not get because she was afraid he would fall and hurt himself. In regard to the children sent for correction and disci- pline it may be said that in trying to overcome a child's fault, the important thing is to speak in such a way that he will remember what has been said to him. To do this the mental hygiene adviser must recall experimental work upon the memory and employ the shortest and most effective meth- od of permanently fixing an idea in the child's mind. Another task in child corrective work is in instructing the parent and occasionally even the teacher to give suitable rewards and punishments. Few people seem to realize that different kinds of punishment are not good or bad in themselves but in proportion to their being beneficial in the case of the particular child. To deprive a child of candy who does not care for it is a non-effective mode of discipline. In 26 MENTAL HYGIENE short, my experience is that the child's likes and dislikes should determine the kind of punishment given him. There are in the case of the animal two incentives that are used in controlling- reward and punishment. These are what are to be used in controlling and developing proper habits in children. While a child's physical likes and dislikes, as for certain foods, etc., may sometimes be appealed to advan- tageously, of course one appeals to higher mental activities when possible. The kind of punishment to be adopted de- pends, as was said, upon the child's preferences. Practically successful government depends on the one hand on giving the child what he likes and on the other in depriving him of what he likes. Isolation may be good for some children. Whether it is to be in the dark or not depends upon its arousing fear of the dark. Putting to bed may be very good for a child as an aid to removing the fatigue which gives rise to the irritability and quarreling, but considering the wide prevalence of masturbation among children, it will be a kind of punishment that one will be somewhat chary of giving, even in the case of a nervous child needing rest. Whipping a child may be very useful in some cases, but one sees fre- quently in the mental hygiene clinic the bad effect on a child's movements of sudden slaps. Whatever mode of punishment is adopted it is very important that some means of getting prompt obedience from the child be em- ployed, for I have found that the inattention so often com- plained of by the teacher can usually be traced to lax home discipline. We can, through applying what we know today, of the conditioned reflex, improve our modes of punishment. In fact all punishment is more or less based upon it. In telling a child what he must not again do, he is sometimes whipped, with the idea that whipping can be finally abandoned and the word alone or CLASSIFICATION OF MENTAL DISTURBANCES 27 the given situation bring about the desired response. What punishment we shall combine with the word and the situa- tion in order that it shall gradually be able to accomplish its purpose, depends, as was just said, upon various considera- tions. Judging from older consulters where liking and dis- liking are too often the motivation principles, I should say that a sense of duty as a mainspring of action needs to be more frequently employed with children. At present the psychological offices connected with the schools are largely for diagnostic purposes, that is, are clearing houses. The work with all these children has shown me that the scope of the work in such offices should be greatly enlarged. In fact they should be turned into mental hygiene clinics where the individual child who is doing unsatisfactory work in school or is delinquent, can be carefully studied and treated in order that his impedi- ments to right action may be overcome or he may be placed where they will not injure others. 1 1 . Cases of mental disturbances connected with the adolescent, menapause, senile and pre-senile periods of life. Much greater information is needed by people in general regarding each of these periods, in order that the pains accompanying the physical and mental disturbances incident to them may be endured with more equanimity. Some of the mental disturbances grow out of the fact that persons especially in the last two periods feel that they are entering upon an unfamiliar and not altogether desirable time of life. The adolescent constantly complains of feel- ing "so strange" as regards life about him and the older personal worries over his lost youth. Unfortunately the com- munity in a suggestive way helps to strengthen these and allied ideas, by its attitude. The grown up boy for ex- ample is treated as a child by his family, and the vital ques- 28 MENTAL HYGIENE tions concerning the problems of life which fill his mind at this time are treated lightly or are altogether ignored. In the case of the old person the daughter gradually takes upon herself the mother's work in the house. On the street she grasps her arm firmly and guides her steps as she would those of a child and almost lifts her into the street car. The task of the mental hygiene adviser is to give all such consulters an adequate philosophy of life and to as- sist them in making any adjustments necessary to the period on which they are entering; also in the case of the older persons, to help them to understand that loss of memory and intellectual power is due more to indolence and laziness than to the fact that they are "growing old." It is the last two periods that need especially to be more care- fully studied. Some few do become insane doubtless from the neglect of those around them during the adolescent period, but the waste in the community of "growing old" too young is immensely greater. When looked at from all sides it is appalling. Oh ! that the community would come to realize how very monotonous a world with only young people in ii would be and that the writer was not entirely wrong who said that youth was given to people to make them endurable until they were old. 1 2. Cases of mental disturbances where "nervousness," "depression," "excitability," or in common parlance an "unstrung" condition is present. The trouble lying at the base of the physical and mental condition indicated by "nervousness," etc., is extremely individual. It may be largely physical as the result of an operation or overwork, or due to an uneconomical use of time and force which results in an inability to accomplish one's work, or to an irritation and impatience as regards others, or to some phy- CLASSIFICATION OF MENTAL DISTURBANCES 2Q sical deformity, or to an influence of a tyrannical old or a young person who insist on imposing- his ideas and habit? on his relatives and friends, or to an unsteadiness of pur- pose, or to hurry growing out of the fact that one has not the ability to accomplish the amount of work desired or demanded, or to the dissatisfaction with life which results from having no set goal toward which one is steadily direct- ing his course, or to sexual irregularities, or to dissatisfac- tion as regards the sexual life, or to difficulties having to do with the domestic relations, or to timidity, or to placing work emphasis on the wrong place, or to lack of interest in one's present occupation, or to having nothing definite to do, or to doubt as to what to undertake, etc., etc. In cases of this class it takes much time to find out the cause of the trouble and when it is found, to remove it, because of the fact that it means the person must often establish entirely new habits of thought and action. I found so many cases where the consulters were helped by a program that I keep the blank (shown below in reduced form) on hand to use for this purpose. This blank is filled in with the patient and then given him to follow out and put + where he had followed the program, and where he has not. The completed program he brings back at his next visit and it is discussed with him. Often this treatment alone removed the "nervous" and "confused" feeling of which he had complained at his first visit. Where a person's nervousness was due to a variety of uncontrolled factors in his daily life, I have occasionally set him to work to try to help some member of his own family, or a relative, or friend suffering from a similar dif- ficulty. A mother, for example, who was given Barker's "Principles of mental hygiene applied to the management of children predisposed to nervousness" to read with a view to rooting out certain of her own nervous peculiarities which MENTAL HYGIENE Name, Address, 7- 8 Mon. Tues. Wed. Thurs. Fri. Sat. Sun. 8- 9 9-10 10-11 11-12 12- 1 1- 2 2- 3 3- 4 4- 5 5- 6 Even were very noticeable in the child, improved her own "nerv- ousness," as well as that of her child. 13. Cases of insomnia. Many of the consulters of the previous class also complain of loss of sleep but there were two cases where this was the sole trouble. A fear that in- sanity would result from it doubtless increased the difficulty in their cases. The methods which had been recommended by their kind friends as sleep-producing, such as counting the number of sheep jumping over a fence, etc., had but in- creased their wakefulness and fears. Another method was employed by the mental hygiene clinic. As people often CLASSIFICATION OF MENTAL DISTURBANCES 3! sleep more hours than they suppose they sleep, the chart below was given to be filled out for a week : NAME, Date Hour of Going to Bed Hour of Getting Up No. of Hours of Sleep Dreams When the consulters found, as they usually did, that they were sleeping many more hours than they had supposed the fears vanished and they soon acquired again the normal number of sleep hours. 14. Cases of lack of emotional control, (anger, ha- tred, jealousy, and other unhealthy emotions predomi- nating.) Emotion is so often the mainspring of action that the problem set to the mental hygiene adviser in dealing with persons who give way to unhealthy feelings is therefore largely one of substituting healthy emotions which may serve as an impetus to action or of transferring the main- spring of action to a healthy intellectual field. It often means the upbuilding of a new world on the part of the consulter and is, therefore, a matter of much time and ef- fort. In such development I have found the keeping of the emotion chart, to be discussed later, very useful. It aroused the consulter to make a continuous effort and thus aided in quickening the formation of a new emotional habit. 32 MENTAL HYGIENE 15. Cases of marked weakness of will, inability to hold the attention, loss of memory, prevalence of images having an hallucinatory character brought three to the mental hygiene office. These cases and those classified else- where could be given to illustrate mental difficulties dis- cussed by Ribot in his works on diseases of the will, atten- tion, etc. One of the most striking of the three cases classi- fied here is that of a woman, sane in all other respects, who stands every day several hours before the washstand in her bathroom washing herself and crying because she cannot stop doing it. A study of the case showed that the removel of duties through the growing up of her children, the ac- quisition of wealth, and a natural love of ease, played an im- portant part as causal factors. 1 6. Cases of failure in adjustment of family and com- munity life. Such persons came because they were suffi- ciently intelligent to realize their social maladjustment and their lack of knowledge and will as regards coping satisfac- torily not only with their personal but also their group problems, such as getting on comfortably with their husbands or wives and interfering relatives and friends ; carrying on their homes or their business successfully ; helping their ac- quaintances and friends in solving their problems ; in short, getting a better grip on the affairs of their daily life. This class of cases makes a greater demand upon one's life experi- ence than any other. To deal properly with the questions brought for solution one is soon made aware that he needs to have lived many years and to have had many and varied experiences. 1 7. Cases of women desiring advice as to pre-natal and infant care. These four persons came because they and their husbands felt that they must have mental help to pre- CLASSIFICATION 09 MENTAL DISTURBANCES 33 pare themselves for the mental training of the coming child. In the present year's work directed to the saving of the child one is astonished when one recalls the health- giving power of properly developing feeling and thinking from birth, to find that a child's mental development is al- most completely ignored in the books dealing with such work. Matters of vital interest, such as the unhealthy and narrowing and incapacitating effect of impressing only par- ental ideals upon the child, the danger to which an only child is exposed and the unhealthy coxplexes that are formed in the very earliest years, are passed over far too lightly. Where the women have come for pre-natal advice they have been directed along these lines as well as in regard to their own mental health. 18. Cases of persons desiring advice as to the most effective methods to employ in "improving and strength- ening their minds." As to the method to be used in stength- ening of the memory, if that was the direction in which the consulter felt he was weak, one must, of couse, consider the cause. For example, it was found that memory was often weak in the direction in which one did not wish to remem- ber. One lady had formed the habit of forgetting engage- ments that she did not care for some reason to keep. Here the forgetfulness had a protective character in quieting the forgetter's conscience as regards her duty in meeting the engagement. Forgetting due to this cause extends in some cases to so many fields that the improving of the memory is a question of transforming the character. Again, loss of memory was sometimes due to an exaggerated subjective or objective tendency. In one of the state insane hospitals at a staff meeting of the physicians not long ago I saw two men who showed in a marked degree what I have often seen in a small degree in many of the consulters. One of them could 34 MENTAL HYGIENE remember with great detail all of the experiences of his personal life, but matters of larger interest, such as the ex- istence of the war in Europe, had been entirely forgotten. The other man could recall nothing of his personal life but knew well what had taken place in a political way in recent years. Cases of this kind are very suggestive from an edu- cational standpoint. They show that the subjective child should be trained to look outward and the objective child inward. Again, want of interest was the cause of a poor memory in certain directions. Such persons resembled the boy who forgot to feed the chickens and bring in the wood and could not remember his school work, but was able to give a very full account of the plot of several moving pictures he had seen. The fact that what had been learned had not been learned in a way to insure its ready reproduction was another cause of poor memory. When the cause of the poor memory had been ascertained, the psychological exercises to be mentioned later were often used with good results to strengthen it. In some of these cases the consulters complained of weak- ness of attention. An assistant cashier in this city used psy- chological exercises for many months to develop concen- tration of attention. Diffused attention had been required for his previous work, but for his new work as assistant cashier, concentrated attention was needed. Some of the at- tention exercises that he used were very simple, as the trac- ing of the figure eight mentally, but they were very effective in accomplishing the desired end. 1 9. Cases of persons desiring advice along the line of vocational selection, training and placement. The total number 15 given in Table II does not really represent the number of such cases. Many of these placed in class II, for example, might have been placed here, for their condition CLASSIFICATION 0* MENTAL DISTURBANCES 35 was sometimes due to their failure in the vocation selected and their recovery was brought about by applying work therapy. In the placement of some of the cases the cooper- ation of one of the employment bureaus of the city was se- cured. The consulter was sent to this bureau after a study had been made in the mental hygiene clinic as to his occu- pational liking and ability and the opportunities in the com- munity for him to carry out his desires. The consulter's his- tory was taken in the mental hygiene clinic as to the time and place of his birth, his present residence, his school record, his previous and present occupation and wages, and the result of the physical and medical examination. He was then given a short mental test after which a card was made out for him to present at the employment office. On this card was sum- marized the result of the consulter's mental and physical ex- amination, (whether he had finished primary, grammar, high school, university or technical school) and his experience (misfit, untrained, experienced, trained). In view of all these things, including his character as shown by his pre- vious life and his general appearance and manner, an opinion was also expressed regarding the particular kind of work that the applicant could probably do with success. The mode of procedure proved very satisfactory. 20. Cases of unclassified mental disturbances. In some of these cases there was no one set of difficulties that predominated sufficiently for classification. In others on account of limited time or for other reason no diagnosis had been made. CHAPTER FOUR THE PSYCHODIAGNOSTIC AND THERAPEUTIC MODES OF TREATMENT EMPLOYED The methods used by the mental hygiene adviser fall into two classes : those having a psychiatrical origin and those based on principles laid down in general psychology and on experiences gained in psychological laboratory work. Again, all the methods used depend to some extent upon the time at one's disposal Introspection is so foreign to the daily think- ing of many peoj*!? and requires so much training before it can be done advantageously, that psychoanalysis is a time- absorbing method and more particularly suited to private office work. It is therefore necessary to modify it some- what when one uses it in the clinic. On the other hand sug- gestion can be applied in so short a period of time that it is better adapted to the clinic if one considers the time ele- ment alone. The History. Occasionally it happens that the examina- tion of what is above the threshold of- consciousness through introspection that is, through looking into one's own mind as one does in reporting to the person who takes the his- tory, not only often reveals sufficient material for a satis- factory diagnosis and therapeutic attack, but also for the re- adjusting and fitting of the consulter to his environment, and for restoring and adjusting the misfits. This was true in the case of a woman in a state of opposition to her husband who was earning $150 per month, while he earned but $125, and insisted on depositing her salary check in a bank to his own credit and doling out money to her in sums, in some cases not exceeding ten cents. No deeper psychological examina- 36 MODES Of TREATMENT EMPLOYED 37 tion was needed for a psychotherapeutic attack. In a thera- peutic way the history-taking itself acts therapeutically through relieving the mind of the heavy burden that it has been compelled previously to bear alone. This was the case with two young men whose fears and worries imme- diately vanished on unburdening their minds in giving their histories. Also of two German women who unburdened their hearts in the clinic, telling how worried they were about their families in Germany from whom they had not heard since we entered the war, and who for fear of being considered pro-German had not dared to mention such worries, and had become ill largely through suppressed grief. The examination of what is under the threshold of con- sciousness through the use of psychoanalysis sometimes acts in a similar way. The mental disturbances of a young woman due to irregularities of conduct in which seduction had played a part, immediately disappeared on being treated by the methods of psychoanalysis. Many of the consulters take kindly to psychoanalytical examination. They call it the examination of their "sub-conscious mind." Before such examination is made it is carefully explained to them that what is termed the "sub-conscious mind" refers merely to that what we have learned through the senses is more or less perfectly preserved under the threshold of consciousness. They are told that careful experi- mentation even in physical research has not yet shown that there is anything in the sub-conscious except what was put there originally through the ordinary use of the senses and that speaking figuratively the mind is merely the storehouse of experiences which have come to us in our previous life through seeing, hearing, etc. That this "sub- conscious mind" is in a dynamic and not entirely in a static 38 MENTAL HYGIENE condition, and that therefore the elements of an experience sometimes re-arrange themselves and that this explains, for example, why he has an image of an acquaintance dressed as he has not previously seen him or of the face of a man he does not recognize. The condensation, symbolization, sub- limation, etc., in the material brought to the surface of con- sciousness, while it makes interpretation extremely difficult, is an advantage often, in that the patient could otherwise not be induced to acknowledge the emotionally colored com- plexes that come to consciousness if he fully realized he was betraying something for which he was directly respon- sible. Later when his confidence is gained and he under- stands that the elements probably have a fact basis, he often becomes interested in arranging them in the original com- plexes. In investigating what is under the threshold of conscious- ness sometimes Freud's method was used ; that is, the con- suiter was given a comfortable semi-reclining chair, told to close his eyes and talk out everything that came into his mind; and sometimes when the consulter has spontaneous visual or auditory images the visual image method was used; that is, the method where the consulter after having had explained to him what visual and auditory images are, closed his eyes and described the images that spontaneously arose. The image method has a more objective character and is more easily described, and in carrying out the instructions the consulter does not feel responsible for the content and has not therefore the temp- tation to conceal what arises in his mind. The image method is useful often from the fact that it gives one the mental material in the form in which it is disturbing the consulter. One can then set to work at once to break up the trouble- MODES OF TREATMENT EMPLOYED 39 some images or to replace them by healthy static or move ment images. In using the method of psychoanalysis and the image method his wrongly executed acts and mistakes in speaking, reading, and writing, and his forgetting of par- ticular words were carefully studied, also any words or melodies that haunted his mind. The study of the consulter's dreams was particularly illuminating. It did not occur to a woman, for example, who told of seeing herself in animated conversation with a man and on awaking felt a glow of pleasure, that she was giving a clew to her present nervous trouble which began in connection with falling in love with another man after her marriage. It is, it seems to me, with children that the diagnostic value of dreams is greatest. Questioning a child as to what he thinks about elicits but a monosyllabic response, but when asked as to what he dreamed about last night and the night before, he gives an enthusiastic account of the airship or something else he saw. His inattentive, dreamy expression as he looks out of the windows in the schoolroom is ex- plained. It is not alone that dreams betray the thoughts that are interfering with the child's work, but they often give one a hint not alone of the child's, but of the adult's normal preferences and aspirations and of the character of the cen- sor that was stifling and paralyzing natural inclination. We know from psychological work in the laboratory that dreams can be transformed and modified. I have often asked myself in listening to a consulter's dreams whether it was not pos- sible to make therapeutic use of such experiments, especially in banishing the dreams that are accompanied by trembling and other accompaniments of fear. Suggestion and hypnotism. Strictly speaking I have not used hypnotism, that is, put a consulter in a complete hyp- notic state during the last two years, though I had used it 4O MENTAL HYGIENE previously a great deal for experimental purposes. I have often employed suggestion for temporary purposes and oc- casionally, though rarely, I have brought on a condition resembling the hypnoidal state. As many of the consulters find it hard to relax I precede the giving of the particular suggestion by a suggestion to bring about a relaxed physical condition. The suggestion for psychotherapeutic purposes I usually give as an accomplished fact, "your head does not ache," or "you do not feel resentment towards your hus- band;" while the suggestion for relaxation is given as an instruction, that is, in a way better suited to getting the consulter to take part himself in bringing about the condi- tion, as "let your right leg relax." In connection with re- laxation, where it is possible to do it effectively, I sometimes teach the consulter to help by auto-suggestion, that is, to say for example, "my right leg is relaxed," or to use some other expression that will help in bringing about an unin- hibited muscular condition. I have found suggestion use- ful in various ways, as in producing rest and sleep, removing physical and mental pain, giving a motive for undertaking and continuing a desirable course of action, etc. I have occasionally used it as a long distance remedy. Through it I have been able, by using the telephone to remove a con- suiter's pain and to bring about a calmer condition at a distance of two hundred and fifty miles. Taken all in all, however, I regard suggestion only as a method to be used in emergencies, until other slower, but in the long run more effective methods can be used. It is usually temporary in its effects and must be frequently renewed. This makes it time consuming, but even where it is not, it tends to weaken the consulter. He should be a partner in his healing; that is, his recovery should be effected through the education of MODES OP TREATMENT EMPLOYED 4* his own thought and will. It is for this reason that the method of persuasion, which as some one says knocks at the front door, and does not, like suggestion, enter by the back stairs, has been preferably used. All things considered, persuasion seems to me the most satisfactory psychotherapeu- tic method and for that reason I have substituted it for sug- gestion wherever possible. Psychoanalysis and suggestion are favorite methods with consulters. They enjoy the free- dom from responsibility that exists in connection with this method. One man came not long ago and asked me to give him psychoanalytical treatment. It required no great amount of probing below the threshold to get at his difficulty which had a sexual origin of an abnormal nature. When re-educa- tion was suggested he was aghast. He was unwilling to make the effort required to substitute for the hurtful and incapacitating .thoughts constantly lurking in *his mind those that were ennobling and power giving. His motive to action was his liking to do things. In his case and that of many others I have come to see that in the Puritan days of duty as a motivation principle the persuasion and education therapy would have been more acceptable to the consulter. The automatic writing method. I have occasionally used it. It threw light on the case of the college girl, for ex- ample, who had written quite unconsciously, the name of a baseball hero all over a theme handed in. The automatic speaking method has, like the automatic writing method, but a limited use. We used it quite unintentionally on one occasion. Our attention was attracted by the whispered words of a feeble-minded boy awaiting his turn in the clinic. Through listening we got information in regard to his activities along sexual lines which enabled us to show that he must no longer be allowed to roam the streets alone. 42 MENTAL HYGIENE Environment therapy. By this is not alone meant the change of scene, getting away from irritating centers, by which one frees himself from painful and monotonous asso- ciations, but also the bringing in of new surroundings where imitation can have an opportunity to act in a health- restoring way. I see more and more in dealing with de- linquent boys and learning where they originally got some of their ideas that resulted in delinquency, that we do not realize fully the possibilities of the moving picture as a convenient method of bringing environment therapy to bear. Occupation and work therapy. Besides those just men- tioned other methods have been used, as the occupation method for rehabilitation purposes ; that is, encouraging the consulter to knit, weave, etc., at first, and later, when he had sufficiently recovered, to undertake some serious remunera- tive work. Of course in occupational therapy the kind of work given is important since each kind of employment has an intellectual influence. Liking is not, however, the only factor to be considered. Knitting, for example, is quieting in its effect and is generally liked, but it frequently allows too much opportunity for a given rnind to surrender itself to unhealthy imaginings. Work therapy was found useful in many different ways. It not only removes anxiety by enabling the consulter to meet the financial obligations that were harassing him, but it also took the attention and interest away from the field that gave rise to the mental disturbance. It developed accuracy and breadth of thought and expression and controlled the emotional absorption, so often present. Enforced work therapy may seem drastic in some cases, but the fact is that it is often the only kind of psychotherapy available. A man who was reported by the medical clinic as able to take up his life again was sent to the mental hygiene clinic. He had all sorts of excuses showing he was MODES OP TREATMENT EMPLOYED 43 unable to work, among others the need of frequent urina- tion. Investigation showed that he gathered and sold junk. The time of year he came to the clinic was unfavorable for his business. While he was waiting for the spring cleaning he came to Mount Zion Dispensary and got not alone medical treatment but doubtless financial help from a charitable or- ganization associated with it. When this last was with- drawn at my suggestion, he took up work and no longer needed or sought advice in regard to his health. Amusement therapy is far more needed, especially by young working women, than many people realize. I have had several cases where the consulter gradually recovered under this mode of treatment alone. Isolation therapy is at present too little used. Experience with the consulter showed that going "into retreat," the keeping of a "quiet hour," has a very beneficial effect on the health. Physical exercises may be used as a psychotherapeutic method. I have employed modifications of the "setting up exercises," "the brain drills," etc., to arouse thought and to increase quickness and accuracy in thinking. In limbering up the mind and body so that voluntary effort (which is partly, probably often, a matter of muscle the overcoming of one's physical inertia) would be easier. Music therapy has been used with good effect in several cases. Naturally the extent to which any of the above methods is applied depends upon the mental make-up of the consulter and the time at one's disposal in applying treatment. My experience during the last two years in working in mental hygiene has brought me to feel that re-education is the method par excellence and it is for this reason that I devote the next chapter to its application. CHAPTER THE METHOD OF RE-EDUCATION In psychotherapeutic re-educational work the principles laid down in general psychology must be the guide. If after getting well started in mental hygiene one will but re-read any modern work on psychology, he will scarcely find a page from which he cannot get valuable therapeutic hints. In psychotherapy treatment one must not be content, however, with merely giving advice based on well established psy- chological principles, but must give the consulter something to do, something that will make him an active participator in bringing about his cure ; appropriate psychological exer- cises must be prescribed. On examining my own psychologi- cal laboratory work (see appendix for the bibliography) to see if there was anything that could be used as mental hygiene exercises, I discovered that nearly every one of the investigations, except No. 4, contained something that could be employed in helping the consulter to be a party in his treatment. This led to a similar re-examination of the in- vestigations of others and I found that what was true of mine, was also true of theirs. Below I summarize and dis- cuss some of the exercises which have been given with good effect. While as yet I have gone but a step with this kind of treatment, it is far enough to convince me that it works beneficially. I am inclined to think that what gives the tinct from that of the physician on the other hand, and the psychologist a place in the psychotherapy today, entirely dis- social worker on the other, is not alone his large knowledge of psychological principles, but also his years of experience in carrying on work in the psychological laboratory. Such knowledge enables one to penetrate into the human mind, 44 METHOD OF RE-EDUCATION 45 which the time needed for the required training in their own special fields of work makes it impossible for the members of the other two professions to acquire. The consulting psychologist will of course have this in common with the physician and social worker, namely, that his usefulness will also depend much upon the amount of general knowledge and experience stored away. As I am not attempting to write a book on clinical psychology, I pass over, without any attempt to enumerate them, the very large number of psy- chological principles which underlie psychotherapeutic treat- ment. As the transforming of psychological experimental work into therapeutic exercises has not been previously taken up, I enumerate and discuss below some of the ex- ercises for: 1. Acquiring emotional control; 2. Strengthening physical and psychical hardening and endurance; 3. Increasing, correcting, and controlling sensation and perception; 4. Doing away with thought confusion and the attendant ineffective action; 5. Enlarging and controlling conscious and sub-conscious mental activity ; 6. Modifying and banishing persistent unhealthy images and ideas; 7. Increasing accuracy and rapidity in thinking, banish- ing mental laziness ; 8. Increasing, strengthening, and controlling attention, memory, and imagination; 9. Eliminating bad habits and establishing good ones ; 10. Increasing accuracy and rapidity of movements and eliminating involuntary abnormal positions and move- ments (tics) ; 46 MENTAL HYGIENE 11. Bringing about muscular relaxation and removing fatigue ; 12. Increasing through practice the ability to do mental and physical work; 13. Correcting and restoring mental and physical activities through the use of imitation; 14. Developing a dignified posture which would help in bringing about courage and composure; 15. Increasing physical, and through it mental lightness; 1 6. Improving speech; 17. Establishing a healthy motivation principle. 18. Restoring and creating normal physical functioning; 19. Establishing normal social and moral activities and parti- cipation; 20. Building up a sane and healthy philosophy of living. i k In helping the consulter in the acquiring of emotional control I frequently use a chart, suggested by a temperature chart, which I call an emotion chart. In Fig. 2 below an emotion chart that has been filled out by a consulter suffering from depression is reproduced. Figure Z. The object of this chart is to trace the effect of the exercise given on the emotional condition. A dot placed on the base line ab always shows that at that time (the numbers on the chart indicate the particular hours of the day) the con- suiter was in an indifferent state emotionally. A dot placed METHOD OF RE-EDUCATION 47 below this line indicates the presence of depression at the particular moment. In general dots placed below the line show the presence of unhealthy emotions as fear, hate, anger, jealousy, at the particular moment. A dot placed above the line ab indicates in this case, the presence of a feeling of happiness. In general dots placed above the line indicate the presence of healthy emotions as courage, love, etc. The dis- tance of the dot above the line ab indicates the strength of the particular emotion at the given time. Where the dots have been connected together by a line, as is done in a temperature chart, the emotion chart gives one a detailed picture of the particular emotional condition from hour to hour. From it one can get information in regard to the effect of the psychotherapeutic advice and exercises given. In this particular case the consulter was at first in a con- tinuous state of depression. After beginning to use certain of the exercises discussed below to bring about a state of happiness, the depressed feelings are shown by the chart to have decreased in strength and frequency, and at various times during the day to have disappeared completely. This chart can be made use of in a variety of ways; as for ex- ample, in tracing the course of a feeling of irritation and nervousness, in showing the emotional condition from hour to hour in a disturbance having a manic depressive coloring, and by slightly modifying it the course of mixed emotions can be shown. One value of a chart is that it helps to arouse the consulter's ambition to keep the particular emotion under control until a habit is established. Present investigations are making people realize more fully that the mind has an enormous influence on the body. The experiments of Cannon and Crile have shown us con- clusively that certain emotions are physically weakening and others life-giving; that one of the most important things in 48 MENTAL HYGIENE psychology is to do away with such emotions as depression, fear, hate, anger, jealousy, etc., the weakening emotions, and to substitute for them joy, courage, love, etc. the strengthening emotions. In general, in seeking to effect the emotional transformation just mentioned an application of the James-Lange theory of the emotions has been made "A man does not smile because he is happy but he is happy because he smiles." The consulter was directed to assume the expression of face and body that corresponds to the particular emotional condition which I wish to have aroused, telling him that the mere intimation of the motion produced it. For example, if a feeling of courage was to be sub- stituted for one of cowardice, he was instructed to stand up straight and sometimes a picture was put before him to look at and imitate. A photograph of the equestrian statue of Joan of Arc at Rheims I have found very effective for this purpose, especially when in large size. Again, if I wish to get rid of a habit of depression and sadness, I insist that the person take smiling exercises at stated intervals. Sometimes he has not laughed for so long a time that the muscles having to do with laughter are not only de- cidedly stiff but their management has been almost for- gotten. Such a person can frequently be helped in this respect by looking at himself in a mirror struggling to smile or at a large smiling face. Persons with a very strong sense of humor looking at the picture on the opposite page, "Spring, gentle spring," which I reproduce from LIFE by permission, start up imitative movements of other parts of the body as well as those of the face and for this reason it is particularly good for this purpose. Reading Mark Twain and other humorous writers can often dispel a feel- ing of depression for a long period. Spring, Gentle Spring METHOD OF RE-EDUCATION 49 There are a variety of things that a consulter can be in- structed to do to dispel an unhealthy emotion when it arises. Using a hot water bottle or increasing the temperature of the room will frequently help, especially if the fire is in a fireplace or wood stove ; these suggestions are not hypotheti- cal, they have been tried and they work. 2. In regard to strengthening physical and psychical endurance. Exercises were prescribed through which agreeable associations, or those having an indifferent char- acter, were built up with the irritating phenomena. Under the use of these the unhealthy effect of unpleasant weather, noises, sights, smells, tastes, etc., have vanished. 3. To increase, correct, and control sensation. Where a visual weakness existed, pictures were given to be examined. After this was done what had been seen was de- scribed and the omissions and additions made, as regards con- tent, were pointed out. The recording of the result in each acted as a stimulant. Not only have these exercises increased the consultant's powers of observation but the reactionary ef- fect on his whole mental life has been beneficial. For the practical value of such an exercise in a normal person, we have proof in the extraordinary observing power along visual lines, developed by Houdon in his son by having him slowly pass a show window and relate afterwards what he had seen in it ; and as the boy became more expert in iden- tifying and naming the objects seen, he encouraged him to increase his speed in passing such a window, with the re- sult that finally he could run past a show window and name every object in it. Where there was observation and memory weakness along other sensory lines than visual, as in that of hearing, touch, etc., appropriate material was substituted for the visual. 5O MENTAL HYGIENE 4. To do away with thought confusion and the attend- ant ineffective action. Here, as was said before, a weekly program was made out with the consulter on a program blank, and he has at the given hour to put in -f~ an d after each item to show when he has followed and not followed it. The program given is brought to the office when completed, for discussion. The minds of many consulters have cleared up surprisingly under this treatment. 5 . The enlarging and controlling of conscious and sub- conscious mental action activity. The majority of mental difficulties exist because certain ideas are voluntarily or in- voluntarily dominating consciousness. This is because of the narrow range of ideation or because certain ideas have acquired in some way a much greater energy as regards arising and controlling consciousness. The effort in the exercises given here is through applying the laws of mem- ory to put the ideas in mind which will compete with, and gradually supplant those that are disturbing, thus giving a healthy direction to the thinking. For this purpose appro- priate poems have been learned and repeated hourly to im- part to them that spontaneous arising character which makes them real competitors of the ideas one wishes to sup- plant. "The Salutation of the Dawn" from the Sanscript, Kipling's "If," "The Twenty-third Psalm," etc., have been useful for this purpose. The value of such committing to memory was strikingly shown in the improved behavior of two children who when brought to the office by their mother to see if something could, not be clone to improve their manners, they were given the following verse by Stevenson, ("The Whole Duty of Children") to learn and recite three times daily: METHOD OF RE-EDUCATION 51 A child should always say what's true, And speak when he is spoken to. And behave mannerly at table; At least as far as he is able. A short quotation containing the idea one wishes to fix in mind is often better than a long poem. Several of the fol- lowing have been used: Imitate, you will; the task before you is to surround yourself with people, etc., that you wish to imitate; The aim in life is to be happy yourself on a high plane and to make others so, as far as you can ; If a man does not know to what port he is start- ing no wind is favorable to him; Use your senses, for they furnish you with the material for your future study and thought; What you shall find is what you shall take with you; Growing old is simply living on one's past; Learn to forget the useless; I am an old man and have had many troubles but most of them never happened; A prophesy helps to bring about its own fulfill- ment; To understand all is to forgive all; The oftener you give your attention to a thing the oftener the thing will attract your attention; When a man has one and the same feeling over and over again, the feeling will in time dominate the man; What we think and feel is almost as important as what we do; He wins who laughs; 52 MENTAL, HYGIENE Thought is motor. If you think a thing long enough, you will act it out; Think before you act. Each immoral act makes reformation more diffi- cult. In regard to influencing the sub-conscious activity which results in disturbing dreams that the trembling state on awakening shows to be injurious to the nervous system, I have made scarcely a beginning, but when I think of the experiments with perfumes, etc., through which dreams have been directed, I see, as I have said, therapeutic possibilities in this direction. Not alone supplanting is to be done, usually to restore one to mental health, but a systematic broadening out of the thought content. In the case of adults there is no case where this can be so well shown as in a mental hygiene office. Such consulters must be advised and helped in doing this after a consideration of their personal likes and capabilities. 6. To break up, to destroy, and banish persistent un- healthy images and ideas means the formulating of exer- cises which will train the will in the particular case to act promptly and persistently along the desired line when oc- casion arises; as for example in the case of a consulter who had an apparition. He saw a ghost at intervals, that is, developing a definite visual image which on occasions was spontaneously projected into space and had to be done away with through mentally tearing it to pieces bit by bit. 7. The materials and method used in the association tests of Woodworth and Wells, in the completion test of Eb- binghaus, and in a hundred mental tests, are useful for increasing accuracy and rapidity in thinking, banishing mental laziness. METHOD OF RE-EDUCATION 53 8. Increasing, strengthening, and controlling attention, memory, and imagination. Where there is a weakness in subjective or objective attention one has but to think over laboratory investigations along this line and immediately a corrective means is at hand. Rapid reading, paragraph reproduction, simple and complicated calculations, are exer- cises that strengthen subjective attention. There are many useful exercises for improving attention. Stimuli can be arranged to direct the consulter's attention away from one objective field to another. In the case of a pain in the heart region that has become more or less a habit, a con- suiter has been trained with relieving effect to direct his attention on his big toe. After he has learned to make this transfer his pain has lessened considerably and sometimes entirely. Each of us has favorite or preferred fields of at- tention and not always a healthy one. That this can be al- tered by arousing, from desire of good health or from neces- sity, an interest in some other field or by furnishing the appropriate stimuli, goes without saying. Occasionally weakness of attention is due to a general relaxed muscular condition, a condition only favorable for dreaming. Muscular tightening up is fundamental in bringing full attention to bear. In the English army "brain drills," in the American the "setting up exercises" show that good attention power is partly a matter of muscular adjust- ment and muscular strengthening. The value of training the attention from a therapeutic standpoint is evident from the improved physical and mental condition of those who have been in Dr. Vittoz's sanatorium where attention train- ing is so much used in treating the patients. Some exer- cises he uses could be improved, it seems to me, as the ban- ishing successively of several objects intentionally recalled, and the differentiating out of a sound and hearing it alone ; 54 MENTAL HYGIENE this could be done through making use of some of the material found in the psychological investigations of the last ten years. In the mental hygiene clinic one clearly becomes acquainted with attention difficulties. One of the most com- mon complaints of the mother who brings her child for treatment is that he is inattentive. Examination very often shows that his inattentive mental state grows out of the kind of training he has had at home. There may be some question in regards to the desirability of military training in the schools, but learning to stand at attention when told to do a thing and being sent to the "guard house" in case of disobedience should be introduced into home life, it seems to me. With the experimental work in memory everybody is so familiar that it is only necessary to remind the reader that many consumers' complaints can be overcome through giv- ing the exercises which will be immediately suggested if one will look over the investigations of Ebbinghaus and those who have followed him. Above all, one should not neglect the studies which have shown the value of one repetition as regards retention, and the ineffectiveness of "nagging" and the lesser ability to recall when one had not expected to be called upon to reproduce what one was committing to memory. Exercises in imagination are needed by us all, but especially by those troubled with mental difficulties which make it necessary for them to modify their old ideals and build up new ones in order to get well. Imagination plays such an important role in the life of each individual in the way of suggesting modes of action that we should no longer neglect cultivating it along higher lines. One often finds in investigating cases of lying and stealing that they can be traced to an imagination which should have been trained long before to work in legitimate fields. METHOD OF RE-EDUCATION 55 9. In connection with the elimination of bad habits and the establishment of desirable ones. I made constant use of James' Principles: 1. Never suffer an exception to occur until a habit is formed. 2. Seize every opportunity for strengthening the habit. 3. Launch habit with a strong and decided initiative. 4. Retain faculty of effort by daily exercise, and those of Watson: 1. Within certain limits the less the frequency of practice the more efficient is each practice period. 2. The less the number of habits formed simulta- neously, the more rapid is the rise of any given habit. 3. W T ithin certain limits, the younger the animal, the more rapidly will the habit be formed. 4. The higher the incentive to the formation of a habit and the more uniformly this incentive is main- tained, the more rapidly and the more uniformly will the habit he formed. Under such conditions the curve illustrating the growth of the habit will rise steadily. Whenever the incentive decreases in intensity (often- times with the actual onset of boredom) there appear pauses and resting places in the curve (places of no improvement). It becomes the work of the' clinical psychologist to explain the plateaus in the work curve, for the consulter becomes discouraged when he sees them and is tempted to give up his practice. I have found Kraepelin's curve of work useful in showing the consulter the meaning of "spurts," "warming up," "over fatigue," etc., in the work connected with forming a habit. 56 MENTAL HYGIENE; The work done on the conditioned reflex, the association reflex, the psychoreflex, etc., suggest methods for establish- ing desirable habits. Reflection on the case of the woman with hay fever who sneezed on seeing artificial roses was suggestive along this line. Too much cannot be said on the development of useful and healthy habits of a child. One is constantly surprised by physical neglect displayed by parents along this line. The inability of the child to dress himself and assist in the work of the household are some of the many things that migh be mentioned. Parents need to look over life and decide on what habits the successful person must acquire and with this ideal in mind set to work to train their children. One does not need to study Mon- tessori to find out what ought to be taught to every child. There are certain things that every human being has to do along the lines of household economy and those things should be taught as early as possible. In fact, the applica- tion of the good common sense which directed our grand- mothers in their parental functions would make us all good Montessori teachers without much special preparation. 10. No exercises are more important therapeutically than those for increasing rapidity and accuracy of movement and eliminating involuntary abnormal positions and movements. Everywhere we see middle aged people with too slow a "tempo," a "tempo" which really corresponds to a de- creased quickness in thinking. By giving physical exercises for increasing the quickness of movement, through con- ventional or spontaneous dancing, especially if accompanied by music, it is surprising how much the consulter improves in what he can accomplish in a day in a physical way. It also restores a self-confidence, and does away with an indifferent attitude which is unhealthy. The general unmoral effect of a slouchy posture ought not to be overlooked. In this METHOD OF RE-EDUCATION 57 connection the mental tests, form-board tests for example, furnish abundant material for exercises and one's success in carrying out the instruction, "speed up," can be meas- ured by using a stop watch, which is of itself a stimulant. Even speech movements need to be increased in rapidity in training consulters. I have found rapid reading very use- ful in accomplishing this. The real reason for speeding up movements is not, of course, in the movement itself, but, as was said, in its reactionary effect on the consulter's think- ing. Through it his mental activity gains in elasticity and power. In cases of chorea, etc., one can by observation easily invent exercises that help in removing abnormal positions and movements, tics. ii. Galbrith's book on Fatigue will be found highly use- ful in bringing out muscular relaxation and removing fatigue. As many emotional disturbances are doubtless increased by tenseness and fatigue, it is extremely important to remove them. In trying to do this I do not encourage long rest periods. Complete physical relaxation during ten minutes' hourly rests, I have found highly beneficial and I frequently prescribe these. Children are often brought to a psychologist for advice because they are nervous and restless. Very often weariness is the cause, and in such cases I advise that they lie down for a short period several times a day. The "fights" and "quarrels" among the children of a family of which so many mothers complain, can be controlled by putting the children in separate rooms to rest. Their affection, solici- tude, and devotion to each other after even a short period of such isolation and rest is almost touching. The fact that fatigue grows out of an unnatural bodily position when various parts of the body are not in equilibrium and results in pain, is too often overlooked. The severe pain in the 58 MENTAL HYGIENE back of the neck in a number of cases has immediately dis- appeared on ceasing to bend over in working. 12. Increasing through practice, ability to do mental and physical work. The consulters have shown a decided increase in efficiency through previously training them- selves to plan and execute a given task without excitement or previously making an appropriate plan of action. 13. The restorative value and the injurious effect of the imitation of others are factors that have to be considered in psychotherapy, and exercises for increasing and diminishing imitation, suitable to the particular case, have to be devised. As has been said, not alone through imitating the poses, etc., of real people but even of those in pictures one can fre- quently greatly improve one's self physically and mentally. In connection with the discussion of imitation one must not neglect to speak of social heredity. Of course the heredity of every child should be carefully looked into and if there are any mental or physical disturbances which may be in- herited, the child should be made immune as far as pos- sible through appropriate training. Much, however, that is called "heredity" is nothing more than imitation. Cases for example of pseudo-tuberculosis and other diseases are oftener found to exist in families where there is a reason to believe from the heredity that there might be a tendency in this direction. The unfortunate part of such beliefs is that the fear of the disease and the constant attention upon the particular part affected, if it does not actually produce the disease, at least probably make a person more sus- ceptible to it. Social heredity is strikingly noticeable in mos't children. One sees it in family peculiarities as re- gards modes of expression and views of life. 1 8. Restoring and creating normal physical functioning. T frequently teach the consulter to use autosuggestion on METHOD OF RE-EDUCATION 59 account of its great value as a pain eliminator. It is a par- ticularly valuable method to use in removing depression. In the long life of a comparatively delicately constituted person like Kant, we see the health significance of such words as "I am so comfortable," as a preparation for going to sleep. If one doubts the significance of suggestion as a pain instigator and destroyer, let him say over and over again for five minutes "My head aches" and observe whether he feels as comfortable at the end of the time. 19. It may seem absurd but some persons have to be trained step by step to participate in the life of those about them. 20. In regard to building up a sane and healthy philos- ophy of life. In many cases it is absolutely necessary not alone to get at a consulter's philosophy of life, but to modify it. One finds in general that persons with mental and nervous troubles have none or that it is inadequate as a guide in coping with a difficult situation. Frequently it is the idea that one is to decide as to what he will do, because he likes to do it, and their liking is a poor guide because it does not rest upon a high emotional or intellectual basis. One has two things in dealing with many consulters: first, to make them see, which is always difficult, the defect in their motivation principle, and second, to urge them to make a substitution for it. Frequently they have not only not the intelligence but they lack the initiative required to form a new one. Often the psychologist must frame a philosophy very simple in form and content and not having a religious basis. One may offer some one else's life principle that ap- pears workable as that of Markham's "The Day and the Work:" To each man is given a day and his work for the day ; And once, and no more, he is given to travel this way. 60 MENTAL HYGIENE And woe if he flies from the task, whatever the odds ; For the task is appointed to him on the scroll of the gods. Occasionally I give my own principle of living which, from a pragmatic standpoint, has a sound basis for myself in that it works when a less crude and bold statement fails to help me : 'I am here, I may die tomorrow, I may live twenty years or even longer. If there is anything after death, everything that I have learned through suffering as well as joy will be a valuable asset. If there is nothing hereafter I shall not know it." The establishment of a philosophy of life is not of course needed by the majority of consulters. It is most needed where a person has reached the point where he knows he is failing and asks himself what is the use of the struggle, by one who is kept from ending his life perhaps only on account of the pain and awkwardness of doing so. The problems of people in general as com- pared with the persons just mentioned are rather on the surface, and aid can usually be given by direct psychothera- peutic advice accompanied by the giving of exercises, things to do, which will act in the way of mental control and in the establishment of healthful and habitual modes of action. One must never neglect to give the patients something to do. It makes them willing to leave the mental hygiene office without the more tangible physician's prescription. This cor- responds to a prescription and to the taking of medicine which patients usually feel will cure them. It is unnecessary to amplify this matter of therapeutic exercises farther, for enough has been already said, doubtless, to give an idea of how the consulter is made a participator in his cure. Just which one or more of the exercises here enumerated should be prescribed in a given case depends, of course, not alone upon the consumer's diffculties, but upon his personal pecu- liarities. CHAPTER SIX. A DISCUSSION OF SOME TYPICAL CASES In treating most of the persons who came to the mental hygiene clinic several different therapeutic methods were employed. This has made it seem best to attempt but rarely to give illustrative cases under the different methods but to devote a special chapter to taking up in an illustrative way several cases, stating what brought the persons to the clinic, the kind of treatment given, and the results obtained. Case I. The man is a well-known business man. He reports that he trembles so violently at times that he is in danger of falling on the street and that this is accompanied by great mental distress. He said that he had frequently in this connection, as well as at other times, an unpleasant consciousness of his finger tips. The medical examination which I insisted on his taking was negative. Phycho- analysis brought out the fact that he was much troubled by an act which he once committed. The analytical study showed that it was evidently not the disgracefulness of the act itself that he was so much worried about as the thought that if it were known, people would ridicule and perhaps avoid him. It was pointed out to him at once that there was no possibility of the acts' becoming known except as he told it. Exercises given for the establishment of asso- ciative connections that would give rise to agreeable emotions when the ideas referred to arose, were helpful. Through looking at a smiling face or resolutely training himself to smile when he thought of this disagreeable act, there was gradually connected with it an agreeable feeling, and the trembling and other physical activities accompanying fear were replaced by the physical activities ac- companying amusement. He was encouraged successfully to stand up and exhale while thinking of the act just mentioned, to face the music as it were. To get the help of unconscious inner imitation in doing this he was advised to look at the photograph of Joan of Arc previously mentioned, or at some similar picture. As it was found that the fear periods occurred more frequently when he was weary, short rest periods at frequent intervals were advised. To remove the unpleasant consciousness of the finger tips he was successfully trained with beneficial result to use it as a signal to direct his atten- tion to his big toe. There was in this case another difficulty which seems to be entirely independent of the painful experience just men- tioned. A film came over his eyes after he had read a short time and he felt as if he were falling asleep. Here, too, mental analysis Si 62 MENTAL HYGIENE reveals the difficulty. By nature this man has the objective habit. He greatly prefers to deal with the external world. The reading of books of a solid character he finds tiresome. Unconsciously this physical difficulty has arisen to protect him in doing what he likes to do. Case 2. When this woman's physician went to the war another physician referred her to me. She had been in bed and had had a trained nurse for many months. Her attacks had an hysterical coloring- and her physician had used suggestion to quiet, her with