Social Work; Essays on the Meeting Ground of Doctor and Social Worker

In suppurative disease, such as appendicitis, it is often difficult to decide when nature is doing better than we can do, and when we can do better than nature. The appendix is a hollow tube the size of one's little finger, and hangs off from one part of the large bowel. When it gets inflamed nature at once begins the defences which I have described in the lung, namely, the walling-off process, which tends to make the bacteria harmless. There is danger that they will spread from the neighborhood of the appendix and produce a very dangerous disease, general peritonitis. Hence nature begins to glue around the appendix the adjacent parts of the bowel and anything else at hand. This generally makes it harmless. Most of us physicians now believe that the great majority of cases of appendicitis cure themselves, and that still more would cure themselves if given a chance. On the other hand, there are cases in which nature does not do her work rightly. Then if the surgeon did not interfere the person would die. That is why medical and surgical judgment, the particular, minute, individual study of the person from hour to hour, makes the difference between right and wrong treatment. The surgeon who operates every time he makes a diagnosis of appendicitis, or who says he will never operate, is just as wrong as the person who gives money the first time he sees a case, or who never gives money. But most surgeons are wiser than that.

I hope through these illustrations to make it clear that nature generally cures disease. When she does not, it is generally incurable. There is a small residuum left for the doctor. We have a function as physicians or nurses. We have a function, and that function is intermediate between two extremes. In disease or in other misfortune, there are three types of fortune, two extremes and a mean: (1) The people who will get out of their troubles whatever you do, get out of their misfortunes, rally to meet their griefs, pull themselves out of financial difficulties, get over their disease. Then (2) there are people on the other side, who will die whatever you do. Some cases of pneumonia, for instance, seem to be doomed from the start. It is the same with many other cases of disease and with some people's misfortunes. We have to face the fact in social work that there are many people whose mental twists and agonies we cannot help in the least, and many people who will be in money difficulties as long as they live. But (3), intermediate between these two extremes – and our happiness and our success depend on our finding that group – are those cases where what we do makes the difference between success and failure. This triple division indicates a point of view which makes, not only for individual understanding of the situation, but for practical success.

Take the case of those maimed by war or accident. There are three classes of them: first, the people who will get back their jobs and get back into industry unaided; they are probably the majority. Then the people who cannot be put back by any process. Finally, there is the rather small intermediate class who, with our help, with a little extra education, with a hand in the back, will get back into work, but who never would succeed, humanly speaking, without our help.

So it is in disease. The vast majority of diseases get well without any help from anybody, and that is the thing we must teach most often and to most people, in season and out of season. In our day and generation few people get a chance of observing that fact, because somebody comes along and gives them a drug. And unless one has seen people get well without any drugs, one continues to believe that it was the last drug given that cured every case of illness one has known to get well. On the other hand, the majority of illnesses that do not get well without drugs will not get well at all. I have mentioned before the figures which seem approximately true in relation to the cure of disease by drugs. Drugs will cure about six or eight diseases out of about one hundred and fifty diseases known to science. Anybody who fails to give a drug for one of those six or eight diseases is criminally negligent. We should press that drug upon the patient. I do not want anybody to think that I do not believe in drugs. I believe in them tremendously, in the particular cases where they are of use. But I do not stand for the habit of bolstering up people's beliefs that we have drugs all ready to cure most diseases.

I think the future of cure by drugs is very hopeful. I do not feel hopeless of our discovering drugs for the one hundred and forty-two out of one hundred and fifty diseases which we still cannot cure. But if we falsely suppose that we have a cure already, we do not hustle around to get it. It is not until we realize that we have not a cure already, that we do hustle around to get it. It is not until we realize that we are now very helpless in medicine that we shall labor in a way to become less so. At present the best that we can do for most patients is to explain what the trouble is, let them know what is going to happen, to preach some hygiene, and above all to make them realize that we care and suffer with them. That is the essence of medical work and of the social assistant's work in the dispensary and in the home.

Industrial disease

Industrial disease is a phrase we have heard much in the last ten or fifteen years, meaning that diseases are caused – some of them – by the conditions to which people are exposed in industry. A great deal of indignation, some of it fruitful, much of it harmful, has been aroused against employers and against the whole system of industry – because we have now recognized the fact of industrial disease. Employers in the past have been more interested in their machinery than in their human help. That is not only bad, but very stupid. Most of us believe that because it is stupid it is not likely to continue indefinitely.

But aside from all these matters of controversy, there is one important distinction to make at the start. (a) Industrial disease in the narrow, strict sense, i.e., something produced by the industry, something which would never have occurred in any form if the person had not been in that industry. (b) Disease affected, modified, in some way by industry, but due in part to other causes.

There are very few clear-cut and common industrial diseases. Lead poisoning is almost the only one. Disease due to the inhalation or swallowing of other poisons and the penetration through the skin or irritation of the skin by definite poisons are real dangers, but not common. More common, more difficult to deal with, and therefore more within the province of the social worker, are the diseases in which industry is only one factor in the complicated skein of causes. Take such matters as exposure to unusual heat or cold, unusual humidity or dryness in industry – very common conditions; or still more, exposure to unusual strain and hurry from what we call "speeding-up" or from the piece-work system. I do not think there is any good evidence that those things produce any single disease. I think there is excellent evidence that they often dip the scale whereby a person who has been in equilibrium, able to get along with his outside troubles, and to keep his balance, is finally knocked down into disease.

A person has tuberculosis. One of the favorite tricks of unscrupulous political orators is to say, "Look at all that tuberculosis due to the greed and the cruelty of employers!" Bad conditions of industry are doubtless a factor in the production of tuberculosis, but we must realize how many and important the other factors are. The eight or ten hours a person spends in industry is often a small factor in producing his ill health, compared to the fourteen or sixteen hours he spends outside the industry. Hence if we are to understand the diseases of workmen we must investigate these hours just as carefully as those in the factory. That is what we ordinarily omit. We find so many cases of tuberculosis in a given industry, and we say, "Ah, then, these cases are due to the hardships of that industry."

In refutation of this idea there is one more dogma packed for transportation, which I should like to offer in the form of a logical fallacy which the mediæval logicians put down in Latin terms: "Post hoc, ergo propter hoc": "After this, therefore because of this." One of our duties as doctors and social workers is to combat fallacies, to teach people to think straight instead of crooked about their ill health and their other troubles. When thus occupied, a large part of our labors will consist in trying to overcome the popular fallacy quoted above. "You went into a particular industry and you had tuberculosis: therefore you had tuberculosis because you went into that industry." "You had a given disease and you took a certain remedy: you got better, therefore the remedy cured the disease." So the superstitions flourish. I do not believe it is easy for any of us to extricate ourselves from that particular fallacy, but we must try.

In industrial disease we have the causative factor of industrial hardship intimately mixed up with other factors. One of my colleagues, Dr. Roger I. Lee, of whose book I have already spoken, investigated, in our clinic at the Massachusetts General Hospital, the cases of one hundred young working-girls, factory employees, who either had tuberculosis or were suspected of tuberculosis – were in what is wrongly called the "pre-tubercular stage," when the doctor has not made up his mind whether the patient has tuberculosis or not. He studied these cases, as people ought to study them, always in proper coöperation with a social worker. He made his own careful observations in the dispensary. Then he employed a social worker to study the girls in the home and outside the home, following up in their lives and personalities the tangles of disease. His total result was that he could not say in any given case that industry had produced a single one of the diseases which he found, though he was not willing to swear that it had not done so. He found that a certain number of these girls, in their perfectly natural search for recreation, were running around the streets or elsewhere until the small hours of the morning. That is an obvious factor in producing a diseased state. It is not that we want to blame people for seeking recreation; but the results cannot also serve as evidence of the harm done by industry, except in a very wide sense in which we might say that industry does harm because it does not provide for recreation, which is, I think, an extreme view.

Dr. Lee's social assistants found that a good many of these girls had no habits of eating. It was not that their habits were so bad, but that they had none of any kind. Sometimes they ate very well and sometimes they did not. Then he found, as of course one would know that he would, the psychical factors in many of these cases – their love affairs and other worries which were often much more deleterious to their health than their habits of sleep or food or even their industrial conditions.

When, therefore, one tries to consider industrial disease, one must realize how complex a thing it is, how essential it is to go beyond the inspection of the factory and to study all the conditions of the lives of the people that one is concerned with.

In a big Western American town that I visited recently, where the automobile tire industry was employing some fifty thousand hands in factories, the most obvious cause for ill health was the tremendous congestion in that town, and as a result the fearful state of the available lodgings. Again most of the factory hands were foreigners; very few of them spoke English; they were wholly dislocated from normal family life, from any connection with their own countries and from their own previous interests. That is in itself a dangerous condition for hygiene as well as for morals. Factors like that must be taken account of when we want to help anybody to get free of the troubles, the fatigue or strain or debility, which we are apt to attribute to industry.

We are keen, and rightly keen, to find and to abolish poisons, such as lead, such as phosphorus, such as carbon monoxide. We ought to be keen to study poisons of that kind, and more interest has lately been concentrated upon them through war work and war industries than ever before. But there are moral poisons which we do not notice or mention. Monotony, for instance. Monotony is not altogether a horrible or hateful fact. Most of us want some monotony in our day. We want a rhythm and a certain recurrence in it, whereby our work comes to seem familiar to us and we do somewhere near the same thing each day. There is rest in that. But how much we need is individual; the dose of monotony, the amount that is good for you and for me is limited. People often get too much, and when they get too much, then it is a moral poison. One of the most appalling things, I think, is its effect upon the mind. I have often wondered whether I ever had or ever would have any mind again, when I have come to the end of such a day. Any one of us, of course, can duplicate that experience, and it certainly ought to make us think hard about the lives of manual workers whose days are quite likely to be like that right along. At the end of such a monotonous day a person may be pretty reckless, may feel that he does not care what happens to him. I have met that in a great many histories. It is not so much that monotony makes machines of them as that it makes wild animals of them.

Another moral poisoning is the sense of injustice, a sense that it is not right that somebody else, whom the Lord did not make very different, has so much more of money and opportunity and happiness than the person himself has. It is altogether a secondary question to discuss whether that is true or not. I do not myself believe that the rich are any happier than the poor. On the whole, I think the evils of money are just as great as the evils of poverty. But the sense of injustice is often just as real even though the reasoning on which it is based is wrong; and the sense of injustice is a moral poison which breaks down health and spoils happiness.

Can we do anything about it? Sometimes. By going over the details of people's lives, by telling them stories of other people's lives, by confessing a great deal about our own life, we can help people to see things differently. When I was speaking of pains in the region of the heart I said that one of the most important things that one could learn is to distinguish between the pain and what we think of it. The pain often cannot be changed, but our interpretation of it often can. The patient often suffers chiefly from what he thinks of the pain, and when he knows that the pain is not due to heart disease and that he probably will live to be a hundred, that particular form of suffering leaves him. So in this matter of the sense of injustice, the causes for suffering may be unchangeable, but if we can change the patient's point of view we may help him a great deal.

A greater evil, I think, than any I have mentioned, and one that we are almost powerless to attack, is lowered sex standards, which come from the crowding of people of all ages and both sexes into industry. As in the housing problem, it is the moral rather than the physical side of crowding that is most serious.

That is why the visiting part of social work seems to me so much the most important. The important part is what we hope goes on in home visits, when the social assistant meets people where they will talk as of course they cannot talk in the dispensary.

PART II

Social Treatment

CHAPTER VIII

SAMPLES OF SOCIAL THERAPEUTICS

1. Order in social treatment

The principles of linkage embodied in the work of the home visitor, in her cooperation with doctors and other social workers, and in good history-taking which avoids the fallacies of the catastrophic point of view, take on a little more impressiveness when we consider what a widely general law that "linking-up" law is. It is the essence of science; indeed, it is the essence of things still wider, for it is the essence of order.

There is an old phrase that "order is heaven's first law." It certainly is an impressively universal principle. How universal this linking-up process is, and how it applies to all possible situations medical and social, can be made to stick in our memories by the phrase, "In view of this, what next?" This is a prosaic and unimpressive-sounding dictum; but with some trivial and some important illustrations I can show that it is really useful.

1. A terrier dog is watching a rat-hole: in view of this, what next? – a question full of importance for the dog and for the rat.

2. A cobbler is working on his shoe: in view of what he has already done upon that shoe, what shall he do next? The value of the shoe, the value of the cobbler's working time, depend upon his seeing truly, and then, in view of that vision, doing whatever is next called for by the conditions of the shoe which he is dealing with.

3. As we go down the bill of fare of a restaurant, we say, "In view of what I have eaten, what next?" Presumably there is a method, an order in our madness.

4. We may have known, in the course of our lives, a few people who, when we ask them a question, think before they answer. These are the people who habitually say to themselves, "In view of this question and of the truth which I should speak, what words should issue from my lips?"

5. The whole science of logic is the science of seeing truly: in view of certain premises, what is next? What follows and must follow, if we are to be logical.

6. Anybody who has got to a certain point in his profession says, "In view of my successes and my failures thus far, what is the next thing for me to do?" One can say the same, and I imagine that most people have often said it to themselves, in relation to friendships: in view of my present affection or dislike for that person, what next? We have come through the world's most gigantic war: in view of this, what next?

7. I tried to exemplify this principle also in our medical and social history-taking. Our histories should be orderly. There is a thing that rightly comes first and a thing that, in view of this, should come next.

8. When the musician composes or plays, he is guided in the writing-out or in the instrumental expression of his musical idea by his consciousness of the whole piece – what is done and still to be done. "In view of this whole," he asks himself, "what notes come next?"

9. When a man prays he says to himself, "In view of my sins and of God, what next?"

It appears, then, that the most trivial and the highest things that go through the human mind, if they go right, follow that formula, because it is simply a way of putting truth in order, and because order is as fundamental to a human mind that is working right and not wrong, as anything can be. The catastrophic point of view, on the other hand, is the point of view of disorder, the belief that things happen "as the result of accident," come upon us without order, were never in view beforehand, occurred for no known reason.

The principle of order is also closely knit to the principle of independence or integrity, which we want to achieve in social work when we give. Physically we want the person to be independent, not depending upon a drug, not needing to be jacked up by a stimulant, not dependent as a sick man is dependent, on nursing, special diets, and long rests. In the economic field we try to avoid making a person depend on a crutch, a support, a pension, which atrophies his economic powers instead of developing them. At least we desire not to weaken them. We want to give and build, to give something that will go on by itself to make him independent of us.

But independence is not altogether a good phrase. No human being, linked up in a world-order as we all are, is ever independent. What we mean by that not altogether satisfactory phrase is that we want to be dependent only upon something that we can rely upon, only upon permanent, central, orderly powers of the universe. Physical independence does not mean independence of food or of rest; one soon comes to the end of his tether if one attempts such independence. Dependence means hanging. We must all hang. But we want to hang upon something that will not let us down, upon food, air, warmth, exercise, rest, such as are always available in an orderly life, or should be.

So in the economic field, no man is economically independent or ever will be. But we want his powers knit into an orderly system that is not dependent upon a protective tariff, on somebody's whim who pays his salary, or on political "pull." We want people to be independent in the sense that they get their living by connection with a well-ordered economic system. Even then, of course, we are not independent. A planet may run into us and we shall then be wrecked in spite of the fact that we are not dependent upon charity or a protective tariff.

Obviously literal independence is also impossible in moral and personal relations. We are never independent of society, never capable of going it alone. The only question is, On what do we depend? Do we depend on one person, or one particular kind of entertainment or stimulation? Or can we find our food in any of a vast number of places and persons which in the natural order are fairly sure to be available? Or in the absence of all finite persons can we find our food in God? That is the fundamental question in relation to personal independence. Its answer states the degree in which our personal history is orderly and not catastrophic.

If one is habitually trying to order his own life in this way, the principles by which he lives will guide his attempts at social treatment and give him continuity and steadiness.

2. Presence of mind in social treatment

All our diagnostic duties, whether as doctor or social worker, are part of our search for truth, physical, economic, mental, and moral, as the basis for medical-social treatment. I have used again and again the figure of chains, each of them starting with the individual's present misfortune, need, or sorrow, as a central link, and radiating in different directions as we trace out the relevant physical and economic facts, the chain of the patient's relationships to family and friends, some of whom he is apt to forget, and finally the chain of mental and moral causes which lead up to the present moment. I believe in that method with all my heart. I also believe it can be employed so one-sidedly, so exclusively, as to spoil social work. The criticism of social work which recurs most often and most justly, I think, is that we are not human enough, not big enough people to do social work, that we have not vision, that we get into mechanical and routine methods which spoil the whole adventure. I know that this is true. We fail because it is difficult for us to drive in span two strongly contrasted ideals only one of which I have yet laid great stress on. Truth and the following out of the links of truth, physical, economic, etc., is a process which we might call looking for the background of the fact that presents itself close to you. We need to see that background. We must not get our perspective distorted. It is the doctor's commonest fault, that he sees only the disease that is just now before him, and nothing of its "background," economic, mental, or moral. Hence he does not make a fundamental diagnosis or prescribe fundamental treatment.

We need in our dispensary work to find truth. Yes; but we need to find joy also in our work; we need to see the foreground. We do not want to have attached to us the stigma and the weakness which we think of in professional work. We are accustomed to believe that professional philanthropists find no joy in their work, which they do as a matter of routine, for pay, without vision and without a sense of the unexpected and momentary values which are precious.

The process of tracing chains, of looking off and away from the patient's present pain, sorrow or poverty for its causes and relations, tends to make us look over the head of the present fact. We all know people who always look over our heads when they talk, and we know how little they get into touch with us. We must not stare into the physical, economic, or mental background so constantly or so fixedly that we cannot see the present fact before us. That is preoccupation. I have often accused myself and my assistants of going about their work with a care-worn air, because we are thinking so much of the fine, helpful plans which we are making and the truths which we are going to discover, or of bothersome details which we have not got round to finishing up. But we shall do no good in the long run unless we enjoy our work. There may be some professions where a man or a woman can be of use who does not draw joy from work, but certainly social work is not such a profession. We have with Stevenson the duty of happiness: