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SEMIANNUAL CONFERENCES.

The sixteenth semiannual conference of the Board and the trustees of the different institutions was held at the State House on Nov. 10, 1906.

The subject for discussion was: Discharge of the insane and defective from institutions.

(1) What classes of patients are suitable for discharge?

(2) Should any such patients be allowed to remain in institutions for a home, work, etc.? If so, why?

(3) Should systematic effort be made to provide for and assist such unrecovered patients to live in the community?

(4) Is there need of an "after-care" system to supplement family care?

(5) How long should an inebriate, temporarily insane and committed as such, be detained? May he properly be detained under commitment as insane for treatment of the inebriate habit longer than necessary for the treatment of insanity?

(6) What general instructions do you give patients and their friends at the time of discharge?

(7) Would it be possible and wise to formulate and print such general instructions for distribution at each institution?

(8) Other aspects of the subject.

The views of the different speakers as expressed at this conference were as follows:

Dr. George S. Adams, superintendent of Westborough Insane Hospital: Question 1: The classes of patients discharged fall readily into four groups.

The first group consists of the recovered cases. Most of these have relatives or friends to whom they can go, and sometimes I discharge them to their employer or permit them to go out and seek employment themselves, and discharge them when they have obtained a satisfactory situation. One or two such cases I have asked the State Board of Insanity to find a place for, and have them under their supervision, but usually there is no difficulty in finding some one to whom we can discharge a recovered case.

The next group contains those who appear to be capable of selfsupport although not recovered, and are discharged to their friends. and are supposed to be under some supervision, although I find that relatives generally permit them to do about as they please. A portion of these cases go on to complete recovery, and some of them are returned to the hospital again.

The third group of cases are those who are not well and who probably never will be well, but who are not dangerous either to themselves or others, and do not require hospital treatment, and can be cared for by their friends at home. Many such cases are willingly taken out by their relatives. The friends of others require some urging before they will undertake to give a patient a trial outside.

The fourth group consists of those who, after a sufficient residence in the hospital to determine their disposition and tendencies, can be cared for by the patient boarding out under the supervision of the State Board of Insanity. I place in this group all those whom I believe would be benefited by being away from hospital life, and also those who, while not being any better off, would be happier away from the hospital. These are the considerations that lead me to recommend cases to the State Board of Insanity, and I do not permit the fact of their being helpful patients influence recommendations.

Question 2: I think there will always be patients who are helpful but who, because of their delusions, habits and propensities, are unsafe persons to trust to family care, and on this account should remain in the institution, and they comprise the larger number of patients who are occupied. Such women patients assist in the ward work, kitchen, laundry and sewing room; and the men, in addition to their ward work, help on the farm and general out-of-door work. Some of these cases are always improving, and a person whom to-day we consider to be unsafe outside of an institution, in a year from now may be considered for boarding out or for discharging to home care. It is certainly a duty owed to the State, which provides care and treatment for the insane, that as many self-supporting cases as possible should be returned to the community, and the best means to this end is, I believe, through the boarding-out system under the supervision of the State Board of Insanity.

Patients whom I would not consider capable of caring for themselves improve to such an extent after being boarded out that they may be discharged as capable of self-support. Boarding out makes

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an adjustment to the ordinary family life in the community that cannot be done in the hospital.

Question 4: I think that the opportunities afforded under the present laws of Massachusetts for supervision by the State Board. of Insanity of boarded out and other cases seem to me ample for the needs of all the cases that can leave the hospital.

Question 5: It is our custom, when an inebriate committed as insane clears up in a few days, to keep him at the hospital three months, believing that by so doing the best good of the patient as well as the State is conserved. Should the insanity persist for one or two months, as is sometimes the case, I keep the patient under observation until free from insanity for at least six weeks.

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Question 6: My instructions to patients and their friends are more apt to be special than general, being applied to the needs of each patient, but in general the friends are advised to see that the patient is occupied, but not given too long hours of labor and not too much responsibility, and that attention is to be given. to their securing a proper amount of sleep. In cases with a history of drinking we emphasize the necessity for abstinence and the avoidance of companionship that will lead to their drinking.

Question: I believe that it would be impossible to formulate and print such general directions, but there will always remain the need of special emphasis being laid upon special condition in nearly every case.

Dr. Henry R. Stedman, trustee of Taunton Insane Hospital:As regards the classes of patients in our hospitals who ought to be discharged, it goes without saying that all who make a good recovery ought to be set at liberty unconditionally, that is, if they have given sufficient indication of their ability to withstand outside life. Where there is a question of this we have the "trial visit" law, which allows us to test them. Chronic, unrecovered patients may be and frequently are discharged, provided their insanity is of a mild nature, that they are not dangerous to themselves or others, do not neglect themselves and are to have proper oversight and surroundings. There is still another class that ought properly to be discharged. I refer to the acute, presumably curable case which has reached the stage where it does not progress, and it is uncertain whether it will go on to confirmed dementia or will convalesce. Here I think a trial visit home is highly advisable. It often marks the turning point to recovery. Excellent authorities have advocated, as the result of long experience, much earlier discharges from institutions for the insane than now prevail. There

are, I think, occasionally patients who ought to be allowed to make the hospital their home, cases which are well while in the institution but who immediately relapse when allowed their freedom. They cannot remain at home and are not suitable for boarding out. It is legitimate to have such patients remain permanently, provided the proceeds of any remunerative work that they may do go toward their support there. Every effort should be made to fit the unrecovered patient to live in the community, but only through a boarding-out system such as our own, which has done and is doing such efficient work in making patients self-supporting who might otherwise be left as charges upon the State.

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For the recovered patient the after-care system is a departure which is, I believe, destined to be a valuable aid toward the prevention of insanity by preventing or delaying relapses. The object of an after-care association is to provide for the temporary supervision, assistance and friendly aid and counsel, through charitable associations, of patients who are discharged, recovered or convalescent, from the hospitals for the insane. Later, when such assistance is in full operation, it may be possible to look after the unrecovered patients. These associations employ paid agents, who go to the homes of recovered or convalescent patients when they are discharged, ascertain what their surroundings are, provide employment, perhaps give them money or clothing, — more than is allowed them on discharge, find out what adverse influences operate against them, and start them under better auspices and hygienic conditions, thus doing something practical to prevent their breaking down as before. It has been well said that society does not fulfill its duty to the insane when it has helped to support and treat them in the hospitals if, on their discharge, it leaves them without support and without resources, and exposes them to the causes which lead to relapse. Such an omission is a mistake, not only from a humanitarian but from an economic point of view. The great point is that this is the only tangible means available for the relief and prevention of insanity. Before the patient has had an attack of insanity advice and caution are thrown away on him, for no attention is paid to them; but when once he has had an attack he will dread its repetition. You then can appeal to him; you then know also just what the adverse surroundings and influences have been which tended to bring on the original attack, and you have something definite to cope with.

This subject was brought before the Conference of Charities and Correction about eight years ago. Then the matter languished and

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