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

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.