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A social assessment of post-discharge adjustment : an exploratory rating of the social functioning of… DeWolf, Marilyn Dawn 1963

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A SOCIAL ASSESSMENT OF POST-DISCHARGE ADJUSTMENT An exploratory r a t i n g of the s o c i a l functioning of patients a f t e r discharge from the Activation Ward of the Vancouver General Hospital. by MARILYN DAWN DEWOLF and KATHERINE LYNNE MANSFIELD Thesis Submitted in P a r t i a l Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK in the School of Social Work Accepted as conforming to the standard required for the degree of Master of So c i a l Work School of Soc i a l Work 1 9 6 3 The University'of B r i t i s h Columbia In presenting t h i s t h esis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I further agree that per-mission for extensive copying of t h i s t h e s i s for s c h o l a r l y purposes may be granted by the Head of my Department or by h i s representatives. I t i s understood that copying or p u b l i -cation of t h i s t h e s i s for f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n permission. Department of The U n i v e r s i t y of B r i t i s h Columbia, Vancouver 8 , Canada. Date I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r a n a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l . - ' m a k e i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r -m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y -p u r p o s e s m a y b e g r a n t e d b y t h e H e a d o f my D e p a r t m e n t o r b y h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g , o r p u b l i -c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t b e a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f j JK L A Ji-A^ T h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , V a n c o u v e r 8 , C a n a d a . n D a t e ABSTRACT The mounting increase in the number of chronically i l l and disabled c i t i z e n s i s a cause of much concern. Accordingly, many diff e r e n t approaches are being taken towards r e h a b i l i t a t i o n . A v i t a l step in measuring t h e i r success i s the evaluation of patients' progress a f t e r a period of treatment. The present study applies to patients who have received service in the new Activation Ward of the Vancouver General Hospital. Many previous studies have focused upon the measurement of physical and s o c i a l r e h a b i l i t a t i o n , but t h i s is an exploratory measurement of the s o c i a l functioning of such "post-discharge" d i s -abled adults. S p e c i f i c a l l y , this study is d i r e c -ted to the assessment of the contributions of the s o c i a l worker, as one member of the treatment team, to the disabled patient and his family. A small sample of patients were selected for the study; a l l were interviewed, arid material from medical and s o c i a l service records wa3 c o l l e c t e d . A rating scale was worked out, to indicate components of general s o c i a l functioning. This was used to rate each patient at time of study, and compared with ratings at time of discharge from the ward. The re-sults were tabulated and evaluated according to the. c r i t e r i a established of (a) physical, (b) material, (c) individual and (d) s o c i a l factors (twenty items in a l l ) . "Movement" in s o c i a l functioning of each . patient during the post-discharge period could thus be assessed. Overall as well as i n d i v i d u a l r e s u l t s are examined, and some case i l l u s t r a t i o n s u t i l i z e d to supplement the assessment. The evidence i s that assessment of the patients' physical and material factors was ade-quately made on the ward. There i s a r e l a t i v e l y poor record of progress a f t e r discharge, however. Soc i a l factors appear among the more s i g n i f i c a n t reasons. There i s evidently need for more thorough evaluation of the personal and s o c i a l f a c t o r s , with-out which the goals of comprehensive r e h a b i l i t a t i o n cannot be achieved. It i s the s o c i a l worker's function to assess these factors. Further r e s p o n s i b i l i t i e s of the s o c i a l worker include the treatment of emotional and s o c i a l factors, the appropriate use of community resources and s o c i a l action measures. In further re-search directed to the development of a comprehensive assessment plan for a comprehensive r e h a b i l i t a t i o n service, the r a t i n g scale i n i t i a t e d here may c o n t r i -bute some guidelines. ACKNOWLEDGEMENTS We wish to express our appreciation to Miss Eleanor Bradley, Supervisor, Child Health Programme, University of B r i t i s h Columbia, for her warm interest and guidance throughout the preparation of t h i s t h e s i s . The suggestions and direction of Dr. Leonard C. Marsh, Director of Research, School of So c i a l Work, have been of great assistance. i To Dr. Brock M. Fahrni, Director of the School of Rehabilitation Medicine, Uni-v e r s i t y of B.C., and Dr. T.H.C. Lewis, our spe c i a l thanks. We are grateful also for the kind co-operation of s t a f f s of the A c t i -vation Ward and Soc i a l Service Department, Vancouver General Hospital, and of Mrs. 0. Lood, Senior Medical Records L i b r a r i a n . TABLE OF CONTENTS PAGE CHAPTER I. REHABILITATION: THE DEVELOPMENT OF A COMPREHENSIVE PROGRAM 1 H i s t o r i c a l perspective of r e h a b i l i t a t i o n concept. Contemporary viewpoint. Concepts of r e h a b i l i t a t i o n in r e l a t i o n to trends in s o c i a l work practice. P r a c t i c a l applications of s o c i a l work in the r e h a b i l i t a t i o n setting. Setting, purpose and scope. CHAPTER II . MEASURING THE SOCIAL FUNCTIONING OF THE 26 PHYSICALLY DISABLED ADULT What i s s o c i a l functioning? C r i t e r i a estab-lished for the measurement of physical and s o c i a l r e h a b i l i t a t i o n . Explanation of the c r i t e r i a established in the present study 0 CHAPTER I I I . APPLICATION AND ANALYSIS OF THE CRITERIA TO SPECIFIC CASES 35 Cases selected f o r analysis. Measuring s o c i a l functioning at time of study. Evaluation of s o c i a l functioning at time of study and at time of discharge. Case i l l u s t r a t i o n s . CHAPTER IV. REHABILITATION: PROGRAM AND'SERVICE IMPLICATIONS 46 Contributions of the study to the r e h a b i l i -t a t i o n program. Implications of the findings f o r s o c i a l work practice in the r e h a b i l i t a t i o n s e t t i n g . Recommendations for further research. TABLES and FIGURES in the Text: Schedule A (Rating Scale) 43 Figures I and II (Movement shown by ratings at time of study and at time of discharge) . 42 TABLE OF CONTENTS APPENDICES: A. Methodology (Interview schedule and letter to patients) . B. Descriptive d e t a i l of patients (Tables I, II and I I I ) . C. Ratings at time of study and at time of discharge (Tables IV and V). D. Bibliography. CHAPTER I REHABILITATION: THE DEVELOPMENT OP A COMPREHENSIVE PROGRAM H i s t o r i c a l Perspective: Throughout the history of Western society, i t i s possible to distinguish three stages in the development of s o c i a l attitudes toward the disabled person. The f i r s t stage resulted from the b e l i e f in 'survival of the f i t t e s t ' , in which the disabled were l e f t to t h e i r own fate or eliminated because of t h e i r abnormalities. With the emergence of the great r e l i g i o n s of the Western world, a more compassionate attitude developed, often in the b e l i e f that through charity, the benefactors would receive divine favor. However, in thi s second stage, while some help was offered disabled persons, no attempt was made to raise t h e i r status from that of 'second class c i t i z e n s ' . We have now reached a t h i r d stage in which the community is assuming r e s p o n s i b i l i t y for disabled c i t i z e n s through i t s governing bodies rather than through the church or private charity alone. A growing recognition of the vulner-a b i l i t y and interdependence of a l l members of modern society has made s o c i a l l e g i s l a t i o n the most appropriate method of preventing and t r e a t i n g s o c i a l problems. Moreover, we are no longer " s a t i s f i e d with the maintenance of the disabled person or even 2 with his medical recovery; we are s a t i s f i e d only with his r e h a b i l i t a t i o n , as f a r as practicable, to a f u l l and normal l i f e of work and l e i s u r e . " Several factors have contributed to t h i s change of attit u d e . In a p r a c t i c a l sense, chronic i l l n e s s with resultant d i s a b i l i t y has emerged as a major s o c i a l problem due to the increase i n proportion to the population as a whole. While chronic i l l n e s s can stri k e at any age, the e x i s t i n g evidence indicates "that disabling i l l n e s s i s less prevalent in the younger age groups, and becomes about 13 times as frequent in people over 65, as among persons under 45." *" Each new medical advance carries with i t a r e h a b i l i -tation problem, for many conditions at one time f a t a l , have been brought under control so that people go on l i v i n g with residual d i s a b i l i t y . In past generations, the family was large and l i v e d s u f f i c i e n t l y close together to share burdens; but, with the i n d u s t r i a l revolution in the nineteenth century and consequent mobility of the labor force, the t r a d i t i o n a l extended family has become scattered. Thus, the burden must be absorbed by the larger community. 1 Ling, T.M. and O'Malley, C.J.S., eds., Rehabilitation  After I l l n e s s and Accident. B a i l l i e r e , T i n d a l l and Cox, London, 1958, p. 1. 2 Roberts, Dean W., quoted in Robert Hansen, "The Socio-Economic Aspects of Cardiac Disease and Chronic I l l n e s s " , Services to the Chronically 111. U.S.Department bf Health, Education and Welfare, Washington, D.C, 1959. 3 This increased proportion of disabled persons dependent upon the community gives r i s e to an economic problem. No advanced nation today can afford the luxury of wasted man power. The price i s , in f a c t , doubled by the hidden costs in loss of productivity of the disabled person over and above that of complex medical services. The only answer i s r e h a b i l i t a t i o n to the greatest l e v e l of s e l f - h e l p possible. For those who remain dependent, the community mu3t provide services to meet th e i r special needs in order that they, too, can l i v e in comfort and without danger of further decline through lack of care. Apart from p r a c t i c a l reasons f o r considering chronic i l l n e s s a s o c i a l problem, more sympathy toward the needs of t h i s group ha3 been in evidence in the present century. This i s due, partly, to a c u l t u r a l value system rooted in Judeo-Christian p r i n c i p l e s and democratic ideology. Our mounting concern f o r the medical, s o c i a l and economic welfare of a l l c i t i z e n s r e f l e c t s a b e l i e f in the worth and dignity of man, his right to develop in freedom to the maximum of his capa-b i l i t i e s and his mutual dependence upon his fellow man to achieve these ends. I t i s also due to developments in the physical, b i o l o g i c a l and s o c i a l sciences which have provided new insights into the causes of i l l n e s s and d i s a b i l i t y . Whereas physical pathology was at one time accepted as the only cause of disease, in recent years there has been a marked tendency to abandon 4 th i s over-simplification and to take into account a l l the factors responsible f o r i l l health: physical, b i o l o g i c a l , psychological and s o c i a l . Increased humanitarian concern i s a resu l t as well of the impact of two world wars and, in North America, the Depression of the 1930's. Both of these events emphasized the v u l n e r a b i l i t y of any person to economic and s o c i a l hazards which could res u l t in loss of earning power. The experience of the Depression stressed the inter-dependence of a l l c i t i z e n s in a complex, i n d u s t r i a l i z e d and urbanized society. As socio-l o g i s t s have observed, a sympathetic i d e n t i f i c a t i o n with a problem enhances the desire to undertake measures f o r t r e a t -ment, control and prevention. I t was the impact of the returned war disabled that i n i t i a t e d a large scale development of r e h a b i l i t a t i o n services in North America. While World War I produced approximately 400 cases of paraplegia among American m i l i t a r y personnel and only two returned home, World War II produced 2,500 cases and, due mainly to the development of a n t i b i o t i c s , 2,100 returned home.^ Thus, there was a s i g n i f i c a n t increase in that propor-ti o n of the population who were dependent both physically and economically. 3 Taylor, E.J., "Rehabilitation in the Latter Half of the Twentieth Century: Recent Advances and Goals," Workshop: Practice of S o c i a l Work in Reh a b i l i t a t i o n . University of Chicago Press, Chicago, 111., p. 7. 5 Both wars dramatized the fact that men and women can overcome apparently insuperable l i m i t a t i o n s to l i v e s a t i s -f y i n g l i v e s and make important contributions to society. Early r e h a b i l i t a t i o n services of the Veterans' Administration focused on physical r e t r a i n i n g and vocational placement. However, chronic i l l n e s s has emotional and s o c i a l implications as well as physical, and patients vary in t h e i r a b i l i t y to adapt spontaneously. It soon became apparent that successful r e h a b i l i -t a t i o n i s affected not only by the physical resources available in the community but also by the individual's own willingness to improve and gain independence. Thus the modern concept of comprehensive r e h a b i l i t a t i o n includes development of the patient's inner resources - the enhancement of his psycho-l o g i c a l drive or motivation to work on his problem - as well as the provision of medical treatment in i t s broadest aspects, and of educational, vocational and other f a c i l i t i e s for restor-ation and development of his capacities. Contemporary Viewpoint: Dr. Howard Rusk of New York University-Bellevue Medical Center has defined the aims of contemporary r e h a b i l i -tation medicine as follows: The f i r s t objective of r e h a b i l i t a t i o n medicine i s to eliminate the physical d i s a b i l i t y i f that i s possible; the second, to reduce or a l l e v i a t e the d i s a b i l i t y to the greatest extent possible; and the t h i r d , to r e t r a i n the person with a residual physical 6 d i s a b i l i t y to l i v e and to work within the l i m i t s of his d i s a b i l i t y but to the h i l t of hi3 capabilities.** As t h i s d e f i n i t i o n suggests, there i s a considerable difference in the r e h a b i l i t a t i o n of a patient with a temporary d i s a b i l i t y from that of a patient with a chronic d i s a b i l i t y . In the former case, the emotional impact i s less severe; the patient is not required to adapt to a new arrangement of l i f e and a c t i v i t y . Once the symptoms of his ailment or accident disappear and function i s restored, he is generally able to resume his normal role in r e l a t i o n to his family, employment and community. In the l a t t e r case, the patient may have to learn new s k i l l s and adapt emotionally and s o c i a l l y to changed role s . Thus, modern r e h a b i l i t a t i o n programs are focused on the needs of the whole person as the following d e f i n i t i o n by the Baruch Committee on Physical Medicine emphasizes: The goal of r e h a b i l i t a t i o n i s to achieve the maximum function of the i n d i v i d u a l and to prepare him physically, mentally, s o c i a l l y and vocationally f o r the f u l l e s t possible l i f e compatible with his a b i l i t i e s . 5 The patient's reaction to his d i s a b i l i t y demands careful appraisal i f t h i s goal i 3 to be achieved. Although i t i s generally accepted that psychological factors can e f f e c t causation, of physical i l l n e s s , i t is not so widely recognized 4 Rusk, Howard A., Rehabilitation Medicine. The C.V. Mosby Company, St. Louis, 1958, p. 7. 5 Rohn, George, "Rehabilitation of A r t h r i t i c Patients", Master of S o c i a l Work Thesis. U.B.C, Vancouver, 1953, p. 5. 7 that they can e f f e c t symptomatology and recovery. A d i s a b i l i t y may mean disfigurement, severe r e s t r i c t i o n of a c t i v i t i e s or loss of' earning capacity. These and a variety of other impli-cations can pose a serious threat to a person's sense of worth, effectiveness and control. Acceptance of d i s a b i l i t y and the limitations i t imposes does not come e a s i l y , therefore. This i s e s p e c i a l l y 30 in a culture where independence and s e l f -management are highly valued; we admire the person who can 'stand on his own two feet'. In order to work toward recovery, a person must assume - to some degree - the "patient r o l e " . 0 This requires a giving up, temporarily, of some r e s p o n s i b i l i t i e s , interests and a c t i v i t i e s . It requires patience, co-operation, an attentiveness to symptoms, and more dependence on others than i s , perhaps, normal. At the end of treatment the person i n the role of "patient" i s expected to r e l i n q u i s h his state of dependency and resume former r e s p o n s i b i l i t i e s as f a r as he i s able. A person's a b i l i t y to take on t h i s role i s affected by his capacity for adapting to change and t h i s can often be greatly enhanced in the treatment process. It i s also affected by the length of time he*is expected to be a patient and by the extent of his d i s a b i l i t i e s . Here again, the chronically 6 Green, Rose, "Use of Identity Concepts in S o c i a l Work Practice," Achieving: S e l f - I d e n t i t y in Modern Society. National Association of S o c i a l Workers, New York, 1962, p. 5. i l l have a greater adjustment to make than the temporarily-incapacitated. Rose Green has i d e n t i f i e d three gross patterns of reaction to i l l n e s s or d i s a b i l i t y . ? The f i r s t i s a denial of the d i s a b i l i t y which suggests that, to acknowledge the condition would profoundly threaten the patient's sense of wholeness, of i n t e g r i t y . The second reaction i s one of p a s s i v i t y . In e f f e c t , t h i s patient acknowledges his condition but accepts i t as something which he cannot or w i l l not change. This patient may be the "martyr"; he may be very dependent or very depressed. Even more misleading is the patient of t h i s type who seems well motivated because of his "conformity, co-operativeness, care in the use of f a c i l i t i e s and materials, and i n d i v i d u a l i t y of a pleasant a.nd amusing kind." ° I t i s usually when discharge plans are being made that >the patient reveals his fear of independence by having continual relapses. More easy to detect i s the t h i r d reaction, that of overt anger or h o s t i l i t y . C r i t i c i s m of everyone, sarcasm, temper and a demanding attitude often hide a f e e l i n g of g u i l t and a fear of r e t a l i a t i o n . 7 Green, Rose, "Use of Identify Concepts in S o c i a l Work Practice," Achieving S e l f - I d e n t i t y in Modern Society. National Association of S o c i a l Workers, New York, 1962, p. 5. 8" Ibid. , p. 6. 9 Sympathy i s frequently lacking for the person who assumes the "sick r o l e " and remains more handicapped than the prognosis would indicate. Nevertheless, what i s appropriate in these circumstances i s not rejection of the person "but increased therapy relevant to the patient's i n t e r a c t i n g medical and psychosocial needs." 9 The challenge to modern r e h a b i l i -tation practice i s " f l e x i b i l i t y in dealing with the s p e c i f i c problems of people whose needs are as numerous and diverse as are t h e i r personalities and t h e i r emotional and physical problems." Throughout the l i t e r a t u r e on medical r e h a b i l i t a t i o n , the importance of the family's motivation for the patient's f u l l recovery i s stressed. This also requires assessment and, often, support during the treatment process. The family must be helped to understand the patient's i l l n e s s , i t s nature and prognosis. Thereby, anxiety i s decreased allowing them to be less protective and more co-operative in helping the patient regain independence. Successful r e h a b i l i t a t i o n i s dependent upon a continuous process of treatment influencing the patient from the time he becomes i l l or injured u n t i l he i s as independent 9 Parsons, T a l c o t t , "Definitions of Health and Il l n e s s in the Light of American Values and S o c i a l Structure," Patients. Physicians, and I l l n e s s , ed. E.G. Jaco, The Free Press, Glencoe, 111., 195#, p. 165. 10 Canada, Department of Labor, "Rehabilitation in Canada," B u l l e t i n of C i v i l i a n R e h a b i l i t a t i o n . (Sept.-Oct.), 1959, p. 16. 10 as possible. Early treatment helps prevent development of the unhealthy dependency in which the patient becomes enmeshed in the role of the "sick person". In addition, as Dr. Eugene Taylor 'notes, " i t has been estimated that SO to 90 percent of patients referred to specialized r e h a b i l i t a t i o n centers are referred for secondary complications or 'overlaid' d i s a b i l i t y which did not resu l t d i r e c t l y from the basic pathology and which need not have occurred had the patient received early r e h a b i l i t a t i o n s e r v i c e s " . 1 1 I t i s l o g i c a l , therefore, that r e h a b i l i t a t i o n services should be provided within general hospitals and that the r e h a b i l i t a t i o n concept should be the focus of a l l treatment given to the patient from the time of his i n i t i a l medical assessment. "The r e h a b i l i t a t i o n s e t t i n g i s b a s i c a l l y a medical f a c i l i t y in which l i f e and degth factors control the environ-ment. The physician must therefore of necessity be the leader of any treatment team." x In the r e h a b i l i t a t i o n setting p a r t i c u l a r l y , the team comprises two general categories of s p e c i a l i s t s ^ those primarily concerned with the medical problems of the patient - medicine, nursing, physiotherapy, occupational therapy, prosthetic services, speech therapy .,11 Taylor, E.J. , "Rehabilitation in the Latter Half of the Twentieth Century: Recent Advances and Goals," The  Workshop: Practice of Soc i a l Work in Reha b i l i t a t i o n , University of Chicago Press, Chicago, 111., I960, p. 7. 12 Blackey, Eileen, " S o c i a l Work in the Hospital: A "Sovciological Approach," S o c i a l Work. 1:2 (April) 1956, p. 25. n u t r i t i o n - and those whose primary objective i s the s o c i a l and personal readjustment of the patient - s o c i a l work, psychiatry, psychology, recreation work, vocational counsel-l i n g and placement. Medical treatment comes f i r s t , n a t urally, but the ultimate s o c i a l and vocational p o t e n t i a l of the patient must be defined as early as possible so that a l l e f f o r t s of the team can be directed toward the goal of comprehensive r e h a b i l i t a t i o n . Because of the prolonged nature of disabling i l l n e s s i t i s also of considerable importance that follow-up services be available either through out-patient f a c i l i t i e s or in the home. With regard to the l a t t e r , at least f i f t y home care programs have been developed through the United States. These provide medical, nursing, therapy and s o c i a l services, medical and sick room supplies, prosthetic appliances, X-rays, laboratory t e s t s , homemaker services and transportation. Only when a f u l l complement of services i s provided to help the patient achieve optimum adaptation to a l l demands of normal l i f e : physical, emotional and s o c i a l , w i l l the goals of r e h a b i l i t a t i o n be r e a l i z e d . Concepts of Rehabilitation in Relation to Trends i n - S o c i a l  Work Practice: The s o c i a l work profession, l i k e the r e h a b i l i t a t i o n 12 f i e l d , has developed in stages. In i t s early years, the focus was lar g e l y on the environmental s i t u a t i o n and on improving s o c i a l p o l i c i e s to ameliorate poverty and s o c i a l decay. Later, with the advant of Freudian -psychology in the 1920's, great emphasis was placed on the i n d i v i d u a l , e s p e c i a l l y on his emotional makeup, almost to the exclusion of s o c i a l factors which influence his reactions. The modern focus is the t o t a l i t y of i n d i v i d u a l and s o c i a l f a c t o r s . S o c i a l v/ork seeks to enhance the s o c i a l functioning of individuals singly and in groups by a c t i v i t i e s which constitute the interaction be-tween man and his environment. These a c t i v i t i e s can be grouped into three functions: restoration of impaired capacity, provision of i n d i v i d u a l and s o c i a l resources and prevention of s o c i a l dysfunction. 2.3 In the medical s e t t i n g , which includes r e h a b i l i t a t i o n services, the s p e c i f i c purpose of s o c i a l work i s to help the patient make f u l l use of medical care, both preventive and therapeutic, and to achieve the f u l l e s t possible physical, emotional and s o c i a l adjustment. S o c i a l work shares with r e h a b i l i t a t i o n the i d e n t i c a l goal of enabling the patient to achieve the maximum of s e l f - h e l p and well-being within his potential physical and emotional l i m i t a t i o n s . But each of 13 Boehra, Werner W., Objectives of the S o c i a l Work  Curriculum of the Future. Vol. 1, S o c i a l V/ork Curriculum Study, Council on S o c i a l Work Education, 1959, p. 54. 13 these two d i s c i p l i n e s n a t u r a l l y focuses on t h i s goal from i t s own point of view. Medical r e h a b i l i t a t i o n puts more emphasis on the patient's physical health and a b i l i t i e s and the best possible development and maintenance of them, whereas s o c i a l work places more emphasis on the emotional and s o c i a l factors in the patient and his s i t u a t i o n as they are expressed in his s o c i a l functioning. Thus, each of these d i s c i p l i n e s shares the same ultimate goal for the patient being treated. Each one has a p a r t i c u l a r professional focus which enhances the work of the other and contributes to the ov e r a l l goal of r e h a b i l i t a t i v e medicine. P r a c t i c a l Applications of S o c i a l Work in the Rehabilitation  Setting. The basic contribution of the s o c i a l worker a3 a member of the treatment team l i e s in her a b i l i t y to make an adequate s o c i a l assessment, and based on that, provide e f f e c t i v e planning and treatment for each patient. There are two aspects to s o c i a l work focus. F i r s t , to a s s i s t the disabled patient to use the t o t a l services to his maximum capacity. Secondly, to enable the patient to become as s e l f - r e l i a n t as possible within his physical l i m i t a t i o n s . Always the s o c i a l worker's attention i s given to the needs and resources of the in d i v i d u a l patient and of his family, and to those resources in the community which w i l l aid i n the treatment process. 14 The s o c i a l assessment, sometimes c a l l e d the psychosocial diagnosis, i s basic to e f f e c t i v e s o c i a l work treatment. Whenever possible, before seeing the patient, the s o c i a l worker should make a careful review of the patient's medical chart, to know the medical diagnosis and tentative treatment plans. The s o c i a l worker, as a member of the medical i n s t i t u t i o n , must understand the implications of the d i s a b i l i t y f or the patient and his family. This knowledge i s esse n t i a l to the s o c i a l worker as a member of the treatment team in a s s i s t i n g the other team members to recognize the psychosocial aspects of the i l l n e s s in planning the patient's care. 1"* Ide a l l y , the s o c i a l worker assesses the patient at the point he is considered as a possible candidate for r e h a b i l i -t a t i o n services. One aim of the worker i s to esta b l i s h a h e l p f u l relationship with the patient, through which he may f e e l free to express his feelings and at t i t u d e s . While the intake interview serves as a beginning step in t r y i n g to understand the patient's objectives, i t i s also u t i l i z e d f o r evaluating his capacities to use a l l the available services. 15 To 14 B a r t l e t t , Harriett M., S o c i a l Work Practice in the  Health F i e l d , National Association of Soc i a l Workers, New York, 1961, p . 7 6 . 15 Grayson, Morris, Ann Powers, and Joseph Levi, Psychiatric Aspects of Re h a b i l i t a t i o n . The Insti t u t e of Physical Medicine and Rehabilitation, New York-Bellevue Medical Center, New York, i 952, p. 31. 15 accomplish t h i s , the s o c i a l worker notes a l l the pertinent factors. The worker wants to assess p a r t i c u l a r l y at t h i s point and in her ongoing work with the patient: how the patient reacts to new situations; how he relates to authority figures; what are the strengths in the patient and his family and the relationships between them; what i s the meaning of i l l n e s s and d i s a b i l i t y to them; how the patient and his family respond to medical care; what are t h e i r attitudes toward the various members of the r e h a b i l i t a t i o n team; what are t h e i r attitudes toward the various members of the r e h a b i l i -tation team; what are t h e i r socio-economic status and a s p i r -ations and t h e i r attitudes toward work - e s p e c i a l l y as these relate to the patient's motivation, capacity and the oppor-tunity presented to him. As assessment of his motivation i s of s p e c i a l importance to an understanding of the patient and his a b i l i t y to use r e h a b i l i t a t i o n services. The major p r i n c i p l e in implementing a successful r e h a b i l i t a t i o n process i s the need to secure the maximum p a r t i c i p a t i o n of the patient and his family, both in understanding the significance of his d i s a b i l i t y and in accepting the goals and techniques of the medical progranu The concept of motivation, i s often considered without due thought about i t s components. It has been simply defined by Dr. Thomas French as "what an i n d i v i d u a l wants and 16 how much he wants i t . " ^  Dr. French speaks of the "push" of discomfort and the " p u l l " of hope, both of which operate at the same time and are expressed in the behavior of the person seeking some sort of help. ^ We are not, in 3 o c i a l work practice, concerned with a l l of the person's motivations which vary in int e n s i t y of need and hope with every d i f f e r e n t aspect of l i v i n g . Rather, we are concerned with his drives and a b i l i t i e s to deal with the problem in the center of attention at a pa r t i c u l a r time. B r i e f l y , the worker's r e s p o n s i b i l i t y in the r e h a b i l i t a t i o n plan i s "to i d e n t i f y the direc t i o n and the potential strength of the patient's moti-vation for recovery, t r a i n i n g or work, i f not for l i f e i t s e l f . " I d e n t i f i c a t i o n of t h i s i s not enough. The s o c i a l worker must then help the patient recognize t h i s himself, enhance i t , and put i t to work in his own in t e r e s t . In the s o c i a l assessment of the patient the following have often been indices pointing to positive motivation and possible success in r e h a b i l i t a t i o n . However, t h i s l i s t does not pretent to be exhaustive: s p e c i f i c or r e a l i s t i c goals in r e h a b i l i t a t i o n , f a i r or reasonable standards of l i v i n g , 15 French, Thomas M., The Integration of Behavior. University of Chicago Press, Chicago, 1952, p. 43. 16 I b i d . , pp. 51-52. 17 Simon, Bernece K., "Challenges to S o c i a l Work: The S o c i a l Casework Method in Rehabilitation - Constant Tool," Proceedings of the Workshop: Practice of S o c i a l Work in  Rehabili t a t i o n. University of Chicago Press, Chicago, I 9 6 0 , p. 37. 17 successful marriage, moderate r e l i g i o u s practice, good work history, f i n a n c i a l independence at lea3t f i v e years prior to i l l n e s s , minimal focus on hypochondriacal symptoms, adequate ego strengths and adequate body image. ^ Actually, to f u l l y understand a person's motivation, we must know his t o t a l personality and s i t u a t i o n , including both the conscious and unconscious meaning of his d i s a b i l i t y to him and his family. Motivation i s helped as well by the attitudes of the team members toward the patient, his family, the d i s a b i l i t y , and the feelings they have about i t . S o c i a l work recognizes that the attitudes and feelings of i t s p r a c t i t i o n e r s toward the individual and his s i t u a t i o n influence the effectiveness of s o c i a l work treatment. ^ ^ s a basic requirement that professional s o c i a l workers must develop self-awareness in the areas of t h e i r reactions to physical handicaps, personality patterns and environmental conditions, so they can best achieve a therapeutic r e l a t i o n s h i p with the person and his IS Rusk, op. c i t . . p. 213. "The "body image" i s one we a l l possess. I t is o r d i n a r i l y outside our awareness and has become endowed with q u a l i t i e s of value or lack of value as a r e s u l t of developmental and s o c i a l experiences. Physical i l l n e s s or deformity may threaten t h i s image, necessitating a change or a defense against the recognition of t h i s change. Since the body image i s integrated with personality organi-zation, such a change threatens the equilibrium of the person-a l i t y . " 19 Abrams, Ruth and Bess Dana, " S o c i a l Work in the Process of R e h a b i l i t a t i o n " , S o c i a l Work. Vol. 2, no. 4, (Oct.) 1957, p. 7. v 16* family. S i m i l a r l y , the other members of the team can help most by creating, through t h e i r attitudes, a climate conducive to recovery. It i s a matter of watchful waiting, alertness to cues, encouragement and readiness to support at each point that the patient shows a b i l i t y to move ahead. The planning and treatment phases of s o c i a l work are based on an understanding of the patient learned from the so c i a l assessment. Planning, which includes short-range and long-range goals, i s always done with the patient, not for him. The patient must be able to become his own "problem-solver", use his own resources, i f e f f e c t i v e treatment i s to be attained. In other words, his motivations and capacity are evaluated and enhanced in hi3 own use of them. In planning, provision i s made for dealing with the facts considered to be central and c r i t i c a l to the patient's co-operation and maximum improvement. Planning may include anything deemed necessary for e f f e c t i v e treatment. I t may point the way for a need to work with the patient's r e s i s -tances to help, his h o s t i l i t i e s to s p e c i f i c and s i g n i f i c a n t people; to work with the family's i n a b i l i t y to accept a disabled member, or to make r e f e r r a l s to such concrete community resources as f i n a n c i a l assistance or homemaker services. Assessment, planning and treatment are considered the p a r t 3 , often not c l e a r l y distinguishable from each other, 19 of an ongoing process. Treatment, of course, involves the implementation of aspects of casework plans at the time they are considered to be most appropriate. S o c i a l casework t r e a t -ment embraces four major areas: environmental manipulation, psychological support, c l a r i f i c a t i o n , and insight therapy. (The l a s t i s not used often and then usually under a psyc h i a t r i s t ' s supervision.) One or more of these methods may be used, but only when dia g n o s t i c a l l y indicated and in l i g h t of the o v e r a l l treatment plan, medical and s o c i a l . Treatment, however, does not usually end at time of discharge. Some patients, i f they and t h e i r families have s u f f i c i e n t strengths, are able to maintain the gains they make on the r e h a b i l i t a t i o n ward a f t e r they leave i t . But many others are not able to do t h i s ; hence, the need for supervised follow-up treatment i s esse n t i a l to keep these people from regressing p h y s i c a l l y , emotionally and s o c i a l l y . Planning for treatment subsequent to discharge i s an inclusive part of any good r e h a b i l i t a t i o n program. I t i s begun as soon as such plans can be conceived in l i g h t of the medical and s o c i a l assessments. I f follow-up plans are to be e f f e c t i v e , they must be made with the patient and his family, and must not be made at the time of discharge. I f the r e h a b i l i t a t i o n s e t t i n g i t s e l f i s not geared to carry out comprehensive follow-up treatment, neither are 20 other community health and welfare resources properly v u t i l i z e d . When the services of any other resources are required, the r e f e r r a l process comes into play and the so c i a l worker i s the l i a i s o n . This aspect of service i n -volves careful preparation of the patient and his family for r e f e r r a l ; free sharing, with the patient's knowledge and permission, of pertinent information with the outside agency; the delineation of respective l i n e s of r e s p o n s i b i l i t y ; and the maintenance of unhindered communication between agencies. When properly u t i l i z e d , outside resources often prove necessary and worthwhile adjuncts in promoting the treatment process and in helping to maintain the treatment gains. Setting The patient sample studied f o r t h i s thesis had a l l received r e h a b i l i t a t i o n services on the Activation Ward (commonly called A 4 ) in the Vancouver General Hospital. This ward was f i r s t established in October, 1961, under the leadership of Dr. Brock M. Fahrni, Director of the School of Rehabilitation Medicine, Faculty of Medicine, The University of B r i t i s h Columbia. It is supported by government only through the B.C. Hospital Insurance Act and does not receive an additional grant as a r e h a b i l i t a t i o n service. Hence, t h i s ward i s termed an "a c t i v a t i o n " unit with emphasis upon the intensive physiotherapy offered. 21 Patients are accepted from other services in the hospital a f t e r t h e i r acute medical treatment has terminated. Any adult patients with physical d i s a b i l i t y r e s u l t i n g from accident or i l l n e s s are accepted on the ward, with no d i s -t i n c t i o n given as to a b i l i t y to pay. Private and s t a f f patients often share the same room. Patients are assessed for treatment on the parent ward prior to transfer there, and must be able to get out of bed and become involved in intensive therapy. Only on rare occasions are patients admitted d i r e c t l y to A4 without f i r s t being patients else-where in the h o s p i t a l . Although the Activation Ward i s located in the basement of the h o s p i t a l , i t i s painted in bright colours and has a cheerful aspect. It i s s t a f f e d by an i n t e r n i s t , general p r a c t i t i o n e r , p s y c h i a t r i s t , f i v e nurses, one physical and one occupational therapist, f i v e ward aides, a d i e t i t i a n shared with other wards, a part-time caseworker. Volunteers of the hospital Women's Auxiliary devote much time to v v i s i t i n g patients and helping with c r a f t s under dir e c t i o n of the Occu-pational Therapist. They also allocate substantial funds each year for r e h a b i l i t a t i o n services. The t o t a l f a c i l i t i e s of the general hospital including s p e c i a l i s t s in a l l medical f i e l d s are available to the patient. Emphasis i s given to keep the patients up, dressed and as active during the day as their physical tolerances w i l l permit. They are encouraged to eat in the dining room and in other ways to work toward as active and independent a l i f e as possible. Purpose The purpose of t h i s exploratory study i s to evaluate the effectiveness of services given by the A c t i -vation Ward of the Vancouver General Hospital. This i s done by examining the present s o c i a l functioning of some of i t s former patients. In order to do t h i s i t was neces-sary f i r s t to define the goals of a comprehensive r e h a b i l i -tation program. Next, the c r i t e r i a for measuring s o c i a l functioning had to be established. Naturally, t h i s study has developed from a s o c i a l work point of view involving the importance of understanding the very d e f i n i t e role that emotional and s o c i a l factors play in a l l l i f e ' s a c t i v i t i e s . From t h i s , contributions of the s o c i a l worker, as one member of the treatment team, are outlined. S p e c i f i c a l l y , these are the assessment and enhancement of the s o c i a l functioning of each i n d i v i d u a l patient. Scope The subjects for the study were drawn from the patients who were treated on the Activation Ward of the Vancouver General Hospital during i t s f i r s t ten months of operation (October 1961 to August 1962). This gave an i n t e r v a l of approximately one and one-half years between the date of discharge and the study. The 150 patients ad-mitted to the ward during this period had come from d i f f e r e n t parts of B r i t i s h Columbia. Therefore, i t was p r a c t i c a l to 23 select only those patients who had residence within the li m i t s of the City of Vancouver. Recognizing that the goals of a comprehensive re-h a b i l i t a t i o n program are limited f o r el d e r l y people, the sample excluded patients of both sexes older than seventy. (Appendix B, Table I ) . The d i v e r s i t y of diagnoses of chronic i l l n e s s (Appendix B, Table II) made i t impossible to select those patients who had a similar i l l n e s s . Therefore, the patients who had long-term d i s a b i l i t i e s as a r e s u l t of the i r i l l n e s s constituted the sample. Thirty-eight patients met these c r i t e r i a . I t was disappointing that only seventeen patients were available f o r actual study. During the i n t e r v a l between discharge from the ward and the time of study, many patients moved outside the study area; some could not be located; and a few had died. (Appendix B, Table I I I ) . The purpose of the study was introduced to the patients concerned by l e t t e r (Appendix A). Data f o r the ratings on each of the 17 patients was then obtained by means of an interview schedule (Appendix A) which was completed at the time of the home v i s i t . The main focus of the study, an exploratory rating scale (Schedule A, Chapter I I I ) , was then formulated, the areas of physical, material, i n d i v i d u a l and s o c i a l factors being considered. Ratings of the patients were then made on a good, f a i r or poor l e v e l of performance 24 i n each area. The average performance i n o v e r a l l s o c i a l f u n c t i o n i n g was e s t a b l i s h e d through t o t a l l i n g the scores f o r each c r i t e r i o n . tn o r d e r to compare l e v e l o f f u n c t i o n i n g at the time o f i n t e r v i e w i n g w i t h t h a t a t the time of d i s c h a r g e , data were a l s o taken from medical and s o c i a l s e r v i c e records and the r a t i n g s c a l e a p p l i e d at the time of discharge from A/f. The r e s u l t s are recorded i n Chapter I I I and the i m p l i -c a t i o n s i n Chapter IV. T h i s study i n v o l v e s o n l y a s m a l l number of p a t i e n t s , hence the r e s u l t s are l i m i t e d . The f a c t t h a t s e v e r a l d i f f e r e n t types and degrees o f d i s a b i l i t i e s were found among the s u b j e c t s a f f e c t s the exactness of the r a t i n g s as w e l l . A f u r t h e r l i m i t a t i o n l i e s i n the f a c t t h a t there was l a c k of c o n s i s t e n c y of r e c o r d i n g of i n f o r m a t i o n on medical and s o c i a l s e r v i c e f i l e s . F r e q u e n t l y , t h i s i n f o r -mation was documented i n a g e n e r a l and s u b j e c t i v e , not a s p e c i f i c and o b j e c t i v e , f a s h i o n . Other w r i t e r s ' ^ have noted the d i f f i c u l t i e s i n making p u r e l y o b j e c t i v e r a t i n g s o f s o c i a l and emotional f a c t o r s . A c t u a l l y , i t i s c o n s i d e r e d that the impressions of r e s e a r c h e r s i n i n v e s t i g a t i n g these areas are of great 20 R i p p l e , 1., " M o t i v a t i o n , C a p a c i t y and O p p o r t u n i t y as R e l a t e d t o the Use o f Casework s e r v i c e s : Plan o f Study", S o c i a l S e r v i c e Review. V o l . 29, no. 2, June 1955. 25 diagnostic importance, but there are l i m i t a t i o n s to t h i s s u b j e c t i v i t y , as well as positive aspects. The c r i t e r i a herein developed have not been subjected on a broader scale to experimental research and are therefore presented as an exploratory measuring device. CHAPTER II MEASURING THE SOCIAL FUNCTIONING OF THE PHYSICALLY DISABLED ADULT What is Social Functioning? So c i a l functioning refers to the t o t a l i t y of an individual's patterns of behavior. These are the expressions of his p a r t i c u l a r b i o l o g i c a l and emotional makeup, in i n t e r -action with the s o c i a l environment of family, friends, economic and p o l i t i c a l i n s t i t u t i o n s . The person's reactions to his present s i t u a t i o n are influenced continuously by his s i g n i f i c a n t past experiences and his hopes fo r the future. C r i t e r i a Established for the Measurement of Physical and  S o c i a l Rehabilitation Several c r i t e r i a f o r the measurement of various aspects of physical and s o c i a l r e h a b i l i t a t i o n have been established in previous studies. However, to the writers' knowledge, none have been developed to measure the s o c i a l functioning of physically disabled adults. A thesis written by Tomalty 1 defined potential for r e h a b i l i t a t i o n in terms of inner and outer resources; that i s , the physiological and psychological c a p a b i l i t i e s of the patient, and the resources 1 Tomalty, S., C r i t e r i a for Successful Rehabili- tation . Master of S o c i a l Work Thesis, The University of B r i t i s h Columbia, Vancouver, I960. 27 within his family and community. However, while capacity for successful r e h a b i l i t a t i o n wa3 assessed, the measurement of the actual l e v e l of the patient's s o c i a l functioning was not. Of considerable relevance to th i s study were the theses written by Varwig and McCallum, ^,3 i n which rating scales for measuring s o c i a l adjustment v/ere devised. These studies focused upon the s o c i a l adjustment of handicapped children, but i t was feasible to adapt to t h i s t h e s i s , c r i t e r i a pertaining to the importance of family strengths and socio-economic factors. McCoy and Rusk inquired into the p r a c t i c a l e f f e c t s of r e h a b i l i t a t i o n services in a follow-up study of 208 orthopedically handicapped persons discharged from four hospitals in Mew York Cit y . They answered the preliminary question, "Is comprehensive r e h a b i l i t a t i o n worthwhile?" by applying the following standard to cases studied** I f the i n d i v i d u a l gains a b i l i t y to function to the maximum of the capa-b i l i t i e s he has l e f t and uses these c a p a b i l i t i e s in a way s a t i s f a c t o r y 2 Varwig, R., Family Contributions in Pre-School  Treatment of the Hearing-Handicapped Ch i l d . Master of S o c i a l Work Thesis, University of B r i t i s h Columbia, Vancouver, I960. 3 McCallum, Mary F., Family D i f f e r e n t i a l s in the  H a b i l i t a t i o n of Children with a Brain Injury. Master of So c i a l Work Thesis, University of B r i t i s h Columbia, Vancouver, 1961. 4 McCoy, Georgia F. and Rusk, Howard A., Rehabili-tation Monograph I- An Evaluation of R e h a b i l i t a t i o n . The Insti t u t e of Physical Medicine and Re h a b i l i t a t i o n , New York University-Bellevue Medical Center, New York, 1953. , to him arid acceptable to the community, v i t may be assumed that his r e h a b i l i -t a t i o n paid - that i t was successful. I f not, i t did not pay - i t was not successful. 5 This inquiry also attempted to determine what factors "appeared most frequently with success and f a i l u r e . " 0 I t was possible to adapt some of these c r i t e r i a to the present study. However, because of the primarily medical focus of the inquiry, i t was necessary to develop further c r i t e r i a in order to measure s o c i a l and emotional aspects of s o c i a l functioning. The most recent and pertinent study on s o c i a l functioning was carried out by the Family Centered Project in 3t. Paul, and was concerned with 'multi-problem' f a m i l i e s . 7 The socio-economic factors were relevant, and were adapted to the measurement of the s o c i a l functioning of persons with physical d i s a b i l i t y . Explanation of the C r i t e r i a Established in the Present Study From a review of these studies, c r i t e r i a of s o c i a l functioning were developed under the main headings J Physical Factors, Material Factors, Individual Factors and S o c i a l Factors. 5 McCoy and Rusk, Ibid.. p. 3. 6 Loc. c i t . 7 Geismar, L.L. and Ayres, Beverley, Patterns of  Change in Multi-Problem Families. Family Centered Project, Greater St. Paul Community Chest and Councils, Inc., St. Paul, July 1959. & Refer to r a t i n g scale, page 43. 2 9 Physical Factors The f i r s t c r i t e r i o n to measure functioning of the physically disabled person i s , understandably, that of " l i m i -tations imposed by d i s a b i l i t y on physical functioning". As i l l n e s s always constitutes a stress, emotional as well as physical, i t follows that a chronic condition with reduction of physical capacity w i l l have a s i g n i f i c a n t impact on s o c i a l functioning. Ratings, therefore, are related to the degree of impairment. "Health factors apart from d i s a b i l i t y " i s considered to be a second important c r i t e r i o n , again because of the stress-producing and l i m i t i n g e f f e c ts of any i l l n e s s . A l i m i t a t i o n of t h i 3 c r i t e r i o n was the fact that only the patient's assess-ment of his health was av a i l a b l e . Thus, a patient who needed to exaggerate his poor health could reduce the o b j e c t i v i t y of the r e s u l t s . "Actual l e v e l of functioning, the next c r i t e r i o n , needed to be measured in order that a comparison could be made between the expected degree of physical impairment and the actual performance of each patient. Thi3 comparison has de f i n i t e implications for the evaluation of r e h a b i l i t a t i o n although, without a l l other c r i t e r i a of s o c i a l functioning, comprehensive analysis of the patient's l e v e l of functioning is impossible. Ratings were made according to the degree to which the patient had attained maximum physical functioning. 3.0 Material factors "Household arrangements" included the physical relationships of rooms to one another (for example, bathroom near bedroom, number of s t a i r s ) ; the f a c i l i t i e s f o r washing, cooking and sanitation; and the equipment including s e l f - c a r e gadgets such as a d d i t i o n a l r a i l i n g s and raised t o i l e t seats. The c r i t e r i o n was rated with regard to the adequacy of arrangements, f a c i l i t i e s and equipment for the needs of each patient. "Employment status", including housework, i s another c r i t e r i o n of importance. I f a patient was capable of f u l l employment on discharge, his s i t u a t i o n was rated good. This rating implies that the patient had retained a very important role in his l i f e . Capability of part-time employment with special arrangements was rated f a i r and unemployability or lack of employment was rated poor. A l i m i t a t i o n of t h i s c r i t e r i o n was discovered when patients were interviewed who had limited c a p a b i l i t i e s for employment and yet were doing f u l l time and sometimes rigorous work. "Economic status" was rated with regard to adequacy of income and the degree of independence from f i n a n c i a l support. The f i n a n c i a l l y dependent person has l o s t control over a matter of great importance to his security and i s in a position which constitutes a threat to h i s sense of personal worth. This i s es p e c i a l l y so i f his values include a high degree of ss^lf-31 s u f f i c i e n c y . The stress of thi s s i t u a t i o n would a f f e c t behavior and attitudes toward others and reduce adequacy of s o c i a l performance. Individual factors "Attitude toward l i v i n g arrangements" i s an important consideration as the disabled person's sense of security often rests heavily upon his feelings about the adequacy of l i v i n g conditions. Patients in nursing and boarding homes have an extra adjustment to make to the personal implications of l i v i n g away from home and in an i n s t i t u t i o n a l i z e d s e t t i n g . "Attitude toward d i s a b i l i t y " greatly affects the person's capacity for s o c i a l functioning. As discussed in Chapter I, unless the person has a r e a l i s t i c acceptance of what the d i s a b i l i t y means to him in his l i f e , he w i l l be hampered in his use of those capacities which remain. Following l o g i c a l l y from the l a s t c r i t e r i o n i s "attitude toward own role in family (or equivalent)". A disabling condition may prevent the person from carrying out former roles as a family member and the meaning of t h i s to him may s i g n i f i c a n t l y a f f e c t his sense of worth. Even when no great reduction of a c t i v i t i e s i s involved, the disabled person's f e e l i n g of importance to his family can be threatened by i l l n e s s and the e f f e c t s i t has. 32 "Motivation" i s divided into three aspects for assessment. "Use of-time", p a r t i c u l a r l y in the case of an unemployable person, i s an appropriate measurement of the person's adjustment to his d i s a b i l i t y and his l i f e s i t u a t i o n . "Motivation for treatment" refers to the patient's a b i l i t y to assume the 'patient' role and become dependent upon the treatment team in order to get well, yet r e t a i n the r e s p o n s i b i l i t y for his own r e h a b i l i t a t i o n . "Motivation - r e a l i t y - o r i e n t e d or inner-oriented" refers to the goals or lack of goals the person has set for himself. Assessment of whether they are r e a l i s t i c in terms of the actual l i m i t a t i o n s imposed by his d i s a b i l i t y i s an important clue to the degree of adjustment he has made and to the o v e r a l l adequacy of his s o c i a l functioning. S o c i a l Factors Family (or equivalent) context is the f i r s t c r i t e r i o n as the actual presence of s i g n i f i c a n t persons in the patient's l i f e whether family or friends has r e a l implications f o r his health and happiness. The next c r i t e r i o n , "family (or equivalent) attitudes towards d i s a b i l i t y " , measures the degree to which family members or friends are accepting of the patient's d i s a b i l i t y . The reactions of the family and friends to the patient may range from understanding and acceptance to overprotectiveness and outright r e j e c t i o n of him. "Family (or equivalent) contributions" relate d i r e c t l y to the degree of emotional warmth and degree of mutual support among the family members. The attitudes of the family a f f e c t the degree to which r e a l i s t i c support w i l l be offered by them to the patient. This c r i t e r i o n , applied at time of study, rates the strengths within the family; applied at time of discharge, i t measures the family's*reactions to the d i s a b i l i t y , as well as the family strengths. " S o c i a b i l i t y " refers f i r s t l y to the patient's responsiveness to others i n hi3 l i f e s i t u a t i o n and secondly, to his relationships with others since his d i s a b i l i t y . "Use of community resources - health, vocational, recreational and counselling" are the l a s t four areas to be rated. These are a l l rated in terms of how r e a l i s t i c the patients have been in t h e i r use of available resources. Two variables in r a t i n g these c r i t e r i a are the inadequacies of some resources in the community, and the d i f f e r i n g degrees to which they have been made, or not made, available to the patients. A l i m i t a t i o n in the rating scale is the grouping together of c r i t e r i a pertaining to external socio-economic factors (such as "household arrangements" and "economic status"), and c r i t e r i a pertaining to psycho-social factors (such as the patient's and family's response to problems created by the d i s a b i l i t y and t h e i r i nteraction with one another). This means that a poor average rating, f o r example, could be based lar g e l y on factors external to the patient rather than to his lack of motivation or family support. In part, this weakness i s overcome by the i n d i v i d u a l case1 analyses that follow the r e s u l t s of ratings in Chapter I I I . CHAPTER III APPLICATION AND ANALYSIS OF THE CRITERIA TO SPECIFIC CASES Cases Selected for Analysis The rating scale was applied to information re-garding a sample of seventeen former patients of the A c t i -vation Ward. Of these, the greatest majority had become disabled due to Cardiovascular Accident. Patients with Rheumatoid A r t h r i t i s and Multiple S c l e r o s i s constituted the next largest group. (Appendix B, Table I I ) . Nine men ranging in age from 48 to 65 and eight women aged 47 to 68 made up the t o t a l group. (Appendix B, Table I ) . The number of male and female patients rated, therefore, were representative of the t o t a l sample. Measuring S o c i a l Functioning at Time of Study While using the interview schedule to obtain data to measure s o c i a l functioning, the feelings and attitudes of patients and family members were also noted. A l l cases were rated once by each of the two writers in an e f f o r t to reduce s u b j e c t i v i t y . (Appendix C, Table IV). For a l l three c r i t e r i a under Physical Factors, the average r a t i n g for the majority of patients at the time of study was f a i r . Under Material Factors, the t o t a l sample 36 was rated good fo r "household arrangements", poor f o r "employ-ment status" and f a i r for "economic status". In the area of Individual Factors, "attitude to l i v i n g arrangements" was, on the whole, good. "Attitude to-ward d i s a b i l i t y " and "attitude toward own role in family" were both rated poor. A s l i g h t majority of patients had a good rating f o r "motivation in use of time". The next largest group was rated f a i r . Again, a s l i g h t majority had a good rating for "motivation f o r treatment" but the next largest group, almost equal in s i z e , were rated poor. The greatest number of the sample obtained a poor r a t i n g for "motivation -r e a l i t y - o r i e n t e d or inner-oriented". That i s , t h e i r goals were either quite u n r e a l i s t i c or they had no goals and were generally apathetic. Under S o c i a l Factors, "family context" was rated good; "family attitudes toward d i s a b i l i t y " was rated f a i r ; and "family contributions" was s i m i l a r l y rated f a i r . "Soci-a b i l i t y " for the sample as a whole was f a i r . "Use of community resources - health" was good. "Use of vocational resources" was rated poor. Even d i s t r i b u t i o n between good, f a i r and poor was found in "use of recreational resources", with an equal number of patients having good and poor ratings. In "u3e of counselling resources", the largest group rated poor and the next largest rated f a i r . 37 Comparison of Level of S o c i a l Functioning at Time of Study  and at Time of Discharge As described i n Chapter I, Method, a l l patients were also rated at the time of discharge from Ward A4, according to information obtained from the medical and s o c i a l service records (Appendix C, Table V). The ratings at the time of study and at the time of discharge were then compared, indi c a t i n g the movement in s o c i a l functioning. Figures I and II,ipage 42 i l l u s t r a t e that the average s o c i a l functioning of the sample moved from good to f a i r between discharge and the time of study. Actual l e v e l of functioning was the only c r i t e r i o n under Physical Factors which d i f f e r e d at time of study from time of discharge. The majority of patients moved from a good ra t i n g at time of discharge to a f a i r l e v e l of actual physical functioning at time of study. This fact indicates that the gains achieved by the time patients l e f t the hospital were not, on the whole, maintained. Under Material Factors, "economic status" regressed from good to f a i r . Speculations as to the reasons for this are: there was incomplete assessment of the actual economic situation while the patients were on the ward; and the high cost of medical care has reduced the number of patients with adequate and independent incomes. "Attitude toward d i s a b i l i t y " , and "motivation -r e a l i t y - o r i e n t e d or inner-oriented", both regressed from a good to a poor r a t i n g . Here again, the p o s s i b i l i t y of i n -s u f f i c i e n t assessment of the patient's attitudes while he was on the ward i s indicated. Lack of complete or appropriate casework treatment to help the patient accept his d i s a b i l i t y and thereby enhance his motivation i s also a d i s t i n c t possi-b i l i t y . Regarding motivation in terms of the patient's goals, i t i s obvious that i f the patient has poor acceptance of his d i s a b i l i t y , he i s u n l i k e l y to work toward r e a l i s t i c goals. I t may be that t h i s c r i t e r i o n was rated good on the ward be-cause the patient showed a favorable response to the treatment regime and the team members. This assessment, however, does not appreciate the patient's underlying f e e l i n g s . "Family context" was rated good at both points in the r a t i n g , but in none of the remaining c r i t e r i a under S o c i a l Factors wa.s there agreement in ratings. "Family attitudes", "family-contributions" and the patient's " s o c i a b i l i t y " a l l showed downward movement from good to f a i r . I t appears that only "family context" was evaluated accurately on the ward, yet this i s not a s u f f i c i e n t assessment of family strengths. It is the quality of family relationships which contributes most to the success of the patient's r e h a b i l i t a t i o n . "Use of recreational resources" was rated good on the ward but was not so c l e a r l y d i f f e r e n t i a t e d between good, 39 f a i r and poor at the time of study. On the ward, patients are expected to participate in the recreation services offered. However, the good r a t i n g in t h i s area is not necessarily a measurement of the patient's wish to use recreational resources. Often, when the encouragement of s t a f f i s unavailable, the patient becomes apathetic. In summary, the r e s u l t of ratings at both points in the study indicated that actual l e v e l of physical func-tioning of the majority of patients regressed in the one and one-half year period following discharge. The greatest downward movement during t h i s period was discovered in s o c i a l and i n d i v i d u a l factors. In the opinion of the writers, the reason for t h i s apparent r e -gression was a lack of f u l l assessment and enhancement of these areas at the beginning of and throughout the treatment process. Case I l l u s t r a t i o n s Mrs. A's s i t u a t i o n i l l u s t r a t e s that of patients who, in the area of "economic status", were rated good at discharge and f a i r at the time of study. Her r e t i r e d husband receives a small superannuation but no medical coverage. He appeared quite anxious when answering the question on ade-quacy of income saying "I have no medical insurance so I have to pay my wife's medical b i l l s myself". He indicated great concern over t h e i r fast declining economic status. 40 Mr. B's rating for "attitude toward d i s a b i l i t y " and "motivation, r e a l i t y - o r i e n t e d or inner-oriented" re-gressed from good to poor. On the ward he was described as "bright and cheerful". He worked hard both on the ward and after discharge at regaining use of his physical capa-c i t i e s . His i l l n e s s is such, however, that doctors have ordered part-time employment only. During the interview, i t was discovered that he has not followed t h i s suggestion. Instead he works six days a week at heavy labor. His cheerful manner appeared to the interviewer to be an attempt to hide deeper feelings about his condition, probably from himself as well as from others. Obviously, Mr. B. drives himself beyond the r e a l i s t i c l i m i t a t i o n s imposed by his d i s a b i l i t y . The reasons for downward movement from good to f a i r in the ratings of "family attitudes", "family c o n t r i -butions" and patient's " s o c i a b i l i t y " was c l e a r l y shown in the case of Mr. C. Assessment of the family while t h i s patient was on A-4 was confined to the presence of family members, and t h e i r physical a b i l i t y to help the patient dress and walk. Nothing was noted of the q u a l i t y of r e l a t i o n -ships between patient and family. When interviewing, i t was observed that the patient had "a pathetic r e l a t i o n s h i p with his wife who i s very domineering, aggressive and subtly blames him for t h e i r lack of s o c i a l contacts". Mr. C. has 41 regressed in a l l areas of s o c i a l functioning since d i s -charge. This information suggests that incomplete assess-ment of family attitudes and contributions (and of the patient's s o c i a b i l i t y ) with consequent f a i l u r e to enhance these factors, have important bearing on the reasons for Mr. C s regression. Mrs. D's extreme lack of responsiveness to recreational f a c i l i t i e s since discharge from A-4 i l l u s t r a t e s the fact that a good use of the f a c i l i t i e s on the ward does not always predict adequate use of resources in the community; deeper assessment of motivation and capacity needs to be made. On A-4 t h i s patient responded to the warm support of team members and volunteers and was described as "cheerful and co-operative". She enjoyed arts and crafts and associations with other patients. At home she was depressed and apathetic. She was so preoccupied with the li m i t a t i o n s imposed by her d i s a b i l i t y that she f a i l e d to u t i l i z e the considerable capacity for work and pleasure remaining to her. As her o v e r a l l s o c i a l functioning is st e a d i l y declining, her husband fears she w i l l soon require more care than he can give her. Findings of the ratings and case analyses have implications both f o r the r e h a b i l i t a t i o n program and the services of the s o c i a l worker on the team. FIGURE I TOTAL RATING OF SOCIAL FUNCTIONING 42 FIGURE II TOTAL RATING OF SOCIAL FUNCTIONING IN EACH FACTOR Physical Material II Individual III Social ^1 Good Fair* Poor At time of study-approx. 18 months later. Good Fair Poor At time of discharge. Good F a i r Poor 43 SCHEDULE A Scale for Measuring S o c i a l Functioning  of Persons with Physical D i s a b i l i t y C r i t e r i a Explanation of Ratings Good Fa i r Poor Physical  Factors A.Limitations imposed by d i s a b i l i t y on physical func-tioning. Physical disa-b i l i t y or i l l -ness is expected to have l i t t l e or no e f f e c t on a c t i -v i t i e s of d a i l y l i v i n g . Should be physi- Expected to be c a l l y able to per- physically unable form some but not to perform most a l l a c t i v i t i e s of dail y l i v i n g . a c t i v i t i e s of dai l y l i v i n g . May require nursing care. B. Health apart from d i s a b i l i t y Good physical health apart from s p e c i f i c d i s -a b i l i t y . Suffers from Has other i l l -minor but not ex- nesses s i g n i f i -tensively d i s - cantly disabling, abling additional i l l n e s s . C.Actual l e v e l of functioning. Functions up to maximum capacity within l i m i t a -tions imposed by physical disa-b i l i t y . Able to use phys- Functioning at a i c a l a b i l i t i e s but l e v e l much below not up to expected expected capacity, capacity. II.Material  Factors A.Household arrangements Household arrange-ments, f a c i l i t i e s and equipment ade-quate' to meet his needs. Lack of some Household arrange-household arrange- ments, f a c i l i t i e s , raents, f a c i l i t i e s or equipment so or equipment nece3-inadequate as to sary for his needs.be a detriment to his physical and emotional well beinj B. Employ-ment status;* Capable of f u l l employment. (In-cludes housework) Capable of some .employment with spe c i a l arrange-ments . Unemployed or unemployable. C. Economic* status. Has adequate, i n -dependent re-sources which pro-vide a l e v e l of l i v i n g s u f f i c i e n t to meet his phys-i c a l , emotional and s o c i a l needs. Resources adequate Support provided but dependent on by others or others f o r support; public assistance or, independent i n - and provides a come-pension3, sav- subsistence l e v e l ings - provides mini- Q f l i v i n g . maT standards of I i v - to ing - no luxuries. 4 4 , C r i t e r i a Explanation of Ratings Good Fa i r Poor III I n d i v i -dual Factors A. Attitude toward l i v i n g arrangements. ' Finds l i v i n g Unsatisfied or Very d i s s a t i s -arrangements com- complaining about f i e d t with l i v i n g fortable and ade- l i v i n g arrange- arrangements, quate. ments. B.Attitude toward d i s -a b i l i t y . Has r e a l i s t i c Feels somewhat Feels l i f e i s understanding of handicapped by d i s - dominated by lim i t a t i o n s and a b i l i t y . Unable to d i s a b i l i t y , has not made them accept d i s a b i l i t y a detriment to or l i v e comfortably l i v i n g . within i t s l i m i -t a t i o n s . C. Attitude toward own role in family (or equivalent) Feels role has Feels role has a l - Feels unimportant; not altered; or, tered somewhat and or, feels impor-has adjusted to has f a i l e d to ad- tant only through new role in terms just to new r o l e . his d i s a b i l i t y , of his l i m i t a t i o n . D. Motivation] - use of time. Has developed i n - Has d i f f i c u l t y Focus on d i s a b i l i t y terests for en- making use of dominated develop-joyment of spare spare time. merit pf spare time time. a c t i v i t y . E. Motivation - for t r e a t -ment . Is able and w i l l - Is too indepen- Indicates a great ing to use help dent, or depen- deal of resistance from others in dent in l i g h t of through attitudes order to help his c a p a b i l i t i e s . ranging from himself. h o s t i l i t y to apathy. F. Motivation - r e a l i t y -oriented or inner-oriented. Has r e a l i s t i c Has goals not in Has markedly un-goals for him- keeping with his r e a l i s t i c goals s e l f and i s l i m i t a t i o n s or or no goals, active in work- has f a i l e d to ing toward them. plan r e a l i s t i c a l l y for future. 45 1 — ' ——— , V Explanation of Ratings c r i t e r i a Good F a i r Poor IV. S o c i a l Factors A. Family (or equivalent) context. Has family and Ha3 family but does Has no family or l i v e s with them. not l i v e with them, close friends. Has one or more close f r i e n d s . B.Family (or equivalent) attitudes toward d i s a b i l i t y . Family members i n - Family members un- Family members dicate an under- accepting - overpro- very threatened standing of any tection or resentment by l i m i t a t i o n s lim i t a t i o n s imposed of li m i t a t i o n s im- imposed by by d i s a b i l i t y and posed by d i s a b i l i t y , d i s a b i l i t y , accept them comfor-tably. C.Family (or equivalent) contributions. Warm family unit. Lack of emotional A marked lack of Members p u l l to- warmth among family concern; or, re-gether in times members. Limited jection evidenced of stress. mutual support. overtly or in more subtle ways. D. Soci -a b i l i t y . Independent, se- Insecure about mak- Demanding and cure in r e l a t i o n - ing s o c i a l contacts attention-seeking; ships. Thinks of since i l l n e s s . C i r c l e or, withdrawn from others as well as of friends reduced un- s o c i a l contacts, himself. r e a l i s t i c a l l y . May be quite defensive. E. Use of Community Resources^ health. Uses health re- Uses health resources Does not use sources promptly but does not become health resources and appropriately involved. May miss and has negati-when needed. appointments or not v i s t i c attitudes. follow medical i n - to them. structions. F. Use of Community Resources: Vocational Uses vocational Recognizes need for Hostile and re-resources approp- vocational services si s t a n t towards r i a t e l y i f re- but requires much use of vocational quired. encouragement to resources. use them. G. Use of Community Resources: Recreational Makes r e a l i s t i c Reluctant to make Has no recreation-use of ^ resources use of resources a l interests or which appeal to f o r recreation. a c t i v i t i e s , his interests. H. Use of Community Resources-Counselling. Has positive a.tti- Reluctant to use Hostile or apa-tude toward use of counselling i f theti c toward counselling agency appropriate. May counselling re-i f and when appro- view them with sus- sources. No i n -priate. picion or resent- volvement other rnent. than of a de-structive or resistant nature. CHAPTER IV REHABILITATION: PROGRAM AND SERVICE IMPLICATIONS Contributions of the Study to the Rehabilitation Program The contributions of a l l the team members play a v i t a l role in r e h a b i l i t a t i o n . Their frequent exchange of information i s necessary i f they are to work as a team for maximum patient benefit. This information must be placed on the medical chart. For treatment purposes, information i s shared to determine the p a t i e n t T s physical and mental a b i l i t i e s , his motivation and reactions to his d i s a b i l i t y . Further, the medical chart i s the only complete and permanent record and must be useful for follow-up and research purposes. While c o l l e c t i n g data for t h i s study, i t was d i s -covered that current records of each team member were not always placed on the medical chart. This not only made i t r d i f f i c u l t to c o l l e c t adequate, data, but i t l i m i t s the services of each member of the treatment team. While conducting the study, the writers found that the majority of the patients had f e l t unprepared for discharge from A-4. Many longed to return to the security and comfort of the ward. This indicates that the discharge of a patient to another environment must be c a r e f u l l y planned. After reassurance by the s t a f f of t h e i r continued interest in him, 47 the patient w i l l be able to absorb the idea of discharge. The patient must be reminded that r e f e r r a l elsewhere can be of value to him once his active r e h a b i l i t a t i o n program i s completed. Then, he i s usually more ready to accept r e f e r r a l to community resources, i f such are indicated, either medical or s o c i a l . To the patient, a r b i t r a r y and abrupt decisions on • his discharge mean abandonment and loss of i n t e r e s t in him. For this reason, attempts to r e f e r an abruptly discharged patient elsewhere tend to either f a i l or create unnecessary d i f f i c u l t i e s . I f such discharge preparation i s not made, the dependence of the patient on medical services may be encouraged, r e s u l t i n g often in ' h o s p i t a l i t i s ' . The writers also noted that the average age of the sample was 59 years. The youngest patient (not included in the sample) who was treated on the ward during the period of study was 28" years old. Why was the ward not used as exten-si v e l y for younger adult patients? Is i t that the treatment team considers younger patients more capable of achieving recovery from d i s a b i l i t i e s independent of r e h a b i l i t a t i o n services? Yet, the needs of the younger disabled patients are d i f f e r e n t from those of the older ones. The former re-quire services to enable them to function adequately in a l l areas, physical, vocational, emotional and s o c i a l , so that they may make f u l l use of the remaining productive adult years. On the whole, patients in the younger age group are able to make a more extensive use of physical r e h a b i l i t a t i o n . In a general h o s p i t a l , i t seems l o g i c a l to assume that compre-hensive r e h a b i l i t a t i o n services should be extended to these patients.' Implications of the Study fo r S o c i a l Work Practice in the  Rehabilitation Setting From th i s study, i t i s obvious that the s o c i a l worker makes a d e f i n i t e contribution in creating a r e h a b i l i -tation program which i s both comprehensive and e f f e c t i v e . The role of the s o c i a l worker e n t a i l s three s p e c i f i c r e s p o n s i b i l i t i e s . The f i r s t l i e s in the careful assessment of the s o c i a l and emotional factors in the patient and his family s i t u a t i o n . Most important i s the assessment of the patient's motivation. It i s not s u f f i c i e n t to say that the patient is well-motivated. It i s necessary to say what i s the degree of his motivation, and f o r what goals. This assessment requires considerable gathering of facts and is therefore time-consuming. But exploring and treating the ' f e e l i n g ' aspect of physical r e h a b i l i t a t i o n is necessary in order to achieve e f f e c t i v e r e s u l t s . Other-wise, attitudes in the patient and his family, and any d e t r i -mental factors in t h e i r s o c i a l and economic s i t u a t i o n might greatly impede his chances for successful s o c i a l functioning. Findings of the study indicate that during the f i r s t k9 ten months of the ward's operation, the s o c i a l worker's knowledge and s k i l l s were not u t i l i z e d to f u l l advantage. The s o c i a l worker's attention was focused more upon the family context and the physical arrangements of the home, rather than upon the family relationships and the patient's attitudes toward his s o c i a l s i t u a t i o n . However, i t must be noted that many changes have been made on the ward since August 1 9 6 2 in the program offered. S t i l l , i t i s the writers' opinion that the s o c i a l services offered to patients and their, f a m i l i e s , and the understanding of them by s o c i a l workers and other team members, could be improved. The second r e s p o n s i b i l i t y of the s o c i a l worker l i e s in the u t i l i z a t i o n of a l l community resources - in the family and community - which are appropriate to meet the patient's needs. The s o c i a l worker plays an important r o l e , along with other team members, in preparing a patient f o r discharge and enabling him and the family to use pertinent outside resources. That several of the sample, when interviewed, were either not aware of or using community resources points up the fact that the s o c i a l worker could emphasize better t h i s aspect of s o c i a l service. A t h i r d r e s p o n s i b i l i t y of the s o c i a l worker i s to interpret the a v a i l a b i l i t y and use of community resources to the other team members. The s o c i a l worker acts as a l i a i s o n between the r e h a b i l i t a t i o n s e t t i n g and outside services. She 50 must implement and maintain the necessary channels of communication between them. This function not only strengthens the services offered by the r e h a b i l i t a t i o n program but also helps in the creation of e f f e c t i v e co-ordi-nation between community agencies, of which the r e h a b i l i t a t i o n s e t t i n g i s one. Further, when gaps in community resources are^apparent, i t i s the s o c i a l worker's role to interpret such inadequacies to the other team members, and e n l i s t t h e i r co-operation in s o c i a l action to e f f e c t some improvement of them. .In performing'all these functions ,responsibly, the s o c i a l worker plays a s i g n i f i c a n t part in helping the patient maintain his r e h a b i l i t a t i o n achievements both on the ward and after discharge. Only by including these functions of the s o c i a l worker, plus those of teaching and research, w i l l the f u l l comprehensiveness of the program be r e a l i z e d . Implications for Further Research An implication of t h i s study i s the need for a more accurate assessment of patients' a b i l i t i e s to u t i l i z e r e h a b i l i t a t i o n services. Assessment i s the basis upon which a l l continuing services r e s t , hence i t i s the f i r s t step to good r e h a b i l i t a t i o n treatment. The writers suggest that the c r i t e r i a established to measure s o c i a l functioning be further refined to develop a comprehensive assessment plan for the r e h a b i l i t a t i o n s e t t i n g . APPENDIX A INTERVIEW SCHEDULE Name Age Family Members Own Home B.H N.H Description PHYSICAL FACTORS: 1. How are you able to manage now compared to when you f i r s t came out of hospital? - the same - better - worse 2.. Can.you do a3 much now as you expected to be able to do? ( n i d ) - y e s - no , 3. Are you able to perform your d a i l y a c t i v i t i e s -(lc) - by yourself with or without the help of gadgets?, - with some help from other people? - with a great deal of help? 4 . How i s your health apart from your d i s a b i l i t y ? - good. ( I b ) - f a i r . - poor, 5. Have you been readmitted to any hosp i t a l since your discharge from A4? MATERIAL FACTORS: 6. Are there any d i f f i c u l t i e s in the household arrange-ments which prevent you from using them? Yes No Comments Kitchen Bathroom Bedroom Family recreation room Getting outdoors Interviewer's impression of attitude: (lib) 7. Were you employed before your hospitalization? 8. Are you employed now? (including housework) Yes ( l i b ) No (If response i s "No" omit 9 and 10) 9. What kind of work do you do? (l i b ) - f u l l time -* part time 10. Is th i s d i f f e r e n t from the work you did before your hospitalization? I f so, in what ways? I f 9 and 10 answered, omit 11 and 12, Alternate questions' (lib)'1 11. Is i t possible for you to work (l i b ) 12. I f so, have you t r i e d or had any d i f f i c u l t y in obtaining a job? 13. Are you f i n a n c i a l l y ( l i e ) - independent , - dependent on others , - on s o c i a l assistance 14. Do you fi n d that your income i s s u f f i c i e n t to provide for your everyday needs? Good F a i r Poor (IIC) ~ adequate food - housing - medical care - recreation - other services needed Comments 15. INDIVIDUAL FACTORS: How has your d i s a b i l i t y (or i l l n e s s ) affected your way of l i f e ? (IIIB) - i s i t a detriment in any way? - i f so, in what ways? - has i t changed your whole l i f e completely? Comments'-16. (IIIc) Do you f e e l your place in the family ( i . e . responsi-b i l i t i e s and privileges) has changed because of your i l l n e s s ? I f so, in what ways? 17. How do you spend your spare time? ( H i d ) SOCIAL FACTORS: (IVb) IS. Have you found your family (or friends) encouraging and supportive? 19. Has i t been necessary f o r the family (or friends) to (IVb) reorganize t h e i r duties since your i l l n e s s ? , (IVd) 20. Has your c i r c l e of friends changed because of your i l l n e s s ? 21. Do you take part in any outside a c t i v i t i e s ? (IVg) - recreation - church 22. Have you used, or are you now using, any health, s o c i a l (IVe. or vocational counselling agencies? f,hf - which ones• - how often? 23. Have you or your family had any contact with s o c i a l workers since discharge from Ward A4? APPENDIX A The Vancouver General Hospital VANCOUVER 9. B.C. PHONE TR 6-3211 W. J. McNaughtan, F.C.I.S., R.I.A., Chairman B. W. Fleck, Vice-Chairman A. L. Wright, Hon. Treasurer L. N. Hickernell, Executive Director January 18, 1963 The Activation ward at the Vancouver General Hospital (Ward A -4) has now "been operating for over a year. We are just starting to make a survey to see how our past patients here have fared since discharge from hospital. Knowledge of your present condition and degree of activity w i l l enable us to find ways and means of improving this service both in the hospital and, through the ancillary services in the home. The f i r s t step in this survey w i l l be in the form of a questionnaire which w i l l be brought to you for discussion by one of our social workers (Miss M. DeWolf and Mrs. L. Mansfield). I would be most grateful i f you could cooperate i n this interview which would be arranged at your convenience when one of the social workers contacts you. At a later date, I am hopeful that we could arrange for you to come up to the ward so that the activation team including myself could see you in person. I am Yours sincerely, T.H.C. Lewis, M.D. TL/es APPENDIX B TABLE I Dis t r i b u t i o n by Age and Sex Age Male Female Under 45 -4 6 - 5 0 1 2 5 1 - 5 5 2 5 6 - 6 0 3 1 6 1 - 6 5 5 1 6 6 - 7 0 2 Total 9 TABLE II Dis t r i b u t i o n by Cause of D i s a b i l i t y Cause of D i s a b i l i t y Patients Cardiovascular Accident 7 Multiple Sclerosis 2 Osteomyelitis 1 Rheumatoid A r t h r i t i s 3 Spondylosis 1 Asthma 1 Parkinson's Disease 1 Diabetes M e l l i t u s 1 Total 17 APPENDIX B TABLE III Disposition of Thirty-eight Patients Disposition Patients Available for study 17 Unable to locate 13 Deceased 3 Moved out of City of Vancouver 4 Declined 1 Total APPENDIX C. TABLE IV Rating S o c i a l Functioning i n the Total Sample (a) at time of study. C r i t e r i a (Schedule A) Ratings Good Fa i r Poor I. Physical Factors; A. Physical l i m i t a t i o n s . B. Health. C. Level of functioning. 3 6 7 10 9 8 4 2 2 I I . Material Factors' A. Household arrangements. B. Employment status. C. Economic status. 13 2 4 2 5 8 2 10 5 I I I . Individual Factors' A. Attitude toward l i v i n g arrangements. B. Attitude toward d i s a b i l i t y , C. Attitude toward own r o l e . D. Motivation - time. E. Motivation - treatment. F. Motivation - r e a l i t y -oriented or inner-oriented. 10 3 3 7 7 3 6 6 5 6 4 6 1 8 9 4 6 8 IV. S o c i a l Factors: A. Family context. 11 5 1 B. Family attitudes. 6 10 1 C Family contributions. 5 9 3 D. S o c i a b i l i t y . 4 9 4 E. Use of resources - health. 8 4 5 F. Use of resources -vocational. 4 6 7 G. Use of resources -recr e a t i o n a l . 6 5 6 H. Use of resources -counselling. Total Physical and Material Total Individual Total S o c i a l 35 33 48 42 33 54 25 36 34 Total Factors 116 129 95 TABLE V Hating Social Functioning in the Total Sample (b) at time of discharge. Ratings Inde-C r i t e r i a (Schedule A) Good Fa i r Poor termi-nant. I. Physical Factors: A. Physical l i m i t a t i o n s 4 9 1 3 B. Health. 4 5 5 3 C Level of functioning. 6 4 3 4 I I . Material Factors: A. Household arrangements. 2 2 5 B. Employment status. - 1 11 5 C. Economic status. 7 4 4 2 I I I . Individual Factors:. A. Attitude towar l i v i n g arrangements. 5 - 4 B. Attitude toward d i s a b i l i t y . 6 4 5 -C Attitude toward own r o l e . 4 4 5 4 D. Motivation - time. 10 2 4 1 E. Motivation - treatment. 11 2 4 -F. Motivation - r e a l i t y -oriented or inner-oriented. 10 2 4 1 IV. Social Factors; A. Family context. 11 4 1 1 B. Family a t t i t u d e s . 6 2 4 5 C Family contributions. 7 2 3 5 D. S o c i a b i l i t y . 5 4 5 3 s . Use of resources - health. 13 3 1 -F. Use of resources - 16 vocational. - - 1 G. Use of resources -recreational. 10 2 2 3 H. Use of resources - 10 counselling. 1 2 4 Total Physical and Material 2 9 25 26 22 Total Individual 51 19 22 10 Total S o c i a l 53 19 21 43 Total Factors 133 63 6 9 75 BIBLIOGRAPHY Books B a r t l e t t , Harriett M. , Analyzing S o c i a l Work Practice by F i e l d s . National Association of S o c i a l Workers, New York, 1961. B a r t l e t t , Harriett M., S o c i a l Work Practice in the  Health F i e l d . National Association of Soc i a l Workers, New York, 1961. Boehm, Werner W., Objectives of the So c i a l Work  Curriculum of the Future. Vol. one, Soc i a l 'Work Curriculum Study, Council on S o c i a l Work Education, 1959. French, Thomas M., The Integration of Behavior. University of Chicago Press, Chicago, 1952. Hamilton, Gordon, Theory and Practice of S o c i a l Case 'Work. 2nd. ed. rev., Columbia University Press, New York, 1956. Hutschnecker, Arnold A., The Wi l l to Live. Permabook, New York, 1956. Kasiu3, Cora, ed., New Directions in Soc i a l Work. Harpers and Brothers, New York, 1954. Ling, T.M. and O'Malley, C.J.3. , editors, Rehabili-tation After I l l n e s s and Accident. B a i l l i e r e , T i n d a l l and Cox, London, 1958. Parsons, Talcott, "Definitions of Health and I l l n e s s in the Light of American Values and Social Structure", Patients. Physicians and I l l n e s s , ed., E.G. Jaco, The Free Press, Glencoe, 111., 1958. BIBLIOGRAPHY Perlman, Helen H., S o c i a l Casework. University of Chicago Press, Chicago, 1957. Rusk, Howard A., Rehabilitation Medicine. C.V. Mosby Company, St. Louis, 1958. Towle, Charlotte, Common Human Needs. National Associ-ation of S o c i a l Workers, New York, 1957. Wilensky, H.L. and Lebeaux, C.N., In d u s t r i a l Society  and S o c i a l Welfare, Russell Sage Foundation, New York, 1958. Theses Master of S o c i a l Work Theses Bradley, Eleanor J . , Mothers' Concept of Rheumatoid A r t h r i t i s in the Child. Master of So c i a l v Science Thesis, Smith College School for So c i a l Work, July, 1954. McCallum, Mary F ., Family D i f f e r e n t i a l s in the Rehabili-tation of Children With a Brain Injury. Master of Soc i a l V/ork Thesis, University of B r i t i s h Columbia, 1961. Maclnnis, Margaret R., Socio-Economic Factors in the  Rehabilitation Potential of A r t h r i t i c Patients. Master of So c i a l Work Thesis, The University of B r i t i s h Columbia, 1958. r Rohn, George, Rehabilitation of A r t h r i t i s Patients. Master of Social Work Thesis, The University of B r i t i s h Columbia, 1953. BIBLIOGRAPHY Tomalty, S h i r l e y F. t C r i t e r i a f o r Successful Rehabili-t a t i o n . Master of So c i a l Work Thesis, The University of B r i t i s h Columbia, I960. Varwig, Renate, Family Contributions in Pre-School :Treatment of the Hearing-Handicapped Child, Master of So c i a l Work Thesis, The University of B r i t i s h Columbia, I960. Watson, Hartley, W., Rehabilitation of the Handicapped, Master of Soc i a l Work Thesis, The University of B r i t i s h Columbia, 1956. Miscellaneous (Journals, P e r i o d i c a l s , Monographs, B u l l e t i n s and other publications). Abrams, Ruth and Dana, Bess, "Soc i a l Work in the Process of Rehabilitation", S o c i a l Work. Vol. 2, no. 4, October 1957. Alger, Ian and Rusk, Howard A., "The Rejection of Help by Some Disabled People", unpublished paper, ' New York University-Bellevue Medical Center, New York, 1954. Better Health Care f o r Canadians. The Canadian Welfare Council, Ottawa, 1962. Blackey, Eileen, " S o c i a l Work in the Hospital: A Soc i o l o g i c a l Approach," S o c i a l Work. 1:2 ( A p r i l ) , 1956. Bluebird B u l l e t i n . "Teamwork and Social Work", Vol. 7, no. 3, February 1, 1958. BIBLIOGRAPHY Bowers, Swithin, O.M.I., "The Nature and De f i n i t i o n of Social Casework Part I I I " , S o c i a l Casework. December, 1947 . Breedlove, James, "Casework in Rehabilitation", S o c i a l  Work. Vol. 2 , no. 4 , October 1957 . Canada, Department of Labor, "Rehabilitation in Canada" B u l l e t i n of C i v i l i a n R e h a b i l i t a t i o n . September -October, Ottawa, 1959 . C o c k e r i l l , Eleanor, "A New Philosophy of Social Work in Chronic I l l n e s s " , Fublic Health News. February 1957 . Committee on Medical S o c i a l Work Practice. "Report of Subcommittee of the Medical S o c i a l Worker in Rehabilitation", National A s s o c i a t i o n of Social Workers, New York, March, 1957 . Duning, Arthur, "Rehabilitation* A New Specialization? S o c i a l Work. Vol. 2 , no. 4 , October 1957 . Geismar, L.L. and Ayres, Beverley, "A Method for Evaluating the S o c i a l Functioning of Families-Under Treatment", S o c i a l Work. Vol. 4 , no. 1 , January 1959 . Geismar, L.L. and Ayres, Beverley, Patterns of Change  in Problem Families. Family Centered Project, Greater St. Paul Community Chest and Councils, Inc., St. Paul, July 1959 . Grayson, Morris; Powers, Ann and Levi, Joseph, Rehabilitation Monograph I I : Psychiatric  Aspects of Rehabil i t a t i o n . The Institute of Physical Medicine Rehabilitation, New York University-Bellevue Medical Center, 1952 . BIBLIOGRAPHY Green, Rose, "Use of Identity Concepts in Soc i a l Work Practice," Achieving S e l f - I d e n t i t y in Modern Society. National Association of Soci a l Workers, New York, 1962. Hamilton, Gordon, "Introduction", S o c i a l Work. Vol. 2, no. 4, October 1957. Hansen, Robert, "The Socio-Economic Aspects of Cardiac Disease and Chronic I l l n e s s " , Services to the Chronically 111. U.S. Department of Health, Education and Welfare, Washington, D.C, 1959. Haselkorn, Florence. "Some Adaptations of Basic Concepts and Pri n c i p l e s f o r Casework Practice in a Rehabilitation Setting", The Workshop: Practice of Social Work in Reh a b i l i t a t i o n . University of Chicago Press, Chicago, I960. Katzen, Faye, "Challenges to S o c i a l Work: In the Rehabilitation Center", The Workshop: Practice  of S o c i a l Work in Rehabil i t a t i o n . University of Chicago Press, Chicago, I960. Lester, Eileen E. f "The Impact of Chronic I l l n e s s on th Patient and his Family", Services to the Chronically 111. U.S. Department of Health, Education and 'Welfare, Washington, D.C, 1959. Ludwig, A.O., "Emotional Factors in Rheumatoid A r t h r i t i s " , The Physical Therapy Review. Vol. 29, no. 8, August 1949. McCoy, Georgia F. and Rusk, Howard A., Rehabilitation  Monograph I: An Evaluation of Reh a b i l i t a t i o n . . The Institute of Physical Medicine and Rehabili-t a t i o n , New York University-Bellevue Medical Center, New York, 1953. McKenzie, M. Bruce, "Rehabilitation and S o c i a l Work", The S o c i a l Worker. Vol. 26, no. 2, January 1958. BIBLIOGRAPHY M i l l e t t , John A.P., "Understanding the Emotional Aspects of D i s a b i l i t y " , S o c i a l Work, Vol. 2, no. 4, October 1957. Primeau, B., "The Medical Restoration Component in a Comprehensive Rehabilitation Programme", Medical Services Journal. Vol. 14, no. 10, November 1958. Ripple, L. "Motivation, Capacity and Opportunity as Related to the Use of Casework Services: Plan of Study", So c i a l Service Review. Vol. 29, no. 2 June 1955. Ripple, L. and Alexander, E., "Motivation, Capacity and Opportunity as Related to the Use of Case work Services: Nature of Cli e n t ' s Problem," Social Service Review. Vol. 30, no. 1, March, 1956. Robinson, C.E.G., "Emotional Factors and Rheumatoid A r t h r i t i s " , The Canadian Medical Association  Journal. August 15, 1957. Robinson, H.A. and Finesinger, J.E., "The Significance of Work Inhibiti o n for Reha b i l i t a t i o n " , S o c i a l  Work. Vol. 2, no. 4, October 1957. Robinson, H.S. , "The Cost of Rehabilitation in Rheumatoid Disease" , Journal of Chronic Diseases Vol. 8, no. 6, December 1958. Robinson, H.S. and Bradley, Eleanor J., "The Rehabili-tation Center and Rheumatic Disease", The Canadian Medical Association Journal. July 15, 1957. Scheele, L.A., "Progress in Prevention of Chronic I l l n e s s , 1949-56", Public Health News. February 1957. BIBLIOGRAPHY Simon, Berriece K., "Challenges to Social Work' The S o c i a l Casework Method in Rehabilitation -Constant Tool", The Workshop' Practice of  Soci a l Work in Rehabilitation. University of Chicago Press, Chicago, I960. Taylor, E.J. "Rehabilitation in the Latter Half ' of the Twentieth Century: Recent Advances and Goals", The Workshop: Practice of S o c i a l  Work in Reh a b i l i t a t i o n . University of Chicago * Press, Chicago, I960. Wallace, Helen M. , Meeting the Needs of the Chronically £11. unpublished paper, University of Minnesota School of Public Health, Minneapolis, 1959. . V f 

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