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

by Richard C. Cabot

I remember a case of very early tuberculosis, but recently established at the summit of one lung, but unfortunately occurring in a patient of very active temperament, prone to fume and worry the instant that he was taken away from his work. He was devoted to his family, but as soon as he was aware of his trouble, he could think of them only as doomed to be dragged down by the contagion of his own disease or by the poverty resulting from his own inactivity. Unfortunately, no proper study was made of this patient's malady. No account was taken of his character and temperament. The condition of his lung occupied the whole field of the physician's vision. The condition of that lung demanded for the patient isolation and complete rest in a sanatorium. This was prescribed and carried out. The patient remained in the sanatorium about two months, fuming and worrying constantly. He then refused to stay any longer, left the institution against the advice of his physician, returned to his family, and died about two months later.

Now I think it is at least probable that had we studied the patient's mind as carefully as we studied his lung in this case, his life might have been saved. But the physician who made the diagnosis and prescribed the treatment could spend but a few minutes upon the case, which formed but one of many trooping past him in his consultation hour at the dispensary. He had no time for the prolonged, detailed, wearisome studies necessary to win this patient's confidence, to make him feel that he was wholly understood, and bring him to the point when he would let himself be reëducated upon the mental side and receive docilely the advice given him. This work should have been carried out by the right type of social worker. Such a visitor would no doubt have realized that one must compromise to a certain extent with the difficulties of the patient's temperament. One must adapt and modify the treatment suitable for the average case because this particular patient differs from many others in important respects.

In the first place, he must be made to understand the importance of a correct mental attitude for the cure of his disease, must be taught that his recovery depends to a considerable extent upon his own efforts at self-control and self-education. Next he must be convinced that his family will be adequately cared for during his absence from work. Furthermore, the complete rest in bed which would probably be advisable for him if one had only the condition of his lung to consider, should probably in his case be modified owing to the fact that his mental state makes it impossible for him to rest when he is confined to bed. In such cases one has the outward appearances of repose but not the reality, one clings to the form but misses the substance. What one has prescribed is in reality enforced impatience, enforced restlessness, because one has put the patient under a régime where no result can be expected except impatient struggling against restraint. Such a patient should be allowed a certain amount of work, carefully chosen and supervised, so as not to exercise the larger muscles of the body and thus produce fever, but sufficient to occupy an active mind and to make the patient forget himself. To find such occupation is difficult, no doubt, but it is not impossible. I have seen it done. In the case which I am now considering, no such effort was made. The patient was excessively lonely and isolated in the sanatorium to which he was sent. The doctor's visits were occupied with physical examination and the reiteration of commands that he should stop worrying and remain completely at rest.

Such treatment violated grossly one of the basal laws of medical psychology, which recognizes that no one ever stops worrying because he is told to do so. To give such a command is as irrational as to tell an epileptic not to have convulsions or a choreic patient not to wriggle his hands. Yet this sort of error is constantly committed by physicians who have been well trained to understand the physical changes of disease, but have never concerned themselves to recognize the simplest and most obvious facts about the mental condition of the sick. As I have already said, it is impossible for the dispensary doctor to become acquainted with the details of the patient's malady, or to find out by investigation and experiment how the patient's mind may be made to aid his recovery rather than to impede it. This is the proper task for a social worker, partly because she has more time, partly because she is a woman, and is for that reason more fitted to get into close touch with the patient's mind and to use skill and tact in managing him.

Such studies of the social worker are equally important in the case of the functional neuroses; for example, in the cases where the patient's troubles can be most effectively attacked by ridding him of his fears. Fear plays a dominant role in the sufferings of many cases both of organic and of functional disease. In a recent examination of six hundred and sixty-two young men about to enter Harvard University, it was found that "there were more boys who thought they had a serious organic defect, usually of the heart, and were found entirely sound than boys who thought they were well and had disease." They had been threatened with heart disease by gymnasium instructors or ill-trained physicians. They had in consequence restricted their physical activities and been haunted by the fear that they might by some unusual exercise of mind or body make themselves seriously ill or perhaps suddenly die. Such fears were all the more disastrous in these young men for being only half realized by themselves. It is exactly these shadowy apprehensions, these dreads which dwell in the half light, never quite faced in full consciousness, which torment and incapacitate us the most. Careful physical examination showed that the young men just referred to were free from all disease, and the clear and emphatic statement of this fact rendered a prompt and important service.

But if such fears haunt the students about to enter Harvard College, who are young men drawn from the better educated and more well-to-do classes, we may be sure that fear plays even a larger part in producing the sufferings of patients such as we examine and treat in a public dispensary. For such patients are very apt to be influenced by groundless rumors, panics, neighborhood gossip. They are prone to believe medical lies which they read in newspapers and in the leaflets and circulars sent to them by charlatans. Almost all their medical education comes to them from such sources, and is made up of a mass of systematic falsehoods designed to excite fear and to produce symptoms by suggestion.

Now if it is true that even among educated and relatively self-conscious classes the most troublesome and incapacitating fears are those which are but dimly known to the patient himself, this is sure to be still more frequently the case among dispensary patients. It is especially difficult and especially important, therefore, that their fears should be understood and brought to light through the investigations of some one who has time, patience, and tact to devote to the task. This cannot be the task of the physician who sees neurological cases in the dispensary, any more than the psychological twists and tangles of the tuberculous patient can be followed out by the specialist in tuberculosis who examines the patient's lungs. It is the proper task of the social worker. When she has brought the patient's fears to light, when she understands the details of his malady, she can communicate these facts to the physician. He then can exorcise the unclean spirits with the full authority of his medical position.

Just here one sees a good example of the proper coöperation between the physician and the social worker in the dispensary. Each brings to light certain elements in the diagnosis. But in the end the physician must unite all the knowledge accumulated either by himself or by his social assistants, and thus must be enabled to act for the patient's benefit on the basis of a body of information much larger than he could have secured alone.

The social worker is also an essential aid to the physician in bringing to light the mental torments and errors which result from difficult personal relations within the family. These difficulties can only be understood by one who visits the patient in his home, becomes intimate and friendly with other members of his family, and understands, therefore, the difficulties that may arise from friction, rivalry, jealousy, and temperamental incompatibility within the home. In some cases the patient's friends and companions in work or school must also be understood. In other words, one must take account of the totality of influences in the patient's environment, the physical influences of nutrition, ventilation, clothing, but also the psychical influences exerted upon him by his family and friends, by his own half-conscious thoughts, by his worries, his remorse, his fears. Many a case of stomach trouble cannot be cured by diet or remedies until one can find out what it is that the patient is worrying about and can enable him to combat and subdue his mental enemies. Innumerable vague pains which the doctor cannot attribute to any organic disease, and for which the use of drugs is only too likely to do harm, yield only when one can study and influence the whole extent of the patient's mental, moral, and spiritual life. Nothing can be excluded here. It is utterly unscientific to close our eyes to any human interest no matter how little we may sympathize with it personally. It is one of the facts of the case, and must be understood and allowed for in our treatment.