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Social workers' recommendations on institutional care in a veterans hospital : an examination of the… McAllister, Clare Nulalinda 1956

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SOCIAL WORKERS* RECOMMENDATIONS ON INSTITUTIONAL. CARE . HI A VETERANS HOSPITAL An E x a m i n a t i o n o f t h e F a c t o r s R e l e v a n t t o S o c i a l Workers* Recommendations as to, t h e N e c e s s i t y o f , I n s t i t u t i o n a l Care f o r M a r r i e d M a l e V e t e r a n s , w i t h S p e c i a l A t t e n t i o n t o t h e Assessment o f M a r i t a l Relationships: Based on M e d i c a l S o c i a l S e r v i c e , Shaughnessy H o s p i t a l , Department o f V e t e r a n s A f f a i r s , Vancouver, B..C.  hy  CLARE NULALINDA MCALLISTER  Thesis Submitted i n P a r t i a l F u l f i l m e n t o f the Requirements 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 Vfork  A c c e p t e d as conforming t o t h e s t a n d a r d r e q u i r e d f o r t h e degree o f M a s t e r o f S o c i a l - Work  S c h o o l o f S o c i a l Work  1956 The U n i v e r s i t y o f B r i t i s h Columbia  In presenting  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of  the r e q u i r e m e n t s f o r an advanced degree a t t h e  University  o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t freely  a v a i l a b l e f o r r e f e r e n c e and  agree t h a t p e r m i s s i o n f o r e x t e n s i v e t h e s i s f o r s c h o l a r l y purposes may of my  study.  I further  copying of  this  be g r a n t e d by the Head  Department o r by h i s r e p r e s e n t a t i v e .  I t i s under-  stood t h a t c o p y i n g o r p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my permission.  Department The U n i v e r s i t y of B r i t i s h Columbia, Vancouver Canada.  written  " C o n s i d e r and c o n s i d e r and always come back t o what you s a i d i n a f l a s h and t o what y o u knew when you saw i t . Margot Ruddock n  "One o f t h e p u z z l i n g f e a t u r e s t h a t g r a d u a l l y came t o l i g h t a s t h e quantum t h e o r y d e v e l o p e d was t h a t e l e c t r o n s , which h a d a l w a y s been re-» garded as p a r t i c l e s , under some c i r c u m s t a n c e s behaved as i f t h e y were waves; w h i l e l i g h t , w h i c h f o r n e a r l y a c e n t u r y h a d been r e g a r d e d as a form o f wave-motion, under some c i r c u m s t a n c e s behaved as i f i t were an aggregate o f corpuscles..... . t h a t i s t o s a y , t h e l o c a t i o n o f a p a r t i c l e cannot be d e t e r m i n e d e x a c t l y a t the same time a s i t s momentun i s e x a c t l y d e t e r m i n e d ; and t h e more a c c u r a t e l y t h e one i s known,, t h e l e s s complete must be o u r knowledge o f t h e o t h e r . T h i s i s known a s t h e U n c e r t a i n t y p r i n c i p l e , or p r i n c i p l e of imperfect s p e c i f i c a tion". S i r Edmund W h i t t a k e r i n the i n t r o d u c t i o n to S i r Arthur Eddington's "The N a t u r e o f t h e P h y s i c a l W o r l d "  ii  Table o f Contents C h a p t e r I . GB&eric Problems I n v o l v e d I n H e l p i n g P a t i e n t s t o Make D e c i s i o n s M e d i c a l c a r e and f a m i l y r e l a t i o n s h i p s viewed h i s t o r i c a l l y * . C u r r e n t programs: p r i v a t e h o s p i t a l s and b o a r d i n g homes. The s o c i a l worker i n t h e h o s p i t a l . P a t i e n t s w i t h and w i t h o u t f a m i l i e s . The l i t e r a t u r e i s d i s c u s s e d . Chapter I I . T y p i c a l S i t u a t i o n s I n v o l v i n g M a r i t a l R e l a t i o n s h i p Patterns A v a i l a b l e r e c o r d s . Comment on v o c a b u l a r y i n u s e . . T y p i c a l cases i n v o l v i n g m a r i t a l r e l a t i o n s h i p s , w i t h o t h e r problems r e q u i r i n g a t t e n t i o n : t h r e e cases o f m e n t a l l y d i s t u r b e d p a t i e n t s a r e c i t e d , and t w e l v e o t h e r c a s e s , o f which t h e l a s t i s g i v e n i n extended, d e t a i l . C h a p t e r I I I . S o c i a l Work S e r v i c e s i n t h e Cases S k i l l and time f a c t o r s . D i r e c t s e r v i c e s : i n i n t e r p e r s o n a l r e l a t i o n s ; adjustment t o i l l n e s s ; r i g h t t o s e l f - d e t e r m i n a t i o n and a d j u s t m e n t t o r e a l i t i e s ; u t i l i z ing resources. I n d i r e c t services: diagnostic informat i o n ; i n t e r p r e t i n g s o c i a l p r e s s u r e s ; use o f d e p a r t m e n t a l r e s o u r c e s ; p u b l i c r e l a t i o n s ; .co-operative work w i t h administration; professional responsibility* Chapter I ? .  How can t h e B e s t S e r v i c e Be G i v e n ?  L i m i t a t i o n s o f d a t a . The f o r m u l a t i o n o f s o c i a l recommendations.. A r e a s f o r f u r t h e r r e s e a r c h ; and recommendations. Appendices. A.  O f f i c e C o n s o l i d a t i o n R e g u l a t i o n s under t h e Department o f V e t e r a n s A f f a i r s A c t , V e t e r a n s Treatment R e g u l a t i o n s , 1955, D o m i c i l i a r y C a r e , S e c t i o n 29,.  B.  Department o f V e t e r a n s A f f a i r s , M e d i c a l S o c i a l . S e r v i c e s , M o n t h l y S t a t i s t i c a l Report*  C.  I n c i d e n c e o f Cases, M e d i c a l S o c i a l S e r v i c e Shaughnessy H o s p i t a l , J a n u a r y , F e b r u a r y , March, 19.56*  D.  An Approach t o A n a l y s i s o f Case R e c o r d s .  E.  Bibliography. iii  Abstract S o c i ? . l Workers* Rgco^nendatipfls on I n s t i t u t i o n a l Care i n a V e t e r a n s H o s p i t a l T h i s s t u d y makes an e x a m i n a t i o n o f t h e f a c t o r s i n v o l v e ed i n s o c i a l w o r k e r s ' recommendations a s t o t h e n e c e s s i t y o f i n s t i t u t i o n a l c a r e f o r m a r r i e d h o s p i t a l p a t i e n t s , a form o f l o n g - t e r m cave a v a i l a b l e - s i t h i n t h e g e n e r a l s e t t i n g o f a D e p a r t * ment o f V e t e r a n s A f f a i r s H o s p i t a l . A t t e n t i o n i s g i v e n t o t h e r e a s o n s g o v e r n i n g t h e " s o c i a l , recommendation" made b y t h e s o c i a l worker, when t h e d e c i s i o n l i e s between t h e g r a n t i n g o f i n s t i t u t i o n a l e£>re, o r t h e p a t i e n t s r e t u r n t o h i s hoiae t o be c a r e d f o r by h i s w i f e . 1  •The a c t i v i t i e s which l e a d t o t h e s o c i a l p r o g n o s i s o n w h i c h t h e recommendation i s based i n t h i s s p e c i a l s e t t i n g , , a r e s i m i l a r t o t h o s e u n d e r t a k e n i n v a r i o u s w e l f a r e a g e n c i e s , where s o c i a l workers a s s i s t f a m i l i e s and d o c t o r s i n d e c i s i o n s a s t o whether c h r o n i c a l l y i l l p e r s o n s may be a t t e n d e d t o a t tome, o r must be c a r e d f o r i n a n u r s i n g home o r s i m i l a r s e t t i n g . . I n answer t o th© q u e r y as t o what elements a r e c o n s i d e r e d i n t h e f o r m u l a t i o n o f a p r o f e s s i o n a l o p i n i o n , t h e i m p o r t a n c e o f assess-; i n g t h e s t r e n g t h s and weaknesses o f t h e - m a r i t a l r e l a t i o n s h i p becomes a major theme o f t h e s t u d y . The method adopted i n t h e s t u d y i s (a) t o s i n g l e o u t a s e r i e s o f cases vwiich i n d i c a t e t h e range o f problems consider-: ed t o be t y p i c a l i n t h e h o s p i t a l s t u d i e s ; (b) t o p r e s e n t t h e recommendations made by t h e s o c i a l w o r k e r and t h e r e a s o n s f o r them; ( c ) t o s p e c i f y as f a r a s p o s s i b l e t h e s e r v i c e s r e n d e r e d by t h e s o c i a l worker i n t h e s e c a s e s * Seven d i r e c t and s i x i n d i r e c t services are distinguished. Attention i s also given t o t i i e k i n d o f f a c t s which' t h e s o c i a l worker f i n d s t o be s i g n i f i c e n t i n a s s e s s i n g thfe s t r e n g t h s o f a m a r r i a g e , s i n c e t h e p r o g n o s i s a r i s i n g from t h e s e , and t h e outcome o f t h e r e s u l t a n t " s o c i a l t r e a t m e n t " , f r e q u e n t l y d e t e r m i n e t h e recommendation. I n a f i n a l c h a p t e r , t h e assessment and m o d i f i c a t i o n o f i n t e r - p e r s o n a l r e l a t i o n s between husband and w i f e and t h e f a m i l y members a r e p r e s e n t e d a s t h e d i s t i n c t i v e a c t i v i t y o f t h e s o c i a l w o r k e r i n t h e h o s p i t a l s e t t i n g s The e x a m i n a t i o n o f t h i s c o n t r i b u t i o n , and o t h e r s made b y t h e s o c i a l worker t o t h e r e s o l u t i o n o f t h e types- o f problems under s t u d y , i s n o t r e p r e s e n t e d as e x h a u s t i v e . I t i s s e t out as an i n i t i a l d e s c r i p t i v e account o f t h e process i n h e r e n t i n t h e f o r m u l a t i o n o f a p r o f e s s i o n a l o p i n i o n , a n a c c o u n t w h i c h might be expanded i n further research.  iv  ACKNOWLEDGEMENTS I s h o u l d l i k e f i r s t t o acknowledge t h e debt o f s e l f and o t h e r o l d e r s t u d e n t s t o M i s s M a r j o r i e Smith,; who  myhas  f o r m u l a t e d p o l i c i e s f o r the S c h o o l o f S o c i a l Work w h i c h have c r e a t e d the o p p o r t u n i t y o f b r i n g i n g q u a l i f i c a t i o n s up t o d a t e . I s h o u l d l i k e a l s o t o e x p r e s s my g r a t i t u d e t o t h e Department o f V e t e r a n s A f f a i r s , n o t o n l y as an  impersonal  e n t i t y , which o f f e r s b o t h t a n g i b l e and i n t a n g i b l e encouragement t o r e s e a r c h i n many f i e l d s , but e s p e c i a l l y i n t h e  person  o f M i s s C e c i l Hay-Shaw, Head, M e d i c a l S o c i a l S e r v i c e , Shaughn e s s y H o s p i t a l , whose s t e a d y i n t e r e s t has. been most h e a r t e n i n g . I Tadyeh.,. who  s h o u l d l i k e t o thank my  t h e s i s a d v i s e r , Mrs. Mary  c r e a t e d an atmosphere i n w h i c h i t c o u l d be  felt  t h a t I had been h e l p e d t o do b e t t e r . L a s t I s h o u l d l i k e t o thank my c h i l d r e n , whose c o n c e r n f o r t h e p r o g r e s s o f my t h e s i s approached t h a t f e l t for their  own.  v  Errata " t h e r e f o r " should read  therefore  " m a r t i a l l i n g " should read  marshalling  SOCIAL JgQfiSERS* RfiCOMMBBPATIOBS OK IffBTITOTIOWAL CARE IH A VETERANS HOSPITAL An Examination o f the Factors Relevant t o S o c i a l Workers' Recommendations as t© t h e n e c e s s i t y o f I n s t i t u t i o n a l Care f o r M a r r i e d M a l e V e t e r a n s , w i t h S p e c i a l A t t e n t i o n t o t h e Assessment o f Marital Relationshipst Based o n 'ffiedieal S o c i a l S e r v i c e , Shaughnessy H o s p i t a l , , department o f V e t e r a n s A f f a i r s , Vancouver, B«C*  vi  Chapter I Generic Problems^Involved i n Helping P a t i e n t s t o Make D e c i s i o n s The c a r e o f the c h r o n i c a l l y i l l  p e r s o n , o l d o r young,  who by the n a t u r e o f h i s i l l n e s s , r e q u i r e s c o n s i d e r a b l e p h y s i c a l a s s i s t a n c e , and, o r n u r s i n g c a r e , has always been one  requiring  s p e c i a l a d a p t a t i o n s i n the c i r c l e o f t h o s e who r e m a i n w e l l and active.  T h i s c i r c l e may be t h e s m a l l one o f t h e immediate  f a m i l y , expanding by v a r i e d degrees t o t h e l a r g e r k i n s h i p o r c l a n group; i t may i n c l u d e the u n r e l a t e d s t r a n g e r , moved by custom o r p i t y , ( t h e "Good S a m a r i t a n ' ) ; i t may be an i m p e r s o n a l 1  group e n t i t y charged w i t h customary o r l e g a l r e s p o n s i b i l i t y t o p l a n f o r the h a n d i c a p p e d p e r s o n . of  t h e Eskimo, who,  We f i n d extremes:  from t h a t  i n t i m e s p a s t , f o r reasons c o n n e c t e d w i t h  the  s u r v i v a l o f t h e younger and ongoing group, exposed the a i l i n g ,  the  i n j u r e d , o r the o l d t o hasten death;^to that o f the French  e x p e d i t i o n who descended Annapurna, c a r r y i n g the b a r e l y l i v i n g , snow-blinded L a c h e n a l , w i t h r o t t i n g f r o z e n e x t r e m i t i e s , down some 28,000 f e e t o f mountain, f r o m i c e t o j u n g l e , s a v i n g him t o climb again.  A t e i t h e r extreme, t h e d e c i s i o n may be grounded i n  1. P r e s s n o t i c e s i n C a n a d i a n papers i n December 1955 t o l d o f a r e c e n t l e g a l ease i n the f a r N o r t h where a man was judged i n n o c e n t o f murder because he p e r m i t t e d h i s f a t h e r t o t a k e h i s own l i f e , i n t h e manner d i c t a t e d by t h i s custom.  2 w e l l thought out c o n v i c t i o n , which has shaped a f e e l i n g o f what i s r i g h t t o expect and r i g h t t o do* F o r any group t h e r e i s the burden and t h e p a i n o f t h e d e c i s i o n as t o what d i s p o s a l s h a l l be made o f t h e a i l i n g I n t h i s he s h a r e s , h i s own  person.  common humanity r e a c h i n g o u t t e n t a c l e -  l i k e t o < t h a t o f t h e group who  a l s o f a c e h i s dilemma, r e g a r d l e s s  o f t h e a c c e p t e d cause o f t h e i r degree o f i n v o l v e m e n t . I n t i m e s p a s t , t h e s i c k were c a r e d f o r a t home, i f by home one may mean a house, a h u t , a c a s t l e , an encampment round a f i r e ; o r p e o p l e — a mother, a w i f e , a t h i r d c o u s i n .  As  the p o e t may have more t o t e a c h us t h a n t h e s o c i o l o g i s t . Frost  1  i n h i s "Death o f t h e H i r e d Man"  usual, Robert  p u t s the f o l l o w i n g d i a -  logise i n t h e mouths o f t h e farmer and h i s w i f e : "Home i s t h e p l a c e , where, when you have t o go t h e r e , •They have t o t a k e you i n . I s h o u l d have c a l l e d i t - Something you somehow haven* t t o d e s e r v e . " The p e s t h o u s e , t h e h o s p i c e , developed f o r t h e c a r e o f t h o s e who had no homes.  M i x e d m o t i v e s may  be a s c r i b e d t o t h e  f o u n d e r s — i n p a r t t o remove i n f e c t e d and i n f e c t i n g b o d i e s t o where t h e y would n o t p o l l u t e the whole, as w e l l as b a s i c f o r the s u f f e r i n g .  concern  Our c i v i l i z a t i o n h a s moved on t o the concept  of a h o s p i t a l or nursing care i n s t i t u t i o n , giving care superior t o t h a t whieh can now be g i v e n i n most homes.  Times have  1. F r o s t , R o b e r t , C o l l e c t e d Poems. "The Death o f t h e H i r e d Man", New Y o r k r e p r i n t e d i t i o n , Garden C i t y P u b l i s h i n g Co. I n c . , 194-2, p. 53.  3  changed s i n c e t h o s e o f the E l i z a b e t h a n h o u s e w i f e  1  who  n  not  o n l y was e x p e c t e d t o know what t o do by way o f immediate  relief  and l a t e r n u r s i n g , b u t , w i t h no c h e m i s t s  clinics  1  shops o r r u r a l  t o h e l p h e r , she had t o produce from h e r own s t o r e r o o m whatever c o r d i a l s , m e d i c i n e s , p u r g e s , s p l i n t s and bandages t h e o c c a s i o n required."  So f a r have we moved from t h e e a r l i e r i d e a o f t h e  home as t h e l o g i c a l and b e s t p l a c e t o c a r e f o r the weakened member o f s o c i t y , t h a t we sometimes have d i f f i c u l t y i n a r r a n g i n g f o r a p a t i e n t s r e t u r n t o h i s home from the h o s p i t a l . 1  Some have l a u g h e d a t , as p r i m i t i v e , the A f r i c a n s brought" t h e i r s i c k t o be c u r e d by Dr. A l b e r t S c h w e i z e r . d i d n o t l e a v e them i n t h e h o s p i t a l , d e t a c h e d from.the  who  They  family  c i r c l e , b u t remained, crouched by t h e b e d s i d e s , t o cook f o r and tend t h e i r s i c k .  They had found a way o f combining the v i r t u e s  o f f a m i l y a f f e c t i o n and s c i e n t i f i c s k i l l s i n t o an i n t e g r a t e d service. C y r i l E. W a d d i l o v e , o f the S o c i e t y o f F r i e n d s , (Quakers) s p e a k i n g i n Vancouver d u r i n g the month o f December, 1955, a t a p u b l i c m e e t i n g , t o l d o f t h i s u n i v e r s a l problem o f the c a r e o f the s i c k , as he had observed i t i n a d i s r u p t e d K o r e a , w i t h hordes o f r e f u g e e s d i s p l a c e d by a N o r t h - S o u t h  conflict,  many u r g e n t l y r e q u i r i n g s k i l l e d l o n g - t e r m m e d i c a l c a r e .  There,  1. H o l e , C h r i s t i n a , The E n g l i s h Housewife i n t h e S e v e n t e e n t h C e n t u r y . C h a t t o & Windus, London, 1953, p. 79.  4 as i n A f r i c a , i t had been customary f o r the. f a m i l y t o accompany the i l l  p e r s o n t o h o s p i t a l , b u t some h a d t r a v e l l e d so f a r t h a t  t h e y n o t o n l y had no immediate f a m i l y , b u t no member o f t h e l a r g e c l a n k i n s h i p system t o o f f e r such s e r v i c e . had t o be i m p r o v i s e d t o meet t h e need.  Nursing service  I t i s of interest that,  i n p l a n n i n g f o r t h e f u t u r e , d e s p i t e t h e temporary arrangements t h a t were n e c e s s a r y due t o wartime f a m i l y d i s r u p t i o n s , t h e y e v i n c e d a s e t t l e d d e t e r m i n a t i o n t o r e t u r n t o t h e f o r m e r system o f f a m i l y c a r e f o r t h e f e e d i n g and n u r s i n g o f t h e p e r s o n i n hospital. C u r r e n t Programs We see t h a t a t v a r y i n g t i m e s and p l a c e s and i n v a r y i n g c u l t u r e s t h e problem o f t h e b e s t c a r e f o r t h e a i l i n g h a s i n v o l v e d d e c i s i o n s , n o t o n l y f o r t h e p e r s o n i n need o f c a r e , b u t f o r t h e f a m i l y and t h e community. On t h i s c o n t i n e n t t h e r e h a s been a r e v e r s a l o f t h e p r o c e s s r e f e r r e d t o above, o f t h e home people g o i n g t o t h e h o s p i t a l with the p a t i e n t , i n the "Montefiore plan" o f h o s p i t a l home c a r e , where arrangements a r e made, i n s e l e c t e d c a s e s , f o r h o s p i t a l s e r v i c e s , m e d i c a l , n u r s i n g , and a n c i l l a r y , t o be g i v e n t o t h e p a t i e n t i n h i s own home.  1  The i n t r o d u c t i o n o f such a p l a n  has been under d i s c u s s i o n i n Vancouver r e c e n t l y , by t h e H e a l t h  1. B l u e s t o n e , E.M., M.D., Minna F i e l d , e t a l j Home C a r e — O r i g i n . O r g a n i z a t i o n and P r e s e n t S t a t u s o f t h e E x t r a m u r a l Program o f M o n t e f i o r e H o s p i t a l . M o n t e f i o r e H o s p i t a l , New Y o r k C i t y , 1949.  5 D i v i s i o n o f t h e Community Chest and C o u n c i l . Throughout Canada, f a m i l i e s r e q u e s t c o u n s e l l i n g a s t o how t o p l a n f o r c h r o n i c a l l y i l l o r h a n d i c a p p e d , o l d o r young p e r s o n s , whom i t t a s k s t h e r e s o u r c e s o f the home t o c a r e f o r . The d o c t o r ; t h e clergyman;  the p u b l i c h e a l t h nurse; the s o c i a l  worker i n a r e f e r r a l c e n t r e , f a m i l y agency, h o s p i t a l o r p u b l i c w e l f a r e department a l l may be c a l l e d on f o r a d v i c e i n such situations. I n g e n e r a l , t h e a l t e r n a t i v e s t o home c a r e a r e i n f i r m a r i e s , r e s t homes and n u r s i n g homes.  As t h e l i t e r a t u r e i s r e -  v i e w e d , f o r example, t h e 54-5 p r e c i s d e t a i l e d i n " C h r o n i c  Illness",  a p u b l i c a t i o n o f t h e U n i t e d S t a t e s P u b l i c H e a l t h S e r v i c e s , we f i n d t h a t t h e t e r m i n o l o g y v a r i e s i n d i f f e r e n t s t a t e s and p r o v i n c e s on t h i s c o n t i n e n t , b u t t h e r e s o u r c e s may be s i m i l a r l y grouped. A check w i t h those charged w i t h t h e enforcement o f the W e l f a r e I n s t i t u t i o n s L i c e n s i n g A c t o f t h e P r o v i n c e o f B r i t i s h Columbia shows t h a t t h e y r e c o g n i z e o n l y two "types o f c a r e . P r i v a t e h o s p i t a l s are l i c e n c e d t o provide care f o r m e d i c a l , c o n v a l e s c e n t a n d . c h r o n i c p a t i e n t s , and must have a graduate nurse i n attendance  a t a l l t i m e s , as t h e p a t i e n t s  admitted require s k i l l e d care.  B o a r d i n g homes a r e a l s o l i c e n c e d  under t h e p r o v i n c i a l a c t ; these may be known a s n u r s i n g homes, o r r e s t homes t o the. g e n e r a l p u b l i c , and may bave, b u t a r e n o t o b l i g a t e d t o have a t r a i n e d n u r s e o n t h e s t a f f .  Practical  n u r s e s o r s k i l l f u l l a y persons m i g h t g i v e t h e s o r t o f c a r e w h i c h  6 i s n e c e s s a r y f o r persons a d m i t t e d , who require considerable  physical  a r e a m b u l a t o r y , but  assiatance.  I n a d d i t i o n , c e r t a i n b o a r d i n g homes, l i c e n c e d by c i t y as l o d g i n g h o u s e s , may s e r v i c e to o l d e r persons. Infirmary for  and  the  o f f e r a tray service or special Such i n s t i t u t i o n s as the M a r p o l e  the Kamloops Home, a r e p r o v i n c i a l i n s t i t u t i o n s  the c a r e o f c h r o n i c a l l y d i s a b l e d p e r s o n s , and  under the L i c e n s i n g  Act.  c a r e o f the c h r o n i c a l l y i l l  do n o t  come -  A Committee o f the Community C h e s t  and C o u n c i l o f G r e a t e r Vancouver, s t u d y i n g  bed  may  f a c i l i t i e s fofe the  i n the a r e a , has  recommended a  500-  i n s t i t u t i o n f o r such p a t i e n t s * As few f a m i l i e s can a f f o r d t h e c o s t o f p r i v a t e l y  a r r a n g e d c a r e on a c o n t i n u i n g  b a s i s , t o s e r v e the needs o f i n -  f i r m persons, s o c i a l workers i n p r i v a t e agencies, m u n i c i p a l w e l f a r e departments and i n t h i s province,  i n the p r o v i n c i a l S o c i a l W e l f a r e B r a n c h ,  a r e o f t e n approached r e g a r d i n g  planning.  S o c i a l w o r k e r s and o t h e r s a c t i n g as a r e s o u r c e t o f a m i l i e s i n t h i s dilemma must have m e d i c a l i n f o r m a t i o n  as t o the k i n d o f c a r e  r e q u i r e d , as a b a s i s from which t o e v a l u a t e c r i t i c a l l y t h e s o u r c e s o f the f a m i l y .  re-  Prom the l a r g e volume o f l i t e r a t u r e  about the m e d i c a l problems o f c h r o n i c a l l y d i s a b l e d p e r s o n s  and  the s o r t s o f i n s t i t u t i o n s r e q u i r e d t o meet t h e i r needs, i t would seem t h a t elsewhere i n Canada and on t h i s c o n t i n e n t , much s c r e e n i n g o f a p p l i c a t i o n s i s n e c e s s a r y , as i n s u f f i c i e n t beds a r e a b l e t o meet the need.  avail-  L i t t l e i s b e i n g w r i t t e n , however, about  7  the n a t u r e o f t h e d e c i s i o n a s t o whether such a p p l i c a n t s , I f m a r r i e d men, may he c a r e d f o r a t home. S o c i a l Workers i n H o s p i t a l s P r o f e s s i o n a l l y , t h e r o l e o f s o c i a l workers i n h o s p i t a l s has  been d e s c r i b e d  as f o l l o w s :  ... . t h e m e d i c a l s o c i a l worker I s a p e r s o n w i t h knowledge and u n d e r s t a n d i n g o f t h e s o c i a l s e r v i c e s , o f community and o f human needs and a s p i r a t i o n s , who t h r o u g h t r a i n i n g h a s d e v e l o p e d s k i l l s i n h e l p i n g p e o p l e t o l i v e w i t h themselves and w i t h each o t h e r , and who b r i n g s t h i s knowledge and s k i l l i n t o a s e t t i n g where t h e p r i m a r y f u n c t i o n i s t h e t r e a t s ment o f p h y s i c a l i l l n e s s . The s p e c i a l c o n t r i b u t i o n e f t h e s o c i a l worker i s i n t h e area o f the p a t i e n t s r e l a t i o n t o s o c i e t y and p a r t i c u l a r l y h i s f a m i l y . The s o c i a l worker i s t h e p e r s o n b e s t equipped t o a s s e s s t h e s o c i a l environment o f t h e p a t i e n t , t o understand the s t r e s s e s i n h i s l i f e outside the h o s p i t a l and what t h e s e may mean i n r e l a t i o n t o h i s i l l n e s s and h o s p i t a l i z a t i o n . The s o c i a l worker i s q u a l i f i e d t o d i a g n o s e t h e s o c i a l p r o b l e m , t o make recommendations w i t h r e g a r d t o a l l e v i a t i o n o f s t r e s s e s , e i t h e r by h e l p i n g t h e p a t i e n t towards a b e t t e r adjustment o r by r e l i e v i n g e n v i r o n m e n t a l pressures.» 1 1  This i s a current  statement on t h e p r e s e n t f u n c t i o n o f m e d i c a l  s o c i a l w o r k e r s i n modern h o s p i t a l s and c l i n i c s .  S o c i a l workers  have come i n t o h o s p i t a l s and i n s t i t u t i o n s f o r t h e c a r e o f t h e s i c k , l o n g a f t e r t h e s e e s t a b l i s h m e n t s h a d been g i v i n g what seemed t o be a rounded s e r v i c e .  They came because e x i s t i n g  services could not, i n a l l cases, restore the s i c k t o f u l l e s t function.  H i s t o r i a n s o f the varying  r o l e s o f s e c i a l workers  1. From an a d d r e s s g i v e n by l i s s C e c i l Hay-Shaw, Head, M e d i c a l S o c i a l S e r v i c e , Shaughnessy H o s p i t a l , t o a S o c i a l S e r v i c e S e c t i o n a l M e e t i n g , D i v i s i o n o f TB C o n t r o l , November 28, 1955, u n p u b l i s h e d .  8 agree t h a t m e d i e a l s o c i a l work i n h o s p i t a l s i n the U n i t e d S t a t e s may he t r a c e d back t o 1902 and i n England t o 1894*  I**  p a r t s o f Canada, and n o t a b l y i n V e t e r a n s H o s p i t a l s i n Canada a f t e r W o r l d War I , n u r s e s were used t o p e r f o r m d u t i e s w h i c h a r e now u s u a l l y viewed as p r o p e r t o s o c i a l w o r k e r s .  S o e i a l workers  i n o t h e r s e t t i n g s had been accustomed t o a p p r o a c h i n g t h e e v a l u a t i o n o f any i n d i v i d u a l ' s c a p a c i t y f o r b e t t e r f u n c t i o n i n g , by s t u d y o f h i s f a m i l y background and c u r r e n t p e r s o n a l s i t u a t i o n as t h e y i l l u m i n e d t h a t c a p a c i t y .  Working i n a h o s p i t a l d i d n o t ,  t h e n , c a l l f o r a new approach t o h e l p i n g p e o p l e .  The ways i n  w h i c h i l l n e s s c o u l d u p s e t normal p a t t e r n s , o r f u r t h e r d i s t u r b already d i s t u r b e d patterns o f adjustment, c a l l e d r a t h e r f o r heightening  o f e x i s t i n g s k i l l s a l r e a d y i n use.  worker l e a r n e d t h a t s h e  1  The s o e i a l  must i n t e r p r e t h e r g o a l s  and p r o c e d u r e s  t o t h o s e o t h e r members o f h o s p i t a l s t a f f s who were sometimes i m p a t i e n t o f t h e s o c i a l w o r k e r ' s c o n v i c t i o n as t o t h e " c l i e n t ' s p  r i g h t to self-determination,"  o r o f a slowness o f pace i n t h e  s o c i a l w o r k e r ' s e f f o r t s t o c a t a l y s e changes d e s i r a b l e i n v i e w of medical diagnosis.  The s o c i a l worker must p o i n t o u t , as  L o r n a C. Brangwin has s a i d w i t h r e s p e c t t o stSneial casework w i t h unhappy m a r i t a l s i t u a t i o n s :  v  1. I n Shaughnessy H o s p i t a l , m e d i c a l s t a f f may be male o r f e m a l e , as may s o c i a l w o r k e r s , F o r c o n v e n i e n c e o f reference., i n t h i s t h e s i s , s o c i a l w o r k e r s a r e f e f e r r e d t o as she and d o c t o r s as he* 2. C a n a d i a n A s s o c i a t i o n o f S o c i a l Workers, B..C. M a i n l a n d Branch,. E t h i c s Committee, March 29, 1954, P a r t I I . , i , (B) . 3. B r a n g w i n , L o r n a A., " M a r r i a g e C o u n s e l l i n g and t h e V i e w p o i n t o f t h e Caseworker", S o c i a l Casework, A p r i i t , 1955.  9 " I f we l o o k o n l y a t the d i s t u r b a n c e i n t h e m a r r i a g e , we a r e m e r e l y c o n s i d e r i n g a symptom. I f ways and means a r e p r e s c r i b e d t o a l l e v i a t e the symptom, w i t h o u t u n d e r s t a n d i n g t h e dynamic f o r c e s w h i c h have caused i t and w h i c h o p e r a t e i n i t s c u r r e n t m a n i f e s t a t i o n s , t h e n n o t h i n g o f l a s t i n g v a l u e can be accomplished . . . . Many (such) m a r r i a g e s a r e a d e q u a t e l y s a t i s f y i n g t o t h e p a r t n e r s o n l y as l o n g as a k i n d o f b a l a n c e can be m a i n t a i n e d i n m u t u a l g r a t i f i c a t i o n o f e m o t i o n a l needs." Those o f o t h e r p r o f e s s i o n a l d i s c i p l i n e s may  be w e l l aware o f  and g r a n t t o the body i t s r i g h t t o slow rythms o f a b e r r a t i o n and r e t u r n t o n o r m a l c y , i n response s t i m u l i , b u t may  to external.and i n t e r n a l  f e e l t h a t th$ s o c i a l worker's f u n c t i o n i s to  push o r p u l l the psyche i n t o p a t t e r n s seen as d e s i r a b l e by those o t h e r than the p a t i e n t .  The  s o c i a l worker's r o l e i s n o t  o n l y one o f d i r e c t s e r v i c e t o h e r c l i e n t , a s p a t i e n t , b u t o f i n t e r p r e t i n g how  the c l i e n t s needs, o t h e r than the p u r e l y 1  p h y s i c a l ones, can b e s t be met,  and a t what pace.  The d e v e l o p i n g acceptance  o f t h e u s e f u l n e s s o f the  medical s o c i a l worker i n h o s p i t a l s , both i n d i r e c t s e r v i c e to p a t i e n t s and i n c o n s u l t a t i o n t o o t h e r s t a f f , i s c l e a r l y s t a t e d i n W o r l d H e a l t h O r g a n i z a t i o n T e c h n i c a l R e p o r t S e r i e s , No.  22 o f  t h i s s e r i e s s t a t e s t h a t one m e d i c a l s o c i a l worker i s r e q u i r e d p e r 200 g e n e r a l h o s p i t a l a d m i s s i o n s o r 2000 o u t p a t i e n t s ( p e r annum); and t h a t two o r t h r e e p s y c h i a t r i c s o c i a l w o r k e r s a r e needed t o each p s y c h i a t r i s t o r one p e r 500 o u t p a t i e n t s ( p e r annum).  10 I n t h e "Standards f o r H o s p i t a l A c c r e d i t a t i o n " ,  the  a c c e p t e d b a s i s f o r r a t i n g Canadian and American h o s p i t a l s , s o c i a l s e r v i c e i s l i s t e d among " s e r v i c e s w h i c h may be m a i n t a i n e d . " The s t a n d a r d s a r e s e t o u t as f o l l o w s : "A. There s h a l l be an o r g a n i z e d department d i r e c t e d by a q u a l i f i e d m e d i c a l s o c i a l s e r v i c e w o r k e r , and i n t e g r a t e d w i t h o t h e r departments o f t h e h o s p i t a l . B. F a c i l i t i e s s h a l l be p r o v i d e d w h i c h a r e adequate f o r t h e p e r s o n n e l o f t h e department, e a s i l y a c c e s s i b l e t o p a t i e n t s and t o m e d i c a l s t a f f , and which assure p r i v a c y f o r i n t e r v i e w s . C. Records o f c a s e work s h a l l be k e p t . Such r e c o r d s s h a l l be a v a i l a b l e o n l y t o t h e p r o f e s s i o n a l p e r s o n n e l concerned, D. D e p a r t m e n t a l and i n t e r d e p a r t m e n t a l c o n f e r e n c e s s h a l l be h e l d p e r i o d i c a l l y . " As e a r l i e r mentioned, e s p e c i a l l y t r a i n e d n u r s e s were t h e f i r s t s o c i a l workers i n Canadian V e t e r a n s H o s p i t a l s , o p e r a t e d a f t e r World War I by t h e t h e n Department o f P e n s i o n s and N a t i o n a l H e a l t h .  A f t e r W o r l d War I I , i n 1945 a s u r v e y under-  t a k e n a t t h e r e q u e s t o f t h e Department o f V e t e r a n s A f f a i r s r e s u l t e d i n t h e s e t t i n g up o f t h e S o c i a l S e r v i c e D i v i s i o n w i t h i n the V e t e r a n s W e l f a r e S e r v i c e B r a n c h o f t h e Department o f V e t e r a n s A f f a i r s , w i t h the D i r e c t o r o f S o c i a l Service responsible to the D i r e c t o r General of Veterans Welfare S e r v i c e s .  At d i s t r i c t  l e v e l s , s o c i a l w o r k e r s r e s p o n s i b l e t o the D i s t r i c t S u p e r v i s o r s o f S o c i a l S e r v i c e were a p p o i n t e d t o work e i t h e r i n d e p a r t m e n t a l  1. B u l l e t i n o f t h e J o i n t Commission on A c c r e d i t a t i o n o f H o s p i t a l s . "Standards f o r H o s p i t a l A c c r e d i t a t i o n " , J a n u a r y 28, 1956. .. :  11 h o s p i t a l s , o r i n d i s t r i c t office's* I n t h e s p r i n g o f 1947, M e d i c a l S o c i a l S e r v i c e was s e t up w i t h Heads a t l o c a l l e v e l s r e s p o n s i b l e t o S u p e r i n t e n d e n t s o f h o s p i t a l s , but with professional r e s p o n s i b i l i t y also to the D i r e c t o r o f M e d i c a l S o c i a l S e r v i c e a t head o f f i c e L e v e l . co-operation  Close  w i t h s o c i a l workers i n d i s t r i c t o f f i c e s has  continued, w i t h a view t o g i v i n g the best p o s s i b l e s e r v i c e t o v e t e r a n s and p a t i e n t s as t h e y may s h i f t from one c a t e g o r y t o another.  F u l l d e t a i l s as t o t h e i n i t i a l and t r a n s i t i o n s t a g e s  o f t h e s e r v i c e and i t s s t a t u s w i t h i n Shaughnessy H o s p i t a l i n p a r t i c u l a r have been s e t o u t i n a r e c e n t t h e s i s by M i s s Clohosey, " S o c i a l I m p l i c a t i o n s o f Readmissions o f Veteran P a t i e n t s t o Shaughnessy H o s p i t a l , DVA".  1  W i t h r e s p e c t t o m e d i c a l s o c i a l work, a s i n o t h e r p r o f e s s i o n a l s p e c i a l i z a t i o n s , t h e g o a l o f a d m i n i s t r a t i o n h a s been t o s e t up f o r t h e v e t e r a n t h e most f u l l y modem and a c c e p t a b l e treatment f a c i l i t i e s . . Shaughnessy H o s p i t a l Shaughnessy H o s p i t a l , a 1200 bed h o s p i t a l s i t u a t e d i n Vancouver, B.C., i s a d m i n i s t e r e d  by t h e t r e a t m e n t S e r v i c e s e f  "Va" D i s t r i c t , t h e Department o f V e t e r a n s A f f a i r s .  Active  treatment i s o f f e r e d t o veterans o f v a r i e d c a t e g o r i e s , t o the R o y a l C a n a d i a n Mounted P o l i c e , t o c e r t a i n I n d i a n s and M a r i n e r s ,  1. 195/4*  M a s t e r o f 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.C.,  12 and t o a c t i v e s e r v i n g p e r s o n n e l i n the t h r e e armed f o r c e s . " I n s t i t u t i o n a l c a r e " , f o r m e r l y known as C l a s s 6 c a r e , hut as S e c t i o n 29 c a r e ,  1  i s a v a i l a b l e to c e r t a i n veterans.  now  Without  g o i n g i n t o the i n t r i c a c i e s o f r u l i n g s on e l i g i b i l i t y , i t may s t a t e d i n a g e n e r a l way  t h a t v e t e r a n s who  t h e a t r e o f a c t u a l war, o r who p e n s i o n , may  have had  be  service i n a  are i n r e c e i p t o f d i s a b i l i t y  be e l i g i b l e for, t h i s c o n t i n u i n g type o f c a r e *  If  m e d i c a l o p i n i o n shows t h a t t h e p a t i e n t ' s c o n d i t i o n w a r r a n t s i t , t h i s may  be g i v e n i n an a c t i v e treatment bed, w i t h i n the main  permanent b u i l d i n g s o f the h o s p i t a l p r o p e r .  I f less close  m e d i c a l a t t e n t i o n and n u r s i n g and o r d e r l y s e r v i c e i s i n d i c a t e d , the p a t i e n t may  be accommodated i n one o f t h r e e f a c i l i t i e s .  The  f i r s t group, commonly known as " t h e e x t e n s i o n " , i s a number o f army h u t s , on t h e grounds o f the h o s p i t a l proper*  Some o f t h e  p a t i e n t s p l a c e d i n t h e s e wards a r e f a i r l y m o b i l e , a b l e t o l e a v e t h e ward and t a k e meals i n the a t t a c h e d d i n i n g room, t o l o u n g e i n the r e c r e a t i o n room, o r go t o the Red C r o s s Lodge on grounds; o t h e r s may  be e o n f i n e d t o bed.  the  H i c r o f t , the f o r m e r  home o f t h e l a t e G e n e r a l Macrae, a handsome mansion s e t on s l o p ing  ground, w i t h i n the c i t y and c l o s e t o shops and t r a n s p o r t a t i o n ,  o f f e r s accommodation t o more m o b i l e p e r s o n s who stairs*  can manage t o use  The George Derby H e a l t h and O c c u p a t i o n a l C e n t r e , i n a  ,1. O f f i c e C o n s o l i d a t i o n ; R e g u l a t i o n s under t h e D e p a r t ment o f V e t e r a n s A f f a i r s A c t ; V e t e r a n s Treatment R e g u l a t i o n s , 1955. See Appendix A f o r E x c e r p t re«Domiciliary Care".*.  13 wooded s e t t i n g , i n Burnaby, c o n s i s t s o f detached h u t s ,  with  c e n t r a l d i n i n g and r e c r e a t i o n h a l l , a d j o i n i n g workshops and other f a c i l i t i e s . : convalescent  A f t e r W o r l d War I I , t h i s was u s e d as a  and r e - t r a i n i n g c e n t r e .  S i n c e , t h e need f o r t h i s  s e r v i c e h a s d e c l i n e d , b u t i t i s a v a i l a b l e t o meet t h i s need and  still,  so may house p e r s o n s r e c o v e r i n g from s e r i o u s i l l n e s s o r  i n j u r y , f o r b r i e f s t a y , as w e l l a s those r e c e i v i n g i n s t i t u t i o n a l care. Persons r e c e i v i n g i n s t i t u t i o n a l care a r e n o t necessari l y o l d , b u t may be young v e t e r a n s w i t h o u t p o s s i b i l i t y o f home c a r e , who a r e i n such p h y s i c a l c o n d i t i o n t h a t t h e y cannot be c a r e d f o r i n o r d i n a r y b o a r d i n g homes.  Nevertheless,  t h e con-  d i t i o n s l e a d i n g t o a need f o r i n s t i t u t i o n a l c a r e a r e most a p t t o o c c u r i n t h e o l d e r age g r o u p s .  As t h e v e t e r a n s o f W o r l d War  I advance i n y e a r s , many o f them a r e p o t e n t i a l c a n d i d a t e s f o r continuing  care. A r e c e n t a n n u a l s t a t i s t i c a l count shows an i n t e r e s t i n g  trends  1  "At m i d n i g h t on 31st. M a r c h , 1954, t h e D e p a r t m e n t a l I n p a t i e n t Census f o r t h e whole o f Canada numbered ,10,501 . . . * The p a t i e n t s ranged i n age from 16 t o 99 y e a r s w i t h an average age o f 56 and a median age o f 60. The g r e a t e s t number, 1 , 3 4 4 p r 12.8 p e r c e n t o f t h e t o t a l were i n t h e 65-69 age g r o u p . L e s s t h a n o n e - t h i r d were under 50 y e a r s o f age; o v e r oneq u a r t e r were 70 y e a r s o f age o r o v e r .  1. W i n f i e i d , G.A. and Wellwood, L., "An A n a l y s i s o f I n - p a t i e n t s Department o f V e t e r a n s A f f a i r s a t m i d n i g h t , 31 M a r c h , 1954"j C a n a d i a n M e d i c a l S e r v i c e s J o u r n a l . V o l * X I . No, 7, J u l y - A u g u s t 1955.  14 The t o t a l f i g u r e i s a l m o s t i d e n t i c a l w i t h t h a t f o r 1950 (10,491). . . . The average age o f p a t i e n t s ^shows an i n c r e a s e o f f o u r y e a r s and t h e median age o f f i v e y e a r s . I n 1950, 38 p e r c e n t were l e s s t h a n 50 y e a r s o f age and o n l y 17.1 p e r c e n t were o v e r 70." The Department o f Veteran's A f f a i r s ' "Va"  District,  i n c l u d i n g t h e V i c t o r i a s u b - o f f i c e as w e l l as t h e Vancouver o f f i c e , has a p p r o x i m a t e l y 10,000 v e t e r a n s i n r e c e i p t o f V e t e r a n s A l l o w a n c e . * These a r e v e t e r a n s o f c e r t a i n  War  service  c a t e g o r i e s , I f o v e r 60, o r younger I f c o n s i d e r e d unemployable. These a r e e l i g i b l e f o r t r e a t m e n t , i n c l u d i n g " s e c t i o n 29 c a r e " * i f indicated. also..  O t h e r s , i n a d d i t i o n t o t h e s e may  be  I n the l i g h t o f these f i g u r e s , i t i s understandable t h a t  r e q u e s t s f o r such c a r e must be c a r e f u l l y s c r e e n e d . who  eligible,  a r e l i t t l e h a n d i c a p p e d o r who  I f persons  c o u l d be accommodated o u t s i d e  a r e a d m i t t e d , t h e r e w i l l be no beds a v a i l a b l e f o r t h o s e u r g e n t l y r e q u i r e such c a r e .  The s c r e e n i n g t a k e s i n t o  who  account  b o t h the s t r i c t l y p h y s i c a l c o n d i t i o n o f t h e p a t i e n t and h i s s o c i a l p o t e n t i a l , s i n c e a knowledge o f b o t h i s r e q u i r e d i n good medicine. The S o c i a l Worker's R o l e The n a t u r e o f s o c i a l workerfel recommendations as t o t h e n e c e s s i t y f o r i n s t i t u t i o n a l c a r e i n t h i s h o s p i t a l may be b e t t e r u n d e r s t o o d i f one l o o k s i n i t i a l l y a t cases where the s o c i a l w o r k e r i s n o t asked t o share i n t h e d e c i s i o n .  1.  V e r b a l i n f o r m a t i o n from c l e r i c a l  section.  15 P u r e l y m e d i c a l c o n s i d e r a t i o n s may h o l d sway when t h e p h y s i c a l amount o f n u r s i n g c a r e i s c o n s i d e r a b l e , w i t h  frequent  a t t e n t i o n o f t h e s o r t w h i c h cannot be g i v e n by an u n t r a i n e d person.  Even t h e n t h e p a t i e n t may ichoose t o r e t u r n t o h i s home,  i f he i s a b l e t o p r o c u r e n u r s i n g o r o r d e r l y s e r v i c e .  These a r e  clearcut decisions. S i m i l a r l y , t h e s o c i a l worker may n o t be c a l l e d on t o share i n p l a n n i n g when i t i s o b v i o u s t o n u r s i n g and m e d i c a l s t a f f t h a t t h e man w i s h e s t o r e t u r n home, and t h a t he c a n r e c e i v e adequate c a r e t h e r e , d e s p i t e c o n t i n u i n g p h y s i c a l d i s a b i l i t y . Through c o n t a c t s w i t h t h e p a t i e n t and perhaps h i s w i f e a s w e l l , the d o c t o r o f t e n e v a l u a t e d s o c i a l c o n s i d e r a t i o n s , such a s l e v e l o f housing  accommodation, a b i l i t y t o f o l l o w d i e t , and t h e k i n d  o f care w h i c h c a n be a n t i c i p a t e d a t home. There a r e , however, a number o f t y p e s o f s i t u a t i o n s , e v a l u a t i o n o f w h i c h may c u l m i n a t e i n t h e d e c i s i o n t o g i v e o r w i t h h o l d i n s t i t u t i o n a l c a r e , where t h e s o c i a l worker may be c a l l ed on. A t l e a s t f o u r t y p e s may be d i s t i n g u i s h e d , as f o l l o w s : A.  I n t h e group sometimes r e f e r r e d t o a s " h o s p i t a l c l e a r -  ance", t h e p a t i e n t no l o n g e r r e q u i r e s a c u t e bed c a r e ; he may be r e f u s i n g t o r e t u r n home; o r he may be r e a d y t o r e t u r n home, b u t h i s w i f e may s t a t e t h a t she i s unable t o c a r e . f o r him. h e l p o f t h e s o c i a l w o r k e r , t h e reasons b e h i n d can be u n d e r s t o o d and a w e l l - f o u n d e d B,  With the  these a t t i t u d e s  d e c i s i o n made.  Cases a r e r e f e r r e d t o t h e s o c i a l worker a l s o , where a  s e r i e s o f admissions  have o c c u r r e d w i t h i n a d e q u a t e r e a s o n ,  from  16  t h e m e d i c a l v i e w p o i n t , so t h a t some s o c i a l o r p e r s o n a l i s suspected as b e i n g t h e r e a l cause.  reason  A solution i s often  f o u n d i n i n s t i t u t i o n a l c a r e , i f changes cannot be made t o p e r m i t t h e p a t i e n t s acceptance 1  C.  a t home.  S o c i a l w o r k e r s a r e asked t o e v a l u a t e p e r s o n a l a t t i t u d e s  and home c o n d i t i o n s where t h e p a t i e n t ' s h e a l t h i s such t h a t i t seems u n l i k e l y he c o u l d be c a r e d f o r a t home, b u t t h e d o c t o r h a s n o t had t h e f a c t s t o form t h e b a s i s o f an o p i n i o n . D.  I n some cases no f o r m a l r e f e r r a l may be made t o t h e  s o c i a l worker, requesting p a r t i c i p a t i o n i n the d e c i s i o n as t o the a l t e r n a t i v e o f home o r i n s t i t u t i o n a l c a r e , because t h e s o c i a l worker h a s e a r l i e r been i n v o l v e d w i t h t h e p a t i e n t o r h i s w i f e , on account o f problems, economic, p e r s o n a l o r o t h e r .  In  the p r o c e s s o f good normal c o - o p e r a t i o n between t h e p a t i e n t , h i s r e l a t i v e s , n u r s i n g and m e d i c a l s t a f f , and on t h e b a s i s o f i n f o r m a t i o n about the home s i t u a t i o n p r o v i d e d by t h e s o c i a l w o r k e r , I t becomes o b v i o u s i n t h e p o o l o f i n f o r m e d d e c i s i o n whieh i s u s u a l l y r e f e r r e d t o as "teamwork", t h a t t h e p a t i e n t s h o u l d go home, o r t h a t he s h o u l d remain f o r i n s t i t u t i o n a l c a r e .  The p r o p r i e t y o f  t h e s o c i a l w o r k e r ' s p a r t i c i p a t i o n and t h e v a l i d i t y o f t h e s o c i a l w o r k e r ' s o p i n i o n a r e i m p l i c i t i n t h e whole p r o c e s s , and may be most r e s p e c t e d when i t has n o t been f e l t n e c e s s a r y t o r e q u e s t them.  I n some such s i t u a t i o n s t h e s o c i a l worker may i n c o r p o r a t e  i n h e r w r i t t e n r e p o r t a recommendation r e g a r d i n g t h e need o f i n s t i t u t i o n a l c a r e , even b e f o r e t h e q u e s t i o n i s f o r m a l l y c o n s i d e r ed by m e d i c a l  staff.  17 D i r e c t r e f e r r a l s o f t h e above t y p e s o f s i t u a t i o n s t o t h e s o c i a l w o r k e r may come f r o m a v a r i e t y o f s o u r c e s :  the  p a t i e n t , o r members o f h i s f a m i l y q r c i r c l e o f f r i e n d s ; medical or nursing  s t a f f ; o t h e r ward s t a f f ; o u t s i d e  agencies.  R e f e r r a l s from p e r s o n s o t h e r t h a n d o c t o r s a r e c l e a r e d  with  medical s t a f f before a c t i o n i s taken. R e f e r r a l s from d o c t o r s may o r i g i n a t e on t h e s e r v i c e s o f m e d i c i n e , s u r g e r y , p s y c h i a t r y , o r any s p e c i a l i z e d s e r v i c e s . Prominent among t h e l a t t e r as a source o f r e f e r r a l s t o S o c i a l S e r v i c e , i s t h e Assessment and R e h a b i l i t a t i o n U n i t , ( i n f o r m a l l y known as "A and R ) , w h i c h h a d i t s o r i g i n i n a G e r i a t r i c Rett  s e a r c h p r o j e c t s e t up as a p i l o t s t u d y i n Shaughnessy H o s p i t a l i n 1951.  n  A and R" h a s i t s own s t a f f o f c o n s u l t a n t s  and i t s  own I n t e r n e , as w e l l as a r e c e p t i o n ward, b u t i t s s e r v i c e s a r e a v a i l a b l e throughout the h o s p i t a l .  I t s purpose i s t o s t i m u l a t e  the maximum o f a c t i v i t y , s o c i a l , economic, m e d i c a l and p e r s o n a l , among o l d e r p a t i e n t s and t h o s e younger ones who a r e s e v e r e l y handicapped.  Where t h e p a t i e n t h a s l i m i t e d r e m a i n i n g p o t e n t i a l ,  s o c i a l s e r v i c e i s o f t e n c a l l e d on t o a s s e s s t h e s o c i a l a s p e c t o f the s i t u a t i o n .  The I n f o r m a t i o n  t h u s g i v e n i s used as m a t e r i a l i n  the d e c i s i o n as t o whether i n s t i t u t i o n a l c a r e must be o f f e r e d . * 1. F o r "A and R" p u r p o s e s , f i v e s o c i a l c a t e g o r i e s have been e s t a b l i s h e d : Satisfactory family or friend relationships and accommodation a v a i l a b l e . Unsatisfactory family or friend relationships but accommodation a v a i l a b l e . Family, f r i e n d s o r l a n d l o r d accept, but unable t o o r s h o u l d n o t g i v e c a r e because o f poor h e a l t h o r u n s u i t a b l e accommodation. S e a s o n a l accommodation a v a i l a b l e w i t h f a m i l y o r friends.  W  o  family  o  r  f r i e n d s o r s u i t a b l e accommodation.  18  P a t i e n t s W i t h and W i t h o u t F a m i l i e s I n a c c e p t i n g r e f e r r a l s from any s o u r c e , t h e s o c i a l w o r k e r may toe e v a l u a t i n g many f a c t o r s , w i t h i n t h e s o c i a l a n d p e r s o n a l s i t u a t i o n o f t h e p a t i e n t . ' There a r e no a v a i l a b l e • f i g u r e s as t o t h e p r o p o r t i o n o f t h e g e n e r a l p a t i e n t p o p u l a t i o n who a r e m a r r i e d , o r o f s i n g l e s t a t u s , I n c l u d i n g widowed, d i v o r c e d o r s e p a r a t e d ; n o t does M e d i c a l S o c i a l S e r v i c e keep f i g u r e s w h i c h a r e s e g r e g a t e d  i n t h i s way.  itself  I t i s known t h a t  a c o n s i d e r a b l e p r o p o r t i o n o f t h e p a t i e n t s f o r whom i t i s n e c e s s ary to consider the p o s s i b i l i t y o f i n s t i t u t i o n a l care, a r e o f " s i n g l e " s t a t u s , t h a t i s t h e y do n o t have a w i f e who i s a t p r e s e n t concerned i n p l a n n i n g r e g a r d i n g them.  Some o f t h e s e ,  even men c o n s i d e r a b l y h a n d i c a p p e d , may go o u t t o " b a t c h " i n t h e i r homes o r i n f u r n i s h e d rooms; some go o u t t o p r i v a t e b o a r d i n g homes; some t o t h e homes o f m a r r i e d b r o t h e r s o r s i s t e r s , and daughters.  sons  I n the case o f the l a t t e r group, s p e c i a l  d i f f i c u l t i e s may a r i s e w h i c h c a l l f o r t h e s e r v i c e s o f t h e s o c i a l w o r k e r , among t h e s e , f e e l i n g s w i t h r e l a t i o n t o d a u g h t e r s ©in sonsi n - l a w a r e p r o m i n e n t , as i s t h e p h y s i c a l c h a r a c t e r o f t h e accommodation a v a i l a b l e * his  C o l o r i n g a t t i t u d e s t o t h e p a t i e n t and  i l l n e s s a r e t h e l o n g s t a n d i n g f e e l i n g s o f t h e f a m i l y , who may  n o t see h i m as a p e r s o n w o r t h y o f t h e i r s a c r i f i c e o f c o n v e n i e n c e and p r i v a c y .  There a r e many e v i d e n c e s  t h a t on t h i s  continent  the c i r c l e o f f a m i l y r e s p o n s i b i l i t y h a s narrowed; o c c a s i o n a l l y a n i e c e o r nephew appears w i t h a r e a l sense o f o b l i g a t i o n t o a n  19 uncle, yet on the other hand i n some families there may be very l i t t l e acknowldgement of o b l i g a t i o n to a brother or father. "Single" patients may neejl the s o c i a l worker's help i f they f e e l rejected by family and f r i e n d s , so that they must accept i n s t i t u t i o n a l care, and t h e i r problems require the exercise o f good judgement and s k i l l . I t i s , however, with the problems o f married veterans who may require i n s t i t u t i o n a l care that the present study coneeras i t s e l f .  S o c i a l workers who have had h o s p i t a l experience,  are impressed.by the q u a l i t y o f the enduring personal r e l a t i o n ship between man and wife, as i t a f f e c t s the p r o b a b i l i t y o f the man's return to h i s home as opposed to h i s acceptance o f I n s t i t u t i o n a l care.  A man may be seriously  handicapped,  p h y s i c a l l y or mentally or both, to the extent that responsibi l i t y f o r h i s care i n the home would be extremely onerous, and yet,  where the relationship has been a rewarding one , h i s  return home I s welcomed.  This i s apt to be so, even i f the  wife i s i n f r a i l health, o r economically burdened. the man may be veiy l i t t l e handicapped,  Conversely,  r e a l i s t i c a l l y speaking*,  as established by,medical investigation, but i f ttoe r e l a t i o n s are poor, the p o s s i b i l i t y o f h i s return home w i l l be c a l l e d into question.  His wife, o r the patient himself, may be able  to voice the r e a l state o f f e e l i n g , or may rather exaggerate the quality or degree o f the patient's physical d i f f i c u l t i e s , or o f h i s wife's health. his  Other "reasons" may be found why  return home i s Impossible, these being brought forward by  20  either partner.  An attack may  be made on DVA  partmental regulations, as a cover.  care or  With m r r i e d a  de-  veterans,  i n short, i t i s frequently the degree of physical handicap, but also often the state of the marriage which determines the p o s s i b i l i t y of home care.  The  stereotype of the married  state accepted i n the community (even i n these days of more ready access to hospitals) i s that of the loving wife  who  awaits eagerly the return of the handicapped person, i n order that he may  be offered the comforts of home.  I t i s therefore  often with l o s s of face, and beclouded by r a t i o n a l i z a t i o n and projection, that the persons whose f e e l i n g s are so deeply i n volved can be brought to voice them.  W i l l I t be h e l p f u l or  h u r t f u l to a s s i s t them to "face the facts"?  Have they  s u f f i c i e n t strength and f l e x i b i l i t y to accept help i n changing i  t h e i r attitudes, especially when contending with some degree of i l l n e s s or d i s a b i l i t y ?  These are the decisions the doctor  asks the s o c i a l worker to a s s i s t i n . Given a highly d e t a i l e d diagnosis and prognosis on the physical state of the patient and perhaps that of h i s wife also, i f her health has beai c a l l e d into question;  given ( i f  occasionally there i s time to secure i t ) a quite f u l l background regarding  the patient and h i s wife, who  wxild venture to p r e d i c t  the quality of the f l i c k e r of decision summarized as "Yes" "No",  that i s generated out of the past relationships of  and wife?  The decision may  or man  sometimes be unspoken, sometimes  l i t e r a l l y shouted, but out of what has i t grown?  Is i t "Good  21 medicine", "good s o c i a l work", good s e r v i c e to the p a t i e n t to t r y to change the d e c i s i o n ? we  I f we  t r y to change i t ,  can  succeed? These questions  which a r i s e from i t ,  on s o c i a l p r o g n o s i s  and  the  concerns  formed the g e n e s i s o f t h i s study.  In  examining them, I t i s n e c e s s a r y t o re-examine p r o f e s s i o n a l p r i n c i p l e s and l i t e r a t u r e ,  to r e ^ t e s t t h e i r v a l i d i t y  a u t h o r i t y i n t h i s frame o f  reference.  and  Literature "The  F a m i l y H e a l t h Maintenance Demonstration, a  c o n t r o l l e d long-term i n v e s t i g a t i o n o f f a m i l y h e a l t h "  1  out, as d i d the p r o j e c t c e n t r e d i n the Peckham H e a l t h 2 i n England New  to study h e a l t h i n normal, w e l l f a m i l i e s ;  sets Centre The  York p r o j e c t u t i l i z e d the s e r v i c e s o f a team o f p h y s i c i a n s ,  p e d i a t r i c i a n s , p u b l i c h e a l t h nurses,  p s y c h i a t r i c s o c i a l workers*  a p s y c h i a t r i s t , p s y c h o l o g i s t s and a c o n s u l t a n t s o c i a l to study a group of f a m i l i e s who  were checked, e v e n t u a l l y ,  a group o f p r e - s e l e c t e d and u n t r e a t e d S t i b e r ' s chapter  scientist against  control families, Charlotte  on the f u n c t i o n s and f i n d i n g s o f the  social  worker n o t e s (Page 56) t h a t "The o v e r a l l p i c t u r e o f r e l a t i o n s h i p between husband and w i f e r e v e a l s much c o n f u s i o n , d i s s a t i s f a c t i o n , and r e s i g n a t i o n . Few o f the a d u l t s appeared to be mature enough to support the demands o f such a  1. "The Family H e a l t h Maintenance Demonstration, a c o n t r o l l e d long-term i n v e s t i g a t i o n o f f a m i l y h e a l t h " , P r o ceedings o f a Round Table a t the 1953 Conference o f the M i l b a n k Memorial Fund, M i l b a n k Memorial Fund, New York, 1954 2. Pearse, Innes, H., M,D. and Crocker, Lucy H* the Peckham Experiment, a Study i n the L i v i n g S t r u c t u r e o f S o c i e t y , London, A l l e n & Unwin, 1943  22  r e l a t i o n s h i p . Men were on t h e whole, p a s s i v e , immature, undependable i n an e m o t i o n a l sense. Women were more a g g r e s s i v e , immature, u n a b l e t o a c c e p t t h e f e m i n i n e r o l e o f w i f e and mother. Disappointment i n t h e i r e x p e c t a t i o n s o f the possi b i l i t i e s o f t h e r e l a t i o n s h i p was common* The r e s i g n a t i o n comes, I b e l i e v e , from some awareness w h i c h t h e y have t h a t some o f the d i f f i c u l t y r e s t s w i t h t h e m s e l v e s and t h a t a n o t h e r o r d i f f e r e n t p a r t n e r would n o t b r i n g about a d i f f e r e n t r e l a t i o n ship." . . . because t h e i r own i d e n t i f i c a t i o n s a r e n o t w e l l founded t h e y cannot t o l e r a t e o r t o l e r a t e u n e a s i l y the t r i p l e s t r a i n o f b e i n g i n d i v i d u a l , spouse and p a r e n t . " n  T h i s i s from a s t u d y o f n o r m a l , f u n c t i o n i n g f a m i l i e s , chosen from a l a r g e random s a m p l i n g .  I f these are the a t t i t u d e s  towards the rewards o f t h e m a r r i e d s t a t e , what s t r e n g t h s a r e t h e r e t o draw on when age and i l l n e s s p l a c e a d d i t i o n a l  burdens  on t h e r e l a t i o n s h i p ? R . M a r g a r e t Cork says o f the w i v e s o f a l c o h o l i c s ; " T y p i c a l o f t h e s e women i s t h e v e r y dependent o r Immature w i f e who i s m a r r i e d t o a man w i t h such g r e a t needs o f h i s own t h a t he i s unable t o meet hers. As a r e s u l t , c o n s t a n t h u r t and f r u s t r a t i o n i s s u f f e r e d by b o t h p a r t n e r s and t h e b a s i c o r normal problems o f m a r r i e d l i f e a r e n e v e r g r a p p l e d w i t h . " :  1  A s i m i l a r s e t o f c o n d i t i o n s i s found where i l l n e s s o f a c h r o n i c o r i r r e v e r s i b l e n a t u r e i n c r e a s e s t h e dependency needs o f one o r b o t h p a r t i e s .  A "dependent o r immature' w i f e "  may have had a s a t i s f a c t o r y r e l a t i o n s h i p throughout h e r m a r r i e d l i f e , but toe u n a b l e t o t o l e r a t e ( i f unhelped) t h e r e v e r s a l o f r o l e s which d e v e l o p s i f the husband becomes e n f e e b l e d due t o age and i l l n e s s , .  C o r r e s p o n d i n g l y , t h e husband has a sense o f  1.. C o r k , R. M a r g a r e t , paper "Casework i n a Group S e t t i n g w i t h Wives o f A l c o h o l i c s " , quoted i n C o n c e r n i n g F a m i l i e s and C h i l d r e n . V o l . 4, No. 5, December 1955, t h e F a m i l y and C h i l d Welfare D i v i s i o n , Canadian W e l f a r e C o u n c i l .  23 f r u s t r a t i o n , not only i n h i s feelings of f a i l u r e i n being unable longer to be the strong man on whom h i s wife leans, but i n h i s own unmet needs, i n not having a strong, managing or even cooperative wife who caigiye. him solace i n h i s dependent state. Even where there has been maturity^ enfeebled health i n both may produce i n each the i l l u s i o n that the other i s f u l l y incompetent and that he (or she) i s the upholder; or a l t e r n a t i v e l y may make tolerable an admission of the quasidependency o f the self*  Marked ambivalence may be notable i n  these situations; a l t e r n a t i o n of pride i n being able to carry on, aad o f hatred o f the o b l i g a t i o n to do so, may produce marked mood swings.  The man who must go home from hospital.,  not to be tended as an i n v a l i d , but to discharge the duties of a mother with respect to an a i l i n g and c h i l d l i k e wife, needs the support o f the s o c i a l worker i n the r o l e , even though i t be one the patient has f r e e l y chosen. In a number o f applications f o r i n s t i t u t i o n a l care, the s o c i a l worker who i s asked to make a s o c i a l assessment observes some degree o f "marital d i f f i c u l t y " as a factor* Florence H o l l i s has said: "The degree o f c o n f l i c t i n marriage, i n other words, i s not an accurate measure of the fundamental d i s s a t i s f a c t i o n s within the marriage nor of the wish to terminate i t . Some marriages break up after r e l a t i v e l y l i t t l e overt expression o f h o s t i l i t y , while others continue to e x i s t through violent b a i l i e s . In order to understand the dynamics o f a given marriage adjustment, we must seek to understand the personalities involved  24 as w e l l as s i t u a t i o n a l f a c t o r s t h a t may be , pressing. The more f u l l y we understand persona l i t y development and these i n t e r l o c k i n g f o r c e s the more completely can we come to understand the s t r e s s e s and s t r a i n s t h a t produce m a r i t a l d i s harmony. "• L  Whether o r not the disharmony i s marked,, i t i s seldom t h a t the p a t i e n t o r h i s w i f e ask o v e r t l y f o r h e l p w i t h t h i s such.  I f the  s i t u a t i o n I s o f the  s o r t where the r e l a t i o n s h i p  i s almost completely unrewarding, the p o s s i b i l i t y o f a l care because o f the p a t i e n t ' s health.needs ( l i k e s e p a r a t i o n Involved  threatening  institutionthe  i n wartime s e r v i c e w i t h the armed  would make a s o c i a l l y a c c e p t a b l e to have the  as  solution.  forces)  I t i s , then,  r i g h t to t h i s s o l u t i o n brought i n t o  question. I n any h o s p i t a l , a t r o u b l e d w i f e , faced w i t h par-» t i c i p a t i o n In the d e c i s i o n as to whether o r not h e r husband home, may  be p l e a s e d  t h a t someone, d o c t o r  s o c i a l worker, reaches out to l e a r n how problem.  She may  take  or  she f e e l s about  the  w e l l , however, f a c e the i n t e r v i e w w i t h f e a r s  t h a t the h o s p i t a l s t a f f a r e "on the T h i s f e a r may  she w i l l  side o f  the s i c k p e r s o n .  loom p a r t i c u l a r l y l a r g e i n a v e t e r a n s ' h o s p i t a l ,  where the m e d i c a l setting,, i n p a t i e n t o r o u t p a t i e n t , forms p a r t o f a l a r g e r framework o f s e r v i c e s a v a i l a b l e to the p a t i e n t  1. H o l l i s , EloBenee;, Women i n M a r i t a l C o n f l i c t F a m i l y S e r v i c e A s s o c i a t i o n o f America, New York, 1949;, pp. 18-19  as  25 a veteran.  This larger setting may be the source of income,  such as d i s a b i l i t y pension, Treatment Allowances, or War Teterans Allowance, so that f e a r of economic loss may increase the burden.  further  The wife or the patient may have been  t o l d by the Legion or regimental group that the patient has the "right  0  to continuing care, i f he wishes i t , and so may  condider  there i s discrimination when the a l t e r n a t i v e of returning home Is c a l l e d i n t o discussion. P a r t i c u l a r care i n establishing a relationship  may  be needed, then, i n the s o c i a l worker whose p a r t i c u l a r goal i s the easing of a marital d i f f i c u l t y , as she approaches the problem through p a r t i c i p a t i o n i n the decision of the itiblent and h i s wife and the doctor as to plans f o r the patient* s future care. The medical s o c i a l worker does not have an easy entree totiae treatment of a marital problem when i t i s t i e d to the threatening dilemma, " W i l l you or w i l l you not care f o r your sick husband at home?"  Resentment colours one answer and  g u i l t the other, each c a l l i n g up i t s defences and r a t i o n a l i z a t i o n s . I f the marriage has been markedly unhappy, the threatening death wish may be very near the surface. er needs to be aware ©f how i s already a problem.  The medical s o c i a l work-  the f a c t of i l l n e s s heightens what  She needs also to be aware of the usual  methods c a l l e d into use by those of her profession i n dealing with marital c o n f l i c t , where the parties have v o l u n t a r i l y sought help.  26 In what way do s o c i a l workers usually a s s i s t i n the resolution or diminution of marital d i f f i c u l t i e s ? H o l l i s "Women i n Marital G a n f l i c t ^ m a y be taken as a standard reference.  In the chapter* "The Range of Casework Treatment"  she suggests a c l a s s i f i c a t i o n of ways of helping "based p r i n c i p a l l y on the means by which the change was about ;; 11  modifying the environment!  brought  psychological support;  clarification;-, i n s i g h t ; the elierit-worker relationship; and the d i f f e r e n t i a l application of these processes.  These are  brought into play as an e f f o r t i s being made to f i n d the roots of the disharmony.  Miss H o l l i s says, (Page 14)  "Object love i s that most e s s e n t i a l of a l l capacities, the a b i l i t y t r u l y to appreciate and love other people, with concern not only f o r what the s e l f can gain, but also f o r the well-being of the other person* To have that sense of fundamental well-being c a l l e d happiness, the adult must be able to give love as w e l l as to receive i t , " The s o c i a l w o r k e r s estimate of the strengths and weaknesses of the marriage, must then involve some minimum knowledge of title persons involved i n i t .  The need f o r s k i l l  and r a p i d i t y of formulation are demanded by and inherent i n the setting, where h o s p i t a l beds must be kept f o r a c t i v e medical treatment, not f o r the slow processes o f change involved i n dealing with friction-rubbing p e r s o n a l i t i e s . ©f the research project which formed the basis f o r her book, Miss H o l l i s says (Page 9)  1*  Ibid  27 "The o v e r a l l i m p r e s s i o n l e f t by t h e f i n d i n g s Is that personality factors l a y a t the root o f , t h e m a r r i a g e c o n f l i c t i n t h e s e f a m i l i e s * An e f f o r t was made t o i d e n t i f y i n s o f a r as was p o s s i b l e from t h e m a t e r i a l , those p e r s o n a l i t y f a c t o r s p a r t i c u l a r l y . h a z a r d o u s t o c o m f o r t a b l e adjustment:. N o t i n f r e q u e n t l y e t h e r f a c t o r s , such a s i n t e r f e r i n g r e l a t i v e s , c e r t a i n c u l t u r a l d i f f e r e n c e s , and economic p r e s s u r e s cont r i b u t e d c a u s a l l y t o t h e maladjustment and sometimes t h e y p l a y e d a major r o l e , b u t more o f t e n t h e y were e i t h e r symptomatic o f t h e p e r s o n a l i t y f a c t o r s o r s u b o r d i n a t e t o them. 0  T h i s i s f r e q u e n t l y borne o u t i n h o s p i t a l  contacts.  M i s s L i l l i a n Carscadden i n h e r t h e s i s "An E v a l u a t i o n o f t h e Clients-Worker R e l a t i o n s h i p "  says:  "The s e l e c t i o n o f t r e a t m e n t methods i s i n f l u e n c e d t o a l a r g e e x t e n t by t h e assessment made o f the l e v e l o f a b i l i t y i i i r e l a t i o n s h i p * The e f f e c t i v e n e s s w i t h w h i c h t h e s e methods a r e u s e d depends on t h e a c c u r a c y o f the d i a g n o s i s made, and the equipment o f the ca$eworker f o r using r e l a t i o n s h i p i n treatment. As  stated e a r l i e r i n t h i s chapter, s o c i a l workers  a c r o s s t h e c o u n t r y , as w e l l as m e d i c a l s o c i a l w o r k e r s i n DVA and o t h e r h o s p i t a l s , a r e i n v o l v e d i n casework h a n d l i n g of requests f o r deciding  t h e q u e s t i o n a s t o whether h a n d i -  capped p e r s o n s may c o n t i n u e a t home, o r must r e c e i v e . i n s t i t u t i o n a l care.  TJaeir common background o f p o s t - g r a d u a t e  t r a i n i n g presumably l e a d s t o an approach t o s o c i a l as a b a s i s f o r s o c i a l recommendations.  diagnosis  The w r i t e r , h a s n o t f o u n d ,  however* t h a t s o c i a l w o r k e r s a r e w r i t i n g o u t the recommendations (  i n g e n e r a l , n o r i n p a r t i c u l a r about such recommendations a s  1.. M a s t e r o f S o c i a l Work t h e s i s , D n i V e r i t y o f B.C. 1951  28  t h e y embody an awareness o f and adjustment o f m a r i t a l  problems.  I i j i s n e c e s s a r y i n the s i t u a t i o n s under s t u d y t o a p p l y as a y a r d s t i c k normal, p r a c t i c e i n d e a l i n g w i t h m a r i t a l  difficulties:,  i l l u m i n e d f u r t h e r by knowledge o f the e f f e c t o f i l l n e s s p h y s i c a l h a n d i c a p on p e r s o n a l i t y and a b i l i t y to  adjust.  and  Chapter I I T y p i c a l Situations Involving i  Marital Relationship The  1  Patterns  r e c o r d s o f the c o n t a c t o f m e d i c a l s o c i a l workers  with p a t i e n t s i n hospitals o f the Department o f Veterans A f f a i r s are p l a c e d i n f o l d e r s h e l d i n l o c k e d f i l i n g M e d i c a l S o c i a l S e r v i c e Departments. t i o n o f three o t h e r copies*  One  cabinets of  the  There i s a normal d i s t r i b u -  copy goes to the ward o r o u t -  p a t i e n t department where the p a t i e n t i s under m e d i c a l superv i s i o n , to be p l a c e d on the c h a r t *  T h i s copy* together w i t h a l l  other m a t e r i a l on the ward c h a r t ; m e d i c a l and n u r s i n g  notes.,  opinions o f consultants, records of s p e c i a l t e s t s , etc., w i l l l a t e r form p a r t o f the h o s p i t a l f i l e , n i i i c h a l s o h o l d s o f previous p e r i o d s ' o f treatment. t i c u l a r h o s p i t a l where  remains i n the  the p a t i e n t i s t r e a t e d .  to the D i s t r i c t O f f i c e f i l e , file  This f i l e  records  One  copy goes  where i t forms part o f a voluminous  c o n t a i n i n g many documents i n a d d i t i o n to the medical ones;  among these may  be papers p e r t a i n i n g to s e r v i c e and  discharge*  s p e c i a l t r a i n i n g , use o f Re-establishment C r e d i t , Pension War  Veterans Allowance i n v e s t i g a t i o n s and  and  rulings,, a i d i n  s p e c i a l problems g i v e n by V e t e r a n s W e l f a r e Services,, etc*. f i l e moves from d i s t r i c t to d i s t r i c t , as may for  par-  This  be n e c e s s a r y , so  that,  example, i f the v e t e r a n moves from Winnipeg to Vancouver,  o r back to Toronto, a complete r e c o r d o f m e d i c a l treatment,  and  30 o t h e r s e r v i c e s which have been used i n h i s i n t e r e s t , ©ay a v a i l a b l e , to accompany him*  The l a s t f i l e  be  t o which c o p i e s  are g e n e r a l l y d i s t r i b u t e d i s the Head O f f i c e f i l e , h e l d I n Ottawa,  Where p a t i e n t s are known to the N e u r o p s y e h i a t r i c  S e r v i c e o f the h o s p i t a l , a f i f t h  copy o f the m e d i c a l  s e r v i c e case r e c o r d I s sent to form p a r t o f t h e i r All  five files,  social  file.  the m e d i c a l s o c i a l s e r v i c e ,  h o s p i t a l , the D i s t r i c t O f f i c e , the Head O f f i c e and the i a t r i c , are h e l d i n l o c k e d c a b i n e t s .  the Psych-  A l l employees o f the  Department o f V e t e r a n s A f f a i r s take an oath o f secrecy, r e q u i r i n g t h a t they not d i v u l g e i n f o r m a t i o n secured i n the of  their duties.  They^ may  course  be suspended from the c i v i l s e r v i c e  i f there i s any breaeh o f c o n f i d e n c e i n t h i s r e s p e c t * M e d i c a l S o c i a l S e r v i c e r e c o r d s are w r i t t e n p r i m a r i l y for  the i n f o r m a t i o n o f the d o c t o r , i n DVA  hospitals.  h o s p i t a l s as i n o t h e r  I n any h o s p i t a l , some n o n - p r o f e s s i o n a l persons  have access t o f i l e s i n the course o f c l e r i c a l work.  In  will  the  Department o f Veterans A f f a i r s , i n the proper performance o f t h e i r d u t i e s , many more n o n - p r o f e s s i o n a l people w i l l have a c c e s s to  the r e p o r t s o f the s o c i a l worker than i n o t h e r s e t t i n g s *  What  the s o c i a l worker knows and r e c o r d s as to a p a t i e n t ' s e a r n i n g s , his  d i s p o s a l o f p r o p e r t y , whether or not he I s l i v i n g w i t h h i s  w i f e , h i s a b i l i t y to do c a s u a l o r r e g u l a r work, may  affect his  r i g h t s i n connection w i t h Pension, War V e t e r a n s Allowance, establishment C r e d i t , o r o t h e r b e n e f i t s .  Re-  I n t i m a t e d e t a i l s o f the  31  patient's way o f l i v i n g are o f no concern to these other members of  s t a f f f o r t h e i r purposes, but do form a part of the record  which i s made as a part o f the s o c i a l worker's formulation o f s o c i a l problems o f the patient as an a i d to the doctor i n furthering improvement or cure. The rules of the Department of Veterans A f f a i r s , which go back to the antecedent Department of Pensions and National Health, require that no secret f i l e s be held.  A l l information  and recorded thinking on the basis of information concerning any p a r t i c u l a r veteran, should be available on h i s f i l e .  This  view i s probably based, among other considerations, on the use of  the f i l e i n hearings and appeals o f the Canadian Pension  Commission, which have some o f the color o f a court o f law.  A  veteran may use, or have released to h i s lawyer, Legion secretary, veteran's advocate, or other duly authorized person, h i s f i l e , i n order to secure f u l l Information from the records, with respect to pension claim. Barely, Medical S o e i a l Service i n t h i s h o s p i t a l follows the pradtice of notation on the records f o r general d i s t r i b u t i o n , " F u l l e r d e t a i l i s being held on MSS f i l e " , o r " F u l l e r d e t a i l on MSS and NPC f i l e s . "  This i s usually done  where there i s much d e t a i l o f a sexual or other h i g h l y c o n f i d e n t i a l nature, and i s seldom resorted to.  No c o n f i d e n t i a l  records are held without such a notation f o r the general f i l e .  32 Medical- S o c i a l Workers* V o c a b u l a r y Because o f the n a t u r e o f the s e t t i n g , and the number o f persons who  must see r e p o r t s , t h e r e i s undoubtedly a t e n d -  ency to r e s t r i c t t h e i r d e t a i l e d content, o v e r and above t h a t u s u a l to s o c i a l workers  1  r e p o r t s i n any m e d i c a l s e t t i n g .  i s acknowledged t h a t m e d i c a l s o e i a l workers  1  It  case r e c o r d s a r e  u s u a l l y more c o n c i s e than those, say, I n f a m i l y agency o r p r o t e c t i o n s e t t i n g s , among o t h e r s which c o u l d be named. s o c i a l workers*  Medical  r e c o r d s tend to g i v e l e s s d e t a i l o f the p r o c e s s  on which t h e i r p r o f e s s i o n a l o p i n i o n i s based, o t h e r s o c i a l workers.  than do those o f  T h i s i s because m e d i c a l s t a f f are i n t e r -  e s t e d i n the s o c i a l workers*  n e t o p i n i o n , r a t h e r than i n the  means by which the findings have been reached.  The doctor* s  time i s a t a premium, and the s o c i a l worker's r e p o r t i s most u s e f u l t o m e d i c a l s t a f f , i f recommendations are c o n c i s e l y  stated.  Some process I s n e c e s s a r y f o r the guidance o f o t h e r s o c i a l worke r s who  may have to d e a l -with the same p a t i e n t i n the f u t u r e ,  but t h i s i s h e l d -to the minimum.  D e s p i t e t h i s pruning o f  f a c t u a l matter, m e d i c a l s o c i a l workers have been c r i t i c i z e d from time to time because r e c o r d s a r e h e l d to be too  voluminous.  Apart from omissions o f the p r o c e s s , i n a l l i t s d e t a i l , by m e d i c a l s o c i a l workers,  they do not as y e t have such a p r e c i s e  s e t o f semantic t o o l s f o r r e c o r d i n g f i n d i n g s , as do the members o f the m e d i c a l p r o f e s s i o n .  The " P h y s i c i a n ' s Pocket  Reference"  1  TI *»Phy s i c l a n k s Pocket Reference to the I n t e r n a t i o n a l . S t a t i s t i c a l C l a s s i f i c a t i o n o f D i s e a s e s , I n j u r i e s and Causes o f Death", Department o f Trade and^Commerce, Dominion Bureau o f S t a t i s t i c s , H e a l t h and W e l f a r e D i v i s i o n , King* s P r i n t e r , Ottawa, 1950,  33 used as an a i d i n c e r t i f y i n g causes ©f death, has major groupi n g s from I t o XVII, broken i n t o 999 sub-groupings, e x c l u s i v e o f those l i s t e d as " C l a s s i f i c a t i o n o f Causes' o f S t i l l b i r t h " * Of the 999 sub-groupings, each i s f u r t h e r broken down*  For  example: XVI,  789, Abnormal U r i n a r y C o n s t i t u e n t s o f U n s p e c i f i e d Cause: 789.0 A l b u m i n a r i a , u n q u a l i f i e d 789.1 A l b u m i n a r i a , o r t h o s t a t i c 789.2 P y u r i a and b a c t e r u r i a 789.3 C h y l u r i a 789*4 Haematuria 789.5 Haemoglobinuria 789.6 G l y c o s u r i a 789.7  Acetonuria  M e d i e a l S o c i a l workers i n t h e i r b a s i c t r a i n i n g , and f u r t h e r i n t h e i r experience i n m e d i c a l s e t t i n g s , must a c q u i r e a ready understanding o f the d o c t o r ' s vocabulary, f o l l o w h i s thinking regarding  i n order to  the treatment needs o f p a t i e n t s .  The d o c t o r i s n o t o b l i g e d , by t r a i n i n g , t o a c q u i r e an understanding  o f the s o c i a l worker* s p r o f e s s i o n a l vocabulary,  cludes many terms which may be r e a d i l y a c c e p t a b l e  which i n -  t o the  p s y c h o l o g i s t o r p s y c h i a t r i s t on the s t a f f o f the h o s p i t a l , b u t which may be p u z z l i n g t o the i n t e r n e , o r t o the c o n s u l t a n t i n medicine o r surgery.  I f the s o c i a l worker were r e c o r d i n g  p r i n c i p a l l y f o r another s o c i a l worker, as i n a f a m i l y agency s e t t i n g , o r f o r a p s y c h i a t r i s t , as i n a mental h e a l t h i t would be q u i t e a c c e p t a b l e  clinic,  to r e f e r i n s o c i a l diagnosis to a  person " S u f f e r i n g from unmet dependency needs", b u t t h i s i s unl i k e l y t o convey t o some members o f the m e d i c a l s t a f f a l l t h a t  34the s o e i a l worker wishes to be understood r e g a r d i n g the p a t i e n t * The s o c i a l worker may thus r e s o r t t o , as i t were, t r a n s l a t e t h e concept i n t o o t h e r terms. The p o i n t being made i s a t w o f o l d one.  I n the f i r s t  p l a c e the s o c i a l worker' does n o t have as w e l l - d e f i n e d and d i f f e r e n t i a t e d a d i a g n o s t i c v o c a b u l a r y i n t h e complicated sphere o f s o c i a l d i a g n o s i s a s does the d o c t o r i n the c o m p l i c a t e d p h y s i o l o g i c a l sphere.  The s o c i a l worker does n o t have an- i n t e r n a t i o n -  a l l y o r n a t i o n a l l y accepted 999  and p l u s p o i n t c l a s s i f i c a t i o n t o  i n c l u d e such s o c i a l l y p e r t i n e n t data as a c o n c l u s i o n t h a t h e r p a t i e n t i s s u f f e r i n g from, l e t us say, e x c e s s i v e dependency* l a c k o f masculine i d e n t i f i c a t i o n , u n r e s o l v e d f e e l i n g s o f g u i l t , o r a p o o r l y developed super-ego.  I n t h e second p l a c e , such  g e n e r a l V o c a b u l a r y as t h e s o c i a l worker does have a t h e r command, a c c e p t a b l e and understandable from one member o f h e r p r o f e s s i o n to another, o r from h e r t o the p s y c h i a t r i s t , does n o t always serve as an a i d i n the doctor* s understanding o f t h e p a t i e n t , so t h a t the s o c i a l worker may be o b l i g e d t o s t a t e t h e d e f i n a b l e cept i n o t h e r terms, t o t r a n s l a t e i t , b a s i c d i f f i c u l t y i n communication.  as i t were.  con-  There i s a  Doctors and s o c i a l workers  both p r o f i t from f a c e t o f a c e d i s c u s s i o n , but t h e w r i t t e n r e c o r d i s e s s e n t i a l t o t h e s e r v i c e expected., I t can t h e r e f o r be seen* t h a t , both on account o f t h e purposes f o r which t h e r e c o r d s have been s e t up, and the n a t u r e o f t h e v o c a b u l a r y i n which they a r e recorded, they do n o t  35  present i d e a l m a t e r i a l from which to analyze the manner i n which the s o c i a l worker formulates s o c i a l recommendations*  They do*  however, a f f o r d the best source a v a i l a b l e . B r i e f O u t l i n e s of Cases  .  •  The s o c i a l w o r k e r s i n s i s t e n c e that a l l persons being 1  helped must be viewed as p a r t i c u l a r i n d i v i d u a l s a r i s e s from the r e c o g n i t i o n t h a t they can only thu3 be seen c l e a r l y .  Never-  t h e l e s s c e r t a i n s i t u a t i o n s , o r aggregations o f p e r s o n a l i t i e s and problems a r i s e r e p e t i t i v e l y .  The cases chosen f o r presenta*-.  t i o n i n t h i s chapter are each " t y p i c a l " , i n t h i s way, o f a l a r g e group o f cases. No case presented has been put together o f , fragments from d i f f e r e n t eases. ,It has been necessary, however^ f o r the p r o t e c t i o n of c o n f i d e n t i a l i t y , and i n observance o f the r u l e s o f the Department o f Veterans A f f a i r s , t o a l t e r some det a i l s , , so t h a t the s i t u a t i o n s from which they are drawn may not be recognizable.  As the l e n g t h o f the records would, i n any  ease,, preclude the presentation o f a f u l l t r a n s c r i p t f o r die-? cussion, each case has been compressed f o r p r e s e n t a t i o n here* The cases chosen f o r p r e s e n t a t i o n c e r t a i n l y d© not comprise the t o t a l range.  I t i s b e l i e v e d that they do represent  a s u f f i c i e n t v a r i e t y o f commonly r e c u r r i n g s i t u a t i o n s to a f f o r d a b a s i s f o r a n a l y s i s o f the t y p i c a l a c t i v i t i e s o f s o c i a l workers i n reaching a s o c i a l recommendation.  The n e c e s s i t y o f i n s t i t u -  t i o n a l care has been c a l l e d i n t o question i n a l l these cases., The cases are presented i n order t h a t an examination may be made  36  as to how the s o c i a l worker formulates the answer to her share of t h i s question.. A..  Mentally Disturbed Patients Decisions about the need f o r i n s t i t u t i o n a l care o f  patients who are quite c l e a r l y mentally disturbed, but not (at l e a s t f o r the present) committable,  are of p a r t i c u l a r i n t e r e s t .  Of such s i t u a t i o n s , thcee are chosen f o r b r i e f review* . A (a) The confused and senile man may be brought to Outpatients or admitted to h o s p i t a l because of. h i s senile state,, or because of. some major physical d i f f i c u l t y .  The physical  complaint may give r e l a t i v e s courage to discuss the behaviour which has been troubling them f o r some time:  memory l o s s ;  wandering and sleeplessness;, careless behaviour i n the management of stoves and taps; i n a b i l i t y to carry out small errands; i n attention to s o c i a l taboos with respeet to dress, bowel and bladder function; f o u l language; are among the complaints most often heard.  Relatives may need to be helped with f e e l i n g s  that some stigma attaches to.them, because o f the mental state of the p a t i e n t . They may not have had opportunity to observe such behaviour i n others.  One member of the family may have  strong f e e l i n g that the family would be demeaned i f the patient were i n s t i t u t i o n a l i z e d .  The responsible member of the family,  (perhaps a wife or son) then needs to be helped to f e e l secure, that he i s making a r i g h t decision i n agreeing to the patient's removal from h i s home.  The s o c i a l worker's t r a i n i n g and s k i l l  37 m u s t b© p u t t o f u l l use: i & o b s e r v a t i o n a n d a w a r e n e s s o f i n t e r a c t i o n s of the f e e l i n g s of d i f f e r e n t  the  f a m i l y members, so -  t h a t a l l may e m e r g e f r o m t h e d e c i s i o n , i n w h i c h a l l s h a r e , some f e e l i n g o f c o n t e n t m e n t , rivalries.  rather  than the heightening  with  of  Such a f e e l i n g o f r i g h t d e c i s i o n i s o f d i r e c t  to the p a t i e n t ,  as Improving  t i m e s s e v e r a l members o f one, but i n e i t h e r give a valid  M s  a b i l i t y to ^ s e t t l e i n " .  benefit Some-  t h e f a m i l y may b e s e e n , s o m e t i m e s o n l y  c a s e , t h e s o e i a l w o r k e r w i l l n o t be a b l e  s o c i a l recommendation u n l e s s she h a s r e a l  t i o n a s t o a t t i t u d e s o f v a r i o u s members o f t h e In  the case o f A(a)  to the l e v e l of e a r l y  it  to  informa-  family*  appeared t h a t he had  childhood for  brought to our a t t e n t i o n .  old  regressed  s e v e r a l y e a r s b e f o r e h e was  L a t t e r l y h e h a d l a d no  inhibitions  a s t o b l a d d e r o r b o w e l f u n c t i o n , h e w a n d e r e d away f r o m home r e a d i l y a n d c o u l d n o t f i n d h i s way f o r e v e n a f e w b l o c k s , s h o p s w h i e h had" b e e n f a m i l i a r f o r many y e a r s * left  alone f o r  He c o u l d n o t  even a few m i n u t e s , because o f h i s l a c k o f  f o r h i s own s a f e t y .  H i s home was o f m o d e s t e c o n o m i c  b u t t h e r e was m a r k e d s o l i d a r i t y o f f a m i l y f e e l i n g . still  r e s i d e d i n t h e home, and because o f v a r y i n g  work and s t u d a y ,  for his  care,  c l e a r t h a t t h i s f a m i l y h a d been a b l e t o t o l e r a t e a s e n i l e p e r s o n much l o n g e r  have found endurable.  status, Young  hours  adults  of  i t  the s t r a i n  sons  con-  seemed '  t h a n most f a m i l i e s  The r o u t i n e s o f p a t i e n t ' s  be  regard  had been a b l e t o a s s i s t the p a t i e n t ' s w i f e  siderably i n sharing r e s p o n s i b i l i t y  caring for  to  and  of  would  38  daughters were to change, and, i n assessing the situation,  it  was agreed that the patient's wife could not carry the burden of M s care along.  The social worker's specific contribution,  apart from the specific recommendation, from the social viewpoint, as,to the necessity for institutional care, was i n aiding the patient's wife to relinquish the care of the patient  -  without g u i l t , as i n his best interests. A (b)  The patient A(b) was f u l l of fears, holding  that his neighbours, and later the police, were seeking him out because of offences which actually he had not committed.  I f his  wife l e f t the house his fears built up increasingly, and he might phone to bring her back from casual employment, or from a v i s i t to friends.  She had considerable s k i l l i n standing as a  buffer between him and his fears, but her patience and her v i t a l resources wore thin under the continuing strain. of  She saw  the loss/the patient's daughter i n tragic circumstances, some years previously, as contributory .to his condition; that i t did not f u l l y or satisfactorily afford her an explanation, her oftenrepeated "but why? why does he have to be this way?" bore evidence,.  With support from the medical staff and social worker,  she was able to accept the patient's return home on three occasions.  Then, as he became progressively more, fearful, i t  became necessary to accept him i n the hospital for continuing care, and later to commit him. A (c)  Physical and Mental Disabilities, wife i s not  39 H e l p f u l . Despite Her A f f e c t i o n .  I n the case o f A ( c ) , h i s w i f e ,  d e s p i t e , o r perhaps because o f the q u a l i t y o f her a f f e c t i o n and concern, was an enemy to h i s best mental e q u i l i b r i u m when a t home. The p a t i e n t had a h i s t o r y o f back complaints,  and a more  recent p h y s i c a l l y d i s a b l i n g c o n d i t i o n , but the focus o f concern which brought him to h o s p i t a l was h i s "nervousness *. 1  To the  p s y c h i a t r i s t he admitted the i n c r e a s i n g strength o f h i s d i s t a s t e f o r h i s w i f e , along w i t h h i s d e s i r e , i n t e l l e c t u a l l y , to cope w i t h the f e e l i n g , An e f f o r t was made by the s o c i a l worker to a s s i s t Mrs. A(c) t o r e a c t i n a more relaxed way to the patient's d i f f i c u l t i e s .  He could s c a r c e l y t u r n o r s i g h a t  n i g h t , but that she l e a p t up to l i g h t a f i r e and produce a eup of tea, making him more tense and r e s t l e s s i n the process. over-reacted  She  t o h i s every minor Vagary o f mood o r p h y s i c a l condi-  t i o n , i n c r e a s i n g h i s already d e b i l i t a t i n g consciousness o f s e l f . The p h y s i c a l s i t u a t i o n o f t h e i r home, remote from access t o t r a n s p o r t a t i o n o r medical care, was an a d d i t i o n a l burden i n the patient's d i f f i c u l t i e s *  H i s w i f e had been dependent on the  p a t i e n t f o r business d e c i s i o n s i n h i s days o f strength and competence, and could not, even w i t h h e l p , move towards a d e c i s — i o n on h e r own to move t o c i t y l i v i n g accommodation.  The p a t i e n t ' s  power o f d e c i s i o n was enfeebled by h i s i n s i g h t i n t o the i r r a t i o n a l i t y o f h i s f e e l i n g s against h i s w i f e , and h i s r e l a t e d f e a r o f suggesting a move which might offend her. seemed to deepen the weakness o f the other,  The weakness o f each Mrs. A(c) could not  40 be h e l p e d t o d e v e l o p s t r e n g t h s  t o compensate f o r t h o s e t h e  patient had l o s t , although h e r devotion questioned.  After several v i s i t s  and a f f e c t i o n were un-  t o t h e h o s p i t a l and r e t u r n s  t o h i s i s o l a t e d home, t h e p a t i e n t was a c c e p t e d f o r care.  continuing  Had I t been p o s s i b l e t o f u r t h e r moderate h i s w i f e ' s r e -  action to his disturbed  s t a t e , i t might have been p o s s i b l e f o r  him  t o manage a t home f o r a l o n g e r  B.  Speedy D e c i s i o n around a P h y s i c a l l y H a n d i c a p p e d  with a Reluctant  period.  but D u t i f u l Wife  • T h i s i s a n example o f a ease where a r a p i d a s s e s s m e n t was made. a  Patient  social  The h o s p i t a l r e c e i v e d a t e l e p h o n e c a l l  s o c i a l worker o f t h e P r o v i n c i a l Welfare Branch, i n . a  from  rural  c e n t r e , i n d i c a t i n g t h a t t h e p a t i e n t ' s w i f e w o u l d n o t be a b l e t o c a r e f o r h i m a t home, a n d s i m u l t a n e o u s l y  t h e r e q u e s t was r e -  c e i v e d f r o m m e d i c a l s t a f f t o a s s e s s t h e home s i t u a t i o n . p a t i e n t had poor use o f limbs being  and speech, f o l l o w i n g  unable t o walk without a s s i s t a n c e .  hemiplaegia,  H i s w i f e was i n t e r -  v i e w e d b y t h e m e d i c a l s o c i a l w o r k e r s , a n d i t was l e a r n e d Era., B h a d known t h e p a t i e n t i n t h e i r e a r l y c h i l d h o o d Eastern her  city.  The  that  i n an  S h e h a d come o u t t o m a r r y h i m a f t e r t h e d e a t h o f  f i r s t husband..  Accustomed t o c i t y l i v i n g  h e r s e l f well to the countryside;  h e r personal  she h a d n o t adapted, relations with  second husband h a d never been rewarding t o h e r . the best o f h e a l t h .  this  S h e was n o t i n  I t was c l e a r t h a t s h e d r e a d e d t h e p o s s i b i l -  i t y o f t h e p a t i e n t ' s r e t u r n home a n d t h e r e s p o n s i b i l i t y f o r h i s care  i n a l a r g e and inconvenient  farmhouse w i t h o u t c l o s e  neigh-  41  bours, yet because of her strong sense of duty she would have undertaken the work.  I t was agreed that the patient could be-  offered i n s t i t u t i o n a l care, and t h i s he accepted without  dis-  comfort, although i n i t i a l l y he had indicated h i s wish to return home.  Some continuing service was given the patient and h i s • ;  wife around certain business problems, and l a t e r the wife was referred f o r medical care and free l e g a l a i d . No d e t a i l e d background information on either person was .taken, no e f f o r t .was made to modify attitudes, but support was given the wife i n accepting a reasonable solution without g u i l t *  C*. Loving Couple* Both i n Physical Decline Mr. C i s t y p i c a l o f a considerable group o f patients where both the patient and h i s wife have very r e a l physical d i s a b i l i t i e s , but the strength of t h e i r feelings, the one f o r the other,, made j o i n t l i v i n g possible f o r a considerable period,, a l though i n s t i t u t i o n a l care had to be accepted In the end,.. Both the patient and h i s wife were o f cultured Scottish background, the man t a l l and heavy, the wife t i n y and f r a i l .  On several  occasions the d e s i r a b i l i t y o f the man's return home was  called  i n t o question, mainly because of the view of a p r i v a t e physician that h i s wife "needed a r e s t " .  He came i n to the h o s p i t a l from  an upcoast resort where he had s e t t l e d a f t e r retirement. The patient had a great deal o f a f f e c t i n g f o r h i s wife, but l i t t l e understanding o f the physical s t r a i n he put on her, i n expecting care i n h i s own home.  As soon as she had regained her strength,  42 the w i f e always w i s h e d " t o t r y a g a i n " . necessary  E v e n t u a l l y I t became  t o p l a c e the p a t i e n t i n i n s t i t u t i o n a l c a r e . The w i f e  f i r s t moved i n t o l i v i n g q u a r t e r s i n the c i t y and l a t e r i n t o a n u r s i n g .home, s e c u r e d w i t h the co-ofperating o f a p r o v i n c i a l s o c i a l worker*  There was  i n t e r m i t t e n t supportive contact w i t h  husband and w i f e , and some c o n t a c t w i t h f a m i l y members.  The  t r a n s i t i o n f r o m independent l i v i n g was b e t t e r b r i d g e d because the s o c i a l worker u n d e r s t o o d  and acknowledged t h e s t r e n g t h o f  the t i e and t h e r e g r e t s when I n s t i t u t i o n a l c a r e was  f o u n d t o be  necessary.. D*  " F e e l i n g s " Determine the D e c i s i o n Mr*  D.'• s s i t u a t i o n , t y p i f i e s one o f those where  super-  f i c i a l , i n f o r m a t i o n as t o p h y s i c a l f a c t s , w i t h o u t knowledge.of the a t t i t u d e o f the man  and h i s w i f e towards one a n o t h e r ,  and  towards the f a c t s , w o u l d g i v e the i m p r e s s i o n t h a t i t would be c a t e g o r i c a l l y i m p o s s i b l e f o r the man  t o r e t u r n home.  Y e t he  was  a b l e t o be o u t o f h o s p i t a l f o r o v e r a y e a r a f t e r t h e d i a g n o s i s o f carcinoma had been c o n f i r m e d .  The p a t i e n t * s e q u i l i b r i u m was  a f f e e t e d , and l a t e r h i s speech.  H i s w i f e ' s appearance  r a t h e r c o n s p i c u o u s l y odd; she was  was  e p i l e p t i c as w e l l a s o f v e r y  l i m i t e d i n t e l l i g e n c e , and was.a r e g u l a r v i s i t e r i n t h e o u t p a t i e n t c l i n i c at another h o s p i t a l .  T h i s c o u p l e had one  very  a t t r a c t i v e c h i l d o f p r e - s c h o o l age, and l i v e d i n r e n t e d s l u m q u a r t e r s where the l a n d l o r d was  f a i r l y friendly.  The  social  w o r k e r ' s home v i s i t s and c o n t a c t w i t h t h e w i f e d i s c l o s e d t h a t  43 the p a t i e n t would he g i v e n adequate c a r e a t home.  W h i l e poor  and drab., h i s rooms were n e a t and warm, and a s m a l l  balcony  would g i v e h i m an o p p o r t u n i t y o f b e i n g o u t o f d o o r s w i t h o u t enc o u n t e r i n g t h e danger o f t r a f f i c both h i s wife-and  his child.  'The p a t i e n t was d e v o t e d t o  H i s w i f e wanted h i m a t home. H e r  f a m i l y who l i v e d n e a r b y , and were f r e q u e n t v i s i t o r s , . a t home would l i v e i n a c l i m a t e o f a f f e c t i o n *  The p a t i e n t ,  The s o c i a l  recommendation was t h a t a l a r g e , l u r c h i n g man, w i t h p o o r c a p a c i t y t o d i r e c t h i s movements s h o u l d go t o slum h o u s i n g , t o be c a r e d f o r by a f e e b l e - m i n d e d w i f e , s u b j e c t t o s e i z u r e s . F o l l o w - u p home v i s i t s d i s c l o s e d t h a t t h e recommendation h a d been a sound o n e , • i t s soundness r e s t i n g o n t h e f e e l i n g s o f t h e h a n d i capped c o u p l e about one a n o t h e r and a b o u t t h e i r home., E v e n t u a l l y , a s t h e p a t i e n t d e t e r i o r a t e d , i t was n e c e s s a r y t o have h i m a c c e p t • i n s t i t u t i o n a l c a r e , and t o s u p p o r t h i s w i f e i n y i e l d i n g up h e r r e s p o n s i b i l i t y f o r c a r e , s t e e l i n g h e r t o r e f u s e h i s hopes o f r e t u r n i n g home a g a i n .  A community agency was  drawn i n w i t h a v i e w t o e n s u r i n g t h e f u t u r e w e l f a r e o f t h e dependent  child.  E.  Repeated A d m i s s i o n s A r i s e from the Home S i t u a t i o n The  s i t u a t i o n o f Mr. E b e l o n g s t o a group where a t t e n -  t i o n i s drawn t o a d i f f i c u l t home s i t u a t i o n by t h e p a t i e n t ' s o b v i o u s r e l u c t a n c e t o l e a v e h o s p i t a l o n repeated' a d m i s s i o n s . p a t i e n t ' s c o n d i t i o n was an o b s c u r e one,  The  involving "dizzy spells"  and " b l a c k o u t s " v i v i d l y d e s c r i b e d b y h i s w i f e as w e l l a s h i m s e l f ,  u but never observed when he was In h o s p i t a l * The s o c i a l worker's contact with him,  Intermittently  as both an inpatient and an outpatient, helped him to admit, with i somewhat lessened resentment, h i s f r u s t r a t i o n a t having had to adopt a woman's r o l e i n housekeeping and earing f o r h i s w i f e , who had  suffered a d e b i l i t a t i n g i l l n e s s some three years, previously*  When i n better health himself, he had enjoyed her dependence on him f o r physical care, and h i s a b i l i t y to provide i t ; now the obligation became increasingly onerous.  A home v i s i t indicated  that l i t t l e could be expected i n moderation of the wife's demands on him, but that he could be helped by the s o c i a l worker to express to some extent h i s resentment of the s i t u a t i o n , and by rel i e v i n g h i s f e e l i n g s thus, to tolerate i t better.  When the  patient was h o s p i t a l i z e d , h i s wife had f i n a n c i a l and personal d i f f i c u l t y In securing temporary housekeepers; on one occasion she asked to municipality to secure her a nursing home bed.  Be-  cause of her own fears regarding, herself, she tended to be unduly alarmist over the patient's condition, thus r e l n f o r c i ^ ^ rather than reducing h i s concern f o r h i s own health.  I t was  necessary f o r the s o c i a l worker to help her to understand the patient's condition better, so that she would not further h i s returns to h o s p i t a l on the s l i g h t e s t pretext.  The patient kept  contact with the s o c i a l worker on v i s i t s to the outpatient department, u n t i l h i s admission f o r what proved to be a terminal illness. In such situations as t h i s , the s o c i a l worker's i n i t i a l  45 f o r m u l a t i o n may n o t be s t a t e d a s such on t h e r e c o r d , b u t becomes i m p l i c i t i n t h e d e c i s i o n t o work p r i n c i p a l l y w i t h one o f t h e m a r r i e d p a r t n e r s , ( i n t h i s case t h e p a t i e n t r a t h e r t h a n h i s w i f e ) , on t h e b a s i s t h a t t h e a t t i t u d e s o f t h e o t h e r p a r t n e r a r e less susceptible of modification.  E f f o r t i s made, however, t o  e f f e c t some change i n b o t h . F.  W i f e Whose H e a l t h P r o b l e m s I n c l u d e E m o t i o n a l F a c t o r s C a p t a i n F, a 7 9 - y e a r o l d p a t i e n t , s u f f e r i n g f r o m  a r t e r i o s c l e r o s i s , w i t h some m i n i m a l memory l o s s and m e n t a l i m p a i r m e n t , was r e f e r r e d t o M e d i c a l S o c i a l S e r v i c e by t h e d o c t o r , w i t h t h e r e q u e s t f o r assessment o f t h e home s i t u a t i o n .  On t h e  ward i t was l e a r n e d t h a t s t a f f viewed t h e p a t i e n t ad d i f f i c u l t and demanding, and a l s o t h a t h i s w i f e and son had b o t h  advised  t h a t h i s w i f e would be u n a b l e t o c a r e f o r h i m a t home, because o f poor h e a l t h .  The p a t i e n t s t a t e d t h a t h i s w i f e was t h e b e s t  o f women, i n t h e b e s t o f h e a l t h , and t h a t he was g o i n g home. When c o n t a c t e d ,  t h e w i f e spoke b o t h o f h e r p o o r h e a l t h , ,  and o f h e r d i f f i c u l t i e s  with the p a t i e n t since h i s  retirement.  Her d o c t o r c o r r o b o r a t e d  h e r statements about h e r b l o o d  pressure  w h i c h h a d been known t o go "as h i g h a s 300", s a y i n g t h a t i t would be d i f f i c u l t f o r h e r t o c a r e f o r t h e p a t i e n t , a s she r e q u i r e d r e s t , b u t o u l d n o t s a y t h a t i t would be i m p o s s i b l e . seemed t h a t t h e e a r l i e r y e a r s o f t h e m a r r i a g e had been  It  tenable,  because t h e p a t i e n t had been much o f h i s t i m e away from home i n the c o u r s e o f h i s b u s i n e s s .  S i n c e r e t i r e m e n t , C a p t a i n F was  d e p i c t e d as d i f f i c u l t and demanding t o an i n c r e a s i n g d e g r e e .  He  46 had n e v e r a t any time been known to' do as much f o r h i m s e l f a s b o i l w a t e r t o make t e a *  Nevertheless  he m a i n t a i n e d he was r e a d y  t o go home and "do e v e r y t h i n g f o r h i m s e l f " . . «  E f f o r t s t o have t h e p a t i e n t a c q u i e s c e t o t h e p r o p o s a l  o f i n s t i t u t i o n a l c a r e were u n a v a i l i n g .  The p a t i e n t s a i d t h a t  h i s w i f e ' s d o c t o r was a f o o l and t h a t h e was no t r o u b l e t o anyone a t home.. E x p l a n a t i o n was. g i v e n t o h i s l a m e n t i n g w i f e and t o h i s r e p e a t e d l y p r o t e s t i n g - son, t h a t we h a d no r i g h t t o compel the p a t i e n t ' s s t a y .  I t was f e l t t h a t t h e y d i d come t o a c c e p t *  a l t h o u g h .they so r e g r e t t e d t h e n e c e s s i t y f o r o u r p o l i c y . a f t e r h i s r e t u r n home, t h e p a t i e n t was r e a d m i t t e d and d i e d .  Shortly  to hospital  . T h i s seems t y p i c a l o f a group o f cases where e m o t i o n a l  problems a r e c o n s p i c u o u s i n t h e w i f e ' s i l l n e s s , w h i c h forms h e r stated reason f o r I n a b i l i t y t o accept the p a t i e n t h a p p i l y a t home.. The p o s s i b i l i t y o f h i s . being o f f e r e d c o n t i n u i n g c a r e  with-  i n t h e veterans', s e t t i n g .would o f f e r a r e a d y s o l u t i o n , i n a separation.  I t would n o t t h e n be n e c e s s a r y t o admit t h e m a r i t a l  d i f f i c u l t i e s , which are not denied, but rather r e a d i l y discussed by t h e w i f e , even on s u p e r f i c i a l c o n t a c t . (represented  The f a m i l y c i r c l e ,  i n t h i s case by one s o n ) , a t t a c k t h e w i t h h o l d i n g - o f  c a r e , w h i c h t h e y , t o o , see a s a s o l u t i o n . . The s o c i a l assessment i n v o l v e s a balancing o f v a l u e s , an enquiry i n t o v a r i e d s o l u t i o n s i n t h e l i g h t ©f "Who would be h u r t by t h i s arrangement? Who by this?"  I n t h i s case, as t h e p a t i e n t had n o t i n i t i a l l y presented  as " l i k e a b l e " on t h e ward, t h e r e was more sympathy f o r t h e w i f e ' s  47  dilemma, than f o r example, i n ease M ( t o f o l l o w ) and the  social  worker had l e s s t o do i n making i t v i v i d to. s t a f f . . G.  P a t i e n t and W i f e A m b i v a l e n t R e g a r d i n g The  their Relationship  s o e i a l w o r k e r i n t h e . f a m i l y agency i s t h o r o u g h l y ,  f a m i l i a r w i t h a group o f c l i e n t s who  come v o l u n t a r i l y t o the  agency s e e k i n g h e l p w i t h a m a r i t a l p r o b l e m , r e t u r n i n g a t i n t e r v a l s o f some months o r y e a r s , u s u a l l y w i t h t h e . same problem* They appear t o seek the s o c i a l worker as a p e r s o n who  will  l i s t e n t o t h e i r c o m p l a i n t s , r a t h e n t h a n as a means t o a changed o r improved r e l a t i o n s h i p w i t h t h e . s p o u s e . ed, some persons  As m i g h t be  anticipat-  caught i n such s i t u a t i o n s a r e known t o m e d i c a l  s o c i a l workers assessing requests f o r i n s t i t u t i o n a l care.  I  have h e a r d them r e f e r r e d t o . a s " o f f a g a i n on a g a i n m a r i t a l  prob-  lems" and the name may  be as good as" any,  Mr. and Mrs.. G showed such a p a t t e r n i n . o u r f o u r - y e a r i n t e r m i t t e n t c o n t a c t w i t h them,  Mr. G s u f f e r e d from c h r o n i c  asthma and c o n g e s t i v e h e a r t f a i l u r e , and had  been.temporarily  l i v i n g a l o n e , a p a r t f r o m h i s w i f e , a t the time when.he was  first  r e f e r r e d to Medical S o c i a l Service, w i t h a view to secnxing  an  o p i n i o n as t o the n e c e s s i t y f o r i n s t i t u t i o n a l c a r e . his  w i f e was  A t t h a t time  i n a n o t h e r p r o v i n c e b u t h i s s i s t e r and h i s  were concerned  f o r h i s w e l f a r e , and a room was  secured n e a r h i s  s i s t e r s home, so t h a t i t was n o t n e c e s s a r y t o m a i n t a i n 1  patient i n hospital.  daughters  the  I n f o u r months the. p a t i e n t came t o o u r  a t t e n t i o n a g a i n , b u t t h e r e were more p r e s s i n g m e d i c a l r e a s o n s f o r  48 h i s s t a y i n h o s p i t a l f o r some t i m e , and he was  discharged to h i s  home, t h i s time w i t h h i s w i f e i n the p i c t u r e , i h a few months time*  He was  seen as an o u t p a t i e n t , and h i s m a r i t a l  difficult-  i e s came t o the f o r e ; the w o r k e r noted: " H i s domestic has been p o o r e v e r a f i f t y - y e a r p e r i o d *  0  situation  I t seemed p r o b a b l e  t h a t the p a t i e n t s h o u l d a c c e p t i n s t i t u t i o n a l c a r e , because o f the d i f f i c u l t i e s a t home, b u t he r e f u s e d t o do so f o r f i n a n c i a l reasons.  A home v i s i t d i s c l o s e d t h a t man  speaking f o r o v e r a y e a r .  and w i f e had n o t been  H i s wife's complaints of h i s d i f f i *  c u l t d i s p o s i t i o n , hypoehondrJ&, and u n r e a s o n a b l e  demands f o r i n ~  c e s s a n t s e r v i c e were s u b s t a n t i a t e d by o t h e r members o f t h e f a m i l y as the r e a s o n s f o r t h e d i f f i c u l t i e s . c r i e d w o l f , now  L i k e " t h e bey  who  t h a t t h e r e was r e a l i t y t o h i s p h y s i c a l c o m p l a i n t s ,  no-one c r e d i t e d him.  Some f i v e months a f t e r h i s l a s t  admission,  the p a t i e n t was a g a i n - a d m i t t e d t o h o s p i t a l , b u t l e f t w i t h i n f o u r months, t h i s time t o l i v e a l o n e .  E i g h t months l a t e r he  was  a g a i n a d m i t t e d t o h o s p i t a l f r o m a h o t e l room where he had been l i v i n g alone*  H i s w i f e ' s coneern f o r him was  r e a c t i v a t e d , , she  began a g a i n t o v i s i t him and they were p l a n n i n g once more t o s e t up a j o i n t e s t a b l i s h m e n t , a t the time o f h i s d e a t h . H*  P a t i e n t and W i f e b o t h Handicapped: F a m i l y I n v o l v e d i n 1  Decisions Mr. H, an 82-year o l d p a t i e n t and h i s w i f e were brought t o the a t t e n t i o n o f M e d i c a l S o c i a l S e r v i c e t h r o u g h  an  o u t s i d e agency, t o whom h i s son and g r a n d d a u g h t e r had gone f o r  49 i n .-losaiss  aSvico fee  ©us h o s p i t a l i s e : * . the  iastltaticBiil  eouli T&e  CSPO,  iistlest  ea?!iyfies£.* fcocn  u Soese  heavy &  too  ^icohoile,  villas  sffsetioa  •;erh^s cs^e ^•ossibiLity  *s-JOiled  n  although i f  there  suitable  p.'S  iriasor,  but  h e T&.S  H© c i s  gioisev.h-. t  by  grorrl4£Q3&t£p..  f  ts  ©ife, c;:rc  sun o b e s e ,  bat  of  rao  efcle  Lies. acre  this  to  In for  >ian  the  Oose  i n cs c i t y  ^IcceS  six  by h i s  um,  i fIt  teres,  ontelleal  th©  .feeding  fcepocif,  ?be  hose S r e . tiont,  centret»  the  ^fcicst,  feelings  the  to  of  su^-ort f r e a  tie  contlntseft  Sor>e t*2»e©  i l t t i the h e l p  th©  ^oe&iM'iity  igyo©^ bis  being sceouptgc^  .£it£eu£h  f  htd  pctisat  Tho $&fci©at  her  H r-. e  the  orl£lz&l contact,  »>ftor t h e  t e a v O t c g has®, to  x&ra  th©  eosfused ©13 vwssn o f  slightly  fc-a£ contributed  of  t ! » t tfcey c o u l d  TT^ey f e l t  mt  fee feaS  bat  I n t h e i r view  vtQuia  ©etsiie.  .*a>a  not l a smy Eoase  for  fco3sit&:iiR<:S v i s i t e d her r e g t t l c r l y . origii^ui  feroscMtts  fluctuating* even v,lth pcg&-*d  coring f o r her.  efce  ;$rovi:2ed  be  considered ffect  rejected  t h a t h$ 0;;eSe i s tne aoet osie&rlEg very  B^S  p r o b a b i l i t y tfct-fc l i e  coBlltioa,  scut-erfi o f h i e flatly  his vife  & £ £ i y fcere  the  coulai  cere  iiffieult  hc*vif^  it  staff,  ^ l r o . - U y UELier coa&l'*erwtlcn f o r  reom f o r M s of  c f M s 80-y©«p o M £ife, v & l l c t  core  ^tic-st  discharge!  fee  the  On 3t8eu£i>icm n i t h steiiet.1  -  found. th:.t  %A  for  ^«n-  t o tSo  to  sent!?-;;- o f  te  ter the  o f ttee Cw6©T.©r«ser*  * « e esn&i&eri&g tiie ^ u c i b l l i t y o f t o j l n g & heu^esceviisg. rcem w i t h Ms  t?if©.  tablished  ~itH  T*':o- asnfcfc-s lcfcjr M E ,  hie  « i f e W£»s  ve?y  fccjoily  es-  ii $Qilo~-nc heae v l & i t offce-p t h e ; . ; i . t i c « t t s f  50 d i s c h a r g e showed b o t h r e a s o n a b l y independent and c o n t e n t e d , a l though t h e f a m i l y were g i v i n g l i t t l e a s s i s t a n c e , now t h e p a t i e n t and h i s w i f e were a l o n e * discharge, month.  Some f i v e months a f t e r t h e p a t i e n t ' s  he was r e a d m i t t e d t o h o s p i t a l and d i e d w i t h i n a  H i s son assumed a r e s p o n s i b i l i t y f o r t h e c a r e o f t h e  patient's wife a t t h i s time.  I n accordance w i t h f a m i l y  tradition,  the s o c i a l w o r k e r was asked t o make a f o r m a l v i s i t o f c o n d o l e n c e , p r i o r to the f u n e r a l . Case I .  '  S i t u a t i o n Requiring Environmental M o d i f i c a t i o n T h i s p a t i e n t , s u f f e r i n g from a severe.;' h a n d i c a p p i n g  h e a r t c o n d i t i o n , was f i r s t b r o u g h t t o t h e a t t e n t i o n o f M e d i c a l S o c i a l S e r v i c e i n t h e f a l l o f 1950..  F i v e s o c i a l w o r k e r s have  d e a l t w i t h t h e p a t i e n t and h i s f a m i l y , and t h e case was a l m o s t continuously  a c t i v e u n t i l h i s d e a t h I n t h e s p r i n g o f 1956.  It  seems h i g h l y i m p r o b a b l e t h a t t h e p a t i e n t w o u l d have s p e n t any time o u t o f h o s p i t a l , h a d i t n o t been f o r t h e e f f o r t s o f M e d i c a l Social Service. The  p a t i e n t was r e f e r r e d s p e c i f i c a l l y w i t h t h e q u e r y  as t o whether t h e r e were any p o s s i b i l i t y o f h i s g o i n g home. "Home" c o n s i s t e d o f a w i f e and two c h i l d r e n o f some t e n and e i g h t y e a r s o f age,  l i v i n g i n two housekeeping rooms i n a t e n e -  ment which bore a p o o r r e p u t a t i o n . P h y s i c a l l y , c o n d i t i o n s would have been poor f o r t h e p a t i e n t , i t was n e c e s s a r y t o c l i m b t o g e t t o t h e s m a l l w r e t c h e d accommodation.  I t was l e a r n e d  stairs that  s e v e r a l s o c i a l a g e n c i e s h a d h a d c o n t a c t w i t h t h e f a m i l y , and t h e r e  i 51 was  i n d i c a t i o n o f b o r d e r l i n e neglect o f the children,,  The,medical  s o c i a l w o r k e r f o u n d t h a t adjustment between husband and w i f e h a d n e v e r been ©f t h e b e s t , . t h e p a t i e n t d i s p l a y e d no g r e a t a n x i e t y t o go home, and t h e w i f e made n© movement t o w a r d s ' s e c u r i n g  quarters  which.would p e r m i t b e t t e r p h y s i c a l l i v i n g c o n d i t i o n s * A f t e r t h e p a s s a g e . o f some three'months, t h e p a t i e n t was, becoming d i s s a t i s f i e d w i t h i n s t i t u t i o n a l c a r e ; h i s i n c r e a s i n g c o n c e r n f o r t h e w e l f a r e o f t h e c h i l d r e n was b e i n g f o s t e r e d . Approximately  one y e a r a f t e r t h e r e f e r r a l t h e p a t i e n t , was making  weekend v i s i t s t o h i s home*  Much o f h i s d i s s a t i s f a c t i o n w i t h  c o n d i t i o n s t h e r e was p r o j e c t e d o n t o J3VA and t h e t r e a t m e n t he became a " d i f f i c u l t * p a t i e n t . :  1  setting,  Some f i v e months l a t e r h i s  h e a r t c o n d i t i o n d e t e r i o r a t e d and he a g a i n was p l a c e d o n s t r i c t bed r e s t *  . A g a i n some f o u r months l a t e r , t h e p a t i e n t h a d made  c o n s i d e r a b l e p h y s i c a l r e c o v e r y and t h e f a m i l y had been a s s i s t e d to move t o a suburban house*  The m e d i c a l  s o c i a l w o r k e r remained  i n c o n t a c t w i t h t h e f a m i l y , much d e t a i l e d work b e i n g p u t i n i i i g e t t i n g household e f f e c t s s e t t l e d *  There was seiae e v l d e n e e  e f q u a r r e l s o m e n e s s between man' and w i f e , and i n d i c a t i o n s t h a t the w i f e was a poor manager.  Nevertheless,, w i t h s u p p o r t i v e  c o n t a c t t h e p a t i e n t remained o u t o f h o s p i t a l u n t i l t&te f e l l o w * * ing spring.  The p o s s i b i l i t y o f i n s t l t u t l o n a i . c a r e was a g a i n  c o n s i d e r e d , b u t a s t r o n g s o c i a l recommendation a g a i n s t s u c h a p l a n was made*  The p a t i e n t was h o s p i t a l i z e d b r i e f l y  twice  52 between the s p r i n g and f a l l o f t h i s y e a r . housing, s t i l l  More s u i t a b l e  suburban to the c i t y was found f o r them.  f a m i l y were quarrelsome w i t h neighbours and landlords..  The De-  s p i t e these d i f f i c u l t i e s , and v a r i e d problems r e l a t e d t o moving, the p a t i e n t seemed a t t h i s time a b l e t o accept t h e n e c e s s i t y o f r e c u r r i n g h o s p i t a l i z a t i o n and subsequent r e t u r n home, without emotional upset,  ^he f a m i l y maintained a  b o r d e r l i n e s o c i a l e q u i l i b r i u m , the w i f e w r i t i n g t o o r contacting arose*  the medical s o c i a l worker as v a r i o u s  difficulties  The p a t i e n t was a g a i n i n h o s p i t a l when the p i p e s o f  the small home f r o z e i n December, but the f a m i l y accommodated themselves t o h i s r e t u r n home f o r C h r i s t m a s . I n March the p a t i e n t was h o s p i t a l i z e d f o r the l a s t time.  The s o c i a l worker, i n t h e words o f an i n t e r n e  "helped him worry" over some l e g a l problems, h i s w i f e ' s h e a l t h , and m a t t e r s i n v o l v e d i n h i s c h i l d r e n ' s The  p a t i e n t d i e d some two weeks a f t e r t h i s  J.  A D u t i f u l Wife Medical  admission.  S o c i a l S e r v i c e had had b r i e f i n t e r m i t t e n t  contact w i t h t h i s p a t i e n t b e f o r e a l care was indicated.. ments r e g a r d i n g  education.  the q u e s t i o n o f i n s t i t u t i o n -  I n 1943 we a s s i s t e d him with  arrange-  g l a s s e s , and i n 1951 he requested and was  r e f u s e d h e l p t o procure m e d i c a t i o n s f o r a non-dependent daughter.  L a t e r i n t h a t y e a r we were r e q u e s t e d to secure  s o c i a l background i n f o r m a t i o n ,  because the p a t i e n t was  53 d i s p l a y i n g i r r a t i o n a l behaviour,  w i t h some evidence  might be due to b a r b i t u r a t e a d d i c t i o n .  that i t  Mr J . was s u f f e r i n g  from h e a r t d i s e a s e , u r i n a r y d i f f i c u l t i e s and a m i l d degree o f diabetes.  T h i s was the f i r s t  d i r e c t c o n t a c t with h i s w i f e .  The h i s t o r y secured from h e r i n d i c a t e d t h a t he had f o r m e r l y been accustomed t o heavy d r i n k i n g and had been physically abusive t o h i s w i f e . with other women*  There had a l s o been evidence o f l i a i s o n s  H i s w i f e I n i t i a l l y t o l d medicd, s t a f f t h a t  she could n o t a c c e p t him a t home, even f o r weekends*  The  p a t i e n t was t e m p o r a r i l y p l a c e d on i n s t i t u t i o n a l c a r e , b u t was soon making r e g u l a r v i s i t s to h i s home, and then home f u l l t i m e . later. admitted  returned  There was a b r i e f s t a y i n h o s p i t a l a y e a r  A f t e r some seven months a t home the p a t i e n t was a g a i n to h o s p i t a l and h i s w i f e d i s c u s s e d (now w i t h the  t h i r d s o c i a l worker to know t h i s p a t i e n t ) h e r d i f f i c u l t i e s i n c a r i n g f o r him a t home.  He was now 00 n fused and blundered  about t h e house a t n i g h t $ he r e f u s e d . t o bathe; she w o r r i e d about h i s " t a k i n g p i l l s " .  Some two months l a t e r , , with  supportive  foilow-up by the case-worker, she took -the p a t i e n t home. A t i n y , competent woman, Mrs J . n e v e r t h e l e s s had health problems o f h e r own and might e a s i l y have d u t i f u l l y , but very u n h a p p i l y ,  agreed  to «are f o r the p a t i e n t .  Because she had had the o p p o r t u n i t y t o v e n t i l a t e h e r f e e l i n g s and because she had been g i v e n the sense t h a t someone was concerned about h e r as w e l l as about t h e p a t i e n t , she assumed the r e s p o n s i b i l i t i e s c h e e r f u l l y .  J  h e p a t i e n t was seen o c c a s i o n a l l y  54 by the s o c i a l worker when, he attended o u t p a t i e n t s . Approximately  a year l a t e r he was r e a d m i t t e d f o r  control o f h i s diabetes. v a n i s h e d ! he appeared good,clean,  Sis former d i f f i c u l t b e h a v i o u r had  to have r e g r e s s e d t o the l e v e l o f a  cheerful infant*  H i s ©ife devoted h e r s e l f t o  c l e a n i n g the house p r e p a r a t o r y to a s a l e so t h a t she s i g h t purchase a house i n which the p a t i e n t might more corafortably be cared f o r on one f l o o r .  She was u n s e t t l e d a t t h e s u g g e s t i o n  t h a t the p a t i e n t sdght be d i s c h a r g e d b e f o r e t h i s was worked e a t . 1 1 t h the assurance o f the s o c i a l worker t h a t she ®as s i n c e r e and n o t s t a l l i n g " , a e d i e a l s t a f f consented n  patient's discharge. Ms  discharge.  t o d e l a y the  The p a t i e n t d i e d about on® month a f t e r  Mrs J . c a l l e d l a t e r t o share w i t h the s o c i a l  eorker d e t a i l s o f h i s death, and has twice s i n c e requested the Department's h e l p t & t h problems e f h e r awn h e a l t h . I t had never o c c u r r e d t o & r s J , t o s e p a r a t e h e r husband because o f h i s abusiveness o r i n f i d e l i t y . h e r a w i f e was a person s&o s t a y e d w i t h h e r husband,  from To neverthe-  l e s s , a t t h e begln*iing o f ear c o n t a c t , -oithout the h e l p o f the s o c i a l worker f o r h e r , she would have i n s i s t e d patient r e c e i v e continuing i n s t i t u t i o n a l care. she wis l e f t teith m  that the  X» t h e end  easy c o n s c i e n c e because o f her ssnse o f  "duty w e l l done" i n c a r i n g f o r h e r l a t e husband, snd she thought of fU  the departaseht as a c o n t i n u i n g support.  A. P a t i e n t ffiwt I n s i s t s e n Going o u t . D e s p i t e  faSical  MY E . was f i r s t brought t o the a t t e n t i o n o f  Advice  55 M e d i c a l S o c i a l S e r v i c e i n 1948.  He  s u f f e r e d from a  c a r d i a c c o n d i t i o n , as w e l l as being d i s a b l e d by He has impressed was  severe  arthritis.  v a r i o u s members o f the s t a f f as a person  probably b a s i c S l y o f l i m i t e d i n t e l l i g e n c e and  a b i l i t y to adjust to l i f e ' s pressures* many s i t u a t i o n s which were  who  inadequate  Superimposed have bees  anxiety producing.  Latterly i t  has seemed probable t h e r e i s some o r g a n i c b a s i s f o r mental c o n f u s i o n and  deterioration.  Mr.. K*s  f i r s t wife died i n tragic  circumstances*  H i s second w i f e i s f i f t e e n y e a r s younger than he and has i n t e r m i t t e n t l y h o s p i t a l i z e d f o r mental i l l n e s s our c o n t a c t .  The p a t i e n t * s o l d e s t son, b o m  been  throughout  i n 1944,  has  had  to lake r e s p o n s i b i l i t y above h i s y e a r s f o r the younger c h i l d , a l i t t l e g i r l bom Mr.  in  1950.  k and h i s f a m i l y have l i v e d i n slum h o u s i n g ,  l a t t e r l y o f such a d e t e r i o r a t e d type (two windowless basement rooms w i t h o n l y a tap) as t© be condemned by c i v i c As the p a t i e n t has  authorities.  moved i n and out o f h o s p i t a l , t h e r e have  been w o r r i e s over h i s w i f e , whether i n mental h o s p i t a l o r a t home.  The p a t i e n t ' s mother-in-law, whom he does n o t  o r h i s mother, who  like,  comes from out o f t.own on the oecasbn,  have sometimes l o o k e d a f t e r the c h i l d r e n .  The C h i l d r e n ' s A i d  S o c i e t y have beea a c t i v e over a p e r i o d o f y e a r s i n a b o r d e r l i n e n e g l e c t eituata,en> and we have shared t h e i r concern planning f o r the p a t i e n t ' s c h i l d r e n *  over  A l l e g a t i o n s r e g a r d i n g the  56 p r o m i s c u i t y o f h i s w i f e have been a p a r t o f the p i c t u r e . When the p a t i e n t was h o s p i t a l i z e d here i n t h e w i n t e r o f 1952-1953 h i s w i f e was a g a i n i n mental h o s p i t a l , and m e d i c a l s t a f f a g a i n f e l t t h a t h i s c o n d i t i o n was such t h a t he should accept i n s t i t u t i o n a l c a r e .  As u s u a l , i n e  p a t i e n t refused,; saying t h a t he cared too much about h i s c h i l d r e n , and needed to be a t home when h i s w i f e was d i s charged. S i n c e then he had had h i s w i f e a t home f o r a p e r i o d . At present she i s i n the P r o v i n c i a l Mental H o s p i t a l , and c o u l d r e t u r n home i f he were a b l e to o f f e r h e r some s t a b i l i t y .  The  p a t i e n t has no I n s i g h t i n t o the a b n o r m a l i t y o f the home s i t u a t i o n but does have a b l i n d , d e t e r m i n a t i o n t o remain out o f h o s p i t a l . Ifo c o n s t r u c t i v e change c a n be a n t i c i p a t e d , and t h e s o c i a l s i t u a t i o n w i l l remain a cause f o r concern on s u c c e s s i v e ho s p i t a l l za t i ens .... Housing  Problems Add t o Other  Difficulties  I n January, 1953, t h i s 73 y e a r o l d p a t i e n t , undergoing treatment on the g e n i t o - u r i n a r y s e r v i c e , was r e f e r r e d because o f h i s concern f o r h i s confused, n e a r l y b l i n d wife.. He alss> w o r r i e d about h o u s i n g , as he and h i s w i f e were a l r e a d y paying h a l f t h e i r s m a l l income i n r e n t , and a change o f l a n d l o r d s brought to move.  the p o s s i b i l i t y t h a t n o t i c e would be g i v e n them  The p a t i e n t s a d u l t f a m i l y were a l l o u t o f t h e c i t y . 1  Mr. L. was a s s i s t e d t o make a p p l i c a t i o n t o one o f t h e low r e n t a l  57 housing p r o j e c t s i n the c i t y .  Meanwhile he went o u t on p a s s ,  and s h a r i n g h i s w i f e ' s c o n c e r n about t h e p o s s i b i l i t y o f b e i n g e v i c t e d , took accommodation a t a r e n t a l t o some 70$ o f income.  The p a t i e n t was d i s c h a r g e d f r o m h o s p i t a l some two  weeks l a t e r .  I n March he r e t u r n e d to t h e s o c i a l w o r k e r a f t e r  attending outpatients.  He e x p r e s s e d  c o n c e r n about t h e d i s -  r e p u t a b l e c h a r a c t e r o f some o f t h e o t h e r t e n a n t s i n t h e b u i l d i n g where he was p a y i n g such a h i g h r e n t a l .  H i s concern f o r  h i s w i f e was mounting. I n May t h i s c o u p l e moved i n t o t h e l o w r e n t a l had  housing  scheme t o which we/made r e p r e s e n t a t i o n s on t h e i r b e h a l f . Soon a f t e r the p a t i e n t wag r e a d m i t t e d t o h o s p i t a l , s u f f e r i n g from a h e a r t c o n d i t i o n *  He was p l a c e d on t h e S e r i o u s l y 111  L i s t and became t e m p o r a r i l y d i s o r i e n t e d a'- The s o c i a l w o r k e r h e l p e d b y v i s i t i n g h i s w i f e , about whom he e x p r e s s e d  concern,  because she was due t o r e t u r n t o h e r eye s p e c i a l i s t .  I n June  the p a t i e n t ' s w e l l i - t o - d o son f r o m t h e E a s t v i s i t e d *  The son  t a l k e d o f moving b o t h t h e p a t i e n t and h i s w i f e t o t h e E a s t , but no a c t i o n was t a k e n .  During the l a t t e r p a r t o f June the  p a t i e n t was d i s c h a r g e d t o h i s home, where t h e s o c i a l w o r k e r made a f o l l o w - u p v i s i t t o t h e h o u s i n g  site.  V e r y soon a f t e r -  wards, we r e c e i v e d a r e q u e s t f o r i n f o r m a t i o n from t h e p s y c h i a t r i c ward o f a n o t h e r h o s p i t a l s t a y e d some e l e v e n days*  where t h e p a t i e n t * s w i f e  W i t h i n two weeks' t i m e , a f t e r h e r  d i s c h a r g e , we were r e c e i v i n g a s e r i e s o f phone c a l l s about t h e p a t i e n t ' s w i f e and h i s a b i l i t y t o p l a n ffir h e r when she seemed  58  t o be i n a f r a n k l y d e l u s i o n a l s t a t e .  The  p a t i e n t was  visited  g i v e n support i n h i s current d i f f i c u l t i e s , culminating  i n his  w i f e ' s c o m m i t t a l to the P r o v i n c i a l M e n t a l H o s p i t a l , , and r e t u r n t© Shaughnessy, where he was t i o n a l care..  A l e t t e r of  Went f o r w a r d t o M e d i c a l S o c i a l S e r v i c e i n the DVA  SOB©  discharged to  Some t h r e e months l a t e r the p a t i e n t t r a v e l l e d  E a s t to make h i s home w i t h h i s son.  t h e r e , as i t was  his  recommended f o r i n s t i t u *  A f t e r f o u r months the p a t i e n t was  a b o a r d i n g home.  referral hospital  f e l t p a t i e n t might need t h e i r s e r v i c e .  two y e a r s l a t e r the p a t i e n t ' s son,. ¥Jho had  come h e r e f o r t h e f u n e r a l , o f the p a t i e n t ' s w i f e * c a l l e d a t Shaughnessy t o g i v e the s o c i a l w o r k e r d e t a i l s r e g a r d i n g p a t i e n t * s d e a t h which had M.  taken, p l a c e  the  earlier..  A Case Where the S o c i a l S i t u a t i o n Determines the Need f o r I n s t i t u t i o n a l C a r e . THIS CASE I S GIVEN IN MORE EXTENDED DETAIL THAN OTHERS, IN ORDER TO GIVE SOME IMPRESSION OF PROCESS The  c a s e o f Mr. ffi may  be c i t e d as t y p i c a l o f  t h o s e r e f e r r e d to i n Chapter One, l o n g e r r e q u i r e s a c u t e bed  "Where the p a t i e n t  care . . .  r e t u r n home, but h i s w i f e may c a r e f o r him."  and  he may  no  be a n x i o u s t o  s t a t e t h a t she i s u n a b l e t o  ^ h i s i s f u r t h e r t y p i c a l o f a group o f c a s e s  where the s i t u a t i o n i s b o u r g h t t o the a t t r i t i o n o f M e d i c a l S o c i a l S e r v i c e i n t e r m i t t e n t l y , , so t h a t i n the a g g r e g a t e o f c o n t a c t s i t becomes a ^ l o n g - t e r m case"..  Contact w i l l ,  whenever p o s s i b l e , be renewed by the s o c i a l w o r k e r who  has  known the f a m i l y i n the p a s t , but sometimes by r e a s o n o f case work c o n s i d e r a t i o n s  o r sometimes because o f change o f  59 staff, a different social worker vx.y enter.  This case has been  carriea by teo social writers, the f i r s t a student cloing f i e l d rork in the agency.  I t i s given ija greater detail than are  other esses presented i n this chapter, i n orcier to give evidence of the Mad of tark. dene by 1&e social worker, « s a batls for the discussion i n Carter Three of the social ^ovka^s activity. the patient was f i r s t referred i n A p r i l , 1952* He was a man of 49 years; the medical opinion given ts-ith the referral was that he had Bade the aaxiattia recovery following an accident,  there was residual d i s a b i l i t y of one ana mt leg*  He  was considered to be definitely unemployable from the physical viewpoint, ana had thus become eligible for War Veterans Allowance, through the Department of Veterans Affairs. form of continuing assistance,  This  saaetiaes ksurat as 'the burnt-  out pension' , taay be paid at single or at married rate, but 1  no additional amount i s paid on account of children.  The patient  had; a son and daughter aged 11 and 9, by a wife 10 years younger than he.  The purchase of their hoxiz-t- had not been completed*  -heir economic situation mjuld not be sn easy one*. The patient had no taught but to return home, Bat his wife had feeea an infrequent v i s i t o r , cad x&eitke tise of M s discharge nearest, said she co&Ld not give him the neeesssry care at home.  She alleged her own poor health and the poor  att tude of the patient towards herself iihen he had hem capable of uork, an attitude tiMch she said had further deteriorated since his accident.  She complained of the patient's foul  60 language when she v i s i t e d , and o f h i s p r e v i o u s b r u t a l i t y t o h e r . On the ward, ike p a t i e n t p r e s e n t e d a s q u i e t - s p o k e n * b i d d a b l e , t r o u b l e t o anyone?*  "no  M e d i c a l and n u r s i n g s t a f f were t h e r e f o r e  n o t s y m p a t h e t i c t o t h e w i f e , who was viewed as v o l u b l e a n d excitable*.  A check w i t h a s o c i a l agency w h i c h had a t one t i m e  k n o m the f a m i l y showed t h a t t h e ? viewed h e r a s u n s t a b l e neurotic*  2he f a m i l y d o c t o r , c o n t a c t e d  and  concerning the w i f e ' s  h e a l t h , e x p r e s s e d t h e same o p i n i o n , b u t a l s o viewed t h e p a t i e n t as a very d i f f i c u l t p e r s o n a l i t y . The w i f e was p e r s u a d e d t o p e r m i t t h e p a t i e n t * s more r e t u r n home/on t h e grounds t h a t t h e r e was c a t e g o r i c a l l y no* f u r t h e r r e a s o n f o r h i s s t a y i n h o s p i t a l , t h a n on any r e a l a c c e p t a n c e o f h i m as a s i c k p e r s o n .  F o l l o w - u p V i s i t s were  made by t h e s o c i a l w o r k e r , and t h e w i f e was g i v e n s u p p o r t i n h e r v i e w o f h e r s e l f as c a r r y i n g o u t a v e r y d i f f i c u l t  task*  s i n c e she i n d i c a t e d she was a i l i n g , p o o r and f o r c e d t o c a r e f o r a d i f f i c u l t husband.. The  ease was reopened about a month l a t e r when t h e  p a t i e n t was r e a d m i t t e d service.  On  C o n t a c t was c l o s e d a f t e r some S i x weeks.  t o h o s p i t a l on « t h e g e n i t o - u r i n a r y ,  r e v i e w o f t h e f i l e i t was f e l t i t would be  d e s i r a b l e t t o g i v e f u r t h e r support to the p a t i e n t a s . a b a s i s f r o m whieh an e f f o r t c o u l d be made t o e l i e i t h i s f e e l i n g s about the home s i t u a t i o n , w i t h a v i e w t o p o s s i b l e m o d i f i c a t i o n o f h i s behaviour,,  ( I t appeared c l e a r , d e s p i t e a d m i s s i o n  o f M s w i f e * s tendency t o s e l f - p i t y and e x a g g e r a t i o n ,  that the  61 p a t i e n t ' s behaviour ant*)  when a t home, was a c t u a l l y most u n p l e a s -  L i t t l e r a p p o r t w i t h t h e p a t i e n t was e s t a b l i s h e d ; h e d i d  .not t a l k s p o n t a n e o u s l y , syllabic.  a n i h i s r e p l i e d were a l m o s t a l w a y s mono-  I t was d i f f i c u l t t o judge whether t h e p a t i e n t was t h e  s o r t o f p e r s o n who m i g h t always have, h a d such a response,, o r whether t h e r e was some d e t e r i o r a t i o n i n a f f e c t , i n c i d e n t a l t o his illness..  Nothing  o f s i g n i f i c a n c e was e l i c i t e d , a p a r t from  the f a c t ' t h a t he h a d p r i d e i n h i s f a t h e r , who h a d been a s c h o o l m a s t e r i n Wales;, and i t was q u i t e c l e a r t h a t he f e i t . a man h a d an i n a l i e n a b l e r i g h t t o be c a r e d f o r i n h i s own home.  He  e x p r e s s e d no f e e l i n g s about h i s w i f e o r c h i l d r e n * He n e v e r became i n v o l v e d w i t h o t h e r p a t i e n t s o n t h e ward*  Apart.from  his  r e a d i n g o f p o c k e t t h r i l l e r s , he appeared t o have r e g r e s s e d t o a s o r t o f v e g e t a b l e l e v e l o f existence...  There c o u l d be no f i r m  o p i n i o n a s t o what e x t e n t the c a u s a t i o n was p h y s i o l o g i c a l * There seemed t o be no a j t r e e t o c a s e work w i t h t h e p a t i e n t and i t was t h e r e f o r e d e c i d e d t o work w i t h t h e . w i f e . v i s i t s were made, i n d e f e r e n c e  to h e r stated c o n d i t i o n o f h e a l t h  and i n v i e w o f h e r home r e s p o n s i b i l i t i e s . was  obtained.  Home  She had been an o n l y c h i l d .  Some p e r s o n a l h i s t o r y H e r f i r s t knowledge  o f t h e p a t i e n t was as a v i s i t o r t o t h e home o f c h i l d h o o d p l a y mates.  L a t e r , as a young working woman, u p s e t by t h e b r e a k i n g  o f f o f a n engagement, she became aware t h a t t h e p a t i e n t was formi n g an attachment t o h e r .  H i s f i r s t w i f e had d i e d , l i v i n g  only  l o n g enough t o p r e s e n t h i m w i t h a s o n who was 1 2 y e a r s o f age when he became engaged f o r t h e second t i m e .  F l a t t e r e d by h i s  (  62  a t t e n t i o n s , a l t h o u g h he was married.  She  n o t f a v o u r e d by h e r p a r e n t s ,  s t a t e d t h a t from the, e a r l i e s t days o f the m a r r i a g e  i t b r o u g h t h e r no h a p p i n e s s . who  saw  she  The  p a t i e n t was  depicted  as a  a w i f e as a p r o v i d e r o f c l e a n c l o t h e s , f o o d and  h o l d c a r e , and convenience.  man  house-  as a bedmate, a l l s o l e l y a t the l e v e l o f h i s He d i d o f f e r h e r some s o c i a l l i f e , but  this i n -  v o l v e d b e e r p a r l o u r s and heavy d r i n k i n g , n e i t h e r o f w h i c h would t o l e r a t e .  She  described  she  i n d e t a i l incidents, i n v o l v i n g h i s  drunkeness, v i l e l a n g u a g e , and p h y s i c a l abuse. r  S i n c e h i s i l l n e s s she  s t r e s s e d t h a t t h e r e had  f u r t h e r p h y s i c a l d e t e r i o r a t i o n i n the p a t i e n t . r e t u r n home from h o s p i t a l he had  After his  o n l y i n a pyjama t o p . regardless  He  first  poor u r i n a r y c o n t r o l ; n o t  were t h e r e problems o f b e d w e t t i n g and d r i b b l i n g , b u t he wander about the house, d e s p i t e  been  only  would  the p r e s e n c e o f v i s i t o r s ,  clad  c a l l e d h e r f o u l names and b e r a t e d  o f whom might be p r e s e n t .  her,  He demanded f r e q u e n t  a t t e n d a n c e u p s t a i r s ; he c o u l d n o t be k e p t on t h e main f l o o r cause the bathroom was  upstairs.  (Mrs. M,  f e e l i n g s , seemed u n a b l e t o t o l e r a t e any use o f a bottle.) her  be-  because o f h e r  own  such e x p e d i e n t as  his  Mrs. M had g r e a t need t o have the c h i l d r e n  s i d e " , m a g n i f y i n g t o them e v e r y d e f e c t i n t h e  h i s t o r y and b e h a v i o u r .  She  "on  patient's  d i d n o t respond t o the w o r k e r ' s  e f f o r t s to have h e r g a i n some a c c e p t a n c e o f the p a t i e n t ' s h a v i o u r as b e i n g the outcome o f h i s s t a t e o f h e a l t h , n o r  bewas  t h e r e any m o d e r a t i o n o f the h e a t o f h e r r e a c t i o n , i n the i n t e r e s t s o f more t r a n q u i l home l i f e f o r the c h i l d r e n .  She  continued to  63  be a m e t i c u l o u s housekeeper and a good manager on l i m i t e d i n come. The  s o c i a l recommendation was made t h a t t h e p a t i e n t  e o u l d n o t be c a r e d f o r a t home.  T h i s recommendation was acceded  t o , b u t n e v e r w e l l a c c e p t e d by m e d i c a l and n u r s i n g  staff, to  whom Mr. M c o n t i n u e d t o p r e s e n t as "a good p a t i e n t " .  He was r e -  c l a s s i f i e d t o s e c t i o n 29, b u t remained on t h e a c t i v e t r e a t m e n t ward* C o n t a c t was m a i n t a i n e d i n v i e w o f t h e sympathy a r o u s e d i n the nursing  s t a f f because t h e p a t i e n t ' s w i f e and c h i l d r e n  d i d n o t v i s i t him.  A g a i n Mrs. M's i n a b i l i t y t o p r e s e n t , t h e  p a t i e n t i n any t o l e r a b l e l i g h t t o t h e c h i l d r e n was n o t e d . C h r i s t m a s v i s i t home was a r r a n g e d . the p a t i e n t used t h e o c c a s i o n  A  The w i f e ' s a c c o u n t was t h a t  to berate her f o r leaving him i n  h o s p i t a l " t o r o t " ; t h e p a t i e n t ' s r e a l i s t i c a l l y based sense o f r e j e c t i o n h a d been h o a r d e d up and g i v e n f u l l e x p r e s s i o n , .  The  p a t i e n t ' s w i f e now t o o k i n b o a r d e r s , she s t a t e d from economic necessity.  I t appeared t h a t she c o u l d . t o l e r a t e t h e s t r a i n o f  p r o v i d i n g f o r s t r a n g e r s , b u t n o t f o r t h e patient..  Further  urin-  a r y d i f f i c u l t i e s and t h e f a c t t h a t t h e p a t i e n t was now o n c a t h e t e r gave.more m e d i c a l r e a s o n f o r h i s r e t e n t i o n i n h o s p i t a l . Mrs. M t h r o u g h o u t t h i s p e r i o d was under m e d i c a l c a r e a t t h e Outpatient's ferred  Department i n a n o t h e r h o s p i t a l , t o w h i c h we had..re-  her. A v i s i t f r o m t h e p a t i e n t ' s b r o t h e r from t h e East., whom  he had n o t seen f o r many y e a r s , brought need f o r c a r e f u l e x -  64 p l a n a t i o n s from the s o c i a l w o r k e r , when he wondered why nephews d i d not v i s i t  the p a t i e n t , and why  his  he c o u l d n o t he  car-  ed f o r i n h i s own home, when he so a c t i v e l y e x p r e s s e d t h e w i s h t o be o u t o f h o s p i t a l . The  ease was  a f t e r seven months.  c l o s e d to S o c i a l S e r v i c e and  The  p a t i e n t had g r a d u a l l y improved t o  e x t e n t o f becoming more a m b u l a t o r y , and was the ward he was  on.  He  reopened the  to be moved f r o m  r e f u s e d t o be s h i f t e d , announced  c a r r i e d out h i s i n t e n t i o n of r e t u r n i n g home.  and  At t h i s point h i s  w i f e t e l e p h o n e d f i r s t the d o c t o r , and, a t h i s s u g g e s t i o n , s o c i a l worker. she had  Her p r o t e s t s were v e r y heated..  She  said  the that  f a l l e n i n a s s i s t i n g the p a t i e n t t o g e t t o the bathroom,  as he c o u l d n o t walk u p s t a i r s a l o n e .  As she h e r s e l f had  been  s l e e p i n g on a c o t , t o y i e l d up bedroom space t o the b o a r d e r s , she had  t o g i v e the c o t t o t h e p a t i e n t and  daughter.  share a bed w i t h  her  Mr. M had k e p t the f a m i l y and b o a r d e r s awake a l l  n i g h t by pounding the f l o o r w i t h h i s cane demanding a t t e n t i o n when he c o u l d not open d o o r s . made him ever.  " i m p o s s i b l e " a t home.  She  s a i d t h a t h i s u r i n a r y urgency  H i s language was  worse t h a n  She had been i n t o u c h w i t h a l a w y e r even b e f o r e  a c c e p t from us e x p l a n a t i o n s  she did.  t h a t we had no r i g h t t o f o r c e  p a t i e n t ' s r e t u r n to h o s p i t a l ,  (The  the  a s s u m p t i o n by w i v e s t h a t  can compel a p a t i e n t ' s a c t i o n s i s a f r e q u e n t one,  and  we  doubtless  a r i s e s f r o m r e c o l l e c t i o n o f e a r l i e r a u t h o r i t y e x e r c i s e d when t h e . p a t i e n t s were i n the armed f o r c e s .  I t would seen t h a t t h e y  65  w i s h f u l l y deny t h e c i v i l i a n s t a t u s o f patients?,  Mrs, M threaten-  ed r e t r e a t i n t o i l l n e s s , and l e g a l s e p a r a t i o n from t h e p a t i e n t , . The p a t i e n t ' s need o f i n s t i t u t i o n a l c a r e seemed now t o l i e i n abeyance u n t i l some f u r t h e r d e t e r i o r a t i o n i n h e a l t h s h o u l d t a k e place, t o f o r c e h i s r e t u r n , o r the wife, c a r r y out h e r t h r e a t s . However, a few days l a t e r he was a d m i t t e d a g a i n t o h o s p i t a l , , s a y i n g o n l y t h a t home c o n d i t i o n s ( s t a i r s , e t c . ) were t o o d i f f i c u l t f o r him. As e a r l i e r s t a t e d , each o f t h e c a s e s p r e s e n t e d i n p r e c i s form i n t h i s c h a p t e r h a s been chosen a s r e p r e s e n t i n g  typic-  a l l y a p r o b l e m r e c u r r i n g f r e q u e n t l y i n many cases w h i c h come t o Medical Social Service.  The range o f c a s e s does n o t p r e t e n d t o  be e x h a u s t i v e , b u t i t i s b e l i e v e d , does p r e s e n t a s u f f i c i e n t base from which, t o p r o c u r e m a t e r i a l w h i c h w i l l p e r m i t a n a l y s i s o f the a c t i v i t y o f t h e s o c i a l worker i n moving towards a s o c i a l recommendation. . A l t h o u g h t h e s e Cases a l r e a d y r e p r e s e n t groups o f t y p i c a l s i t u a t i o n s , I t might be p o s s i b l e t o group them f u r t h e r — > f o r example, by t h e end-product o f t h e recommendation  FOR o r  AGAINST i n s t i t u t i o n a l c a r e j, a c c o r d i n g t o t h e s t r e n g t h o f t h e ' m a r i t a l r e l a t i o n s h i p ; o r according to the s o c i a l diagnosis o f the n a t u r e o f t h e whole problem I n v o l v e d .  As t h e y do n o t n e c e s s a r i l y  r e p r e s e n t t h e f u l l range o f problems, such f u r t h e r g r o u p i n g would appear I r r e l e v e n t t o t h e purpose o f t h e study.. The I n t e n t i o n i n p r e s e n t i n g eases i s t o o f f e r c a s e s w h i c h a r e t y p i c a l , , and w h i c h d i s p l a y a t l e a s t a c o n s i d e r a b l e v i e w o f t h e range o f a c t i v i t y o f t h e case w o r k e r .  Chapter I I I S o c i a l Work S e r v i c e s i n t h e Cases H a v i n g examined i n Chapter One t h e u n i v e r s a l i t y o f t h e problem under s t u d y , i t s n a t u r e i n t h e p a r t i c u l a r s e t t i n g , a n d the u s e f u l n e s s o f t h e p r o f e s s i o n a l l i t e r a t u r e i n r e s o l v i n g o u r d i f f i c u l t i e s ; h a v i n g i n C h a p t e r Two p r e s e n t e d some c a s e s  chosen  as p y p i c a l ; i t i s now proposed t o examine t h e n a t u r e o f t h e s o c i a l w o r k e r ' s a c t i v i t y i n making t h e s o c i a l recommendation f o r or against the n e c e s s i t y o f i n s t i t u t i o n a l care. s o c i a l w o r k e r approach, t h e problem?  How does t h e  What are t h e s e r v i c e s she  g i v e s , d i r e c t l y and i n d i r e c t l y , i n t h e s e r v i c e t o t h e p a t i e n t ? C e r t a i n l y i t . i s n o t always p o s s i b l e t o s e c u r e a l l t h e background i n f o r m a t i o n t h a t might i d e a l l y be d e s i r e d , i f t h e s i t u a t i o n o f t h e p a t i e n t and h i s w i f e a r e t o be u n d e r s t o o d . I t i s o n l y on t h e b a s i s o f such knowledge o f t h e i r f e e l i n g s about one a n o t h e r , and t h e p a t i e n t ' s i l l n e s s , as i t a f f e c t s t h a t ing,  feel-  t h a t t h e s o c i a l w o r k e r can t r u l y see t h e i r s i t u a t i o n i n t h e  l i g h t o f t h e s e a anemone-like s l i p p i n g , s l i H I n g , f o l d i n g , u n f o l d i n g f a c t t h a t f e e l i n g s a r e ; and, h a v i n g seen, d e c i d e whether i t w i l l be n e c e s s a r y t o a c c e p t , o r d e s i r a b l e t o endeavour t o alter existing attitudes.  I n some c a s e s t h e d e c i s i o n t o a l t e r  may be made and t h e e f f o r t pursued, whether s u c c e s s f u l l y o r u n successfully.  The a v a i l a b i l i t y o f t i m e i n w h i c h t o c a r r y om\ t h e  67  e f f o r t w i l l have an e f f e c t on t h e apparent j u s t i c e o f t h e s o c i a l prognosis;  I f a man and w i f e approach a f a m i l y ageney a b o u t a  m a r i t a l d i f f i c u l t y > t h e y may spend s i x months o r two y e a r s i n s o r t i n g matters o u t i  I f a man e n t e r s h o s p i t a l , he does so f o r  the t r e a t m e n t o f h i s h e a r t c o n d i t i o n o r h i s h e m i p l e g i a , l e t us s a y — h e i s n o t asking f o r s o c i a l treatment o f h i s  marriage  d i f f i c u l t y , even though m e d i c a l s t a f f may see i t a s c l e a r l y c o n t r i b u t i n g t o f a i l u r e t o make t h e maximum r e c o v e r y from t h e physical disability*  I f the p a t i e n t g i v e s h i s consent,  fully,  r a t h e r than g r u d g i n g l y , t h e r e i s u s u a l l y n o t any l e n g t h y p e r i o d a v a i l a b l e i n w h i c h he c a n u s e t h e s k i l l e d h e l p o f t h e s o c i a l w o r k e r t o a c h i e v e some a m e l i o r a t i o n o f t h e p e r s o n a l  situation*  There a r e o f t e n sound m e d i c a l and a d m i n i s t r a t i v e reasons f o r p r e s s u r e e n t h e s o c i a l w o r k e r t o come t o a f i r m p r o g n o s i s and make a f i r m recommendation, w i t h i n a timespan, w h i c h , i n any o t h e r s e t t i n g , would be c o n s i d e r e d t o o f f e r t o o b r i e f a base from which t o come t o sound c o n c l u s i o n s . The m e d i c a l s o c i a l w o r k e r must then b r i n g t o h e r c l i e n t the soundly-based  c o n v i c t i o n t h a t she h a s a s much r i g h t t o p r o b e ,  s k i l l f u l l y and p u r p o s e f u l l y ( a l t h o u g h sometimes a t t h e c o s t o f temporary p a i n ) a s has t h e d o c t o r .  The j u s t i f i c a t i o n c a n o n l y  be t h e same a s t h a t w h i c h j u s t i f i e s t h e p h y s i c i a n ' s approach t o t h e more p u r e l y p h y s i c a l d i f f i c u l t i e s , t h e most i n f o r m e d  direc-  t i o n o f s k i l l t o produce b e t t e r f u n c t i o n , o r a t l e a s t t o a v e r t f u r t h e r l o s s o f f u n c t i o n , whether s o c i a l o r p h y s i c a l .  The s o c i a l  68  worker i n the h o s p i t a l s e t t i n g needs c o n f i d e n c e  i n her. s k i l l  and  needs warmth o f approach i n o r d e r t o e n t e r s u c c e s s f u l l y i n t o h e r d i f f i c u l t t a s k i n the b r i e f time a l l o t t e d . Because o f the t i m e f a c t o r , a f u l l s o c i a l s t u d y i s n o t (  always completed, as a s e r v i c e t o a i d i n the u n d e r s t a n d i n g o f p a t i e n t ' s problems.  The  the  s e r v i c e s w h i c h a r e r e n d e r e d have been  g r o u p e d . f o r d i s c u s s i o n i n t o d i r e c t and i n d i r e c t s e r v i c e s . . I  be-  l i e v e t h a t t h e c o n s i d e r a b l e v a r i e t y o f t a n g i b l e and l e s s t a n g i b l e s e r v i c e s g i v e n by s o c i a l w o r k e r s i n v e t e r a n s h o s p i t a l s - c a n f i t t e d , w i t h o u t too much w a r p i n g o r b e n d i n g , i n t o the t i o n o f s e r v i c e s o f f e r e d below.  be-  classifica-  I t i s proposed t o d i s c u s s  these  i n r e l a t i o n t o t h e "sample" eases w h i c h were s e t out i n compressed f o r m i n C h a p t e r  Two.  S e r v i c e s Rendered D i r e c t l y t o t h e P a t i e n t and H i s 1.  life  I d e n t i f y i n g the N a t u r e o f the I n t e r - p e r s o n a l  Relations  When, t h e s o c i a l w o r k e r becomes i n v o l v e d i n the d e c i s i o n as t o whether a m a r r i e d p a t i e n t s h o u l d r e t u r n t o h i s home o r may  require continuing care, her f i r s t  task i s to i d e n t i f y  the  n a t u r e o f the r e l a t i o n s t h a t e x i s t between him and h i s w i f e , w i t h l a t e r a t t e n t i o n t o t h e s e as t h e y a r e a f f e c t e d by the t u d e s o f c h i l d r e n o f the m a r r i a g e , o r o t h e r r e l a t i v e s . . worker i s r e q u i r e d t o form a judgment.  The  I n i t i a l l y t h i s may  attisocial be  c r u d e , based on t h e o b s e r v a t i o n o f the most o b v i o u s f a c t s , and. may  be s t a t e d i n t h e s i m p l e o p i n i o n :  t i o n s are bad*  r e l a t i o n s a r e good, r e l a -  S k i l l e d a t t e n t i o n t o the. n e x t question,..- why?  69  may  show t h a t "good" i s n o t n e c e s s a r i l y as h e l p f u l as i t f i r s t  presents  i t s e l f , and t h a t "bad"  may  be s u s c e p t i b l e o f change*  P e r s o n s w i t h "good" r e l a t i o n s h i p s may  s t i l l need a s s i s t a n c e i n  f a c i n g the s i t u a t i o n , encompassed i n i l l n e s s , , age, economic  and l i m i t e d  resources. I n the t h r e e cases o f "A E e n t a l l y D i s t u r b e d P a t i e n t " , ,  i n (a) and  (b) r e l a t i o n s were warm and  t o t h e p a t i e n t concerned*,  I n ( e ) , however, a l t h o u g h t h e r e  be no q u e s t i o n t h a t the p a t i e n t had and  s u p p o r t i v e and h e l p f u l can  a loving wife, her a f f e c t i o n  c o n c e r n took forms t h a t were d e l e t e r i o u s , r a t h e r t h a n h e l p *  f u l to h i s recovery.  The w i f e d i d not respond t o the  social  worker's e f f o r t s t o s e c u r e a change i n h e r ways o f e x p r e s s i n g  her  c o n c e r n f o r the p a t i e n t ' s w e l f a r e , B and J a r e s i t u a t i o n s where the m a r r i a g e had been t o a l a r g e . e x t e n t unrewarding t o t h e w i f e , o r where i t had a t l e a s t b r o u g h t a f u l l measure o f p a i n and d i s a p p o i n t m e n t . , I n B  the  s o c i a l worker f e l t t h a t t h e w i f e s h o u l d not be burdened with: t h e care of the p a t i e n t .  The  degree o f h i s p h y s i c a l h a n d i c a p  i n t o the recommendation, but so a l s o d i d the degree o f  entered  "sacrifice"  t h a t would have been e x p e c t e d o f the w i f e , i f c a l l e d upon t o  care  f o r him a t home,.  that  I n J t h e s o c i a l worker came t o t h e o p i n i o n  t h e w i f e c o u l d , w i t h adequate s u p p o r t i n h e r d i f f i c u l t  role,  u n d e r t a k e t h e c a r e o f the p a t i e n t , and t h i s she p r o v e d a b l e t o for a considerable  do  period, despite her i n i t i a l r e f u s a l .  I n C and D are examples o f t r u l y a f f e c t i o n a t e  couples.  70  o f v e r y d i f f e r e n t s o e i a l backgrounds, t h e one an o f f i c e r and h i s l a d y , t h e o t h e r a l a b o u r i n g man and; h i s f e e b l e - m i n d e d w i f e .  In  b o t h s i t u a t i o n s , however, because o f the m u t u a l warmth o f f e e l ing,  t h e p a t i e n t was e n a b l e d t o be l o n g e r a t home than m i g h t  have been p r e d i c t e d , on t h e b a s i s o f h i s p h y s i c a l c o n d i t i o n alone* I n such a case a s t h a t depjtted i n 3?, t h e r e i s a b a s i c a l l y good r e l a t i o n s h i p , ' b u t one b a r e l y h a v i n g t h e s t r e n g t h t o endure t h e s t r a i n , o f t h e w i f e ' s l o n g dependence, w h i c h l e f t t h e p a t i e n t ' s own s i m i l a r needs unment. I n F and M, whatever t h e w i f e ' s i n i t i a l e n t r e e i n t o the m a r r i a g e ( i n t h e e a r l i e r c a s e t h e r e i s l i t t l e  information,  i n M more), h e r f e e l i n g s a t t h e time t h e p a t i e n t i s b r o u g h t t o a t t e n t i o n a r e a k i n t o h a t e and f e a r .  These f e e l i n g s , once a d -  m i t t e d , b r i n g g u i l t and d e f e n s l v e n e s s i n t h e i r t r a i n .  I n the  M c a s e an e f f o r t i s made by t h e s o c i a l w o r k e r to' a s s i s t i n working  through t h e s e f e e l i n g s , and t h e e f f o r t  fails.  I n H, o f i n t e r e s t a r e n o t o n l y t h e r e l a t i o n s o f t h e p a t i e n t w i t h h i s wife,' b u t t h o s e w i t h h i s s o n and g r a n d d a u g h t e r , t h e i r f e e l i n g towards h i s w i f e , and t h e i n t e r a c t i o n s o f t h e s e . Initially,  t h e " f a m i l y " ask outside help I n planning  for his  w i f e , t h e y seem t o be somewhat r e j e c t i n g o f h i m b u t s a y t h e y a r e w i l l i n g t o care f o r her; they then proceed t o p l a c e her,  with  c i t y h e l p ; l a t e r when t h e p a t i e n t and h i s w i f e a g a i n s e t up joinfc h o u s e k e e p i n g , t h e f a m i l y do n o t v i s i t ; i n t h e end,  after  71  the p a t i e n t ' s death, they accept r e s p o n s i b i l i t y f o r h i s w i f e . I t i s n e c e s s a r y f o r t h e s o c i a l worker n o t o n l y t o be aware o f t h e s h i f t i n f e e l i n g , b u t o f t h e i r i m p a c t o n t h e p a t i e n t and his-plans.  The p a t i e n t ' s l i f e h a s a l w a y s c o n s i s t e d , n o t j u s t  o f h i m as an i n d i v i d u a l , b u t one who i s a member o f a f a m i l y . I t i s e a s i e r i n a h o s p i t a l t h a n i n some o t h e r s e t t i n g s , t o i g n o r e , i f c a r e i s n o t e x e r c i s e d , t h e s h i f t i n g ferment o f f a m i l y f e e l i n g s as t h e y i m p i n g e on t h e p a t i e n t and h i s changing  situation.  The s o c i a l w o r k e r i s t h e r e t o a s s e s s t h e q u a l i t y  and e f f e c t o f t h e s e s o c i a l f a c t o r s ? , 2.  F u r t h e r i n g U n d e r s t a n d i n g o f and Adjustment t o I l l n e s s  and P r e s c r i b e d Regimen I t must be a d m i t t e d t h a t none o f t h e eases chosen f o r t h i s study I l l u s t r a t e p a r t i c u l a r l y w e l l t h e s o r t o f d i r e c t s e r v ice  that medical s o e i a l workers i n h o s p i t a l s are o f t e n c a l l e d  on t o g i v e .  The f e e l i n g s of. p a t i e n t s and t h e i r f a m i l i e s about '  p r e s c r i b e d d i e t s , t h e i r m i s u n d e r s t a n d i n g s about t h e n a t u r e o f an i l l n e s s , o r t h e e f f e c t s o f p r e s c r i b e d t r e a t m e n t , may be d e a l t w i t h i n i t i a l l y by t h e d o c t o r , t h e d i e t i c i a n , t h e p h y s i o - t h e r a p i s t , t h e X - r a y t e c h n i c i a n o r some o t h e r member o f s t a f f .  The  s o e i a l w o r k e r may be c a l l e d o n t o r e i n f o r c e t h e p a t i e n t ' s understanding o f t h e i n f o r m a t i o n already given, b u t i n p a r t i c u l a r t o u n d e r s t a n d t h e o r i g i n o f and t o d e a l w i t h t h e emotions t h a t a r e b l o c k i n g a genuine a c c e p t a n c e o f t r e a t m e n t n e c e s s i t i e s , and a b i l i t y t o p u t them t o good use..  72  Where some o f t h i s a c t i v i t y h a s o c c u r r e d i n t h e eases chosen,, t h e e x t e n t o f t h e a c t i v i t y h a s t o some e x t e n t been o b scured by the omission o f d e t a i l i n the r e d u c t i o n t o precis.. F o r i n s t a n c e * i n t h e case o f Mr,. J i as i t i s p r e s e n t e d ,  there  i s r e f e r e n c e t o h i s " s u f f e r i n g , * • from a m i l d degree o f diabetes'**  T h i s p r e s e n t e d a problem i n h i s r e t u r n home, a t one  p o i n t , . On account o f seme v i s u a l d i s a b i l i t y he c o u l d n o t admini s t e r h i s own i n s u l i n * • H i s w i f e d e c l a r e d , almost w i t h t e r r o r , t h a t she c o u l d not " s t i c k a n e e d l e i n t o " him. Because o f a knowledge o f t h e e a r l i e r d i f f i c u l t i e s i n t h e m a r r i a g e , t h e s o c i a l .worker f e l t t h a t t h i s r e p r e s e n t e d a r e a l  emotional  b l o c k t o t h e w i f e and she was n o t p r e s s e d t o change*  The p a t i e n t  made h i s own arrangements t o have h i s d a i l y does g i v e n a t a s m a l l p r i v a t e h o s p i t a l n e a r h i s home. In for  t h e s i t u a t i o n o f Mr* E one o f t h e s p e c i f i c  reasons  a home v i s i t was t o g i v e h i s w i f e a b e t t e r u n d e r s t a n d i n g o f  the n a t u r e o f h i s i l l n e s s .  Because o f h e r f e a r o f b e i n g  left  a l o n e , w i t h o u t t h e p a t i e n t t o c a r e f o r h e r , she panicked when he had one o f h i s d i z z y s p e l l s , t h e r e b y r e i n f o r c i n g , h i s  concern  and f e a r s about h i s own c o n d i t i o n . She was H e l p e d t o u n d e r s t a n d t h a t i t was n o t n e c e s s a r y t o r u s h h i m t o h o s p i t a l e a c h time he f e l t dizzy.. The v i s i t was n e c e s s a r y as she was c o n f i n e d t o t h e house and e o u l d n o t v i s i t h o s p i t a l .  I t a s s i s t e d i n postponing  the p a t i e n t ' s r e t u r n f o r t r e a t m e n t . I n A ( c ) an e f f o r t was made by t h e s o c i a l w o r k e r t o  73  f u r t h e r a d j u s t m e n t s i n the a t t i t u d e o f the p a t i e n t s  wife.  1  H e r way  o f r e a c t i n g t o the p a t i e n t ' s p h y s i c a l and m e n t a l d i s -  a b i l i t i e s a c t u a l l y r e s u l t e d i n t h e i r exageration. c o u l d n o t be h e l p e d t o a d j u s t and  the p a t i e n t ' s  d e t e r i o r a t e d , h i s admission f o r continuing 3.  S u p p o r t i n g the P a t i e n t ' s B i g h t t o The  Because  she  condition  c a r e was  necessary.  Self-Determination  p r o p o s e d code o f ^ethics- o f the C a n a d i a n A s s o c i a -  t i o n of S o c i a l Workers worker should recognize t o make t h e i r own  1  s t a t e s ( P a r t I I , 1 (B) ) : "The  social  and a c c e p t the r i g h t o f p e r s o n s s e r v e d  d e c i s i o n s and  t o a c t f o r themselves  unless  t h e y f r e e l y g i v e t h i s a u t h o r i t y t o the agency, o r u n l e s s  the  ageney must a c t i n a p r o t e c t i v e r o l e i n o r d e r t o s a f e g u a r d  the  p e r s o n s s e r v e d o r the community." S o c i a l w o r k e r s have been t r a i n e d i n the l i g h t o f principle. application.  this  A h o s p i t a l can become an a c i d t e s t i n g ground f o r i t s The  " r i g h t to self-determination"  can become a t  t i m e s the r i g h t t o s e l f r d e s t r u c t i o n , o r t o d e s t r u e t l v e n e s s the r i g h t s o f o t h e r s .  What can be done i s to g i v e the  of  patient  a f u l l u n d e r s t a n d i n g o f the m a t e r i a l s from w h i c h h i s d e c i s i o n must be made, and his  f u l l support i n our s u b s c r i b i n g g e n u i n e l y to .  r i g h t t o do h i s own  deciding.  O n l y i f he i s s e n i l e , p s y c h -  o t i c or temporarily not i n f u l l c o n t r o l of h i s f a c u l t i e s ,  may  1. C a n a d i a n A s s o c i a t i o n o f S o c i a l W o r k e r s , B.C. M a i n l a n d Branch,. March 29, 1954, m a t e r i a l r e c e i v e d from the N a t i o n a l Committee on E t h i c s , "Proposed Code o f E t h i c s f o r C.A.S.W." Mimeographed.  74 we p r o p e r l y decide f o r him.  By the e x e r c i s e o f the s k i l l s o f  the case worker, understanding p a s t experiences which, have made i t d i f f i c u l t f o r t h e p a t i e n t to come t o wise d e c i s i o n s , we may sometimes a s s i s t him t o adopt more f r u i t f u l courses o f a c t i o n than he might a c c e p t ,  unaided.  As i n P, where "repeated admissions a r i s e from the home s i t u a t i o n " , t h e r e a r e many cases where the p a t i e n t i s saying i n h i s a c t i o n s , and can he persuaded t o s a y i n words, t h a t he f i n d s i t p a i n f u l and d i f f i c u l t to l e a v e the h o s p i t a l f o r h i s home.  The s t e r e o t y p e  o f t h e h o s p i t a l seen by t h e  community and sometimes a l s o phantasled  by the h o s p i t a l  S t a f f i s t h a t o f t h e p a t i e n t g r a t e f u l f o r h i s cure o r r e m i s s i o n o f symptoms who r e t u r n s to a welcoming f a m i l y . always h o l d  T h i s does n o t  t r u e ; he c a n r e t u r n to t h e burden o f c a r e s ,  than to the p l e a s u r e s  o f convalescence.  rather  I t i s a matter o f  s k i l l e d p r o f e s s i o n a l judgment, w i t h i n t h e competence o f the s o c i a l worker, t o d e c i d e hew much o f t h e f e e l i n g r e g a r d i n g the care i t i s safe t o s i p h o n o f f , a s too much r e l e a s e  will  arouse f e e l i n g s o f g u i l t whichtil11 o n l y add to the p a t i e n t ' s discomfort.  I n F, g i v e n h e l p t o express h i s f e e l i n g s , and  some c o n t i n u i n g was  i n t e r m i t t e n t supportive  contact,  the p a t i e n t  enabled t o make h i s own d e c i s i o n t h a t he would be most  comfortable i n r e t u r n i n g home t o care f o r h i s w i f e . I n 6 , the p a t i e n t e x e r c i s e d h i s p r i v i l e g e o f r e t u r n i n g home, d e s p i t e the Information t h a t i t was t o o much  75  f o r h i s wife's h e a l t h to provide  the s o r t o f care he needed.  I t was d i f f i c u l t f o r h e r to express t h i s to the p a t i e n t , because o f h e r a f f e c t i o n f o r him and h e r w i s h t o care f o r him  i f at a l l possible.  Had she l i v e d i n the c i t y , where  the m e d i c a l s o c i a l worker might have d e a l t w i t h h e r d i r e c t l y r a t h e r than through i n t e r m e d i a r i e s , an e a r l i e r d e c i s i o n might have been a r r i v e d a t .  I n the end -the p a t i e n t d i d  accept t h a t he must be c a r e d f o r i n t h e i n s t i t u t i o n a l s e t t i n g , but he r e q u i r e d support a f t e r h i s d e c i s i o n was made. a c t i v i t y o f the s o c i a l worker i n m o b i l i z i n g community to p r o v i d e  The resources  care f o r h i s w i f e , a f t e r he had come permanently  i n t o our s e t t i n g , h e l p e d him t o f e e l t h a t he had made t h e r i g h t decision. I n F , the p a t i e n t d i d n o t a c c e p t e f f o r t s t o have him a l t e r h i s d e c i s i o n to r e t u r n t o h i s home. l i n e case where one f e l t  T h i s was a b o r d e r -  t h a t h i s judgment was somewhat  Impaired, and y e t n o t t o a degree where there would be j u s t i f i c a t i o n for exercising authoritative control. worker's r o l e l a y , then, i n m a i n t a i n i n g  The s o c i a l  acceptance from h i s  w i f e and son o f h i s r i g h t to s e l f - d e t e r m i n a t i o n , even when it  so s a d l y a f f e c t e d h i s w i f e ' s p h y s i c a l c o n d i t i o n . I n K, where the p a t i e n t i n s i s t e d on going o u t to h i s  p s y c h o t i c w i f e and n e g l e c t e d  c h i l d r e n i n slum h o u s i n g , d e s p i t e  the o p i n i o n o f the m e d i c a l s t a f f t h a t from the s t r i c t l y p h y s i c a l viewpoint he r e q u i r e d our c a r e , the s o c i a l worker was unable to e f f e c t any change i n the p a t i e n t s d e c i s i o n . 1  76 The consequences f o r t h e c h i l d r e n a l s o caused community c o n c e r n w h i c h was n o t s h a r e d by t h e p a t i e n t . exercise r e s t r a i n t .  We s t i l had no r i g h t t o  The s o c i a l w o r k e r ' s r o l e t h e r e f o r e l a y i n  p a r t i n g a i n i n g a c c e p t a n c e by s t a f f  and t h e s o c i a l w o r k e r s  o f an o u t s i d e agency, t h a t we c o u l d n o t d e t a i n t h e p a t i e n t , even i n what appeared t o be h i s own b e s t i n t e r e s t s and t h o s e o f his  children. 4-  G i v i n g o r R e i n f o r c i n g U n d e r s t a n d i n g o f MA As s a i d i n number 2:  Regulations  " F u r t h e r i n g adjustment t o i l l -  n e s s and p r e s c r i b e d regimen", cases chosen f o r p r e s e n t a t i o n cannot i l l u s t r a t e e q u a l l y w e l l a l l t h e s e r v i c e s g i v e n by t h e m e d i c a l s o c i a l worker.  Those w h i c h i l l u s t r a t e  particularly  w e l l s o m e s e r v i c e s may show l e s s w e l l o t h e r s , w h i c h i n a c t u a l 1  day t o day work a r e f r e q u e n t l y  given.  This i s true o f the s o c i a l worker's r e s p o n s i b i l i t y t o give explanations  o f departmental r e g u l a t i o n s .  Actually, this  i s n o t , p e r se. a p r i m a r y r e s p o n s i b i l i t y o f t h e s o c i a l w o r k e r , but f a l l s s t r i c t l y w i t h i n the province o f the Veterans W e l f a r e Officer.  (See I I I . I n d i r e c t S e r v i c e s , 3.)  However, t h e s o c i a l  worker may o f t e n i n i t i a t e such d i s c u s s i o n , o r respond t o t h e patient's questions  i n a b r o a d way, w i t h d e t a i l s t o be f i l l e d i n  l a t e r by t h e W e l f a r e O f f i c e r .  Or t h e s o c i a l worker may be c a l l -  ed on f o r m a l l y , o r drawn i n i n f o r m a l l y , t o t h e n e c e s s i t y o f d e a l i n g w i t h t h e p a t i e n t ' s f e e l i n g s as t h e y a r i s e around t h e r e g u l a -  77  tions.  "The V e t e r a n s C h a r t e r " ^ c o n t a i n s some t h i r t y A c t s , o u t -  l i n i n g t h e r i g h t s and p r i v i l e g e s o f v e t e r a n s *  Many o f t h e s e ,  as w i t h l e g i s l a t i o n g o v e r n i n g t h e a f f a i r s o f t h o s e o t h e r than, v e t e r a n s , a r e supplemented renewed and r e v i s e d .  by c o p i o u s r e g u l a t i o n s , f r e q u e n t l y  I n t h e n a t u r e o f a reward f o r t h e d i s -  charge -of p a t r i o t i c d u t i e s , i n v o l v i n g r i s k t o l i f e , and p h y s i c a l and o t h e r changes t o t h e person., t h e v e t e r a n * s p r i v i l e g e s a r e f e l t b y h i m t o be r i g h t s .  E s s e n t i a l l y , and a l s o because  t h e r e a r e a c t i v e p r e s s u r e groups i n t h e Canadian L e g i o n and o t h e r s e r v i c e men's o r g a n i z a t i o n s , p u s h i n g f o r change, and b u i l d i n g on any e x i s t i n g sense o f i n j u s t i c e , much e m o t i o n attaches t o the i n t e r p r e t a t i o n e f l e g i s l a t i o n ,  ©eductions from  W a r V e t e r a n s A l l o w a n c e on account o f h o s p i t a l i z a t i o n ! t h e g r a n t i n g o r w i t h h o l d i n g o f T r e a t m e n t A l l o w a n c e s , depending  on  m e d i c a l ©pinion a s t o whether o r n o t a p a t i e n t I s b e i n g t r e a t e d f o r h i s pensionable d i s a b i l i t y * pension r a t e s ; o p i n i o n s as t o whether e n A l l o w a n c e may be p a i d a t t h e m a r r i e d o r s i n g l e rate«-about such, r u l i n g s p a t i e n t s may have f e e l i n g s q u i t e p a s s i o n a t e . i n t h e i r i n t e n s i t y , none t h e l e s s so because a s o u r c e o f Income may be i n v o l v e d * Where a r e many ways o f d e a l i n g w i t h a n g e r ; o f t e n i n t h e h o s p i t a l t h e s o c i a l worker's way h a s come t© be respected,... because i t i s found t h a t i t i s h e l p f u l t o t h e p a t i e n t .  The  p e r s o n l e s s s k i l l e d i n u n d e r s t a n d i n g and d e a l i n g w i t h emotion ;  may say " i t i s wrong t o f e e l l i k e t h a t " , o r "you mustn't t a l k 1.  "The V e t e r a n s C h a r t e r " , K i n g ' s P r i n t e r , Ottawa.  78  l i k e that".  The s o e i a l w o r k e r , from t r a i n i n g and e x p e r i e n c e  knows t h a t w i t h one p e r s o n t h e e x p r e s s i o n of- f e e l i n g may  most  w i s e l y be encouraged, b u t t h a t w i t h a n o t h e r i t i s i m p e r a t i v e i t be dammed back.  Dealing w i t h departmental r e g u l a t i o n s I s  n o t j u s t a m a t t e r o f r e c i t i n g o r r e i t e r a t i n g f a c t s , b u t of, guaging t h e r e a s o n s f o r r e a c t i o n s t o them.  T h i s an a r e a where  t h e s o c i a l worker i s p r o p e r l y c a l l e d on f o r s e r v i c e . I n c a s e s such as A ( b ) , t h e p a t i e n t " f u l l o f f e & r s % t h e f a m i l y o f t e n e x p e r i e n c e s a g r e a t sense o f r e l i e f when i n s t i t u t i o n a l c a r e i s o f f e r e d t o a p e r s o n who t u r b e d and t h e r e f o r e a hurden i n t h e home. A(b),  i s mentally d i s -  Sometimes, as w i t h  a f t e r a p e r i o d on o u r p s y c h i a t r i c ward, o r t h e ward i n  t h e E x t e n s i o n where d i s t u r b e d c a s e s a r e s e g r e g a t e d , i t becomes " c l e a r t h a t o u r f a c i l i t i e s a r e n o t adequate*to c a r e f o r t h e p a t i e n t , but t h a t commital t o t h e P r o v i n c i a l M e n t a l H o s p i t a l i s necessary.  I t i s o f t e n necessary i n these s i t u a t i o n s f o r t h e  s o c i a b worker, t o e x p l a i n and r e - e x p l a i n why c o n t i n u e t o be c a r e d f o r by t h e Department. A(b),  the p a t i e n t  cannot  I n t h e case o f M r s .  t h e r e were no p r o l o n g e d p r o t e s t s , b u t t h e s e a r e sometimes  f o r t h c o m i n g , even from v e r y w e l l a d j u s t e d p e r s o n s , who may  feel  t h a t t h e Department o f V e t e r a n s A f f a i r s has an o b l i g a t i o n t o p r o v i d e any s o r t o f t r e a t m e n t needed by t h e v e t e r a n . As i n H, d e p a r t m e n t a l c a r e f o r the aged and somewhat a i l i n g p e r s o n would o f t e n seem t o o f f e r "an easy way o u t " o f  79 f u r t h e r o b l i g a t i o n by t h e f a m i l y .  Why  the h o s p i t a l s t a f f would  p r e f e r t o see t h e p a t i e n t o u t s i d e the. h o s p i t a l w a l l s r e q u i r e s a good d e a l o f e x p l a n a t i o n t o the f a m i l y , n o t because o f t h e f a c t s t h e m s e l v e s , but because o f f e e l i n g s w h i c h have been g e n e r a t e d o v e r a l e n g t h y p e r i o d i n many l i v e s . 5.  A r r a n g i n g f o r U t i l i z a t i o n o f Community R e s o u r c e s Among t h e d u t i e s o f m e d i c a l  s o c i a l workers l i s t e d f o r  a l l g r a d e s , i n p o s t e r s o f t h e C i v i l S e r v i c e Commission a d v e r t i s ing  vacancies i n various establishments, I s :  "Duties:  Under  the d i r e c t i o n o f t h e Head o f t h e M e d i c a l S o c i a l S e r v i c e D e p a r t s ment, and i n c l o s e c o l l a b o r a t i o n w i t h t h e , m e d i c a l to  s t a f f ... . .  c o - o p e r a t e w i t h community h e a l t h and w e l f a r e o r g a n i z a t i o n s  i n t h e I n t e r e s t o f such p a t i e n t s , " A knowledge o f . a p p r o p r i a t e community r e s o u r c e s i s r e l a t i v e l y r e a d i l y a c q u i r e d , even though new  a g e n c i e s a r e c o n t i n u a l l y forming  their policies. may  and o l d ones changing  A t the l e v e l o f mere knowledge o f p o l i c y , i t  n o t e l w a y s be too r e a d i l y d e t e r m i n e d , f o r i n s t a n c e , w h e t h e r  a p e r s o n s h o u l d be sent t o t h e F a m i l y S e r v i c e Agency, t o t h e • F a m i l y C o u r t , o r t o F r e e L e g a l A i d , i f the p r e s e n t i n g p r o b l e m seems t o be one o f m a r i t a l d i f f i c u l t y o r s e c u r i n g m a i n t e n a n c e . S h o u l d t h e A l c o h o l i c be sent t o A l c o h o l i c s Anonymous o r t o t h e Alcoholism Foundation, i a t r i c ward?  o r r a t h e r be t r e a t e d on o u r own  psych-  C o u l d the S a l v a t i o n Army b e s t h e l p him? S h o u l d he  and h i s w i f e t o g e t h e r go t o the F a m i l y S e r v i c e Agency?  These  a r e q u e s t i o n s i n v o l v i n g a knowledge o f agency p o l i c i e s .  They  are also pre-eminently  q u e s t i o n s i n v o l v i n g a good  understanding  80  of the person r e q u i r i n g the s e r v i c e . Sometimes t h e r e i s no d i f f i c u l t y i n d e c i d i n g t h a t t h e r e i s o n l y one agency w h i c h c a n meet t h e c l i e n t * s n e e d i  He  i s t e m p o r a r i l y unemployable and w i t h o u t f u n d s , and h i s w i f e ean g e t h e l p o n l y i n t h e form o f s o c i a l a s s i s t a n c e . The w e l l a d j u s t e d person,, mature and competent, may have even m o r e . d i f f i c u l t y i n a c c e p t i n g t h i s r e s o u r c e than t h e immature, dependent person.  How c a n t h e p a t i e n t and h i s w i f e be h e l p e d t o use t h e  only resource a v a i l a b l e ?  T h i s i s a m a t t e r o f u n d e r s t a n d i n g why  t h e y f e e l a s t h e y do about i t . , a s s e r t independence?  I s t h e r e an unwonted need t o  an o l d h i s t o r y o f " r e l i e f " d u r i n g t h e  d e p r e s s i o n ? a r e t h e r e q u e s t i o n s about t h e ownership o f property*;, t h e s t a t u s o f t h e m a r r i a g e , o r some o t h e r m a t t e r , w h i c h t h e y dread t o answer? To make "a good r e f e r r a l " f o r a more i n t a n g i b l e s e r v i c e i s n o t easy, a l t h o u g h i t may be easy t o see t h e p a t i e n t s 1  need o f t h e s e r v i c e e a r l y i n t h e m e d i c a l s o c i a l w o r k e r * s tact.  con-  I f one does n o t c a r r y t h e p a t i e n t ' s u n d e r s t a n d i n g o f t h e  problem f a r enough, he w i l l n o t make t h e contact;, i f one c a r r i e s i t t o o f a r , he w i l l r e t u r n t o t h e r e f e r r i n g s o c i a l w o r k e r , a s t h e one w i t h whom he h a s e s t a b l i s h e d a warm r e l a t i o n s h i p , r a t h e r than t o t h e s o c i a l worker i n t h e new agency* I n t h e c a s e s c i t e d , community r e s o u r c e s have been w i d e l y drawn o n . A f t e r W o r l d War I I t h e Department o f V e t e r a n s A f f a i r s s t r e s s e d t o i t s s t a f f t h a t t h e r e s h o u l d be no d u p l i c a t i o n o f e x i s t i n g community s e r v i c e s .  The v e t e r a n i s p r i m a r i l y a  81 c i t i z e n and r e t a i n s t h e r i g h t s : o f any c i t i z e n * ,  The p a t t e r n i s  t h e r e f o r e w e l l e s t a b l i s h e d o f drawing on e x i s t i n g s o u r c e s o f help, a v a i l a b l e to a l l citizens.. I n A, t h e cases o f m e n t a l l y d i s t u r b e d p a p i e n t s , i t i s n o t e d t h a t DVA p a t i e n t s move on t o t h e P r o v i n c i a l  Mental  H o s p i t a l where t h a t type o f c a r e i s i n d i c a t e d . R e f e r e n c e h a s been made above t o problems i n h a v i n g r e l a t i v e s a c c e p t t h e nedessity o f that sort o f care*  I n B, m e d i c a l c a r e a t t h e o u t -  p a t i e n t department o f a n o t h e r h o s p i t a l was a r r a n g e d , and F r e e L e g a l A i d was s e c u r e d f o r a d i i e e i n b u s i n e s s  difficulties.  I n C, r e p o r t s o n t h e p a t i e n t ' s home s i t u a t i o n ;  later  p l a n n i n g f o r t h e move o f h i s w i f e t o V a n c o u v e r ; and f i n a l l y t h e p r o v i s i o n o f n u r s i n g home c a r e f o r h e r ; were p r o v i d e d by w o r k e r s o f the P r o v i n c i a l S o c i a l Welfare Branch.  This resource i s o f t e n  used, and i n B r i t i s h Columbia we a r e p a r t i c u l a r l y f o r t u n a t e i n h a v i n g t h i s u n i f i e d s e r v i c e t o w h i c h r e f e r r a l s c a n be made* P a t i e n t s ' p e r m i s s i o n t o g i v e m e d i c a l and o t h e r p e r s o n a l i n f o r m a t i o n i s o f course secured before contact i s i n i t i a t e d .  I n D,  where t h e p a t i e n t and h i s w i f e both had p h y s i c a l and m e n t a l h a n d i c a p s , we see t h e u s e o f a community agency t o ensure b e t t e r p l a n n i n g f o r t h e i r p r e - s c h o o l aged c h i l d .  Had t h i s p a t i e n t  l i v e d e l s e w h e r e than i n g r e a t e r Vancouver o r V i c t o r i a , t h e S o c i a l W e l f a r e B r a n c h might have been c a l l e d o n t o a s s i s t i n t h i s situation* I n E, t h e p a t i e n t ' s w i f e h e r s e l f c a l l e d on a m u n i c i p a l  BZ  agency t o a s s i s t h e r , by r e q u e s t i n g n u r s i n g home c a r e .  I t was  f o u n d , however, t h a t h e r r e q u e s t had i t s o r i g i n i n h e r  exagerat-  ed v i e w o f o u r p a t i e n t ' s c o n d i t i o n .  With a better-knowledge o f  h i s c o n d i t i o n , and w i t h o u r s u p p o r t t o h i m i n h i s r o l e o f o f f e r i n g h e r c a r e o n h i s r e t u r n home, o u r s e r v i c e c o n s i s t e d , i n e f f e c t , o f h e l p i n g t h e p a t i e n t ' s w i f e HOT t o use t h e community agency*  I t s s e r v i c e s became u n n e c e s s a r y , because o f s e r v i c e  g i v e n from t h e v e t e r a n s h o s p i t a l .  A g a i n i n H, we f i n d t h e  p a t i e n t ' s w i f e ' s f a m i l y c a l l i n g on m u n i c i p a l b o a r d i n g home c a r e f o r h i s w i f e .  service to provide  T h i s was used f o r a p e r i o d ,  u n t i l t h e p a t i e n t was b r o u g h t t o t h e p o i n t where he and h i s wife could again l i v e together.  We see t h a t i n such c o - o p e r a -  t i v e work, M e d i c a l S o e i a l S e r v i c e i s n o t o n l y e f f e c t i n g a saving i n treatment costs i n o u r s e t t i n g , b u t i s r e l i e v i n g the community o f the. n e c e s s i t y o f p r o v i d i n g c a r e f o r t h e p a t i e n t ' s wife, . I n the home s i t u a t i o n o f K, I t h a s been n e c e s s a r y t o c o - o p e r a t e w i t h t h e C h i l d r e n ' s A i d S o c i e t y from t i m e t o time r  w i t h r e g a r d t o p l a n s f o r c a r e o f t h e p a t i e n t ' s c h i l d r e n , and a l s o t o d i r e c t c o m p l a i n t s t o t h a t agency a s t h e one competent t o a c t , when we d i d n o t have s t a t u t o r y a u t h o r i t y .  Some  contact  w i t h m e d i c a l s o c i a l w o r k e r s a t E s s o n d a l e h a s a l s o been n e c e s s a r y i n the s i t u a t i o n .  A t t i m e s i t may be s u i t a b l e t o a c t a s g o -  between between t h e p a t i e n t and t h e community agency, a t t i m e s i t may be d e s i r a b l e , w i t h t h e p e r m i s s i o n  o f t h e p a t i e n t and  m e d i c a l s t a f f , f o r a s o c i a l worker o f t h e community agency t o  83  contact the p a t i e n t d i r e c t l y .  Good p l a n n i n g  i n the best i n t e r -  e s t s o f t h e p a t i e n t and h i s f a m i l y i n t h e s e s i t u a t i o n s w i l l depend on a p r o p e r u n d e r s t a n d i n g o f what t h e community agency c a n and cannot do i n h i s I n t e r e s t s *  This helps  t o keep h i s demands  r e a l i s t i c and p l a c e s h i m I n a b e t t e r s t a t e t o b e n e f i t f r o m treatment* I n t h e ease o f L a h o u s i n g problem i s one o f s e v e r a l difficulties*  This i s a d i f f i c u l t y which f r e q u e n t l y casuses  c o n c e r n , as so many o f t h e p a t i e n t s a r e on l i m i t e d i n c o m e , most f r e q u e n t l y some c o m b i n a t i o n o f O l d Age P e n s i o n , War V e t e r a n s A l l o w a n c e and d i s a b i l i t y p e n s i o n ; t h e b a s i c m a r r i e d War V e t e r a n s A l l o w a n c e r a t e b e i n g $108 m o n t h l y f o r man and w i f e , b u t t h i s may go t o $120 m o n t h l y .  Those who own t h e i r own s m a l l homes  may be i n d i f f i c u l t y w i t h r i s i n g  taxes, f u e l costs, e t c .  Those  who must r e n t , e s p e c i a l l y i f i n t h e c i t y , must u s u a l l y pay more t h a n t h e y c a n a f f o r d f o r s e l f - c o n t a i n e d accommodation, o r s h i f t t o t h e rooming-house l e v e l o f a m e n i t y .  Because o f t h e  lack o f low-rental housing p r o j e c t s , despite the existence o f a number o f o r g a n i z a t i o n s i n t h e c i t y f u r t h e r i n g such development, we a r e n o t f r e q u e n t l y a b l e t o r e c e i v e f a v o u r a b l e for our patients*  consideration  T h i s i s c e r t a i n l y n o t because o f a n y d i s c r i m -  i n a t i o n , b u t because o f t h e p i t i f u l l a c k o f h o u s i n g b e i n g a v a i l a b l e t o meet t h e needs o f t h e l o w income group. do dueceed i n s e c u r i n g a f a v o u r a b l e  made  When we  r e p l y , a s i n t h e & ease,,  we s h a r e t h e d e l i g h t o f t h e new t e n a n t s t o t h e f u l l .  The  a v a i l a b i l i t y o f such accommodation may a t times swing t h e  84 balance as to the n e c e s s i t y o f i n s t i t u t i o n a l c a r e . i t may  In general  be s t a t e d , however, t h a t i n the area o f housing  are not s u f f i c i e n t r e s o u r c e s w i t h which to I n the M case Mrs. M was  there  co-operate.  r e f e r r e d to the o u t p a t i e n t  department a t another h o s p i t a l , not o n l y so t h a t she might have necessary medical  care, but to o b t a i n some f a c t u a l i n f o r m a t i o n  on h e r claims t h a t she was  p h y s i c a l l y unable to care f o r her  husband, although she c o u l d p r o v i d e f o r boarders.  Referrals  f o r m e d i c a l care o f p a t i e n t ' s wives are o f so f r e q u e n t o e c u r r ance t h a t they are d i s c u s s e d i n a s e c t i o n a p a r t , below. 6.  M o d i f y i n g Environment Some of the medical  s o e i a l worker's work 1B modifing  environment has a l r e a d y been d i s c u s s e d under the p r e v i o u s headi n g o f " u t i l i z a t i o n o f community r e s o u r c e s " , (as f o r example i n c o n n e c t i o n with h o u s i n g ) .  T h i s i s because much o f our  ability  to e f f e c t changes i n the more e x t e r n a l f a c t o r s o f the p a t i e n t ' s s i t u a t i o n depends on the use of community agencies used by o t h e r s than v e t e r a n s . We  do have, however, w i t h i n our own  setting, consider-  a b l e f l e x i b i l i t y i n the r e g u l a t i o n s which a f f e e t the economic circumstances o f p a t i e n t s i n the r e c e i p t o f pensions allowances.  The  and  s o c i a l worker o f t e n takes note o f changes  which might be arranged  i n the p a t i e n t ' s i n t e r e s t and ssks  Veterans Welfare O f f i c e r to l o o k i n t o the d e t a i l s .  the  Here, i n  l i n e w i t h the u s u a l acknowledgement of competence i n the area  65 o f " f e e l i n g " , care must be taken t h a t the p a t i e n t ' s hope not s e t on °a sure t h i n g " 3 he i s warned t h a t time may a r u l i n g i s secured, and w i s e l y be  elapse  be  before  t h a t the n a t u r e o f the r u l i n g cannot  predicted* There are a l s o funds, p r o v i d e d  Shaughnessy H o s p i t a l and  by the A u x i l i a r y t o  o t h e r s o u r c e s , s e t up as- "the  Superintendent's Fund" and d i s b u r s e d  Hospital  by Medical. S o c i a l S e r v i c e *  T h i s i s need t o meet s p e c i a l emergency s i t u a t i o n s , sometimes f o r patients leaving h o s p i t a l u n t i l a continuing  r e s o u r c e can -  be drawn ©n, sometimes t o meet s p e c i a l heeds o f bed and  patients  their families* At times, as i n ease I , the environmental changes a r e  secured as needed to b e n e f i t the p a t i e n t , by m o b i l i s i n g I r s * I had  f a m i l y t o a c t on i t s o m .  the  remained f o r y e a r s i n sub-  standard housing o f a p h y s i c a l n a t u r e sueh t h a t the p a t i e n t , because o f h i s p h y s i c a l c o n d i t i o n , c o u l d n o t r e t u r n home*  With  the h e l p o f the s o c i a l worker, although change came about  slowly,  Mrs.. I h e r s e l f secured suburban h o u s i n g , b e t t e r s u i t e d t o  the  needs o f the c h i l d r e n , and p a t i e n t ' s r e t u r n home. datioru  such t h a t i t formed no b a r r i e r t o  L a t e r she moved t o more s u i t a b l e aeeosmBo-  I n i t i a l l y she had  seemed i m m o b i l i s e d and h e l p l e s s .  cause o f the f i r s t changes which the w i f e was  affairs  a r e a l f a t h e r t o h i s c h i l d r e n , d e s p i t e the n e c e s s i t y d f  current returns  to h o s p i t a l .  Be-  enabled t o make,  the p a t i e n t a g a i n became an a c t i v e p a r t i c i p a n t i n f a m i l y and  the  re-  86 Our l a c k o f r e s o u r c e s t o secure adequate h o u s i n g  for  p a t i e n t s has a l r e a d y been d i s c u s s e d . 7.  A r r a n g i n g t o Meet W i f e s H e a l t h Meeds 1  The  s e r v i c e o f a r r a n g i n g t o meet t h e h e a l t h needs o f  p a t i e n t s ' ^ w i v e s i s t o be d i s c u s s e d s e p a r a t e l y , r a t h e r than under 5r  U t i l i z a t i o n o f community r e s o u r c e s , because i t i s a  s p e c i a l i z e d s e r v i c e , which i s f r e q u e n t l y c a l l e d f o r .  Elderly .  p a t i e n t s w i t h l i m i t e d economic r e s o u r c e s a r e o f t e n found to>be w o r r y i n g about t h e h e a l t h of t h e i r w i v e s , who  are without  the  means t o secure m e d i c a l c a r e , a t a time when the needs o f  the  p a t i e n t s t h e m s e l v e s a r e b e i n g a d e q u a t e l y met.  The  s o c i a l work-  e r s a r e t h e r e f o r o f t e n asked t o d i s c u s s t h e s e s i t u a t i o n s w i t h p a t i e n t s , whether o r n o t t h e q u e s t i o n o f i n s t i t u t i o n a l c a r e f o r the p a t i e n t , s h o u l d h i s w i f e n o t be a b l e t o c a r e f o r him, i s involved. Our u s u a l r e s o u r c e s , f o r p a t i e n t s who  l i v e i n greater  Vancouver, a r e t h e o u t p a t i e n t s departments o f the V a n c o u v e r General or St. Paul's H o s p i t a l s .  For other centres i n the  P r o v i n c e , we have no d i r e c t r e s o u r c e s .  I f t h e needs o f c h i l d - ,  r e n , as w e l l as t h e w i f e , a r e i n v o l v e d , o r i f t h e r e i s somethinge x c e p t i o n a l i n t h e s i t u a t i o n , t h e S o c i a l W e l f a r e B r a n c h may  be  c a l l e d on, w i t h a v i e w t o t h e i r drax^ying on l o c a l r e s o u r c e s i n the home community. I n s i t u a t i o n s where i n s t i t u t i o n a l c a r e i s under c o n s i d e r a t i o n , a r e f e r r a l f o r o u t p a t i e n t c a r e f o r the w i f e may  some-  87  t i m e s , as i n B, be g i v e n a s m e r e l y i n c i d e n t a l s e r v i c e .  This  f o r m o f a s s i s t a n c e o f t e n b r i n g s o u t t h e warmest e x p r e s s i o n s o f gratitude.  H e a l t h needs have f r e q u e n t l y been unmet f o r e x t e n d -  ed p e r i o d s , due t o p e r s o n s n o t b e i n g aware t h a t h e l p was a v a i l able.  Wives seem p a r t i c u l a r l y touched t o know t h a t t h e r e i s  c o n c e r n f o r t h e i r h e a l t h , a s w e l l as t h a t o f t h e v e t e r a n p a t i e n t , even though we c a n n o t o f f e r d i r e c t s e r v i c e w i t h i n o u r own s e t t ing. A t t i m e s , a s i n t h e D c a s e , where b o t h t h e p a t i e n t and h i s w i f e had c o n s i d e r a b l e p h y s i c a l h a n d i c a p , t h e w i f e i s already r e c e i v i n g necessary  s e r v i c e , but contact w i t h the  m e d i c a l s o c i a l worker i n t h e o t h e r s e t t i n g means t h a t each h o s p i t a l b e t t e r u n d e r s t a n d s t h e needs o f t h e o t h e r p a r t y t o t h e marriage,  and so i s b e t t e r a b l e t o s e r v e I t s own patient..' * The e x t e n t o f t h e i n t e r a c t i o n between man and w i f e and  t h e i r i l l n e s s e s i s w e l l i l l u s t r a t e d i n case B.  We d i d n o t a t  any time have a d i r e c t m e d i c a l r e p o r t on I r s . E, b u t she was known t o have h a d a s t r o k e .  An e x a c e r b a t i o n i n t h e p h y s i c a l  d i f f i c u l t i e s o f e i t h e r one produced an exaggeration i n t h e symptoms o f t h e o t h e r . A t t i m e s t h e w e l l - a d j u s t e d w i f e , who h a s a c c e p t e d o u r support i n t h e d i f f i c u l t t a s k o f c a r i n g f o r a husband who w o u l d o t h e r w i s e have r e q u i r e d i n s t i t u t i o n a l c a r e , t u r n s t o us l a t e r f o r a d v i c e i n h e a l t h problems o f h e r own. case o f M r s . J .  T h i s was so i n t h e  •  $8  I n .some s i t u a t i o n s , a s t h e c a s e s o f Mr. & and Mr. L , t h e p a t i e n t s w i f e may be r e c e i v i n g c a r e f r o m a p r i v a t e p h y s i c i a n , 1  on t h e b a s i s a v a i l a b l e t o o l d age pensioners,, h o l d i n g t h e p r o v i n c i a l "blue medical  card".  Our m e d i c a l  staff or the  p a t i e n t ' m a y be h e l p e d by. f a c t u a l i n f o r m a t i o n on t h e t r u e medic a l c o n d i t i o n o f t h e w i f e , so t h a t we t a k e a c t i o n I n t h e l i g h t o f t h a t knowledge. I n cases l i k e t h a t o f Mr. M, where t h e w i f e a l l e g e s h e r h e a l t h a s one o f t h e p r i n c i p a l r e a s o n s f o r b e i n g u n a b l e t o care f o r the p a t i e n t , a r e f e r r a l t o the outpatients  depart*  ment, i n p a r t f o r t h e p u r p o s e o f s e c u r i n g an o p i n i o n , may be h e l p f u l t o a l l concerned. f a c t s concerning  I n t h i s case a knowledge o f t h e  t h e w i f e e n a b l e d us t o f o c u s on the: r e a l  d i f f i c u l t y , , w h i c h was a m a r i t a l one o f l o n g s t a n d i n g .  .  Indirect Services . 1*  Securing d e t a i l , ranging from s e l e c t e d f a c t s t o f u l l  s o c i a l h i s t o r i e s , a s r e q u i r e d b y m e d i c a l s t a f f , a s an a i d t o d i a g n o s i s and treatment*  .  . The s e c u r i n g o f a s o c i a l h i s t o r y i s w e l l known t o p r o f e s s i o n a l s t a f f , , a n d w e l l a c c e p t e d by l a y p e r s o n s , when i t i s t o be used a s a p a r t o f t h e m a t e r i a l on w h i c h a n e u r o p s y c h i a t r i c d i a g n o s i s i s based.  Of o u r three cases o f mentally  disturbed  p a t i e n t s c i t e d i n I I , A, s o c i a l h i s t o r i e s were s e c u r e d (b) and (c)>.  on two.,  The time and c r i t i c a l judgment p u t t o u s e by t h e  m e d i c a l s o c i a l worker i n s e c u r i n g i n f o r m a t i o n f r o m t h e p a t i e n t  89 and,  o r h i s w i f e , e n a b l e t h e time o f t h e n e u r o p s y c h i a t r i c s.taff  t o be p u t t o i t s most h i g h l y s k i l l e d use, r a t h e r t h a n i n t h e winnowing o f f s e t s . I n Shaughnessy. H o s p i t a l , ' i n l i n e w i t h a r o u t i n e p r a c t i c e i n s t i t u t e d a t the request o f the Neuropsychiatric  . -  S e r v i c e , m e d i c a l s o c i a l w o r k e r s see t h e g r e a t b u l k o f t h e p a t i e n t s who a r e r e f e r r e d from o u t p a t i e n t s , b e f o r e appointment i s made*  a psychiatric  I t i s l e f t i n the professional d i s c r e t i o n  o f t h e s o c i a l w o r k e r whether a f u l l y d e t a i l e d s o c i a l h i s t o r y i s s e c u r e d , o r whether m e r e l y a few d e t a i l s a r e t a k e n on t h e current s i t u a t i o n .  S o c i a l workers a r e a l s o expected to :  exer-  c i s e judgment as. t o whether.an appointment i s u r g e n t l y and i m mediately  r e q u i r e d , o r whether s e v e r a l days may p a s s b e f o r e an  appointment, w i t h o u t f u r t h e r d e t e r i o r a t i o n o f t h e p a t i e n t . On o t h e r s e r v i c e s , t h e s o c i a l worker i s i n c r e a s i n g l y r e q u e s t e d t o s e c u r e i n f o r m a t i o n on t h e p a t i e n t * s background, o r h i s b e h a v i o u r .when a t home, a s an a i d i n d i a g n o s i s .  The u s e -  f u l n e s s o f such i n f o r m a t i o n can r e a d i l y be seen i n a c a s e such as t h a t Mf Mr. E:. "Repeated A d m i s s i o n s A r i s e from t h e Home S i t u a t i o n " , where m e d i c a l s t a f f had a much, b e t t e r u n d e r s t a n d i n g o f the nature o f h i s "blackouts" a f t e r the s o c i a l worker's I n t e r v i e w s w i t h t h e p a t i e n t and h i s w i f e . I n ease 3, where t h e r e was some q u e s t i o n o f b a r b i t - , u r a t e a d d i c t i o n , t h e knowledge, s e c u r e d from the, w i f e , t h a t t h e p a t i e n t was t a k i n g " p i l l s " , was o f a s s i s t a n c e t o m e d i c a l s t a f f .  90 i n confirming t h e i r suspicions.  I n f o r m a t i o n as t o the p a t i e n t ' s  c o n f u s e d b e h a v i o u r , h i s n i g h t wandering e t c . , was  also of  a s s i s t a n c e to medical s t a f f i n presenting a c l e a r View o f the t  patient.  'Sometimes i n t h e c o n t r o l l e d atmosphere o f t h e ward,  under t h e a u t h o r i t y o f s t a f f , and f o l l o w i n g p a t t e r n s adopted by o t h e r s on the w a r d , p a t i e n t s appear much l e s s d i s t u r b e d t h a n I B t h e i r norm.  The  s o c i a l w o r k e r can t a k e time t o judge whether  t h e w i f e ' s a c c o u n t i s an exaggerated,  or a factual  one.  Such h i s t o r i e s a r e v a l u a b l e i n the t r e a t m e n t  setting,  n o t j u s t as t h e p r o c u r i n g o f c o l l e c t i o n s o f f a c t s , a l t h o u g h i n i t s e l f may  be i m p o r t a n t .  that  They a r e a l s o h e l p f u i because t h e  s o c i a l w o r k e r ' s c o n t a c t conveys t o the w i f e the v a l i d c o n v i c t i o n t h a t someone a t t a c h e d to treatment t i o n s and c a r e s how  services respects her  she f e e l s about the f a c t s .  T h i s may  a h i g h l y t h e r a p e u t i c e f f e c t on t h e q u a l i t y o f h e r w i t h the a c t u a l p a t i e n t .  observahave  relationship  I t i s undoubted, ( i s u s u a l l y e x p r e s s -  ed i n b e h a v i o u r , b u t sometimes even i n words) t h a t a w i f e f e e l a s o r t e f j e a l o u s y o f the p e r s o n c o m f o r t a b l y  may  hospitalized  (as she v i e w s i t ) w h i l e she c o n t i n u e s t o b e a r t h e burdens o f daily living.  Good h i s t o r y t a k i n g , w h i l e f o c u s s e d on  the  p a t i e n t , w i l l thus be o f c o n s i d e r a b l e a s s i s t a n c e t o t h e w i f e , 2.  F u r t h e r i n g Understanding  o f S o c i a l P r e s s u r e s on  P a t i e n t , , by m e d i c a l , n u r s i n g and a u x i l i a r y To the w r i t e r ' s way r e a l understanding  the  staff.  o f t h i n k i n g , the f u r t h e r i n g o f t h e  and a c c e p t a n c e o f t h e p a t i e n t , as a  person,  91  seen i n r e l a t i o n t o o t h e r s — h i s w i f e , h i s f a m i l y , h i s employer*, h i s n e i g h b o u r s , along w i t h h i s economic s i t u a t i o n , e t c . , i s one o f t h e most v a l u a b l e s e r v i c e s g i v e n by t h e s o c i a l worker.: •  The i n t e r n e who w r i t e s on t h e ward c h a r t " p a t i e n t may  be d i s c h a r g e d  t o h i s home t o d a y " , d o u b t l e s s  visualizing a  c o m f o r t a b l e m i d d l e c l a s s home, when a c t u a l l y t h e man's w i f e and even c h i l d r e n ' a r e u n p r o v i d e d f o r i n Quebec, and h e h a s n e i g h e r a room n o r a j o b t o g© t o h e r e , i s n o t p r a c t i c i n g good m e d i c i n e . (An exaggerated, b u t , a l a s , n o t an i m a g i n a r y example I s chosen.) The  r o l e o f t h e s o c i a l w o r k e r i n t e a c h i n g an u n d e r s t a n d i n g o f  the p a t i e n t a s a p e r s o n r a t h e r t h a n a s a d i s e a s e , d e s e r v e s stress.  T h i s i s n o t done by t h e s t a n d i n g up and d e l i v e r i n g o f :  l e c t u r e s , b u t by day t o day c o n t a c t on t h e wards.  I t i s inter-  e s t t h a t t h e p a r t i c u l a r l y s e n s i t i v e I n t e r n e , who h i m s e l f i s c a p a b l e o f s e c u r i n g a good p i c t u r e o f t h e p a t i e n t ' s  social  s i t u a t i o n , i f o f t e n the. one who e a r l i e s t comes t o make good u s e o f t h e s o c i a l w o r k e r , n o t o n l y as a means t o s e c u r e a f u l l e r picture, o f h i s p a t i e n t s , but as the p r o f e s s i o n a l person w i t h i n the h o s p i t a l s e t t i n g who i s b e s t equipped t o h e l p t h e p a t i e n t w i t h t h e many p e r s o n a l d i f f i c u l t i e s w h i c h o f t e n have a d i r e c t e f f e c t oh t h e c o u r s e o f h i s i l l n e s s .  The s o c i a l worker may be  asked t© h e l p i n a p a r t i c u l a r way, o r may be g i v e n a f r e e hand t o p r o c e e d as h e r competence d i c t a t e s , , The p a t i e n t w i l l be g i v e n more s y m p a t h e t i c a c c e p t a n c e and h a n d l i n g b y n u r s i n g  s t a f f , i f t h e y a r e aware, o f t h e p r e s s u r e  i  92 of  t h e home s i t u a t i o n .  ample.  In.such a case as E , we see a good ex-  The h i s t o r y secured i s n o t o n l y o f v a l u e t o m e d i c a l  s t a f f , aa d i s c u s s e d i n I n d i r e c t S e r v i c e s , 1, above, b u t i s h e l p f u l t o t h e nurses.  T h i s p a t i e n t ' s p a r t i c u l a r need was f o r r e -  m i s s i o n i n h i s unceasing  t a s k o f being l e a n e d on. by h i s p h y s i c -  a l l y handicapped and dependent w i f e ; he h i m s e l f needed t o l e a n , we may say.  Without a knowledge o f t h e home s i t u a t i o n , ward  s t a f f might w e l l say o f p a t i e n t ' s f r e q u e n t admissions,  " I don't  know why he comes i n a l l the time; h e t a l k s about those  black-  outs, b u t you never see anything wrong w i t h him w h i l e i s i s on the ward."  W i t h the knowledge t h a t he has been c a r i n g f o r  some y e a r s f o r h i s i n v a l i d w i f e , he i s g i v e n more acceptance and sympathy when he e n t e r s h o s p i t a l and t h i s a s s i s t s i n meeting h i s need,* We may have s i m i l a r r e s i s t a n c e , but t o t h e p a t i e n t ' s wish to go out,, as i n K, where medical  s t a f f f e l t t h a t from t h e  p h y s i c a l viewpoint i n s t i t u t i o n a l care was necessary*  I n many  senses h i s r e t u r n home seemed f o o l i s h , o r wrong; b u t w i t h a knowledge o f h i s home s i t u a t i o n , h i s concern f o r h i s m e n t a l l y i l l w i f e , h i s a f f e c t i o n f o r h i s c h i l d r e n , h i s need t o do so c o u l d be b e t t e r t o l e r a t e d . I n t r i n s i c a l l y , o f course, i n every request f o r i n s t i t u t i o n a l care o f a m a r r i e d v e t e r a n , home background, a " h i s t o r y " i s required.  As a l r e a d y s t a t e d i n Chapter One, V I , t h e necess-  a r y i n f o r m a t i o n may be known to the d o c t o r , and a r e q u e s t f o r i n v e s t i g a t i o n i s c e r t a i n l y not n e c e s s a r i l y referred t o the  93 s o c i a l worker.  P r o p e r d e c i s i o n s around t h i s q u e s t i o n c a n o n l y  be made a s t h e home s i t u a t i o n i s c l e a r l y e n v i s a g e d and u n d e r s t a n d i n g ^ dealt with.  T h i s may r e s u l t i n recommendations  w h i c h on t h e s u r f a c e appear e x t r a o r d i n a r y , a s we see i n cont r a s t i n g - D and M.. I n one i t seemed i n i t i a l l y c l e a r t h a t t h e man s h o u l d n o t go home, i n t h e o t h e r t h a t t h e r e was no a d v e r s e reason;; y e t t h e s o c i a l recommendations r a n e x a c t l y c o u n t e r , and were a c c e p t e d a s v a l i d by m e d i c a l s t a f f . I n t h e case o f M,, where he p r e s e n t e d a s a "good" p a t i e n t on t h e ward, a l t h o u g h h i s b e h a v i o u r i n t h e home was so d i f f i c u l t and a n t i - s o c i a l , t h e s o c i a l w o r k e r ' s r e p o r t was a c c e p t ed as f a c t u a l , b u t g a i n e d no sympathy f o r t h e s i t u a t i o n o f t h e w i f e n o r t h e dilemma o f t h e c h i l d r e n i n so d i s t u r b e d a home situation. The  u n d e r s t a n d i n g o f t h e s o c i a l worker's a b i l i t y t o  h e l p p a t i e n t s h a s developed f a r when a l l g r a d e s o f s t a f f f r e e t o make r e f e r r a l s o f p a t i e n t s who a r e d i s t u r b e d . although n o t i n connection  3.  I recall,  w i t h any o f the c a s e s c i t e d , a n  o r d e r l y who t o l d o f a p a t i e n t s L e g i o n f o r him,  feel  b u t I knew y o u  "He wanted me t o c a l l t h e Yfere  t h e one h e s h o u l d t a l k t o . "  C o - o p e r a t i o n w i t h Veterans, W e l f a r e O f f i c e r s i n p u t t i n g  Departmental R e s o u r c e s t o t h e P a t i e n t ' s B e s t Use. Under I I , D i r e c t S e r v i c e s , 4, G i v i n g o r R e i n f o r c i n g / -Understanding o f DVA R e g u l a t i o n s ,  a good d e a l I s c o v e r e d o f  what a l s o b e l o n g s i n t h i s s e c t i o n under I n d i r e c t S e r v i c e s t o Patients*  Because o f changing s t a f f , r e f e r r a l s o f c e r t a i n  94 s o r t s o f problems may be made I n d i s c r i m i n a t e l y t o e i t h e r VWQfs o r s o c i a l workers i n the h o s p i t a l -  Where r e f e r r a l s a r e i n i t i a l *  l y made d i r e c t l y t o t h e a p p r o p r i a t e  one, i t may be f o u n d t h a t  t h e r e a r e a r e a s o f c o n c e r n w h i c h c o u l d b e s t be d e a l t w i t h b y the otherwells  The u s u a l b a s i s o f c o - o p e r a t i o n works e x t r e m e l y  VWO*s a r e e x p e c t e d t o d e a l w i t h m a t t e r s o f d e p a r t m e n t a l  l e g i s l a t i o n and b e n e f i t s a v a i l a b l e t o t h e v e t e r a n ; S o c i a l w o r k e r s make r e f e r r a l s t o o u t s i d e s o u r c e s o f a s s i s t a n c e , and d e a l  with  s i t u a t i o n s where t h e f e e l i n g s o f t h e p a t i e n t o r h i s f a m i l y a r e greatly involved.  U n l e s s each pays d e f e r e n c e t o t h e a r e a s b e s t  s e r v e d by t h e o t h e r , t h e p a t i e n t w i l l n o t r e c e i v e t h e f u l l e s t e x t e n t o f s e r v i c e t o w h i c h he i s e n t i t l e d .  There, t h e r e f o r ,  t a k e p l a c e d i s c u s s i o n s o f s i t u a t i o n s , on a c o n s u l t a t i o n b a s i s , where the" s o e i a l w o r k e r n e v e r s e e s t h e p a t i e n t , and t h e W e l f a r e O f f i c e r e o n t i n u e s t o c a r r y on d i r e c t c o n t a c t , o r where a re-f e r r a l h a s been made t o t h e s o c i a l w o r k e r , b u t i t i s f e l t t o have t h e s i t u a t i o n h a n d l e d by t h e W e l f a r e O f f i c e r , .  best  Discuss-  i o n s and r e f e r r a l s a l s o f l o w i n t h e o p p o s i t e d i r e c t i o n . 4«  Sharing  i n P u b l i c Relations f o r the Setting  Out o f whatever m y s t e r i o u s f a b r i c s t h e m o r a l e o f t h e many employees o f a l a r g e i n s t i t u t i o n i s c r e a t e d , two f a c t o r s may be seen t o be prominent;  harmonious working- r e l a t i o n s h i p s  and m u t u a l r e s p e c t o f v a r i o u s l e v e l s o f s t a f f ; and t h e sense t h a t t h e i n s t i t u t i o n b e a r s a good r e p u t a t i o n w i t h t h e p u b l i c , because t h e harmonious w o r k i n g r e l a t i o n s h i p s have r e s u l t e d i n . good s e r v i c e  95 to  the p a t i e n t s .  M e d i c a l s o c i a l s e r v i c e s t a f f share i n these  satisfactions. In  such a case as L, the son r e t u r n s to the h o s p i t a l  some two y e a r s a f t e r our l a s t c o n t a c t , i n p a r t to stop t o t a l k w i t h t h e s o c i a l worker about the manner o f o u r former p a t i e n t ' s death which took p l a c e i n a d i f f e r e n t DVA h o s p i t a l .  This i s  done because the son t h i n k s o f the m e d i c a l s o c i a l worker as someone who i s n o t a mere f u n c t i o n a r y , but who saw h i s f a t h e r , the former p a t i e n t , as a person, r a t h e r than a c i p h e r ; as someone, too,  who found t h e means o f l i g h t e n i n g some o f the p a t i e n t ' s  difficulties.  I n the J case, the p a t i e n t ' s widow, a f t e r h i s  death, r e t a i n e d a s i m i l a r f e e l i n g about the m e d i c a l  social  worker^ and came t o h e r f o r counsel r e g a r d i n g p e r s o n a l health' problems-  The f e e l i n g o f s a t i s f a c t i o n w i t h the s e r v i c e o f the  h o s p i t a l , which i s expressed i n such c o n t a c t s , d i f f u s e s i n an atmosphere which reaches o t h e r p a t i e n t s , b u i l d i n g dence, and making them more a c c e s s i b l e t o h e l p .  their  confi-  I t also  reaches  the p u b l i c and a f f e c t s t h e i r a t t i t u d e towards the i n s t i t u t i o n and i t s s e r v i c e s . In  another a r e a the m e d i c a l s o c i a l worker i s i n a  p o s i t i o n to g a i n improved  acceptance f o r the i n s t i t u t i o n *  We  r e c e i v e many e n q u i r i e s from p r i v a t e persons and o u t s i d e agencies as to c e r t a i n v e t e r a n s ' e l i g i b i l i t y benefits.  f o r treatment o r other  I t i s n o t the f u n c t i o n o f m e d i c a l s o c i a l s e r v i c e t o  r u l e on e l i g i b i l i t y ,  and a p p r o p r i a t e a u t h o r i t i e s w i t h i n the  96 department w i l l be c o n s u l t e d , b u t t h e s o c i a l worker serves, a s a u s e f u l channel  for outside enquiries*  We a r e t h u s p l a c e d i n a  p o s i t i o n where we can d e a l w i t h t h e f e e l i n g s aroused by u n f a v o u r a b l e r u l i n g s , o r e x p l a i n the r e a s o n s b e h i n d 1  complicated  legislation. The  s i t u a t i o n s i n w h i c h we cannot g i v e  Information  o f t e n arouse considerable adverse f e e l i n g , b u t w i t h s u i t a b l e e x p l a n a t i o n p e r s o n s c a n u s u a l l y a c c e p t why we cannot g i v e i n formation without p a t i e n t ' s consent. I n c a s e s such as F, where t h e h e a l t h problems o f h i s w i f e i n c l u d e d e m o t i o n a l f a c t o r s , and v/here o u r d e c i s i o n t o o f f e r i n s t i t u t i o n a l c a r e t o t h e p a t i e n t would have o f f e r e d a s o c i a l l y acceptable b a s i s o f separation, the handling of our r e f u s a l I s v e r y much a m a t t e r o f p u b l i c r e l a t i o n s .  The f r u s t r a t i o n s and  d i f f i c u l t i e s o f t h e p e r s o n a l s i t u a t i o n a r e so g r e a t t h a t t h e p a r t i e s t o them w i s h t o deny a l l c o n t r i b u t o r y r e s p o n s i b i l i t y . . I t i s easy f o r them t o s a y t h a t t h e Department o f V e t e r a n s A f f a i r s i s e n t i r e l y , o r l a r g e l y r e s p o n s i b l e , so t h a t t h e h a t e and rage w h i c h p r o p e r l y a t t a c h t o t h e p e r s o n a l s i t u a t i o n become a t t a c h e d t o u s . However, i f p e r s o n s i n t h e s i t u a t i o n o f M r s .  F  sense o u r s i n c e r e c o n c e r n and sympathy f o r t h e i r dilemma,, and o u r r e a l r e g r e t t h a t we cannot o f f e r t h e d e s i r e d s o l u t i o n . , much l e s s adverse f e e l i n g i s attached t o our r e f u s a l . I n assessing applications f o r i n s t i t u t i o n a l care,  sit-  u a t i o n s around w h i c h c l u s t e r s so much f e e l i n g on t h e p a r t o f t h e  97 patient and h i s family, careful handling with understanding of and respect f o r the feelings engendered i s p a r t i c u l a r l y necessary.  I t i s therefor expeciaaly useful, from the viewpoint of  public r e l a t i o n s , to have the s o c i a l worker involved i n the necessary recommendations. 5.  Co-operative Work with Administration: while  accepting administrative pressures, furthering s o c i a l goals. I t i s necessary i n any setting that professional s t a f f accept the propriety of the p o l i c y they are c a l l e d upon to a s s i s t i n furthering. recommended i s :  As f o r s o c i a l workers, the o b l i g a t i o n  1  (H) The s o c i a l worker should carry out agency objectives and p o l i c i e s as prescribed to the best of h i s capacities and according to h i s code of ethics, working continually through agency channels to improve h i s services and presonnel practices. (I) I f agency p o l i c y or procedure v i o l a t e s prof e s s i o n a l standards the s o c i a l worker should . . . . The s o c i a l worker who cannot herself f u l l y accept the Tightness of r u l i n g s regarding i n s t i t u t i o n a l care, i s unl i k e l y to be able to help such a troubled person as Mrs. F to accept the fact that the patient, her husband, cannot be given continuing care, even though Mrs. F and her son f e e l that t h i s i s the only solution.  The two s o c i a l workers who worked i n i t -  i a l l y with cases H and I strongly shared the conviction i m p l i c i t In administrative p o l i c y , that i t i s important f o r every person  1.  "Proposed Code of E t h i c s f o r CASW", i b i d c i t . , p.2.  98 who  can achieve any degree of independence outside h o s p i t a l to  he helped to do so.  S o c i a l workers who  could not accept t h i s  p o l i c y could not have c a r r i e d to completion the lengthy case work process which was necessary to resolve these two  diffi-  c u l t situations and get these two patients out of h o s p i t a l . . The s o c i a l worker i s able to undertake such a v i g o r ous, longterm kind of a c t i v i t y i n selected cases, respecting the goals of administration, because she works i n an atmosphere where the goals and opinions of the s o c i a l worker are reciproca l l y respected.  As an example we observe the M case, where the  s o c i a l worker's recommendation that the patient should not r e turn home was approved, despite early minimal physical findings on the patient's degree of handicap. 6.  The S o c i a l Worker's Broad Professional R e s p o n s i b i l i t y  to Others than the P a t i e n t One of a s o c i a l worker's most basic ways of working i s i n the necessity of seeing a wider c i r c l e of persons whose, interests i n t e r r e l a t e with those of the c l i e n t .  The focus on  the i n d i v i d u a l c l i e n t i s usually set by the agency within which the s o c i a l worker operates:  f o r example., a c h i l d , I f a C h i l d -  ren's Aid Society; a wife or husband i f a Family Court; a . patient i f a h o s p i t a l .  The s o c i a l worker w i l l be exercising  her professional function probably i n very close proportion as she focuses on others than the c l i e n t , seeing the periphery equally c l e a r l y with the center of i n t e r e s t .  The degree of t h i s  99 d i f f u s i o n i s i n c o n t r a d i s t i n c t i o n t o the f u n c t i o n o f the l a w y e r o r d o c t o r , whose s k i l l must be d i r e c t e d t o s e c u r e the  greatest.  d i r e c t b e n e f i t f o r h i s c l i e n t o r h i s patient,. The  s o e i a l worker* s approach becomes n o t i c e a b l e i n  p l a n n i n g f o r the c o n t i n u i n g c a r e o f p a t i e n t s : by t h i s p l a n ? who  who  w i l l g a i n by t h a t p l a n ? what may  w i l l be on  hurt  cursory  o b s e r v a t i o n appear t o be b e n e f i c i a l t o the p a t i e n t , may  be  t o be p o t e n t i a l l y d e t r i m e n t a l when one  of a  clearer social picture.  The  i s i n possession  p a t i e n t ' s g r e a t e s t comfort  d e v e l o p i f he I s a s s i s t e d t o a c c e p t some h u r t i n o r d e r o t h e r s may  be h u r t l e s s .  He may  seen  may that  r e q u i r e such h e l p because  age,  i l l n e s s and r e s u l t a n t dependence i m p a i r h i s s o c i a l J u d g m e n t . T h i s may  be so* e s p e c i a l l y i f he i s t a k i n g i n t o a c c o u n t t h e  w i s h e s ,of a w i f e s i m i l a r l y i m p a i r e d , been uneasy f o r years..  The  o n l y when i t can be seen how l i v e s o f others..  w i t h whom r e l a t i o n s have  p a t i e n t i s r e a l l y seen as  himself  h i s d e c i s i o n s impinge on t h e . ;  The U n i t e d N a t i o n s d e f i n i t i o n o f a s o c i a l 1  worker s t a t e s t h i s :  ". . * t h e w e l l - t r a i n e d s o e i a l w o r k e r  makes the n e a r e s t p o s s i b l e approach t o f u l l and c o n s t a n t n e s s o f the i n t e r p l a y o f s o c i a l , economic and f o r c e s I n the l i v e s o f the t r o u b l e d p e o p l e who  aware-  psychological come t o . h i m f o r  assistance." The  development o f t h i s sense o f r e s p o n s i b i l i t y i n  1. Quoted I n mimeographed m a t e r i a l d i s t r i b u t e d by Dr. L.C. Marsh from " T r a i n i n g i n S o c i a l Work, an I n t e r n a t i o n a l S u r v e y " , New Y o r k , U n i t e d N a t i o n s , 1950.  100 action is  seen i n such s i t u a t i o n s as the K case and t h e M c a s e ,  both of patients with c h i l d r e n .  In  these there, i s  the o b l i g a -  t i o n o f c o n c e r n f o r what w i l l be t h e i m p a c t o f d e c i s i o n s i n s t i t u t i o n a l c a r e , as i t  alffects the c h i l d r e n .  around  I n one  case  t h e C h i l d r e n ' s A i d S o c i e t y i s a c t i v e ; : i n t h e o t h e r an e f f o r t made t o e n l a r g e t h e w i f e ' s s i t u a t i o n on t h e  sensitivity  to the e f f e c t o f  the  children.  I n a l l c a s e s , i n the n a t u r e o f cussion,  is  there Is  concern f o r  as w e l l as for\ the p a t i e n t .  the w i f e , In  the problem under  dis-  d i r e c t l y as a person,  c a s e s s u c h a s E a n d F we s e e  the e f f e c t o f f l u c t u a t i o n s i n the p a t i e n t ' s h e a l t h and m e n t a l ' s t a t e as they a f f e c t the h e a l t h o f the w i f e .  The q u e s t i o n  b e c o m e s , who h a s t h e p r i m a c y i n t h e s t a t u s o f p a t i e n t ? i d e a l , answer i s  The  nfelther.  Even i n a s i t u a t i o n where the w i f e h a s good h e a l t h and r e a l m a t u r i t y , a s i n A (a) mentally disturbed patients, i t  and  A (b),  physical  two c a s e s  i s of help i n the  is  :  interested in her  (the wife)  as w e l l as the p a t i e n t .  c a s e i t was n e c e s s a r y t o b r i n g  the p a t i e n t i n t o  and the w i f e r e q u i r e d support I n  of  decisions  w h i c h m u s t be m a d e f o r h e r t o f e e l t h a t t h e s o c i a l w o r k e r  ly  then  In  one  care immediate-  the d e c i s i o n .  In  c a s e t h e w i f e t o o k t h e p a t i e n t home t h r e e t i m e s a f t e r  the  other  successive  admissions to h o s p i t a l , i n p a r t because o f t h i s breadth, o f  focus,  w h i c h saw h e r d i f f i c u l t i e s a n d r e s p o n s i b i l i t i e s w i t h r e s p e c t c o n c e r n , and w h i c h o f f e r e d h e r c o n t i n u i n g support i n  carrying  and  101 them, so t h a t she d i d n o t f e e l i s o l a t e d from the a s s i s t a n c e the h o s p i t a l could o f f e r . I n case D t h e mother o f the p a t i e n t ' s w i f e , and t h e p a t i e n t ' s s i s t e r - i n - l a w as w e l l , were I n v o l v e d I n g i v i n g  support  to the w i f e , which i n p a r t made i t p o s s i b l e f o r t h e p a t i e n t t o be a t home f o r a w h i l e , b e f o r e i n s t i t u t i o n a l care became n e c e s s ary.  B o t h were seen by the s o c i a l worker.  The w i f e ' s mother,  i n p a r t i c u l a r , was h e l p e d by the knowledge t h a t someone stood by t o a s s i s t i n p l a n n i n g .  Chapter IV How  Can the Best Service Be Given?  At the outset of t h i s study i t was envisaged that i t might fee possible to set up an exhaustive schedule f o r analysis of case records*  I t was thought that large numbers of records  might thus be analysed and so i t might become possible to say what were the q u a l i t i e s of a good marriage! that i s , i f a good marriage were to be defined as one where a wife was w i l l i n g  and  able to take home from h o s p i t a l and give good care to a veteran who would otherwise require long term i n s t i t u t i o n a l care. t h i s end, An approach to analysis of case records was n  To  set up"  (see Appendix D.) , I t was discarded as a tool o f the study, because M ! the data, though even more extensive than that offered, would s t i l l not y i e l d the means to forecast what might be the answer of a p a r t i c u l a r patient and a p a r t i c u l a r wife to the question: S h a l l t h i s man go home?  Yet, to a degree, asking the r i g h t  questions does help towards the r i g h t answers.  I t i s therefor  useful to look at the discarded schedule as an example of the kind of approach s o c i a l workers, i n or out of h o s p i t a l s , can make to diagnosing the s p e c i a l quality of a p a r t i c u l a r m a r i t a l problem.  ;  103  The collection of the sort of data referred to i n the analysis i s d i f f i c u l t because i t requires the assessment of many variables*  There are many stages between the positive and  negative pole of each variable. lie?  Where does the middle ground  Where does good or favourable begin, and bad end, as we  look from one pole to the other?  Social workers are accustomed  to working with such data, and are expected to be able to do so, without coming to moral judgments, or condemning their clients because of the observed quality of the clients* feelings or actions*  They are expected, despite the slippery quality of the  data with which they work, to be able to come to some sort of . "social diagnosis".  In the setting of Shaughnessy Hospital  and other veterans hospitals, they are expected to be competent to make a social recommendation as to the necessity of i n s t i t u tional care. Formulation of Social Recommendations Although other social workers, i n hospitals and v a r i e d settings, are concerned with similar decisions, nothing has been, found written-directly to the point.  Medical social  workers must therefor be guided by what they have learned about the effect of illness on normal persons, and the professional approach to helping with the marital problems of those who are not i l l .  The normal pace of case work, as determined by the  strengths of the clients concerned, may have to be modified by the exigencies of illness, and the pressures of other than  104 s o c i a l aspects o f treatment.  The p r o c e s s o f f o r m u l a t i o n o f  sound recommendations i s one w h i c h d e s e r v e s c o n s t a n t c r i t i c a l assessment  and r e v i e w , I n o r d e r t h a t i t may he.more s o u n d l y  based i n u n d e r s t a n d i n g o f t h e p a t i e n t s who a r e i n need o f help.. How, t h e n , does t h e s o c i a l worker come t o t h e s o c i a l recommendation?  I n t h e f i r s t p l a c e , f a c t s such as t h o s e m a r t i a l l -  ed i n t h e s c h e d u l e I n t h e .Appendix need t o be observed*  The  securing o f these I s not a separate process, but i s p a r t o f the s o c i a l treatment*  The d i s t o r t i n g , m a g n i f y i n g o r d i m i n i s h i n g  m i c r o s c o p e o f t h e p a t i e n t ' s way o f f e e l i n g about f a c t s i s o f t e n more i m p o r t a n t t h a n t h e f a c t s t h e m s e l v e s . have w i v e s who a r e i n poor h e a l t h .  B o t h Mr. E and M r . P  Mr. E c a r e s f o r h i s w i f e ,  but h a v i n g done so w i l l i n g l y i n t h e p a s t , he now does so w i t h i n t e r m i t t e n t r e l u c t a n c e ; M r . F, s e e i n g o n l y h i s own needs, t h a t h i s w i f e h a s any h e a l t h problems a t a l l .  denies  So we m i g h t r u n  through o t h e r c a t e g o r i e s o f f a c t r e f e r r e d t o i n t h e s c h e d u l e , r e c o g n i z i n g t h a t what i s s i g n i f i c e n t i s n o t t h e f a c t , b u t t h e f e e l i n g s t h a t c l u s t e r around i t .  We may r u n t h r o u g h  economic,  problems, by some viewed w i t h g r i e f , by some w i t h p h i l o s o p h i c a l calm; t h r o u g h v a g a r i e s o f b e h a v i o u r o f t h e spouse, by some viewed w i t h rage and r e j e c t i o n , by some w i t h t o l e r a n c e and h e l p f u l n e s s , t h e c o n c l u s i o n i s t h e same:  the "fact  1 1  i s not the  i m p o r t a n t w e i g h t I n t h e b a l a n c e , t h e f e e l i n g " r i g h t o r wong", " r e a s o n a b l e o r u n r e a s o n a b l e " , soundly o r s h a k i l y based, can o u t weigh t h e f a c t ; i t i s t h e f e e l i n g t h a t c o u n t s .  105  The b a s i c , i r r e p l a c e a b l e s k i l l o f the s o c i a l worker i s t h a t o f estimating the q u a l i t y o f f e e l i n g s attached i c u l a r variations of possible solutions.  to.part-  The s o c i a l worker  must be aware o f norms o f f e e l i n g , j u s t as the p h y s i c i a n I s aware o f norms o f pulse o r r e a c t i o n s to drugs.  Aware o f norms,  and evaluating the p a r t i c u l a r s i t u a t i o n i n t h e i r l i g h t , weighing the strengths and weaknesses of the p a r t i e s , the s o c i a l worker may decide that the f e e l i n g can be changed i n tone.  We  have seen the s u c c e s s f u l r e s u l t s of such a case work.effort based on such a prognosis, i n A (b) and E. We see unsuccessful effort i n M.  I n other s i t u a t i o n s , such as D, where the s o c i a l  worker recommended that the p a t i e n t might r e t u r n home t o a beneficent atmosphere, o r F where the s o c i a l worker reported that i t was useless to endeavour t o r e s t r a i n the p a t i e n t from returning home, no e f f o r t was made t o induce any change i n f e e l i n g tone.  Such d e c i s i o n s r e s t on the s o c i a l prognosis  t h a t the  f e e l i n g s o f the persons concerned are sound and mature, despite the d i s t u r b i n g i n t r u s i o n o f i l l n e s s ; o r that they are so deepl y rooted i n Immaturity t h a t they seem u n l i k e l y t o be suscepti b l e t o change i n the time a t our d i s p o s a l . What I s being s a i d i s that the most important o f t h e services o f the s o c i a l worker, the one on which r e s t s t h e crux of the s o c i a l recommendation, i s that discussed i n Chapter Three, " i d e n t i f y i n g the nature o f the i n t e r p e r s o n a l r e l a t i o n s . " The camper sees c l e a r l y , i f he i s no tenderfoot, that from bonedry pitchwood o f cedar stump, quick-leaping flames w i l l f o l l o w  10.6 the. m a t c h ; h u t from b a r n a c l e - c o v e r e d ,  sea-sodden hemlock p i c k e d  from the water* s edge, s c a r c e l y even smoke can be e x p e c t e d . t h e s o c i a l w o r k e r , from t h e c o l l a t i o n o f such f a c t s as i n t h e schedule  So  listed  i n the a p p e n d i x , w i t h t h e a d d i t i o n o f  the  m i n u t i a e d i s c e r n a b l e t o t r a i n e d o b s e r v a t i o n , and w i t h  skilled  judgment o f the a r e a s o f f e e l i n g i n v o l v e d , comes t o a c l e a r p i c t u r e o f p r o b a b i l i t i e s , t e c h n i c a l l y c a l l e d the s o c i a l d i a gnosis.  From t h i s m a t e r i a l , and i d e a l l y w i t h the  fullest  p a r t i c i p a t i o n o f the p a r t i e s concerned, a s o c i a l recommendation i s made,, on t h e q u e s t i o n o f home o r i n s t i t u t i o n a l  care*  A competence t o u n d e r s t a n d and t o work w i t h the f e e l i n g s o f p a t i e n t s and t h e i r f a m i l i e s comes b e s t from a r e a l knowledge o f the h i s t o r y o f p a s t f e e l i n g s i n the p e r s o n b e i n g helped. ships?  What were h i s e a r l i e r , i f n o t h i s e a r l i e s t r e l a t i o n What was h i s ' e x p e c t a t i o n o f the r e l a t i o n s h i p o f m a r r i a g e ?  To what degree has i t been met unrewarded?  o r t o what degree has i t been  A l l o f t h e m a t e r i a l s , o r even t h e most d e s i r a b l e  m a t e r i a l s on which t o base a judgment, may  n o t be a v a i l a b l e *  B u t from the f a c t s , f e e l i n g s and r e l a t i o n s h i p d i s c e r n a b l e on b r i e f c o n t a c t , t h e s o c i a l worker i s u s u a l l y a b l e t o make a h e l p f u l recommendation. The e x i s t i n g r e c o r d s , w h i c h must be used i n an  effort  t o u n d e r s t a n d b e t t e r the p r o c e s s by w h i c h the s o c i a l worker . comes to t h e s o c i a l recommendation, do n o t n e c e s s a r i l y . a f f o r d us complete m a t e r i a l f o r u n d e r s t a n d i n g i s as i t should be*  of that process.  the r e c o r d s a r e n o t s e t up as an  This  explanation  107 o r j u s t i f i c a t i o n o f t h e s o c i a l worker's d e t a i l e d  activities*  The f u n c t i o n o f t h e r e c o r d s i s t o i n f o r m t h e d o c t o r o f t h e s o c i a l w o r k e r s c o n c l u s i o n s and recommendations 1  the p a t i e n t ' s b e t t e r w e l f a r e -  as t h e y a f f e c t  W h i l e i t h a s been p o s s i b l e i n  t h i s ' s t u d y , t o break down t h e s e r v i c e s g i v e n , d i r e c t l y and i n ~ d i r e c t l y , t h e r e i s seldom d e t a i l e d m a t e r i a l  a v a i l a b l e on w h i c h  t o base an a n a l y s i s o f t h e methods by w h i c h the s o c i a l w o r k e r approaches what has been d e s c r i b e d , e a r l i e r i n t h i s s e c t i o n , , as " t h e c r u x o f t h e s o c i a l r e c o m m e n d a t i o n — i d e n t i f y i n g t h e nature o f the i n t e r p e r s o n a l  relations."  R e l e v a n c e o f t h e Work t o t h e P u r p o s e s o f a H o s p i t a l . , t o the B a s i c Heeds o f P a t i e n t s The f u n c t i o n o f h o s p i t a l s i s t o a s s i s t t h e i r p a t i e n t s i n making t h e f u l l e s t r e c o v e r y from i l l n e s s .  Because i t was  i n c r e a s i n g l y r e a l i z e d t h a t r e c o v e r y depended n o t s o l e l y on p h y s i c a l f a c t o r s , but on the whole a d j u s t m e n t o f t h e whole p e r s o n , m e d i c a l s o c i a l w o r k e r s have become a s t a n d a r d p a r t o f the p r o f e s s i o n a l  s t a f f o f modern h o s p i t a l s .  I n t h e h o s p i t a l w h i c h forms t h e s e t t i n g f o r t h i s study, medical s o c i a l workers are f r e q u e n t l y s o c i a l recommendations care o f p a t i e n t s .  c a l l e d on t o make  on t h e d e s i r a b i l i t y o f the i n s t i t u t i o n a l  T h i s i s because t h e s o c i a l w o r k e r ' s a b i l i t y  to assemble t h e s o r t o f f a c t u a l i n f o r m a t i o n  d e t a i l e d i n the  s c h e d u l e i n t h e a p p e n d i x , and the superimposed a b i l i t y t o a s s e s s the f e e l i n g s o f the p a r t i e s concerned, do r e s u l t i n recommendat i o n s which are u s e f u l to medical s t a f f .  103 I n t h e h o s p i t a l s e t t i n g , the doctor takes  responsibil-  i t y f o r t h e m a r t i a l l i n g o f the resources appropriate t o the d i f f e r e n t i a l t r e a t m e n t o f each p a t i e n t .  I n the assessing o f  the d e s i r a b i l i t y o f i n s t i t u t i o n a l ' c a r e f o r p a t i e n t s , s o c i a l f a c t o r s •weigh s t r o n g l y f o r a l l p a t i e n t s , but - e s p e c i a l l y so f o r m a r r i e d men.  I t i s a p p r o p r i a t e t h a t the s o c i a l worker,  skilled  i n a s s e s s i n g r e l a t i o n s h i p s , b e c a l l e d on t o a s s i s t t h e d o c t o r i n these  situations.  A r e a s f o r F u r t h e r R e s e a r c h and Recommendations 1*  The. " t y p i c a l " c a s e s chosen f o r p r e s e n t a t i o n i n - t h i s  study have been used m e r e l y a s a s t e p p i n g - s t o n e t o t h e a n a l y s i s o f t h e k i n d s o f s e r v i c e s g i v e n by t h e s o c i a l w o r k e r i n t h e p r o cess o f coming t o a s o c i a l recommendation.  S t a r t i n g from t h i s  t e n t a t i v e t h i n k i n g o n t h e k i n d o f p r o c e s s used, and h a v i n g s e t up f o r d i s c u s s i o n a l i s t o f s e r v i c e s , i t would be of. c o n s i d e r ^ a b l e i n t e r e s t t o use t h e s e a s a method o f s t u d y i n g a l a r g e group o f cases.  A r e many s e r v i c e s b e i n g g i v e n w h i c h do n o t f i t  the p a t t e r n w h i c h has been h e r e s e t up?  into  The w r i t e r s a c q u a i n t 1  ance w i t h many o t h e r cases suggests t h a t t h e p a t t e r n i s ^ a n adequate o n e , b u t i t would b e o f i n t e r e s t t o make an o b j e c t i v e t e s t , and t o e x p l o r e t h e p o s s i b i l i t y of a n a l y t i c a l 2.  classification.  Breakdown o f M e d i c a l S o c i a l S e r v i c e Cases by P r o b l e m s : As e a r l i e r s t a t e d i n C h a p t e r O n e M e d i c a l S o c i a l 1  1.  See a l s o M o n t h l y R e p o r t form i n Appendix B,  109  S e r v i e e s t a t i s t i c s do n o t r e q u i r e any c a t e g o r i z a t i o n o f t h e t y p e s o f problems met i n t h e cases b e i n g s e r v e d , a l t h o u g h t h e y a r e broken down i n o t h e r ways.  Methods f o r such breakdown by  problems, and a f o l l o w - u p o f t h e b l o c k o f cases I n v o l v i n g d e c i s i o n s on i n s t i t u t i o n a l c a r e , would y i e l d , m a t e r i a l f o r further Interesting study. E a r l y i n t h i s s t u d y i t had been p l a n n e d t o canvass o t h e r l o c a l s o c i a l w o r k e r s , i n such s e t t i n g s as t h e V a n c o u v e r G e n e r a l and S t , P a u l ' s H o s p i t a l s ; M e d i c a l S e c t i o n , C i t y S o c i a l S e r v i c e ; and t h e S o c i a l W e l f a r e B r a n c h ; w i t h a v i e w t o s e c u r i n g I n f o r m a t i o n as t o t h e methods by w h i c h t h e y p r o c e e d t o t h e d e c i s i o n whether c l i e n t s must be g i v e n n u r s i n g o r b o a r d i n g home c a r e , a t p e r s o n a l o r p u b l i c expense,, o r whether t h e y may be c a r e d f o r a t home.  I n f a c t , some t e n t a t i v e c o n v e r s a t i o n s  took p l a c e , along t h e s e l i n e s .  A p a r t from t h e p a r t i c u l a r  i n t e r e s t s o f t h e c l i e n t s concerned, t h e s e d e c i s i o n s i n v o l v e much " p u b l i c r e l a t i o n s " and much e x p e n d i t u r e f r o m t h e p u b l i c purse.  I t was o f i n t e r e s t t h a t t h e problem suggested f o r study  i m m e d i a t e l y apprehended a s an e n t i t y by those t o whom i t was broached:. T h i s problem i s o f g e n e r a l i n t e r e s t and c o n c e r n t o s o c i a l workers.  I t i s hoped t h a t t h i s study may s t i m u l a t e  f u r t h e r i n t e r e s t and s t u d y o f t h e d e c i s i o n s as t h e y a r e approached i n o t h e r s e t t i n g s .  Such e x p l o r a t i o n might i n c l u d e p r a c t i c e  i n o t h e r Department o f V e t e r a n s A f f a i r s H o s p i t a l s ,  110 On r e v i e w o f t h i s s t u d y , t h e w r i t e r does n o t see i t as l e a d i n g . t o sweeping recommendations f o r change. amined t h e b a s i s o f work o f m e d i c a l  I t h a s ex-  s o c i a l workers i n a hosp-  i t a l where s o c i a l s e r v i c e meets w i t h a wholesome measure o f a c c e p t a n c e , so t h a t methods o f eo<-operation w i t h m e d i c a l  staff  a r e always i n a f l u i d c o n d i t i o n , w i t h m i n o r p r o g r e s s i v e changes s h i f t i n g i n t o improved p r a c t i c e .  These a r e n o t always r e f l e c t s  ed i n t h e I n d i v i d u a l r e c o r d s o f c a s e s , b u t i n growing m u t u a l r e s p e c t o f t h e v a r i e d p r o f e s s i o n s s e r v i n g t h e p a t i e n t , so t h a t , r e l a t i o n s h i p s a r e e a s i e r , r e f e r r a l s more i n f o r m a l and s e r v i c e to p a t i e n t s b e t t e r .  M o n t h l y r e p o r t s r e f l e c t such changes.  In  a t e a c h i n g h o s p i t a l , w i t h a s u b s t a n t i a l new group o f i n t e r n e s moving i n t o t h e h o s p i t a l a n n u a l l y , changes d e v e l o p t h r o u g h o u t t h e y e a r i n t h e d o c t o r s a b i l i t y t o use t h e s o c i a l worker i n 1  the s e r v i c e o f the p a t i e n t . I t would n o t be o u t o f p l a c e however, t o r e i t e r a t e some o f t h e a n n u a l o r more f r e q u e n t c a u t i o n s w h i c h a r e s i g n p o s t s on t h e road t o b e t t e r c o - o p e r a t i o n . S o c i a l w o r k e r s s t r e s s t h e need o f e a r l y r e f e r r a l s , p a r t i c u l a r l y i n c a s e s o f m a r r i e d v e t e r a n s who may r e q u i r e i n s t i t u t i o n a l care.  An e a r l y s o c i a l assessment w i l l p e r m i t time f o r  the g a t h e r i n g o f f a c t s , t h e o b s e r v a t i o n o f f e e l i n g s and a sound recommendation.  I f t h e s o c i a l w o r k e r i s c a l l e d i n on t h e l a s t .  day o f t h e p a t i e n t s s t a y ; on t h e b a s i s o f " t h i s man does n o t 1  appear t o need c o n t i n u i n g c a r e , b u t h i s w i f e w i l l h o t a c c e p t  Ill him a t home"j o r " t h i s man's h e a l t h i s such t h a t he s o u l d r e m a i n i n c a r e , h u t he demands t o r e t u r n home", t h e s o c i a l recommenda* t i o n c a n s c a r c e l y he as sound a s i f more time had been a l l o w e d for i t s formulation. With respect t o the records o f the s o c i a l department,  service  s e t down a t whatever time i n t h e h o s p i t a l i z a t i o n  t h e s o e i a l worker i s c a l l e d o n f o r h e l p , i t i s p r o b a b l e t h a t c o n t i n u e d d e p a r t m e n t a l s e l f - s t u d y and s e l f - c r i t i c i s m c o u l d l e a d to t h e i r improvement.  Without producing s o e i a l s e r v i c e r e p o r t s  so d e t a i l e d and u n w i e l d y a s t o be an o b s t a c l e r a t h e r t h a n a h e l p to busy d o c t o r s , I t s h o u l d be p o s s i b l e t o r e f i n e o r winnow t h e d a t a s e t down i n s u p p o r t of t h e s o c i a l d i a g n o s i s .  Such d a t a  s h o u l d n o t o n l y i n d i c a t e why t h e s o c i a l worker sees t h e p r o b lems as she r e p r e s e n t s them I n h e r . a r e a o f r e s p o n s i b i l i t y , , b u t is s h o u l d e x p l a i n why t h e s o c i a l t r e a t m e n t / under t a k e n and f o r e shadow t h e r e s u l t s .  I f the l a t e r the r e s u l t s a r e n o t a s a n t i c i -  p a t e d , t h e r e a s o n s f o r t h e v a r i a t i o n from t h e p r o g n o s i s m i g h t be c o n s i d e r e d and added I f possible.. Such s u c c i n c t p r o c e d u r e s , c o n c i s e l y f o r m u l a t e d , meet t h e s p e c i a l needs o f r e c o r d i n g i n a m e d i c a l s e t t i n g , a s p r i m a r y i l y a report to the doctor.  They would a l s o f u r t h e r t h e p u r -  poses o f f u r t h e r m e d i c a l s o c i a l work r e s e a r c h , n o t o n l y i n t h e many a s p e c t s o f t h e c u r r e n t s t u d y l e f t b a r r e n and u n c u l t i v a t e d , b u t i n t h e many o t h e r problems w h i c h a w a i t o u r p r o f e s s i o n a l self-cri ticism.  112 Appendix A O f f i c e Consolidation Regulations under t h e Department o f V e t e r a n s A f f a i r s A c t V e t e r a n s Treatment R e g u l a t i o n s . 1955 D o m i c i l i a r y Care. S e c t i o n 29 D o m i c i l i a r y c a r e , and t r e a t m e n t when n e e d e d , ' w h i l e r e c e i v i n g such c a r e , may, a t t h e d i s c r e t i o n o f the Department h a v i n g r e g a r d t o h i s c i r c u m s t a n c e s , he g i v e n t o a v e t e r a n d e s c r i b e d i n s u b s e c t i o n (1) o f s e c t i o n 12 o r t o a v e t e r a n o r o t h e r person d e s c r i b e d i n p a r a g r a p h ( a ) , ( b ) , (c) o r (d) o f s u b s e c t i o n (1) o f s e c t i o n 13, s u b j e c t t o t h e f o l l o w i n g donditions: (a)  t h a t the veteran o r other person i s t o t a l l y disabled;  (b)  t h a t he s h a l l , i f t h e Department s o : d i r e c t s , a s s i g n o r pay t o t h e Department f o r a d m i n i s t r a t i o n any o r a l l o f h i s income and r e s o u r c e s and, i n a c c o r d a n c e w i t h a s c a l e s e t by t h e Department may, a f t e r p r o v i d i n g f o r h i s depende n t s and a t r u s t f u n d and c o m f o r t s and c l o t h i n g , a p p l y towards the c o s t t o the Department an amount n o t e x c e e d i n g $120 a month, p r o v i d e d t h a t any p e n s i o n p a i d t o the Department i n r e s p e c t o f dependents s h a l l be u s e d f o r t h e b e n e f i t o f such dependents; and  (c)  t h a t treatment r e q u i r e d w h i l e r e c e i v i n g . d o m i c i l i a r y c a r e s h a l l be g i v e n under t h i s s e c t i o n ; p r o v i d e d t h a t , when t r e a t m e n t w h i c h may be g i v e n under s e c t i o n 5, 6 o r 22 i s r e q u i r e d f o r a c o n t i n u i n g p e r i o d o f t h r e e months o r l o n g e r , i t may be g i v e n under such s e c t i o n *  S u b - s e c t i o n (l) o f S e c t i o n 12: S u b j e c t t o s u b s e c t i o n s (2) and ( 3 ) , treatment may be g i v e n i n Canada t o a v e t e r a n w i t h i n t h e meaning o f t h e War V e t e r a n s A l l o w a n c e A c t , 1952, whose s e r v i c e and l i m i t e d income and o t h e r c i r c u m s t a n c e s e n t i t l e him t o be a r e c i p i e n t u n d e r t h e A c t , o r t o such v e t e r a n who would be a r e c i p i e n t i f t h e p e n s i o n u n d e r t h e O l d Age S e c u r i t y A c t r e e e i v * ed by him o r h i s spouse o r b o t h were deducted f r o m h i s Income.  113 P a r a s , ( a ) . f b ) . (c) and (6) o f S u b - s e c t i o n ( l ) o f S e c t i o n 13. S u b j e c t to s u b s e c t i o n ( 2 ) , treatment may be g i v e n t o : (a)  a veteran (i) •  (ii)  (b)  who i s receiving pension f o r a d i s a b i l i t y r e l a t e d t o the s e r v i c e which q u a l i f i e d him as a v e t e r a n , o r had overseas s e r v i c e and was honourably discharged, or served i n World War I , and i n World War I I on o r b e f o r e August 15,, 1945,, and was honourably d i s c h a r g e d ;  a person who (i)  served  i n World War I , o r i n World War I I , i n any o f H i s Majesty's f o r c e s o t h e r than those o f Canada, o r i n any o f the f o r c e s o f H i s Majesty's A l l i e s o r of the Powers a s s o c i a t e d w i t h H i s M a j e s t y , and who was r e s i d e n t o r d o m i c i l e d i n Canada o r Newfoundland on August 4* 1914 i f s e r v i c e was i n World War I , o r on September 1, 1939* i f s e r v i c e was i n World War I I , o r was n o t so r e s i d e n t o r d o m i c i l e d b a t has r e s i d e d i n Canada o r Newfoundland f o r a t o t a l p e r i o d o f a t l e a s t twenty y e a r s and who, i n any ease,,., i s r e c e i v i n g pension f o r a d i s a b i l i t y r e l a t e d to such s e r v i c e , o r had o v e r seas s e r v i c e and was honourably d i s charged, o r 1  ( i i ) i n World War I i n any o f H i s M a j e s t y ' s f o r c e s o t h e r than those o f Canada and who was d o m i c i l e d i n Canada o r Newfoundland when he became a member o f such f o r c e s , o r who served i n World War I i n any o f H i s M a j e s t y ' s f o r c e s o t h e r than those o f Canada o r i n any o f the f o r c e s o f H i s M a j e s t y ' s A l l i e s o r o f the Powers a s s o c i a t e d w i t h H i s M a j e s t y and has r e s i d e d i n Canada f o r a t o t a l p e r i o d o f a t l e a s t twenty . y e a r s and, i n any case, was a v e t e r a n who served i n World War I I on o r bef o r e August 15, 1945, and was honourably discharged)  1U z p e r s o n who wc-s r e c r u i t e d i n Newfoundland i n ' any o f t h e f o r c e s r a i s e d i n Newfoundland by o r on b e h a l f o f t h e U n i t e d Kingdom f o r s e r v i c e i n World War I I and who i s r e c e i v i n g p e n s i o n f o r a d i s a b i l i t y r e l a t e d t o such s e r v i c e , or.who had o v e r s e a s s e r v i c e and was h o n o u r a b l y d i s charged; a p e r s o n who s e r v e d a s a member o f a C a n a d i a n c o n t i n g e n t i n t h e zone o f t h e m i l i t a r y o p e r a t i o n s i n South A f r i c a i n w h i c h t h e f o r c e s o f t h e U n i t e d Kingdom were engaged p r i o r t o J u n e 1, 1902., o r any f o r m e r member o f E l s M a j e s t y ' s f o r c e s , o t h e r t h a n Canadian f o r c e s , , who s e r v e d i n t h a t zone d u r i n g t h e South A f r i c a n War and was d o m i c i l e d i n Canada o r Newfoundland immedi a t e l y p r i o r t o O c t o b e r 11,, 1899* o r was n o t so d o m i c i l e d b u t h a s r e s i d e d in.Canada o r Newf o u n d l a n d f o r a t o t a l p e r i o d o f a t l e a s t twenty y e a r s , i f i n any c a s e he l a n d e d i n South A f r i c a p r i o r t o J u n e 1, 1902; • , ., *  No. o f S o c i a l Workers No. o f S t u d e n t s  .Mg&m OF IN-PATIENTS  General w o ma c t 'act  A.  & R.  ...  act '  K  D E P A R M N T OF VETERANS AFFAIRS K E D I C i SOCIal SERVICES MONTHLY STATISTIC;,! REPORT  D.N.D. Inact act act  Research  ~IHT-  act a c t  Total act  Inact  General I n ' 0-..t  Bospital District Month NUMBER OF INTERVIEWS Research D.N.D. A. & R. In  Out  In  Out  .edecme 5ur g e r y Psychiatry L'.B.  S e c t i o n 29 Dther Dther  OUT-PATIENTS C.P.C. GENERAL OPD ?OLLOi;-UP ^TAFF I0TBER HOSPITALS TOTALS GRAND TOTALS Other I n t e r v i e w s T o t a l Case Load  Total Interviews  In  Out  Total  Total •  I n • Out  SOURCE OF REFERRAL OF NEi'T & REOPENED CASES: "  ' •  '  '  ''  .iii.ii  irr  .i  .i i II  (  i  n  • M M M H W M M M M -  •  V  ._ NEW . (a)  Doctor  (b)  Other H o s p i t a l S t a f f  (c)  Other. D V A H o s p i t a l s o r D i s t r i c t s  (d)  Other D . V . A . P e r s o n n e l  {e)  Patient  (f) (g)  Relatives Community  (h)  R o u t i n e Coverage  REOPENED :  ^  •  TOTAL  '  "  :  '  ;  .  '• _  _  ' _  :  ;  NUMBER OF CASES CARRIED FROH "PREVIOUS IvIONTH • • « • • • • • TOTAL CASE LOAD . .  .  .  .  .  V ." . . . . . . . . . . . . . . .  '  CASES CLOSED 1.  No f u r t h e r a c t i o n needed.  2.  By r e f e r r a l t o (a) Other DVA h o s p i t a l  .  (b) V;elfare S e r v i c e s  . ,  (c) Community TOTAL NUMBER OF CASES CLOSED  .  .  NUMBER OF CASES CARRIED FORWARD  ; .  .  i  .  .  .  .  .  .  .  .  . . . •.-..' .  .  .  '  •  '.' '  Head of. m e d i c a l S o c i a l S e r v i c e Dept. Q.Ivl.V.H. #704/54  116 Appendix C . I n c i d e n c e o f Cases Medical S o c i a l Service Shaughnessy H o s p i t a l J a n u a r y . F e b r u a r y . March. 1956 Jan. 1*  Wo. o f c a s e s i n v o l v i n g alternative of return home o r i n s t i t u t i o n a l care.  2... No. o f t h e s e c a s e s where man h a s w i f e . 3,  4.  5.  No., o f t h e s e cases w h i c h were s p e c i f i c a l l y r e ferred re possible i n s t i t u t i o n a l care* No. o f t h e s e cases known t o Assessment and Reh a v i l i t a t i o n Unit. O v e r a l l Departmental Casel o a d i n c l u d i n g t h e s e and a l l o t h e r cases. •  Feb.  21  1  8  2  -  3  Mar.  Total  5  34  4  19  11  1  3  15  6  1  4  11  197  190  173  560  117 Appendix D An Approach t o A n a l y s i s o f Case Records I.  Q u e s t i o n s t o be Answered f o r B o t h Man and W i f e A,  Physical Health: 1. 2. 3. 4.  B.  A c t u a l d i a g n o s i s and p r o g n o s i s o f p h y s i c a l d i s ability. A t t i t u d e t o d i s a b i l i t y — i s i t o r c a n i t become r e a l i s t i c and c o n s t r u c t i v e ? Long o r r e c e n t o n s e t o f h a n d i c a p s ? Nature o f care required. ( f o r m a n — i s d i s a b i l i t y pensionable?)  Mental Health: Q u e s t i o n s 1 t o 4 as above.  I I . M a r i t a l Data: A.  The M a r r i a g e : 1. 2. 3. 4. 5. 6. 7.  B.  Former u n i o n s o f w i f e ; any c h i l d r e n ? Former u n i o n s o f man; any c h i l d r e n ? S t a t u s o f c u r r e n t u n i o n — l e g a l , common-law, e t c . H i s t o r y o f i n f i d e l i t y since current union. D i s p a r i t y o f age. Sexual adjustment. E t h n i c , c u l t u r a l and r e l i g i o u s backgrounds f o r both.  A t t i t u d e s to the Marriage: 1. 2.  Happy now? f o r m e r l y happy? n e v e r happy? I s t h e r e open q u a r r e l i n g ? armed peace w i t h t e n s i o n ? v i o l e n c e ? bad language? e x c e s s i v e d r i n k i n g ? 3. Do. t h e p a r t n e r s have common amusements? s i m i l a r f e e l i n g s about t h e house o r home, sympathy f o r d i f f e r i n g i n t e r e s t s , common f r i e n d s ? 4. What was t h e man's i d e a l o f a w i f e ? : . What was t h e woman s i d e a l o f a husband? 5. I s t h e r e c o - o p e r a t i o n i n t h e a p p r o a c h t o c h i l d r e n , whether a d u l t o r minor? 6. Dominance. :  1  118 III.  Economic: 1. 2. 3.  IV.  A t t i t u d e s o f Others.: 1. 2. 3.  V.  Man's f o r m e r employment, p r e s e n t s o u r c e o f income. W i f e ' s former employment, p r e s e n t s o u r c e o f Income. S p e c i a l burdens on income: c o m p l e t i n g home owners h i p payments; h i g h r e n t a l ; d e b t ; c h i l d r e n ; w i f e ' s h e a l t h needs, e t c .  A t t i t u d e o f c h i l d r e n o f any u n i o n : w i l l t h e y m a g n i f y o r moderate any e x i s t i n g d i f f i c u l t i e s ? Do t h e y l i v e near? What a r e t h e a t t i t u d e s o f o t h e r r e l a t i v e s o f b o t h parties? What a r e t h e a t t i t u d e s o f n e i g h b o u r s , and o f p e r s o n s i n g r o u p s t o which t h e p a r t i e s a r e a t t a c h e d ? What i s t h e a t t i t u d e o f t h e community?  Resource's: What r e s o u r c e s a r e a v a i l a b l e i n t h e community t o meet S p e c i a l needs? as h o u s i n g , h e a l t h needs, problems o f c h i l d r e n , p a r t - t i m e housekeeping, e t c .  119  Appendix S Bibliography Books 1,.  B r e c k i n r i d g e , Love, L i t t l e and Manning, Community S e r v i c e s f o r O l d e r P e o p l e — t h e Chicago P l a n , a Wie'boldt Foundation P r o j e c t , W i l c o x and F o l l e t t Co., Chicago, 1952;*  2*  Cabot, R i c h a r d , S o c i a l S e r v i c e and the A c t o f H e a l i n g . Dodd, Mead, New York, 1928.  3*  Calnan, W i l f r e d M i c h a e l , The E f f e c t i v e n e s s o f F a m i l y Case Work. Master o f 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, 1948.  4.  Cannon, I d a , On the S o c i a l F r o n t i e r o f M e d i c i n e . Harvard U n i v e r s i t y P r e s s , 1952.  5.  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