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

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

Richard Clarke Cabot

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

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.

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 "Œuvre 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.

PART I

Medical-Social Diagnosis

CHAPTER I

THE MEDICAL STANDING, DUTIES, AND EQUIPMENT OF THE SOCIAL ASSISTANT