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The family as a rehabilitation resource : the assessment and application of family strengths and weaknesses… Hagerman, Goldie Jeune 1959

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THE FAMILY AS A REHABILITATION RESOURCE The A s s e s s m e n t and A p p l i c a t i o n o f F a m i l y S t r e n g t h s and Weaknesses i n t h e R e h a b i l i t a t i o n o f Male A r t h r i t i c P a t i e n t s : C a n a d i a n A r t h r i t i s a n d Rheumatism S o c i e t y (B.C. D i v i s i o n ) , M e d i c a l C e n t r e , 1955-58. by GOLDIE JEUNE HAGERMAN T h e s i s S u b m i t t e d 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 t h e Degree o f MASTER OF SOCIAL WORK i n t h e S c h o o l o f S o c i a l Work A c c e p t e d as c o n f o r m i n g t o t h e s t a n d a r d r e q u i r e d f o r the d e g r e e o f M a s t e r o f S o c - l a l Work S c h o o l o f S o c i a l Work. 1959 The 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 i i ABSTRACT Physical d i s a b i l i t y r e s u l t i n g from a r t h r i t i s i s a wide-spread problem: when the sufferer i s the breadwinner of a family, i t i s p a r t i c u l a r l y serious, creating the need for sp e c i a l services not only for the disabled person, but also for his family. But the treatment p o t e n t i a l of the patient also depends on how far his family i s i n turn a source of strength or weakness to him. This i s a casework "dimension" that i s far from f u l l y explored. This thesis considers the family as a treatment resource i n the r e h a b i l i t a t i o n of a group of male a r t h r i t i c breadwinners who have been in-patients at the Canadian A r t h r i t i s and Rheumatism Society (B.C. Division) Medical centre i n Vancouver, B. C , for at least three months. While focusing on the patient i n his family group, the study undertakes an intensive examination of the material found i n case records and related correspondence from the Medical Centre's S o c i a l Service Department, a c l i n i c a l s o c i a l work s e t t i n g . The outcome of the exploration was to emphasize two approaches: (a) the recognition of factors i n family behaviour toward the patient which connote family strength, and (b) t h e i r a p p l i c a t i o n i n casework to help meet the patient's needs . Four comparative cases (two each of "strong" and"weak" examples) were selected to i d e n t i f y the variables a f f e c t i n g employment, treatment, and family i n t e r a c t i o n . The r e s u l t s of t h i s analysis were then applied to the process of diagnosis and treatment to the t o t a l cases (seven) for which c l i n i c a l and s o c i a l information was a v a i l a b l e . The s p e c i f i c findings are (1) that the patient's family could influence p o s i t i v e l y the patient's r e h a b i l i t a t i o n p o t e n t i a l ; (2) that family strength could be recognized i n a c l i n i c a l s e tting treating the patient; (3) that c e r t a i n a d d i t i o n a l kinds of diagnostic information are required p r i o r to the patient's admission to the Medical Centre for treatment. A r a t i n g scale of family strength can be envisaged as an experimental counterpart of t h i s complex adjust-ment process. Some p r a c t i c a l implications for future service are discussed. In presenting t h i s thesis i n p a r t i a l fulfilment of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It i s understood that copying or publication of this thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. The University' of B r i t i s h Columbia, Vancouver's, Canada. Department of i i TABLE OF CONTENTS Chapter 1 R e h a b i l i t a t i o n of the D i s a b l e d Breadwinner Page The a r t h r i t i c d i s e a s e s , a nation-wide problem. The concept of r e h a b i l i t a t i o n and the i n f l u e n c e of the p a t i e n t ' s f a m i l y . The r e h a b i l i t a t i o n process and the r o l e of the s o c i a l worker. The Canadian A r t h r i t i s and Rheumatism S o c i e t y (B.C. D i v i s i o n ) , M e d i c a l Centre, the s e t t i n g of the present study. Scope and method of study 1 Chapter 2 R e c o g n i z i n g Family F a c t o r s i n R e h a b i l i t a t i o n S e l e c t i o n of cases f o r study. V a r i a b l e s i n f l u e n c i n g r e h a b i l i t a t i o n . A n a l y s i s of s e l e c t e d comparative cases: d i s a b l e d breadwinners. C r i t e r i a of f a m i l y s t r e n g t h 16 Chapter 3 The Concept of Family S t r e n g t h : Casework  A p p l i c a t i o n s . P a t i e n t - f a m i l y d i a g n o s i s and treatment i n a c l i n i c a l s e t t i n g . The concept a p p l i e d to the d i a g n o s i s and t r e a t -ment of the sample cases. A r a t i n g s c a l e of f a m i l y s t r e n g t h . Treatment i m p l i c a t i o n s 46 Chapter li Improving Treatment Resources B e t t e r d i a g n o s i s may h e l p the f a m i l y . Lack of in f o r m a t i o n , a l i m i t a t i o n . Treatment i m p l i c a t i o n s of t h i s study. Suggestions f o r f u r t h e r i n v e s t i g a t i o n . Community i m p l i c a t i o n s 64 Appendix: Bib l i o g r a p h y 88 T a b l e s : 1 Numerical D i s t r i b u t i o n of Male P a t i e n t s at the C.A.R.S. M e d i c a l Centre, 1955 to 1958, A c c o r d i n g to age 20 2 Comparative R a t i n g of Family S t r e n g t h s . 63-A Schedules: A Summary of V a r i a b l e s A f f e c t i n g the R e h a b i l i t a t i o n of Four P a t i e n t s '41-A B Summary of O b j e c t i v e V a r i a b l e s A f f e c t i n g the R e h a b i l i t a t i o n of Three P a t i e n t s ~. 46-A C Summary of Family S t r e n g t h Assessments 57-A THE FAMILY AS A REHABILITATION RESOURCE The A s s e s s m e n t and A p p l i c a t i o n o f F a m i l y S t r e n g t h s and weaknesses i n t h e R e h a b i l i t a t i o n o f Male A r t h r i t i c P a t i e n t s : C a n a d i a n A r t h r i t i s and Rheumatism S o c i e t y (B.C. D i v i s i o n ) M e d i c a l C e n t r e , 1955-58. CHAPTER I ) REHABILITATION OF THE DISABLED BREADWINNER P h y s i c a l d i s a b i l i t y due to c h r o n i c i l l n e s s r e s u l t s i n the prolonged economic dependence * of many a competent, p r o d u c t i v e Canadian. Apart from the d i s c o m f o r t s u f f e r e d , i f the v i c t i m i s a f a m i l y ' s breadwinner o r the mother of young c h i l d r e n , the r e -s u l t a n t s o c i a l problems of d i s a b i l i t y become more e v i d e n t . The A r t h r i t i c Diseases - A Nation-wide Problem^ The a r t h r i t i c d i s e a s e s , which take many forms, are c h r o n i c d i s o r d e r s of widespread i n c i d e n c e i n Canada. A r t h r i t i s Is the name a p p l i e d to a group of rheumatic d i s e a s e s which a f f e c t the 2 j o i n t s and sometimes other body s t r u c t u r e s as w e l l . Among the most common forms are rheumatoid a r t h r i t i s and M a r i e - S t r u m p e l l s p o n d y l i t i s . 3 These two, and other forms of a r t h r i t i s , i f they are n e g l e c t e d , and even w i t h the a p p l i c a t i o n of p r e s e n t l y - a v a i l -able modes of treatment ( i n one out, of f i v e c a s e s ) , may l e a d t o s e r i o u s d i s a b i l i t y and d e f o r m i t y . While s t a t i s t i c s do not t e l l the whole s t o r y of the economic and s o c i a l l o s s occasioned by a r t h r i t i c d i s a b i l i t y , the f o l l o w i n g 1 F a c t s About A r t h r i t i s and the Canadian A r t h r i t i s and Rheumatism  S o c i e t y , a pamphlet p u b l i s h e d by the C.A.R.S., 1959> i s the source of m a t e r i a l used i n t h i s s e c t i o n . 2 "Rheumatic d i s e a s e s " i s the broader c l a s s i f i c a t i o n which Includes a l s o the n o n - a r t h r i t i c . i l l n e s s e s such as b u r s i t i s , s c i a t i c a , and lumbago which, a l t h o u g h p a i n f u l , do not a f f e c t the j o i n t s and are u s u a l l y l e s s s e r i o u s than a r t h r i t i s . 3 M a r i e - S t r u m p e l l s p o n d y l i t i s so named a f t e r F r e n c h and German doctors a s s o c i a t e d w i t h i t s i d e n t i f i c a t i o n . estimates prepared (1957) by the Dominion Bureau of S t a t i s t i c s of the Department of N a t i o n a l H e a l t h and Welfare, are eloquent: 50,000 Canadians are t o t a l l y or s e v e r e l y d i s a b l e d , and another 115,000 are p a r t i a l l y d i s a b l e d by a r t h r i t i s . The annual cost to Canadian workers i n l o s t wages i s $75,000,000.00, r e p r e s e n t i n g f o r workers and business 9 , 0 0 0 , 0 0 0 working days. Of a l l those d i s a b l e d by a r t h r i t i s , 68 per cent are of working age, 18 t o 6I4. y e a r s . E i g h t y per cent of those s u f f e r i n g from rheumatoid a r t h r i t i s , the most s e r i o u s form and one f o r which t h e r e i s no s p e c i f i c cure, are between the ages of 20 and 50 y e a r s . These estimates are of p a r t i c u l a r importance to t h i s study, although the study i s concerned w i t h a s p e c i f i c group of bread-winners w i t h rheumatoid a r t h r i t i s and M a r i e - S t r u m p e l l s p o n d y l i t i s . The estimate i m p l i e s that a r t h r i t i s most commonly occurs i n the prime of l i f e when the a r t h r i t i c i s l i k e l y to be i n v o l v e d i n p r o v i d i n g f o r a f a m i l y . T h i s i n d i c a t e s t h a t the problems of a r t h r i t i c s and t h e i r f a m i l i e s appearing i n the s m a l l group to be examined may r e c u r elsewhere. F u r t h e r , those whose d a i l y l i v e s i n v o l v e heavy p h y s i c a l t o i l or emotional s t r a i n tend to be p a r t i c u l a r l y s u s c e p t i b l e to the a r t h r i t i c d i s e a s e s . A r t h r i t i s , though i t d i f f e r s w idely i n d u r a t i o n , s e v e r i t y , and k i n d of treatment r e q u i r e d , a f f e c t s the j o i n t s of the body/.'causing s t i f f n e s s inflammation, p a i n , and s w e l l i n g , Rheumatoid a r t h r i t i s a f f e c t s p a r t i c u l a r l y the body's p e r i p h e r a l j o i n t s , w h i l e M a r i e - S t r u m p e l l s p o n d y l i t i s a f f e c t s mainly the s p i n e . That the di s e a s e s preclude the strenuous a c t i v i t y necessary t o the manual labo u r e r who may a l s o be a f a m i l y breadwinner i s e v i d e n t . Treatment of a c h r o n i c , d i s a b l i n g i l l n e s s , which must be adapted to each i n d i v i d u a l case, i m p l i e s a l s o a prolonged p e r i o d of care and heavy expense not i n d i c a t e d i n the above estimates of wage l o s s . The Canadian A r t h r i t i s and Rheumatism S o c i e t y , B. C. D i v i s i o n , was formed i n 19I48 on the recommendation of a meeting of re p r e s e n -t a t i v e s of h e a l t h departments, u n i v e r s i t i e s , and the m e d i c a l p r o f e s s i o n , c a l l e d by the M i n i s t e r of N a t i o n a l H e a l t h and Welfare i n r e c o g n i t i o n of the above f a c t s . F u r t h e r d e s c r i p t i o n of t h i s o r g a n i z a t i o n w i l l be c i n c l u d e d i n t h i s chapter. R e h a b i l i t a t i o n and the Fam i l y of the D i s a b l e d Breadwinner The g o a l of treatment of the d i s a b l e d person i s h i s rehab-i l i t a t i o n . R e h a b i l i t a t i o n i s a concept capable of a wide range of d e f i n i t i o n s encompassing the r e t u r n of the d i s a b l e d person to g a i n f u l employment, or more e x t e n s i v e l y , "the c u l t i v a t i o n , r e s t o -r a t i o n , and c o n s e r v a t i o n of human resources.""'" The l a t t e r d e f -i n i t i o n seeks t o i n c l u d e "the young, the a d u l t , and the aged, i n a l l t h e i r c a p a c i t i e s and p o s s i b i l i t i e s . " T h i s i s an i d e a l o b j e c t i v e , and i n i t s emphasis on the dynamic and n o u r i s h a b l e q u a l i t y of human c a p a c i t i e s , i t i s a k i n t o the philosophy p r o f e s s e d by s o c i a l work p r a c t i t i o n e r s by which a l l t h e i r e f f o r t s on b e h a l f 1 & 2 Whitehouse, F r e d e r i c k A., " R e h a b i l i t a t i o n as a Concept i n the U t i l i z a t i o n of Human Resources," The E v o l v i n g Concept o f  R e h a b i l i t a t i o n , Monograph I, J u l y , 1955• The American A s s o c i a t i o n of S o c i a l Workers, Washington, D.D., p. 22. - h-of the disabled person are guided. In practice this concept of rehabilitation of the person with a problem of physical disability Is expressed i n the total regard by helping persons of his needs, his capacities to meet them, and the means required for their satisfaction. 1 Failure In practice to achieve the ideal of rehabilitation i s , obviously, occasioned by the practical limitations of the helping person and of the re-sources available. Those resources which are available in the disabled person's own a b i l i t i e s , and in his environment, must be utilized to their fullest possible extent. The disabled person's family, in this context, might be con-sidered as one such resource or source of enabling assistance to meet his needs. This point of view does not ignore or discount the fact that these families are made up of persons each having his own individual needs, (the most important of which had probably been met by the breadwinner), or that they are as individuals limited in their a b i l i t i e s to meet them. Obviously, small children are necessarily dependent. The contention i s , rather, that families are involved in the rehabilitation of the disabled person in com-plex ways which w i l l be examined in ensuing chapters of this thesis. 1 Human needs may be broadly identified as those needs which must be met for survival and personality growth of the human being. Charlotte Towle, in Common Human Needs, (the American Association of Social Workers, 1955) classifies needs as follows: the need of every person for physical well-being; for development of intellec-tual capacity; for relationships with others, particularly in early formative years; for respect and understanding of his s p i r i t u a l sig-nificance. - 5 -The Purpose of This Study. The purpose of this thesis is to explore, and, i f possible, assess the a b i l i t y of families to meet certain needs of their disabled breadwinners. The object is to indicate ways In which the family might be enabled as a resource to improve the disabled breadwinner's rehabilitation potential. The Rehabilitation Process and the Role of the Social Worker. The process of rehabilitating a disabled breadwinner, considering the rehabilitation goal to be the maximum use of his residual strengths, may be divided into two parts as the process is observed in practice. The f i r s t involves assessment of the person's problem of disability, and of his residual strengths to overcome i t , and is termed "diagnosis." The second involves the process of resolving the problem by appropriate means and enabling the person to u t i l i z e his residual strengths. The term "treatment" is applied to this part of the total process. The purpose of diagnosis might be said to be the determination of rehabilitation potential; of treatment, the rehabilitation of the person. The role of the social worker in the rehabilitation process implies social diagnosis and treatment of the disabled person in his total environment and this includes his family setting. A social diagnosis as distinguished from a medical diagnosis or functional assessment (although i t must u t i l i z e both) is the pro-duct of an on-going process of helping the person through a therapeutic relationship and environmental change to meet his - 6 -needs. 1 I t i s based not only upon i n f o r m a t i o n obtained from the person through such a r e l a t i o n s h i p i n an agency where he appears f o r h e l p at a g i v e n time--a " c r o s s - s e c t i o n " of h i s present behaviour p a t t e r n and apparent success i n p r o b l e m - s o l v i n g --but a l s o upon h i s behaviour i n the p a s t . T h i s f u r t h e r Implies a " v e r t i c a l " examination to give a more r e a l i s t i c assessment o f h i s c a p a c i t i e s t o meet h i s needs b e f o r e as w e l l as a f t e r the onset of i l l n e s s . By t h i s means the degree of " d i s a b i l i t y " h i s i l l n e s s has caused may be determined. " D i s a b i l i t y " i s considered i n t h i s s o c i a l context as a problem, a l b e i t a complex one, which the treatment phase of the process o f r e h a b i l i t a t i o n i s designed to overcome. The degree of s o c i a l d i s a b i l i t y v a r i e s f o r each person and must be assessed not only by determining h i s f u n c t i o n a l impairment and m e d i c a l p r o g n o s i s , but a l s o through examination of the l i f e t a sks he has undertaken. Por example, the degree of s o c i a l d i s a b i l i t y experienced by an u n t r a i n e d manual l a b o u r e r who has assumed the r o l e of breadwinner f o r a wife and f a m i l y of dependent c h i l d r e n may be g r e a t e r than f o r a well-educated and more adaptable person without incumbents. The e f f e c t of d i s a b i l i t y on employment i s an aspect of the d i s a b i l i t y problem of great importance, both i n d e t e r m i n i n g 1 Helen H a r r i s Perlman, S o c i a l Casework, The U n i v e r s i t y of Chicago Press, 1957; Chapter X I . - 7 -i n d i v i d u a l r e h a b i l i t a t i o n p o t e n t i a l and i n c o n d i t i o n i n g the r e h a b i l i t a t i o n p r o c e s s . I t i s a s u b j e c t which deserves much broader c o n s i d e r a t i o n than can be accorded i t w i t h i n the scope of t h i s t h e s i s . Just as t h e r e are evident degrees of d i s a b i l i t y , there may be expressed a range of e m p l o y a b i l i t y s u i t a b l e to r e s i d u a l c a p a c i t i e s of d i s a b l e d persons. T h i s range of employ-a b i l i t y , to be provided f o r , r e q u i r e s a v a r i e t y of a v a i l a b l e jobs. Dr. J . A. P. M i l l e t , C h i e f of P s y c h i a t r i c S e r v i c e of the American R e h a b i l i t a t i o n Committee, makes r e f e r e n c e to t h i s i n the f o l l o w i n g remarks: "The f i n a l c r i t e r i o n of success i n the program (of r e h a b i l -i t a t i o n ) i s the acceptance of the p a t i e n t i n s a t i s f y i n g and remunerative employment, i n which he proves h i m s e l f capable of g i v i n g s e r v i c e s a t i s f a c t o r y t o the employer. Obviously, there are many i n d i v i d u a l s whose d i s a b i l i t y i s so great t h a t they cannot ever be i n t e g r a t e d w i t h the g e n e r a l working f o r c e i n c o m p e t itive i n d u s t r y . For these l e s s f o r t u n a t e ones s p e c i a l centres of a c t i v i t y are badly needed, s u i t e d to t h e i r maximal c a p a c i t y f o r c r e a t i v e output. The establishment of centres i n Great B r i t a i n where such groups have found p r o f -i t a b l e employment and s o c i a l s a t i s f a c t i o n s which would other-wise have been denied them provides us w i t h a c h a l l e n g e to our own r e s o u r c e s , b o t h p r o f e s s i o n a l and s o c i a l . " 1 R e f e r r i n g a g a i n t o the example s t a t e d above of the l a b o u r e r and the well-educated person without incumbents, comparatively speaking, the r e h a b i l i t a t i o n p o t e n t i a l , i f the r e h a b i l i t a t i o n g o a l i s re-employment, may be l e s s - f a v o u r a b l e f o r the l a b o u r e r , though the f u n c t i o n a l d i s a b i l i t i e s of the two persons are approximately the same. S o c i a l aspects of d i s a b i l i t y are t h e r e f o r e important t o 1 M i l l e t , John A. P., "Understanding the Emotional Aspects of D i s a b i l i t y " , an address,. I n s t i t u t e on R e h a b i l i t a t i o n , Report of  Proceedings, Bryn Mawr C o l l e g e , Bryn Mawr, Perm., 1 9 5 6 , p. 52. r e h a b i l i t a t i o n , and the value of a s o c i a l d i a g n o s i s to determine the r e h a b i l i t a t i o n p o t e n t i a l of each d i s a b l e d person i s e v i d e n t . The Canadian A r t h r i t i s and Rheumatism S o c i e t y , B. G. D i v i s i o n  M e d i c a l Centre; S e t t i n g of the Present Study. Human needs and t h e i r s a t i s f a c t i o n s are seen to be complex and i n t e r r e l a t e d and a broad range of s e r v i c e s i s r e q u i r e d to meet them. The modern development.of r e h a b i l i t a t i o n "teams" working i n r e h a b i l i t a t i o n " c e n t r e s " to h e l p the d i s a b l e d person, might be considered p r a c t i c a l r e c o g n i t i o n that h i s need f o r a h e a l t h y p h y s i c a l body i s the most important of a l l . The teams, composed of s p e c i a l -i z e d treatment p e r s o n n e l - - d o c t o r s , nurses, p h y s i o t h e r a p i s t s , occup-a t i o n a l t h e r a p i s t s , and s o c i a l workers--act t o provide such a range of s e r v i c e s . These s e r v i c e s may i n c l u d e , to give a sampling, d i a g n o s t i c s e r v i c e s , v o c a t i o n a l c o u n s e l l i n g , medical, s u r g i c a l , p s y c h i a t r i c , and d e n t a l care, h o s p i t a l i z a t i o n , t r a i n i n g , o c c u p a t i o n a l t o o l s , job placement, and " f o l l o w - u p " of the p a t i e n t a f t e r h i s d i s c h a r g e . Many of these s e r v i c e s may be a v a i l a b l e o u t s i d e such a cen t r e e i t h e r by b r i n g i n g them t o the p a t i e n t or by r e f e r r a l of the p a t i e n t t o the a p p r o p r i a t e sources. The Canadian A r t h r i t i s and Rheumatism S o c i e t y , B. C. D i v i s i o n M e d i c a l Centre, i n Vancouver, i s one such centre f o r the d i a g n o s i s and treatment of persons s u f f e r i n g from the Rheumatic d i s e a s e s . T h i s i s the s e t t i n g i n which the d i s a b l e d persons d e s c r i b e d i n t h i s t h e s i s have r e c e i v e d i n t e n s i v e treatment- as i n - p a t i e n t s d u r i n g the three years 1955 to 1958. The i n f o r m a t i o n obtained i s drawn from that recorded by s o c i a l workers i n the Centre's S o c i a l S e r v i c e Department. . 9 -The development of C.A.R.S., a n a t i o n a l , n o n - p r o f i t o r g a n i z a t i o n i n c o r p o r a t e d under f e d e r a l law, has been d e s c r i b e d e l s e w h e r e . 1 The B. C. D i v i s i o n of C.A.R.S. was the f i r s t e s t a b l i s h e d o f eig h t which now serve every p r o v i n c e In Canada except P r i n c e Edward I s l a n d and Newfoundland. The Vancouver M e d i c a l Centre, which shares some f a c i l i t i e s , . i n c l u d i n g the accommodation, of the G.P. Strong R e h a b i l i t a t i o n Centre, i s an i n t e g r a l p a r t of s e r v i c e s which i n c l u d e 26 branches throughout B.C. Through t r a v e l l i n g m e d i c a l c o n s u l t a n t s , d i r e c t m e d i c a l treatment, physiotherapy, o c c u p a t i o n a l therapy, and s o c i a l s e r v i c e , the D i v i s i o n serves approximately 3>500 p a t i e n t s a n n u a l l y , and provides s p e c i a l drugs to p a t i e n t s of low income.^ Each p a t i e n t considered f o r treatment i n the Centre r e c e i v e s a m e d i c a l , f u n c t i o n a l , and I d e a l l y , a s o c i a l assessment b e f o r e h i s admission. F a c i l i t i e s i n the Centre l i m i t the number of i n - p a t i e n t s to 10 persons at any one time, a l t h o u g h others l i v i n g i n the Centre's v i c i n i t y are served on an o u t - p a t i e n t b a s i s , and a ve r y few who cannot manage s e l f - c a r e are admitted t o the n u r s i n g wing of the G.F. Strong R e h a b i l i t a t i o n Centre. The average p e r i o d of treatment i s about t h r e e months, and the cost of t h i s ( f o r room, board, and treatment d u r i n g the p e r i o d 1955 to 1958 was about |9»50 to $10.50 1 Rohn, George, R e h a b i l i t a t i o n of A r t h r i t i s P a t i e n t s , Master of S o c i a l Work T h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1953? PP ll|.-l8 2 F a c t s About A r t h r i t i s and the Canadian A r t h r i t i s and Rheumatism  S o c i e t y , C.A.R.S., 1959. - 10 -per day) i s borne f o r each p a t i e n t by the p r o v i n c i a l government, or by C.A.R.S. or both.^- In r a r e cases the p a t i e n t has p a i d f o r h i s own care or has c o n t r i b u t e d . Of the 80 p a t i e n t s admitted d u r i n g the thr e e years, only f i v e could pay f o r t h e i r own care, and another 15 p a t i e n t s c o n t r i b u t e d t o t h e i r s . The oth e r 75 per cent could make no c o n t r i b u t i o n s . T h i s i n d i c a t e s the modest means of most of the p a t i e n t s admitted, and i m p l i e s the great cost to them of c h r o n i c i l l n e s s , any p e r s o n a l savings having been p r e v i o u s l y absorbed f o r treatment s e r v i c e s . The process of s e l e c t i n g p a t i e n t s f o r admission i m p l i e s a p r o v i s i o n a l assessment of the p a t i e n t ' s r e h a b i l i t a t i o n p o t e n t i a l . The complexity of t h i s e s s e n t i a l l y d i a g n o s t i c process has been i n d i c a t e d by a former Centre m e d i c a l d i r e c t o r i n a l e t t e r to a B. C. ge n e r a l p r a c t i t i o n e r who r e f e r r e d a s e v e r e l y - d i s a b l e d p a t i e n t . (The p a t i e n t was e v e n t u a l l y admitted to the n u r s i n g wing by s p e c i a l arrangement). The statements p e r t a i n i n g t o h i s f u n c t i o n a l a s s e s -sment are quoted as f o l l o w s : " I t i s extremely d i f f i c u l t to p r e d i c t whether a p a t i e n t i s capable of improvement under the i n t e n s i v e r e h a b i l i t a t i o n program a v a i l a b l e at the C.A.R.S. M e d i c a l C entre. However, because of the nature of the p h y s i c a l set-up, there are c e r t a i n c r i t e r i a which the p a t i e n t must f u l f i l l . No bed-s i d e n u r s i n g s e r v i c e i s a v a i l a b l e and, i n f a c t , the Centre i s much l i k e a super b o a r d i n g home. The p a t i e n t s must be able to dress themselves, a t t e n d t o t h e i r u s u a l tasks of 1 The B.C. Government's former S o c i a l Welfare Branch of the Department of H e a l t h and Welfare, now a separate department, The Department of S o c i a l Welfare, sponsors r e h a b i l i t a t i o n " t r a i n e e s " at the G.F. Strong R e h a b i l i t a t i o n Centre on a quota of 12 persons at any one time. - 11 -d a l l y l i v i n g , and go to the dining-room by t h e m s e l v e s — e i t h e r i n a wheelchair or walking. Since t h e r e are no n u r s i n g attendants, and no o r d e r l y s e r v i c e , p a t i e n t s must be a b l e to look a f t e r themselves. " The i n t e n s i v e type of physiotherapy and o c c u p a t i o n a l therapy makes i t e s s e n t i a l that t h e i r d i s e a s e be at l e a s t i n c l i n i c a l r e m i s s i o n . The l e n g t h of time r e q u i r e d i s great, most p a t i e n t s r e q u i r i n g at l e a s t three months and some longer b e f o r e any great improvement can be expected." Thus there are c e r t a i n l i m i t a t i o n s i n the number of p a t i e n t s admitted and the amount of t h e i r f u n c t i o n a l d i s a b i l i t y which are imposed by the e x i s t i n g f a c i l i t i e s of the Centre. The m e d i c a l d i r e c t o r went on i n t h i s l e t t e r to recommend that the p a t i e n t be assessed m e d i c a l l y by the C.A.R.S. t r a v e l l i n g c o n s u l t a n t , when next he v i s i t e d the p a t i e n t ' s area of r e s i d e n c e . "Under these circumstances and c o n s i d e r i n g the p h y s i c a l d i s a b i l i t y of (the p a t i e n t ) I do not t h i n k i t wise at the present moment to d i s r u p t h i s f a m i l y l i f e t o b r i n g him down to Vancouver f o r assessment b e f o r e admission to the Centre." S o c i a l assessment of the p a t i e n t who l i v e s i n an area other than Vancouver and environs which C.A.R.S. caseworkers r e a c h must be done by the p r o v i n c i a l S o c i a l Welfare Department workers. The Department's investment i n a c c u r a t e assessment of r e h a b i l i t a t i o n p o t e n t i a l , and the p a t i e n t ' s f a m i l y concern i n h i s r e h a b i l i t a t i o n process i s i n d i c a t e d by the m e d i c a l d i r e c t o r as f o l l o w s : "Because of the r e l a t i v e l y great cost, and the l e n g t h of time as w e l l as the l i m i t e d supply of beds a v a i l a b l e , some assurance i s r e q u i r e d t h a t the p a t i e n t w i l l b e n e f i t from the treatment, and t h e r e f o r e the S o c i a l Welfare (Branch) r e q u i r e s a r a t h e r d e t a i l e d m e d i c a l r e p o r t from t h i s o f f i c e , b e f o r e they w i l l c o n s i d e r any p a t i e n t ( f o r c o n t r i b u t i o n to the cost of h i s c a r e ) . . . " I t i s s i n c e r e l y hoped that we can do something f o r (the p a t i e n t ) , but on two or three occasions i n the-past year or - 12 -two we have admitted patients to the Centre without having them f i r s t assessed, and this has resulted i n a great deal of heartbreak for both patient and the staff. This patient would appear to be well settled and happy in his home surroundings, and I would not like to disturb this unless we feel that i t would be worthwhile." Further correspondence concerning this patient, a 50 year-old logger who had been unable to work and support his wife and daughter for some years, and was now supported by his wife, was directed by the head of the C.A.R.S. Social Service Department to the provincial Social Welfare Branch. The letter requested S.W.B. opinion on the patient's rehabilitation prospects, and defined the term "rehabilitation" for this purpose as follows: "...By rehabilitation I do not mean a complete recovery and job-placement. There are varying degrees of rehabilitation, and even i f a man, like (the patient), could be helped physically to be less of a burden to himself and family, such a step might be worthwhile." The C.A.R.S. medical consultant had also directed a letter to the patient's private doctor, stressing the need for "a report from the social worker i n your d i s t r i c t as to environmental and social status of the patient and his family, and a short medical report as to his condition and prognosis." The designated worker visited the patient's home, and determined that the wife's income exceeded the maximum allowable for S.W.B. sponsorship. The patient, loath to spend his small savings, already depleted by the cost of treating his illness, told the worker that, since he had no hope of returning to work, he would rather not "gamble" his residual savings on treatment at the Centre. Eventually, after some months, during which time reports from the local C.A.R.S. physiotherapist were submitted to the Medical - 13 -Centre that the patient'3 physical condition was deteriorating, he was admitted to the Centre under C.A.R.S. sponsorship. He received medical attention, physical and occupational therapy, and casework; was discharged three months later able to walk 100 feet unaided, and much further with crutches. Although he could not become reemployed, he managed later to help paint his house. The caseworker summed-up the case stating: "The (rehabilitation) goal has been more than achieved." Each team member concerned in this man's rehabilitation and his family, had contributed to his recovery. To determine the nature and assess the relative importance of any one service to the achievement of rehabilitation potential is very d i f f i c u l t . This i s , however, necessary to the primary aim of this thesis: to determine what influence, i f any, family factors have in the patient's rehabilitation. The Method of Study Cases were selected from the 80 patients (half of them males, half females) who attended C.A.R.S. as residential patients during the three years, 1955 to 1958. Those selected were married male breadwinners admitted from and discharged to their homes, both urban and rural in B . C. They were the fathers of dependent children living in their homes. A l l families were, therefore, families of "procreation" for purposes of this study, and the wider family connections were not considered in selecting the sample group. A further selection was made of those whose ar t h r i t i c condition was of a kind for which there was nO specific "cure", and for which - Ik -the medical prognosis was uncertain. Chosen f i n a l l y for detailed examination of their f i l e s -including case records, medical reports, and related correspondence —were seven patients. These were rheumatoid arthritics and Marie-Strumpell spondylitics with peripheral joint involvement, five of whom had become gainfully-employed following their discharge from the Centre. It was considered that in order to achieve rehabilitation—to reach his maximum potential--the disabled person's needs for Income, personal care ( i f indicated by his condition), and for emotional support and encouragement to use his residual strengths, had to be met. The demonstrated a b i l i t i e s of the patient-family groups to meet these needs plus the means they employed to do so was the focus of the analysis. These activities and attitudes were collectively considered "family factors". Obviously, other objectively-and subjectively-determined variables such as age, severity of the disease, vocational training previously attained, and av a i l a b i l i t y of employment In his residen-t i a l area had to be considered in addition to family factors as determinants of rehabilitation potential. It was assumed that each patient had received appropriate treatment of a uniform standard at the Medical Centre. From such an analysis i t was hoped that those factors which characterized the behaviour of a "strong" family (one able to meet the patient's special needs) might be applied to the assessment of other patient-family groups with the purpose to indicate means - 15 -whereby a patient's family might be enabled as a treatment re-source. Certain limitations should be noted here in the use of case records for analytical purposes. Such limitations relate, f i r s t l y , to the variety and amount of material recorded in a c l i n i c a l setting when the patient Is not seen in his family group, and secondly, to the need to rely on correspondence with provincial workers, who might not be familiar with the rehabilitation process, for family information. In only four out of ten cases examined in the total group were the patient's families interviewed by a caseworker, either from C.A.R.S. or from the provincial Social Welfare Branch. Most of the information obtained on patient and family a t t i t -udes comes from subjectively-recorded impressions by the caseworker of the patient's interviews with him, and allowance must be made for this. CHAPTER I I RECOGNIZING FAMILY FACTORS IN REHABILITATION The problem of d i s a b i l i t y of a f a m i l y ' s breadwinner presents many aspects t o the h e l p i n g person. Environmental i m p l i c a t i o n s of d i s a b i l i t y as they a f f e c t the man's re-employment p o t e n t i a l have been co n s i d e r e d b r i e f l y i n the preceding chapter, and w i l l be examined f u r t h e r i n the course of t h i s chapter. The caseworker, p l a n n i n g treatment s e r v i c e s w i t h each p a t i e n t from the "base" of a c l i n i c a l s e t t i n g such as the C.A.R.S. M e d i c a l Centre, has the b e n e f i t of a comprehensive assessment p r o v i d e d by the team as a whole of the p a t i e n t ' s present p h y s i c a l and emotional c a p a c i t i e s . T h i s must be supplemented by i n f o r m a t i o n r e l a t i n g to the p a t i e n t ' s t o t a l environment to know what, i n f a c t , he i s "up a g a i n s t " i n attempting to resume h i s task of p r o v i d i n g economically f o r h i m s e l f and h i s f a m i l y . In the p a t i e n t ' s home environment h i s f a m i l y may be considered both as a p o s s i b l e (and complex) i n f l u e n c e i n h i s r e h a b i l i t a t i o n , and as a p o s s i b l e r e s o u r c e to meet h i s needs. Always present i n p l a n n i n g treatment i s the t h r e a t of the c h r o n i c i l l n e s s ; of the u n p r e d i c t a b i l i t y of i t s course, which may upset a r e t r a i n i n g or re-employment p l a n t e m p o r a r i l i t y or permanently. The emotional impact of t h i s u n c e r t a i n t y on the p a t i e n t ' s a b i l i t y t o use h i s r e s i d u a l s t r e n g t h s i s of v i t a l concern to the h e l p i n g person i n understanding the p a t i e n t ' s needs. E v i d e n t l y , some environmental i n f l u e n c e s on re-employment p o t e n t i a l may be o b j e c t i v e l y observed and d e s c r i b e d . T h i s i s t r u e of some f a c t o r s a f f e c t i n g the p a t i e n t ' s p h y s i c a l w e l l - b e i n g , such - 17 -as income p r o v i s i o n or p e r s o n a l care when he cannot h e l p him^ s e l f . Other I n f l u e n c e s must be r e c o g n i z e d by the observer through impressions gained of the way the p a t i e n t r e l a t e s to others i n h i s environment i n the process of meeting h i s needs; of the way he r e l a t e s to the members of h i s f a m i l y , and t o h e l p -i n g persons, and the way f a m i l y members r e l a t e to him. What, f o r example, i s the p a t i e n t ' s a t t i t u d e t o the l o s s of h i s breadwinner r o l e , and what are the a t t i t u d e s of f a m i l y members to h i s ne c e s s a r y dependence? How might these a t t i t u d e s a f f e c t h i s r e h a b i l i t a t i o n ? Evidence t h a t f a m i l y r e l a t i o n s h i p s may be of s i g n i f i c a n c e i n the p a t i e n t j s r e h a b i l i t a t i o n appears i n a previous study conducted at the C.A.R.S. M e d i c a l C e n t r e . 1 From examination of socio-economic f a c t o r s , such as m a r i t a l s t a t u s , a f f e c t i n g the r e h a b i l i t a t i o n of a group of a d u l t male rheumatoid a r t h r i t i c s — b r e a d w i n n e r s and o t h e r s — t r e a t e d as r e s i d e n t i a l p a t i e n t s d u r i n g the years 1952 t o 1955, the author noted that those who were married and l i v i n g i n " s t a b l e " f a m i l y groups were best a b l e to adapt t o the l i m i t s imposed by i l l n e s s , and to make best use of the r e h a b i l i t a t i o n s e r v i c e . ^ The. purpose of t h i s chapter i s to examine the ways i n which each breadwinner-patient's f a m i l y adapted to h i s d i s a b i l i t y ; i n 1 Maclnnis, Margaret R., Socio-economic F a c t o r s i n the R e h a b i l i  t a t i b n P o t e n t i a l of A r t h r i t i c P a t i e n t s . Master of S o c i a l Work t h e s i s , U n i v e r s i t y o f B r i t i s h Columbia, 1958. 2 I b i d . p. 69. - 1 8 -particular,family modes of adapting to the interruption or curtailment of his gainful employment, and the economic dependency this Implied, as these might have influenced his chances of rehabilitation. ("Rehabilitation" for the purpose of this analysis includes re-employment suitable to the physical capacities of the patient, and from which he derives some emotional satisfaction). In other words, to determine how the patient's family—those persons with whom he lived and for whom he had provided before and after the onset of illness—met their own and the disabled person's special needs. With the above-mentioned purpose, examination of the on-going rehabilitation process as seen and recorded by caseworkers from the various sources available was undertaken to answer the follow-ing questions: 1 . Could some patlent-family groups be recognized as stronger or better-able than others to reach the patient's rehabilitation objective? By what means could they be so recognized? 2. In the strong families, what are the things one builds on in casework? 3. If some patient-family groups were stronger than others, what could be done to help strengthen the weak patient-family groups to improve the patient's chances of rehabilitation? [[.. Are these influences i n the family ever significant enough t o b e m a j o r or even deciding factors in the patient's rehabilitation? - 19 -Selection of Cases for Study. In order to answer the questions above-stated, i t was necessary to identify variables which appeared to affect the patient's employment and to determine the place occupied by the patient's family In attaining the rehabilitation objective. The sources of information utilized were the case recordings, corres-pondence, and medical reports on each of a group of male breadwin-ner-patients who were medically-diagnosed rheumatoid arthritics or Marie Strumpell spondylitics, and who received similar treatment for their condition. The information available on a l l (39) male patients who were admitted to the C.A.R.S. Medical Centre from various points in British Columbia during the three years, 1955 to 1958> was examined. A time period of at least one year between the patient's discharge from the Centre and examination of the record was allowed for the patient's re-establishment in employment i f he was able to accomplish this. From these. 39 cases were chosen those men who were married and had wives and dependent children livi n g with them for whom they were, or had been, un t i l their illness prevented this, the sole breadwinner. The patient might previously have had out-patient treatment at the Medical Centre or at a C.A.R.S. branch, but this was his f i r s t admission. The patient's family group was defined for purposes of selection uniformity as being the patient's wife and child or children living in the same home and on the same income or incomes. - 20 -Ages of the total group of 39 male patients admitted to the C.A.R.S. Medical Centre, 1955 to 1953, ranged from 6 to 66 years. The f i n a l sample of seven were patients whose ages ranged from 34 to 55 years, a l l being, therefore, of normally-employable ages. These distributions are shown in the following table: Table 1 Numerical Distribution of Male Patients  at the C.A.R.S. Medical Centre, 1955 to  1958, According to Ag~eT Age Patients Admitted to Centre Selected for Study l - 19 2 0 20 - 29 8 0 30 - 39 3 2 ko - 49 7 4 50 - 59 13 1 6o - 69 6 0 Totai 39 7 The patient-family group in each of these seven cases could by this delimitation be examined as a significant factor in the patient's rehabilitation. This significance could be-assumed because the patient had expressed recognition in interviews with the Social Welfare Branch, or C.A.R.S. caseworker, or other person - 21 -connected w i t h h i s treatment at the Centre, t h a t h i s f a m i l y was concerned w i t h and i n f l u e n c e d by h i s plans f o r the f u t u r e . I n what ways and by what means these p a t i e n t - f a m i l y groups i n f l u e n c e d the p a t i e n t ' s r e h a b i l i t a t i o n Is i l l u s t r a t e d i n the f o u r cases which f o l l o w . These f a m i l i e s a p p a r e n t l y demonstrated d i f f e r i n g degrees of s t r e n g t h i n meeting the s p e c i a l needs of t h e i r a r t h r i t i c bread-winners . V a r i a b l e s I n f l u e n c i n g R e h a b i l i t a t i o n These records were searched f o r i n f o r m a t i o n which could c o n c e i v a b l y have a b e a r i n g on e m p l o y a b i l i t y . Such i n f o r m a t i o n concerned age of the p a t i e n t , d u r a t i o n o f i l l n e s s , number of dependents, e d u c a t i o n and v o c a t i o n a l t r a i n i n g he possessed, a t t i t -ude of the p a t i e n t t o treatment which he understood would improve h i s e m p l o y a b i l i t y , a t t i t u d e of the f a m i l y t o the p a t i e n t ' s depen-dency, and reso u r c e s m o b i l i z e d to improve the p a t i e n t ' s p h y s i c a l and v o c a t i o n a l s k i l l s . By t h i s process i t was determined t h a t the m a t e r i a l could be c l a s s i f i e d from the p o i n t of view of the persons o r i g i n a l l y r e c o r d i n g i t as f o l l o w s : Ca) Those f a c t o r s or v a r i a b l e s a f f e c t i n g e m p l o y a b i l i t y of the p a t i e n t which could be assessed and d e s c r i b e d o b j e c t -i v e l y , such as age, d u r a t i o n of I l l n e s s i n years, e t c . (b) Those f a c t o r s or v a r i a b l e s a f f e c t i n g e m p l o y a b i l i t y of the p a t i e n t which had to be assessed and d e s c r i b e d sub-j e c t i v e l y , and which r e f l e c t e d the aim of the observer ( u s u a l l y the caseworker) and h i s concept of means where-by t h i s g o a l might be reached. This i n v o l v e d a case-worker's and other team members' assessment of - 2 2 -"attitudinal" or emotional aspects through interviewing and observing the patient in the Medical Centre or in his home, or both. A complete outline for analysis of each case is as follows: (a) Those variables affecting employability of the patient  which can be assessed and described objectively: (1) the course and severity of the disease in relation to the patient's physical a b i l i t y to perform work; ( 2 ) a v a i l a b i l i t y in the immediate area in which the patient and his family live of employment suitable to his age, degree of disability, and' training, when the patient is in relative remission of the disease; (3) the patient's work pattern in the past as shown by length of periods of employment and unemployment as related to periods of a r t h r i t i c exacerbations (and not to another form of disability such as mental illness, alcoholism, etc.); (ll) resources mobilized to cover living costs and costs of medical care during the patient's periods of dependency and treatment from the following sources: (a) the patient's personal savings and property; (b) family employment and personal help to the patient; Cc) community resources such as social assistance, and C.A.R.S. treatment services. (b) Those variables affecting employability of the patient  which must be assessed and described subjectively: ( 1 ) attitude of the patient to work and family respons-- 23 -i b i l i t y b e f o r e and a f t e r the onset of h i s i l l n e s s ; t o dependency on others f o r income and p e r s o n a l care; ( 2 ) a t t i t u d e s of the p a t i e n t ' s f a m i l y to the dependency of t h e i r breadwinner and t o plans t o r e s t o r e h i s independence. Thus the f a m i l y ' s e f f e c t on e m p l o y a b i l i t y i s conceived t o occur through a c t i v i t i e s and a t t i t u d e s r e l a t i n g to the p a t i e n t ' s p h y s i c a l and emotional needs. These a c t i v i t i e s and a t t i t u d e s are expressed through (1) the p r o v i s i o n of income and p e r s o n a l s e r v i c e s t o the p a t i e n t d u r i n g h i s p e r i o d s of dependence, and (2) acceptance of the p a t i e n t ' s dependency needs and support of plans f o r h i s i n -dependence. The l a t t e r i m p l i e s an examination of those a t t i t u d e s which lend support to h i s resumption of employment. A n a l y s i s of S e l e c t e d Comparative Cases: D i s a b l e d Breadwinners. The f o u r comparative cases which are analysed a c c o r d i n g to the previous o u t l i n e s h a l l be named "Mr. Wehrner","Mr. Thompson", "Mr. Rigby", and"Mr. Lewis". Each had become employed f o l l o w i n g d i s c h a r g e from the Centre. The f i r s t to be examined i s the case of Mr. Wehrner. Th i s I | 8-year-old man, f a t h e r of a teen-aged son, came to Canada from e a s t e r n Europe w i t h h i s f a m i l y of o r i g i n at 18 y e a r s , s e t t l i n g i n a p r a i r i e c i t y . There were other members of h i s p a r t i c u l a r r e l i g i o u s s e c t , noted f o r I t s c u l t u r a l s o l i d a r i t y , i n the same c i t y . (a) Those v a r i a b l e s a f f e c t i n g e m p l o y a b i l i t y of the p a t i e n t which  can be assessed and d e s c r i b e d o b j e c t i v e l y . When he came to the M e d i c a l Centre, Mr. Wehrner, a rheumatoid - 2k -a r t h r i t i c f o r 1 3 years, was s u f f e r i n g p a i n and s t i f f n e s s i n most j o i n t s of h i s body, but t h e r e was l i t t l e evidence of any p h y s i c a l l i m i t a t i o n . Though he had been l i v i n g f o r the past 1 2 years i n a r u r a l area, and had, u n t i l admittance to the Centre, been working p a r t - t i m e on h i s farm, he had managed to a t t e n d a C.A.R.S. branch f o r weekly physiotherapy treatments. He was considered by the r e h a b i l i t a t i o n team to be f i t f o r " l i g h t employment" on d i s c h a r g e from the M e d i c a l C e n t r e . 1 His treatment p e r i o d had extended to f o u r months. P l a n n i n g f o r h i s re-employment i n v o l v e d a l s o c o n s i d e r a t i o n of jobs which were a v a i l a b l e and s u i t a b l e t o the p a t i e n t ' s age, degree of d i s a b i l i t y , and t r a i n i n g . Mr. Wehrner s t a t e d t h a t he had completed the e q u i v a l e n t of p u b l i c s c h o o l e d u c a t i o n i n h i s former country, and was without other v o c a t i o n a l t r a i n i n g . Though he had i n the past engaged i n a v a r i e t y of jobs, i n c l u d i n g mining and m i l l work, he could be c o n s i d e r e d v o c a t i o n a l l y e l i g i b l e only f o r manual la b o u r . While at the Centre he made the d e c i s i o n t o move to an urban community where l i g h t e r , u n s k i l l e d jobs were a v a i l a b l e . He bought a house i n the c i t y , moved h i s f a m i l y , and f o l l o w i n g d i s c h a r g e from the Centre, obtained a j a n i t o r i a l job. The p a t i e n t ' s work p a t t e r n was r e l a t i v e l y s t a b l e . He had 1 The term " l i g h t employment", f r e q u e n t l y used by.medical p r a c t i t i o n e r s , i n the w r i t e r ' s experience, i m p l i e s only t h a t the p a t i e n t i s to some degree f u n c t i o n a l l y d i s a b l e d . F u r t h e r e x p o s i t i o n In each case of s p e c i f i c d i s a b i l i t i e s and types of employment a v a i l a b l e , or which might be a v a i l a b l e t o the p a t i e n t , i s at l e a s t r e q u i r e d to determine " a c t u a l " re-employment p o t e n t i a l . The term may be s a i d to imply the p a t i e n t Is need f o r employment of which he i s f u n c t i o n a l l y capable. See a l s o the comment of Dr. J . A.P. M i l l e t quoted on page seven of t h i s t h e s i s . - 25 -worked since leaving school—some 3l+ years ago, 30 of these years having been spent in Canada. He came to B.C. during the Depression period of the 1930's, and while employed in m i l l work, bought a house in a good city residential area. In the course of this employment, in 191+2, he was injured, receiving compensation for a period of incapacity under the Workmen's Compensation Act. He blamed his accident for his a r t h r i t i s . When he was able to return to employment, his doctor having advised lighter work, he bought and sold in sequence a dairy farm and a fr u i t farm. In spite of investments in the fruit farm, l i t t l e revenue was realized although the small holding was debt-free, and readily salable when he decided to move to the city. Resources available to the patient to cover his living costs and costs of medical care were derived from his savings and his wife's employment. Savings had been minimized by an investment in his farm, plus family maintenance costs and medical expenses, and the lack of revenue from the farm had forced the wife to do day work. The patient remarked to the C.A.R.S. caseworker, "I have paid more money to doctors than I have for my board." The family did not apply for social assistance. (b) Those variables affecting employability of the patient which  must be assessed and described subjectively. Examination of the patient's attitude to re-employment and family responsibility by the C.A.R.S. caseworker revealed this patient to be authoritative and decisive, with extreme fear of dependency on his wife and family which implied for him loss of status. Also noted was a tendency to project on authority the - 26 -blame f o r any d i f f i c u l t i e s he encountered i n the course of t r e a t m e n t — a f u r t h e r i n d i c a t i o n of h i s r e f u s a l to accept h i s p h y s i c a l l i m i t a t i o n s . He d i s c u s s e d h i s needs and problems r e a l i s t i c a l l y , however, and while using treatment r e s o u r c e s came to the d e c i s i o n to move h i s f a m i l y t o the c i t y and to f i n d l i g h t e r employment. " I used to wear the pants i n the f a m i l y , but I can't any longer, and my wife does not," he s a i d i n the i n i t i a l stage of h i s treatment. "Before my i l l n e s s we had a happy home. I want to get that back. T h i s i l l n e s s has made me cranky and ten s e . " The p a t i e n t ' s f a m i l y a t t i t u d e s t o h i s dependency and plans f o r h i s re-employment were assessed by the C.A.R.S. caseworker at the M e d i c a l Centre. The f a m i l y was not seen. The caseworker noted i n the r e c o r d of i n t e r v i e w s w i t h the p a t i e n t t h a t " t h e r e appeared to be a good r e l a t i o n s h i p between husband and wife, "the p a t i e n t having complete assurance t h a t the f a m i l y would accept and a c t on any d e c i s i o n he made. E s t a b l i s h e d i n l i g h t e r employment, the p a t i e n t r e v i s i t e d the Centre as an o u t - p a t i e n t , r e p o r t i n g h a p p i l y , "Now I am a man a g a i n . He could, he s a i d , " t a l k back now" to h i s employer. S i g n i f i c a n c e o f the Wehrner Family i n Re-employment; An E s t i m a t e . T h i s p a t i e n t ' s f a m i l y was a p o s i t i v e f a c t o r i n h i s re-employ-ment. The f a m i l y was (a) a purveyor of resources of income and home maintenance, and (b) a source of support f o r h i s p s y c h o l o g i c a l independence. His wife a p p a r e n t l y accepted and complemented the a u t h o r i t a r i a n nature of the breadwinner-husband-father r o l e as the p a t i e n t v i s u a l i z e d i t . One might a l s o s p e c u l a t e i n t h i s case t h a t , - 27 -should the wife have been unable t o work, the f a m i l y might have c a l l e d upon the wider k i n s h i p and r e l i g i o u s group f o r support. This f a m i l y gave an impression of " s t r e n g t h . " The second case to be examined i s that of Mr. Thompson. Th i s 14.1-year-old man, a Canadian of B r i t i s h o r i g i n , and the f a t h e r of three teen-aged c h i l d r e n , came to the M e d i c a l Centre w i t h M a r i e - S t r u m p e l l s p o n d y l i t i s and p e r i p h e r a l j o i n t involvement. The d i s e a s e had f i r s t occurred seven years p r i o r t o t h i s course of i n t e n s i v e treatment, f o l l o w i n g a minor mishap w h i l e the p a t i e n t was employed as a postman. (a) Those v a r i a b l e s a f f e c t i n g e m p l o y a b i l i t y of the p a t i e n t which  can be assessed and d e s c r i b e d o b j e c t i v e l y . The course a n d ' s e v e r i t y of h i s d i s e a s e was such t h a t , although the prognosis f o r M a r i e - S t r u m p e l l s p o n d y l i t i s i s g e n e r a l l y considered more f a v o u r a b l e than i t i s f o r rheumatoid a r t h r i t i s , Mr. Thompson had not been working f o r over two y e a r s . He could accom- ' p l i s h a l l p e r s o n a l care and was not, t h e r e f o r e , dependent f o r these needs, but he found walking very d i f f i c u l t . At time of d i s c h a r g e from the Centre, though there was c o n t i n u i n g a c t i v i t y o f h i s i l l n e s s , he had responded s a t i s f a c t o r i l y to physiotherapy, and m e d i c a l treatment, and was considered by the team to be f i t f o r " l i g h t employment". This c o n t r a i n d i c a t e d h i s r e t u r n to farming i n which occ u p a t i o n he had been engaged. Age and degree of d i s a b i l i t y , then, presented r e l a t i v e l y f a v o u r a b l e i n d i c a t i o n s f o r re-employment, a l t h o u g h the d i s e a s e was s t i l l a c t i v e and might a t any time become so severe as to r u i n h i s - 2 8 -plans. This patient had to his credit in obtaining lighter work the completion of senior matriculation and some typing and book-keeping, this advantage being lessened in value by the fact that he had never, for any significant length of time, applied his knowledge. He had completed school during the Depression years of the 1930's when jobs were d i f f i c u l t to obtain. He had then found i t necessary to follow in his labourer father's footsteps and he had worked for some years as a labourer with his father's employers. The ensuing variety of semi-skilled jobs he obtained by changing his place of residence, finding i t necessary on these occasions to rely on his family to operate a heavily-mortgaged farm which he had in the meantime acquired. While he was at the Centre the patient's family was s t i l l living in the rural area where no "white collar" jobs were available. It was apparent that either dependence upon the family and outside sources (public assistance) for income was necessary, or a move to an area where a more suitable type of employment was available, i f he was to maintain his Independence. Mr. Thompson's work pattern prior to the onset of art h r i t i s as well as after the onset had shown some instability, not a l l accounted for by his present il l n e s s . In his approximately 21 years of employment, including self-employment in farming, he had held seven jobs, but he had made a continuous effort to remain independent. These jobs included unskilled labour as indicated, which he left following an attack of pleurisy, and both semi-skilled and c l e r i c a l employment with a government service during - 29 -wartime. He had left this, because of what he described as "eye trouble", to obtain outside work, and chose farming. Without experience in farming, though he worked hard, he quickly became involved in debt for equipment and found i t necessary to take a job as a heavy-equipment operator in northern Brit i s h Columbia to supplement farm earnings and meet the payments. His physical condition deteriorated, and he obtained lighter work as a construction camp cook. At this time he suffered a severe peripheral joint involvement of arthritis which up until that time had been confined to his spine. His next job as a garage mechanic was interrupted by another exacerbation of his disease, and he was hospitalized. From that time u n t i l his discharge from the Centre, he had not worked. Resources available to the patient to cover his li v i n g costs and costs of medical care were derived from the efforts of his family on the farm and from social assistance. Personal savings were n i l , and debts amounted to f 3 , 0 0 0 . 0 0 at the time of the patient's entering the Centre. In spite of his efforts, his own farm equipment was repossessed and the family became tenants on their farm. As the patient was unable to work, his wife and teen-aged children, particularly the eldest daughter, aged 17, struggled to continue operating with l i t t l e resultant revenue, their reward being only a place to l i v e . The wife had for several years worked away from home, and when about one year before the patient's ar r i v a l at the Centre, her health broke down, temporary social assistance was given the family. This also provided medical care for the patient who was periodically - 30 -hospitalized during the two years prior to treatment, for from three to six months at a time. The patient was referred through his own doctor for a functional assessment to the C.A.R.S. travelling medical consult-ant. Intensive treatment for three months at the Medical Centre was financed by the provincial Social Welfare Branch. By this time the disease had run a seven-year course and the patient had been totally unemployed and dependent for the past two years. Following his discharge from the Centre the patient completed successfully a bookkeeping course which had been arranged during his stay-there. He then moved with his family to another d i s t r i c t where c l e r i c a l employment was available, obtained a suitable job and built his own house. (°) Those variables affecting employment of the patient which must  be assessed and described subjectively. In the course of an unspecified number of interviews with the patient prior to intake, the Social Welfare Branch worker in that area entered the patient's home to assess his e l i g i b i l i t y for social assistance. Using Information obtained on this basis, the attitude of the patient to re-employment and family responsibility was determined. The S.W.B. worker, in a report to C.A.R.S., described the patient as being "not an aggressive person, but he has shown considerable determination and persistence in trying to remain independent." The worker believed that with improvement in his physical functioning he would soon become self-supporting; that he had "some feeling" about his wife working. - 31 -There was no other i n f o r m a t i o n a v a i l a b l e concerning the p a t i e n t ' s e x p e c t a t i o n s of treatment at the M e d i c a l Centre or of what i t could accomplish f o r him, p o s s i b l y due t o the s o c i a l worker's l a c k o f i n f o r m a t i o n about the treatment plan, the g e n e r a l prognosis of the type of a r t h r i t i s from which he s u f f e r e d , and the employment o p p o r t u n i t i e s a v a i l a b l e t o a d i s a b l e d person i n t h a t a r e a . The C.A.R.S. caseworker i n the Centre met a tense, anxious man " s e e t h i n g w i t h suppressed anger", a c c o r d i n g to the r e c o r d , who, wh i l e he could not express h i s h o s t i l i t y d i r e c t l y , acknowledged a s t r o n g f e e l i n g of p e r s o n a l inadequahcy. T h i s was r e l a t e d to h i s wife's employment while he was dependent. He would not d i s c u s s h i s f a m i l y r e l a t i o n s h i p s i n d e t a i l , but remarked that he was d e p r i v i n g h i s e l d e s t daughter of p r o f e s s i o n a l t r a i n i n g t o which he h i m s e l f had only i n s p i r e d . (He had wanted t o t r a i n as a teacher f o l l o w i n g h i s h i g h s c h o o l , but found t h i s f i n a n c i a l l y i m p o s s i b l e ) . T h i s f a m i l y need was a main focus of h i s a n x i e t y t o become a g a i n employed. There was a l s o some d e f e n s i v e c r i t i c i s m of h i s wife as b e i n g " h i g h l y nervous", and at times "very d i f f i c u l t " . He d i d not r e l a t e t h i s v e r b a l l y t o the heavy demands upon her, but t h i s he i m p l i e d . His a t t i t u d e t o h i s f a m i l y ' s dependence on s o c i a l a s s i s t a n c e r a t h e r than on h i s wife's employment was not expressed. The a t t i t u d e of the p a t i e n t ' s f a m i l y t o the dependency of t h e i r breadwinner and to plans t o r e s t o r e h i s independence r e c e i v e d l i t t l e a t t e n t i o n from the S o c i a l Welfare Branch worker who intervi e w e d the f a m i l y . One could c e r t a i n l y assume t h a t the s t r a i n - of p r o v i d i n g f o r the f a m i l y had aggravated the wife' s p h y s i c a l and - 32 -emotional i n s e c u r i t y and t h a t she would be unable to t o l e r a t e much of her a r t h r i t i c husband's h o s t i l i t y which a t t i t u d e o f the p a t i e n t t o h i s wife had been r e a d i l y evident to the caseworker. One might s p e c u l a t e f u r t h e r t h a t the p a t i e n t had focused much f e e l i n g on h i s e l d e s t daughter whose ambition to become a nurse he was anxious t o h e l p r e a l i z e . (The C.A.R.S. caseworker o f f e r e d to i n v e s t i g a t e means of f i n a n c i n g t h i s t r a i n i n g ) . F i n a n c i a l h e l p i n the form of s o c i a l a s s i s t a n c e had come to t h i s f a m i l y when i t was a b s o l u t e l y necessary, when the wif e could no longer assume j o i n t l y w i t h the c h i l d r e n the breadwinner r o l e . S i g n i f i c a n c e of the Thompson Family i n Re-employment: An E s t i m a t e . T h i s f a m i l y was a p o s i t i v e f a c t o r , a l t h o u g h o u t s i d e h e l p was r e q u i r e d , i n the p a t i e n t ' s re-employment because i t was (a) a purveyor of re s o u r c e s of income and home maintenance, and (b) a source of m o t i v a t i o n t o the p a t i e n t ' s recovery, p a r t i a l l y as a means to l i v e out the d e s i r e he had expressed i n h i s own l i f e f o r "something b e t t e r . " T h i s f a m i l y a l s o gave an imp r e s s i o n o f " s t r e n g t h " . With the wife' s r e c o v e r y one might p r o j e c t t h i s s i t u a t i o n and c o n s i d e r the f a m i l y as a resource to pr o v i d e f o r the p a t i e n t d u r i n g p o s s i b l e f u t u r e p e r i o d s of dependency. The t h i r d case t o be examined i s that of Mr. RIgby, a 3^-year-o l d f a t h e r of th r e e pre-school-aged c h i l d r e n who was admitted t o the M e d i c a l Centre w i t h M a r i e - S t r u m p e l l s p o n d y l i t i s and p e r i p h e r a l j o i n t involvement. - 3 3 -(a) Those v a r i a b l e s a f f e c t i n g e m p l o y a b i l i t y of the p a t i e n t which  can be assessed and d e s c r i b e d o b j e c t i v e l y . S ince the onset of the d i s e a s e seven years before admission to the M e d i c a l Centre, i t s course and s e v e r i t y had been such t h a t Mr. Rigby had h e l d a s e r i e s of some e i g h t jobs, f i n a l l y becoming a j a n i t o r and bus d r i v e r . He had continued t o work u n t i l a few weeks b e f o r e admission t o the Centre, when the p a i n i n h i s back n e c e s s i t a t e d h o s p i t a l i z a t i o n . The p a t i e n t had found h i s present employment a f t e r many attempts, i n c l u d i n g farming and s a l e s , the l a t t e r i n v o l v i n g a move t o an urban a r e a . The Rigbys had moved from the c i t y t o t h e i r present r u r a l neighbourhood because, the p a t i e n t s t a t e d , he and h i s w i f e had become " f e d up" w i t h c i t y l i f e . He f e l t t h a t he could combine the j a n i t o r work and b u s - d r i v i n g very w e l l , and wanted t o r e t u r n t o t h a t employment f o l l o w i n g h i s treatment at the Centre. He was g i v e n leave-of-absence by h i s employer w i t h the understand-i n g that he would be a b l e to resume the same employment upon d i s c h a r g e . Mr. Rigby was not i n t e r e s t e d i n r e t r a i n i n g , he t o l d the C.A.R.S. caseworker, a l t h o u g h a r e f e r r a l ' t o the Vancouver Youth C o u n s e l l i n g S e r v i c e t o which he consented estimated him to be a man of above-average i n t e l l e c t u a l c a p a c i t y , and q u i t e capable. He had a meagre grade-school education, and h i s area of r e s i d e n c e o f f e r e d no v a r i e t y i n more h i g h l y - t r a i n e d jobs. Mr. Rigby's work p a t t e r n d i s p l a y e d some i n s t a b i l i t y , p o s s i b l y due to r e s i d u a l e f f e c t s of i n j u r i e s which had preceded the onset of h i s present i l l n e s s . A t 10 years of age while l i f t i n g a l o g he - 31+ -had experienced a severe back s t r a i n , and a g a i n at 15 w h i l e s k i d d -i n g logs f o r f i r e wood he i n j u r e d h i s back and knees. Another i n j u r y , t o which he a s c r i b e d the onset of h i s i l l n e s s , had o c c u r r e d seven years b e f o r e . With savings gained through employment, he bought a farm s t a r t i n g , he s a i d , from " s c r a t c h " . He had to give up t h i s p r o j e c t because of back p a i n and there f o l l o w e d , as mentioned above, a s e r i e s of jobs i n c l u d i n g work on a p o u l t r y farm and s e v e r a l jobs as salesmen. These were temporary due to the i n s o l v e n c y of two companies he worked f o r , and he moved back to the r u r a l a r e a . His c h i l d r e n were born d u r i n g t h i s time. Resources used by the p a t i e n t t o cover l i v i n g costs and c o s t s of m e d i c a l care were d e r i v e d from h i s own work, a l t h o u g h f o r a time p r i o r t o h i s admission to the M e d i c a l Centre i t had been necessary because of h i s p a i n and exhaustion on completing v-his bus r u n f o r h i s wife to f i l l i n as j a n i t o r . The p a t i e n t r e c e i v e d i n f r e q u e n t treatment from a C.A.R.S. p h y s i o t h e r a p i s t ; i n f r e q u e n t because of h i s i s o l a t i o n and d i s t a n c e from a C.A.R.S. branch, (b) Those v a r i a b l e s a f f e c t i n g e m p l o y a b i l i t y of the p a t i e n t which  must be assessed and d e s c r i b e d s u b j e c t i v e l y . The a t t i t u d e of the p a t i e n t to work and f a m i l y r e s p o n s i b i l i t y was determined from s e v e r a l sources of i n f o r m a t i o n . The C.A.R.S. caseworker found the p a t i e n t to be a q u i e t , i n s e c u r e , unhappy man w i t h marked f e e l i n g s of inadequancy as a breadwinner and as a man. That t h i s had been apparent a l s o to the C.A.R.S. t r a v e l l i n g m e d i c a l c o n s u l t a n t who saw him while he was l i v i n g at home was i n d i c a t e d i n a m e d i c a l assessment r e p o r t . The d o c t o r commented, "Because of - 35 -the emotional turmoil in this man's environment, i t is considered that he would benefit by social casework during this period (in the Medical Centre)". The report of the Youth Counselling Service described the patient as being of near-superior intelligence, but "very unhappy in his home and marital relationship." The patient's attitude to treatment, however, was good. He showed physical improvement and was judged capable on discharge of returning to f u l l employment. The patient was uncommunicative with the C.A.R.S. caseworker concerning his family relationships, but did express apprehension about the Youth Counselling Service test. Although he saw the value of the test and consented to take i t , he feared that "they would find out how ignorant I am." The attitude of the patient's wife to her husband's illness and the insecurity of her position was clearly expressed to the C.A.R.S. Social Service, f i r s t l y , In a report of a C.A.R.S. staff member, not a caseworker, who visited the home, and again through a cr i s i s which developed while the patient was in the Centre. During the home v i s i t i t was evident, contrary to the Social Welfare Branch worker's assessment report which had been requested by C.A.R.S. that there was "a good relationship" between the patient and his wife, actually a relationship destructive of his chances for re-establishment existed. The wife, bit t e r l y resenting the additional manual work her husband's illness had occasioned, remark-ed that she planned to supplement her own training and return to work while"George stays home to do the cooking and mind the baby." At the Centre the patient received a letter from his wife informing him that she had applied for and had been granted employment by his own employer. She reminded him that as more than one member of the same family could not be hired, according to organization policy, he would not be returning to his job. The patient was greatly perturbed, and noting his reaction, the doctor commented in a letter to the patient's employer that " i f the situation develops as threatened, the patient could continue to deteriorate." Through this intervention of the C.A.R.S. staff, initiated with the approval of the patient, his job was saved and the couple were allowed both to continue in their jobs. No information was available concerning arrangements for daycare of their children, and i t is assumed that these were.made privately by the couple. Significance of the Rigby Family in Re-employment: An Estimate. While the patient's wife could work to supplement the family income, her competition with the patient and her insecurity were negative factors in determining his chances of re-employment, and, in the judgment of the doctor, the situation could have been con-ducive to the patient's physical deterioration. This family gave an over-all impression of "weakness." The fourth, and last, of the cases to be examined isi that of Mr. Lewis, at 55 years, the eldest of the four patients, and the father of two teen-aged children. He was of the four the patient who had experienced the most recent onset of his disease, which was rheumatoid a r t h r i t i s . - 37 -(a) Those v a r i a b l e s a f f e c t i n g e m p l o y a b i l i t y of the p a t i e n t which  can be assessed and d e s c r i b e d o b j e c t i v e l y . The course of the d i s e a s e , while r e l a t i v e l y b r i e f , h a v i n g f i r s t appeared one year b e f o r e h i s acceptance f o r treatment at the M e d i c a l Centre, was very severe, i n v o l v i n g his-knees and a n k l e s . The c o n d i t i o n was d i f f i c u l t m e d i c a l l y to c o n t r o l because the p a t i e n t could not t o l e r a t e c e r t a i n drugs which were o f t e n most s u c c e s s f u l In c o n t r o l l i n g the d i s e a s e . He developed i n sequence g a s t r i c u l c e r s which had p r e v i o u s l y bothered him, and p s o r i a s i s , n e c e s s i t a t i n g the i n t e r r u p t i o n f o r h o s p i t a l i z a t i o n of h i s treatment p e r i o d at the Centre. He spent a t o t a l of s i x months between the h o s p i t a l and the Centre. An urban r e s i d e n t , who had been self-employed f o r l£ years i n the c o n s t r u c t i o n business as a s k i l l e d tradesman, Mr. Lewis f a c e d the need to d i s c o n t i n u e t h i s b u s i n e s s i n favour of l i g h t e r work, which, i n s p i t e of h i s age, could c o n c e i v a b l y be found i n an urban a r e a . He had been r a i s e d on a p r a i r i e farm and r e c e i v e d only a p u b l i c s c h o o l e d u c a t i o n . However, he had continued t o educate him-s e l f when p o s s i b l e , had s t u d i e d bookkeeping and soon a f t e r the onset of h i s i l l n e s s had taken a course i n r e a l e s t a t e s e l l i n g which he d i d not manage to complete. A Youth C o u n s e l l i n g S e r v i c e assessment, a d m i n i s t e r e d while he was at the Centre, found him w e l l a b l e t o manage a c l e r i c a l job, but noted that h i s age and p h y s i c a l handicap were d i s c o u r a g i n g f a c t o r s i n seeking re-employment. A major p h y s i c a l improvement was noted f o l l o w i n g h i s d i s c h a r g e - 38 -from the Centre w i t h the a d m i n i s t r a t i o n of a nexv medicine. Mr. Lewis recovered, and a g a i n became employed. The f a c t t h a t he l i v e i n an urban area and had been w e l l e s t a b l i s h e d there was g r e a t l y i n h i s f a v o u r . The s t a b i l i t y of h i s work p a t t e r n as a f a c t o r i n h i s r e -employment p o t e n t i a l was evidenced i n h i s steady employment s i n c e h i s e a r l y 'teens. There had been some i r r e g u l a r i t y o f employment d u r i n g the D e p r e s s i o n of the 1930'3 which could be accounted f o r by the f a c t of job shortages at that time. The p a t i e n t ' s s h i f t of employment s h o r t l y a f t e r the onset of h i s d i s e a s e , was r e l a t e d to h o s p i t a l i z a t i o n f o r surgery to t r e a t h i s g a s t r i c u l c e r . Another severe e x a c e r b a t i o n had occurred when h i s w i f e had been h o s p i t a l -i z e d f o r s u r g e r y . Resources used by the p a t i e n t to cover l i v i n g costs and costs of m e d i c a l care were s u p p l i e d by o u t s i d e sources i n the form of s o c i a l a s s i s t a n c e . The p a t i e n t had exhausted h i s savings and had a heavy mortgage on h i s home, which was l o c a t e d i n a good r e s i d e n t i a l s e c t i o n of the c i t y . His wife took c l e r i c a l employment but be came me n t a l l y i l l at the b e g i n n i n g and was h o s p i t a l i z e d d u r i n g the year f o r p r o l o n g e d ' p e r i o d s . The two c h i l d r e n worked d u r i n g t h e i r h o l i d a y s , and the f a m i l y r e c e i v e d s o c i a l a s s i s t a n c e w hile the p a t i e n t was i n the Centre, plu s c o n t i n u i n g a t t e n t i o n from the urban S o c i a l Welfare Branch worker. (b) Those v a r i a b l e s a f f e c t i n g e m p l o y a b i l i t y of the p a t i e n t which  must be assessed and d e s c r i b e d s u b j e c t i v e l y . The a t t i t u d e of the p a t i e n t to work was evidenced i n h i s t e n a c i t y to remain employed, and h i s f e e l i n g of r e s p o n s i b i l i t y f o r - 39 -his family was indicated by his expressed r e l i e f when they were granted social assistance. The caseworker noted his extreme anxiety about loss of income, expressed i n i t i a l l y by apathy, depression, and disinterest in treatment. He responded physically as well as emotionally after provision was made for the family. The patient was considered a mature and decisive person by the caseworker, as his employment record would indicate, but the demands upon him had become excessively great. The attitude of the patient's family to the dependency of their breadwinner, and to plans to restore his independence could be ass-essed through an interview the caseworker had with the wife. Mrs. Lewis was seen by the caseworker during the assessment period prior to the patient's admission to the Centre and while he was s t i l l in hospital for treatment of an exacerbation of his i l l n e s s . She was at that time disoriented and extremely anxious, blaming her-self for her husband's illness because of her (necessary) dependence on him when he was i l l . She suffered a severe mental breakdown shortly after this, and was hospitalized to receive psychiatric treatment. The two children who were described by C.A.R.S. staff members who had seen them as being responsible and understanding of their parents' d i f f i c u l t i e s were provided with summer camp employment during their vacation from school. The caseworker concluded on the record of this case: "It seems that this is a situation where a man has tried to continue on and support his family while his illness has placed many strains on the family to the point where they are a l l quite upset at the - ko -present time." S i g n i f i c a n c e of the Lewis Family i n Re-employment: An E s t i m a t e . T h i s p a t i e n t ' s f a m i l y was a n e g a t i v e f a c t o r i n the man's r e -employment because of t h e i r t o t a l dependence on him. However, t h i s case i l l u s t r a t e s the value of w e l l - t i m e d s e r v i c e s t o r e - e n f o r c e the e x i s t i n g s t r e n g t h s of what might be termed a "weak" f a m i l y . A summary of the p r e c e d i n g m a t e r i a l , , i n d i c a t i n g the v a r i a b l e s which a p p a r e n t l y i n f l u e n c e d each p a t i e n t ' s re-employment p o t e n t i a l i s presented i n Schedule !A l !( page 4 I-A). C r i t e r i a of F a m i l y S t r e n g t h A n a l y s i s of these f o u r cases has shown that among those v a r i a b l e s i n f l u e n c i n g the p a t i e n t ' s r e h a b i l i t a t i o n , h i s f a m i l y group i s a s i g n i f i c a n t , and, as i n the case of Mr. Rigby, can be a d e c i s i v e f a c t o r . T h i s i n f l u e n c e may be exerted through (1) f a m i l y employment and p r o v i s i o n of p e r s o n a l care; (2) p a t i e n t -f a m i l y a t t i t u d e s to the p a t i e n t ' s dependence and plans f o r h i s independence. P h y s i c a l r e s o u r c e s had been met i n three of the cases by the wife's employment. (Mr. Lewis, the f o u r t h p a t i e n t , r e c e i v e d no support from h i s wife who gave evidence i n her mental breakdown of her own unmet dependency needs).. T h i s was a " l a s t r e s o r t " i n each case and the husband had shown i n h i s work h i s t o r y h i s d e t e r m i n a t i o n to remain independent even while a g g r a v a t i n g h i s p h y s i c a l c o n d i t i o n . The a t t i t u d e of each p a t i e n t t o h i s w i f e ' s employment was s i m i l a r . Each gave e x p r e s s i o n t o h i s uhhappiness over t h i s r o l e -- in -r e v e r s a l and h i s r e s u l t a n t f e e l i n g of inadequacy.1 That the p a t i e n t s were a l s o i n these expressions p r o j e c t i n g t h e i r f r u s t r a t -i o n and f e a r of c h r o n i c and p r o g r e s s i v e i l l n e s s , and r e a l i z e d i n t h e i r wives' employment the extent of t h e i r d i s a b i l i t i e s , was an important f a c t o r . T h i s d i d not, however, d i s c o u n t the f a c t t h a t w i t h d i s c o n t i n u i t y of the breadwinner r o l e they were f e e l i n g an accompanying l o s s of s t a t u s . The f a m i l y a t t i t u d e to the p a t i e n t ' s i l l n e s s proved a d e c i s i v e f a c t o r i n each case. Examination of a v a i l a b l e i n f o r m a t -i o n on f a m i l y a t t i t u d e b e f o r e , d u r i n g and a f t e r the p a t i e n t ' s treatment i n the M e d i c a l Centre shows t h a t when the p a t i e n t ' s w i f e and c h i l d r e n were ab l e t o accept r e a l i s t i c a l l y the p a t i e n t ' s need because of h i s i l l n e s s t o be dependent, a b e t t e r work adjustment was made. Both p a t i e n t s , one who was s t i l l i n a r e l a t i v e l y s o l v e n t f i n a n c i a l p o s i t i o n , and another without funds but w i t h a good b a s i s f o r r e t r a i n i n g , moved t h e i r r e s p e c t i v e f a m i l i e s t o an area where they could f i n d more s u i t a b l e employment. Mr. Lewis was t o t a l l y dependent on o u t s i d e sources, though h i s w i f e had attempted employment, and Mr. Rigby's wife was a p p a r e n t l y too threatened by her husband's i l l n e s s to be a p p r e c i a t -i v e of h i s need f o r support and encouragement. Without o u t s i d e 1 The term " r o l e " a s o c i o l o g i c a l concept, i s here regarded as the s o c i a l i d e n t i t y of a person i n a d e f i n e d l i f e s i t u a t i o n , i n t h i s case h i s f a m i l y s i t u a t i o n . I t r e f e r s " t o the way i n which an i n d i v i d u a l p e r c e i v e s h i m s e l f and i s p e r c e i v e d i n r e l a t i o n to the expectations of s o c i e t y " . (Dr. Herman D. S t e i n , " S o c i o - c u l t u r a l Concepts i n Casework P r a c t i c e " , Smith C o l l e g e S t u d i e s i n S o c i a l  Work, February, 1959• Smith C o l l e g e S c h o o l f o r S o c i a l Work, Northampton, Mass.). - 41 - A -SCHEDULE A Summary of Variables A f f e c t i n g the  Rehabil i t a t i o n of Four Patients A Objective Variables. Patient Functional A v a i l a b i l i t y Work Pattern Resources Goal of Employment Income Personal Care (a) (b) (c) Wehrner "Light" Employment No Steady X X Self Thompson "Light" Employment No Some i n -s t a b i l i t y X X Self Rigby Employment (unspecified) Yes Some i n -s t a b i l i t y X X Self Lewis "Light" Employment Yes Steady X Hospit-a l i z e d . B Sub.iec t i v e Variables Patient Attitude of Patient General Attitude of Family Rehab i l i t a t i o n Goal^ Reached i n Family Wehrner Thompson Rigby Lewis /In each case the Vpatient expressed (anxiety over,loss (of his breadwinner /role and expressed ^determination to Vbecome re-employed Positive - encouraging Positive - encouraging Negative - discouraging Negative - discouraging Yes Yes P a r t i a l l y P a r t i a l l y 1 Sources of Information; C.A.R.S. case records and f i l e s for a l l four; home v i s i t s i n the Thompson and Rigby cases; c l i n i c a l interview with a Lewis family member. 2 Functional goal so expressed as " l i g h t " employment by medical p r a c t i t -ioners indicates the patient's need for employment of which he i s function-a l l y capable. (See pages Y and Z*t- ). Re h a b i l i t a t i o n goal includes also the patient's return to employment and his emotional security i n so doing. 3 (a) patient's personal savings and property, lb) family employment. (c) community resources i . e . s o c i a l assistance). - 42 -i n t e r v e n t i o n i t i s d o u b t f u l whether these p a t i e n t s might have become re-employed. The c o n c l u s i o n s may be summarized as f o l l o w s : The breadwinner r o l e i n a f a m i l y group i s g e n e r a l l y regarded i h North American cultures as the p r e r o g a t i v e and o b l i g a t i o n of the male who d e r i v e s s t a t u s from adequate r o l e performance. When t h i s r o l e i s d i s c o n t i n u e d , emotional d i s t u r b a n c e s may r e s u l t , not o n l y from the i n s e c u r i t y attendant upon l o s s of income. T h i s may be evidenced i n the behaviour of each f a m i l y member and i n i n t e r -f a m i l y r e l a t i o n s h i p s . To these s t r e s s e s , caseworkers must be s e n s i t i v e i n order to h e l p the p a t i e n t s o r t out and c l a r i f y the r o l e s w i t h which he experiences s t r e s s so t h a t the attendant c o n f l i c t s may be r e s o l v e d . The problems of r o l e r e v e r s a l has been examined by a noted p s y c h i a t r i s t , Dr. Nathan Ackerman i n a r e c e n t l y p u b l i s h e d study, The Psychodynamics of Family L i f e . Dr. Ackerman w r i t e s as f o l l o w s : "Family r o l e s must be s e x - a p p r o p r i a t e , w e l l - d e f i n e d , and capable of f u l f i l l i n g the e s s e n t i a l needs of i t s members i n a r e c i p r o c a l r o l e i n t e r a c t i o n . Where c o n f l i c t and f r u s t r a t i o n of p e r s o n a l needs emerge the f a m i l y must have p s y c h o l o g i c a l r e s o u r c e s f o r r e a c h i n g a c o r r e c t p e r c e p t i o n o f the problem." 1 1 Ackerman, Nathan W., The Psychodynamics of Family L i f e , B a s i c Books Inc., New York; 195«. Page 328. - hi -Evidence of the effect of reversal of roles may be seen i n the behaviour of members of the four families examined i n t h i s chapter. Ylfhen the family income i s obtained through employment of the wife outside the family group there are emotional reper-cussions which can negate r e h a b i l i t a t i o n e f f o r t s . To the disabled man whose wife works, d i s a b i l i t y means pract-i c a l l y that he must meet his own personal needs and those of young children as best he can i n the absence of other resources. Each patient had carried on i n his breadwinner r o l e as long as possible, giving up t h i s r o l e to his wife, though this was a,:,necessary step, with reluctance. While i n some cases expressing recognition of the s t r a i n on his spouse caused by his dependence, and appreciation of the fact that she was meeting income need, there was evidence of the h o s t i l i t y toward her for the usurpation of his status which this implied. His a b i l i t y to r e f r a i n from expressing t h i s h o s t i l i t y i n disparaging his wife through recognizing the s i t u a t i o n and doing what he could to constructively a l l e v i a t e i t , could be counted an asset i n the family's success to meet his needs. The wives of these disabled persons displayed a variety of reactions to the r o l e - r e v e r s a l . For a l l of them t h i s meant greatly-increased physical and mental stress, but there was much evidence i n one case (Rigby) that the r e v e r s a l g r a t i f i e d a latent desire to compete under favourable circumstances with the husband. This had apparently further reinforced the husband's f e e l i n g of inadequacy, apart from the fact that the s p e c i a l circumstances involved nearly resulted i n the loss of the job he had held. The wife was also apparently i n c o n f l i c t about t h i s , for she refused - kk -t o a c c e p t t h e f a c t o f t h e p a t i e n t ' s d i s a b i l i t y w h i l e f o r c i n g h i m f u r t h e r i n t o a n e m o t i o n a l l y - d e p e n d e n t r o l e . I n t e r - f a m i l y r e l a t i o n s h i p s h a d , w i t h p a t t e r n s o f f a m i l y f u n c t i o n , e v i d e n t l y b e e n s e v e r e l y d i s t u r b e d by t h e b r e a d w i n n e r ' s d e p e n d e n c e , a l t h o u g h t h e i n f o r m a t i o n f r o m w h i c h t h i s was drawn d i d n o t g i v e a c l e a r p i c t u r e o f t h e p r e - i l l n e s s p a t t e r n . As one p a t i e n t r e m a r k e d , " B e f o r e my i l l n e s s we h a d a happy home. I want t o get t h a t b a c k . T h i s i l l n e s s has made me c r a n k y and t e n s e . " F u r t h e r r e c o g n i t i o n o f t h e i m p a c t o f i l l n e s s on t h e f a m i l y g r o u p has b e e n o b s e r v e d b y D r . J . A . P . M i l l e t who w r i t e s as f o l l o w s : "The s h a t t e r i n g o f t h e u s u a l p a t t e r n o f e q u i l i b r i u m by t h e d i s a b i l i t y . . . i m p l i e s n o t o n l y t h e a l t e r e d e q u i l i b r i u m w i t h i n t h e body and m i n d o f t h e d i s a b l e d p e r s o n , b u t a c o r r e s p o n d i n g d i s -e q u i l i b r i u m i n t h e e n v i r o n m e n t o f w h i c h he i s a d y n a m i c p a r t . Changes o c c u r i n t h e d o m e s t i c s c e n e : p a r e n t s , w i v e s , s w e e t h e a r t s , o r c h i l d r e n c a n no l o n g e r r e a c t i n t h e same w a y . . . . T h e g r o u p has s u f f e r e d a s o c i a l a m p u t a t i o n o f one o f i t s component members."-*-P a r t i c u l a r l y r e l e v a n t t o t h e f u t u r e o f t h e d i s a b l e d a r t h r i t i c i n h i s f a m i l y i s t h e f o l l o w i n g q u o t a t i o n , a l s o f r o m D r . M i l l e t : "The more u n c e r t a i n t h e outcome, t h e l e s s t h e p o s s i b i l i t y o f r e s t o r i n g t h e o r i g i n a l p a t t e r s o f e q u i l i b r i u m , t h e more l i v e l y 1 M i l l e t , J o h n A . P . , Op. C i t . ; p . 54. - k$ -are these disturbances apt to become, and the greater the obstacles,.that w i l l be placed on the road to rehabilitation.''^ Therefore, to achieve r e h a b i l i t a t i o n , provision of income resources and personal help from within the family should be accompanied by recognition of the patient's need to be dependent, and at the same time, of his need to u t i l i z e r e s i d u a l strengths. A strong family, i n addition to providing assistance to the patient, demonstrates these attitudes of recognition and under-standing i n t h e i r behaviour toward him. Family strength might be said to rest upon the c l a r i t y and complementary nature of breadwinner and housewife roles and the family members'. recognition of external r e a l i t i e s . 1 I b i d . p. 55. CHAPTER I I I T H E CONCEPT OP F A M I L Y S T R E N G T H : CASEWORK A P P L I C A T I O N S T h e r e c o g n i t i o n o f f a m i l y s t r e n g t h s a n d w e a k n e s s e s h a s b e e n a m p l y d e m o n s t r a t e d i n t h e p r e c e d i n g c h a p t e r . A r e l a t e d , b u t p r a c t i c a l l y d i f f e r e n t , a s p e c t o f t h e same s u b j e c t i s t h e a p p l i c a - t i o n o f t h i s k n o w l e d g e i n c o n t i n u i n g c a s e w o r k . 1 How c a n t h e p a t i e n t w i t h w e a k f a m i l y s u p p o r t s b e a i d e d ? How a r e t h e f a m i l y r e s o u r c e s , w h e n t h e y e x i s t , u t i l i z a b l e ; how c a n t h e y b e b e s t b u i l t u p o n ? T o e x p l o r e t h i s i s s u e o f t h e d i a g n o s t i c a n d t r e a t -m e n t v a l u e s w h i c h t h e c o n c e p t o f f a m i l y s t r e n g t h may h a v e f o r t h e p r a c t i s i n g c a s e w o r k e r , s e r v i n g t h e d i s a b l e d b r e a d w i n n e r i n a c l i n i c a l s e t t i n g , t h e s e q u e s t i o n s w i l l b e f o l l o w e d o u t i n a l l s e v e n c a s e s o f t h e s e l e c t e d s a m p l e , i n c l u d i n g t h e f o u r p r e v i o u s l y p r e -s e n t e d . I n t h r e e o f t h e s e c a s e s , i d e n t i f i e d a s F a m i l i e s " A " , " B " , a n d " C " , o t h e r v a r i a b l e s t h a n t h o s e p r e v i o u s l y o u t l i n e d a s i n v o l v i n g t h e f a m i l y w e r e o f g r e a t e r r e l a t i v e i m p o r t a n c e i n d e t e r m i n i n g t h e e m p l o y m e n t p o t e n t i a l o f t h e p a t i e n t . A s i s i n d i c a t e d i n S c h e d u l e B , ^ t w o o f t h e s e p a t i e n t s , e a c h w i t h a h i g h d e g r e e o f p h y s i c a l i m p a i r m e n t , w e r e f u n c t i o n a l l y - r a t e d i n c a p a b l e o f e m p l o y m e n t . T h e s e c a s e s w i l l , h o w e v e r , b e e x a m i n e d f o r (1) f a m i l y s t r e n g t h , o r t h e 1 S o c i a l c a s e w o r k i s o n e o f t h e m e t h o d s o f s o c i a l w o r k w h i c h h a s b e e n d e f i n e d a s " a p r o c e s s u s e d b y c e r t a i n h u m a n w e l f a r e a g e n c i e s t o h e l p i n d i v i d u a l s t o c o p e m o r e e f f e c t i v e l y w i t h ' t h e i r p r o b l e m s . " ( P e r l m a n , H e l e n H a r r i s , S o c i a l C a s e w o r k , T h e U n i v e r s i t y o f C h i c a g o P r e s s , C h i c a g o , 1957. P-T+TT 2 P a g e I4.6.-A. - 46 - A -SCHEDULE "B" Summary of Objective Variables Affecting  the Rehabilitation of Three Patients• (Cases in which family factors not predominant). Patient Functional Goal 2 Availability of Employment Work Pattern Resources Income^ Personal Care (a) .(b) (c) "A" "Employment" Yes Steady X Self "B" "Self-help" Yes Steady X Family »C" "Self-help" Yes Steady x Family 1 Sources of information were: C.A.R.S. records for a l l three, supplementary home v i s i t s for "B" and "C"; no c l i n i c a l interviews with a family member vrere possible. 2 "Self-help" implies that the patient is not capable of becoming employed due to severe disability, and that a lesser goal has been established by the treatment team at C.A.R.S. See also footnote, Schedule '-'A", page 41- A. 3 (a) patient's personal savings and property. (b) family employment. (c) community resources i.e. social assistance. - hi -a b i l i t i e s o f t h e f a m i l y g r o u p w h i c h c a n b e r e c o g n i z e d i n a c l i n i c a l s e t t i n g a s a c t i n g p o s i t i v e l y t o i m p r o v e t h e b r e a d w i n n e r ' s r e h a b i l i t a t i o n p o t e n t i a l , a n d ( 2 ) f o r m e a n s w h e r e b y i n t h e i r a b s e n c e o r p r e s e n c e t h e s e a b i l i t i e s m a y b e s u p p l e m e n t e d o r s t r e n g t h e n e d b y s o c i a l w o r k m e t h o d . T h e c o n t e n t o f t h i s c h a p t e r , t h e n , i s c o n c e r n e d w i t h p a t i e n t -f a m i l y d i a g n o s i s , a n d t r e a t m e n t o f t h e p a t i e n t i n a f a m i l y c o n t e x t . P a t l e n t - F a m i l y D i a g n o s i s a n d T r e a t m e n t i n a C l i n i c a l S e t t i n g . -——I-—f4M___-_l__»__--WM~-——_____—^ I n S o c i a l c a s e w o r k , d i a g n o s i s c a n n o t b e c o n s i d e r e d a p a r t f r o m t h e o n - g o i n g p r o c e s s o f h e l p i n g a p a t i e n t o r c l i e n t t h r o u g h a t h e r a p e u t i c r e l a t i o n s h i p a n d e n v i r o n m e n t a l c h a n g e t o m e e t h i s n e e d s . T h e d e d u c t i o n o r d i a g n o s t i c p r o d u c t w h i c h e m e r g e s f r o m e x a m i n i n g t h e r a m i f i c a t i o n s o f h i s p r o b l e m a n d a s s e s s i n g h i s a b i l i t i e s — h i s s t r e n g t h s - - t o s e e k a s o l u t i o n a r e a l w a y s b o u n d u p w i t h a p l a n f o r a c t i o n . 1 S u c h a t r e a t m e n t p l a n , c o n d i t i o n e d b y t h e p r o b l e m , t h e f a c i l i t i e s o f t h e p l a c e w h e r e t h e p e r s o n s e e k s h e l p , a n d t h e m e a n s a t h a n d t o m e e t h i s n e e d s , m u s t , t o b e e f f e c t i v e , h a v e t h e f u l l s u p p o r t a n d u n d e r s t a n d i n g o f t h e p e r s o n i n v o l v e d . W h e n a t r e a t m e n t p l a n i s e x t e n d e d t o t h e p a t i e n t i n h i s f a m i l y g r o u p t h i s i m p l i e s t h a t t h e s o c i a l w o r k e r h a s h i s c o -o p e r a t i o n . 1 I b i d : p a g e 16I4.. - 48 , When the patient receives casework treatment in his family group the social worker enters the home upon the patient's recognition that he has a problem requiring such help. This recognized problem maybe, for example, lack of income accompany-ing disability, or a need for nursing care which the worker, i f resources are available, must provide. The worker recognizes, at the same time, that there are always attitudinal or emotional aspects to any problem, and that the patient's family is involved. While the worker's focus remains on the patient, in dealing with these so-called "underlying" aspects-of the problem, this focus should not preclude consideration of the needs of his family as individual members, or of means to meet them. Indeed, the caseworker must actively "engage" the family In the treatment of the patient i f he Is to realize his rehabilitation potential. This may be accomplished through special s k i l l s appropriate to the needs of the person interviewed and the present situation.^- The r e a l i s t i c facts of art h r i t i s as the disease affects the patient's physical and emotional functioning, and the meaning the illness has for him, are seldom f u l l y understood by his family —those nearest him In relationship. The necessity of such inter-pretation, well-timed, was evident in the previously-described 1 Perlman suggests that the caseworker's spoken communications with his client are of two main kinds. -"One consists of questions and comments, aiming to draw out to a maximum the client's relevant participation. The other consists of information and counsel aiming to provide the client with some necessary knowledge or guidance." (Perlman, Op.Cit.: page 159)• - 49 -cases, the Rigby case in particular. It w i l l be recalled that outside intervention was f i n a l l y forced on an emergency basis to retain the patient's job for him. The need was evident for c l a r i f i c a t i o n of the limits imposed on him by his illness; of the Inevitability of a certain amount of reversal of responsibilities between the husband and wife; of the emotional conflict and strain on their relationship that this would imply. Counselling regarding ways and means of adjusting to these new stresses and strains may be indicated to help the patient rechannel his energies into another "lighter" form of work. Retraining, particularly for the older patient, is frequently a disturbing experience when he considers the need to "begin a l l over again", and although free retraining services may be provid-ed through various agencies, the patient requires emotional support im making use of them. Such support and encouragement from his family members, If they are enabled to provide this through casework interpretation plus r e l i e f from environmental pressures occasioned by the loss of income, may go a long way to assist the breadwinner in becoming independent. Patient-Family Diagnosis in a C l i n i c a l Setting. The seven patient-family groups w i l l be examined in accord-ance with the c r i t e r i a previously stated of family strength. Patient-family diagnosis, the product of examining the problem of disability of the patient in his family group, and of assess-ing the a b i l i t i e s of the group to seek a solution, is based mainly upon information obtained from the patient in a c l i n i c a l setting. The need is evident, considering the concurrent nature - 50 -o f d i a g n o s i s and t r e a t m e n t , f o r s u c h i n f o r m a t i o n t o be o b t a i n e d by a s o c i a l w o r k e r w i t h t h e p a t i e n t i n h i s home. However, i t i s p o s s i b l e f r o m a v a i l a b l e I n f o r m a t i o n t o i n d i c a t e g e n e r a l l y t h e a b i l i t i e s w h i c h t h e g r o u p have d e m o n s t r a t e d t o meet t h e i r n e e d s and t o a d j u s t t o t h e changed c i r c u m s t a n c e s . The f i r s t o f t h e f a m i l y g r o u p s t o be c o n s i d e r e d i s t h e W e h r n e r f a m i l y . A summary o f d i a g n o s t i c i n f o r m a t i o n on e a c h f a m i l y and a n a s s e s s m e n t o f t h e r e l a t i v e s t r e n g t h s o f e a c h i s s e t o u t i n S c h e d u l e G. 1 To r e p e a t , t h e c r i t e r i a o f f a m i l y s t r e n g t h , a s t r o n g f a m i l y , i n a d d i t i o n t o p r o v i d i n g a s s i s t a n c e t o t h e p a t i e n t , r e c o g n i z e s t h e p a t i e n t ' s n e e d t o be d e p e n d e n t , and a t t h e same t i m e , h i s need t o u t i l i z e r e s i d u a l s t r e n g t h s . F a m i l y s t r e n g t h m i g h t be s a i d t o r e s t upon t h e c l a r i t y and c o m p l e m e n t a r i t y o f t h e b r e a d w i n n e r and h o usewofe r o l e s , and t h e f a m i l y members' r e c o g n i t i o n o f e x t e r n a l r e a l i t i e s . The c o u p l e ' s u n d e r s t a n d i n g and a c c e p t a n c e o f t h e i n e v i t a b l e changes w h i c h o c c u r i n t h e i r r e l a t i o n s h i p i s o f paramount i m p o r t a n c e . ^ The Wehrner F a m i l y Mr. Wehrner, a [(.8-year-old a r t h r i t i c , g ave l i t t l e e v i d e n c e o f any p h y s i c a l l i m i t a t i o n a l t h o u g h he s u f f e r e d c o n s i d e r a b l e 1 Page 57-A. 2 I t m i g h t be n o t e d h e r e t h a t t h e b r o a d e r f a m i l y g r o u p o u t s i d e the home h a s n o t r e c e i v e d t h e c o n s i d e r a t i o n i n t h i s e x a m i n a t i o n o f c a s e s t h a t i t may d e s e r v e . I n t h e s e v e n c a s e s , r e l a t i v e s o f t h e f a m i l y d i d n o t a p p e a r t o be s o u r c e s o f a s s i s t a n c e t o h e l p r e -l i e v e t h e l o a d r e s u l t i n g f r o m th e b r e a d w i n n e r ' s d i s a b i l i t y . A b r o a d e r s a m p l i n g o f c a s e s m i g h t have i n d i c a t e d the i m p o r t a n c e t h i s " e x t e n d e d f a m i l y g r o u p " c o u l d have i n t h e p a t i e n t ' s r e h a b i l i t a t i o n . - 51 -p a i n a n d h a d w o r k e d o n l y p a r t - t i m e o n h i s f a r m . T h e f a r m was d e b t - f r e e , b u t p r o v i d e d l i t t l e r e v e n u e , a n d M r . W e h r n e r h a d p a i d h e a v y m e d i c a l b i l l s . He c o u l d manage h i s own p e r s o n a l c a r e , a n d was c o n s i d e r e d f i t t o r e t u r n t o l i g h t e r e m p l o y m e n t . R e t r a i n i n g was n o t i n d i c a t e d b e c a u s e o f h i s l a c k o f e d u c a t i o n a l b a c k g r o u n d . T h e r e b e i n g n o p o s s i b i l i t y o f " l i g h t e r " j o b s i n h i s r e s i d e n t i a l a r e a , M r . W e h r n e r m o v e d h i s f a m i l y t o a n u r b a n a r e a w h e r e h e o b t a i n e d m o r e s u i t a b l e e m p l o y m e n t a n d d e r i v e d m u c h g r a t i f i c a t i o n f r o m t h i s . I n c o m e f o r t h e f a m i l y , w h i c h i n c l u d e d a t e e n - a g e d s o n , h a d b e e n s u p p l e m e n t e d b y t h e w i f e ' s o u t s i d e e m p l o y m e n t i n u n s k i l l e d w o r k . T h e C . A . R . S . c a s e w o r k e r f o u n d M r . W e h r n e r t o b e e m o t i o n a l l y h e a l t h y a n d r e a l i s t i c a b o u t h i s s i t u a t i o n . He r e a d i l y e x p r e s s e d h i s c o n c e r n a b o u t t h e l o s s o f s t a t u s h i s w i f e ' s a s s u m p t i o n o f t h e b r e a d w i n n e r r o l e i m p l i e d f o r h i m , b u t h e r e t a i n e d h i s a u t h o r i t a r i a n a t t i t u d e t o w a r d h i s f a m i l y . N o t i n g t h a t t h e p a t i e n t h a d " m a n y s t r e n g t h s " t h e c a s e w o r k e r r e c o r d e d t h e f o l l o w i n g a s e v i d e n c e : " 1 . H i s a b i l i t y i n t h e p a s t t o p r o v i d e f o r h i s f a m i l y ; 2. H i s r e a l i z a t i o n o f h i s own a n d f a m i l y ' s n e e d t o d o s o m e t h i n g a b o u t t h e s i t u a t i o n ; 3. H i s d e t e r m i n a t i o n t o c h a n g e h i s l i v i n g s i t u a t i o n t o f i t i n w i t h h i s p h y s i c a l l i m i t a t i o n s ; 1}.. H i s a b i l i t y t o r e c o g n i z e a n d c h a n g e some o f h i s f e e l i n g s - 52 -regarding independence and to accept and use the treatment offered." The caseworker's impression of the family's a b i l i t y to meet the patient's emotional needs was indicated by his comment that there existed "a good relationship between husband and wife." The family apparently accepted, but also supported the authorit-arian nature of their breadwinner's role in this family, and reinforced his drive for independence. The Thompson Family. Mr. Thompson, a [(.1-year-old spondylitic, with peripheral joint involvement, had not been working on his farm for two years. Though he found walking very d i f f i c u l t he could manage his own personal care and on discharge from the Medical Centre was considered f i t to return to "lighter" employment. This required retraining for which he had a high school background and good motivation. Income had for several years been provided by his wife's outside employment until her health began to f a i l , and his 'teen-aged children helped operate the heavily-mortgaged farm on which they had become tenants. Social assistance helped carry the family through the patient's treatment and retraining period u n t i l they could move to an area where lighter employment was available. The patient became well-established in a c l e r i c a l job, and was building his own house. The Social Welfare Branch worker described Mr. Thompson as "not an aggressive person, but he has shown considerable determin-ation and persistence in trying to remain independent." To the - 5 3 ~ C.A.R.S. caseworker, Mr. Thompson expressed concern about h i s wife's having to work, remarking that she was " h i g h l y nervous and i r r i t a b l e " at t imes. He f e l t t h a t h i s i l l n e s s was d e p r i v i n g h i s f a m i l y , p a r t i c u l a r l y h i s e l d e s t daughter who was a p p a r e n t l y a source of s t r e n g t h to him. T h i s f a m i l y c o n t r i b u t e d to the income which maintained the p a t i e n t and were a c t i n g p o s i t i v e l y t o meet h i s emotional needs. His r e a l i s t i c outlook was a s t r o n g l y s u p p o r t i v e f a c t o r i n t h e i r e f f o r t s . The Rigby Fam i l y . Mr. Rigby, aged 3 l x , and the f a t h e r of t h r e e pre-school-aged c h i l d r e n , had continued to work at h i s b u s - d r i v i n g job w i t h a leave-of-absence f o r treatment at the Centre. His. i l l n e s s ( s p o n d y l i t i s ) , w h ile t h i s had allowed him to accomplish only p a r t of h i s p r e s c r i b e d d u t i e s , l e f t him able to manage h i s own p e r s o n a l care. Those d u t i e s which he could not d i s c h a r g e were assumed by h i s wife, a woman c o n s i d e r a b l y b e t t e r - e d u c a t e d and t r a i n e d than the p a t i e n t . D u r i n g h i s treatment p e r i o d at the Centre she r e t u r n e d to her previous employment. The p a t i e n t was d e s c r i b e d by the C.A.R.S. caseworker as being a very r e p r e s s e d person who d i d not d i s c u s s h i s problems, but d i d i n d i c a t e h i s f e e l i n g s of inadequacy as a breadwinner and as a man. P s y c h o l o g i c a l t e s t i n g r e v e a l e d a very unhappy horn© and m a r i t a l r e l a t i o n s h i p and t h i s i m pression was r e i n f o r c e d by d i r e c t o b s e r v a t i o n of the w i f e ' s behaviour toward her husband. That t h i s r e l a t i o n s h i p was a negative and a c t u a l l y d e s t r u c t i v e one was borne out i n the w i f e ' s assumption of a job - Sh -which would, without intervention, have precluded her husband's re-employment in his former job. Under the severe stress of her responsibility she did not appear to recognize that his illness placed limitations on his performance, and that he had no choice in becoming more dependent. The Lewis Family. Mr. Lewis, at £5, though his rheumatoid arth r i t i s was of comparatively recent origin, was hospitalized frequently by his illness and reaction to steroids. He was unable to work in any capacity and was completely dependent for his personal needs. Sometime after his discharge from the Centre, he improved under different medication and was able to resume employment. Because of knee and ankle involvement he was not able to manage his personal care. He had no financial resources and his urban home was heavily-mortgaged. His wife attempted to support the family, which Included two 'teen-aged children, but became disabled and dependent through mental i l l n e s s . The children showed strength in providing their own spending money by working during holidays. Mr. Lewis, the C.A.R.S. caseworker recorded, though depress-ed and apathetic, had definite strength and could r e a l i s t i c a l l y recognize the needs of his family and his own limitations. He was greatly relieved when social assistance was provided. It appeared that he was the strong person on whom the wife had been totally dependent, and that she was unable to accept the loss of the breadwinner. The family managed to stay together only through resources available from outside agencies. - 55 * Family "A" Mr. "A", a 3 8-year-old s p o n d y l i t i c , was admitted t o the M e d i c a l Centre f o r treatment from the h o s p i t a l . He r e t u r n e d on d i s c h a r g e t o h i s former employment as a sheet metal worker. During h i s f i v e month's i l l n e s s h i s w i f e supported the f a m i l y of the p a t i e n t and two school-aged c h i l d r e n w i t h an u n s k i l l e d job, and continued t o work f o l l o w i n g the p a t i e n t ' s r e t u r n t o employment. She l a t e r l e f t the p a t i e n t f o r a pro-longed v i s i t t o her own home. Subsequent v i s i t s of the p a t i e n t t o the Centre showed t h a t the burdens of home, c h i l d r e n , and job, i n h i s wife's absence, had r e s u l t e d i n h i s p h y s i c a l d e t e r i o r a t i o n . Although he used f u n c t i o n a l treatment w e l l , Mr. "A" was found by the caseworker to be r i g i d and u n r e a l i s t i c i n h i s a t t i t u d e toward h i s p h y s i c a l and i n t e l l e c t u a l l i m i t a t i o n s and h i s h i s t o r y showed severe emotional d e p r i v a t i o n d u r i n g h i s c h i l d h o o d . He was very c r i t i c a l and abusive of h i s wife as a wif e and mother, remarking t h a t he was the only one who could "keep the c h i l d r e n i n l i n e . " I n t h i s case, while the wife p r o v i d e d p h y s i c a l r e s o u r c e s , i t was apparent t h a t t h i s f a m i l y group, because of the p a t i e n t ' s emotional c o n d i t i o n , could probably not meet h i s emotional needs. Family "B" Mr. "B", a [|.9-year-old a r t h r i t i c , w i t h c l e r i c a l t r a i n i n g , had shown f u n c t i o n a l improvement and w i t h r e t r a i n i n g was con s i d e r e d - 5 6 -employable prior to his treatment in the Medical Centre. However, he could not tolerate steroids, developing ulcers, and his condition regressed after discharge. His wife took employment to support the patient and their three school-aged children. The patient expressed his concern about this arrangement, remarking that he knew how hard i t was for his wife to go to work, adding regretfully that his children did not remember him "as anything else but a cripple." They had asked, he said, why he could not be like other fathers. He was, however, very demanding of their time in meeting his needs for personal care. Mr. "B" was found by the caseworker to be emotionally rigid, attempting to control his treatment, and in severe conflict over the loss of breadwinner status to his wife. Resentment of his eldest son, who he f e l t was taking his place in the family, appeared to stem from an emotional disturbance which predated his present illne s s . While the family provided income and contributed to his personal.care, i t was doubtful whether they could adequately meet his emotional needs. Family "C". Mr. "C", a L[.9-year-old art h r i t i c , had after 23 years of hard manual labour suffered permanent knee deformity which made his own goal of re-employment seem impossible to attain. While his trade union membership guaranteed him a job with the mining company he had served for many years, he was unable - 57 -to work because of repeated exacerbations o f h i s i l l n e s s . With the use of s t e r o i d s he developed u l c e r s and had repeated set-backs, r e g r e s s i n g a f t e r h i s di s c h a r g e from the Centre. He became a b l e to manage some p e r s o n a l care, but h i s wife, a s m a l l woman, the mother of two young c h i l d r e n , had t o l i f t and h e l p him from h i s c h a i r . The f a m i l y r e c e i v e d s o c i a l a s s i s t a n c e and some Income from a boarder i n t h e i r home, which was l o c a t e d i n a r u r a l area at the top of a h i g h h i l l . The S o c i a l Welfare Branch worker found the wife to be "very c o - o p e r a t i v e a l t h o u g h a great w o r r i e r . She endeavours t o encour-age her husband and be c h e e r f u l In h i s presence." Mrs. "C" complained, however, that her husband had "no sympathy or compassion" f o r her. She s u f f e r e d from migraine headaches which were severe enough to be a p p a r e n t l y d i s a b l i n g . Mr. "C" was found to be extremely anxious and depressed, e x p r e s s i n g a "work-or-nothing" a t t i t u d e . He s a i d , when f u n c t i o n a l gains r e l i e v e d some of t h i s t e n s i o n , t h a t he r e g r e t t e d the s t r a i n h i s i l l n e s s had imposed on h i s wife, who chould not a f f o r d a " b a b y - s i t t e r " and consequently, "she never gets out." D u r i n g periods of improvement th e r e was evidence t h a t the p a t i e n t ' s emotional needs were b e i n g met when he was b e t t e r a b l e t o manage some p e r s o n a l care, although he co u l d not become employable. - 57 - A -SCHEDULE C Summary of Family Strength Assessments. (Seven Cases) C r i t e r i a of Family Strength 1 Assessment of Family Strength Patient Income Provision Personal Care Acceptance of Dependence Encourage-ment of i n -dependence Wehrner Contrib- Not uting required Yes Yes Strong Thompson Contrib- Not uting required Contributing Yes Strong Rigby Contrib- Not uting required No No Weak Lewis No No No Yes Weak "A" Yes Not required Doubtful Doubtful "Border-; l i n e " "B" Yes Contrib-uting Doubtful Doubtful Some Strength "C" Contrib- Contrib- Contrib-uting uting Doubtful uting Strong r 1 C r i t e r i a of family strength are described i n d e t a i l on pages HO-tf' 2 This patient-family unable to meet his own group needs would be decidedly weak were the for personal care. patient - 58 -Patlent-Family Treatment The economic and emotional depredations which chronic, severe illness of the breadwinner makes on family group strength are illustrated in these seven c a s e 3 . Had economic assistance been available to supplement income at the onset of the disease, together with treatment of the patient's physical and emotional condition, this degree of stress might have been avoided. Nursing care was indicated in two of the cases. In two cases there were severe emotional problems which apparently predated the patient's present illne s s . In the relatively brief treatment period at the Centre, these emotional problems, i f recognized by the patients, were not explored. It is possible that, with continued supportive casework for the patients and their families, and interpretation to their wives of the patients' needs and limitations, better results might have been obtained. A Possible Comparative Rating The prime purpose of a study of the kind set out so far is to sharpen up analysis and recognition of causative and signi-ficant factors. It becomes evident, however, that further development of this kind of analysis might lead potentially to the devising of a rating scale, in this instance, for family strengths for certain classes of patients. Without claiming more than experimental value, this has been tried out in what follows. - 59 -The "rating scale" represents an attempt to evaluate and compare the demonstrated a b i l i t y of each patient-family group to meet their disabled breadwinner's physical and emotional needs, and thereby contribute to his rehabilitation. In the process of constructing the scale, and i n order to strengthen i t , i t was found necessary to incorporate a "dynamic" aspect in assessing family strengths. In addition to factual material descriptive of the patient-family group's behaviour at the time of the patient's treatment in the Medical Centre which involved a diagnostic "cross-section" of behaviour patterns, an "on-going" aspect was included. This is illustrated as follows: When the cri t e r i a of a "resource" family, as previously described, are applied to each patient-family grdup>actiorB which favour the patient's rehabilitation tend to be offset by others which do not. Por example, the family, while encouraging the patients indepen-dence, may f a i l to recognize his limitations imposed by illness, thus aggravating his physical condition. Alternatively, the degree of dependence exhibited by some hitherto hard-working breadwinners who have become disabled, i f this dependence is totally accepted by their families, may lessen their potential for independence. Also, when the wife is providing income from 1 Rating scale; page 63-A. - 60 -employment outside the home, unless there are others who can meet the severely-disabled patient's needs for personal care, he must meet his own, and may, as well, suffer emotionally from loss of status with this reversal of roles. The means adopted in rating scale construction to express the dynamic aspect was the positive or negative numerical weighting of each factor (such as provision of income by the family; family encouragement of the patient's independence) as i t was objectively or subjectively observed in the behaviour of each patlent-family group. A positive rating indicates that the family has in specific ways (documented in the case histories previously presented) provided for or contributed to the patient' rehabilitation by meeting his physical and emotional needs. If the family has not provided for these needs, or If there is evidence that what they have done is discouraging the breadwinner independence, a negative rating is recorded. The numerical values are a convenient means of summarizing and comparing family strengths. (A further explanation of assi-gned values is given below the Table). A l l families f a l l between the two extremes of "total" demonstrated adequacy of the family to provide for the patient, and "total" demonstrated Inadequacy. For example, i t is possible, though a breadwinner was so severely disabled his chances were small of returning to work in any but a protected environment, that with adequate income from savings or the employment of other family members; with family-provided personal care and acceptance of the limitations imposed - 6 l -by the patierrtfs i l l n e s s , t o gether w i t h encouragement to use h i s r e s i d u a l s t r e n g t h s c o n s t r u c t i v e l y , the p a t i e n t might be r e h a b i l i t a t e d . Such a f a m i l y would r e c e i v e a r a t i n g of f 8 . I f , on the other hand, the p a t i e n t had no f a m i l y , f o r whatever reason, and was t o t a l l y without e i t h e r income or emotional support, the r a t i n g would b e - 8 . I t should be emphasized t h a t these r a t i n g s assess only f a m i l y s t r e n g t h s . The other v a r i a b l e s i n f l u e n c i n g the p a t i e n t ' s r e h a b i l i t a t i o n , such as age, s e v e r i t y of the d i s e a s e , and employ-ment o p p o r t u n i t i e s , have been excluded i n dete r m i n i n g the r a t i n g . However, the r a t i n g a c t u a l l y c a l c u l a t e d f o r each p a t i e n t - f a m i l y group r e f l e c t s t h a t group's comparative importance i n r e l a t i o n to the other f a m i l i e s among v a r i a b l e s r e l a t i n g t o the p a t i e n t ' s use of the Centre s e r v i c e s and h i s adjustment t h e r e . These v a r i a b l e s have been considered elsewhere as b e i n g r e l a t e d to r e h a b i l i t a t i o n p o t e n t i a l . 1 The b a s i s f o r t h i s f a c t concerns the f u n c t i o n of the agency from which these cases are drawn, and the type of i n f o r m a t i o n recorded by the agency's caseworkers. The m e d i c a l - s o c i a l problem which i s at the centre o f C.A.R.S. agency concern determines i n t h i s s e t t i n g o f s k i l l e d caseworkers the i n f o r m a t i o n which i s obtained from the p a t i e n t and r e c o r d e d . 1 Maclnnis, Margaret R., Op. C i t . - 62 -If family interraction Is closely related to the patient's treatment of his illness, and hence his rehabilitation, there is more information on f i l e concerning family relationships. This was evident in the four i l l u s t r a t i v e cases outlined in the preceding chapter in each of which the family played a major or even decisive role in rehabilitation. In the group of three cases, while families exerted an influence, they were evidently not as important as such other variables as the severity of the handicap or emotional problems i n determining the patient's rehabilitation potential. The patient in Family "A", although achieving re-employ ment, had presented an emotional problem prior to the illness onset which current family relationships appeared to aggravate. The overall ratings indicate that of the seven patient-family groups considered, the rural Wehrner family with it s immigrant spondylitic breadwinner is the strongest. The urban Lewis family, the family of a rheumatoid a r t h r i t i c breadwinner whose wife was disabled by mental illness is the weakest. The others f a l l between these two on the scale of their demonstrated a b i l i t i e s to contribute to their breadwinner's rehabilitation. One important difference not indicated by the comparative overall rating is the degree of emotional need of the individual patients. The breadwinners in Families "A" and "B" were emotion-ally disturbed and would impose relatively greater burdens on any family group to meet their emotional needs.. It should again be emphasized that patient-family diagnosis in this thesis is limited to a study at one short period of time, that is during the time immediately preceding, during and shortly - 6 3 -a f t e r the p a t i e n t ' s treatment i n the M e d i c a l Centre. L i m i t e d i n f o r m a t i o n precluded the more acc u r a t e c o n s i d e r a t i o n §f " v e r t i c a l " f a c t o r s i n d i a g n o s i s i . e . p a t i e n t - f a m i l y group behaviour p a t t e r n s p r i o r t o the onset of the breadwinner's i l l n e s s and a f t e r . Obviously the s t r o n g e s t f a m i l y might i n t e n y e a r s ' time become g r e a t l y weakened by the i n c r e a s e d s e v e r i t y of the p a t i e n t ' s i l l n e s s , or h i s w i f e ' s i n a b i l i t y t o work wi t h advancing age or i l l n e s s . A f u t u r e study of each of these p a t l e n t - f a m i l y groups might produce q u i t e d i f f e r e n t r a t i n g s . Treatment I m p l i c a t i o n s of the R a t i n g S c a l e Some p a t I e n t - f a m i l y groups, even without o u t s i d e h e l p , have had p o s i t i v e value f o r t h e i r breadwinner's r e h a b i l i t a t i o n . Others have l i t t l e t o o f f e r toward h i s becoming independent and a g a i n c a r r y i n g on i n h i s breadwinner r o l e i f there i s work s u i t a b l e t o h i s a b i l i t i e s . W i t h i n the l i m i t a t i o n s imposed by b a s i c i n f o r m a t i o n sources as i n d i c a t e d above, the s c a l e presents a p i c t u r e of comparative s t r e n g t h s of the f a m i l i e s s t u d i e d . Family weakness s i g n a l s the need f o r h e l p from sources o u t s i d e the f a m i l y group. With the p r o v i s i o n of s e r v i c e s i n the form of income, m e d i c a l treatment, and emotional support through casework t o r e i n f o r c e r e s i d u a l s t r e n g t h s i n the p a t l e n t - f a m i l y group, the weakest Lewis f a m i l y continued to f u n c t i o n f o r the b e n e f i t of i t s breadwinner and the other f a m i l y members i n s p i t e of the severe s t r e s s e s . Without these s e r v i c e s the f a m i l y could not have s u r v i v e d as a group. - 6 3 - A -Table 2 Comparative R a t i n g of Family S t r e n g t h s . P a t i e n t -Family Group Demonostrated a b i l i t y of the F a m i l y to meet the P a t i e n t ' s p h y s i c a l needs Demonstrated a b i l i t y of the F a m i l y to meet the P a t i e n t ' s emotional needs. Over-a l l R a t ing Income P r o v i s i o n P e r s o n a l Care Acceptance of Dependency Encourage-ment of Independence Wehrner / 1 0 / 2 / 2 / 5 Thompson 1 / X ' 0 / 1 / 2 / 4 Rigby / 1 0 - 2 o — __ - 3 Lewis - 2 - 2 - 2 / 2 - 4 Fa m i l y "A" / 2 0 - 1 - 1 0 F a m i l y "B" / 2 / 1 - 1 - 1 / 1 Family "C" / 1 / 1 - 1 / 1 / 2 R a t i n g s : A p o s i t i v e answer r a t e s / 2; a n e g a t i v e answer r a t e s -2; A q u a l i f i e d answer, " c o n t r i b u t i n g " , r a t e s / 1; A q u a l i f i e d answer, " d o u b t f u l " , r a t e s -1; A need met by the p a t i e n t h i m s e l f , i n the c o n t e x t , r a t e s 0. CHAPTER IV IMPROVING TREATMENT RESOURCES Human needs and their satisfactions are complex and interrelated. When needs are unmet the problems which arise are equally complex and d i f f i c u l t of resolution. The concepts set forth in this thesis relate to problems arising from chronic illne s s . When the breadwinner of a family is disabled by a r t h r i t i s , the loss or reduction of his income and of his independence occasioned by his physical handicap invariably has serious repercussions on the man himself and on his family. It is the resolution of these problems which is the goal.of the rehabilit-ation process. It has to be achieved in his personal environment: ih that of his family group, and in his community. His need for a healthy body and mind--the family's need for an able breadwinner, a stable husband and father capable of play-ing his part in the family drama—is the primary focus of this process. The man needs health, peace of mind, and security In his family role, but these needs cannot always be met because of the chronic nature and incurability of the disease, and the permanent damage which sometimes accompanies i t . Not only does this damage occur to his body, but also to his self-esteem--to his feeling of self-worth and adequacy as a man. In the absence of other resources from his kinship group or community, he is thrown back upon his family for help In providing income, physical care, and emotional support and understanding. The family may not be able to meet his needs, - 65 -but i f s t r o n g , i t i s c e r t a i n l y b e t t e r a b l e to do so. I f the f a m i l y i s weak, unless i t s members may depend on resources out-s i d e the f a m i l y g r o u p — r e l a t i v e s , or community a g e n c i e s — t h e group Is i n danger of d i s i n t e g r a t i o n under the s t r e s s . Even a s t r o n g f a m i l y cannot be expected t o withstand ^ i n d e f i n i t e l y the great s t r e s s of d i s a b l i n g i l l n e s s of i t s breadwinner. When the mother works the f a m i l y i s f o r c e d nearer i t s b r e a k i n g p o i n t . Treatment s e r v i c e s must be a v a i l a b l e i n the community to support and m a i n t a i n f a m i l y s t r e n g t h ; to prevent the weak f a m i l i e s from becoming weaker or d i s i n t e g r a t i n g . B e t t e r D i a g n o s i s May Help the Family. P r a c t i s i n g caseworkers i n s o c i a l agencies are f r e q u e n t l y i n v o l v e d In the s o c i a l d i a g n o s i s and treatment of persons whose most evident problem i s d i s a b l i n g i l l n e s s . T h e i r o b j e c t i v e i n a s s i s t i n g such a person must be the reinforcement of h i s r e s i d u a l a b i l i t i e s , b o t h p h y s i c a l and emotional, t o r e g a i n the maximum s o c i a l f u n c t i o n i n g of which he i s capable. I n h i s s o c i a l m i l i e u , the p a t i e n t ' s f a m i l y i s the most r e l e v a n t to him, and s u b j e c t t h e r e f o r e t o the caseworker's c o n s i d e r a t i o n , b o t h as a r e s o u r c e , and as a group of i n d i v i d u a l s w i t h t h e i r own r e l a t e d needs and problems. A problem f a c i n g the r e s e a r c h e r i n t h i s study has been, "How can we as p r a c t i t i o n e r s improve s e r v i c e s to the a r t h r i t i s - d i s a b l e d breadwinner i n h i s f a m i l y group?" Caseworkers i n a c l i n i c a l s e t t i n g see the p a t i e n t w i t h i n l i m i t s imposed by time, agency f u n c t i o n , and knowledge of the p a t i e n t ' s and h i s f a m i l y ' s a b i l i t i e s t o meet h i s needs. F u r t h e r l i m i t s are Imposed by the - 66 -extent and v a r i e t y of resources at hand. W i t h i n these r e a l i s t i c l i m i t s the caseworker must sharpen d i a g n o s t i c and treatment s k i l l s and improve r e s o u r c e s . A p p r o p r i a t e treatment i s based upon sound d i a g n o s i s . The method used i n t h i s study, as d e t a i l e d i n Chapters I and I I , i s a form of r e s e a r c h which i s indigenous t o s o c i a l work because i t i s concerned w i t h the improvement of treatment s k i l l s and r e s o u r c e s . There can be no such t h i n g as a s o c i a l " l a b o r a t o r y " , of the type a v a i l a b l e to the p h y s i c a l s c i e n t i s t , to e x t r a c t and examine the i n t e r r a c t i o n of two i s o l a t e d v a r i a b l e s . S o c i a l work r e s e a r c h must be developed from on-going casework p r a c t i c e by methods s u i t a b l e t o the p a r t i c u l a r problem at hand. Such r e s e a r c h may t h e r e f o r e be regarded, "not as the a p p l i c a t i o n of s p e c i a l methods, but as a process of o b t a i n i n g f a c t s or knowledge t h a t h e l p us (as p r a c t i t i o n e r s ) determine what d e c i s i o n s t o make and what a c t i o n s to take.''^ In other words, a d i s t i n c t i o n i s made between r e s e a r c h as a p r a c t i c e of methodology, or "what i s done", and as a process of f i n d i n g out something we need to know, "what should be done." The s o c i a l r e s e a r c h process has, i n common w i t h other forms of r e s e a r c h , f i v e i d e n t i f i a b l e steps or stages which are as f o l l o w s : 1 Gordon, W i l l i a m E., "Can Research Help S o c i a l Work—Some P r a c t i c a l Suggestions", from Tenth A n n i v e r s a r y C e l e b r a t i o n , U n i v e r s i t y of Tennessee School of S o c i a l Work, N a s h v i l l e , Term., - 67 -1. E s t a b l i s h i n g the g o a l of the p r o j e c t ; 2. a n a l y s i n g the problem; 3. d e s c r i b i n g or s t a n d a r d i z i n g the a c t i v i t y ; [j.. measuring the degree of change as a r e s u l t of the a c t i v i t y ; 5. determining the c a u s e - e f f e c t r e l a t i o n s h i p of f a c t o r s which induced t h i s change."'" These f i v e steps may be r e c o g n i z e d though not always e x p l i -c i t l y i n the process of d i a g n o s i s and treatment of each case. C e r t a i n l y , the process may be observed b o t h i n the on-going p r a c t i c e of casework, and i n s o c i a l work r e s e a r c h . In the r e s e a r c h process u t i l i z e d i n t h i s study, t h r e e of the f i v e steps are observed as f o l l o w s : (1) the g o a l i s e s t a b l i s h e d of the breadwinner-patient's r e h a b i l i t a t i o n ; (2) the amount of d i s a b i l i t y due to a r t h r i t i s i n r e l a t i o n t o employment p o t e n t i a l i s analysed In order t o i d e n t i f y among the v a r i a b l e s a f f e c t i n g employment the s p e c i f i c i n f l u e n c e of the p a t i e n t ' s f a m i l y group; (3) the r e s u l t s are a p p l i e d to the process of d i a g n o s i s and treatment of the p a t i e n t i n a c l i n i c a l s e t t i n g t o c o n s i d e r how h i s f a m i l y might be used as a re s o u r c e i n h i s treatment. A r a t i n g s c a l e , a f o u r t h step, could be developed as a measurement 1 French, David, Measuring R e s u l t s i n S o c i a l Work, Columbia U n i v e r s i t y Press, 1952, Chapter V. - 68 -a d d i t i o n to the complex process of a s s e s s i n g the degree of change i n f a m i l y s t r e n g t h s over a p e r i o d of time. T h i s would demand more r e s e a r c h , and continued " o p e r a t i o n a l " a p p l i c a t i o n of the s c a l e ; but i t i s at l e a s t o u t l i n e d i n the present study. T h i s t h e s i s was c o n f i n e d to the records of on-going p r a c t i c e of d i a g n o s i s and treatment of one p a r t i c u l a r agency, the Canadian A r t h r i t i s and Rheumatism S o c i e t y , B. C. D i v i s i o n , M e d i c a l Centre. The m a t e r i a l has been recorded by caseworkers over a t h r e e - y e a r p e r i o d w i t h i n d i v i d u a l r e h a b i l i t a t i o n goals h a v i n g been determined f o r each p a t i e n t . The second major step i n t h i s r e s e a r c h process might be d e s c r i b e d as " g e t t i n g o u t s i d e " of the on-going a c t i v i t y i n o r d e r to analyse the m a t e r i a l . T h i s has been done i n Chapter I I t o determine what f a c t o r s or " v a r i a b l e s " could be i d e n t i f i e d as i n f l u e n c i n g the r e h a b i l i t a t i o n of d i s a b l e d breadwinners. , While only a s m a l l sample of cases was a v a i l a b l e , c e r t a i n v a r i a b l e s were i d e n t i f i e d from the i n e s c a p a b l e f a c t s of the nature of the d i s e a s e , and the b a s i c problems i t c r e a t e d f o r the man and h i s f a m i l y by making him t e m p o r a r i l y or permanently unable to work. The c o n c l u s i o n reached from t h i s a n a l y s i s Is c l e a r l y that, i n the r e h a b i l i t a t i o n of each p a t i e n t f o r whom s u i t a b l e r e -employment was the s e l e c t e d goal, the f a m i l y was an important i n f l u e n c e . In two cases, the f a m i l y group could be d e s c r i b e d (or assessed) as a p o s i t i v e , i n two cases as, on the whole, a negative i n f l u e n c e . Given t h i s knowledge t h a t f a m i l i e s can exert a p o s i t i v e i n f l u e n c e on the p a t i e n t ' s r e h a b i l i t a t i o n , the second q u e s t i o n - 69 -was: how can such knowledge be applied to the practice of case-work In a c l i n i c a l setting? It was therefore necessary to determine what behaviour characterized a strong patient-family group, and to apply certain crit e r i a of strength in the family to the diagnosis of a group of cases seen in the same c l i n i c a l setting, and to indicate treatment implications of such a diagnosis. An experimental by-product of this process was a rating scale, developed to bring into clearer focus the compar-ative strengths of the families whose patients were seen in the c l i n i c a l setting. If applied periodically, this scale might be considered as a means to measure the degree of change, following the application of various forms of treatment. Lack of Information, a Limitation. In this research project a practical limitation, which has been previously-noted, is the lack of Information on the patient's family group; their attitudes to the patient's illness, and the ways in which they had met the patient's needs prior to his illness, or even after. This i s , of course, related to the focus of the agency on the patient in a medical setting, not in his home, and the need for the caseworkers to rely for information on the patient alone and on sources outside the agency, unless the • patient's family resides in the Vancouver area. These outside sources, requested by C.A.R.S. to furnish social and financial -information, were apparently oriented to financial e l i g i b i l i t y -determination. Not only in the research process but also In casework practice there is much evidence of the need for family information - 70 -as expressed by p r a c t i t i o n e r s . T h i s l a c k of i n f o r m a t i o n as a l i m i t a t i o n of the d i a g n o s i s of cases p r i o r t o t h e i r admission to the M e d i c a l Centre maylbe noted on examination of correspond-ence between caseworkers and the p r o v i n c i a l S o c i a l Welfare Branch a g e n c i e s . The f o l l o w i n g l e t t e r (acknowledged by the S.W.B., but w i t h -out answering the ques t i o n s Implied) from the C.A.R.S. caseworker i s quoted as evidence. (The p r o s p e c t i v e p a t i e n t was a li7-year-o l d widow, the mother of two school-aged sons, who had been r e f e r r e d by a l o c a l d o c t o r from a s m a l l centre i n the B. C. i n t e r i o r ) . "...Some knowledge o f ( t h e P a t i e n t ' s ) f a m i l y s i t u a t i o n and how she handles i t would be h e l p f u l to us i n a s s e s s i n g how she might be ab l e t o s e t t l e i n t o the program here and use the treatment a v a i l a b l e . I t i s our experience that p a t i e n t s w i t h a l o t of unresolved problems at home f i n d i t d i f f i c u l t to concentrate on treatment, and tend t o want to leave b e f o r e they have gained as much b e n e f i t as otherwise might be the case. We b e l i e v e (the p a t i e n t ) has had d i f f i c u l t y i n the past making up her mind to come to the Centre f o r i n t e n s i v e treatment, so we are anxious, now that she seemingly wants to come, that she be g i v e n h e l p and encouragement to do so, but the r e a l i t i e s of her s i t u a t i o n need to be taken Into c o n s i d e r a t i o n and be understood by those t r y i n g to h e l p her." The Importance of t h i s i n f o r m a t i o n i n a s s e s s i n g cases f o r In t e n s i v e treatment i s a t o p i c which was not s p e c i f i c a l l y d e a l t w i t h i n t h i s t h e s i s , but which i s h i g h l y r e l e v a n t to t h i s study. I t i s i n t e r e s t i n g to note that the caseworker's experience which had l e d her t o conclude the i n f o r m a t i o n was necessary b e f o r e the p a t i e n t should be admitted f o r treatment was c l e a r l y borne out i n the further- development of t h i s case f o l l o w i n g the p a t i e n t ' s admission to the M e d i c a l Centre. While her rheumatoid a r t h r i t i s had r e s u l t e d i n l i t t l e p h y s i c a l l i m i t a t i o n , her a p a t h e t i c approach t o treatment i n the Centre and l a c k of c o - o p e r a t i o n f r u s t r a t e d the p h y s i o t h e r a p i s t s and o c c u p a t i o n a l t h e r a p i s t s , and t h e i r impressions are so recorded i n case conference notes. She was d i s c h a r g e d from the Centre w i t h l i t t l e p h y s i c a l improvement and no evident improvement i n her p h y s i c a l and emotional dependence on her sons. Other treatment resources were c e r t a i n l y i n d i c a t e d i n her home environment, but her i n t e n s i v e treatment at the Centre at that p a r t i c u l a r time, and without supplementary s e r v i c e s , was not. While t h i s example i s drawn from another group of p a t i e n t s — t h e women b r e a d w i n n e r s — t h e r e were other l e s s - d r a m a t i c examples i n the male group s e l e c t e d . ^ For purposes of dete r m i n i n g what d i a g n o s t i c i n f o r m a t i o n had been r e c e i v e d concerning the male group of p a t i e n t s by the C.A.R.S. caseworkers p r i o r to t h e i r admission to the Centre, the w r i t e r f u r t h e r examined the seven f i l e s f o r d i a g n o s t i c "items" then a v a i l a b l e . (Whether the p a t i e n t ' s f a m i l y was at any time, b e f o r e or d u r i n g h i s treatment, i n t e r v i e w e d has been i n d i c a t e d i n footnotes t o Schedules A and B)* These "items" were judged by the w r i t e r i n the process of a n a l y s i n g the d i s a b i l i t y - e m p l o y m e n t problem to be e s s e n t i a l t o 1 A caseworker's comment i s reco r d e d on the r e c o r d of the p a t i e n t from Family "A" (see (Chapter I I I ) t h a t the p a t i e n t 1 s " m a r i t a l d i f f i c u l t i e s . m i g h t sabotage treatment p l a n s . " T h e - m a r i t a l r e l a t i o n s h i p proved t o be a negative f a c t o r i n the p a t i e n t ' s r e h a b i l i t a t i o n . - 72 -the d e t e r m i n a t i o n of r e h a b i l i t a t i o n p o t e n t i a l , and were the components of v a r i a b l e s i n f l u e n c i n g re-employment, l i s t e d in.: Chapter I I . The Items s e l e c t e d were both the " o b j e c t i v e " ones of age, d u r a t i o n of the i l l n e s s , and employment h i s t o r y as r e l a t e d to the onset of the d i s e a s e and i t s s e v e r i t y , income sources, and, secondly, the " s u b j e c t i v e " items or those r e q u i r i n g d e s c r i p t i v e m a t e r i a l which was, as the case a n a l y s i s has f u r t h e r i n d i c a t e d , important t o r e h a b i l i t a t i o n of the p a t i e n t . These items were, f i r s t l y , the a t t i t u d e of the p a t i e n t to h i s present s i t u a t i o n ( r e f l e c t e d i n h i s a t t i t u d e to proposed treatment which he understood would c o n t r i b u t e to h i s independence) and, secondly, the f a m i l y ' s a t t i t u d e to the p a t i e n t ' s dependency. Included a l s o f o r t h i s purpose was a c l o s e l y - r e l a t e d item--housing of the p a t i e n t and h i s f a m i l y . Would the p a t i e n t have t o cope w i t h s t a i r s or steep grades i n going t o and from h i s work? These items were l i s t e d and each case was checked f o r pre-admission i n f o r m a t i o n . R e s u l t s showed that while a home v i s i t might have been made t o a r u r a l or urban f a m i l y , t h a t , w i t h the exc e p t i o n of housing on which i n f o r m a t i o n appeared i n only one case, the o b j e c t i v e i n f o r m a t i o n a v a i l a b l e was provided mainly by medic a l r e p o r t s ; t h a t s u b j e c t i v e i n f o r m a t i o n on the f a m i l y ' s a t t i t u d e s was seldom a v a i l a b l e . F u r t h e r , i t was necessary t o r e l y on the C.A.R.S. m e d i c a l c o n s u l t a n t ' s estimate o f the p a t i e n t ' s " m o t i v a t i o n " to use treatment on the b a s i s of one or two i n t e r v i e w s h e l d i n a c l i n i c a l s e t t i n g . T h i s estimate appeared to r e s t upon the p a t i e n t ' s employment r e c o r d and h i s expressed f e e l i n g about b e i n g unemployed. - 73 -These estimates of motivation, without knowing what, in fact, the patient was "up against", were not in a l l cases borne out in his performance after leaving the Centre. The estimates were made on the basis of inadequate information. Concerning the patient's attitude to treatment, in one case (Family "C"), the consultant who saw the patient in the cl i n i c said he was "doing remarkably well in spite of his deformities," and the S.W.B. worker who briefly visited the home to determine financial e l i g i b i l i t y , said he was "remarkably self-sufficient." The physiotherapist who treated the patient in his home remarked, however, in a note to the travelling consultant, that he was "too dependent on his wife, although capable of self-help. He needs a great deal of encouragement." The possibility of over-identification with the patient's wife who the physiotherapist described as "a small woman...who has to l i f t and help the patient" cannot be .discounted in determining her degree of objectivity. The difference i n these accounts, however, cannot be ignored, and the need for a more thorough study (and recording of the results obtained) in the patient's home environment is indicated before his admission to the Centre. Treatment Implications of this Study. Treatment of individual patients following from analysis of each case in Chapter II have not been described i n detail in this thesis of which the ultimate purpose is to indicate how, from its assessment, a family group might be enabled as treatment resource for the patient. C.A.R.S. provides treatment - Ik -b o t h i n a c l i n i c a l s e t t i n g and, through " s e l f - h e l p a i d s " developed f o r each i n d i v i d u a l p a t i e n t by the o c c u p a t i o n a l therapy department, and physiotherapy, i n the p a t i e n t s ' homes. The s o c i a l s e r v i c e department of C.A.R.S. devotes much time t o h e l p i n g the p a t i e n t s use such treatment r e s o u r c e s , and, i f the p a t i e n t ' s home i s w i t h i n the environs of the M e d i c a l Centre, i n t e r p r e t i n g t o the f a m i l y members the need f o r t h e i r support of the p a t i e n t i f he i s to become more s e l f - r e l i a n t . " F u l l " treatment of the p a t i e n t n e c e s s i t a t e s regard f o r h i s t o t a l w e l l - b e i n g , as a person, as a f a m i l y member, and as a member of h i s community. T h i s i s an i d e a l which i n i t s r e a l i z -a t i o n i s l i m i t e d by the s k i l l s of those who would h e l p him, and the resources a v a i l a b l e . Various approaches t o treatment must be co - o r d i n a t e d t o assure that the p a t i e n t i s not "segmented" by s p e c i a l i z e d h e l p i n g p e r s o n s — d o c t o r s , p h y s i o t h e r a p i s t s , o c c u p a t i o n a l t h e r a p i s t s , and s o c i a l w o r k e r s — a n d t h a t he i s not considered apart from h i s f a m i l y . The team approach to r e h a b i l i t a t i o n i s a p r a c t i c a l r e c o g n i t i o n of t h i s concept of " f u l l " treatment of the "whole" person, but t h e r e are v a r y i n g degrees of such c o - o r d i n a t i o n . I f the f a m i l y i s over-looked as a resource and, indeed, as a p a r t of the team, the r e h a b i l i t a t i o n s e r v i c e s are inadequate, and the process of r e h a b i l i t a t i o n handicapped from the b e g i n n i n g . That the p a t i e n t ' s f a m i l y should be regarded as an " e x t e n s i o n " of the treatment team i s the c o n t e n t i o n of Dr. John A. P. M i l l e t , P s y c h i a t r i s t I n - C h i e f of the American R e h a b i l i t a t i o n Committee. O u t l i n i n g c e r t a i n b a s i c approaches t o the task of r e h a b i l i t a t i n g - 75 -the d i s a b l e d , Dr. M i l l e t s t a t e s as f o l l o w s : "..the s t r u c t u r e and a t t i t u d e s of the f a m i l y , as w e l l as t h e i r economic s t a t u s , should be f u l l y and s y m p a t h e t i c a l l y i n v e s t i g a t e d by the s o c i a l worker on the team, whose r o l e i s t o act as ambassador from the r e h a b i l i t a t i o n team t o the f a m i l y , and to see that the f a m i l y i s made t o f e e l a par t of the team. At times her s p e c i a l i z e d s k i l l s may be c a l l e d f o r I f some member of the f a m i l y Is i n need of su p p o r t i v e t h e r a p y . " ! Dr. M i l l e t made these f u r t h e r comments on the f i n a n c i a l needs of the f a m i l y group i n r e l a t i o n to the p a t i e n t ' s r e h a b i l i t a t i o n which are r e l e v a n t t o the present d i s c u s s i o n of •treatment i m p l i c a t i o n s of t h i s study: " F a m i l i e s vary a l l the way from b e i n g extremely embarrassed and r e l u c t a n t t o accept a s s i s t a n c e to making angry p r o t e s t s a g a i n s t the n i g g a r d l y subsidy which i s pr o v i d e d . . . S i n c e i t i s h i g h l y important to the p a t i e n t t h a t h i s f a m i l y be as f r e e from a n x i e t y and h o s t i l i t y , as p o s s i b l e , the approach which the...worker has t o the very d e l i c a t e b u s i n e s s of i n v e s t i g a t i n g and r e p o r t i n g on the s i t u a t i o n i s q u i t e important. In some cases a n x i e t y due to some other cause may lead to undue a n x i e t y about money, so that adequate f i n a n c i a l su'bs.idies do not n e c e s s a r i l y b r i n g the r e l i e f t h a t might be a n t i c i p a t e d . " ^ I t might be noted a g a i n t h a t s o c i a l workers from the C.A.R.S. r e h a b i l i t a t i o n team do not v i s i t the p a t i e n t ' s home unless the p a t i e n t i s w i t h i n the urban environs of the M e d i c a l Centre. This i s o b v i o u s l y an inadequacy i n the team's approach to treatment, although the d i f f i c u l t i e s i n v o l v e d i n c o v e r i n g the l a r g e geographic area from which the p a t i e n t s are drawn i s acknowledged. 1 M i l l e t , John A.P., M.D., "Understanding the Emotional Aspects of D i s a b i l i t y , " an address at the I n s t i t u t e on R e h a b i l i t a t i o n , June 1956, Bryn Mawr C o l l e g e . Op. C i t . ; page 6 l . 2 I b i d ; page 62. - 76 -Supplementary casework s e r v i c e s which, the p r o v i n c i a l S o c i a l Welfare Department might be expected to p r o v i d e are not a v a i l a b l e . The task which t h a t Department r e c o g n i z e s i n p r a c t i c e , the d e t e r m i n a t i o n of f i n a n c i a l e l i g i b i l i t y f o r the p a t i e n t ' s treatment at the Centre, though i t may appear to be a r e l a t i v e l y s t r a i g h t - f o r w a r d procedure, i s a process i n v a r i a b l y charged w i t h emotional content f o r the p a t i e n t and h i s f a m i l y . T h i s may be the b a s i s , i n the hands of a s k i l l e d s o c i a l worker, f o r a c t i v e l y engaging the f a m i l y as a resource and as p a r t of the treatment team to h e l p the c l i e n t use a v a i l a b l e f a c i l i t i e s . T h i s could mean the d i f f e r e n c e between the p a t i e n t ' s s u c c e s s f u l r e h a b i l i t a -t i o n and h i s r e g r e s s i o n i n t o permanent dependency. The need f o r s k i l l e d s o c i a l workers to enter the p a t i e n t ' s home on whatever b a s i s i s i n d i c a t e d by the needs of the p a t i e n t and h i s f a m i l y i s elemental to the r e h a b i l i t a t i o n p r o c e s s . T h i s study has emphasized a p a r t i c u l a r environmental approach to c o n s i d e r a t i o n of the p a t i e n t ' s needs and problems, n o t i n g behaviour of the p a t i e n t i n h i s f a m i l y group and the manner i n which i t s members meet h i s needs. Obviously t h i s i s not the whole of the casework approach, j u s t as the "whole" person i s not simply t o be d e s c r i b e d i n the r o l e s he p l a y s . N e i t h e r i s the f a m i l y composed of persons whose t o t a l a c t i v i t i e s are centered w i t h i n the f a m i l y group. The f a m i l y l i v e s i n a s o c i a l and c u l t u r a l m i l i e u which must be taken i n t o account i n d e t e r m i n i n g the ways they c u s t o m a r i l y use to meet t h e i r needs, t h e i r concepts of r o l e playing^ and t h e i r a t t i t u d e s to r e c e i v i n g a s s i s t a n c e from outside sources. The methods and objectives of the social caseworker have been briefly noted in Chapter 1^ Social diagnosis is the product of an on-going process of helping the person who seeks help i n carrying out one or more of his everyday tasks through a thera-peutic relationship and environmental modification to meet his needs. Such a relationship is fundamental to the helping process and must be established not only with the disabled person but also with his family members i f the family is to be considered a treatment resource? The patient's "environment" includes not only his external but also his "internal" environment—the psychological import of his experiences. The question is not which of these two aspects of total environment should be emphasized—a question which has had a profound influence on the development of casework method— but of how the "whole" person might best be understood and involved in seeking a solution to his problem. Increased 1 See pp. 5>-6 2 Helen Harris Perlman, has recently written as follows: "... casework diagnosis and treatment must of necessity deal not merely with the person who asks for help, the person called the "client", but with the living network of those people with whom he is in v i t a l interaction, whom he affects and by whom he is affected. In large part this is what is implied by the idea of "family diagnosis", an idea which has captured much interest and effort today—the idea that the family is a dynamic network of relation-ships and that any member does not simply dwell within i t , but rather is in continuous interaction with i t . " (Perlman, Helen Harris, "Social Casework Today", Public Welfare, The Journal of the American Public Y/elfare Association, April, 1959, page 53.) - 78 -knowledge of both sociodynamlcs and psychodynamics has become available to caseworkers in recant years, and today's challenge is to select and use what is valuable from these sources in the process of helping persons who seek agency assistance. Each • patient presents problems in which there appear varying pro-portions of situational and psychological pathology. It w i l l be recalled from the cases described in Chapters II and III of this thesis that two of the patients, those from Families "A" and "B" were clearly in need of help to free them from emotional blocks to living satisfying and productive lives in their family groups; to perform adequately in their family role. Others were to a greater degree the victims of adverse external circumstance which had left them without sufficient educational background to compete for other than manual labour, and yet they felt that they must continue to be the family breadwinners. When, in the process of social work, environmental modifica-tion is attempted by the caseworker, the necessity for further refinement of treatment s k i l l s is evident. The role of the social worker in enabling each patIent-family group to accept the changes in their lives resulting from the enforced dependency of their breadwinner, and to help the patient use treatment requires s k i l l in Interviewing several persons at one time, and involves the art of motivating the family "to use themselves in the interests of others...to achieve some balance between the - 79 -simultaneous and o f t e n c o n f l i c t i n g wants and needs of s e v e r a l people. These are no easy t a s k s . T h e s o c i a l worker's r o l e i n each f a m i l y w i l l be c o n d i t i o n e d by t h e i r needs and c a p a c i t i e s to use a v a i l a b l e h e l p . The worth of i n v o l v i n g the f a m i l y i n the treatment process, however t h i s may be accomplished, i s i n d i c a t e d i n r e s u l t s of s o c i a l r e s e a r c h conducted at The Research Centre of the 2 U n i v e r s i t y of Chicago's s c h o o l of s o c i a l work. Those persons who brought i n t e r - p e r s o n a l problems, p a r t i c u l a r l y m a r i t a l and p a r e n t - c h i l d c o n f l i c t t o agencies "tended to continue t o work w i t h the agency when other people i n t h e i r l i v e s were s u p p o r t i v e r a t h e r than undermining. Conversely, i f the r o l e played by other people i n t h e i r l i v e s was impeding they tended to drop out of s e r v i c e . : V The r e l e v a n c e of these f i n d i n g s t o the problems of f a m i l i e s of d i s a b l e d breadwinners who are e x p e r i e n c i n g the d i s t u r b e d r e l a t i o n s h i p s consequent to r o l e r e v e r s a l , would bear f u r t h e r c o n s i d e r a t i o n which w i l l not be accorded here. With the f a c t o r s of p a t i e n t - f a m i l y s t r e n g t h which have been presented i n t h i s t h e s i s as the minimum d i a g n o s t i c knowledge requirement to be recorded, the caseworker may prepare a p a t i e n t -f a m i l y d i a g n o s i s which should i n d i c a t e the means t o s t r e n g t h e n 1 Perlman, " S o c i a l Casework Today", Op. C i t . , Page 51+. 2 R i p p l e , L i l i a n , " F a c t o r s A s s o c i a t e d w i t h Continuance i n Casework S e r v i c e . " - S o c i a l Work, V o l . I I , January, 1957. - 80 -t h e f a m i l y a s a g r o u p a n d a s a r e s o u r c e t o m e e t t h e p a t i e n t ' s s p e c i a l n e e d s . H e l p i n g t h e p a t i e n t t o u s e r e s o u r c e s s h o u l d p r o v i d e f u r t h e r a s s u r a n c e t h a t a n y g a i n s h e m a k e s f r o m i n t e n s i v e t r e a t m e n t s e r v i c e s s u c h as a r e p r o v i d e d a t t h e C . A . R . S . M e d i c a l C e n t r e a r e n o t l o s t u p o n h i s r e t u r n t o h i s h o m e . One m u s t c o n c l u d e t h a t m u c h e n v i r o n m e n t a l l y - i n d u c e d s t r e s s o n a l l f a m i l i e s a n d t h e d i s i n t e g r a t i o n o f w e a k f a m i l i e s m i g h t b e p r e v e n t e d b y t h e e a r l y t r e a t m e n t o f t h e p a t i e n t , w i t h t h e p r o v i s i o n b y c o m m u n i t y a g e n c i e s o f a d e q u a t e i n c o m e f o r h i m s e l f a n d h i s f a m i l y , a n d , i f n e c e s s a r y , p e r s o n a l c a r e f o r t h e p a t i e n t i n h i s h o m e . W h e n t h e w i f e w o r k s , e m o t i o n a l r e p e r c u s s i o n s may n e g a t e t h e a c h i e v e m e n t o f t h e r e h a b i l i t a t i o n o b j e c t i v e s , a n d t h e r e a r e , a p p a r e n t l y , f e w f a m i l i e s w h o , t h o u g h i n i t i a l l y s t r o n g , c o u l d s t a n d u p i n d e f i n i t e l y u n d e r t h e s t r a i n s o f c h r o n i c i l l n e s s w i t h o u t o u t s i d e h e l p . I n t h e a b o v e , t h e p a t i e n t h a s b e e n c o n s i d e r e d i n i n t e r a c t i o n w i t h h i s f a m i l y g r o u p . Some i n d i c a t i o n w i l l b e g i v e n h e r e b r i e f l y o f t h e i n t e r r e l a t i o n o f t h e f a m i l y w i t h t h e l a r g e r c o m m u n i t y , a n d t h e i m p l i c a t i o n s o f f a m i l y p a t t e r n s f o r p a t i e n t - f a m i l y d i a g n o s i s a n d t r e a t m e n t . T h e f a m i l y c a n n o t b e c o n s i d e r e d a p a r t f r o m t h e e x t e r n a l f o r c e s a n d h e r e d i t a r y p a t t e r n s w h i c h s h a p e a n d i n f l u e n c e t h e r o l e c o n c e p t s w h i c h t h e f a m i l y m e m b e r s w i l l h a v e o f w h a t , f o r e x a m p l e , c o n s t i t u t e s t h e r o l e o f a g o o d h u s b a n d a n d f a t h e r ; o f how h e s h o u l d b e h a v e i n r e l a t i o n t o h i s f a m i l y . The f a m i l y b e h a - v l o u r ^ p a t t e r n s s k e t c h e d i n C h a p t e r I I s u g g e s t e d t h a t w h i l e t h e p a t i e n t s r e a c t e d t o r o l e r e v e r s a l i n s i m i l a r w a y s — w i t h t h e - 81 -d e t e r m i n a t i o n t o b e c o m e r e - e m p l o y e d - - t h a t e a c h was m o t i v a t e d t o s o l v e h i s p r o b l e m i n d i f f e r e n t w a y s w h i c h b o r e some a p p a r e n t r e l a t i o n t o f a m i l y e x p e c t a t i o n s . M r . W e h r n e r , t h e e a s t e r n E u r o p e a n i m m i g r a n t , f e a r e d t h e l o s s o f a u t h o r i t y i m p l i c i t f o r h i m i n e a r n i n g t h e f a m i l y I n c o m e , a n d u p o n h i s r e c o v e r y , e x p e r i e n c e d s a t i s f a c t i o n i n b e i n g a b l e t o " t a l k b a c k " t o h i s e m p l o y e r . H i s d e c i s i o n t o move h i s f a m i l y was made w h i l e a t t h e C e n t r e , w i t h o u t d o u b t o f h i s f a m i l y ' s s u p p o r t o f a n y p l a n h e s h o u l d m a k e , a l t h o u g h t h i s i m p l i e d a m a j o r c h a n g e i n t h e i r l i v i n g a r r a n g e m e n t s . M r . R i g b y , who h a d m a r r i e d a woman b e t t e r - e d u c a t e d t h a n h i m s e l f , h a d n o s u c h a u t h o r i t y i n h i s h o m e , a n d t h e r o l e -r e v e r s a l w h i c h was p r a c t i c a l l y f o r c e d u p o n h i m , c o u l d h a v e m e a n t h i s r e g r e s s i o n i n t o c o m p l e t e d e p e n d e n c e . M r . T h o m p s o n , t h e s o n o f a l a b o u r e r , was m o t i v a t e d f o r " s o m e t h i n g b e t t e r " f o r h i s f a m i l y , - a n d h i m s e l f t o o k a d v a n t a g e o f r e - t r a i n i n g o p p o r t u n i t i e s w i t h m a r k e d s u c c e s s , w h i l e M r . L e w i s , d e p r i v e d o f a n e d u c a t i o n i n h i s e a r l y l i f e , was v e r y a n x i o u s t o r e - t r a i n a n d e s t a b l i s h h i m s e l f i n d e p e n d e n t l y i n b u s i n e s s . A n o t a b l e f a c t o r i n t h e f o u r c a s e s was t h a t t h e e x t e n d e d f a m i l y g r o u p — t h e k i n s h i p r e l a t i o n s h i p s o u t s i d e t h e h o m e — w e r e n o t o f s i g n i f i c a n c e a s s o u r c e s o f f a m i l y f i n a n c i a l s u p p o r t . M r . W e h r n e r b e l o n g e d t o a r e l i g i o u s g r o u p n o t e d f o r i t s s o l i d a r i t y a n d s u p p o r t o f i t s a d h e r e n t s . T h i s w o u l d c o n c e i v a b l y h a v e b e e n t h e g r o u p t o w h i c h h e w o u l d h a v e r e c o u r s e r a t h e r t h a n a p p l y f o r s o c i a l a s s i s t a n c e . I t may b e s a i d t h a t s u c h f a c t o r s a s f a m i l y s t r u c t u r e , - 82 -k i n s h i p r e l a t i o n s , r e l i g i o u s a f f i l i a t i o n , and s o c i a l c l a s s are of v i t a l importance to caseworkers i n d e t e r m i n i n g how a p a t i e n t w i l l use agency help.-*-Suggestions f o r F u r t h e r I n v e s t i g a t i o n T h i s study suggests two problems f o r f u r t h e r i n v e s t i g a t i o n . These are (1) a r t h r i t i c d i s a b i l i t y of the mother of dependent c h i l d r e n and the means whereby her f a m i l y might be strengthened to meet her needs and those of her dependent c h i l d r e n ; and (2) the l a c k of w e l l - t i m e d supplementary casework s e r v i c e s f o r d i s a b l e d persons and t h e i r f a m i l i e s i n the p r o v i n c e of B r i t i s h Columbia. A r e l a t e d problem, the evident inadequacy of i n f o r m a t i o n a v a i l a b l e from the p r o v i n c i a l Department of S o c i a l Welfare to C.A.R.S., which s p e c i a l i z e d agency provides a range 1 The i m p l i c a t i o n s f o r the caseworker of such s o c i o - c u l t u r a l f a c t o r s i n f a m i l y l i f e are examined by Dr. Herman D. S t e i n In h i s a r t i c l e , " S o c i o - c u l t u r a l Concepts i n Casework P r a c t i c e " . (Smith  C o l l e g e S t u d i e s i n S o c i a l Work, Feb., 1959, Smith C o l l e g e S c h o o l of S o c i a l Work, Northampton, Mass.). D e f i n i n g " e t h n i c " as r e f -e r r i n g t o "any group w i t h a core of c u l t u r a l homogeneity", Dr. S t e i n w r i t e s as f o l l o w s : "As s o c i a l workers we tend to be a ccept-in g of d i f f e r e n c e and i n t e r e s t e d i n e t h n i c d i f f e r e n c e s . However, there i s more to t h i s e t h n i c component than meets the eye. We are beyond the s u p e r f i c i a l d i f f e r e n c e s of dress and food p r e f e r -ences. S o c i a l v^orkers have, f o r example, begun to note d i f f e r e n c e s i n f a m i l y s t r u c t u r e among e t h n i c groups. Studi e s have g i v e n us more i n s i g h t to d i f f e r e n c e s i n r e l a t i o n to a u t h o r i t y , to s e e k i n g help, t o . a t t i t u d e s towards d i s c u s s i n g p e r s o n a l problems, to responses to i l l n e s s , and the l i k e . The i m p l i c a t i o n s f o r d i a g n o s i s are e x t e n s i v e . When the c l i e n t Is not of the same e t h n i c group as the worker, i t becomes most important s y s t e m a t i c a l l y to r a i s e such questions as...how does the c l i e n t see the agency, the worker, and h i s problem? Would he t a n d to see the agency as a u t h o r i t a r -i a n , as a p o l i t i c a l o u t f i t , as e s s e n t i a l l y h o s t i l e , as b e l o n g i n g to him?...In those e t h n i c groups w i t h m o d i f i e d extended k i n s h i p types of f a m i l y systems i t i s r a r e to f i n d I n d i v i d u a l s who would n a t u r a l l y d i s c u s s p e r s o n a l , i n t i m a t e f a m i l y problems w i t h s t r a n g e r s , even p r o f e s s i o n a l s t r a n g e r s . I n the American middle c l a s s t h i s i s q u i t e common because of our r e l i a n c e on the o u t s i d e expert." of treatment s e r v i c e s i n the M e d i c a l Centre and i n the p a t i e n t ' s home, l i m i t s the e f f e c t i v e n e s s of treatment. The p r o v i n c i a l Department, i n sponsoring these p a t i e n t s , and i n g r a n t i n g funds to the S o c i e t y , has a f i n a n c i a l investment i n e f f e c t i v e treatment. The need to s t r e n g t h e n p r o v i n c i a l w e l f a r e s e r v i c e s , and to examine r e l a t i o n s , r e s p o n s i b i l i t y , and c o - o p e r a t i o n between p u b l i c and p r i v a t e agencies g e n e r a l l y must be r e c o g n i z e d i f human resources of the d i s a b l e d are to be u t i l i z e d to t h e i r f u l l e s t e xtent. The B.C. community as a whole may a l s o be s a i d to d e r i v e , at the very l e a s t , the b e n e f i t of a s e l f - m a i n t a i n i n g and s t a b l e family."*' Community I m p l i c a t i o n s of This Study In Chapter I the w r i t e r has i n d i c a t e d that the problems presented by these p a t i e n t s and t h e i r f a m i l i e s , because of the wide-spread i n c i d e n c e of a r t h r i t i s and the age of i t s v i c t i m s , might be more p r e v a l e n t i n Canada. The value of e a r l y m e d i c a l d i a g n o s i s and treatment of the d i s e a s e has been i n d i c a t e d by m e d i c a l estimates t h a t f o u r out of f i v e rheumatoid a r t h r i t i c s t r e a t e d i n the e a r l y stages of the d i s e a s e do not s u f f e r s e r i o u s p h y s i c a l d e f o r m i t y . However, the Dominion Bureau of S t a t i s t i c s 1 A r e c e n t study of the cost of the r e h a b i l i t a t i o n program provided by C.A.R.S. (B.C.Division)- f o r a sample group of 36 rheumatic p a t i e n t s has shown t h a t the b a s i c cost of the program has been recovered t o the community i n "earned" income over a two -year p e r i o d subsequent t o the p a t i e n t s ' d i s c h a r g e from the M e d i c a l Centre. The decreased cost i n the two years t o the community i n f i n a n c i a l support of the h i t h e r t o dependent persons was estimated at $6,000.00. (Robinson, H a r o l d S., M.D., "The Cost of R e h a b i l i -t a t i o n i n Rheumatic Disease", J o u r n a l of Chronic D i s e a s e s , V o l . 8, No. 6, December, 1958, pages 713 - 718). - 8 L , -estimate that there are some 5°,000 t o t a l l y - or s e v e r e l y -d i s a b l e d , and another 115,000 p a r t i a l l y - d i s a b l e d Canadians, would seem to i n d i c a t e t h a t such e a r l y d i a g n o s i s and treatment i s not a v a i l a b l e or i s not u t i l i z e d by the p a t i e n t s . From examining the few cases presented i n Chapters I I and I I I , i t i s evident t h a t the p a t i e n t s had worked as long as they p o s s i b l y could without f i n a n c i a l a s s i s t a n c e , a p r a c t i c e t e n d i n g to cause d e f o r m i t i e s which e x i s t i n g treatment s e r v i c e s could not f u l l y r e p a i r . The employment of wives, the mothers of young c h i l d r e n , was a " l a s t - r e s o r t " of the p a t i e n t s i n v a r i a b l y h a ving emotional r e p e r c u s s i o n s which i n c e r t a i n s i t u a t i o n s could negate r e h a b i l i t a t i o n e f f o r t s . At the present time i n Canada the " t o t a l l y " d i s a b l e d p e r s o n has a r i g h t t o s o c i a l a s s i s t a n c e upon proof of need through c a t e g o r i c a l or n o n - c a t e g o r i c a l schemes, wi t h supplementary b e n e f i t s payable to r e c i p i e n t s i n B r i t i s h Columbia, A l b e r t a , Saskatchewan, On t a r i o , and the Y u k o n . There i s no guaranteed minimum income f o r most employed Canadians who are unable t o work because of s i c k n e s s or temporary d i s a b i l i t y . The w r i t e r would suggest t h a t the f o l l o w i n g measures are i n d i c a t e d t o encourage the e a r l i e r and more e f f e c t i v e use of treatment s e r v i c e s such as are now provided by the Canadian A r t h r i t i s and Rheumatism S o c i e t y , the pioneer s e r v i c e i n meeting the needs of the rheumatic d i s e a s e p a t i e n t : - 85 -1. A n a t i o n a l program, such as a cash s i c k n e s s b e n e f i t program to provide a g r e a t e r measure of f i n a n c i a l s e c u r i t y f o r o a l l persons who are unable to work because of s i c k n e s s or temporary d i s a b i l i t y . - * - Such a scheme must pr o v i d e income to the d i s a b l e d person and h i s f a m i l y as a r i g h t and not as a " l a s t -r e s o r t " . 2. A n a t i o n a l scheme of h e a l t h insurance t o cover m e d i c a l expenses i s r e q u i r e d . H o s p i t a l insurance on a n a t i o n a l s c a l e i s a welcome step i n the r e l i e f of f a m i l i e s from some of the burden of i l l n e s s on t h e i r incomes. 3. Treatment s e r v i c e s focused on the i n d i v i d u a l i n h i s f a m i l y group should be a v a i l a b l e to supplement present c l i n i c a l r e s o u r c e s . M e d i c a l care i s a necessary f i r s t step i n the p a t i e n t ' s r e h a b i l i t a t i o n , but by no means the whole of i t . S e r v i c e s such as are p r e s e n t l y provided by C.A.R.S., of o c c u p a t i o n a l therapy to suggest c r e a t i v e o u t l e t s f o r the d i s a b l e d person and " s e l f - h e l p " aids t o h i s p e r s o n a l care, l i g h t e n the burden on h i s f a m i l y members. Casework to h e l p the p a t i e n t and h i s f a m i l y use these and other r e s o u r c e s i s e s s e n t i a l . [j.. There i s need f o r agencies to examine c l o s e l y the r e s i d u a l s k i l l s and a b i l i t i e s of each d i s a b l e d person i n r e l a t i o n 1 As recommended by the Canadian Welfare C o u n c i l . ( S o c i a l  S e c u r i t y f o r Canada,, a p o l i c y statement adopted by the annual meeting of the C.W.C., January, 1958. The Canadian Welfare C o u n c i l , Ottawa). - 86 -to the present employment s i t u a t i o n and to a v a i l a b l e jobs i n h i s neighbourhood. The term " l i g h t employment" which i s f r e q u e -n t l y used by m e d i c a l p r a c t i t i o n e r s i s meaningless i n a s s e s s i n g the a c t u a l employment p o t e n t i a l of the d i s a b l e d person without a f u l l s o c i a l assessment. Employment can go f a r i n meeting the needs of such a p e r s o n — p a r t i c u l a r l y I f he i s the nominal breadwinner of a f a m i l y — f o r s e l f - r e s p e c t and a g o a l i n l i f e . F or the many who cannot compete f o r jobs i n the r e g u l a r employ-ment market, s h e l t e r e d workshops are u r g e n t l y r e q u i r e d wherein the d i s a b l e d person might have a work t r y - o u t experience, and, i f he i s able to do so, e v e n t u a l l y "graduate" to compete i n the r e g u l a r market. R e h a b i l i t a t i o n workers have f r e q u e n t l y noted the heartbreak of the person who has u t i l i z e d a v a i l a b l e t r e a t -ment to the f u l l e s t only to become discouraged by h i s i n a b i l i t y t o f i n d a s u i t a b l e job. F u r t h e r , the p h y s i c a l improvement which has r e s u l t e d from the a p p l i c a t i o n of a v a r i e t y of c o s t l y , s p e c i a l i z e d s e r v i c e s i n the i n t e r e s t of the p a t i e n t ' s w e l l - b e i n g , i f he must r e t u r n to heavy manual labour, i s undone. I 4 . . There i s need i n the B. C. community f o r g r e a t e r awareness of the impact of chronic i l l n e s s on f a m i l i e s , and the problems which w i l l a r i s e r e q u i r i n g community a t t e n t i o n . The problems are consequent to f a m i l y ' s needs. Through i t s program of r e s e a r c h , treatment, and education, The Canadian A r t h r i t i s and Rheumatism S o c i e t y has exposed the unmet needs of the person d i s a b l e d by rheumatic d i s e a s e , and i s p o i n t i n g the way to f u r t h e r develop-ment and expansion of these s e r v i c e s . These e f f o r t s must r e c e i v e i n c r e a s e d f i n a n c i a l support and encouragement. - 87 -A P P E N D I X - 88 -BIBLIOGRAPHY Books Perlman, Helen Harris, Social Casework. The University of Chicago Press, Chicago, 1957• Towle, Charlotte, Common Human Needs. American Association of Social Workers, New. York, 1955. French, David, Measuring Results in Social Work. Columbia Univer-sity Press, 1952. Ackerman, Nathan W., Psychodynamics of Family Life,Basic Books Inc., New York, 1958. Articles, Reports, Etc., Canadian Arthritis and Rheumatism Society, B.C. Division, Facts  About Arthritis and the Canadian Arthritis and  Rheumatism Society. Vancouver, 1959• Whitehouse, Frederick A., "Rehabilitation as a Concept in the Utiliza t i o n of Human Resources," The Evolving  Concept of Rehabilitation. Monograph I, July, 1955, The American Association of Social Workers, Washington, D.C. Millet, John A. P., "Understanding the Emotional Aspects of Dis-ab i l i t y " , Institute on Rehabilitation, R Qport of Proceedings^ Bryn Mawr College, Bryn Mawr, Penn., T9Fb~: Perlman, Helen Harris, "Social Casework Today". Public Welfare, April, 1959» The American Public Welfare Assoc-iation, Chicago. Ripple, Lilian, "Factors Associated With Continuance In Casework Service". Social Work, Vol II, January, 1957. Stein, Herman D., "Socio-cultural Concepts in Casework Practice". Smith College Studies in Social ¥i/ork, February, . 1959, Smith College School of Social Work, Northampton, Mass. Robinson, Harold S., M.D., "The Cost of Rehabilitation in Rheumatic Diseases". Journal of Chronic Diseases, Vol. 8, No. 6, December, 1958, St. Louis. Canadian Welfare Council, Social Security for Canada. Canadian Welfare Council, Ottawa, 1958. - 89 -Gordon, W i l l i a m E., "Can Research Help S o c i a l Work - Some P r a c t i c a l S uggestions". Tenth A n n i v e r s a r y  C e l e b r a t i o n , U n i v e r s i t y of Tennessee School of S o c i a l Work', N a s h v i l l e , Term., 1952. Theses Maclnnis, Margaret R. Socio-economic F a c t o r s i n the R e h a b i l i t a t i o n  P o t e n t i a l of A r t h r i t i c P a t i e n t s . Master of S o c i a l Work t h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1958. Rohn, George, R e h a b i l i t a t i o n of A r t h r i t i s P a t i e n t s . Master of S o c i a l Work t h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1953. 

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