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

The physical analogies of these mental faults are interesting, I think. A person who has too great physical shiftlessness gets a bed-sore. Healthy people when they have lain in a certain position in bed for a time feel a discomfort and therefore instinctively turn over. We shift ourselves now and then in our chairs as we sit, and thus we relieve pressure which in turn would produce injury. But in chronic illness the patient sometimes lies in one position so long that he wears out his tissues till the raw flesh or even the bone is exposed. That is just as true on the mental side of life, true of us all.

There is nothing I hate more than seeming to take a pharisaical attitude in our social diagnoses. All of us probably have failed to shift when we should. We might be more useful to-day if we had shifted more wisely. Still, we are getting along somehow, and some other people come to us for advice because they are even more shiftless than we. I never yet made a social diagnosis in anybody that I could not make also in myself. It is only a question of degree.

Industrial shiftlessness is an obvious example. A person gets into the wrong job and then does not get out of it. Most people choose their professions by the most irrational process or lack of process that can be conceived of. When a boy is ready to choose a profession, does he look around him, study the alternatives, and select one? Not at all. He does what the next man does, what his father did, what he happens to have heard most about. This is true whether people are pressed for money or not. They choose their job for no good reason; they are thrown into work by something pretty near to "chance." But they are often saved from the full consequence of their mindlessness because they shift. They shift either within the job or into another job. I got into medicine first on the laboratory side, began by writing a book on the blood and doing an unconscionable amount of work in the laboratory. It was wrong. I was not fitted for it, and luckily I knew enough to shift. Social medicine was what I wanted. So many a man shifts within his profession. That is why the wrong choice made at the start does not always get people into serious trouble. But the chronically shiftless man remains immobile. He does not know where else he might be besides the place where he is. So he stays where he happens first to fall, gets bitter, hard, poor, drunken, all because he is in the wrong niche.

One sees racial shiftlessness when people cross the ocean and try to take root in a new country. This racial non-adjustment has very tragic results. We see it, for example, in the Armenians in America who have come from a civilization two centuries back, and cannot jump these two centuries. Hence comes the breaking-up of moral and industrial standards because they have come suddenly into a civilization to which they cannot adapt themselves.

A third kind of shiftlessness one might call domestic shiftlessness. An English servant girl married an Italian fruit-dealer. She was taken home into his Italian family in Boston and had to try to fit herself to Italian customs. She and her husband got along excellently. But it was very hard for her to understand the shifts which she must make in order to adapt herself to his family. She was an old patient of mine, and after her marriage she brought her physical troubles to me, quite ignorant of the fact that she was worn out by family friction. My efforts were devoted chiefly to teaching her Italian customs and defending her husband's family to her. I did not know any too much about it. I had myself to learn the subject which I was set to teach, as one does so often in social work. I had to find out the meaning of many queer Italian customs in order to interpret them to her. At first she had no idea that when one crosses a racial line one must shift considerably. But she has finally learned it, and she is happy now.

I have spoken of two social deficiencies – ignorance and shiftlessness. I believe there are very few cases in the social worker's domain which fail to show some sort of ignorance, some sort of shiftlessness, as an element in the social diagnosis. Such diagnoses must usually be long. They are complicated and cannot often be expressed in one word. The word "feeble-minded" and the word "tramp" ("Wanderlust") are among the rare examples of a brief social diagnosis which explains all the physical, economical, moral misfortunes which one finds in a person. But generally one cannot find such a phrase. So one makes a number of statements as one makes a list of many diseased states in the different organs of the human body. I do not regret this. The best medical diagnoses, those made after death, contain from thirteen to seventeen items on the average. One of my chief tasks during the last fifteen years has been to study diagnoses made after death and compare them with those made in life. The real diagnosis as it is revealed at autopsy contains on the average thirteen to seventeen items. The diagnosis made during life contains often but two or three items. This brevity is characteristic of the very partial truth contained in our clinical diagnoses. Therefore I do not altogether regret it when I see in a social diagnosis a long series of items referring one after another to the main departments of human life. When we are making our medical diagnoses we try to say what is wrong with the heart, the arteries, the kidneys, the stomach, etc., in each patient. So in making our social diagnoses we ought to go through some such list as I have begun to give here. Is ignorance a factor? If so, where? Is shiftlessness in this particular case a factor, and how? There are certain organs of the human soul which one can go through and check up. (Anything the matter here? Anything the matter there?) as one goes through the bodily organs to make a medical diagnosis.

Instability

The shiftless person, in the sense in which I define the words, is the person who does not move often enough, who rests too long on one particular set of habits so that he allows the world to move away from him while he is left high and dry. Or he allows himself to get fixed in one little set of habits and becomes a person with one idea. That is shiftlessness, the person who cannot accommodate or adapt himself.

The opposite of this is instability– the defect of the person who shifts too often, who cannot stay in one field long enough. In the physical field this applies to people with motor nervousness, people who never can keep still. But we are more interested, of course, in the psychical side of it. Any piece of work can be said to have three phases, something like the phases that Sir Almoth Wright has emphasized in his writings on immunity. We have first a stage of interest and elation, then a slump, a depressed or negative phase, as Wright said, a stage when things are not going smoothly or when organization seems endlessly complicated. Then is the time when, if we are of an unstable type, we throw up our work. The unstable person cannot believe that the undertaking is going on and up to a third or positive phase, which in the end will be on a higher level than the phase in which we started. Normal people habitually expect these three phases in every human undertaking. They foresee the negative phase before they get out of the first one. Hence they are not astounded or bitter when the inevitable slump comes in the second phase. But the unstable person breaks off at that point and tries something else. It constitutes one of the most serious blots in any one's record if we find that he has changed his work four or five times already. "Why did you leave your first job?" we ask, and, "Why did you leave the second one?" There is never a satisfactory reason for so many changes. These people are rolling stones; they gather no moss. They never accumulate skill, power, and money as the result of having stuck long enough in one place.

We see mental instability also in temperament, in spirits. Many people get into trouble because they do not realize their own "negative" and "positive" phases. Most people, we say, have their ups and downs. But if we take our ups and downs too seriously, then we may talk about suicide as so many people do. It is in these emotionally unstable phases that people give offence to others, quarrel with their families, lose their jobs.

Instability is much less important in the adolescent stage. Many a parent has been in despair over his adolescent children. "Nothing good ever can come out of that boy. He is too unstable," the parent is apt to say. Yet great good often does come out of such a boy, simply because he grows older. Such a boy is generally between thirteen and nineteen. Tremendous physical changes are going on, which are rather more than he can manage. Hence he becomes for a time unreliable, capricious, moody. There is almost no degree of mental instability and unsatisfactory conduct which may not wholly disappear as we get past the adolescent stage.

On the other hand, the older a person is the more serious the outlook in a case of instability. A woman in the vicinity of sixty drifted into my hands some years ago, after having been the round of doctors whose diagnosis was essentially instability. Although I labored very long and prayerfully with that individual, I cannot say that I produced any considerable effect.

Remember always the possibility that such instability is due to drugs. Among the most unstable people are the morphine-takers, and because that has among other symptoms concealment and lying, it does not easily come to light. In the evening the morphine-taker is full of prowess, is full of hope, ready to make engagements for nine o'clock the next morning. But he almost never turns up for that engagement the next morning. This morning depression is common also in many other diseases, such as neurasthenia and that rare disease, anemia. The anemic patient has a hard time getting up in the morning, but it is the fault of his red corpuscles and not of his character.

Another phase of instability is abnormal suggestibility, abnormal openness to influence or "suggestion" in the psychological sense. I cannot count the number of fond but foolish mothers who have said to me about a child, "John is a good boy, only he is weak. He gets led astray by his companions." Everybody is and ought to be somewhat suggestible, normally suggestible. The man who is not suggestible is the person with a monomania, who can see nothing but his own view, is stupidly attached to one set of ideas and so cannot learn. But one can easily be too suggestible. Over-suggestible people run after every craze, are impressed with each new religion, or are tremendously excited with each new friend and think of each new experience: "Ah! This is what I have been looking for all my life. Nothing else matters." This is especially common at the adolescent age, but it is a danger for all of us, men and women of every age. We get carried away by popular crazes, by influences, by suggestions, so that we cannot remember the good that there was in our previous beliefs and interests. If so we are mentally unstable in this respect.

We see in every dispensary many cases of abnormal physical suggestibility, people who think that they have caught every disease that they hear about. Among medical students and nurses in training there are always some who become convinced that they have the disease which they have just been studying in the hospital. In the social assistant's work as a taker of histories she must remember that. Highly suggestible people give curiously misleading histories because they become obsessed with the idea that they have some terrible disease. There are three examples of abnormal suggestibility which in my experience recur with especial frequency: heart disease, cancer, insanity. People are amazingly prone to fancy that they have heart disease. If they have any symptoms in that part of the body where they are taught to believe that the heart resides, or if they have heard anybody talk of heart disease, or especially if anybody whom they know has recently died of heart disease, there are many people likely first to believe that they have heart trouble, and then to have actual symptoms which they attribute to heart disease. They often say nothing about this fear. That is just why it is so essential for social workers to dig it out in the course of their history-taking. When people are afraid of a thing they are especially apt to conceal that fear.

Insanity is feared, I think, even more often than heart disease. Every doctor is consulted by people who are sure on most trifling evidence that they are going insane. We hear people say, "Why my mind must be failing, for I read down a page and when I get to the bottom I cannot remember what I have read." Or, "I am losing all memory. I met a man recently suddenly and I could not remember his name." These two normal fatigue-products – failure of attention or failure of memory – often make people think that they are going insane. A third result of fatigue which often frightens people is the sense of unreality. Such people say, "I seem to be numb. Things do not seem real to me. I talk to people and I wonder if it is not all a dream. Am I not going crazy?" There have been interesting essays written by French psychologists on the "Sense of the Déjà Vu." For a few hours whatever we say or do seems a repetition; we have said, done, heard all that before we fancy. It is a very disquieting sense. But it is usually nothing but fatigue.

Cancer I suppose is the most dreaded of all diseases, but one of the most unnecessarily feared. Patients may appear at the dispensary for most trifling pains or stomach troubles, troubles that all of us would disregard, and when we inquire why it is that they have come, sometimes a long distance and at considerable expense, we find out that it is because they have recently heard or read something about cancer, or remembered that there is cancer in the family. We cannot be too careful to tell people that cancer is not hereditary. People are apt to think it hereditary, but this is one of the medical fallacies that we should all of us do our part to eradicate from the public mind.

I will mention one or two other common groundless physical fears. We should teach people that if they have a pain in the left side of the chest the chances are about nine out of ten that the heart is perfectly sound. If they have a pain, as they say, "across the kidneys," the chances are ninety-nine out of one hundred that the kidneys are perfectly healthy. The newspaper advertisements of charlatans do all they can to make people think that a pain in the back must be kidney trouble. We must fight such poisonous influences.

FOOTNOTE:

CHAPTER V

MENTAL INVESTIGATION BY THE SOCIAL ASSISTANT (continued)

Fears and forgetfulness

It is not merely because of a doctor's mental habit that I speak of life in terms of diagnosis and treatment. For though those particular words are medical, any part of life can be thus conveniently summed up. One tries to find out the facts about some region of life in which one works or plays, fights, loves, or worships (diagnosis), and then one tries to do something about it (treatment). If one makes a friend one tries to find out something about him and then to treat him accordingly. If one comes to a new city one tries to diagnose its geography and to direct one's self accordingly. If there is anything not included in that set of phrases about the behavior of the human being towards the world, I do not know it. Therefore it seems natural to sum up social work also in terms of diagnosis and treatment.

I referred in the last chapter to social ignorance as a possible item in a social diagnosis. I meant to recall those parts of a person's outfit for dealing with life in which he is deficient because of ignorance, industrial ignorance, or educational ignorance, or physical ignorance. I went on to recall two other mental deficiencies or sources of incapacity, shiftlessness and instability.

In this chapter I want to exemplify fears as sources of inefficiency or deficiency, as causes of sickness, economic dependence, and unhappiness. Christian Scientists define almost all human ills in terms of fear. That is extreme. I know many people who do not seem to suffer from any fears whatever. I sometimes wish they suffered from a few more. I should not say at all that fears were the cause of all evil, or that the fearless person was perfect. Still, fear is a very great factor in social ills. I mentioned in the last chapter the three commonest physical fears as met with in medical practice: fears about the heart, about cancer, and about insanity. I sometimes feel that I will never let a patient go from me without saying, "You have not got heart disease, you have not got cancer, you are not going insane," even if he came to me for a cut forger or an ingrowing toe-nail. No one but a physician can appreciate how many people dread one of these three diseases.

But about physical fears as about other fears, the most important thing to know is that they are disabling, crippling, in proportion as they are not recognized, or only semi-conscious. I am one of those who believe that one should not talk about unconscious consciousness, although synonymous phrases are very popular among modern psychologists. But we all of us know that a large part of our mental life is in a half light, neither in full consciousness nor in oblivion. These half lights may be quite harmless, but often they are especially mischievous. Our vague, undefined experiences produce the fears which trouble us most. Fear of the dark and fear of ghosts exemplify this rule, but it holds just as well for fears about disease.

Partly because of this vagueness, people often do not tell the doctor about their most serious fears. One has to go out of one's way to reassure people about their fears, because they so often conceal them. Of course there are exceptions to that. People come to a doctor often for nothing else except fears. But that is not true of the majority of patients nor of those suffering the most harmful and haunting fears. It is for that reason that I am trying to give some idea of where to look for facts that do not come spontaneously to you as patients tell their stories. If the social assistant has not the medical knowledge or the authority necessary to reassure the patient, she can bring him to somebody who has. At the present time there is no piece of medical service more clean-cut and satisfactory than the power to reassure a person about an illness that he thinks he has, half-consciously fears he has, and therefore tries to banish from his mind. To discover groundless fears, then, fears of poverty, of ridicule, of marital unhappiness, and to cure them by bringing them to light, is the task that I think every social worker should consider as part of her job, in so far as she is connected with medical work, as she must be always so far as I see.

It is astonishing how often people are relieved by knowing a truth which we shrink from imparting. I recently examined at a Red Cross Dispensary in Paris an old lady in face of whose troubles I was a little daunted when I came to carrying out the principle of telling the truth as I have long preached and tried to practise it. She had a chronic asthma. She suffered a good deal from it both night and day, and I could not see the slightest prospect that she would ever be any better, because in people past middle life asthma is for all intents and purposes an incurable disease. When I had finished examining this old lady and faced my task of telling her the truth, I did not feel comfortable about it at all. But I gave her the facts. The outcome was striking. "Oh, yes," she said, "I rather thought that my asthma is incurable. I did not expect that you could do anything to cure it. All I wanted was to make sure that I had not got tuberculosis on top of it." About this fear of tuberculosis she had said not a word to the history-taker. It came to light quite unexpectedly. But when I assured her that she had not got tuberculosis on top of her asthma, she seemed quite contented and hobbled away very happily, puffing and blowing as she went.

That illustrates the relief that comes to people from finding that a deeper-concealed fear is groundless. Again and again I have pushed myself up to the task of telling people what I knew they had to know, and then found that instead of prostrating them I had relieved them of torturing uncertainty.

I will relate an experience which shows how far this truth extends. An elderly lady, whom I had known for nearly twenty-five years at the time this incident happened, was in the habit each spring of coming from New York, where she lived, to Boston, where she used to live, to make a round of visits among her friends. While still on one of these visits she telephoned me one day to come and see her. As I entered the house where she was staying, I was met, as I have been met so many times, by a member of the household, who, with finger on lip and every precaution for silence, beckoned me into a side room and proceeded to tell me "what nobody else must know." It was something like this: That my friend the old lady had begun the first of her round of visits about a month before this. On that first visit it had become pretty obvious to her friends that she was mentally queer. She was not a millionaire, yet she was spending and giving away an extraordinary amount of money. She was ordinarily a person of quiet habits and not prone to hurry about, but now she was making the dust fly all the time. She was ordinarily modest. She had now become boastful. The first friend with whom she stayed believed, as people usually do, that it would be dangerous to tell her anything about her mental condition, yet found it impossible to keep her in the house. Therefore the hostess made the excuse that she had a maid leaving and could not really keep a visitor just now. Would my friend mind moving on to the next visit? She moved on to Number Two; naturally the same thing happened there. So the second hostess passed her along to Number Three. She was with Number Four at the time when she called me.

All this was given me in the strictest secrecy in the little anteroom close to the front door. My informant then tried to pledge me not to tell the old lady the truth, fearing an outbreak of violence. But as I had a good while ago sworn off all forms of lying, I refused to make any such promise.

I went upstairs to see the patient. She poured out to me one of the most pitiful stories I ever heard – the same story just given, but from her own point of view. So far as she could see, her friends were all playing her false in some way, or losing their affection for her. She knew that it was not by accident that one friend after another had politely shown her the door. Something was being concealed from her. What could it be? She was really worn out, she said with worry and sorrow about it.

I told her at once the whole truth. I told her that she was insane. I could also tell her truthfully that she would come out of it (as she did), but that I must now take her away from this house, shut her up, and take care of her. "Oh," she said, with immense relief in her voice, "is that all? Is it nothing worse than that? Insanity is nothing compared to losing all your friends." Insanity is one of the greatest of human fears, but for this old lady, as for most of us, there is something still worse – the fear that one has not a friend in the world. Even to know that she was doomed to what most people would consider one of the worst of fates was to her a relief; for there was a worse fear in reserve, and that she now knew was groundless.

The treatment of fears, the only treatment that I know of, is that we face them, look straight at them, as we turn a skittish horse's head right towards the thing that he is going to shy at, so he can look at it squarely. So we try to turn the person's mental gaze straight upon the thing that he fears.

People frequently consult a doctor because they are afraid of fainting, fainting in church or in the street, for example. In such cases I have found it most effective to say, "Well, suppose you do – what harm will it do?" From the answers to this question I find generally that the patients have in the back of their minds, unconfessed, unrealized, the fear that if they faint and nothing adequate is done to cure them they will die. They do not know that people who faint come to just as well if they are let alone, and that all the fussing about that is usual when people faint is useful merely to keep the bystanders busy and not to revive the patient.