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

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

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

FOOTNOTE:

CHAPTER V

MENTAL INVESTIGATION BY THE SOCIAL ASSISTANT (continued)

Fears and forgetfulness

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

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

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

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

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

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

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

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

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

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

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

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

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

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 - Bosanquet, Helen. The Standard of Life and Other Studies. (London, Macmillan & Co., 1898.) The Family. (London, Macmillan & Co., 1906.)] 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.

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.

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.