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

Especially is this true in the field of visceral neuroses or nervous symptoms referred by the patient to one or another organ – the stomach, the pelvic organs, the bowels – in which nevertheless no evidence of disease can be found. In these diseases English, French, and American physicians alike persist for the most part in humoring and soothing the patient by the administration of remedies known to have no real influence upon disease and designed chiefly to make the patient feel that something is being done for him. This is superficial treatment. It makes no attempt to attack the determining causes of the disease. Whether or not there are any psychogenic diseases, whether or not purely psychical events can be proved to produce the group of symptoms known as neurasthenia, psychasthenia, or hysteria, or whether there are physical causes contributing to produce the symptoms, this at any rate may be said with confidence: that if we are to root out the patient's trouble, if we are to bring about anything approaching a radical cure, we must attack the mental symptoms directly and upon their own grounds, that is, by mental means, chiefly by reëducation. The mental element in these diseases is at any rate the most vulnerable point of attack. It is here that we can most profitably exert therapeutic pressure.

Even in organic disease, such as tuberculosis or arteriosclerosis, it may still be true that we can help the patient chiefly through psychotherapy. There may be little that we can do for his arteries or his lungs, and indeed the incurable destruction which has gone on in these organs may not at the time that we are treating the patient be producing any symptoms. All his symptoms just now may depend upon mental states which we can quite easily influence and thereby cure him of all that at present torments him, though we recognize that the organic malady remains untouched, unimproved. Many a case of tuberculosis suffers chiefly from his fears of the disease or from his discouragement. If we can rid him of his constant dread that the disease will advance or will injure others, if we can give him courage, the natural healing power of his tissues may be all that is needed to bring about the arrest of the disease. On the other hand, even an incipient case of pulmonary tuberculosis may go steadily on from bad to worse, because the patient is constantly fretting and worrying about his own condition, or about the present sufferings of his family.

I remember a case of very early tuberculosis, but recently established at the summit of one lung, but unfortunately occurring in a patient of very active temperament, prone to fume and worry the instant that he was taken away from his work. He was devoted to his family, but as soon as he was aware of his trouble, he could think of them only as doomed to be dragged down by the contagion of his own disease or by the poverty resulting from his own inactivity. Unfortunately, no proper study was made of this patient's malady. No account was taken of his character and temperament. The condition of his lung occupied the whole field of the physician's vision. The condition of that lung demanded for the patient isolation and complete rest in a sanatorium. This was prescribed and carried out. The patient remained in the sanatorium about two months, fuming and worrying constantly. He then refused to stay any longer, left the institution against the advice of his physician, returned to his family, and died about two months later.

Now I think it is at least probable that had we studied the patient's mind as carefully as we studied his lung in this case, his life might have been saved. But the physician who made the diagnosis and prescribed the treatment could spend but a few minutes upon the case, which formed but one of many trooping past him in his consultation hour at the dispensary. He had no time for the prolonged, detailed, wearisome studies necessary to win this patient's confidence, to make him feel that he was wholly understood, and bring him to the point when he would let himself be reëducated upon the mental side and receive docilely the advice given him. This work should have been carried out by the right type of social worker. Such a visitor would no doubt have realized that one must compromise to a certain extent with the difficulties of the patient's temperament. One must adapt and modify the treatment suitable for the average case because this particular patient differs from many others in important respects.

In the first place, he must be made to understand the importance of a correct mental attitude for the cure of his disease, must be taught that his recovery depends to a considerable extent upon his own efforts at self-control and self-education. Next he must be convinced that his family will be adequately cared for during his absence from work. Furthermore, the complete rest in bed which would probably be advisable for him if one had only the condition of his lung to consider, should probably in his case be modified owing to the fact that his mental state makes it impossible for him to rest when he is confined to bed. In such cases one has the outward appearances of repose but not the reality, one clings to the form but misses the substance. What one has prescribed is in reality enforced impatience, enforced restlessness, because one has put the patient under a régime where no result can be expected except impatient struggling against restraint. Such a patient should be allowed a certain amount of work, carefully chosen and supervised, so as not to exercise the larger muscles of the body and thus produce fever, but sufficient to occupy an active mind and to make the patient forget himself. To find such occupation is difficult, no doubt, but it is not impossible. I have seen it done. In the case which I am now considering, no such effort was made. The patient was excessively lonely and isolated in the sanatorium to which he was sent. The doctor's visits were occupied with physical examination and the reiteration of commands that he should stop worrying and remain completely at rest.

Such treatment violated grossly one of the basal laws of medical psychology, which recognizes that no one ever stops worrying because he is told to do so. To give such a command is as irrational as to tell an epileptic not to have convulsions or a choreic patient not to wriggle his hands. Yet this sort of error is constantly committed by physicians who have been well trained to understand the physical changes of disease, but have never concerned themselves to recognize the simplest and most obvious facts about the mental condition of the sick. As I have already said, it is impossible for the dispensary doctor to become acquainted with the details of the patient's malady, or to find out by investigation and experiment how the patient's mind may be made to aid his recovery rather than to impede it. This is the proper task for a social worker, partly because she has more time, partly because she is a woman, and is for that reason more fitted to get into close touch with the patient's mind and to use skill and tact in managing him.

Such studies of the social worker are equally important in the case of the functional neuroses; for example, in the cases where the patient's troubles can be most effectively attacked by ridding him of his fears. Fear plays a dominant role in the sufferings of many cases both of organic and of functional disease. In a recent examination of six hundred and sixty-two young men about to enter Harvard University, it was found that "there were more boys who thought they had a serious organic defect, usually of the heart, and were found entirely sound than boys who thought they were well and had disease." They had been threatened with heart disease by gymnasium instructors or ill-trained physicians. They had in consequence restricted their physical activities and been haunted by the fear that they might by some unusual exercise of mind or body make themselves seriously ill or perhaps suddenly die. Such fears were all the more disastrous in these young men for being only half realized by themselves. It is exactly these shadowy apprehensions, these dreads which dwell in the half light, never quite faced in full consciousness, which torment and incapacitate us the most. Careful physical examination showed that the young men just referred to were free from all disease, and the clear and emphatic statement of this fact rendered a prompt and important service.

But if such fears haunt the students about to enter Harvard College, who are young men drawn from the better educated and more well-to-do classes, we may be sure that fear plays even a larger part in producing the sufferings of patients such as we examine and treat in a public dispensary. For such patients are very apt to be influenced by groundless rumors, panics, neighborhood gossip. They are prone to believe medical lies which they read in newspapers and in the leaflets and circulars sent to them by charlatans. Almost all their medical education comes to them from such sources, and is made up of a mass of systematic falsehoods designed to excite fear and to produce symptoms by suggestion.

Now if it is true that even among educated and relatively self-conscious classes the most troublesome and incapacitating fears are those which are but dimly known to the patient himself, this is sure to be still more frequently the case among dispensary patients. It is especially difficult and especially important, therefore, that their fears should be understood and brought to light through the investigations of some one who has time, patience, and tact to devote to the task. This cannot be the task of the physician who sees neurological cases in the dispensary, any more than the psychological twists and tangles of the tuberculous patient can be followed out by the specialist in tuberculosis who examines the patient's lungs. It is the proper task of the social worker. When she has brought the patient's fears to light, when she understands the details of his malady, she can communicate these facts to the physician. He then can exorcise the unclean spirits with the full authority of his medical position.

Just here one sees a good example of the proper coöperation between the physician and the social worker in the dispensary. Each brings to light certain elements in the diagnosis. But in the end the physician must unite all the knowledge accumulated either by himself or by his social assistants, and thus must be enabled to act for the patient's benefit on the basis of a body of information much larger than he could have secured alone.

The social worker is also an essential aid to the physician in bringing to light the mental torments and errors which result from difficult personal relations within the family. These difficulties can only be understood by one who visits the patient in his home, becomes intimate and friendly with other members of his family, and understands, therefore, the difficulties that may arise from friction, rivalry, jealousy, and temperamental incompatibility within the home. In some cases the patient's friends and companions in work or school must also be understood. In other words, one must take account of the totality of influences in the patient's environment, the physical influences of nutrition, ventilation, clothing, but also the psychical influences exerted upon him by his family and friends, by his own half-conscious thoughts, by his worries, his remorse, his fears. Many a case of stomach trouble cannot be cured by diet or remedies until one can find out what it is that the patient is worrying about and can enable him to combat and subdue his mental enemies. Innumerable vague pains which the doctor cannot attribute to any organic disease, and for which the use of drugs is only too likely to do harm, yield only when one can study and influence the whole extent of the patient's mental, moral, and spiritual life. Nothing can be excluded here. It is utterly unscientific to close our eyes to any human interest no matter how little we may sympathize with it personally. It is one of the facts of the case, and must be understood and allowed for in our treatment.

More and more frequently in America the dispensary physician is consulted about the physical and mental condition of children and adolescents who are sent to him from courts. The judges, especially in our juvenile courts, are coming to realize that their legal training, their knowledge of the nature, the evidence, and the prescribed punishments for proved offences, is only a small part of their equipment if they are to deal with juvenile offenders in such a way as to promote the public good. The legal profession is beginning to realize that the physical, mental, and moral study of juvenile offenders is essential if one is to do anything to prevent their offending again. If penology is to be constructive and reformatory, if it is not merely to represent revenge, repression, and intimidation, our judges must know something of medicine and especially of medical psychology. In this field, as in the field of the functional and visceral neuroses, France has furnished the leaders, but apparently these leaders have been insufficiently followed. The work of Binet in the psychological measurements of school-children's intelligence seems to us in America to have been epoch-making. We recognize its limitations, we recognize that in its details it cannot be universally followed. But we have taken up the suggestions and the method of Binet, and gratefully acknowledging our indebtedness to him we have tried to carry these suggestions and methods much further, to apply them to the needs of older children and to the examination of those who cannot read and write. Binet's tests depended altogether too much upon the use of books and upon linguistic facility. Yet with some modifications they seem to us in America to be of the greatest value, and in the remarkable book The Individual Delinquent (Macmillan Co.) by Dr. William Healy, of Boston, and in the books of his associates and followers, the science of medicine and medical psychology are intimately interwoven with the investigations and reports of the social worker.

In the first of the books to which I have just referred, Dr. Healy presents in detail the cases of over three hundred children who were sent to him as a physician and medical psychologist by the judge of the Juvenile Court in Chicago, who requested Dr. Healy to aid him in his legal treatment through a medical and psychological study of each case. Dr. Healy with his corps of assistants and social workers studied in each child the physical condition, especially the presence or absence of defects of sight and hearing, and the mental condition carefully measured by tests based upon those of Binet, but extended considerably by Dr. Healy himself and by others. But he adds to the facts thus ascertained a careful investigation of the child's social environment, both physical and psychological; that is, of all the influences – hereditary, domestic, economic, industrial, and personal – which have contributed to lead the child into crime. The influence of other boys and girls of the same age, of associates in work or school, is investigated; also the good or bad example of parents, the amount and quality of schooling, and the presence or absence of religious instruction.

All these latter investigations are carried out for Dr. Healy by social workers. Their results are then pooled with those obtained by him after the physical and psychical examination of the child at the dispensary.

One sees, then, that Dr. Healy and the other Americans who have followed him in this field, insist upon covering in every case four classes of facts:

(1) The child's physical condition.

(2) The child's mental condition.

(3) His physical environment.

(4) His mental, moral, and spiritual environment.

All this investigation is necessary because it is now recognized that crime may be committed because the child is an epileptic; because he is feeble-minded; because he is strained and tortured by defects of sight and hearing; by inability to keep up in school on account of these defects; because he is abnormally susceptible, under the influence of comrades, cinema shows, and sensational literature; because his inheritance, his education, or his home training has been defective or bad.

Since there is no reasonable doubt that physicians and judges will more and more coöperate in the study of offences against the law, and will more and more need the assistance of social workers to complete their studies and to carry out the reforms which those studies suggest, it can easily be appreciated that the social workers need to be familiar with the methods and results of psychological examination in this field of work.

Mental diagnoses in social work

The idea that social work necessarily concerns the poor is wholly wrong. It concerns the sick; it concerns the tuberculous; some of the sick and some of the tuberculous are poor. Others are not. The State provides dispensaries for tuberculosis, and the people pay for them out of the taxes. Hence all the people feel that they have the right to go there and that they are not in any sense accepting charity in going there. But social work is done in all these dispensaries. Thus the connection between medical and social studies is tending to upset the old idea that social work is necessarily concerned with poverty, and that economic studies are the main part of it.

In America our leading ideas about social work (formerly called charity), came originally from England and from the studies of English economists. Hence to a considerable extent economic considerations have governed the history and evolution of social work even up to the present day. Economists and people interested especially in political economy have studied, practised, and spoken and written upon these subjects, and all who are governed by the traditions inherited from England are still obsessed by the idea that money and money troubles are the gist of social work.

Nobody should turn up his nose at economics. Anybody who is careless in money matters is sure to come to grief. But in my medical-social work, which has included a large number of cases where poverty existed, I have almost never found the economic trouble to be the essential one. Economics is everywhere present, everywhere subordinate. That is an adaptation of a saying of the German philosopher Lotze: "Mechanism everywhere present, everywhere subordinate." The idea applies also to economics which has many qualities in common with mechanics. I shall therefore lay especial stress in this book, not upon economic but mental deficiencies, which in most cases seem to me more fundamental than economic need or physical weakness.

A considerable portion of all social diagnoses should contain the word ignorance. I wish to distinguish ignorance from moral fault. It is true that somebody's sin, somebody's evil-doing is the fundamental thing in the social diagnosis of many cases. I have never yet studied carefully a case involving social work without finding some moral weakness as an important element in the trouble. Moral elements always enter into the study of a case of social work, but they are often not the main element, often subordinate.

Ignorance, of course, is permanent. If we were not ignorant we should never progress. Ignorance therefore does not necessarily mean culpable ignorance, but still it may be the keynote to the trouble in which any of us finds himself. Consider industrial ignorance, ignorance of where best to turn one's forces. It would be impossible to say that any of us is free from that. Are we perfectly sure that we have found the place where the Lord intended us to work? This lack may not be such as to bring us into trouble. It may not force us to seek social aid. Yet the lack of a clear idea about where we ought to be working, how we can earn the most money, do the most good, and be happiest – that is a deficiency that none of us is free from.

Industrial ignorance has been the ultimate diagnosis in some of the cases that I have studied. The patient is an industrial misfit. He has not found his niche. Perhaps there is no niche existing for him. Some people seem to be made for another planet or another century. Evidently, then, conception of an industrial misfit is wide, perhaps vague. Yet it often dominates the economic situation. Your patient perhaps cannot earn his living because he is working with only about one quarter of his powers, and that the least useful quarter. That with which he is trying to earn his living may be a mere superficiality. Half the women that I know in industry are working with a wholly superficial part of themselves, unconnected with any of their deepest interests. That is less true of social workers than of any other body of women. They often can put the best of themselves into their work. But many women in industry, in business, hate it. They may be earning enough, but are unhappy and unsatisfied, because the powers with which they were meant to labor for the service of their kind are not being used at all.

Medical ignorance: A quarter, perhaps, of our task as social workers, is medical instruction, the breaking-up of medical ignorance. Most well-trained physicians of the present day do not believe that many diseases can be cured by medicine or by surgery. We do not have great confidence in chemical, physical, or electrical therapeutics. We believe that when sick people are helped by a medical man or a social worker it is because they have learned something of what we call how to live, a large term which we usually limit to mean how to look after their physical machine.

As I talk with supposedly educated people, I am amazed to see how little people who have lived forty or fifty years in the same tenement of clay have learned about that structure. I do not mean that everybody ought to study physiology. I mean, for example, such a simple thing as how to rest. One cannot rest just as somebody else rests. We have individual finger-prints, no two alike, and individual hand-writing. So we have – and should have found – our own way of working and of resting, which is probably as individual as our finger-prints. But we follow each other like sheep.

The instructions we give to a tuberculous patient are needed because of his medical ignorance or that of others. I once received a wonderfully touching letter from a middle-aged tuberculous lawyer who finally learned the medical facts necessary to save his life through reading a popular magazine. He was being treated for tuberculosis, about as badly as a human being could be treated, but he did not know this. He had gone to the best doctor in his vicinity. Through reading in a popular magazine an account of a medical conference on the treatment of tuberculosis he finally learned the truth and cured himself. Medical ignorance in relation to diabetes, to stomach trouble, to venereal disease, to heart disease, it may be one of our tasks to remove before inculcating the régime needed in these troubles.

Educational ignorance, ignorance of proper institutions and methods to give a man the power which he needs, is often exemplified in relation to industrial training. One sees people in industry who could do a great deal better work if they had better training. But they do not know where to get it. In many cities there are scholarships and funds for people who show ambition to be better trained. Educational ignorance, then, as well as industrial and medical ignorance, may bring people into economic trouble, even into physical trouble. Such people often turn up at a dispensary asking the doctor merely to cure a headache or a stomach-ache. Yet if the doctor is wise he will find this other trouble hidden in the background.

Obviously ignorance as a cause of trouble is a historic, not a catastrophic, cause. Ignorance does not happen suddenly. Its bad results accumulate gradually.

Shiftlessness

Another mental element in social diagnosis I call shiftlessness, in a particular sense that I want to define. Not shiftlessness in the sense of a general moral accusation, but as a failure of adjustment – maladjustment, due to shiftlessness in the sense of an inability to shift when there is a need for it. Professor Edouard Fuster[1] has spoken of social treatment as consisting almost entirely of helping people towards a better self-adjustment to their actual or attainable environment. People often make a failure of their lives because they do not shift when the proper time arrives. There are also people who shift too often, on the other hand. I shall speak of that later.