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.