Social Work; Essays on the Meeting Ground of Doctor and Social Worker
by Richard C. Cabot · English · Gutenberg #49545 · 318,220 chars · public domain (US)
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Title: Social Work; Essays on the Meeting Ground of Doctor and Social Worker
Author: Richard C. Cabot
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*** START OF THE PROJECT GUTENBERG EBOOK SOCIAL WORK; ESSAYS ON THE MEETING GROUND OF DOCTOR AND SOCIAL WORKER ***
Books by Richard C. Cabot
PUBLISHED BY
HOUGHTON MIFFLIN COMPANY
A LAYMAN'S HANDBOOK OF MEDICINE. With Special Reference to Social
Workers.
WHAT MEN LIVE BY.
SOCIAL WORK. Essays on the Meeting-Ground of Doctor and Social Worker.
SOCIAL WORK
ESSAYS ON THE MEETING-GROUND OF DOCTOR AND SOCIAL WORKER
BY
RICHARD C. CABOT, M.D.
[Illustration: Logo]
BOSTON AND NEW YORK
HOUGHTON MIFFLIN COMPANY
The Riverside Press Cambridge
1919
COPYRIGHT, 1919, BY RICHARD C. CABOT
_All Rights Reserved_
TO
MARY E. RICHMOND
WHOSE ILLUMINATING BOOK ON "SOCIAL DIAGNOSIS"
MARKS AN EPOCH IN THE DEVELOPMENT OF SOCIAL WORK
PREFACE
Most writers who disclaim thoroughness are prone to describe their work
as an outline, a sketch, or an introduction. But the chapters of this
book are more like spot-lights intended to make a few points clear and
leaving many associated topics wholly in the dark. Possibly such
isolated glimpses may serve better than a clear outline to suggest the
interest of the whole topic. At any rate, that is my hope.
Part of the same material has been used in lectures given at the
Sorbonne in the early months of 1918 and published by Crès & Cie. under
the title of _Essais de Médecine Sociale_.
CONTENTS
INTRODUCTION: HISTORICAL DEVELOPMENT OF SOCIAL
ASSISTANCE IN MEDICAL WORK vii
PART I: _Medical-Social Diagnosis_
I. THE MEDICAL STANDING, DUTIES, AND EQUIPMENT
OF THE SOCIAL ASSISTANT 3
II. HISTORY-TAKING BY THE SOCIAL ASSISTANT 28
III. ECONOMIC INVESTIGATION BY THE SOCIAL ASSISTANT 47
IV. MENTAL INVESTIGATION BY THE SOCIAL ASSISTANT 66
V. MENTAL INVESTIGATION BY THE SOCIAL ASSISTANT, CONTINUED 96
VI. THE SOCIAL WORKER'S INVESTIGATION OF FATIGUE, REST,
AND INDUSTRIAL DISEASE 112
VII. THE SOCIAL WORKER'S BEST ALLY--NATURE'S CURE OF DISEASE 127
PART II: _Social Treatment_
VIII. SAMPLES OF SOCIAL THERAPEUTICS 151
IX. THE MOTIVE OF SOCIAL WORK 176
INTRODUCTION
HISTORICAL DEVELOPMENT OF SOCIAL ASSISTANCE IN MEDICAL WORK
I
The profession of the social worker, which is the subject of this book,
has developed in the United States mostly within the past twenty-five
years. Probably ten thousand persons are now so employed. It is known by
various titles--social worker, school nurse, home and school visitor,
welfare worker, hospital social worker, probation officer--varying
according to the particular institution--the hospital, the court, the
factory, the school--from which it has developed. But although the use
of these visitors has been developed independently by each institution,
and largely without consciousness of what was going on in the others,
yet the same fundamental motive power has been at work in each case.
Because this is so, we shall do well, at the outset of our study of home
visiting, to get a clear conception of the common trunk out of which
various types of home visitor have come like branches.
Why has such an army of new assistants been called into existence? For
this reason: In the school, in the court, in the hospital, in the
factory, it has become more and more clear, in the last quarter of a
century, that we are dealing with people in masses so great that the
individual is lost sight of. The individual becomes reduced to a type, a
case, a specimen of a class. These group features, this type of
character, of course the individual possesses. He must be paid as "a
hand," he must be enrolled in a school as "a pupil," admitted to the
dispensary as "a patient," summoned before the court as "a prisoner."
But in this necessary process of grouping there is always danger of
dehumanization. There is always danger that the individual traits, which
admittedly must be appreciated if we are to treat the individual
according to his deserts, or to get the most out of him, will be lost
sight of. We shall fail to make the necessary distinction between A and
B.
It is the recognition of this danger which has led, in the institutions
which I have mentioned, to the institution of the social worker. Above
all of her duties it is the function of the social worker to discover
and to provide for those individual needs which are otherwise in danger
of being lost sight of. How are these needs found? In schools,
hospitals, factories, courts, and in the home visiting carried out in
connection with them, one can discern the two great branches of work
which in the medical sphere we call _diagnosis and treatment_.
Thus, in the school, it is for the individualization of educational
diagnosis and of educational treatment that the home visitor exists. The
educational authorities become aware that they need to understand
certain children or all the children of a group more in detail--each
child's needs, difficulties, sources of retardation. This _educational
diagnosis_ is made possible through the home visitor's study of the
child in the home and out of school hours. There follows a greater
individualization of _educational treatment_. The teacher is enabled,
through the reports of the home visitor, to fit his educational
resources more accurately to the particular needs of the scholar, so
that they will do the most good.
In the juvenile courts the judge needs to understand more in detail the
child's individual characteristics, the circumstances, the temptations,
which preceded and accompanied the commission of the offence which now
brings the culprit before him. This is _penological diagnosis_, and the
court visitor or probation officer, sometimes simply called the social
worker, makes a study of the law-breaker in his home and in relation to
all the influences, physical or moral, which may help to explain the
commission of the particular offence which has brought him into trouble.
All this leads to the greater precision of _penological treatment_.
Understanding more in detail why this particular boy has committed this
particular theft, how he differs from other boys who have stolen, the
judge is much more likely to choose wisely those measures of treatment
which in the long run will do most to reëstablish the individual as a
healthy member of society.
In the factory the object of the employer in setting a home visitor or
welfare worker at work is to create the maximum of satisfaction and
good spirit among his employees, whereby each will do his best work and
be as little likely as possible to change his employment. In the old
days, when shops were small and the employer could know his employees
personally, no intermediary such as a home visitor was necessary. The
employer could keep human touch with his men. He could know not merely
the amount of work done by each man, but something of the circumstances
of his life, something of his personality, his adventures and
misfortunes, so that help could be extended to him from time to time
when special need occurred. It is only when the workshop has grown to
the enormous size familiar in modern industrial plants that this
relation of employer and employee has to be supplemented through the
mediating offices of the home visitor.
It is this same process of evolution, the same heaping-up of groups till
finally they become unmanageable, which has led to the employment of the
social worker in other institutions. It is because the schoolmaster must
teach so many that he can no longer know his pupils and their families
individually that he has to employ the home visitor to keep him better
in touch with them. It is because the judge tries so many prisoners that
he cannot grasp and pursue all the detailed characteristics of those who
come before him for judgment that he is compelled to get them at
second-hand from a home visitor.
So finally when we approach the reasons for which the medical home
visitor has come in the better dispensaries of the United States to be
an essential part of the institution, we find that the unmanageable
increase in the number of patients to be treated by the doctor is one of
the chief reasons why the home visitor has become necessary. In the old
days and in country practice especially, it was doubtless possible for
the doctor to follow the lives of his patients individually as
acquaintances, and through many years, to watch the growth and
development of families, to know their members as a friend and not
merely in a professional capacity. He would meet them as a neighbor, in
church, in town meetings, in agricultural fairs, in village sports and
holidays. Thus he would touch the lives of his fellow citizens on many
sides, and when he came to their aid in his narrower professional
capacity he could supplement his diagnostic findings and his therapeutic
resources out of the wealth of knowledge which years of association with
them outside the sick-room had furnished him.
II
But in the evolution of the particular type of social worker who is the
subject of this book, the home visitor connected with a dispensary,
there are other forces besides those described above, other motives
besides that common to the rise of all the types of home visitors in all
the other institutions named. For in the dispensary, not only has the
number of applicants greatly increased, but it has increased because
people realized that there was much more to be obtained by going to a
dispensary than was formerly the case. The development of medical
science and of the resources of diagnosis and treatment which can now be
put at the service of the dispensary patient, has served to attract more
patients there. But these new resources have also complicated the work
of the physician in a dispensary, and made it more difficult for him to
remember each patient and all the details about each patient as the
physical, chemical, psychological, biological facts emerge in the
complex ramifications of modern diagnosis and treatment.
In the old days the dispensary, as its name suggests, was a place to
dispense, to give out medicine in bottles or boxes. The patient
mentioned the name of his ailment, the corresponding remedy was given.
It was a quick and simple business--no individual study, no prolonged
labor was necessary. Moreover, one dealt only with a clearly defined
class, the poor. There was no danger that the numbers applying for
relief would swamp the institution or make it impossible for the
dispenser to do his work properly.
But within the past quarter of a century the dispensary, especially in
the United States, has received a new idea, an access of fresh life.
Largely because it has become associated with universities and been used
as an instrument of medical teaching, the influence of scientific
medicine has begun to be felt there. This influence has enlarged and
remodelled the dispensary in two respects. First it has compelled the
introduction of modern accurate methods of diagnosis, instruments of
precision, _time-consuming processes of examination_, specialization of
labor, and subdivision of function, for the skilful application of these
methods. The dispensary physician is no longer content to treat a
headache or a cough as an entity, to dispense this or that drug as the
remedy for such a symptom. He must discover if possible the underlying
disease, and, moreover, the individual constitution and life-history in
the course of which the patient's complaint now rises for the moment to
the surface like a fleck of white foam on an ocean wave. But how is the
physician to gain this radical and detailed knowledge of his patient's
life outside the dispensary and enveloping the particular complaints for
which he now demands relief?
His difficulties are only increased when diagnosis is complete and he
turns to the labors of treatment. For with the advance of modern medical
science there are left now but few physicians who believe that disease
can often be cured by a drug. It is recognized by the better element of
the medical profession all over the world that only in seven or eight
out of about one hundred and fifty diseases clearly distinguished in our
textbooks of medicine, have we a drug with any genuine pretensions to
cure. What is to take the place of drugs in dispensary treatment? In
hospital patients we have the hospital régime, the unrivalled
therapeutic values of rest in bed, the services of the nurses; but in
dispensary practice all this is impossible. What is to take its place?
For a good many years this question remained unanswered in American
dispensaries, and as a result thereof there developed the pernicious
habit of giving drugs no longer believed in by the physician, the custom
of giving what we call _placebos_, remedies known to be without any
genuine effect upon the disease, but believed to be justified because
the patient must be given something and because we know not what else to
do or how else to satisfy him.
III
It was at this very unfortunate and undignified stage in the development
of our dispensary work in America that we received priceless help from
France, help which I am all the more anxious to acknowledge to-day
because it has not, I think, been fully appreciated in the past. We in
America have not given to France the full expression of the gratitude
which, for her services in the field of medicine, as in even more
important phases of our national life, it is to-day particularly fitting
that we should utter. The timely contribution made by France at this
halting and unsatisfactory stage in the evolution of our dispensaries
came through the work of the great Dr. Calmette, of Lille.
Calmette's introduction of the anti-tuberculosis dispensary as a focal
centre of the fight against tuberculosis contained among other
important provisions the institution of the _visite domiciliaire_. The
functions of the person making this visit were not precisely the same as
those of the social worker whom I am describing in this book, but the
latter may truly be said to have grown out of the former, nourished by
some contributing elements from other sources. So far as I know,
Calmette was the first to see that in the struggle of the dispensary
against this particular disease, tuberculosis, it is essential to make
contact with the home, and to treat the disease there as well as at the
dispensary itself. In Calmette's view the function of the _visite
domiciliaire_ was an outgrowth of his bacteriological training and his
bactericidal plan for treating tuberculosis. The home visitor was a part
of the plan of antisepsis, a method of destroying the bacteria through
disinfection and sterilization of the premises and of the patient's
linen. In America the work of the home visitor in cases of tuberculosis
has been concerned less with the disinfection and bactericidal
procedures than with the positive measures of hygiene, such as the
better housing of the patient, better nutrition, better provision for
sunlight and fresh air, and above all instruction of the patient as to
the nature of his disease and the methods to be pursued in combating it.
But the great debt which we owe to Calmette was the linkage of the
dispensary and the home by means of the home visitor. In America we have
applied this principle, outside the field of tuberculosis, to all other
diseases, and we have broadened the field of work assigned to the social
worker. Nevertheless, the idea was primarily Calmette's.
There was another leading idea of Calmette's which we have followed
first in relation to tuberculosis, later in dealing with other diseases.
Like Calmette we have stopped wholesale drugging, and put our trust in
those scientific hygienic procedures which carry out our knowledge of
the nature of the disease which we are combating. Calmette's measures
have the tone and the point of view of preventive medicine, and of that
sound science which we have learned to associate with the Pasteur
Institute and all that development of medicine which took its rise from
Pasteur.
The focussing of interest upon a single disease which began, so far as I
know, with Calmette's anti-tuberculosis dispensaries, has been fruitful
in many ways. In the first place, it has enabled science once more to
_conquer by dividing the field_, to help humanity by devoting itself to
a single manageable task. Like others of Calmette's ideas, this
isolation of a single disease for group treatment in dispensaries has
been followed in fields with which he never concerned himself. Thus we
have had special classes for cases of heart disease, for diabetes, for
syphilis, for the digestive disturbances of infancy, and for
poliomyelitis. A valuable measure of success has come in each of these
diseases through the concentration of attention, at a special day and
special hour by a special group of physicians and assistants, upon one
disease at a time. We have even used class methods and taught the
patients in groups as scholars are grouped and taught at school.
But there has come another signal advantage in the point of view adopted
by Calmette in his dispensary campaign--the point of view, namely, of
public health and public good. It has freed us from the limitations
contained in the old idea that a dispensary is an institution concerned
solely with the poor. Tuberculosis, of course, like every other
infectious disease pays but little respect to distinctions of property.
From the point of view of the State a tuberculous individual is as
dangerous to others and a cured tuberculous patient is as valuable as a
possible asset to the State, whether his income is above or below a
certain figure, whether, in other words, he is inside or outside the
imaginary group sometimes called the poor. From the institution of
tuberculosis dispensaries with their home visitors in America, the
poverty of the individual ceased to be a necessary badge for admission.
Especially since many of our dispensaries have been instituted and
maintained by the State, and therefore are paid for by all its citizens
in their taxes, any one so unfortunate as to acquire tuberculosis, or be
suspected of it, feels himself wholly justified in seeking help at a
State-maintained tuberculosis dispensary. In this respect, as in many
others, the campaign against tuberculosis has had a value far greater
than its measure of success in checking that disease. It has introduced
methods which were applicable outside the field of tuberculosis. One of
these, as I have already said, was the utilization of the home visitor.
A second was the disregarding of property lines. A third was the frank
and confident reliance upon scientific measures and the relegation of
eclecticism and quackery to the hands of those who make no pretence at
scientific education or honest dealings with the public.
IV
I must speak at this point of another great French contribution towards
the occupation which in its fully developed state we now call social
work. I mean that which at present receives ordinarily the name of the
"OEuvre Grancher." Grancher proceeded upon the same sound
bacteriological foundations which guided Calmette. Since children are
especially susceptible to tuberculous infection (though they rarely show
alarming signs of it till later years), he planned the _separation of
children from the neighborhood of tuberculous parents_ or other
tuberculous persons as an essential measure for preventing contagion. I
am not concerned now with the enormous benefit derived by the forces
struggling against tuberculosis from this insight of Grancher's, nor
with the part which it has played in such success as that fight has
already attained in the United States and elsewhere. What interests me
particularly in connection with the topic of this book, is that the
procedures suggested by Grancher led the physicians who came in contact
with the tuberculous individual in a dispensary to extend their interest
to other persons who did not present themselves at the dispensary as
patients. It is not obvious at first sight how great a transforming
principle is thereby introduced. Hitherto the doctor had been passive in
his activities at the dispensary. He had concerned himself with such
patients as chanced to appear there. He had never taken _the active or
aggressive attitude_, searching for possible patients among those who
had made no attempt to avail themselves of his services. Now he goes to
find patients.
This is an epoch-making change. The physician becomes henceforth not
merely a person who stands ready to treat disease when the accidental
and incalculable forces of custom, hearsay, and natural propinquity
bring the patient to him. He becomes now a person who actively wars
against disease, who searches it out wherever it may be found. Thus he
approaches for the first time the possibility of truly preventive
action, the possibility of killing disease in its infancy or preventing
its birth. For it is well known that preventive action in relation to
disease is well-nigh impossible if we are forced or accustomed to wait
until the disease has made such progress that the patient himself is
aware of it and forced by its ravages to ask medical aid. Ordinarily the
patient seeks the physician only when he has broken down. From the
point of view of public health and public good, this is grievously late,
far too late. It is as if one inspected an elevator only after it had
fallen and killed or maimed its passengers, instead of inspecting it at
regular intervals so as to prevent its breaking down.
In this series of aggressive steps in the campaign against tuberculosis
whereby one seeks out possibly infected children, brings them to a
dispensary for examination, and separates them from their infected
parents or house-mates, the social worker is the all-important
executive. She finds the children, brings them or has them brought to
the dispensary, and sees that financial aid or other assistance is given
so as to carry out the isolation demanded by our bacteriological
knowledge of the disease.
V
As far back as 1895 the reforms introduced by Calmette and Grancher in
the field of tuberculosis had begun to modify and improve the treatment
given in our dispensaries, not only to tuberculosis but to all other
diseases. Especially it had favored the growth of home visiting, at
first for the specific ends for which it was designed by Calmette and
Grancher, but later for the prosecution of various related purposes
which the very process of visiting brought to light. Not only in
tuberculosis, but in other diseases, it was soon found that a knowledge
of home conditions and of the family was essential for the treatment of
the single patient who chanced to appear at the dispensary.
It was my good fortune during the ten years preceding 1905 to work as a
member of the board of directors of a private charitable society caring
for children deserted by their parents, orphaned, cruelly treated; also
for children whose parents found them unmanageable or for children who
had special difficulties in getting on at school. The work of this
society brought to me detailed knowledge of the life-histories of a good
many children. I watched the careful studies made by the paid agents of
the society into the character, disposition, antecedents, and record of
the child, his physical condition, his inheritance, his school standing.
I noticed during these years how the agents of this society, to whom the
child was first brought by its parents or by others interested in it,
utilized to the full the knowledge and resources of others outside its
own field; how, for example, they enlisted the full coöperation of the
child's school-teacher, secured facts and advice from the teacher, and
agreed with her upon a plan of action to be carried out both by her and
by the home visitor in concert. Moreover, I saw how physicians were
consulted about the child, and how their advice and expert skill
contributed something quite different from that obtained from the
teacher or that gained by the home visitor herself. The priest or
clergyman connected with the family was also asked for aid, and
sometimes could give very great help, differing essentially in kind
from that given by the teacher or by the doctor. If there were problems
involving poverty on the part of the parents, other societies concerning
themselves particularly with the problems of financial relief were asked
to aid, in order that indirectly the help given to the parents might
make itself felt in the better condition of the child. Sometimes free
legal advice was obtained from the legal aid society formed for the
purpose of giving such advice to those who were unable to pay for it.
As I watched the application of this method over a period of a good many
years and in the case of a great many children, I saw a good many
failures in addition to some most encouraging successes. But what most
of all impressed itself upon me was _the method_, the focussing of
effort on the part of many experts upon the needs of a single child, the
coöperation of many whose gifts and talents varied as widely as their
interests, to the end that a single unfortunate child might receive
benefit far beyond what the resources of any single individual, no
matter how well intentioned, could secure.
I have said that the doctor was a member of the group whose efforts were
focussed upon the needs of a single child, but he was never a very
closely connected member of this group. A few charitably inclined
physicians, personal friends of those directing the charities, were
called upon again and again to help out in individual cases by examining
a child, by giving advice over the telephone or otherwise. Through the
free hospitals and dispensaries help was also obtained for the physical
needs of persons who had come to the notice of the different charitable
associations by reason of economic need or other misfortune. But the
medical charities, the hospitals, dispensaries, convalescent homes, and
the benevolence of individual physicians were not well connected with
the group of charitable associations which I have been referring to
above.
At this period, in 1893 and 1894, I had been working for some years as a
dispensary physician, concerning myself chiefly with perfecting the
methods of diagnosis in a dispensary, so that the patient could obtain
there a diagnosis as correct and scientifically founded as he could
obtain from a private physician. But in the course of these efforts for
a complete and exact diagnosis which should do justice to the actual
needs of the patient, I found myself blocked. I needed information about
the patient which I could not secure from him as I saw him in the
dispensary--information about his home, about his lodgings, his work,
his family, his worries, his nutrition. I had no time--no dispensary
physician had time--for searching out this information through visiting
the patient's home. Yet there was no one else to do it. My diagnoses,
therefore, remained slipshod and superficial--unsatisfactory in many
cases. Both in these cases and in the others where no diagnosis was
possible from the physical examination alone, I found myself constantly
baffled and discouraged when it came to treatment. Treatment in more
than half of the cases that I studied during these years of dispensary
work involved an understanding of the patient's economic situation and
economic means, but still more of his mentality, his character, his
previous mental and industrial history, all that had brought him to his
present condition, in which sickness, fear, worry, and poverty were
found inextricably mingled. Much of the treatment which I prescribed was
obviously out of the patient's reach. I would tell a man that he needed
a vacation, or a woman that she should send her children to the country,
but it was quite obvious, if I stopped to reflect a moment, that they
could not possibly carry out my prescription, yet no other filled the
need. To give medicine was often as irrational as it would be to give
medicine to a tired horse dragging uphill a weight too great for him.
What was needed was to unload the wagon or rest the horse; or, in human
terms, to contrive methods for helping the individual to bear his own
burdens in case they could not be lightened. Detailed individual study
of the person, his history, circumstances, and character were frequently
essential if one was to cure him of a headache, a stomach-ache, a
back-ache, a cough, or any other apparently trivial ailment.
Facing my own failures day after day, seeing my diagnoses useless, not
worth the time that I had spent in making them because I could not get
the necessary treatment carried out, my work came to seem almost
intolerable. I could not any longer face the patients when I had so
little to give them. I felt like an impostor.
Then I saw that the need was for a home visitor or a social worker to
complete my diagnosis through more careful study of the patient's malady
and economic situation, to carry out my treatment through organizing the
resources of the community, the charity of the benevolent, the forces of
different agencies which I had previously seen working so harmoniously
together outside the hospital. Thus I established in 1905 a full-time,
paid social worker at the Massachusetts General Hospital, to coöperate
with me and the other physicians in the dispensary, first in deepening
and broadening our comprehensions of the patients and so improving our
diagnoses, and second in helping to meet their needs, economic, mental,
or moral, either by her own efforts, or through calling to her aid the
group of allies already organized in the city for the relief of the
unfortunate wherever found. To bring the succor of these allies into the
hospital and apply it to the needs of my patients as they were studied
jointly by doctor and home visitor, was the hope of the new work which I
established at that time.
In the thirteen years which have elapsed since this period, about two
hundred other hospitals in the United States have started social work,
some of them employing forty or fifty paid social workers for the needs
of a single hospital. Unpaid volunteer work has always been associated
with that of the paid workers in the better hospitals.
I should mention, in closing this chapter, three forms of medical-social
work which had been undertaken previous to 1905, and which were more or
less like the work which I have just described, though not identical
with it:
(1) The after-care of the patients discharged as cured or convalescent
from English hospitals for the insane (1880). The visitors employed in
this work followed the patients in their homes and reported back to the
institution which they had left. Their labors were directed chiefly to
the prevention of relapses through the continuation in the home of the
advice and régime advised by the hospital physician and previously
carried out in the institution.
(2) The work of the Lady Almoners long existing in the English hospitals
had begun about the time that I started medical-social-service work in
America, to change its character so as to be more like the latter.
Originally the purpose of the Lady Almoners was to investigate the
finances of hospital patients in order to prevent the hospital from
being imposed upon by persons who were able to pay something, but who
represented themselves as destitute and therefore fit subjects for the
aid of a charitable hospital. Gradually, however, the Lady Almoners had
begun to be interested in the patients as well as in the hospital funds,
and had begun to labor for the patients' benefit as well as for the
hospital's. This brought them near to the idea of hospital social
service as practised in this country since 1905.
(3) The visiting nurses or public health nurses, employed by a Board of
Health or by private agencies for the care of contagious diseases in the
home and also for the nursing of the sick poor whatever their malady,
have found it more and more difficult in late years to confine their
work wholly to physical aid. They have been forced to take account of
the patients' economic, mental, and moral difficulties, to extend their
work beyond the field of nursing proper, and thus to approach very
closely to the field of the social worker. It is my own belief that the
frontier separating visiting nurse and medical social worker should be
rubbed out as rapidly as possible, until the two groups are fused into
one. The visiting nurse must study the economic and mental sides of the
patients' needs, and the social worker must learn something of medicine
and nursing. Then the two groups will be fused into one, as indeed they
are fast fusing at the present time.
SOCIAL WORK
_PART_ I
MEDICAL-SOCIAL DIAGNOSIS
SOCIAL WORK
CHAPTER I
THE MEDICAL STANDING, DUTIES, AND EQUIPMENT OF THE SOCIAL ASSISTANT
I have said in the Introduction that _home visiting_ may easily and
properly spring up in connection with various institutions; for example,
in connection with the schools, courts, or factories of the city as well
as with the dispensaries. But it is essential in home visiting, no
matter what institution it is connected with, that the social assistant
should be distinctly recognized as _part of the machinery_ of that
institution, or, in other words, as one of the means by which that
institution does its work. If she is connected with the schools, she
should be a part of the school system alone, not responsible to a Board
of Health or to any other outside agency.
So in the type of home visiting which now particularly concerns us, it
is essential to make it clear from the outset that the social worker is
a part of the medical organization. She is one of the means for
diagnosis and treatment. All that she does from the moment when she
first scrapes acquaintance with the patient is to be connected with the
condition of the patient's health. She is not to pursue independent
sociological or statistical inquiries. She is not to be the agent of any
other non-medical society. It is unfortunate even if her salary should
be paid from any source other than the medical institution itself.
There are great advantages in this apparently formal and obvious point
of connection. In the first place the _medical method of approach_ to
close relations, to friendly relations, with a group of people, is
decidedly the easiest. Persons who may be suspicious or resentful of our
approach if we appear primarily as investigators, or primarily as
persons concerned with economic or moral control, will welcome the
visitor if she appears as the arm, the cordially extended hand, of the
medical institution where they have already found welcome and relief. I
know well that charity organization workers, court workers and others
may establish just as close a relation with their clients _in the end_
as is possible for the medical social worker. But the start is harder
and needs more experience. Because disease is the common enemy of
mankind, all sorts and conditions of men are instinctively drawn
together when it becomes necessary to resist the attacks of disease as
the enemy of the human family. Members of a family may disagree about
many matters, and may be far from congenial with one another in ordinary
times and upon ordinary subjects, but will draw together into the
closest kind of unity if any one attacks the family, accuses or
criticises the family. So human beings of widely different environment,
taste, economic status, heredity, may find it quite easy to begin and to
maintain friendly relations when that which brings them together is
their common interest in the struggle against disease. It is, indeed,
almost too easy to get friendly with people when they are suffering
physically and we are endeavoring, however lamely, to bring them relief.
The medical avenue of approach, then, the plan and hope of establishing
intimate relations with a person or a family while we are trying to give
them medical assistance, offers incomparable advantages. These
advantages become clearer still if we compare them with the special
difficulties which arise if one tries to begin an acquaintanceship with
financial inquiries or with moral investigations. People who will agree
on everything else will quarrel on money matters. There is nothing that
so easily leads to friction, suspicion, and unfriendliness, as the
interview in which one is trying to make out whether people are speaking
the truth, the whole truth, and nothing but the truth, in relation to
their income and expenditure. This matter very naturally seems to people
their own business. They quite naturally resent inquiries on such
matters by strangers. They feel attacked and in defence they are apt to
conceal or color the truth. And yet, if a friendly relation has first
been established through the patient's recognition of our genuine desire
to help his physical difficulties, the financial inquiries which make a
necessary part of the home visitor's work can much more easily follow.
One has to understand what money is available in order to make the best
plans for nutrition, for home hygiene, for rest and vacation--all of
which naturally form part of our medical interest. I wish to make quite
clear here my appreciation that good social workers never begin their
relationships with a client by assuming a moral fault on his part and
never push the economic questionnaire into the first interview. All I
wish to point out is that it is perhaps easier for the medical social
worker than for others to avoid these blunders.
At the outset of a relationship which aims to be friendly,
investigations which start with the assumption that there has been some
_moral fault_ or weakness in those whom we wish to help are even worse
than financial inquiries. The instant that the social worker finds
herself in the position of a moral critic, it becomes next to impossible
that a friendly relation not hitherto established, shall be built up
from the beginning. Late in the course of a friendship established long
before, moral help, even moral criticism, may be welcome. But it cannot
often or easily be one of the topics of conversation, one of the points
of investigation, in the early stages of what we hope to make a friendly
relation.
Everything stands or falls with this. We cannot even teach hygiene, we
cannot even make medical principles clear unless we have succeeded to
some extent, perhaps without any merit on our part, perhaps through
extraordinary good fortune, in acquiring a genuine liking for the person
whom we want to help. Once that is attained, we can work miracles. But
if it is wholly lacking, we cannot count upon accomplishing the simplest
interchange of accurate information; we cannot achieve the most
elemental hygienic instruction.
But there is another signal advantage in the medical point of approach
to a relationship which, as I have said, must be friendly in fact, not
merely in name, if it is to succeed in any of its ulterior objects. When
the social worker begins the difficult task of acquiring her influence
in a family, she starts with a great deal in her favor if she appears in
the home as _the agent of the physician_. He has prestige. By reason of
his profession, by reason of the institution which he represents, by
reason of confidence already established by him in the patients' friends
and neighbors, the new family is ready to have confidence in him. He is
not thought to have any axe to grind. He is assumed to be genuine in his
desire of helpfulness. Therefore any one who appears in his name, as his
assistant, has a great deal in her favor, especially when compared with
the visitors of societies which might be supposed to begin with economic
or moral suspicions about the family. If the visitor appears in the home
with the prestige of a medical institution enhancing the value of her
own personality, she has a very definite advantage.
_Light on the severity of illness_
I have said that it is essential to the success of a medical visitor's
work that she should be part of the medical machine, acknowledged as the
doctor's agent, concerned wholly with helping to carry out his plans.
But we must ask now, _what part_? And the answer is that the social
worker is an assistant to the physician both _in diagnosis and in
treatment_. I will begin with an account of what she is to do as his
assistant in diagnosis.
She is to discover, so far as she can, _what_ the disease is, _how much_
the disease is, and _why_ it is. I do not mean, of course, that she is
to ape the doctor's scientific investigations, that she is to use
instruments of precision, or to try to prescribe medicines. But she is
to help the physician in some of the following ways:
He is often very much at a loss to be sure how bad the patient's
symptoms really are, how much the patient suffers, how serious the case
is. The social worker is often able to help in discovering why the
patient really came to the dispensary, discovering, perhaps, that the
reason is such as to show that the malady is really a trifling one. She
may find, for instance, that the patient has come merely because her
husband had to come, anyway, and she thought she would get the benefit
of whatever there was to be had in the way of medical assistance at the
dispensary, even though, unless her husband had been going, anyway, it
would not have occurred to her to make the independent visit upon her
own account. Or, again, the visit may be due chiefly to curiosity,
especially if the dispensary has been newly established or has added
some new features to its methods of diagnosis and treatment. These facts
are passed along from person to person; the person hearing of them may
appear as a patient chiefly to see just what it is that her neighbors
are getting when they go to the dispensary. I have known a patient to
come merely because he was alarmed as a result of a recent conversation
with a friend. His friend had been hearing about heart trouble and had
mentioned some symptoms such as pain about the heart or cold extremities
or dizziness. Any one sick or well on hearing such symptoms may easily
remember that he has had them himself not long ago, or may even begin to
feel them as a result of suggestion. Straightway, perhaps, he will
betake himself to the dispensary, complaining of symptoms which never
would have been noticed but for his talk with the friend.
Or, again, the patient may have some definite organic disease or some
obstinate train of discomforts and physical inconveniences. But he has
adapted himself to them tolerably; he has settled down to bear or forget
them as best he may. He may know that his troubles are really incurable
and yet not serious. He may have become as accustomed to them as he is
to an uncomfortable lodging or to a modest income. Yet, as a result of
some temporary fatigue, some newspaper paragraph, some fragment of
gossip overheard, there may arise in him a crisis of alarm and worry
about his familiar discomforts or inconveniences. Thereupon he may
betake himself to a dispensary, and give the physician an account which
may be very difficult to interpret, because the physician does not
understand the train of events which appear acute and new in that they
have led the patient just now, rather than at any earlier time, to seek
advice. After nearly twenty years' experience of dispensary work I
should say that in no respect can a social worker give the doctor more
welcome help than by discovering now and then reasons such as I have
just suggested whereby the patient comes to the dispensary now rather
than at any other time, and at a season not really connected in any
special way with the nature of his disease.
Perhaps I can make this clearer by contrast with its opposite. A person
who has just developed a scarlatinal rash, who has just coughed and
raised a considerable quantity of blood, who has just lost the power to
move half of his body, who has just begun to have swelling of the face,
naturally consults a doctor at once. If he then comes to a dispensary
for treatment, he has come at a time which is the right time, the
reasonable time, considering the nature of his malady. Something new has
happened. An attack has been made which should be foiled if possible at
once. The clue for usefulness on the part of the doctor is thus fairly
clear. If, on the other hand, a person has had more or less back-ache
all his life, and has grown used to getting along and doing his work,
even enjoying life in spite of it, he may suddenly come to a dispensary
for that back-ache because he has seen in the newspaper the wholly false
statement that pain in the back means kidney trouble. Yet when he comes
to the dispensary _he may say nothing whatever about his having seen
this newspaper advertisement_. Indeed, it is very unlikely that he will
mention this at all. He will describe his back-ache as something which
demands immediate treatment, and the doctor may set in motion extensive
and probably useless activities of investigation or treatment which
never would have been undertaken had he known just what it was that
brought the patient to the dispensary that day rather than months
earlier or later.
So far I have spoken only of cases in which the visitor's studies in the
home make it clear that the case is not as bad or not as manageable as
it might have seemed if one had known only what the patient himself
could reveal in the dispensary. But occasionally on reaching the
patient's home the visitor may find reason to believe that the symptoms
are much more serious, the disease much more urgent, than could have
been realized from the story told and the facts obtained at the
dispensary. The visitor may find in the home conditions of
disorganization, dirt, disorder, serious malnutrition, discouragement
on the part of other members of the family, arguing a much more serious
condition of the patient than one would have realized from talking with
him at the dispensary. As a result of such findings the doctor, who must
spend his energies for the patients who need him most, will see that he
had better give more time and more effort to the patient than he would
otherwise have thought right.
Still, again, the visitor may find that the symptoms are neither more
serious nor less serious than he would have supposed from the dispensary
interview; yet the clinical picture is different from the doctor's
because the patient has thrust into the foreground of the clinical
picture something which further knowledge shows to be really
unimportant, while he has said almost nothing of some other feature of
the trouble which is really much more serious. For example how much does
the patient really eat, how does he do his work, are there complaints
about him from his "boss," has he _always_ had the cough which he has
only just now begun to complain of? Such questions can be better
answered after visits at the home and talks with the whole family.
Clearly the supplementary information thus secured by the social worker
will count for nothing unless clearly explained to the doctor, and is
taken up by him as part of the evidence on which he bases his diagnosis
and his treatment. It is absolutely essential that the social worker
should not merely make her visits and record them in her notebook, but
should incorporate her findings in the medical record and deliver them
not formally but effectively to the doctor's mind.
Such help is needed because she can often learn far more in the quiet of
an interview at home than would be possible for the doctor despite all
his medical skill. For at the dispensary he questions the patient when
he is confused and forgetful, alarmed, perhaps, by the sights and sounds
of the clinic, and so very unlikely to give a correct and well-balanced
account.
_Nests of contagious disease_
So far I have been describing the work of the social worker as a process
of finding out how much ails the patient and what his symptoms signify.
But it is also a part of the social worker's duty to find how much
disease is present not only in the individual who appears in the clinic,
but in his immediate environment, to discover _nests, foci or hotbeds of
disease_. In the case of a disease like smallpox, this is obvious. If a
patient presented himself at a dispensary with the pustules of smallpox
upon his body, it would be criminal negligence on the part of the
physician not to set on foot a search of that patient's home, his
industrial environment, or, in the case of a child, his school
environment, for evidence that others have been exposed to the same
contagion and possibly already infected. This sort of duty cannot be
abandoned merely because there is no health officer at hand. It is a
crying need and must be attended to at once.
Now in a minor degree this is true of many other diseases as well as
smallpox. We are beginning to realize that it is true of tuberculosis,
so that when one case of advanced and therefore contagious tuberculosis
is seen at the dispensary, machinery should automatically and invariably
be set in motion to search out possible paths of contagion from that
patient to others, just as if he had smallpox.
This principle which is well established in the case of dangerous
contagious diseases like smallpox and diphtheria, and is beginning to be
established in relation to tuberculosis, is even more important in
dealing with syphilis. Every case of syphilis means more cases of
syphilis, and the danger of still more each day that the contagious
patient is at large. No physician has done his duty unless, after seeing
a case of syphilis, he attempts, through a social worker or otherwise,
to get knowledge of others from whom this disease has been acquired, or
to whom it may be freshly spread. At the Massachusetts General Hospital
each patient with syphilis is asked to bring to the clinic for treatment
the person who infected him. The method sounds impossible _but in fact
it works_, and many cases are thus brought under treatment and prevented
from infecting others.
With contagious skin diseases such as scabies or impetigo, the principle
is obviously the same, though the dangers of disregarding it are not so
great. With typhoid fever, which not very infrequently shows itself
even at a dispensary, the duty of the social worker is not so much to
search for other persons through whom it may have been contracted or to
whom it may be spread, as to investigate the water-supply and the
milk-supply of the patient and of others in his environment. One case of
typhoid always means more cases, usually more cases acquired, not by
contact with one another, but through their share in a contaminated
water-supply or milk-supply. The social worker, therefore, should know
how to search out contaminated water-supplies, or at least to put in
motion such machinery of public health investigation in the city or town
where the case arises as may lead to good detective work in the attempt
to track down the source of the trouble. It has been well said that
every case of typhoid is some one's fault. It has even been asserted
that for every case of typhoid some one should be punished. Certainly
there are some grounds for such an assertion.
_Hotbeds of industrial disease_
Commoner and not less important than the contagious diseases that I have
just mentioned are industrial diseases, or diseases aggravated by the
conditions of industry. A physician may serve for many months in a
dispensary without seeing a case of smallpox, of trichiniasis, or of
typhoid fever, or feeling it his duty to set in motion the forces that I
have just mentioned for rooting out the sources of contagion and
preventing their further spread. But he cannot serve a month in any
well-attended dispensary without seeing cases of industrial disease in
the narrow sense, such as lead poisoning, or of independent disease
aggravated by the conditions of industry, such as the functional
neuroses of cigar-makers or of telephone operators. With such diseases,
as with the infectious and contagious diseases, the presence of one case
in the clinic should lead straight to the inference that there are
others elsewhere, out of sight but no less important from the point of
view of public good. This conclusion should lead in turn to the search
through a social worker for the cases of disease which do not present
themselves to any physician, which may be totally unknown even to the
patient himself, yet which are important to the health of the nation.
Difficult though this field of industrial disease has shown itself to
be, difficult though it is to separate out that portion of the patients'
complaints which can justly be referred to the conditions of his work,
and to distinguish it from the portions which are due to the way he
lives, to his inheritance, to his habits or to diseases like
tuberculosis and syphilis which may have been acquired without any
connection with his work,--nevertheless we must try to disentangle and
to recognize the elements in this knotty problem. And we can hardly fail
to see that the social worker is an essential and logical assistant in
the processes of investigation which we must carry out. If we can ever
unravel the tangled skein of causes and effects whereby the hours of
work, the strain of work, the patients' heredity and his home
conditions, all combine to produce the symptoms of disease, it will be
through such intimate, prolonged, detailed studies as the social worker
can carry out, especially if she becomes a friend of the family. The
doctor in his hours of consultation at the dispensary certainly can
never do it. The official agent of the Board of Health, perhaps feared,
certainly not a natural confidant for the family, may easily miss the
truth which the social worker unearths, provided always she succeeds in
differentiating herself altogether from the impersonal and professional
investigator, and gradually becomes in the mind of the family and in
truth their friend.
I said above that the social worker should try to find out what disease,
how much disease, and why this disease is present. The answers to these
three questions cannot be kept separate. If one knows how much
importance to attribute to a given symptom and whether it is as bad as
it seems or worse than it seems in the dispensary interview, one may be
steered straight to a correct diagnosis. To know _how much_ disease may
thus mean knowing _what_ disease is present. Furthermore, the
understanding of these questions, even though it be only partial and
unsatisfactory, leads us a considerable distance towards understanding
why the disease has arisen. The search for sources for contagion is an
example of a search for a _why_ in disease. The search for psychical
factors--groundless fears, misleading newspaper advertisements,
distracting rumors--all this is also a search for the cause as well as
for the nature of disease.
The social worker's investigations into the cause of disease may perhaps
be still further exemplified. I once sent a social worker to my
patient's home with the request that she try to find out what I had
failed to find out, namely, why a young girl could not sleep. Physical
examination of the girl had revealed no cause; the exploration of such
parts of her mind as she would reveal to me had thrown no light upon the
trouble. I was at a loss and asked for help through the more intimate
knowledge of the patient sometimes to be gained through a social
worker's studies. Such a search might easily have been fruitless--it
often has been fruitless in my own experience. But in this case it was
almost comically swift in reaching its goal. The visitor found that this
girl was sleeping with two other girls of about her own age, in a bed
hardly more than a metre wide. It needed only that she should acquire a
separate bed for herself, which she was able to do without any financial
assistance. She then regained her power to sleep. How often have such
cases been treated with drugs or perhaps with more complicated
physio-therapeutic or psycho-therapeutic procedures, when some simple
fact like the size of the bed, the temperature of the sleeping-room, or
the mental activities of the evening immediately preceding bedtime, are
really responsible for the whole trouble.
_Medical outfit of the social worker_
In order to carry out the particular procedures of diagnosis and
treatment which belong within the province of the social worker, a
certain amount of medical knowledge is needed. Because this is true, it
has often been assumed that the social worker must be a trained nurse,
prepared by months or years of experience in a hospital. But experience
has shown that much of the knowledge possessed by nurses who have had
this training cannot be used by the home visitor. On the other hand, the
information which the social worker needs is often quite lacking even in
well-trained nurses. Furthermore, it may be said with truth that the
training of a nurse, as we know it in America at any rate, really unfits
a woman in some respects for the work of a social worker, since it
accustoms her to habitual obedience and subordination. These habits are
very useful in their proper place, but they are antagonistic upon the
whole to the temper and mental activity which is important in the social
worker. I mean the temper of aggression in relation to disease, and the
mental attitude of the teacher and leader in relation to the patient.
But of this point it will be more in place to speak when I come to
consider the functions of the social worker as a teacher.
Let us return, then, to the question, What knowledge should the social
worker possess in order to do her part in the "team-work" of the
medical-social dispensary? Her knowledge should approximate that of the
public health officer. Like him she should be, above all, familiar with
what is known to medical science about _the causes of disease_. This is
of great importance because it is especially in this field of medical
science and medical ignorance that the public, the patients among whom
the social worker will work, is most in need both of new knowledge and
of the uprooting of old error and superstition. Medical science knows
very little of the causes of many diseases. But our patients, especially
the more ignorant of them, are very glib and confident in their
assertions as to what has caused the particular disease from which they
just now suffer. They tell us about their "torpid livers," their
"congestive chills," their "ptomaine poisonings" and the like. Their
supposed but unreal knowledge is extensive and detailed. Indeed, so
stubborn are their beliefs upon such matters that they often present a
firm wall of resistance which must be broken down by the social worker
before any truth upon these matters can be introduced into their minds.
The social worker, then, should share such knowledge as the medical
profession possesses about the causation of infectious disease, about
direct personal contagion, and also about the indirect _methods by which
disease is conveyed_ from person to person through insects or through
instruments and utensils, such as the barber's razor, the family towel,
or the public drinking-cup. She should be familiar with the small body
of knowledge which we possess upon the transmission of disease by
drinking-water, by milk, and other kinds of food. She should appreciate
our still smaller body of knowledge about the relation of disease to
climate, to weather, and to other physical agents such as the extreme
heat and cold produced by some industrial processes, and the action of
X-rays.
In addition to this definite and specific knowledge of causes, she
should know the generally accepted views of the medical profession on
the subject of _bodily resistance_, _immunity_, inheritance, the
diseases and perversions of metabolism, and the other non-bacterial
factors in the production of disease. Above all, she should realize the
_multiplicity of causes_ which science more and more clearly recognizes
in their single result. She should learn both by precept and by
experience that for a single fact such as disease or health there are
always many causes, so that any one who points confidently to a single
cause, such as cold, fatigue, bacteria, or worry as a sufficient
explanation of a person's disease, is almost certain to be wrong.
Obviously, this truth bears a close relation to what is to be said on
the "historic and catastrophic points of view." Chapter III.
The importance of teaching the social worker all that is known about the
transmission and causation of disease is due to the following fact:
whatever we succeed in accomplishing in our efforts at _preventive
medicine_, whatever we do to nip disease in the bud or to check the
spread of epidemics, is due to our knowledge of the causes of disease.
The instructions of the doctor at the dispensary can accomplish but
little in this field when compared with the detailed teaching of the
social worker in the patient's house, in his workshop, in the schools
and factories where disease is spread so much more frequently than in
the dispensaries. If we hope to show people how they can avoid the
disasters of illness, our teaching should be given in the very place
where these disasters most often occur. There we can illustrate and
demonstrate with the objects in sight what is to be done and to be
avoided.
It is for this reason that the social worker is above all others the
person who can convey life-saving information to the public in an
effective way. A considerable amount of this precious knowledge is now
possessed by the medical profession; but it is shut away useless,
unavailable, in medical libraries and in doctors' minds. The social
worker can fight disease by spreading the contagion of medical truth.
She can multiply the foci from which truth can spread still more after
she is gone, just as disease is redistributed again and again from new
nests of infection.
The _prognosis of disease_, like its causation, is a subject on which
the social worker should know almost as much as the doctor. This is
possible because medical knowledge on this subject is still so very
limited. For the purposes of one who has to combat the poverty, sorrow,
idleness, and corroding fears which disease produces, knowledge of
prognosis is a most useful tool. For example: if one is to make plans
for the care of a group of children during their mother's illness, one
must have some idea how long that illness is going to last. If it
affects the bread-winner of the family, how long will he or she be
disabled, and how completely; what are the hopes of ultimate and
complete recovery; will chronic invalidism follow; is it worth while in
this particular disease to spend a great deal of money and time in
trying to achieve a complete cure, or is cure so improbable and at best
so incomplete that our resources can be expended more wisely in other
directions?
A knowledge of prognosis will help the home visitor greatly in the
solution of such problems. But it must be added that such knowledge as
she already possesses about the prognosis of a disease, such as
tuberculosis or heart trouble or kidney trouble, must always be
supplemented by all the information that she can gain from the doctor as
to the present prognosis in the case of the particular patient with whom
the social worker has to deal. For the general prognosis of a disease is
greatly modified by the particular circumstances in each individual
case.
Physicians are not at all eager to impart their knowledge about
prognosis, because this knowledge is so limited and so faulty. No
scientific man likes to make definite statements upon so indefinite and
hazy a matter as prognosis. Nevertheless, it is essential for the
patient's good that the doctor should be asked to give her as clear and
definite a statement as is possible for him to make with the facts that
he possesses. For it is only upon the basis of such a statement that an
intelligent plan of social treatment can be constructed.
Besides acquiring all that she can learn of the causes and prognosis of
disease, the social worker should be familiar with the symptoms of the
more important and _common types of disease_. There are now several
books written particularly with the object of conveying to social
workers and others such knowledge as I have referred to, yet without any
pretence of equipping the person either for nursing or for the practice
of medicine. I will mention here a book by Dr. Roger I. Lee, Professor
of Hygiene in Harvard University, "Health and Disease: Their Determining
Factors" (Little, Brown & Co., Boston, 1917), and my own book, "The
Layman's Handbook of Medicine" (Houghton Mifflin Co., Boston, 1916).
In order to understand such books, and to arrange her knowledge of
disease in such form that it may be easily handled, the social worker
must have a slight knowledge of anatomy and physiology, so that she can
arrange the symptoms of disease in connection with the different systems
of organs: circulatory, digestive, respiratory, urinary, nervous, and
locomotive.
Finally, the social worker must know the _principles of hygiene_, in
order that she may effectively combat medical quackery and the prevalent
medical superstitions of the people. That portion of hygiene which is
both securely founded upon scientific evidence and useful in the
preservation of health, makes up only a very small body of knowledge, so
that it can be easily mastered by any intelligent person. Our knowledge
upon such matters as diet, exercise, bathing, sleep, ventilation, when
such knowledge is both scientific and practically useful, could be
written upon a very few pages. It consists largely of negatives which
contradict the current superstitions.
In my own work in this field I have found it essential that there should
be no mystery and concealment, no obscurantism and mediæval Latin in the
methods of treatment which the social worker explains or carries out
under the doctor's directions. She must be able to deal with the
patients frankly, openly, without concealment or prevarication.
Otherwise she will not have moral force enough behind her statements to
bring them home to the patient so as to secure any reform in his
hygienic habits. Such reforms are difficult enough in any case. They are
usually impossible unless they can be initiated by one rendered eloquent
and convincing by the consciousness that she leans upon the truth and
has nothing to conceal. If she has mental reservations, if she is trying
to protect the authority of the physician in a statement which she does
not believe to be wholly true, the force of her appeal will be so
weakened that it will probably be ineffective.
_Technical methods_
There are some technical processes of diagnosis and treatment which are
usually carried out by the visiting nurse, but which may well be
performed after a brief training by the social worker who is not a
nurse. Among these are:
(1) The accurate reading of the patient's temperature, pulse, and
respiration, which she must often teach the patient to do for himself
and to record accurately and clearly. This is of especial importance in
tuberculosis, for in suspected cases of this disease one often needs
daily measurements of the temperature as an aid in determining the
diagnosis or in estimating the severity of the case and the fitness of
the patient for work.
(2) The arrangement of a window tent or some other device for insuring
the maximum of fresh air for the tuberculous patient both day and night.
This device is also useful in pneumonia, typhoid fever, and other
diseases, in case they are to be cared for at home and not in a
hospital.
(3) The application of simple dressings to wounds, abscesses, and common
skin diseases such as eczema, and impetigo.
(4) The care of the skin in bedridden patients. Our primary object here
is the prevention of bedsores, those ulcerations which occur in very
emaciated patients at the points where their weight presses a bone
against the bedclothes.
(5) The simpler procedures for the preparation of milk for sick children
and of other foods commonly advised for patients who are confined to
bed.
(6) The methods of emptying the lower bowel by means of an enema.
Into the details of these procedures this is not the place to enter, but
I wish specially to assert that all of them may be learned within a few
weeks by persons who have not studied medicine or had the full course
for the training of a nurse. Any one who possesses these simple bits of
skill can do all that is necessary for the physical care of the sick
poor in their homes, unless continuous attendance upon the patient is
necessary. Such attendance is not within the province of the social
worker. But in the technical procedures just described it is all the
more important that she be expert, because such skill makes her a
welcome visitor and a trusted adviser outside the field of medicine.
Because she has given relief by dressing a wound, curing a skin disease,
or applying a poultice, she will be listened to with liking and with
confidence when, later, she comes to give advice in economic,
educational, or moral difficulties.
CHAPTER II
HISTORY-TAKING BY THE SOCIAL ASSISTANT
History-taking concerns the social assistant especially because
history-taking is one of the things one does, if one is wise, in any
matter in which one is trying to help a human being. Even if you were
concerned to help not a stranger, but a member of your own family, still
you would need a story or history of the person's life whether you wrote
it down or not.
_History and catastrophe_
In our attempts to be of use to people in their misfortunes, there are
two very common and quite opposite points of view (roughly the right and
the wrong), which I call (_a_) the "historic" and (_b_) the
"catastrophic," the accidental, or the emergency point of view.
Confronted with people's troubles, whether physical or mental or
spiritual, we are tempted, and above all _they_ are tempted to regard
the sickness, the poverty, or the sorrow in the light of an emergency,
an accident, and therefore as something to be treated at once and by
means which have little to do with the past and the future. On the other
hand, the standpoint of science and philosophy, and of any one who has
labored long in the field of social work with or without science or
philosophy, is the point of view of history. This is the habit of mind
which makes us believe that a supposed "accident" belongs in a long
sequence, a long chain of events, so that it is impossible to understand
or to help it without knowledge, as extensive as our time and our wisdom
will allow, of that whole chain.
Consider a few examples which contrast these two points of view. When a
boy is brought into court for stealing, it is almost always his attempt,
and the attempt of those who defend him, to show that such a thing has
never happened in his life before; he "just _happened_ to steal." But as
we inquire more closely into the facts, we almost always find that this
is a fundamentally untrue statement of the case. For the offence which
brought him into court is almost never the first offence. He has always
stolen before. On the present occasion he was a member of a boy's gang;
it was not in the least accidental that he got into that group of boys.
As we search back in his history, and perhaps into his father's history,
we find reasons why he is what he is now. Again, we are trying to help
some wayward girl who has taken an immoral step. We are told what a
wholly unforeseeable _accident_ it was that got her into her trouble.
But if we can get a good picture of her past, we find that we could have
traced the tendency to weakness of this kind from the time she was born.
So it is in medical matters. _Emergencies are rare._ I remember being
called out of a sound sleep one night to go "as quickly as possible" to
see a man who had discovered a lump upon his breast bone. He was quite
sure that the swelling had appeared since the time when he went to bed.
It was then one o'clock in the morning, and he had gone to bed at
eleven. Well, I found a slight bony irregularity in his breast bone
which doubtless had been there about forty-five years, as he was
forty-six years old. He did not pretend that it hurt him, and did not
undertake to show that he was ill in any other way. But this lump had
come and naturally he wanted help at once.
The great importance of the contrast between the historic and the
catastrophic points of view is, in the first place, that one way is on
the whole right and the other on the whole wrong; but still more, that
the patients whom we are going to deal with, and all the unfortunate or
needy people whom the social assistant tries to help, are very fond of
the wrong point of view and hang to it extraordinarily. It is _the_
natural first impression of any untrained person that his troubles
"simply happen" without any explanation that he knows. So that we have
to start at once to tear down a structure of innocent and lifelong
belief on the part of the patient, that troubles come suddenly and by
accident. We have to disillusion him, a process which naturally he does
not take to particularly pleasantly.
Our task in a dispensary is the same. The patient almost always starts
with _the catastrophic point of view_, and can only be very gradually
engineered into the other. And yet our work in relation to public health
is largely to be summed up as finding out how,--that is by what history,
through what chain of events, people come to be sick. Repetition and
extension of disease can be checked only in case we succeed in finding
such clues. Hence our labors to change people's point of view in this
particular respect are as worth while as anything we can do, and we must
not be discouraged by the fact that, week after week and year after
year, we come up against the same difficulties, the same conviction,
that troubles "just come" and have no cause.
I have said that the historic prejudice is essentially right and the
catastrophic prejudice essentially wrong. Of course, there are
exceptions. A man may be run over in the street for reasons that we
cannot discover to be connected in any possible way with his previous
history; a man gets a burn, gets a broken leg, is hit by a missile in an
air raid over London or Paris, in ways that are essentially
catastrophic. And yet even in the field of accidents, industrial
accidents for instance, the more we study, the more we find that
injuries are not wholly accidental. The whole of science is the attempt
to prove that nothing is an accident, that everything comes out of
previous causes. The percentage of accident in the so-called
"accidental" injuries decreases as we study industrial accidents. (_a_)
They happen at certain hours of the day more than at other hours of the
day: if they were really accidental this would not be so. (_b_) They
happen on certain days of the week, especially Mondays, for obvious
reasons. (_c_) They happen especially to greenhorns, to the newcomers,
who have not learned how to avoid them. One of the expenses incidental
to hiring new help is the expense of accidents. Thus these events turn
out to have a good deal of law and reason, a good deal in the history of
the individual (alcoholism?), and the nature of the industrial process
(speeding up?) which helps to explain them. By eliminating such
causative factors, we may prevent some accidents.
The remedies that we apply fit the type of trouble; _in so far as the
trouble is accidental or catastrophic, the remedy is mechanical_; in so
far as the thing is historical and continuous, the remedy cannot be
mechanical. When a man breaks his leg we put on a splint; that is
mechanical. But if he is in a low state of health and the fracture won't
unite, we have to do something non-mechanical, physiological,
psychological. We may have to get him into a different state of
nutrition or even into a better state of mind before his tissues will
heal.
Our job, then, in taking histories--that is, in finding out how things
happen that lead up to disease or misfortune--should begin by writing
down _the thing for which the patient comes_--headache, cough,
emaciation, poverty, desertion, unemployment. This is the "presenting
symptom"; it should always be the first thing written down in our
history, not in terms of medical diagnosis such as asthma or anemia, but
in the form of a complaint. Our attempt is first to put that down, to
get a starting-point, and then to weave that into a chain of evidence
which we call a history. That history makes it possible to make a
diagnosis and to plan treatment.
_The network of events_
But the particular event, the particular complaint for which the patient
comes to us, is woven not merely into one chain of evidence, but into
several. Let us carry out the metaphor of the chain. We must imagine
many chains woven into one another like the chain-armor of the mediæval
knight. Each link is a fact. But many chains of facts are interwoven in
the history of one single patient. First there is the chain of medical
evidence, the links (or symptoms) leading up to a diagnosis; second, the
chain of social evidence, which we try to classify on our social history
card. Third, we must trace the links in the chain of relationship with
other people, other members of the family, with friends and fellow
workers or schoolmates. Finally, the chain of heredity, of which we
cannot make much at present except in relation to tuberculosis and
mental disease or mental deficiency. But these studies of heredity in
its bearing on character are going to be more important as the science
of social work develops.
Our first attempt, then, after determining the "presenting symptom," is
to find out by a series of questions _how this symptom is linked up into
a tissue composed of many chains of facts_. Our next task which is
usually difficult, and frequently impossible, is to find out why this
great tissue of evidence issues just now in one particular "presenting
symptom." Why did the patient come to us to-day? This question is often
impossible to answer because the patient does not know, though he may
think he knows. Nevertheless, the social worker must try to find out.
Often it is not until we have known and liked a person for days or weeks
that we find out why he came to us at this particular time. Yet the
answer to this question may be the most important thing that we can find
out. For two reasons it is important; first, because it furnishes the
clue to all our later investigation and assistance in this case;
secondly, because it may show that the individual's complaints are not
of any significance at all.
I can illustrate this by a case studied at the Massachusetts General
Hospital in Boston. We looked up a series of patients at their homes in
order to find out if we had really been of any service. The cases were
not selected, but were taken from our files in numerical order. Among
others we visited a lady whose malady had been diagnosed as "sacro-iliac
strain." She had been given a prescription for a belt. We wanted to find
out whether she had ever bought the belt and whether it had helped her.
After some difficulty the visitor finally got the following details:
The lady had come from a city twenty miles distant from Boston. She had
taken an early morning train, and could not get back to her home the
same night. Hence she could not soon make another trip like that. She
came to have her eyes examined. Now it happened that we had no eye
clinic at the hospital at that time. But the lady had heard a great deal
about the hospital and its efficiency. She was determined not to go home
without having got something out of the hospital. So when she was told
at the Admission Desk that she could get no treatment for diseases of
the eye, she wandered into the medical clinic, trying to remember or
imagine some symptoms for the relief of which she could be admitted to
the clinic. Finally she managed to get out some sort of a story about a
pain in her back; she was referred to the orthopedic division; there a
diagnosis of sacro-iliac disease was made and a belt was advised. When
she got home, of course, she laughed at the idea of buying a costly
belt.
Now, if we could have found out in the beginning why she came to the
hospital, we might have saved a good deal of bother for a good many
people. It is astonishing how many patients turn out to have as little
reason for coming now as this lady did. One of the things that shows the
arbitrariness of choice in selecting a time for visiting the hospital,
is the striking diminution in the number of patients in the week before
Christmas. That suggests that there are many postponable visits. Or
again, patients may come merely because somebody else from the same
neighborhood is coming.
_Listening and questioning_
As the history-taker traces out the symptoms of the patient's illness
after finding an answer to this first question, _Why to-day?_ two
opposite habits of mind must be employed, one passive, the other active.
We must be sure that the patient shall feel that he has had a good
listener, that his troubles have really been appreciated. But if we are
constantly putting in questions, as we certainly must later, the patient
does not feel that he has been listened to. We desire first of all to
get his own story in his own words, passively. We may not necessarily
write down a single word of it. But I have found that the patient's own
way of expressing the nature of his troubles is often important and
characteristic. It helps to prevent our histories from looking too much
alike, which is their commonest fault. Hence we should get into them
somewhere a phrase or several phrases reported passively in the
patient's own words; if possible a phrase in which he describes his
"presenting symptom," the thing of which he chiefly complains.
But the second stage in the process of taking a patient's history is the
most important. In this part we should be active, not passive. We must
attack our task with a tool in our hand, _a mental tool fitted to rake
out of the mass of confused ideas in his mind certain significant
facts_. That rake is a logical schedule of questions which you use upon
him actively, not passively, and by using which you get answers either
negative or positive. Whenever you think well, you _think with a
schedule_ of that kind in your mind. If you pack a trunk well, you pack
it using a list, a schedule of the things that ought to go into that
trunk. Our printed social face-card helps us to think and question with
a schedule before us, to think in an orderly way, without forgetting our
items, and thus to select what we need out of the mass of disorderly
facts in the patient's memory.
In the second phase of history-taking, then, which begins after we have
listened appreciatively but quietly to the patient's own
version--usually catastrophic and full of fanciful theories--we lead him
by questions (but not by "leading questions") along the paths which will
open up a full view of the trouble, medical or social, which has been
suggested to us by the patient's first statements. Suppose, for
instance, one happened to know of an extraordinarily rare but curable
disease, one symptom of which the patient had mentioned, "My hair comes
out by handfuls." One would go on to ask, "Do you feel warmer or colder
than usual this winter?" Then, "The expression of your face is not
notably changed, is it, so that your friends comment on it?" "Is your
skin drier or moister than usual?" "Does your tongue bother you in any
way?" "Is your mind more or less active than usual?" Thus one would
confirm or refute the suggestion of the disease called myxoedema, a
suggestion which was given to us by the patient's first complaint--rapid
loss of hair. Given one symptom in a known group, one can trace out the
others as the anatomist who finds a single fishbone may be able to
reconstruct imaginatively the whole fish.
I said just now that we must not ask "leading questions." If we do, we
can make a patient of a very suggestible type of mind say anything. If
you ask him whether he has any symptom whatsoever he may obligingly say
"yes." The way to avoid this is to put our questions in the negative:
"You have no headache at all, have you?" "You do not cough?" "You never
spit blood?" By these negatives we can get at the positive symptoms if
they are present.
Schedules of questions to be used in history-taking may be medical or
social. Some of the social question-lists are suggested in later
chapters of this book. A masterly account of social questioning is
contained in Miss Mary E. Richmond's "Social Diagnosis" (published by
the Survey Associates, New York, 1917).
I wish now to illustrate the methods to be used by social workers in
questioning patients about their symptoms so as to assist the doctor in
his diagnosis.
_Pain: How long?_ For a day, a month, a year, six years? Very chronic
pains are seldom serious but seldom curable. Headache that has lasted
years either has no cause known to medical science, or else it means
neurasthenia. In either event it is apt to be stubborn. A headache that
has lasted only a day, and did not occur before, cannot possibly be due
to migraine. This suggests how the length of time that a pain has lasted
is very important in diagnosis. The patient will often say, "I have
always had it"; but to this we should oppose a pretty strong
cross-examination. The patient usually means that he has had it off and
on throughout an indefinite period. We ask him then, "When did you first
have it?" and then, "How much of the time--half the time, a quarter of
the time, for one day a week or one day a month?"
_Pain: Where?_ Patients rarely come to a doctor for a single _point_.
But pain in several points is never as significant as pain in one point.
One cannot learn much from scattered pains in relation to what ails the
patient and what to do for him.
_Pain: How bad?_ That is a very difficult question to get the answer to.
There is no thermometer or measure for pain. I suppose every doctor has
wished many times that he had one. But there are certain rough measures
which are of some use in judging how bad a pain is. (1.) We ask, "Does
it compel you to lose sleep?" Some headaches may be pretty severe and
yet a person sleep despite the pain. It may link itself up with a
dulling of consciousness leading to sleep. But most pains and even most
headaches that do not keep a person awake are not as bad as those that
do. (2.) We ask, "Does it prevent work?" Any one can see all sorts of
limitations to the use of that criterion. A man with a rugged type of
mind will work with a pain that another weaker man will give up to. Yet
the question does bring out evidence of some value.
(3.) Another criterion, more subtle and not quite so useful, is this,
"Do you feel the pain more when you are quiet or when you are moving
about?" The pains due to organic diseases are generally worse when one
moves; while the functional type of pains are apt to be better when one
moves about. One forgets it. Quite often patients are very lucid and
candid about this.
_Pain: How aggravated? How relieved?_ (_a_) A pain may be aggravated by
position--for example, when the patient is on his feet--or worse when he
is lying down--a headache, for instance. Most abdominal pains are worse
when the patient is on his feet. (_b_) A pain may be aggravated by
motion. Most of the surgical injuries, sprains, strains, tears of muscle
or ligament, and fractures of bones are naturally made worse by motion.
Pain may be aggravated by certain particular motions, as is the case
with some of the innumerable pains in the back. Lumbago is a pain
characteristically described as one that comes when the patient tries to
lace his boots. Especially when he tries to get up from that position,
the pain is intolerable. Pains in the chest are often worse on deep
breathing--pleuritic pains, for example. But other thoracic pains may
also be made worse by deep breathing. (_c_) Pain may be aggravated by
the taking of food, or by movements of the bowels.
Pain may also be relieved in any of these ways. The most important thing
that one can know about a stomach pain is that it is relieved by food.
The majority of all stomach pains are aggravated by food. Pains are also
relieved by heat or cold or by drugs or by rest. But those are not very
important points. They may be important in relation to what we do to
help the patient, but not in relation to diagnosis. Some pains, whatever
their cause, are relieved by cold, more by heat, and most are also
relieved by rest.
Next to pain, _Cough_ is the symptom, especially in the colder months of
the year, that we have most to deal with. The question _How long?_ is
vastly the most important one about cough. One can also measure its
_severity_ by the question, "Does it keep you awake?" and to some extent
by the question, "Does it prevent work?" More important is the question,
"Is it dry or productive of sputum?" The patient's description of his
sputa in gross, without any microscopic examination, is also of a good
deal of use. There are usually three things a patient can tell us about
it: either it is yellow, or it is white, or it is bloody. There are two
other important questions about bloody sputa. Unless one gets these
answered, the mere fact of spitting blood is not important. We must know
whether there are merely streaks of blood which one often sees in the
sputa of anybody who coughs hard, are of no importance, and have nothing
to do with tuberculosis. But if, in contrast with this, we can really
establish evidence of the spitting of blood in quantity, we have almost
proved a diagnosis of tuberculosis. In ninety-nine cases out of one
hundred the spitting of blood in quantity means tuberculosis. "In
quantity" means a cupful or thereabouts of pure blood. If the doctor
does not find tuberculosis after that he should nevertheless assume it,
for it is almost always there. I should pay no attention to negative
physical finding in such a case.
The next point to ask about is whether the patient's _breathing_ is
_wheezy_. When a horse has become broken-winded we can hear his
breathing in the street as he comes along. He has become emphysematous.
We find this wheezing respiration in emphysema, asthma, and bronchitis,
which are diseases important for us to distinguish from tuberculosis; we
almost never get it in tuberculosis.
If the patient complains of _dyspnea_--difficult, rapid breathing,
"short breath" as we say--we shall ask about _oedema_ or swelling of any
part, especially of the legs.
In every patient who has a cough we are concerned primarily with the
diagnosis of one disease, that is, tuberculosis, its presence or
absence. Hence every patient who coughs should be questioned about the
other symptoms of tuberculosis and especially about _emaciation_. A man
with a chronic bronchitis or emphysema does not lose much flesh; he
does not become emaciated. A person does not become thin from throat
trouble. Hence emaciation, especially recent, is a helpful guide to the
doctor in making up his mind. _Fever_ we investigate for the same
reason. The only disease that often causes cough and fever during a long
period is tuberculosis. Unfortunately the patient's statement about
fever is usually unreliable. We can believe most of what he says on the
rest of these points. But he does not know whether he has fever or not.
In women we must ask also about the _monthly sickness_, because it is
suppressed in cases of moderately advanced tuberculosis. Nephritis,
anemia, heart trouble and emotional disturbances may have that same
effect. It is a measure of the degree of disease, not its type.
For the purpose of dispensary consultations I do not think we should
take any family histories except when we suspect tuberculosis. But when
the history leads us to think that the person may have tuberculosis, the
social worker can help the doctor by asking the patient questions about
the possibility of the same disease in mother, father, or others who are
in contact with the patient--grandfather, grandmother, or other
relatives or friends living in the same house. We believe less and less
in the heredity of tuberculosis, more and more in infection by contact.
If separated from a tuberculous father or mother in early infancy we
believe that the child does not acquire tuberculosis. But the main mode
of infection is by association in the same house, over a prolonged
period, with people who have tuberculosis. Often the patients do not
know or will not confess that anybody in the family now has tuberculosis
or has died of it. But if we can establish the fact that one of the
patient's family has died after having a cough for many years, that he
grew very weak, and spit blood, we have established the diagnosis
without the name. Not the degree of relationship to a tuberculous
patient, but _the amount of time spent in the same house with a
tuberculous individual_--what we call the degree of "exposure" to
tuberculosis--_is the important thing_.
_Past history_
After getting the patient's present symptoms, one should ask, "Were you
ever sick _previous to this illness_? If so, what troubles have you
had?" That is of use in clearing up the limits or boundaries of the
present illness. The sicknesses which the patient says he has had are
not of very much use to us in diagnosis because we cannot get true
answers. The patient's diagnoses or his doctor's are apt to be vague or
meaningless. But the questions about the patient's past history tend to
make him more clear as to the date when his present illness began. Hence
his answers on these points should be written down very briefly, a word
or two only about each, and usually in the words used by the patient.
In our written histories in hospitals we usually take a considerable
body of notes about the patient's habits. I do not advise this for
social workers. But there are certain routine questions which should be
asked of all patients concerning their _appetite_, _bowels_, _sleep_,
_weight_, and _work_. The answers should be recorded in a separate
paragraph, at the end of the history.
What is printed here is meant to give a sample, not a full account, of
medical-history-taking. Competence in this field takes long practice.
Nevertheless the intelligent social worker can learn in a few weeks to
be of great assistance to the doctor by taking either in the dispensary
or in the home such histories as I have sketched.
In social-history-taking there is no single order or schedule of
questions agreed upon by all social workers. But there should be _some_
order and system determined partly by the personality of the worker and
partly by the nature of the trouble. If poverty or destitution is the
presenting symptom, one must find out the items in the family budget,
the figures of income and outgo, paying especial attention as in medical
histories to the question, "_How long?_" How long have you paid that
rent, earned that wage, been without a job, taken boarders, been in
debt?
Is sickness, childbirth, alcoholism, injury a factor?
Is there any family history of tuberculosis, pleurisy, insanity,
epilepsy, feeble-mindedness? Of miscarriages or of "scrofulous"
children and "blood diseases"?
What previous hard times? What economic and moral high-water marks and
low-water marks can we trace in the past history?
What relatives, friends, employers, doctors, teachers, neighbors,
landlords, social agencies, public officials or records can be consulted
for additional light on the person and his troubles?
From all these sources one arrives finally at an opinion on "_what sort
of person_ are we trying to help--what sort physically, mentally, and
morally?" That is the central fact.
CHAPTER III
ECONOMIC INVESTIGATION BY THE SOCIAL ASSISTANT
It should be clear from what I have said already that the work of the
social assistant _may_ have nothing to do with poverty. Her only
business in visiting a family may be to assist the doctor in his
diagnosis and treatment by bringing him additional facts about the
nature, seriousness, or cause of the disease and about the means by
which it may be combated.
But in many, perhaps most, of the families whom the social assistant
attempts to befriend, there is a call for relief, for financial
assistance, for money, food, coal, and clothes. This appeal like most
medical appeals is apt to take the _form of an emergency_. Help (we are
told over the telephone) is needed at once, or disaster will follow. The
family is eager for immediate relief, not for a slow and painstaking
investigation of the causes which have led up to the present state of
things, or of the exact nature of their present troubles. They are like
the sick in this respect. Prompt relief from pain is what the sick
demand, not the tedious processes of questioning and examination. They
want a remedy, a pain-killer, morphine or its equivalent.
But we all know the dangers of giving morphine for the relief of pain.
It never cures a disease; it only stifles a symptom. It gives delicious
ease; but the need for its use soon recurs. Hence there is always
danger that before long the patient will have to fight, not only the
disease which originally caused him pain and made him call for morphine,
but the morphine habit in addition. This is all familiar. But not every
one realizes that the giving of money in case of poverty is as dangerous
as the giving of morphine in sickness. Money like morphine satisfies an
immediate need and hence is eagerly welcomed by the sufferer. But of
money as of morphine it is true that a single dose soon makes the
patient call for another, and often a larger dose; that it soon makes
the patient dependent on this sort of relief, and so forms a dangerous
habit. With the rarest exceptions, to give money or to give morphine
does not cure. The state of things which produced the pain or the
poverty is sure to recur. For (as I have said above) the patient's
belief that his present troubles are an unforeseeable accident, a sudden
catastrophe, is almost never true. The truth is that his pain or his
poverty are but the last chapters in a long story produced by causes
which can usually be traced out, and whose future action can often be
foreseen. By giving money we are covering up a smouldering fire, not
quenching it.
For economic bankruptcy or breakdown, like physical bankruptcy or
breakdown, is generally the result of _faulty organization_ in the
system of income and expenditure. Physically a person breaks down
because he has been spending more energy than he can recoup by rest,
food, and recreation. Economically he breaks down because his scale of
expenses exceeds his regular income. Hence it gives but temporary relief
to pay the bankrupt's debts, to cancel the sufferer's pain. The
operation will soon have to be done over again unless some constructive
plan for increasing his income or decreasing his expenditure can be
worked out. _Giving creates dependence_ because it atrophies industrial
and moral initiative, just as a crutch or a splint causes muscles to
waste. Powers unused atrophy. If we support a person, except
temporarily, he will soon lose the power of self-support.
But the point of view impressed upon us by the sufferer himself is apt
to be quite the opposite. What he wants is something immediate and
temporary for the relief of something accidental. The beggar who meets
us in the street has "accidentally" lost his purse and asks of us a
small sum of money to reach his home. Often I have said to such an
applicant, "Meet me at the railroad station half an hour before the
train leaves for your home. I will buy you a ticket and see you on
board." _He never comes._ This is an extreme instance and involves
almost always a deliberate attempt to deceive us. In home visiting it is
not like this. The sufferer does not usually intend to deceive.
Nevertheless his misfortunes are pictured by him as accidental and
temporary catastrophes, maiming a life which needs no general
reconstruction. He is so sure of this that he is apt to force the idea
upon us unless we are alert, bracing ourselves to question it and to
make sure that it is true. But actual experience has shown me and
hundreds of others that this point of view is almost never true.
It is not chance that the family is just now poor. It is no emergency
which we are summoned to meet. It could have been foreseen long before
and it will certainly recur unless we can trace out its causes and
prevent their acting as they have hitherto. Hence the detailed,
prolonged, individual study of the family's economic state is necessary.
One must find out, first of all, all the details of income and outgo.
The family is likely to forget some of these, so that one must be ready
to assist their memory.
Further, one must inquire carefully into possible sources of help from
relations, friends, fellow members in some club or association, and so
forth. For next to self-help the help from those naturally bound up with
one is best. Compared with impersonal charity, it is less artificial. It
is less destructive to the natural family relationships which it is
always our ultimate ideal and our immediate job to maintain or to
restore so far as possible. Whatever disturbs or threatens them is
hostile to the social interests for which we labor.
Naturally one does not invoke the help even of family, friends, or
fellow club members, unless it seems impossible for the individual,
under the best plan that he and you can think out together, to get along
without outside help. But if we are convinced that, for the present at
any rate, this financial self-maintenance is impossible, it is to
securing help from those nearest to the sufferer that one should look
with least regret. Gifts or loans from members of his family or from
friends are more likely to be taken seriously by the recipient. He is
less likely to feel (as he does with an impersonal agency or charity
fund) that he can draw from a bottomless pit of money without making any
one else the poorer. Moreover, when he takes money from his brother or
the fellow member of some club, the pressure for regaining his economic
balance is likely to be exerted from without him as well as from within.
He feels the pressure of his debt and thereby is stimulated towards
regaining his independence.
The sufferer's "catastrophic" point of view, which tends to isolate the
present trouble from all its causes, to represent it as temporary and
accidental, is related to his tendency to state that he has no friends,
relations, or social connections through whom help could come to him.
Without any deliberate attempt to deceive us, he quite naturally forgets
some of his relations. He does not want to appeal to them. Hence they
fall into the background of his mind, and are not easily recovered. When
one finds them for him he is apt to say, "I did not think of him because
I am not on speaking terms with him"; or, "I would not on any account
take money from her, or allow you to ask her to help me." But such a
sufferer may very properly be asked, "Why is it that you are willing to
take money from me, a stranger, or from this impersonal charitable
agency, when you are not willing to call upon your own relations nor
even to let them know that you are in trouble? You are concealing it
from them, are you not? Is there really any good reason for this? Will
it not be easier for you, as well as for them, that they should know at
once? Are you not really storing up trouble for yourself, postponing the
evil day which, when it comes, will be worse than anything which you
would have to bear at present?"
Of course, in all such advice we intend to say nothing that we should
not wish to have said to ourselves. The social worker tries to treat
people always as she would wish to be treated. But one cannot always
avoid giving pain or even estrangement. Because such interviews are
necessarily difficult and may result in disaster to the relationship
that we are trying to establish, they should be postponed if possible
until we have already established in other ways a friendly
understanding, a structure of friendship which will bear the strain of
penetrating inquiries such as these economic matters necessarily entail.
I have said that the first guide to helpful economic relief is a
realization of its danger. The next is awareness of the advantages of
self-help and the truth that next to self-help, assistance from those
naturally and nearly related to one is best.
The third principle, by following which we may hope to do the greatest
good and run the least risk of harm in our giving, is this: never give
hastily except in extraordinarily rare emergencies such as acute hunger
or exposure to the elements. In all other cases give in accordance with
a plan worked out as carefully as may be, whereby we are confident that
our giving can be temporary. Sometimes we can arrange that it shall come
to an end automatically. That usually means that we arrange for a loan
rather than a gift, with repayment either by instalments or in lump sum
upon a definite date.
(_a_) _Loans._ It is in the hope of rendering service by these means
that there have been organized philanthropic loan associations which
lend money at low rates of interest and sometimes without interest or
upon security which the commercial loan companies would not accept. The
sufferer with whom we are dealing may know nothing of the existence of
such agencies. If so, to connect him with one of them, to help in
furnishing the security necessary to negotiate a loan, may perhaps be
the best way in which we can help. Or one may buy some rather expensive
article such as a piece of medical apparatus, with the clear
understanding that we are to be repaid in instalments or at weekly
intervals.
(_b_) _Tools of a trade._ Another example of the kind of giving which
comes to an end and does not tend to form a habit like the morphine
habit, is exemplified when we buy a man the necessary tools of his
trade, or the stock and furniture necessary to start a store. The belief
on which we rest in such cases is that after the initial act of
acceptance, after an initial period of dependence, the individual will
become self-supporting and independent.
(_c_) _Furniture._ Or, again, one may give or loan a cooking-stove, so
that the sufferer may no longer have to eat at restaurants, or some
furniture in order that he may get the benefit of the lower rent to be
had when one hires an unfurnished room. In all these cases the ideal
thing is to arrange for repayment in small instalments. Failing this we
try to think out a plan such that after the original expenditure the
sufferer will be able to go on independently.
(_d_) _Aid in illness._ A fourth example of temporary interference in
the form of financial aid, is a gift or loan of money to tide a person
over an illness, to make his convalescence complete or to rest him when
he is dangerously tired. Usually such aid can be rendered through
services or institutions (nurses, hospitals, convalescent homes) which
do not involve giving money outright.
(_e_) _Aid during unemployment._ A fifth good reason for giving money or
other forms of relief temporarily is to tide the sufferer over a period
of unemployment, during which he is actively looking for work or for
better work than he now has. Sometimes we can assist him in this search.
But there is danger in this. A man is less likely to keep a job that
some one else finds for him than one which he finds for himself. Still,
we may help him without harming him in case we can give him facts,
names, positions, employment agencies by means of which he may secure
employment, he himself taking the active part in securing the job.
_Information, which is what we here furnish, is one of the least
dangerous of gifts._
In all these cases the principle is like that whereby we do surgery.
Surgery is a temporary injury to the body done with the expectation of
ultimate good, a temporary interference of outside powers with the
natural self-maintenance of the organism, in order that those functions
may ultimately go on not only independently, but more satisfactorily
than before. The surgery may kill the patient, or leave him worse than
he was before. But our reasonable expectation is (in case our surgery is
good) that his health--that is, the capacity of his body to maintain
itself, or develop itself--will be improved. So in economic surgery we
foresee a speedy end to the need for aid. The person is to be put upon
his feet by our aid; our services can soon be dispensed with. The need
will not recur. It is not chronic. It was not his fault and therefore is
not likely to return upon him soon because of continuance of the same
defect.
Obviously one must try to make clear--or, still better, try to have it
clear without explanation, understood because of our previously
established relation of trust, confidence, and affection--that it is not
because of parsimony or close-fistedness that we are refusing to give
quickly, constantly, and without inquiry. Medical analogies must
constantly guide us and be in the minds of those whom we try to help.
We refuse money, as we refuse morphine, for the patient's good. We try
to make our giving of money temporary and self-checking, for the same
reason that we try never to begin giving morphine unless we can foresee
a speedy termination of it, a speedy cessation of the need for it, as we
do when we give it in gall-stone colic or acute diarrhea, or just before
a surgical operation. If morphine were a possession of the doctor's, as
money is a possession of the visitor or those whom she represents, then
the doctor might often seem stingy, cruel, selfish in his refusal to
give it. We must make it clear if we can that our hesitations,
limitations, or refusals in relation to money have no more connection
with our own control over that money, our own enjoyment of it, our own
sense that we have any right to it, than the doctor's refusal to give
morphine rests upon his desiring to take the morphine himself instead of
giving it.
All this is difficult to make clear, and it is chiefly for this reason
that I have repeatedly insisted that the financial approach, the
financial ground for an _entente cordiale_, should not be used early in
our dealings with the sufferer, but should if possible be postponed
until, through medical service and personal intimacy, something
approaching true friendship has been established.
It should be clear from what I have said that our judgments about giving
financial aid can be sound, can result in doing good without harm or (as
in surgery) good with a small element of harm, only in case they are
the fruit of detailed, prolonged, individual study. It cannot be a
wholesale matter. It cannot be done in exactly the same way in the case
of any two individuals.
Let us stop to realize for a moment how arduous, how bold a task we have
undertaken. We hope to construct a person's economic future better than
he can construct it himself. We hope to see what the individual himself,
despite the vividness and pressure of his immediate need, has not been
able to see for himself--namely, how he can get himself out of his
financial difficulties. We who do not wear the shoe are venturing to say
where it pinches and how the pressure may be relieved, and to know about
this better than the sufferer who feels the pressure in his own person
and longs for its relief as it is hardly possible for any one else to
desire it. It is almost as if we were trying to use his mind for him. It
must not be that. But if it is not to be that, we must be sure that our
aid is given through stimulating the individual to think for himself.
"What do you think," we must constantly be asking him, "is the best way
out of this our difficulty?" He must feel that we know it to be _our_
difficulty as well as his, that we are not looking on with the cold gaze
of an outsider, that we suffer in his suffering, and still that it is at
last his, and that with all our best efforts we can only contribute a
little to what must be for the most part his own reconstruction, a
reconstruction like that which the body performs when it heals a wound
which the surgeon or the physician can only encourage a little towards
its natural healing.
Without being impudent enough to attempt to use the sufferer's mind for
him, to force our wills upon him, to take his burdens off his shoulders,
to fill his place or to assume his responsibilities, we must try to help
him in all these respects, largely by the kind of sympathy which
stimulates, the kind of affection which encourages, the affection which
changes useless brooding, ineffectual worrying, destructive grieving,
into their opposites. We can help him to think by suggesting resources,
possibilities that he does not know or that he has forgotten, by
furnishing new material on which his mind may work, by helping to
generate the power, the hope, the concentration, the prolongation of
thought out of which new solutions may be born. He must really think of
something new. He must really invent something, if he is to get upon his
feet and become independent once more. Ordinarily necessity is the
mother of invention. We pull ourselves out of our difficulties when we
finally realize that we must because disaster is otherwise imminent. But
such pressure of necessity as would generate inventiveness in one
person, may generate only despair in another. It is to avoid this
tragedy, it is to make fruitful what were otherwise fruitless, that we
hope to warm the sufferer into better life. We hope to rouse in him, by
affection or by the stimulus of new facts (perhaps), the courage
necessary to see his situation afresh and to reshape it.
Because we are comfortable where he is suffering, because we have free
power of thought whereas his mind is numb and cramped, we may be able to
think of some possibilities, some changes, some sources of hopefulness
which he could not even imagine. He cannot take them from us ready-made.
If he does they will be useless to him. But if we have reached the
central fire of his life, if we have stimulated not this faculty or
that, but the centre of his personality, then by the grace of God we may
be able to do with him what he alone could not do.
_Housing_
A part of the economic life of our patients, aside from the food and
clothes for which they may most urgently ask our aid, is their housing.
(_a_) Is it hygienic?
(_b_) Is it as inexpensive as can be obtained with due
consideration of health, decency, distance from work, from friends,
from amusements?
(_c_) Is it large enough to safeguard the decencies of family life?
The last of these questions is the most important of all.
It should be among the medical duties of the visitor to investigate the
hygienic aspects of the home in order to explain them to the doctor, who
can then include them among the facts on which his diagnosis,
prognosis, and treatment are based. The social worker may then try to
carry out such improvements in housing as the combined judgment of the
doctor and the social worker suggests. More important than medicines,
often, is the provision for proper warmth and proper ventilation of the
patient's rooms during the day and especially at night. Darkness, dirt,
poor ventilation, favor the growth of germs, vermin, parasites of all
sorts. They also depress the vigor and power of the human organism to
resist disease. Doctors and social workers cannot hold Utopian views in
matters of housing, but must content themselves with trying to secure
something a little better than they find in the worst of the patient's
lodgings, especially when these lodgings represent conditions below the
family's own standard of living at some previous time. People adapt
themselves wonderfully to bad hygienic conditions, and once so adapted,
they may be able to preserve their health for a long period. But if then
a family is suddenly forced to crowd itself into smaller, darker,
dirtier, noisier quarters than it has been used to, or if a family group
increases its numbers within the same quarters, the adaptive powers of
the human organism may be overstrained and break down.
It is against these conditions especially that the social worker and the
doctor should labor. Housing problems are among the most difficult of
all that confront society. Yet we should pledge ourselves to attempt
some improvement, not disdaining slight gains because we are enamored of
distant Utopias.
Sometimes people are living beyond their means, are accepting bad
quarters at high prices when they could get as good or better quarters
for less money in some less crowded and popular district. Human beings
have a strong tendency to stay wherever they find themselves, to settle
down by chance and resent any suggestion of change even for their own
greater comfort. After a few months any place soon comes to have the
attractions of home merely because we have been there. Hence we stick in
the same place, though we may know that it is chance and not choice or
necessity that has put us there. Under these conditions a social worker
may do real service by her greater knowledge of other lodgings at lower
prices, or (what is essentially the same thing) better lodgings for the
same price now paid. If the social worker is familiar, as she should be,
with the lodging conditions in the neighborhood in which she works, she
may be able to give a patient facts about lodgings which were either
unknown to him, or more probably unrealized, because he has never seen
them. Our mental horizon becomes restricted. Any one who enlarges it by
presenting new and helpful possibilities serves us well.
So far I have spoken of the housing question mostly from the standpoint
of health or cheapness, but, as I have already suggested, the moral
aspects of the problem are still more important. It is difficult, for
many impossible, to preserve personal decency and to keep family
morality at a proper level, when adults and grown-up children are forced
to sleep in the same room. Lifelong injuries to body and soul may be
forced upon innocent children in this way. Nothing can be more important
than this. We must remember, however, that custom and previous habits
play a vast part here. One race or one set of people may have so
adjusted themselves as to preserve decency under conditions impossible
for another. We cannot generalize. We must know the particular people
with whom we are dealing, and we must know their previous habits and
standards in case they have shifted their lodging or increased the
number of persons in a room within a short time, as is so frequently the
case.
_Working conditions_
Work and the conditions of work are among the most important and the
most difficult of the economic problems in which a social assistant may
find herself inevitably involved. These concern the patient's trade, the
physical and moral conditions under which he practises it, his fitness
or unfitness for it, the wages he receives, the future possibilities of
advancement in pay and type of work which it offers. In all of these
problems the social worker can sometimes help a little because of her
greater freedom of mobility, mental and physical. She is not tied to her
task as blindingly, as deafeningly, as the manual worker is. She may
know more or be able to find out more as to labor markets, as to other,
possibly better, positions, shops, employers. She may be able to see,
better than the worker himself, his fitness or unfitness for the work he
is doing. She may be able to realize better than he that his trade
presents an _impasse_, has in it no possibilities of development,
personal or financial. She may realize better than he the bad effects of
his work upon health or morality. In all these respects she may be able
to give the safest, and in some ways the most satisfactory, of all
help,--namely information.
I do not underestimate the difficulties of such help. It is not easy to
know more about a man's business than he does. Yet if the social
worker's education, her health, her circle of acquaintances, is greater
than that of the wage-worker, she may really be of some assistance to
him even in the field that is more specially his own and that she can
understand but superficially. It is for this reason among others that
the social worker cannot be too broadly educated, too fresh physically,
too vigorous in her powers of thought and observation, too widely
acquainted in her community.
Among the problems growing out of the basal economic needs of which I
have just spoken, are others with which I cannot here deal adequately.
Such are:
(_a_) The problem of industrial hygiene and industrial disease.
(_b_) The problems of school hygiene and school medicine, since school
life is the industrial life of the child, who even receives wages for
going to school in some communities.
(_c_) The industrial and psychological problems of those who are maimed
by accident, war, or disease.
(_d_) The problem of industrial insurance and health insurance.
All of these questions involve matters of State action, legislative
control, and economic reform with which I do not wish to deal. But I
wish to make it clear, in closing this chapter, that the social worker
as a citizen is as much interested in these hopes for radical economic
reforms as any one else can be, though she does not regard them as her
special business.
Preventive medicine and the daily fight against individual cases of
disease which we hope some day to prevent--these two activities go on
side by side, each helping the other. The social worker corresponds to
the private practitioner of medicine; the economic reformer and
discoverer corresponds to the laboratory student of preventive medicine
or to the public health official. In social work as in medicine the case
worker should bring to the inventor and reformer new facts and
illustrations suggestive of the evils to be reformed or possibly of the
ways of combating them. And in the difficult, often disappointing, task
of trying to help individuals, the case worker will also take part of
his inspiration from the hopes and ideals of a better economic order
sketched for him by the legislative reformer. The method and technique
of economic investigation is complex and difficult. For a masterly
treatment of this and all other aspects of social diagnosis Miss Mary E.
Richmond's epoch-making book on "Social Diagnosis" should be consulted.
(Published by the Survey Associates in New York City.)
CHAPTER IV
MENTAL INVESTIGATION BY THE SOCIAL ASSISTANT
Ever since the days of Charcot, France has been the land of medical
psychology. France has never failed, as other countries have failed, to
take full account of the mental factors, the mental causes and results
in disease.
In America, on the other hand, the conspicuous disregard of medical
psychology by physicians has led to widespread and serious revolt on the
part of the public. Our physicians have too often treated the patient as
if he were a walking disease, a body without a mind. Medical psychology
has been neglected in our medical schools and in the practice of our
most successful clinicians. The result has been a revolt upon the part
of the laity, expressed in the popularity of the heretical healing cults
such as Christian Science and New Thought. These unscientific and
unchristian organizations illustrate an error opposite to that of the
physicians, but no greater in degree. Indeed, I think that our
physicians are more to be blamed than the leaders of these irrational
cults, because our physicians having received a scientific training
ought to be more thorough, more unprejudiced, more devoted to the truth,
and therefore less inclined to shut their eyes to a huge body of facts.
The physician often shuts his eyes to the existence of the mind as a
cause of disease. The Christian Scientist shuts his eyes to the
existence of the body as a cause of disease. Both are equally and
disastrously wrong. But the medical profession is on the whole more to
blame, because they ought to know better, whereas the heretical healing
cults have grown up among uneducated men who could not be expected to
avoid the sort of narrowness and prejudice from which liberal education
ought to free us.
The situation in America, then, is very different and on the whole worse
than in France. There, scientific men, educated physicians have taken
the leadership in the field of medical psychology. In America it has
been left for ignorant enthusiasts, devoid of any scientific training or
breadth of culture, to press upon our attention the neglected elements
of medical practice, and to lead a revolt against the medical
profession, an anti-scientific revolution which numbers its adherents by
millions. But in neither country has our established knowledge of the
mental elements of disease been properly incorporated into medical
practice, especially into the practice of dispensary physicians, and it
is here that the social worker forms an essential link in the chain of
effective action. Let me describe more completely what I mean by the
mental element in disease.
I refer not merely to the so-called nervous diseases, the neuroses and
psychoses, the myriad forms of nervousness without recognizable basis in
organic disease, but also to the mental complications and results of
serious organic diseases such as tuberculosis, arteriosclerosis, and
surgical injuries. The classical studies of Charcot, Pierre Janet, and
others have made clear to the whole world the existence of a body of
diseases in which the mental functions are obviously deranged while
still the patient is not insane in any legal sense, and does not show on
physical examination any evidence of gross organic disease.
Neurasthenia, psychasthenia, hysteria, are among the more common types
marked out by the studies of great psychologists and clinicians. Little
or nothing has been added by the studies of German, American, and
English physicians to our knowledge of these diseases. But throughout
the history and development of France's leadership in the study of these
diseases, one cannot help noticing that interest is concentrated largely
upon diagnosis; comparatively little attention is paid to treatment. The
great leaders have not been extensively followed. Their suggestions have
not been carried out on a large scale nor followed sufficiently into the
field of practical therapeutics.
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.
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:
[1] Conférence Interalliée des Mutilés. Paris, May, 1917.
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.
Make a person face "the worst" and you disarm its terrors.
"But suppose I get faint on the street?"
"Well, you probably will just sit down on the curbstone until you come
to."
That remark does not sound as if it would reassure a person even if
made with a laugh. But it does, because he is thereby freed of a fear of
something much worse, a fear that lurks in the background of his mind.
There is one other thing to be said about the treatment of fears. If a
person fears to do any particular act, such as going to church or into
the subway, if he fears to be alone in crossing a big square, if he
fears to get into a crowd (all these are common fears), the most
important thing is to _force him to do what he most fears_.
"Do the thing you are afraid of, or soon you will be afraid of something
else as well. And the more you do what you fear to do, the less you will
be afraid of it, because your act will bring you evidence of the truth.
Your act will prove to you that you can do the thing that you fear you
cannot. That fact will convince you a great deal more than all the
talking that your doctor or anybody else can do. You will get conviction
by reality, the best of all witnesses."
Among the poor, with whom we deal part of the time in social
work--though I insist that social work is concerned with the rich as
well--we have to face _economic fears_. In America and England economic
fears are a very real evil--fears of the work-house, fears of coming to
be dependent, of having no place of their own, are what poor people
often dread. Again, the clue for our usefulness is to find out what
people do not tell us of these economic fears, and then to see if we can
make them groundless.
In a certain number of people (I do not feel competent to say how large
a portion), life is rendered miserable by _the fear of being found out_.
I happened, as I have already said, to get driven some years ago into a
position where I thought it best to swear off medical lying. One of the
surprising parts of this experience was the sense of relief which I felt
when I knew that there was no longer anything in my medical work that I
was afraid of having any one find out. It was in benevolent, unselfish
medical lies that I had been dealing, according to the ordinary practice
of the medical profession. But as soon as I decided that I could abandon
these and need no longer fear that any patient might find out what was
being done to him, I had the sense of a weight taken off my shoulders.
_Forgetfulness_
There is a very eloquent passage in one of Mrs. Bernard Bosanquet's
books[2] about social work, in which she describes the psychology of the
poorer classes among whom she worked in London, and dwells especially on
their characteristic forgetfulness. They cannot learn because they
cannot remember. They cannot learn how to avoid mistakes in future
because they cannot remember past mistakes. One well-known difference
between a feeble-minded person and a person competent to manage the
affairs of life, is that the former forgets so extraordinarily, and
therefore cannot build up through remembrance of his past how to steer
better through the future. Of course we all of us have this disease in
varying degrees. We all forget, in the moral field as well as the
physical, things that we ought to remember. There are things that we
ought to forget. After we have started to jump a fence, we must not
remember the possibility of our failing. The time to remember that is
before we have begun to jump. Moreover, there is no particular benefit
in remembering our own past mistakes if they are such that we cannot do
anything about them, morally or any other way.
There are things, then, that we ought to forget, but allowing for these,
forgetfulness means forgetting the things which we ought to remember. In
alcoholism it is extraordinary how much the person forgets. One cannot
fail to be struck by the fact that the alcoholic gets into trouble again
and again because he cannot fully remember what happened before. In the
field of sex faults this truth is equally obvious. A man is unfaithful
to his wife because he allows himself to forget his wife--his memory of
her is for the moment blotted out. Nobody could violate his own
standards in this field if he could vividly remember them. Hence if we
are to help any one else to govern himself in matters of affection we
must help him to remember, help him _by planning devices that make it
nearly impossible to forget_.
Bad temper can ordinarily be explained by forgetfulness. We can hardly
lose our temper with a person if we remember the other sides of his
nature opposed to that with which we are just now about to quarrel.
Nobody consists wholly of irritating characteristics. We all possess
them; but we all possess something else besides. Hence if we can realize
some of our own moments of wrath, I think we must confess that for the
moment the person with whom we were enraged possessed for us but a
single characteristic. The rest were forgotten.
My account of these five common types of mental deficiency: ignorance,
shiftlessness, instability, fears, forgetfulness, is general and vague.
I mean to make it so. If my suggestions are of any use to the reader it
will be because he is able to make his own specific applications. I
want, however, to mention one example of a much more specific fault,
namely, _nagging_. In social work we often see families broken up or
seriously cracked by some one's nagging. It consists in reminding people
of their defects and shortcomings in season and out of season, until the
reminder finally gets upon their nerves. You are aware that your
husband, your wife, your child, has some very deleterious fault.
Admittedly he has it and it is constantly getting him into trouble. So
you want to be quite sure that it never gets him into trouble again;
and hence you keep reminding him of it again and again until you produce
an irritation that only aggravates the original fault.
Why do I take so trivial and specific a case as this? Because I can
remember several cases where I could not possibly leave out nagging when
I came to make my social diagnosis. It was one of the chief factors. One
cures this disease, in case one does help it at all, by making the
nagging person conscious of what it is that he is doing. The nagging
impulse is like an itch. _It recurs and scratching does not stop it._
The nagger does not know quite why he does it; he finds himself doing it
almost in his sleep. Hence we try to wake him up, to make him conscious,
if we can, of his foolishness, of the kind of harm he is doing, and of
the degree of incurability he is inducing in the person whom he is
trying to cure.
I will now sum up the last four chapters in a diagram which we have used
in Boston at the Massachusetts General Hospital to assist us in making
our social diagnoses. A social diagnosis can very seldom be made in one
word, such as _idiocy_ or _tramp_. It must include the patient's
physical state. It must summarize a person's physical, moral, and
economic needs. Our best social diagnoses, such as _idiocy_ or
_feeble-mindedness_, do not refer to the mind only. They refer to the
body just as much. Feeble-mindedness is a statement about the child's
body, his brain, his voracious appetite, the diseases to which he is
likely to succumb, his extraordinary susceptibility to cold, and his
poor chances of growing up. One says a great deal about the physical
side of a child as soon as one pronounces the word "feeble-minded." Also
one says a great deal about his financial future. One knows that the
feeble-minded child will never rise beyond a very low point in the
economic scale. One says also a great deal about his moral future. We
all know to what sexual dangers and temptations he is especially
exposed. And on the purely psychological side one can predict his entire
unteachability beyond a perfectly definite limit. All this is given in
the medical-social diagnosis, "feeble-mindedness."
This is an example, then, of an ideally complete and compact, though a
very sad, social diagnosis. It is almost the only good one we have
worked out as yet. The only other is "tramp." The tramp in a technical
sense is a person who has what the Germans call "Wanderlust." He is
unable to stay in one place. Perpetually or periodically he desires to
move and to keep moving. The tramp is a medical-social entity. He has
certain physical limitations, certain economic limitations, certain
moral deficiencies. But in America he is rather a rare being. One does
not see many typical tramps here.
Since few social (or medical-social) diagnoses can be stated in a single
word, one is usually forced to write down one's diagnosis in a great
many different items. As a guide I made four years ago a schedule for
our use at the Massachusetts General Hospital. Use--the only test for
that sort of thing--has shown this schedule to be of some value.
+ 1. Physical--+ a. Heredity.
| + b. Health.
+ I. The Individual --| + a. Mental deficiency.
| + 2. Mental --| b. Mental disease.
| | c. Temperament.
| + Character.
Diagnosis |
shall -| + a. Food. Clothes.
characterize| | Housing.
| | b. Industrial
| | conditions.
| + 1. Physical--| c. School conditions.
| | | d. Climate. Natural
| | | beauty or
+ II. His Environment-| + ugliness.
| + a. Family and
| | friends.
+ 2. Mental --| b. Education.
| Play.
+ c. Religion.
To make a social diagnosis we should make a summary statement about the
individual in his environment. That summary is to include his mental and
physical state, and the physical and mental characteristics of his
environment. (I here use the word "mental" to include everything that is
not physical; that is, to include the moral, the spiritual, every
influence that does not come under physics or chemistry.)
When the investigation of a patient is divided between doctor and social
worker, the doctor studies his physique; the social worker studies the
rest. I believe that there is nothing that we can want to know about
any human being, rich or poor, that is not suggested in that schedule.
Suppose, reader, that a friend of yours was engaged to be married.
Suppose you wanted to know something about the fiancé. You would
certainly want to know about his health and his heredity; then what sort
of a person he was, his mentality, whether he had any money--what are
the obvious physical facts about his environment. To what influences has
he been subjected, and what mental supports, such as education and
recreation, family, friends, and religion, can he count upon? You would
not want to know any more and you ought not to want to know any less.
So in summing up a social diagnosis I think it is convenient to use the
four main heads that I have put down here. I think these headings will
remind us of everything that we want to put down, and of everything that
we may have forgotten to look up. That is one function of such a
schedule--to remind us of the things which we have forgotten.
Made up in such a way as this, of course the social diagnosis will have
many items, and like medical diagnosis it will be subject to frequent
revisions. The doctor who never changes his diagnosis is the doctor who
never makes one, or who makes it so elastic that it means nothing. So
social workers should never fear to add to, to subtract from or to
modify their social diagnoses.
The best medical diagnoses--those made after death--often contain
fifteen or twenty items. Before death in a recent case we found
pneumonia. After death we found in addition: meningitis, heart-valve
disease, kidney trouble, gall-stones, healed tuberculosis, and ten minor
troubles in various parts of the body.
So a good social diagnosis will name many misfortunes of mind, body, and
estate, healed wounds of the spirit that have left their scar,
ossifications, degenerations, contagious crazes which the person has
caught, deformities which he has acquired.
FOOTNOTE:
[2] Bosanquet, Helen. _The Standard of Life and Other Studies._ (London,
Macmillan & Co., 1898.) _The Family._ (London, Macmillan & Co., 1906.)
CHAPTER VI
THE SOCIAL WORKERS' INVESTIGATION OF FATIGUE, REST, AND INDUSTRIAL
DISEASE
_Fatigue and rest_
Fatigue is more important for medical-social workers to understand than
any single matter in physiology or any aspect of the interworkings of
the human body and soul, because it comes into almost every case from
two sides: (_a_) from the workers' side because the quality of work that
she puts into trying to help somebody else depends on how thoroughly she
is rested, and how much she has to give; and (_b_) from the side of the
patient, his physical, economic, and moral troubles, because fatigue is
often at or near the root, of all these troubles. It is unfortunate that
in spite of its importance, we do not know much about fatigue from the
physiological point of view. Since the war of 1914-1918 we have
prospects of knowing more about it than ever before; for one of the
grains of good saved out of the war's enormous evils has been the
fruitful studies of fatigue made in England, studies more valuable than
any that I know of.
Let us take fatigue in some of its very simple phases, as it applies to
your life and mine. The first thing to recognize is that it can affect
any organ; our stomachs can get tired just as well as our legs. When a
patient complains of pain, vertigo, nausea, we first ask ourselves,
"What disease has he got?" That is correct. Disease must be found if it
is there. But the chances are he has no disease, but only a tired
stomach, since fatigue easily and frequently affects that organ. When
the whole person has been strained by physical, moral, and especially by
emotional work, he may give out anywhere. He may give out in his weakest
spot, as we say. That weak spot is different in different people.
Therefore the study must be individual. We cannot do anything important
with our own lives until we learn how and when we get tired. It is the
same with people whom we try to help in social work.
Fatigue, then, may be _referred_ to any particular spot in the body.
People often go to an oculist to see what is the matter with their eyes,
when there is nothing in the world the matter with their eyes: the
honest oculist tells them that they are tired, and that for some reason
unknown to him their fatigue expresses itself in the eyes.
This is a very common and very misleading fact. The patient finds it
hard to believe that medicine ought seldom to be put on the spot where
he feels his pain. If the pain is in his stomach he wants some medicine
to put in his stomach and not a harangue on his habits, which is usually
the only thing we can really do to help him. If he has a pain in his
back he wants a plaster or a liniment for his back. It is very hard to
get people out of that habit of mind, and we shall surely fail unless
we are clear about it ourselves. It must be perfectly clear in our
minds, or better, in our own experience, that fatigue may be referred to
one spot or to another, in such a way as seriously to mislead us. I
suppose that half of all the pains that we try to deal with in a
dispensary--and pain, of course, is the commonest of complaints--are not
due to any local or organic disease in the part. Doubtless there are
some wholly unexplored diseases or disturbances of nutrition in that
part, as there may be in the eyes when they ache because you have been
walking up a mountain. But medical science knows nothing about that.
What we do know is that the pain, if it is to be helped, will be helped
not by thinking about that spot or doctoring it, but by trying to get
that person rested.
Fatigue, then, ought to be one of our commonest medical-social
diagnoses, and to help people out of it, one of the attempts that we
most often make. In Dec., 1917, a dozen or more Y.M.C.A. boys consulted
me in France, all with coughs, all wanting medicine to stop the cough,
and most of them a good deal disappointed because they were told to go
home and go to bed, told that they were tired, and that this fact
depressed their resistance against bacteria, so that bronchitis or
broncho-pneumonia resulted.
The second point, then, that one wants to make about _fatigue is_, that
it is _the commonest cause of infectious disease_. Pasteur's great
discovery, which set modern medicine upon the right bases, sometimes
gets twisted out of perspective. Sometimes we fail to realize that the
seed may fall upon stony ground. The seed, of course, is bacteria, and
its discovery was Pasteur's immense service to humanity. But Pasteur was
so busy that he did not emphasize the truth that a seed can fall upon
good ground or upon bad ground. When bacteria fall upon bad ground, that
is, upon healthy tissue, they do not grow, they do not spring up and
multiply. Tired tissues, as has been abundantly proved by animal
experimentation, are prone to infection. They are good soil for the
growth of bacteria. It is true generally; it is true locally. A part
that has been injured, for instance, a part that has been bruised
without any break in the skin, without the entrance of any infection
from the outside, is damaged by something that hurts its resisting power
as fatigue does. Such a part will often become inflamed, will often
become subject to the action of bacteria which must have been in the
body already, but which had been kept on the frontier by our powers of
resistance.
Our "powers of resistance," then, which we cannot more definitely name,
which we do not as yet know to be identified with leucocytes or with
anything else, can get tired. When they get tired we "catch" a cold or a
diarrhea, or a hundred things which seem to have nothing to do with
fatigue, but _have_ nevertheless.
_Accumulated fatigue or physical debt._ If you go up a long flight of
steps at a moderate rate, you can get to the top without being tired;
if you go up at a rapid rate, as most of us do, you are tired at the
top. Physically you put out the same amount of energy, I suppose. I do
not see that there can be any considerable difference in the energy
consumed by the performance of that act whether we do it slowly or
quickly. The difference is that in the first case we _rest between each
two steps_ as we rest between each two days at night. When our
activities are so balanced as not to run in debt, we rest between each
two steps. You and I can walk at our individual peculiar gait on the
level for a long time without any accumulation of fatigue, often with
refreshment. But push us and we are soon exhausted. Suppose that our
normal walking rate is three and a half miles an hour; push us to four,
and it may not be a quarter of a mile before we are done up, because we
have not been able to avoid accumulated fatigue by resting between each
two steps. It has been said that in rowing the crew that wins is the
crew that rests between each two strokes. The person who does not get
tired is the person who rests between each two days. He does not
accumulate fatigue. It is the accumulation that finally breaks you,
makes you bankrupt. It is the little unnoticed bit added day by day,
week by week, month by month, that makes the break.
Fatigue we should think of as running in debt. One of the figures of
speech that has served me best in teaching patients how to live is that
figure of income and outgo. I have often said to people, "Physically
you are spending more than you earn, not to-day merely, but right along.
You must earn more than you spend. You must get a plus balance in the
bank. Then you can run along with fatigue or illness."
That figure of speech helps us also to express another fact about
fatigue, which is important to recognize in ourselves and in our
patients, because otherwise we get thrown off the track: _delayed
fatigue_. The first day that your income begins to be less than your
expenditures, nothing necessarily happens. The bank does not proclaim
that there is no deposit there. It is some days later, usually, that you
begin to reap your troubles. It is the same in physical fatigue.
Patients say to us, "I slept ten hours last night. I spent a virtuous
Sunday. Why should I be tired to-day?" We should answer, "Because of
something you did last Tuesday or thereabouts." We all are familiar with
this in relation to sleep. It is not the day after a bad night, but
several days later that its effects depress us.
Delayed fatigue, then, is an important thing to notice in ourselves and
to bring home to the people that we are trying to help. I suppose one
could say that _a great part of our business in social work is to call
people's attention to things_; if they have recognized them before, they
will perhaps get a lesson out of what we say. Such matters are _referred
fatigue_, _delayed fatigue_, _accumulated fatigue_,--familiar enough,
only the person does not act on them because he does not notice them.
The fatigue-rest rhythm, the alternation of fatigue and rest, I have
already phrased by the metaphor of earning and spending. You can phrase
it
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