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Social casework for in-patients in a veterans' hospital : an analytical survey of social services rendered… Bateman, Ellen Leona 1957

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SOCIAL CASEWORK FOR IN-PATIENTS IN A VETERANS' HOSPITAL An Analytical Survey of Social Services Rendered i n Relation to the Psychosocial Problems of a Group of Male In-Patients, Shaughnessy Hospital, 1956. ELLEN LEONA BATEMAN Thesis Submitted i n P a r t i a l Fulfilment of the Requirements for the.Degree of MASTER OF SOCIAL WORK i n the : School•of Social Work Accepted as conforming to the standard required f o r the degree of Master of Social Work School of Social Work 1957 The University of British>Columbia i v ABSTRACT The social worker i n a medical setting functions as a member of a team, whose aim i s to achieve the greatest possible r e h a b i l i t a t i o n of patients and families handi-capped by i l l n e s s . This study i s an examination of psycho-social problems and i s an exploratory survey (comparable to others which have been made i n different settings) aimed at clearer i d e n t i f i c a t i o n of problems i n which the services of the social worker are relevant, and of the nature of these services. It applies i n this instance to male hospitalized veterans. The method used i n the survey was to compile per-tinent data on d i s t r i c t o f f i c e , hospital, and social ser-vice records of a sample group of'50 male in-patients, referred to the Medical Social Service Department, Shaugh-nessy Hospital, January-June, 195^* The information was extracted from the case records by means of a schedule. Classi f i c a t i o n s were developed to show the frequency and d i s t r i b u t i o n of (a) psychosocial problems and (b) kinds of s o c i a l services rendered. A selection of case summaries was used to i l l u s t r a t e further the nature of problems, and the methods used i n treating them. The findings revealed that M.S.S.D. services are being.used mainly for those younger hospitalized veterans with f a i r potential f o r r e h a b i l i t a t i o n . There i s indica-tion of potential value i n extending the services to older veterans. Most requests fo r service continue to be related mainly to practical problems such as economic and housing needs, as well as for aid with medical diagnosis. The frequency and variety of psychosocial problems indicates need for increased direct service applied to the more i n -tangible psychological problems related to i l l n e s s and handicap. Discussion on the implications of the study findings includes possible means of increasing the effectiveness of social services. This requires, among other things, further studies of services related to particular needs, broader interpretation of s o c i a l services, and demonstra-tion of the effectiveness of intensive or long-term case-work i n the treatment of patients. Such developments should increase the effectiveness of the over-all pro-gramme for the r e h a b i l i t a t i o n of the veteran patient. V ACKNOWLEDGMENTS It i s with, sincere appreciation that I extend my acknowledgment for the very generous help and interest of the many persons who have assisted i n this study. In particular I should l i k e to thank Miss Cecil Hay-Shaw,.Head of the Medical Social Service Department, whose interest made the study possible, and a l l the members of the sta f f f o r the i r con-tinuous support and suggestions. I wish also to thank Dr. Leonard C. Marsh, Mrs. Mary Tadych and Miss Muriel Cunliffe, of the School of Social Work, University of B r i t i s h Colum-bia, for their assistance i n formulating and evaluating the material included i n the study. F i n a l l y , I am sincerely grateful to my friends and family, who have encouraged and assisted me throughout the various phases of the study. TABLE OF CONTENTS i Chapter I. Social Services in the Treatment of the Hospit- alized Patient The development of social work in medical settings. Psychosocial aspects of illness. The functions of the medical social worker. Veterans' rehabilitation programmes. Welfare services. Medical social services. Shaughnessy Hos-p i t a l Medical Social Service. Focus and method of study Chapter II. The Needs and Problems of the Hospitalized Veteran  Referred to Medical Social Service Department Referrals to Medical Social Service. Characteristics of ::. the study group. Medical diagnosis and treatment c l a s s i f i c a -tions. Psychosocial problems. Problems of the veteran i n -patient. Case illustrations Chapter III. Social Services Rendered The use of resources. The nature of social services. Social services rendered. The weighting of services i n rela-tion to the psychosocial problems. Case illustrations Chapter IV. Social Services and the Veteran In-Patient Philosophy and setting. Review of the main findings. Implications for treatment and community. Recommendations. Conclusions Appendices: A. Schedule for Case Analysis. B. Bibliography. i i i TABLES AND CHARTS IN THE TEXT Table 1. Source and reason for referral to M.S.S.D 25 Table 2. Primary medical diagnoses by age grouping 35 Table 3. Frequency of presenting problems as seen by patient and others 42 Table 4« Frequency of accompanying problems as seen by patient and others 45 Table 5« Frequency of underlying problems as seen by patient and others 47 Table 6. Number and frequency of M.S.S.D. contacts 63 Table 7« Distribution of social services i n relation to presenting and accompanying problems 68 (b) Charts Figure 1. Department of Veterans Affairs executive, branch, and administrative organization at Head Office 13a Figure 2. The position of the Medical Social Service Department i n the D.V.A. organization and within Shaughnessy Hospital 16a Figure 3. Dependents among the two major marital groups...... 30a Figure 4^  Distribution of social services <- 65a SOCIAL CASEWORK FOR iDJ-PATIENTS IN A VETERANS' HOSPITAL CHAPTER I SOCIAL SERVICES IN THE TREATMENT OP THE HOSPITALIZED PATIENT "To cure the human body, i t i s necessary to have a knowledge of-the whole of things."''" This statement presumably made by Hippocrates some 2400 years ago, has had varying signi-ficance i n the treatment and care of the i l l person throughout the decades. In the last century, the influence of the wars and the emphasis on restoration which has emerged i n the f i e l d of medicine has influenced the development of services to meet the needs of the sick and handicapped. The Development of Social Work i n Medical Settings The period from approximately I85O to 1918, which has 2 been described as the "Machine Age of Medicine", saw advances in bacteriology, the techniques of surgery, radiology and treat-ment by drugs. The attention of the medical profession was drawn almost wholly to the physical and chemical causes of diseases. The general practitioner, who continued to know his patients as possessors of families, homes and jobs, was l i k e l y to take these adjuncts into account when he treated them. The hospital special-i s t , on the other hand, dealt mainly with the treatment of the 1. ROBINSON, C. Canby, The Patient as a Person, The Common-wealth Fund, New York, 1939, p. 1. 2. MORRIS, Cherry, Social Casework i n Great Britain, Faher and Faher Ltd., London, 1950. - 2 -disease for which the patient was referred. At the same time as specialization i n treatment i n s t i t u t i o n s increased and new know-ledge was "being accumulated i n the practice of medicine, psychia-try and related technological f i e l d s , recognition was being given to the need for creation of new services which would aid i n the u t i l i z a t i o n and integration of these advances. Medical science was achieving success i n a l l e v i a t i n g many of the physiological ravages that i l l n e s s creates, but medical practitioners saw that the t o t a l welfare of the i l l could not be assured through tech-nological and chemical advances alone. Although the f i r s t "Lady Almoner""1" was appointed i n I89O to the Royal Free Hospital i n 2 London as an economy measure, this action, i n s t i t u t e d by S i r Charles Loch and other members of the London Charity Organization, led to broader concern for the social problems of the ' i l l person. One of the consequences was the establishment, i n I906, of the Hospital Almoners' Council. The functions of this Council were the training of Almoners,' promoting their appointment to hospi-t a l s and guiding professional p o l i c i e s . ^ From these beginnings u n t i l World War II, the Almoners constantly endeavoured to interest the hospital i n the social needs of the patients. Through the 1. As pointed out by Dr. Richard Cabot i n a paper e n t i t l e d "Hospital and Dispensary Social Work", reprinted i n Expanding Hori- zons i n Medical Social Work, University of Chicago Press, 1955» the English word 'Almoner', which naturally connects i t s e l f with the giving of alms, has been supplemented i n English usage by phrases l i k e s ocial service, social work, etc. . 2. The Lady Almoner's duty was to determine the f i n a n c i a l e l i g i b i l i t y of patients applying to the hospital dispensary for free care. 3. CANNON, Ida,!., On the Social Frontier of'Medicine. Harvard University Press, Cambridge, 1952* - 3 -influence of the new medical t r a d i t i o n and the ef f o r t s of the Almoners i n providing for evacuees, the interest of the B r i t i s h Ministry of Health was aroused, and i n 1940 a c i r c u l a r to hospi-t a l s gave instruction for the Almoners to undertake additional "welfare duties". In America, even as early as l864» medical s t a f f s of hospitals expressed a desire to know about the l i v i n g conditions and family situations of the patients. The "loss of patients" who did not return for treatment and the resultant spread of disease led to the i n s t i t u t i n g of home v i s i t i n g as part of the training of student doctors at the New York Infirmary for Women and Children. In other areas home v i s i t i n g was carried out both by student doctors and nurses i n training, mainly to determine what sort of environment the patient l i v e d i n and to ensure that he knew how to follow medical instruction. In 1905 Br* Richard Cabot, Physician to Out-Patients at the Massachusetts General Hospital, secured the support of interested persons to establish a sub-department with a "suitable person to investigate and re-port to the doctor, domestic and social conditions bearing on diagnosis and treatment".* I t was his hope that this person would ".....form the l i n k between hospital and the many societies, i n s t i t u t i o n s and persons whose aid could be enlisted". This "suitable person" was Miss Garnet Isabel Peltpn, a so c i a l worker at the Dennison House Settlement i n South Boston. By 1914 the. 1. Ibid. p.48. - 4 -hospital social workers were s u f f i c i e n t l y accepted by the Adminis-tra t i o n of this hospital to warrant Miss Ida M. Cannon being given the t i t l e "Chief of Social Service". Coverage was now extended to in-patients as well as to those attending the c l i n i c s . At the National Conference of Social Work i n Kansas City i n 1918, the American Association of Hospital Social Workers was organized. Other countries followed the lead of England and the United States, and by the 1930s hospitals i n Germany, Prance, Japan, Denmark, Sweden and the Commonwealth Nations were using the services of Almoners or social workers i n providing treatment to the patient. By 1924 there were ten social service departments established i n hospitals i n Canada. Psychosocial Aspects of Ill n e s s The concept of disease has enlarged i n recent years to include psychosocial theory. I t i s being viewed as a reaction of the organism as a whole to external and internal impacts which tax i t s capacity for adaptation. The importance of the influence of the social and environmental aspects of i l l n e s s and medical' care has come into the fore, and recognition i s developing for the need of including these factors i n the medical'curriculum. The teaching of social factors, i n medical and psychiatric set-tings, has involved the use of a wide variety of methods, i n -1. The t i t l e of the organization was subsequently changed to "American Association of Medical Social Workers". In the f a l l of 1955> A.A.M.S.W. amalgamated with the "National.Association of Social Workers", and i s now known as the Medical Section r6f this organization. Essentially American, N.A.S.W. i s , however, open to membership by Canadian so c i a l workers. - 5 -eluding lectures, demonstrations, home v i s i t s , conferences and discussion of selected cases.* In both the teaching and the practice of medicine there i s a growing awareness that i l l n e s s or handicap involves for the individual his t o t a l personality and s o c i a l situation. D i f f e r e n t i a t i o n i s made between emotional disturbances which are the cause of physical i l l n e s s and those which are the r e s u l t . The meaning of i l l n e s s i s different f o r each individual and he w i l l react to i t i n accordance with.his own established pattern of behaviour. I l l and handicapped persons have, i n common with a l l other persons, certain basic needs. The most important of these i s the need to be loved and wanted and to f e e l secure, whether one i s l i v i n g with his own family or i s l i v i n g i n a substitute family setting. This i s as true of the adult or the aged person with a chronic i l l n e s s as i t i s of the handicapped c h i l d . For most persons, i l l n e s s , especially that requiring hospitalization, may be an unpleasant, f e a r f u l situation which gives r i s e to anxiety. As Frances Upham points out "the whole experience of i l l n e s s and care may s t i r up repressed fears of 2 inadequacy, mutilation and annihilation". The patient may fear the unknown, or, when surgery i s required, he may f e e l further threatened by permanent d i s a b i l i t y or loss of l i f e . In addition 1. F o r . f u l l description see;;Joint Committee on the(Teaching of Social .and Environmental Factors;in Medicine,:Widening"Horizons  i n Medical:Education,i published'for * The Commonwealth 1Fuhd^. New York, by Harvard:University Press, Cambridge, Mass.,:194§» 2. UPHAM, Frances, A Dynamic Approach-to•Illness, FiSiA.A., New York; 1949. p . l5» -- 6 -to these basic anxieties, the sick person i s concerned about his prognosis and the p o s s i b i l i t y of disablement which may prevent his return to a more or less normal way of l i v i n g . The patient's tolerance of his state of dependency and experiences of pain and discomfort depends upon his personality and adaptability. For the average, reasonably well adjusted individual, the disadvan-tages of being unable to manage his own a f f a i r s and being i n a state of poor health outweigh the advantages of the extra atten-tion from loved ones, the physical care and the security of the hospital setting. For the less well integrated personality, i l l n e s s may provide satisfactions because of the implications of discomfort, dependency and authoritative milieu. For some patients, hospitalization or treatment may f u l f i l unconscious needs to be cared for, to punish themselves, or to escape the pressures of everyday l i v i n g with which they f e e l unable to cope. In addition to the recognition of the emotional aspects of i l l n e s s , emphasis i s being placed upon the social factors which influence the patient's treatment. Hospitalization and i l l n e s s may create economic pressures for the patient and his family, as well as involve the loss of a job or change of voca-tion. Separation may impose physical as well as emotional st r a i n on patients and their families, depending on the nature and ex-tent of the disablement and convalescence. For some families the change i n marital roles, with the wife assuming some or a l l of the husband's usual r e s p o n s i b i l i t i e s , may create a severe problem. - 7 -The Functions of the Medical Social Worker The use of the multi-discipline team i s the method by which the i n s t i t u t i o n can ensure that the t o t a l needs of those patients who are physically and mentally handicapped, and others who have multiple problems - s o c i a l , psychological, vocational, economic, etc. - w i l l he adequately met. This implies integration of e f f o r t s and inter-action between the doctor, nurse, physio-therapist and other s t a f f who are concerned with the treatment and r e h a b i l i t a t i o n of the patient.''' From i t s early beginnings at the Royal Free Hospital i n London, social work has continued to extend i t s e l f , i n co-operation with medicine, to forward i t s aim of returning the patient to as f u l l a measure of health and a b i l i t y to function as a productive member of society as possible. While operating continuously as a member of a professional team i n the medical i n s t i t u t i o n , s o c i a l work has retained i t s own identity with the practice of social casework, which has for i t s generic basis,the understanding of man as a bio-chemical organism functioning i n a s o c i a l milieu. It aims at helping the individual and groups to achieve more sat i s f y i n g adjustments and thus provides a more adequate social environment. As defined by Swithun Bowers, Social Casework " i s an art i n which knowledge of the science of human relations and s k i l l i n relationship are used to mobilize capacities i n the individual and resources i n the community appropriate for better 1. COOLET, Carol H., Social Aspects of Illness, W. B. Saunders Co., Philadelphia and London, 1951* • - 8 -adjustment between the c l i e n t and a l l or any part of his t o t a l environment".^ It implies a b e l i e f i n the essential worth of the individual and concerns i t s e l f with various factors — physical, emotional and social - which influence the individual i n his re-action to l i f e experiences and, p a r t i c u l a r l y , to the balance be-tween inner and outer forces affecting his response i n a given situation. With recent developments i n both medicine and social work, there have been changes i n practice within the f i e l d , and the function of the social worker i n a medical setting i s being c l a r i f i e d and re-defined, as Eebecca Frost has concluded from her 2 survey of medical and social work l i t e r a t u r e . The relationship of the physician-patientrsocial worker has become closer. The physician and social worker are operating more consistently on a team basis. Social work function i n r e l a t i o n to administration has moved to p a r t i c i p a t i o n i n programme planning, policy formu-l a t i o n and standard setting. According to the standards set forth by the American Association Medical Social Workers,^ the practice of social work i n a hospital should embody the major areas of: the practice of social casework; participation i n programme plan-ning and policy formulation within.the medical i n s t i t u t i o n ; 1. BOWERS, Swithun,O.M.I., "The Nature and Definition of Social Casework: Part III", Journal of'Social Casework,'Vol;30, No.10, 1949, p.417. 2. FROST, Rebecca, The Changing Emphasis i n the Function of  the Medical Social Worker, Master of Social Work thesis, University of Southern Cali f o r n i a , American Association Medical Social Workers, Washington, D.C, July, 1955' 3. A Statement of Standards to be Met by Social Service De- partments i n Hospitals, C l i n i c s and Sanatoria, American Associa-tion of Medical Social Workers, Washington, D.C, 1949. - 9 -p a r t i c i p a t i o n i n the development of social and health programmes i n the community; par t i c i p a t i o n i n the educational programme for professional personnel and s o c i a l research. In a hospital setting, the main purpose :of which i s medical treatment, the primary concern of the social worker i s with the social needs and problems as they relate to i l l n e s s , physical handicap and medical care. "Medical social problems exist when either the medical aspects i n a case situation impinge oh the s o c i a l , or the social aspects on the medical, or both. The medical social worker's focus i s on the inter-action of the two more than on the t o t a l i t y of the medical or the s o c i a l . This focus on the inter-action i s consonant with purpose of the medical eare programme which establishes ^ the boundaries of the medical social worker's function." Thus the medical social aspects of the situation become the focus of attention. In order to help the sick person the so c i a l worker must be concerned with a number of things. As de-2 fined by Leonora B. Rubinow these are: the medical problem; the kind of person the patient i s ; his environment; and the re-sources of the community which are available to him. In r e l a t i o n to the medical problem, the social worker may a s s i s t the doctor by informing him of s o c i a l and emotional problems which have ;a,bearing upon.the i l l n e s s ^ :and may;help.the 1. WHITE, Grace, "Distinguishing Characteristics of Medical Social Work", Readings i n the•Theory and Practice•of'Medical  Social Work, University of Chicago Press, Chicago, 1954j* p.119* 2 . RUBINCW, Leonora B.,,"Medical Social Service", Expanding  Horizons i n Medical Social Work, University of Chicago;Press, Chicago, 1 9 5 5 ' - 10 -patient to overcome obstacles that stand i n the way of his follow-ing medical instruction. Such obstacles might be fi n a n c i a l handi-cap, fears related to the i l l n e s s or d i f f i c u l t i e s i n family r e l a -tionships. When a permanent d i s a b i l i t y occurs the social worker may be called upon to aid the patient or his family make the best possible adjustment within the physical and psychological l i m i t a -tions as ddfined by the doctor. In medical social planning the preventive aspects, as well as the immediate problem, are born i n mind. One of the objectives of the worker, as with the rest of the treatment team, i s to guard against recurrence or unfavorable progress of the patient's i l l n e s s . Miss Minna F i e l d points out the difference i n the approach of the social worker to that of the other members of the treatment team and summarizes the value of this approach. "The s o c i a l worker's approach i s governed by an attempt to see the problem as the patient sees i t , to allow the patient to move at his own pace and to make his own deci-sions towards a goal that he has helped to set for himself Knowledge about the patient as a tot a l human being, which i s gained through training and experience, not only helps the social worker to understand the patient's problems but also to sense the strengths within the patient himself and among members of his immediate social c i r c l e which can be drawn upon for the solution of these problems. Such sources of strength and support can often be found among members of the family, friends, employers, co-workers as well as social and re l i g i o u s organizations. M^ 1. FIELD, Minna, "Role of the Social Worker i n a Modern Hospital", Social Casework Journal, Vol .34» No.9> November 1953. - 11 -Veterans' Rehabilitation Programmes Rehabilitation and after-care, as used i n contemporary practice, " i s the restoration of the handicapped to the f u l l e s t physical, mental, s o c i a l , vocational and economic usefulness of which they are capable"."'' 2 Veterans have for, many years been recognised as a special group of Canadian citizens with particular r e h a b i l i t a t i v e needs. The present programme for their r e h a b i l i t a t i o n had i t s inception prior to World War I when recognition was given to the economic requirements.of certain disabled o f f i c e r s through the payment of pensions by the Government. Provision was made for hospital accommodation, employment and pensioning of the disabled veteran with the establishment of the M i l i t a r y Hospitals Commis-sion i n 1915, an& "the Board of Pension Commissioners i n 1916. The amalgamation of these two commissions under The Department of Soldiers'. C i v i l Re-Establishment i n 1918 saw the advancement of vocational programmes and the i n s t i t u t i o n of counselling services for the disabled. As the World War I veterans" gradually established them-selves i n c i v i l i a n l i f e there was, for a time, a s h i f t i n the 1. This- d e f i n i t i o n was adopted by The National Council on Rehabilitation, New York, at i t s National Conference i n 1946. 2. A veteran, as defined i n the Statutes of' Canada, 1945> i s : (i) "A person who has. been on active service i n the- Canadian forces or i n receipt of active service rates of pay from such forces during the war; ( i i ) A person domiciled in' Canada who served i n the forces of (His) Majesty other than the Canadian forces and was so domi-c i l e d at the time he joined any such forces for the pur-pose of-war," and who has been discharged from such services." - 12 -f o c u s on r e h a b i l i t a t i o n towards g r e a t e r c o n s i d e r a t i o n of the v e t e r a n s ' treatment and p e n s i o n needs. The e x i s t i n g departments were absorbed i n 1928 i n t o the newly c r e a t e d Department of Pensions and N a t i o n a l H e a l t h . I n the y e a r s between World Wars I and I I much . l e g i s l a t i o n was executed and many s p e c i a l bureaux and commissions were c r e a t e d t o a s s i s t the v e t e r a n i n h i s e f -f o r t s toward r e - e s t a b l i s h m e n t i n the community. The War V e t e r a n s ' Allowance A c t , 1930, was enacted to p r o v i d e a l i v i n g a l l o w a n c e , ahalagous t o o l d age p e n s i o n , - t o the v e t e r a n who had seen s e r v i c e i n an a c t i v e t h e a t r e of war and who c o u l d no l o n g e r meet h i s economic needs because of age or i n c a p a c i t y . The V e t e r a n s ' A s s i s t a n c e Commission e s t a b l i s h e d i n 1936 undertook measures t o a i d the unemployed and u n s k i l l e d v e t e r a n . With the advent of World War I I , a General A d v i s o r y Committee, composed of members of the v a r i o u s F e d e r a l Government Departments which would be a s s o c i a t e d w i t h the r e h a b i l i t a t i o n of the v e t e r a n , undertook a study of a l l the phases or problems which would a r i s e i n the r e s t o r a t i o n of former s e r v i c e p e r s o n n e l t o c i v i l l i f e . The l e g i s l a t i o n * which was enacted as a r e s u l t o f the work of the f i f t e e n subcommittees i n r e s p e c t t o such m a t t e r s as e d u c a t i o n , employment, l a n d s e t t l e m e n t , e t c . , p r o v i d e d the most comprehensive programme of r e h a b i l i t a t i o n devised,anywhere.2 1. '. The V e t e r a n s Charter, Ottawa, K i n g ' s P r i n t e r , 1947 ( w i t h subsequent amendments), i s a c o m p i l a t i o n o f . t h e A c t s of the_Cana-d i a n P a r l i a m e n t t o a s s i s t Canadian v e t e r a n s . 2. A study of the measures, s e t up by t h i s committee i s o u t -l i n e d i n Wood, Walter S., R e h a b i l i t a t i o n . ( A Combined O p e r a t i o n ) , Ottawa, Queen's P r i n t e r , 1953. The Rehabilitation Branch was,; formed within the department i n 1940. In 1944 "the Department of Pensions and National Health was dissolved and the present Department of Veterans A f f a i r s was created."'" Legislation enacted i n that year, and subsequently, has dissolved some of the benefits available to veterans during the post-war years, but i n the main r e h a b i l i t a t i v e resources such as Land Settlement and Re-establishment Credit are s t i l l available to veterans. Medical treatment for the pensioner, the War Veterans Allowance recipient - and the f r o n t - l i n e veteran who i s unable to provide i t himself i s i n the nature of a continuing benefit, as i s the case with the Pension Act and the War Veterans. Allowance Act. Welfare Services Under the direction of Lt. Col. Stewart Sutton, a social service programme had been developed during the war by the Army. At the request of Dr. W. P. Warner, Director General of Treatment Services, Col. Sutton undertook a study of the need for s o c i a l 2 workers i n D.V.A«, a"t "the same time as the counsellors of the Re-h a b i l i t a t i o n Branch were becoming aware of the need for special s k i l l s and information i n dealing with the social problems pre-sented i n their Contacts with veterans. The results of the study led to the establishment of the present Welfare Services Branch."^ 1. Figure 1 shows the Executive, Branch and Administrative organization of the Department of Veterans A f f a i r s at the head o f f i c e l e v e l . 2. D.V.'A. and Department of Veterans A f f a i r s are used i n t e r -changeably througllbut this study. 3. Welfare Services i n Vancouver are directed by a Superin-tendent of Welfare Services who is responsible, to both the D i s t r i c t Administrator and to the Director General of Welfare Services i n Ottawa. - 13a -MHISTER FUNCTIONALLY CANADIAN PENSION COMMISSION FOR ' ADMIM.SERVICES DEPUTY .MINISTER . CHIEF OF INFORMATION •• ASSISTANT DEPUTY MINISTER INSPECTION STAFF' POLICY POLICY POLICY Veterans Welfare Services Branch Treatment Services Branch Prosthetic •Services Branch For Admin Services For Admin Services For Admin. Services T DEPARTMENTAL SECRETARY FUNCTIONALLY WAR VETERANS ALLOWANCE.BOARD FOR ADMIN. . SERVICES POLICY. ..POLICY . •: POLICY Veterans .. Bureau .;. Branch Vet.er.ans' Insurance ";,Branc,h ' Veterans Land Act & Soldiers Settlement Board Branch For Admin, Services For Admin. Servic.es \ For Admin. Services Directorate of Personnel & Administrative Services 1.,Personnel D i v i s i o n 2. Central Registry-D i v i s i o n 3. War jService Records D i v i s i o n 4. O f f i c e Services D i v i s i o n •Directorate of Finance, Purchasing & Stores, 1. Estimates & F i n a n c i a l Con-t r o l D i v i s i o n 2. Research & S t a t i s t i c s D i v i s i o n 3. Purchasing D i v i s i o n 4. Stores and Equipment. D i v i s i o n 5. Stationery & O f f i c e Suppl i es D i v i s i o n Directorate Legal Services 1. Prof es s i onal Legal S t a f f . D i v i s i o n 2 .Investigations . & Special Incidents D i v i s i o n Directorate Engineering, Accommodation & Transport 1. Engineering Services D i v i s i o n 2. Accommodation D i v i s i o n 3. Motor Transport . D i v i s i o n Figure 1: • Department of Veterans A f f a i r s : Executive, Branch and Administratiye Organization at Head O f f i c e . After a period of experimental work, the policies of the branch, as defined i n May 1948, provided f o r social workers whose main re s p o n s i b i l i t i e s were: providing consultation to Veterans Wel-fare Officers, and not necessarily dealing with social problems at f i r s t hand; operating a teaching programme with the object of improving a l l welfare services; maintaining a l i a i s o n with 'com-munity agencies; providing casework services on a non-continuing basis i n respect to social problems which were of concern only to the department; assisting i n research i n co-operation with the research d i v i s i o n . The Branch also assumed res p o n s i b i l i t y f o r administering the Assistance Fund devised to meet emergency needs of War Veterans Allowance recipients. Veterans' Welfare Officers function i n the Administra-tive setting, i n the f i e l d and i n the hospital setting. Those Welfare Officers who work i n hospital settings contact a l l hospi-t a l i z e d veterans to,ensure that the patient i s aware of benefits to which he i s entitled under D.V;.A. l e g i s l a t i o n , and.to make known to the prpper authorities the situation of any veteran who i s not receiving those benefits. • Part of their function i s to help the hospitalized or outpatient veteran solve problems which do not affect his treatment. These frequently concern social aspects such as housing, finances, and most especially, employment. Medical Social Services During the experimental stage, when r e s p o n s i b i l i t i e s of the Social Service Division were being c l a r i f i e d , a medical social - 15 -service unit functioned within the Branch. Consideration was, however, being given to the adv i s a b i l i t y of a l l medically oriented dis c i p l i n e s within D.V.A. following a similar chain of responsibi-l i t y . With the issuance of an administrative order on May 1, 1947> Medical Social Service was separated from Welfare Social Service and established as a separate department, responsible to the Director General of Treatment Services. The general policy to be followed by the Department was set forth i n a c i r c u l a r l e t t e r * which stipulated that each Medical Social'Service Department should become an integral part of the hospital set-up, responsible to the hospital Superintendent. Although the departments follow the same chain of responsibility as other treatment personnel within the hospital, they have a direct l i n e of communication, on a con-sultative basis, with the Director of Medical Social Service, D.V.A. The function of a D.V.A. Medical Social Service depart-ment, as set forth by the Director General of Treatment Services, 2 i s consistent with generally accepted standards for social ser-v i c e departments i n hospitals; i t d i f f e r s only i n the respect that i t i s authorized to provide services for veterans under D.V.A. medical care. 1. Circular Letter, 1947-138, December 6, 1947? Medical Social Service - General Policy. Refer to C.L. 1927-122, October 21, 1947* 2. A Statement of Standards, op.cit. - 16 -Shaughnessy Hospital Medical Social Service Shaughnessy Hospital* i n Vancouver, and Veterans' Hospital i n Victoria are the main centres which provide treat-ment for veterans i n the "VA" d i s t r i c t which comprises British Columbia. At Shaughnessy Hospital provision i s made for patients 2 requiring convalescent care i n ancillary units, while domicilliary care i s provided in the "Extension", a group of buildings situated on Shaughnessy Hospital grounds. Prior to the o f f i c i a l establish-ment of the Medical Social Service Department at Shaughnessy i n 1947,^ social services had been provided by nurses since the establishment of separate hospital f a c i l i t i e s for veterans i n the Vancouver area i n 1916. Two professionally trained social workers had been employed in the Neuropsychiatric C l i n i c since 1940. The medical social service department serves the main hospital and the units which give domicilliary and convalescent care. The present establishment i s for seven medical social wor-kers; there are currently two vacancies. Caseworkers are a l l o -cated to specific wards within the main hospital and i n the other units, such as the Jean Matheson Memorial Pavilion and the 1. A history of the development of Shaughnessy Hospital i s given i n : CLOHOSEY, Mary E.A.B.E., Social Implications of Re- Admissions of Veteran Patients to Shaughnessy Hospital, Master of Social Work thesis, University of British Columbia, 1954« 2. Domicilliary care i s a special service exclusively designed for the veteran who requires total care on a more or less permanent basis. The veteran may receive this care because of infirmity or disablements which have not changed after being treated i n the most superior manner possible. 3. Figure 2 shows the position of the Medical Social Service Department within Shaughnessy Hospital. - 16a -MINISTER OP VETERANS' AFFAIRS DEPUTY MINISTER ASSISTANT DEPUTY. MINISTERS DIRECTOR GENERAL TREATMENT SERVICES O T T A W A DIRECTOR MEDICAL SOCIAL SERVICES S H A U G H N E S S Y H O S P I T A L Business . Administration Senior Treatment Medical Officer (Hospital Superintendent) Research] 1 Assistant Hospital Superintendent!— C L I N I C A L Otolaryn-gology & Ophthal-mology Surgery Radio-logy r— Education Auxiliary Services S E R V I C E S Dentris try Patho-logy Anaes-thesia Medicine #L Internal Medicine Tuber-culosis Derma-tology Neuro-logy Psych-iatry Physical Medicine Medical Social Services Since early 1956,patients with active Pulmonary Tuberculosis are treated by Provincial T.B. Control. Figure 2. The Position of the Medical Social Service  Department i n the DVA Organization and within Shaughnessy-Hospital. . "Extension". The programme of -the department has continued to develop since i t s inception and services are gradually being ex-panded to cover new areas. Like the other divisions of the Treatment Services Branch, Shaughnessy Medical Social Service has associated i t s e l f with the university. Staff members are encouraged to take advantage of the opportunities provided for completion of their professionali training. Staff members also participate i n the training of social work students both at the university and i n the hospital setting. Internships-may be pro-vided through D..V.A. to assist students. The department constantly engages i t s e l f i n study of the problems of the patients and methods of rendering services on their behalf. In addition to individual case conferences, part of the weekly staff meetings are given over to this study. Considerable evaluative research has been done both i n r e l a t i o n to the services offered and to the nature of problems of s p e c i f i c groups of patients. The department's interest i n gaining i n f o r -mation which would aid i n the improvement of i t s services led to the development of this project. The questions, which set the focus of this study are: What services are given i n r e l a t i o n to the t o t a l i t y of medical-social problems of the patient? How are the services weighted i n r e l a t i o n to the existing problems?-, What are the problems - presenting, accompanying and underlying -which give r i s e to the need for social services? - 18 -Focus and Method of Study Social services i n Shaughnessy Hospital are extended to both male and female veterans and to some active service personnel. Because of the wide diversity i n the types of services requested and given by the department, i t was decided, therefore, to l i m i t the study to a survey of the problems and services given on behalf of a particular group of patients so that f a i r l y e x p l i c i t informa-i tion could be obtained. Information has been obtained, i n a pre-vious study* regarding veterans receiving service as out-patients. A research project i s currently being undertaken with regard to female veterans. In order to ascertain the nature and frequency of d i f -ferent types of social services extended to veterans i n re l a t i o n to their psycho-social problems, i t was decided to review the history of a sample of one-fifth of the male in-patients referred to the M.S.S.D. within a six-month period. The period January 1, 1954 ^° June 30 , 1956, was chosen because this would allow for an assessment i n terms of the current resources and programmes a v a i l -able to help meet the problems and because services would probably have been completed by the time this study was i n i t i a t e d . A sur-vey of the Medical Social Service case register for the period chosen revealed that of the 458 new and re-opened cases referred to the department during this time, 257 of these were male i n -patients. The cases for study were obtained by selecting every-T~. PATON, John R.D., and WIEBE, John, . Medical Social ServiceTn a Veterans' Hospital Out-Patients' C l i n i c : A Comparative., Sample study or uases Referred and. not Referred for Social Service, Shaughnessy Hospital, 1954- Master of Social Work thesis, University of B r i t i s h Columbia, 1954* - 19 -f i f t h male in-patient referred and were found to total 51. The la s t case was disregarded i n order to f a c i l i t a t e tabulation. The sample represents 11.1 per cent of the tot a l r eferrals and 20 per cent of the male in-patients referred during this period of time. A schedule was used to co l l e c t a l l the pertinent i n f o r -mation on individual patients which was contained i n their medical, d i s t r i c t office"'" and social service f i l e s . Some limitations were encountered i n this method of study. Implications and conclusions drawn from such surveys point up the types of resources and ser-vices used to meet some of the needs of sp e c i f i c groups of people, and allow for an. assessment of the nature of casework services. 2 As has, been pointed out i n other surveys, this method does not allow for the weighting of the re l a t i v e importance of the prob-lems, assessment of the degrees of social d i s a b i l i t i e s , or for an evaluation of the spe c i f i c nature of the problems. The lack of details i n some records, and the wealth of information i n others, led to d i f f i c u l t i e s i n establishing c r i -t e r i a for evaluation. In some instances, for example, patients' attitudes regarding such matters as education were noted, while, i n other cases, no accurate information could be found regarding 1. " D i s t r i c t Office" refers. to the. local. D.V.A. administra-tion o f f i c e . The s e r v i c e - f i l e of veterans l i v i n g i n "VA" d i s t r i c t are kept i n this o f f i c e . They contain original documents pertain-ing to the veteran's period of service as well as copies of other records, correspondence, etc., which pertains to any aspect of medical, legal, welfare or other matters affecting the veteran and his dealings with D.V.A. 2. REED, George A., The Placement of-Adolescent Boys: A Sur-vey-Review of the Problems of Adolescent; Boys i n Care, of the Children's Aid SPci^yv Vancouver, B.C.:- Master' of '"Social Work thesis, University'of'British 1 Columbia, 1953-- 20 -even the school grade attained by the patient. Generally speak-ing, the pattern of recording observed i n the sample group i s that of b r i e f summaries. It sometimes happened that no comments were made regarding the specific social circumstances of the patients. Some further discussion w i l l be devoted to this i n a l a t e r chapter. There were also some limitations inherent i n the categories chosen for the schedule. For example, factual information only, concern-ing, data such as employment, was obtained because the schedule did not allow for assessment of individual attitudes concerning these matters.. This information was u t i l i z e d , where recorded, i n the assessment of the patient's problems. The f i l e s did not always specify the request for service i n the categories used. In some instances, more than one reason for r e f e r r a l was stated, thereby making i t necessary for the researcher to make an arbitrary deci-sion as to the primary reason. Classi f i c a t i o n s have been used to set up a.number of tables which w i l l show the frequency of problems and services. A comparison of problems, as seen from the different points of view of those concerned i n finding solutions, serves as a basis to show', i n part, the kinds of services which can be given, de-pending on how the individuals see the: needs. The.material i n the survey, does hot give detailed background information on the problems. The case i l l u s t r a t i o n method i s used to show factors entering into the problem picture and the need for service. CHAPTER.II THE SEEDS AID PROBLEMS:OP THE HOSPITALIZED VETERAN REFERRED TO MEDICAL SOEIAL SERVICE. DEPARTMENT One aim of this study was an evaluation of the methods used i n treating the social problems of the veteran in-patient who was referred to Medical Social Service. The study of the social situation of the hospitalized veteran and his family can be approached from several different angles. The problems or situation for which the patient'may require services can be seen from many different points of view. The p o s s i b i l i t y of as s i s t i n g the individual to find a satisfactory solution to his problems de-pends, i n large measure, upon how the patient views himself and his circumstances. It may depend also upon which person i n his environment recognizes the existence of a d i f f i c u l t y , and how this- comes to the attention of the helping person. The existence of problems for which social work services are requested may come to attention i n terms of a presenting, problem or a symptom of d i f -f i c u l t y . This may d i f f e r from and be only the effect of another more deeply rooted problem. Certain needs, pressures and ex-periences may not be easily recognizable and the patient himself, or other persons i n his environment, may have no awareness of these. It may happen that a l l those concerned i n the finding of a solution to the problem are aware of the causative factors as - 22 -well as of the symptoms of d i f f i c u l t y . There may be additional d i f f i c u l t i e s which have an influence upon or aggravate the s i t u a -tion for which the patient or his family requires aid, and which may bear upon the solution of the presenting problem. The objec-tive of the helping person i s . t o define the central problem and the patient's, or relatives', feelings about i t i h terms of the chief interacting causes. These may be physical, psychological, economic - or cultural i n various weightings. Diagnosis of the possible constellation of problems, and methods of dealing with these, i s based upon an assessment of the severity of the social r e a l i t y and the degree to which the patient or his family i s troubled by the d i f f i c u l t y . The current social r e a l i t i e s -of the person requiring help may be examined i n several areas such as .his physical condition, his achievement, •, his affectional t i e s , his environmental circumstances and c u l t u r a l * influences. The individual with a psychosocial problem may be experiencing stress i n any or several of these areas, or he may .. , have res'ources i n these areas upon which he can draw to f i n d a solution of his d i f f i c u l t y . In assessing the problems of an i n d i -vidual requiring help, the social worker, or other helping person, may need to have knowledge of the individual's-interaction with family, other groups important to him, and with his total community, 1. As defined by M. J. Herskovits, Man and. His Works,'A.A.Knopf, Hew York,.1948, p.17, "Culture i s the complex whole that includes knowledge, b e l i e f , art, morals, law, custom and other' c a p a b i l i t i e s and habits acquired by man as a member of society." - 23 -depending upon the nature of the d i f f i c u l t i e s with which he needs help. The way i n which the individual himself, as well as his associates, .reacts to the problem i s of primary importance. The individual's behaviour represents his way of meeting his needs within' the framework of his environment and the r e a l i t i e s he faces. Some of his internal needs may c o n f l i c t with others, or.he may be frustrated i n meeting his needs by the external world, and thereby f a i l to attain a pattern of behaviour which permits him, or his close associates, to live, comfortably or constructively i n his world. When the individual i s unable to'attain for'himself a satisfactory interaction with persons i n his environment, he may request help himself or some person may request i t on his behalf. Referrals to Medical Social Service Medical social service, practised i n collaboration with other professional personnel, i s an integral part of the multi-d i s c i p l i n e services offered the veteran patient within the treat-ment i n s t i t u t i o n . Referrals to the department may be made by any member of'the treatment team, other D.V.A. personnel, the patient or his relatives, or by some person i n the "outside" community. Services may be requested as an aid i n planning and administering medical treatment for the veteran, or as a help i n resolving social and emotional problems which have a' bearing on his medical condition or treatment. The-referral process, that i s , the way i n which a-'patient:is referred, and whether i t i s done by a person he trusts for purposes concerned with his welfare, has received • no consideration i n this study, even though this may have con-siderable bearing on the problem and:the methods which could be used i n meeting the patient's needs. The sources and reasons for referrals of the study group to medical social service are summarised i n Table 1. Sixty-two per cent of the referrals were made by doctors, wjiile ten per cent were made by other hospital s t a f f . In recent years, with the allocation of workers to sp e c i f i c wards, certain cases observed by the worker i n her rounds, or previously known to the department, may be opened or re-opened routinely at her discre-tion. Pertinent social history information can then be discussed with the doctor. The smallest number of ref e r r a l s of the i n -patient group (2. per..cent.) 'jf ell within this category of routine coverage. An examination.of the total number of cases referred to the department during the period covered by the study.revealed a correspondingly low number (2.6 per cent) of ref e r r a l s obtained i n this way. .Only six per cent of the patients requested services of their own accord. The reasons for referrals of the 50 cases studied were-,, divided almost i n equal proportions within the f i v e categories set forth i n the schedule.' One of the main services of the department i s to assist ,the medical -staff by obtaining information about the patient's experiences, or social and emotional problems, which may - 25 -Table 1: Source and Reason for Referral to M.S.S.D. (Percentage Distribution) R e i i s o n f o r R e f e r i • a 1 Source of Referral Social History Social Assess-ment Economic Problem Personal & Social Adjustment Dis-charge Plans P.C. of Cases Referred Doctor 20 10 8 6 18 62 Other Hospi-t a l Staff _ 4 — 4 2 10 Other D.V.A. Personnel — — 4 2 2 8 Routine Coverage — — — _ 2 2 Patient - - 4 2 - 6 Relatives - - - 6 2 8 Community 2 2 - - 4 Total 20 16 18 20 _ ' 26 100 Source: Sample count of Medical Social Service Department case records. have a relationship to his i l l n e s s . Requests for social history accounted for twenty per cent of the re f e r r a l s . The discharge of patients from hospital frequently presents problems,-!.especially for the patient who has reached;the point where the hospital can offer him nothing more i n the way of treatment and when, because of advanced age or physical handicap, he requires some sort of specialized care. When d i f f i c u l t i e s arise, or are anticipated i n the course of discharge of veteran patients, they can be referred to the social service department. Twenty-six per cent of the - 26 -study group were referred "by f i v e different sources for aid with problems related to discharge. Requests for assessment of the patient's social circumstances as an aid i n treatment planning, i.e. , his home or environmental circumstances, and the attitudes of his associates toward his d i s a b i l i t y , accounted for sixteen per cent of the r e f e r r a l s . The high proportion of patients referred for social history or assessment and for discharge planning indicates that medical st a f f s t i l l tend to think of M.S.S.D., i n large measure, as a source of help i n planning treatment or after-care for patients. The timing of referrals to M.S.S.D. and the number of times the social worker continued to participate i n the patient's treatment has not been assessed. It should be noted, however, that with.,the majority of referrals for social history or social assessment, the worker's a c t i v i t i e s were terminated upon completion of this phase of the treatment planning. The comparatively low numbers of re-fe r r a l s made with a view to direct help for the patients indicates that there is. room for more use of M.S.S.D. i n direct treatment planning and possibly more need for use of psychosomatic; approach to treatment planning. Characteristics of the Study Group The circumstances of the group were analyzed from the point of view of age, marital status, l i v i n g ' circumstances, income and other factors having a bearing on the medical-social problems. B e f o r e examining the g e n e r a l c h a r a c t e r i s t i c s of the group, some f a c t s c o n c e r n i n g v e t e r a n s and t h e i r treatment right's as w e l l as ot h e r b e n e f i t s a v a i l a b l e t o them by v i r t u e of t h e i r , s e r v i c e i n the armed f o r c e s s h o u l d be noted. Under the V e t e r a n s ' Charter' of Canada p r o v i s i o n i s made f o r the treatment of former and a c t i v e members of the armed s e r -v i c e s under some 29 d i f f e r e n t s e c t i o n s , as o u t l i n e d i n the Veterans Treatment R e g u l a t i o n s . .They may q u a l i f y f o r f r e e h o s p i t a l i z a t i o n and c a r e under s e v e r a l s e c t i o n s , such as by rea s o n of a s e r v i c e -connected d i s a b i l i t y , as r e c i p i e n t s of W.V.A., or because-of i n -adequate income and r e s o u r c e s . Most o f those v e t e r a n s e n t i t l e d to f r e e m e d i c a l c a r e would be a l l o t t e d the r e g u l a r comforts a l l o w -ance of about seven d o l l a r s per month.while h o s p i t a l i z e d . Those r e c e i v i n g treatment f o r s e r v i c e - c o n n e c t e d d i s a b i l i t y would be en-t i t l e d t o r e c e i v e f u l l p e n s i o n r a t e s d u r i n g t h e i r p e r i o d of h o s p i -t a l i z a t i o n . Rates are governed by the extent t o which such s e r v i c e disablement c o n s t i t u t e s a v o c a t i o n a l handicap. The dependents of d i s a b l e d v e t e r a n s are p r o v i d e d f o r by an a d d i t i o n a l monthly a l l o w -ance. W.V.A. p r o v i d e s f o r payment of s i x t y d o l l a r s per month t o a s i n g l e v e t e r a n and one hundred and e i g h t d o l l a r s per month t o m a r r i e d v e t e r a n s . Under W.V.A. l e g i s l a t i o n no p r o v i s i o n i s made f o r dependent c h i l d r e n i f b o t h p a r e n t s are l i v i n g . The maximum income a W.V.A. r e c i p i e n t may r e c e i v e from any source i s one hundred and twenty d o l l a r s monthly. M e d i c a l b e n e f i t s are f o r the v e t e r a n o n l y . No med i c a l or d e n t a l c a r e i s . p r o v i d e d f o r the wives or children of veterans through D.V.A. Age: Of the 50 patients under study, the ages ranged from 18 to 92 years. Five broad age c l a s s i f i c a t i o n s were used and i t was found that over one th i r d (36 per cent) of the group f e l l within the 26 to 45 year range. Twenty-four per cent were i n the next age grouping of 46 to 65 years. Contrary to what one might expect i n a study of a group of hospitalized veterans, only twenty per cent were within the 66 to 75 aEe range. Eighteen per cent were over 16. The smallest number (4 per ;cent) were i n the 18 to 25 year category. A census of patients i n DVA insti t u t i o n s at midnight on March 31, 1955?^ showed the greatest number were i n the 60 to 64 age group with a median age of 60 years. This showed an increase of 5 years i n the median age as compared to the previous census of in-patients i n 1950. This indicates that there was probably a substantial increase i n the average age of in-patients i n the year between the last census and the time the par t i c u l a r veterans studied were referred to M.S.S.D. From these figures,, i t i s ob-vious that the veterans being referred to Shaughnessy M.S.S.D. f a l l within the younger age group of hospitalized patients. This fact, coupled with an examination of the reasons for r e f e r r a l , indicates that the department i s being used, at least i n part, for those patients whose potential for re h a b i l i t a t i o n i s greatest. 1. .. WIHFIELD,- .G. A., M.D., and WELL-WOOD, -L., ";An Analysis of • In-Patients, .Department of Veterans A f f a i r s , at Midnight, -3L March, 1955", Canadian Services Medical Journal, Queen's Printer, Ottawa,; Vol.XII, 1956'.' - -- 29 -Educationt Of the 50 veterans studied i t was found that fo r t y - s i x per cent had received elementary education, t h i r t y per cent had some high school training, and four per cent had attended university. No information was available concerning the educa-tional background of the remaining twenty per cent. Three veterans had additional technical training and one veteran had completed a business course. Employment Status: The occupational experience of the patients- was widely representative, ranging from unskilled manual labour to the practising of professions. Although a l l the patients studied were unemployed (by reason of hespitalization) at the time of their r e f e r r a l to M.S.S.D., employment was c l a s s i f i e d according to the usual work situation of the patient when he was not i n hospital or according to his work situation at the time of admis-sion. An equal number of veterans were, i n the two categories of re t i r e d and steadily employed, and accounted- for f i f t y - s i x per cent of the t o t a l . Twenty—two per cent were considered medically unemployable by virtue of the degree of d i s a b i l i t y for which they were receiving pension, or by c e r t i f i c a t i o n by.attending medical s t a f f . Veterans who had irregular work record immediately prior to admission, with frequent periods of unemployment, and job changes, were c l a s s i f i e d as occasionally employed. Sixteen per cent were i n this category. Three patients had been unemployed at the time of admission and had no prospects of employment upon-, discharge. It i s interesting to note that half pf the eight - 30 -v e t e r a n s who were r e c e i v i n g treatment f o r t h e i r p e n s i o n a b l e d i s -a b i l i t i e s were s t e a d i l y employed. The t h r e e v e t e r a n s who were c l a s s i f i e d as unemployed were i n the 26 t o 45 y e a r age group, were m a r r i e d , and two had dependent c h i l d r e n . - A l l had p r e v i o u s h o s p i t a l a dmissions, one w i t h f i v e and one w i t h s i x . M a r i t a l S t a t u s : About h a l f of the v e t e r a n s i n the study group (48 per cent) were m a r r i e d , and of these twenty-two per cent were i n the 2-6 t o 45 a g e range. An equal number of v e t e r a n s f e l l i n t o the c a t e g o r i e s of s i n g l e and separated,' w i t h e i g h t e e n per cent i n each group. The r e m a i n i n g s i x t e e n per cent were i n the o t h e r t h r e e c a t e g o r i e s , w i t h f i v e widowed, two l i v i n g i n common-law u n i o n and one d i v o r c e d . S i x t y per cent of the group l i s t e d t h e i r wives as dependents, and they had a t o t a l of f o r t y - s e v e n dependent c h i l d r e n . Three, of the v e t e r a n s i n the s e p a r a t e d c a t e -gory d i d not c o n s i d e r t h e i r wives as dependents, w h i l e s i x d i d , a l t h o u g h they may or may not have been s u p p o r t i n g them. -None of the v e t e r a n s had any o t h e r dependents b e s i d e s wives or c h i l d r e n . A breakdown of the v e t e r a n s ' m a r i t a l s t a t u s and dependents by age groupings ( F i g u r e 3) p o i n t s up t h a t the m a r r i e d v e t e r a n s i n the 26 t o 45 a g e range had a s u b s t a n t i a l l y l a r g e r number of de-pendents than any of the o t h e r groups. L i v i n g C i rcumstances: For. the purposes of t h i s s t u d y , the term r u r a l was used t o d e s i g n a t e the l i v i n g a r e a of any v e t e r a n whose u s u a l r e s i d e n c e was o u t s i d e of the Vancouver c i t y l i m i t s , and urban as w i t h i n the c i t y l i m i t s . 'Veterans' may come - 30a -DEPENDENTS AMONG. THE TWO MAJOR MARITAL GROUPS (a) 15 20 25 3 q Married Veterans Wives Children 00 Separated Veterans Wives Children (c) IO 15 20 25 30 Age Group of Veterans 18-25 26-45 46-65 66-76 76 (a) the sample group of 50 veterans included 9 single men and 5 widowers. (b) includes veterans l i v i n g i n common-law union. (c) includes divorced veterans. Figure 3. Dependents among the two major marital groups (Shaughnessy Hospital, 1956) - 31 -from any part of the province to receive treatment at Shaughnessy Hospital. Over half of the study group (58 per cent) were l i v i n g i n urban Vancouver at the time of their admission to hospital. The remainder of the group usually made their home i n some loca-tion outside the c i t y . This figure i s significant i n considering the services which can be given to the families of the hospitalized, veteran and i n many instances to the patient himself. Only eighteen veterans habitually l i v e d i n their own homes and f i v e l i v e d i n rented houses. Six ordinarily l i v e d i n boarding care and four i n the homes of rela t i v e s . The usual l i v i n g arrangements of twelve patients f e l l i n equal numbers i n the categories of rented apart-ment, sleeping room, hotel, and no fixed address. Two of the re-maining four patients customarily l i v e d i n shacks and two were cared for i n the hospital's domicilliary units. The housing circumstances of the patient may or may not present problems, depending upon his physical condition and upon how he or his family f e e l about the accommodation. Income; Eighteen of the f i f t y patients were receiving d i s a b i l i t y pensions. Of these, seven were under 46 years of age, and only two were 76 or over. Seven veterans were receiving pen-sions for eighty-five per cent or more d i s a b i l i t y . Twenty-six per cent of the study group were receiving W.V.A.., and of these, ten veterans were 65 years of age or more. Only three veterans were i n receipt of the maximum amount of W.V.A. Three veterans were receiving both W.V.A. and d i s a b i l i t y pension. Very l i t t l e i n f o r -- 32 -mation was available concerning the income or financial circum-stances of those veterans who were not in receipt of income from some D.V.A. source, except in cases where the patient or his family was experiencing economic d i f f i c u l t i e s . Pour veterans had no income from any source. The total monthly income of nineteen veterans was known at the time of their referral to M.S.S.D. and showed a maximum of four hundred dollars, with an average of one hundred and twenty-seven dollars per month. Since the largest pro-portion of the study group are married men with dependents, this figure indicates that at least a portion of these families are liv i n g on marginal or low incomes, and may be encountering social d i f f i c u l t i e s , at least in part, for this reason. These figures do not show the numbers of cases nor the degree to which marginal i n -come families are affected by the patient's i l l n e s s . They do not indicate whether or not the income situations were affected by the receipt of veterans' benefits. These factors were taken into con-sideration i n the assessment of the problem picture in the analysis of the cases. Relatives; To f a c i l i t a t e an understanding of the nature of the social problems of the group, an examination was made of their family constellations and of the relationships between the members of the veteran's family. Some general characteristics may be noted i n relation to the total group. Information was not available on one veteran. Of the remaining forty-nine, only three were unattached or had no near relatives. Twenty-six patients had - 33 -wives who were in good health, and six had wives who were i l l . Nine veterans had one liv i n g parent, and seven had two l i v i n g parents. Over half of the group (54 per cent) had l i v i n g brothers or sisters, and one veteran was found to have seventeen siblings. Seventy-two per cent of the group had children, totalling seventy-nine in a l l . The relationships between the patient and individual family members, as well as with other persons, were classified as good, f a i r , indifferent or poor. The assessment was based on the observation of the relationships between the patient and family or others i n his environment, as recorded by the social worker. As used here the assessment of relationships pertains to the affec-tional ties existing between the veteran and his relatives in terms of genuine concern for one another's welfare. The assessment gives no indication of the relative's willingness to assume responsibility for the care of the patient, or to co-operate in recommended treat-ment plans. Relatives might desire that the patient feel loved and wanted, and be able to meet some of his needs in this regard, and yet be unable to meet other needs because of the influence of ex-ternal factors, such as economic or housing conditions. In some instances the relatives' positive feelings for the patient might act as a detriment to his treatment because of attitudes of over-solici-tousness, etc. No assessment could be made of the family relation-ships of five of the veterans. Of the other forty-five patients, twelve had poor or indifferent relationships with a l l relatives, while three of the group had, at best, f a i r relationships with any - 34 -kin. Sixty per cent of the patients had a good relationship with at least one member of his family. Medical Diagnosis and Treatment Classifications In considering the social problems of any group of hospitalized patients, the nature of their illnesses i s of primary importance, since a l l planning of services has a direct relationship to the medical condition of the individual. Some indication i s given of the degree of disablement, or of the patient's limitations in s e l f -care by the examination of the numbers of patients receiving dis-a b i l i t y pensions, or in need of domicilliary care (page 31). These factors are affected to a large degree by the patient's and rela-tives' feelings about the illness - that i s , the interpersonal relations and anxieties relating to the illness.• The social worker takes these factors into consideration in assessing the total situa-tion. The classification under which the hospitalized veteran qualifies for treatment also has considerable bearing on the nature of his social problems, and the services which he may require. For the purposes of this study, illnesses were classified into the same fourteen categories used in an analysis of DVA in-patients, 1 and the actual diagnoses were obtained from the patients medical record. ¥/here any question arose as to the diagnostic group under which the particular illness should be classified, this was discussed with medical staff. 1. WINFIELD, G.A. and WELLWOOD, L., op.cit. - 35 -The census of patients in DVA treatment institutions taken at midnight March 31> 1955> showed that the largest number (15.2 per cent of the total) were Psychotics, with the second largest group (12.29 per cent) i n the category of Diseases of the Circulatory System. The third largest group were receiving treatment primarily for Diseases of the Nervous System and Sense , Organs. Psychoneurotics represented two point sixteen per cent of the total departmental load. Of the group of in-patients re-ferred to M.S.S.D., the largest number (22 per cent) had a primary diagnosis of psychoneurosis. The second and third largest groups were receiving treatment for Diseases of the Circulatory System and for Psychoses, and represented eighteen per cent and fourteen per cent of the study group. A breakdown of the.primary medical diagnostic groupings by age is shown in Table 2 . These figures clearly indicate that social services are requested on behalf of an exceptionally high proportion of in-patients diagnosed as having psychoneuroses. The highest percentage of this group f a l l in the 26 to 45 age range. The proportions of in-patients referred to M.S.S.D. who are receiving treatment in other medical diag-nostic groupings does not di f f e r significantly from those receiv-ing treatment in D.V.A. institutions, except that only four per cent of the study group had Diseases of the Nervous System. At the time of referral to M.S.S.D., twenty-six per cent of the group qualified for treatment as recipients of W.V.A. The - 35a -Table -2 . Primary Diagnoses by Age Grouping Diagnostic Group Age ..Groups Total 18-25 26445 46-65 66T76 76+ Malignant Neoplasms ' 1 • _' _ 1 1 Respiratory Tuberculosis — 1 1 — 2 DiabeteB Mellitus — — - : 2 — 2 Psychoses 1 3 1 - 2 7 Psychoheuroses 1 5 4 1 - 11 Diseases of Nervous System'and Sense Organs - 1 - -• - 1 Diseases of the Circulatory !System - 2 1 6 - • 9 Diseases of the Respiratory System - 1 - - 3 4 Diseases of the Digestive System - 1 - . - - 1 Diseases ofithe Genito-urinary 'System - 1 1 - 2 4 Diseases of Skin and Cellular Tissue - : - 1 • - ' - 1 Diseases of Bones and Organs of•Movement - • 1 - - • - 1 Fractures j Poisonings, and Violence - : 2 2- 1 * 1 6 Total 2 18 12 10 8 50 Sources Compiled from'medicalrrecbrds, Shaughnessy Hospital. - 36 -majority of these patients were i n the older age brackets, although two were under 46. Eighteen per cent were receiving treatment f o r service-connected d i s a b i l i t i e s , and over half of these were i n the 26 to 45 age range. Eight veterans q u a l i -f i e d f o r treatment i n the section of inadequate income or re-sources, with over half of these i n the 26 to 45 ag© range. Pour veterans were q u a l i f i e d under the section where examina-tion and treatment of a service d i s a b i l i t y i s given when there i s uncertainty as to the need for treatment in.hospital, or as to the primary condition f o r which treatment i s needed. Another four patients were service personnel, treated at the request of the Department of National Defense. Four veterans were c l a s s i -f i e d as domicilliary care patients, i n need of treatment while receiving such care, subject to both to t a l physical d i s a b i l i t y and f i n a n c i a l agreements. Three of the group were treated f o r a non-entitled condition, and were responsible f o r payment of the hospital account. Three were treated f o r an emergency condition which did not allow for transfer to another i n s t i -tution, but where the patient could not qualify i n any other class. One veteran was being examined at the request of the Canadian Pension Commission, and another received treatment f o r a d i s a b i l i t y for which pension i s paid by other non-military organi zat ions. Over half of the patients i n the study group (56 per cent) had had at least one previous hospital admission, with one having had sixteen admissions. Of these, eight veterans had primary diagnoses of psychosis or psychoneurosis. Thirty per cent of the group had f i v e or more previous admissions, and of these, the majority were i n the 26 to 45 age group. Of the four veterans aged 16 or over who had previous hospital admissions, three had been admitted f i v e or more times. Psychosocial Problems Since so much of this study involved a d e f i n i t i o n of problems, i t was necessary to devise a c l a s s i f i c a t i o n for these which would be adaptable from the point of view of any of those referring.the patient or his family, and would have uniform meaning f o r , a l l the cases. Because this c l a s s i f i c a t i o n was to be u t i l i z e d i n diagnosis of not only the presenting and accom-panying problems fo r which social services were required, but also of the possible underlying or causative factors, i t was necessary to choose broad general groupings;. It was essential also to ensure that these categories could be ones which were easily recognizable and acceptable from the point of view of any of those persons who might be concerned with the d i f f i c u l -t i e s . They had, therefore, to be stated i n non-technical terms, but ones which would identify the s p e c i f i c areas i n which the individuals were encountering d i f f i c u l t i e s . After a careful - 38 -examination of !the varied problems encountered i n the s i t u a -tions of the patients, and'the possible contributing or under-l y i n g factors, a ' c l a s s i f i c a t i o n was evolved. Only thoseprob-1ems indicated by some person concerned with 1the veteran or his family were considered. The;assessment of the possible factors underlying the patient•s'problems was based on information con-cerning his t o t a l situation, and background experiences, as observed from a study of the information contained i n the re-cords. 'The broad'categories used for the problems c l a s s i f i c a -tion were: I. Economic - Includes i n s u f f i c i e n t income or resources to meet current needs of the individual or family, such as medical care :for patients', families, indebtedness due to unexpected'drains on resources,- inadequate management of income,: and other problems related to financing. I I . Housing 1- This d i v i s i o n includes lack of shelter or accommodation adequate to meet the requirements of the patient orrhis family. It covered also the need for housekeeping services•>and boarding care'for incapacitated veterans or other members of their;families. I l l : Vocational"- This"category covered several items connected with employment:difficultiesj such'as!educational training, seasonal'or;irregular employment, need of a job or d i f -ferent .'kind: of employment. ! 'It 1 included employment " d i f f i -c u l t i e s '<• engendered by 'a- faulty attitude 6t psychological problem which'was not considered s u f f i c i e n t l y " i n c a p a c i t a t -ing to warrant ..W."V. A; or ; d i s a b i l i t y entitlement. It covered.also physical d i s a b i l i t y of;a?degree which.re-quired 1 t h e i n d i v i d u a l to have'sheltered employment. TV. Physical:Disability!or .Limitations - Included. diagnosed conditions of'either'chronic 1 or acute.physiological or anatomical impairment which would constitute a'vocational handicap tor:severely l i m i t * the ;person'in"self-care or normal l i v i n g a c t i v i t i e s . V. Anxieties °fe"Medical"Diagnosis fand^'Tf eatmerit Plan -Included'in this :category 'ijrere .misunderstandings or fear - 39 -of i l l n e s s , medical treatment and lack of acceptance of the medical diagnosis and i t s implications. It covered also i n a b i l i t y to co-operate i n treatment recommendations and anxieties connected with the medical setting. VI. Mental or Personality Disorder - This c l a s s i f i c a t i o n covered conditions of psychosis, psychoneurosis, mental retardation, and severe psychopathology as diagnosed "by medical s t a f f . Deviant behaviour such as alcoholism are included i n this group as well as the adjustment re-actions of late l i f e where these had been indicated i n medical diagnosis. VII. Inter-personal Relations - Covered d i f f i c u l t i e s i n the social and personal interaction between the patient and other persons i n his environment and includes discord i n marital, parent-child, s i b l i n g , and other relationships affecting the adjustment of any of the individuals to the r e a l i t y situation. Concerns with s e l f , inadequate responsivity i n relationship and s o c i a l i z a t i o n are i n -cluded i n this category where the individual had not been diagnosed as mentally i l l . Problems of the Veteran In-Patient The main aim of this study i s an evaluation of the kinds of social services rendered on behalf of a group of i n -patients, and the weighting of the services i n r e l a t i o n to the psychosocial problems. The nature of services which can be given depends i n large measure upon the source of r e f e r r a l and how the patient and referring person views the needs and problems. One way of gaining a better understanding of the services and the weighting of these i s to examine the problems as seen from the point of view of those persons concerned i n assessing the d i f f i c u l t i e s and i n finding a solution. These, were the patient, the relatives, the doctor and the s o c i a l worker. In the - 40 -majority of cases a l l four persons had not been brought into the planning. In some instances, relatives were not available or' were not contacted; i n others, the patients, were not i n t e r -viewed. The usual procedure i n this setting i s for the patient's permission to be obtained prior to contact with his family. Sometimes, because of patient's i l l n e s s or condition, the doctor suggests contact with relatives without the veteran's permission. Sometimes, relatives who had requested social services, or who were seen at the doctor's request, asked that the patient not be informed of the contact. Patients occasionally refused to have relatives seen, and i n a few instances, where the medical con-di t i o n of the patient was not related to the problems, the doctor was not contacted or his view of the social situation was not recorded. For these and other reasons, i t was not pos-si b l e to tabulate the problems as seen by a l l four persons i n every case. Whenever more than one problem was seen i n any of the three divisions - presenting, accompanying or underlying -the total number were tabulated i n the appropriate categories. Only those problems indicated i n the records were considered i n evaluation of the need or d i f f i c u l t y for which so c i a l ser-vices were given. These were tabulated under presenting or accompanying problems i n order to make i t possible to assess the services, and the weighting of these, i n r e l a t i o n to the needs. M.S.S.D. services are rendered not only on the basis - 41 -of problems as presented but also as diagnosed by the worker. For the purposes of this study, presenting problems represent the d i f f i c u l t y or d i f f i c u l t i e s for which the M.S.S.D. i s re-quested to give service. Accompanying problems are those which have a bearing on the immediate need or concern, and which have to be considered i n i n s t i t u t i n g a social treatment plan, and for which a need for services, might also be seen. Underlying problems represent the causal factors which have precipitated the situation or d i f f i c u l t i e s with-which the patient or family requires help* The assessment of M.S.S.D. services, and the weighting of these, w i l l be based on the social worker's c l a s s i -f i c a t i o n of the major or presenting problem and the secondary or accompanying problem with which the patient or his family J was considered to need help. It may be that some problems adtually being experienced by the c l i e n t or his family were not recorded. The study does not attempt to show the method by which social diagnoses are made, but rather, the constella-tion of problems as seen by the various personsi The s t a t i s t i -cal material does not show the nature of the problems but represents only the gross categorization. Presenting Problems; The numbers and percentages of presenting problemsiwith which the veteran or his family required help as seen by.those concerned i n the 50 cases studied-is shown i n Table 3; An examination of these figures w i l l aid i n Understanding - 42 -Table 3 . Frequency of Presenting Problems as Seen by Patient and Others Presenting Problems Patient Family Doctor Social Worker I. Economic 38.2 18.6 24.0 25.0 II. Housing 23.6 22.2 24.0 21.5 III. Vocational . 2.9 - 2.0 1 .8 IV. Physical Disability 14.7 14.8 10.0 8.9 V. Medical Treat-ment Anxieties 5.9 22.2 10.0 16.0 VI. Mental or Per-sonality Disorder 5.9 18.5 20.0 1-7.9 VII. Inter-personal Relations 8 . 8 3.7 10.0 8.9 Total K o -P.O. 34 100 27 100 50 100 56 100 Sources sample count of Medical Social Service case records. how the patient and his relatives see their needs. In every case the social worker had made a diagnosis of the presenting problems. This accounts in large part for the greater number seen by the social worker in comparison with the other persons. Those patients contacted saw the greatest proportion of problems in the area of economic d i f f i c u l t y , while the relatives saw more problems in relation to anxieties regarding the patient's medical condition and i n relation to housing. This could be - 43 -anticipated since relatives might be more l i k e l y to request services i f they were concerned about the i l l n e s s and what this condition w i l l mean to the patient or to themselves. It i s usual, for example, that the social worker w i l l be requested by the psychiatrist to contact the patient's nearest r e l a t i v e for completion of a form and for help with understanding the i l l n e s s of those patients who are committed to the Provincial Mental Hospital. Since such a large proportion of the group were 1diagnosed as*psychotic, i t i s understandable that the relatives saw more need f o r help i n this area. "Relatives might be more l i k e l y to be contacted by M.S.S.D. regarding housing for those patients referred for discharge planning, or i n need of specialized after-care. An:analysis of the presenting problems f o r which so c i a l services were required, as seen by the doctor i n his refe r r a l s to MiS.S.D., or i n his discussion with the so c i a l worker, were seen to be highest i n the categories designated as:economic, housing and mental or personality disorder; the least number seen to be vocational. These figures are con-sistent with the doctors' reasons f o r re f e r r a l s , since the highest percentage of their requests were for social histories and discharge planning, as well as for economic aid f o r the patients. - 44 -When the social workers 1 assessments of the present-ing problems are examined, i n comparison with numbers of prob-lems as seen by others, they are most similar i n the categories of vocational and economic. The most s t a t i s t i c a l l y s i g n i f i c a n t difference appeared i n the category designated as anxiety re medical diagnosis and treatment plan. Sixteen per cent of the to t a l number of presenting problems seen by the so c i a l worker were i n this category. This figure can be considered to be high i n view of the fact that the majority of re f e r r a l s were fo r social history and assessment of the so c i a l situation of the patients i n connection with mental disorders and discharge plans^ as'well §s f o r economic aid for the patients. Accompanying Problems; The frequency of accompany-ing problems i n the cases studied (Table 4) indioates that the patients saw the largest number of accompanying problems as being vocational. Coupled with this was their expression of anxiety vin <relation to medical diagnosis and treatment plan-ning. In most instances these problems were associated with economic pres e n t i n g ' d i f f i c u l t i e s . The patients' families saw a correspondingly high percentage of secondary problems i n these two categories. The highest percentage of accompanying problems as indicated by the doctors were i n the category of physical l i m i t a t i o n and d i s a b i l i t y ; ah almost equal percentage were - 45 -Table *4>' Frequency of Accompanying Problems :as Seen : >^y Patient'and Others. Accompanying Problems Patient Family Doctor Social ; Worker I. Economic 7.2 — 4.3 3.6 I I . Housing 7.2 - 4.3 3.6 I I I . Vocational 32.1 31.0 23.3 20.0 IV. Physical D i s a b i l i t y 14.2 16.3 27.7 23.6 V. Medical?Treat-ment Anxieties 32.1 42.0 25-5 32.7 VI. Mental or Per-sonality Disorder _ 5-3 6.4 5.4 VII. Intef-personal Relations 7.2 5.3 8.5 10.9 No. Total P.C. 28 100 19 100; 47 100 ; 55 100 Source: sample count of Medical Social Service case records. i n the categories of vocational and anxiety. The l a t t e r two were most frequently associated-with presenting'problems of psychological disorders, with vocational problems affecting the younger veterans p a r t i c u l a r l y . When'the numbers of secondary or accompanying d i f f i -c u l t i e s as diagnosed by M.S.S.D. were tabulated, they were found to be s i g n i f i c a n t l y higher than those'seen by any of the - 46 -other individuals i n the category of inter-personal relations. The highest proportion of secondary problems as seen by the 'M.S.SiD. were anxieties related to treatment planning or medical diagnosis and of physical l i m i t a t i o n or d i s a b i l i t y . Underlying Problems: The underlying d i f f i c u l t i e s were seen to be the main factors 'creating problems for which the patient or his family required social services. These under-l y i n g d i f f i c u l t i e s were generally of long-standing nature, i r r e -vocable or early l i f e experiences of the patient. In any instance where there were problems created by these basic factors which could be dealt with they were indicated as pre-senting or accompanying d i f f i c u l t y . The frequency of underlying problems i s shown i n Table 5» In 8 of the 5° cases there was i n s u f f i c i e n t information recorded, or available concerning the individual's circumstances or background, to enable assessment of ithe possible underlying factors. While i t would have been desirable, an accurate attempt to document diagnostic material would have been outside the scope of this study. In no instance was anattempt made to assess 1the basic factors where informa-tion»was available only about the immediate needs with which the patient-orshis relatives required help. The'majority of the patients saw the.main problem which |ed to their need f o r help as being one.of physical d i s a b i l i t y or handicap. In only one instance did a patient recognize mental or personality disorder - 47 -Table 5» Frequenoy of Underlying Problems as Seen by Patient and Others.(A) ~ Underlying Problems Patient Family Doctor Social Worker IV. Physical D i s a b i l i t y 77.0 66.7 35-6 32.6 VII Mental or Per-sonality Disorder VII; Inter-personal Relations 7.6 15.4 33.3 31.1 33.3 30.4 37.0 No. Total P.C. 13 100 12 100 45 100 46 100 Source: Compiled from D.V.A. Vancouver D i s t r i c t Office f i l e s and from M.S.S.D. case records. . (A) Insufficient information to allow assessment i n 8 cases. as being the basic cause of a need f o r service. This i s i n direct contrast to the large proportion of patients with diag-nosed problems i n this category. However, i n a great many of those cases the M.S.S.D. was called upon to obtain s o c i a l h i s -t o r i e s , and the patients or their relatives frequently i n t e r -preted the problems to be a result of physical d i s a b i l i t i e s or war experiences. The i n a b i l i t y of the patients and families to recognize the basic factors contributing to their problems i s t y p i c a l of cli e n t s i n this kind of setting. - 48 -The doctors and social workers assessment of these basiiS factors, where recorded, generally concurred. D i f f i c u l -t i e s were seen to have arisen out of personality or mental d i s -orders and physical d i s a b i l i t y or li m i t a t i o n an almost equal number of times. The highest proportion of problems were seen to be related to disturbances i n interpersonal or family r e l a -tions, and these were generally long-standing. Case Il l u s t r a t i o n s The study of problems shows only a gross categoriza-t i o n and does not indicate the spe c i f i c nature of these. The following case examples w i l l c l a r i f y the method of tabulating the problems. Case 13t The patient, a ninety-one year old veteran of the Riel Rebellion, was referred to M.S.S.D. by the doctor because he and his wife were upset by the patient's confinement i n a security section of the psychiatric ward. He had been diag-nosed as undergoing "senile changes", and had been transferred to this ward because of his mental confusion and his tendency to wander about the premises. The couple had been married for sixty-four years. They had never been separated for any length of time u n t i l the patient's hospitalization. The patient had formerly had a suc-cessful career, and had been l i v i n g i n his own home i n the ' - 49 -i n t e r i o r of the province. The patient's wife, s t i l l an al e r t , active woman of eighty-nine years, was l i v i n g i n a Vancouver hoarding home, so that she could v i s i t the patient daily. The presenting problems, as seen by the patient's wife, doctor and soc i a l worker, were anxiety re the medical diagnosis and the treatment plan for the patient. Both the worker and the doctor considered the patient's physical limitations to be an accom-panying problem, since this made other treatment planning f o r the patient d i f f i c u l t ; the underlying factor was the patient's mental deterioration. Case 20s i l l u s t r a t e s a r e f e r r a l by the doctor re-questing a social history on a t h i r t y year old man who was diag-nosed as alcoholic and for whom psychiatric treatment was being considered. The patient was a man of above average intelligence, with professional training which he was unable to use ef f e c t i v e l y because of his drinking problem. He had been married but at the time of the r e f e r r a l had been separated f o r several years. This young man had alienated himself from his relatives because of his behaviour. He had experienced an extremely disturbed and unhappy childhood, with the loss of his loved father i n his early adolescence and disturbed relationship with his m e n t a l l y - i l l mother. The patient had l i v e d with stable relatives and had a good relationship with them u n t i l becoming alcoholic i n l a t e r - 50 -years. The presenting problem as recogniged by the patient, doctor and social worker was personality disorder. A l l those concerned saw vocational d i f f i c u l t i e s as an accompanying prob-lem; both the doctor and social worker saw the disturbances i n the patient early inter-personal relations as the factor under-l y i n g the present problems. Case 45 j A sixty-eight year old veteran was referred to M.S.S.D. f o r help with his personal and social adjustment. He was a diabetic whose physical condition was further compli-cated by mental retardation. The patient was depressed that his common-law wife had l e f t him f o r the second time while he was hospitalized and had taken with her a l l his possessions. He was considering taking legal action against her on this ac-count, but he also wished to have her return to him because of his affectionate t i e to her, and because of his dependency. The patient bad had two previous marriages, both of which had been unhappy ones. There were seven children of t h e " f i r s t marriage, two of whom were i l l . Patient saw his children occasionally but could not continue satisfactory relationships with them for any length of time. His second marriage had ended after three years of quarrels, separations and re-unions. The patient was able to recognize, to some extent, his i n a b i l i t y to maintain good health or otherwise manage his li£e on his own. The presenting problems, as seen by the patient, doctor and - 51 -s o c i a l worker, were interpersonal relations and housing. The doctor and worker considered the patient's physical l i m i t a t i o n as an accompanying problem, and his mental retardation as the underlying factor which could not be changed. CHAPTER III SOCIAL SERVICES RENDERED Social services are generally thought of as those channels of helpfulness that social agencies and their case workers'extend to their c l i e n t s . The problems presented by or on behalf kf the c l i e n t s , their wish for service, and the requirements of the community determine i n large part what services are rendered. Social services i n a veterans' hospi-t a l setting, as i n any medical setting, are rendered i n r e l a -t i o n to the social needs and problems related to the patient's i l l n e s s , physical handicap, and medical care and are given i n collaboration with other professional personnel, within the setting and within the community. The late Ruth Hubbard, a public health nurse, has described what goes into a team r e l a -tionship and into the giving of services on behalf of.an i n d i -vidual as a member of a team. This'definition seems applicable to the functioning of a team i n the hospital, i n a DVA setting or i n the larger communityt "To be part of a team means that one must be extremely well prepared i n his own f i e l d , that he must see himself i n re l a t i o n to the contribution of others, that he must sense constantly the changing needs of the individuals whom he and the group are serving, that he must accept the corresponding changes i n his - 53 -contribution and the contributions of other team members to these needs, t.hat he must have the courage to say what he can do and why he feels that he can do that thing bet-ter than another, that he must have the grace to give up what he l i k e s to do i f another can do i t better. It means further that he must learn to do the things which do not come easily i f they can best be done by him f o r the good of a l l . It means the w i l l to p u l l with others and the integrity to withdraw from those parts of an undertaking which are not h i s . It means the enduring belief.that together we can do things which none of us individually could do alone, and that the togetherness makes possible a concept of the job which i s greater than the sum of the individual parts."! Social treatment of d i s a b i l i t y related to i l l n e s s i s often directed, not only to the individual, but to the immediate social group of which he i s a part. There i s no age at which the. group ceases to have a part i n the patient's response to his d i f f i c u l t y or to be affected by his problems. The importance of the wider interest group, the community, seems to increase as the person grows older because the opportunities for work, play and recognition are set i n a system of conformity and competition. It i s the expectation of the community that a man w i l l plan and provide for his family a secure economic and social position, gaining increasing prestige or status, as he develops i n s k i l l and r e sponsibility of judgment, and as he increases control of his own a f f a i r s . This i s the concept of s t a b i l i t y so heavily stressed as the basis of a healthy family and community l i f e . For the individual suffering some disabling physical handicap, chronic i l l n e s s or s o c i a l problem there are additional factors which may prevent him from achieving t h i s expectation. The way 1. Abstracted from an address, "Inter-Agency Communication - the Mortar for Individual Services", a paper prepared by Stephen L. Angell, for presentation at the Rational Conference of Social Work, St. Louis, Mo., 1956. i n which the sick person and his immediate group meet the experience of i l l n e s s , and i t s effect, i s determined i n part by what they bring to i t . What the environment and community offer them as a means whereby to compensate, to maintain a balance, or to develop their capacity to l i v e within the d i s -a b i l i t i e s , also has an influence. The Use of Resources The medical s o c i a l service department serves as l i a i s o n i n coordinating the D.V.A. and community resources which are available to help meet the needs of the hospitalized veteran or his family. A comprehensive review of the resources for meeting the needs of the patients and their families would be outside the scope of this study. Some knowledge of the re-sources available w i l l aid i n an understanding of the nature of social services rendered to this particular group. Some consideration has already been given to the resources available within D.V.A.* Those patients who have problems i n locating suitable housing, who are i n fi n a n c i a l need and are e l i g i b l e for aid through D.V.A., and those who are experiencing d i f f i c u l -t i e s i n re l a t i o n to vocational training or job placement, may be referred to the Veterans* Welfare Services. Two D.V.A. special placement o f f i c e r s are attached to the National Employment 1. See Chapter I, pp.13-14. Service i n Greater Vancouver and redeive re f e r r a l s of those patients who present an employment handicap. An outline of the services which the community of Greater Vancouver has established to meet the needs and problems of i t s c i t i z e n s * shows there are some f i f t y - n i n e community agencies providing family, children's, child-guidance and recreational types of services. The services of any of these agencies can be u t i l i z e d when the patient's prob-lems relate more s p e c i f i c a l l y to c h i l d and family welfare or to recreational needs. Public welfare and social assistance agencies are available to help those patients, and their families, who are i n economic stress and who are not e l i g i b l e ' f o r f i n a n c i a l assis-tance through D.V.A. resources. In addition to the Community Chest and public agencies there are some agencies supported by private groups or under religious auspices which offer emergency fi n a n c i a l aid or shelter to those who are i n e l i g i b l e f o r public assistance or whose needs are too urgent to await the establish-ment of their e l i g i b i l i t y . Patients who reside i n rural areas of the province may be referred to the Social Welfare Branch for f i n a n c i a l aid, as well as for casework help with other social problems. Members of the veteran's family who are i n need of medical care and who are unable to obtain i t privately, because of limited income, may be referred to the Out-patient departments of two c i t y hospitals. The Provincial Mental Health Services may be called upon to 1. Directory, Greater Vancouver Community Chest and Council Agencies, October, 1956. provide psychiatric care f o r those patients who may not be e l i g i b l e to receive treatment at Shaughnessy. The Nature of Social Services In social work l i t e r a t u r e i t i s recognized that medical social casework i s the primary concern of the social service department i n the h o s p i t a l . 1 Members of the department have the casework point of view and methods inherent i n a l l their a c t i v i t i e s . Interviewing and the use of relationship are basic common factors i n a l l casework. It i s recognized that change may be brought about i n the situations or adjustment of clients by "the application of various casework processes or groups of techniques. In any given case, several different 2 means or methods may be used". The application of s o c i a l work process and the choice of treatment methods depends on the problem, the aim, the t r e a t a b i l i t y of the person i n need of help, and the s p e c i f i c purpose for which the organization exists. The main considerations included i n the practice of social casework are the building of professional relationship; the establishment of confidence; the maintenance of focus on s p e c i f i c goals; and the use of prac t i c a l resources."^ 1. GOLDSTINE, Dora, Readings i n the Theory and Practice of Medical Social Work, University of Chicago Press, 1954. 2. HOLLIS, Florence, "The Techniques of Casework", Prin- ciples and gechniques i n Social Casework, Family Service Asso-c i a t i o n of America, New York, 195°• P«413. -3. HAMILTON, Gordon, Theory and Practice of Social Case- work, Columbia.University Press, New York, 1951» Chapter 9» - 57 -Every disorder f o r which an individual or family may require social service help i s the result of the faulty i n t e r -action of two sets of factors - outer and inner. On this basis, i t i s possible to make a simple d i v i s i o n of casework treatment methods into two broad categories of services - indirect and direct. Many situations are essentially environmental and must therefore be treated environmentally. In the giving of environ-mental or indirect services, the patient, or family, i s helped through an a l l e v i a t i o n of the outer problems, by removal or changing of some of the outer tensions and by reinforcing oppor-tunities i n the environment f o r expression of inner needs and by providing the means of r e s t i t u t i o n . In the giving of practi c a l environmental services or the manipulation of the immediate milieu to further the better functioning of individuals within a sp e c i f i c group, the emphasis f a l l s on helping the c l i e n t to use, either within the agency or through another agency, the resources neces-sary to meet the needs. Many patients and the i r families can manage their own adjustment to change and go on getting and giving s a t i s f a c t i o n i n social l i f e i f they can know what resources are available to them, and how to approach them. In this case, exploration of the need, diagnosis of the problem or situation, and mobilization of the cl i e n t ' s efforts to change the situation, through the use of the resources, are the main considerations. Since every case has both psychological and so c i a l components, indirect services are given with an understanding of the person and his emotional reactions. Certain types of cases c a l l f o r cooperative work between the medical social service department and other community agencies, e.g., a case i n which there are serious medical s o c i a l problems, and where the family has been previously known and has a strong contact with the rco.mmunity agency, or a case i n which new problems that arise are the major responsibility of another agency. If the medical social service department i s unable to obtain service from an outside resource, i t may have to assume responsibility for some form of treatment i t s e l f . When an individual applies, or i s sent, fo r a prac t i c a l service, the social worker may recognize addi-tional or deeper problems. Unless the c l i e n t wishes treatment i n these areas, they cannot be dealt with. In the giving of direct services or treatment, the purpose of interviewing i s to induce or reinforce attitudes favorable to the maintenance of emotional equilibrium and to personality growth or change. The worker's a c t i v i t i e s are primarily related to the c l i e n t ' s subjective r e a l i t i e s , his emotional c o n f l i c t s , feelings, etc. The primary purpose i s to effect a better adjustment of the individual to his environ-ment through effecting a better adjustment to himself. In direct treatment, the worker's a c t i v i t i e s are directed toward the release of tensions or diminution of c o n f l i c t s that are l i m i t i n g the individual i n the use he i s making of himself and his environment. Tensions may he created f o r the family, or the patient with physical or mental handicaps, as he attempts to adjust to his limitations and to add himself to his group. Direct help may be needed to aid patients or t h e i r families to l i v e with the effects of sickness, or, as an aid to per-sonal development under d i s a b i l i t y . When the patient or family require help with inner emotional tensions or d i f f i c u l t i e s ^ the emphasis i s on the use of the worker-client relationship, but i s comprised of related, yet distinguishable, methods of treatment. Individuals may require the sustaining security of another person sincerely interested i n their welfare, but may need, or be able to use this help i n different forms and at different levels of inten-s i t y . 'Listening with a purpose' may sometimes be the form of treatment used to help patients do something constructive with d i s a b i l i t i e s resulting from inner stress. The decision of whether help w i l l be offered through the therapy of environmental change or the direct treatment of inner emotional disturbances, and the form of treatment, de-pends partly on the problem and on what w i l l help the individual the most. In each instance the caseworker i s guided by her understanding of the needs of the patient and family, their capacity to use help, and by the limitations of the agency or community resources. Because problems and needs d i f f e r f o r - 60 -individuals, both direct and indirect services, and different methods of social casework treatment are used i n different cases. They may also be weighted d i f f e r e n t l y i n similar.cases, according to the diagnosis of the to t a l situation of the patient and family. With this concept of social casework and i t s a p p l i -cation i n a veterans' hospital setting i n mind, a c l a s s i f i c a -t i o n of services was evolved for use i n assessing the soc i a l treatment plans applied i n the cases under study. Services were divided into indirect and direct services and were c l a s s i -f i e d into the following f i v e categories: Indirect Services: -A. Explanation and Offer of Service - Information and explanation of • M.S.S.D. services and of resources available to meet need i s given i n every case. In some instances the patient or family sees no need.of such service or does not wish r e f e r r a l at the time of contact. In some cases they see no need of service i n respect to certain problems, although help may be given i n re-l a t i o n to other d i f f i c u l t i e s . B. Referral - Included i n this category was the direction Of either the patient or some member of his family to another resource, such as an agency giving f i n a n c i a l assistance. To indicate the type of resource being used, a further breakdown was made within the category into the divisions of Welfare Services, other D.V.A. Hospital, and Community Resource. The social worker, when, ref e r r i n g patients to community agencies, generally does this with the knowledge and approval of the medical s t a f f . C. Economic Aid - Included the obtaining of clothing from the hospital stores or a loan or grant from the Hospital Superintendent's Assistance Fund (not exceeding ten d o l l a r s ) . - 61 -D. Social Assessment and Diagnostic Aid to Assist Medical  Staff - This category covered the obtaining of i n f o r -mation regarding the patient's environment, family composition, and relationships between individual family members or other persons i n the environment, as well as data concerning background experiences, a t t i -tudes of the patient or those associated with him, and appraisal of sources of care for the patient. E. Environmental Modification - For the purpose of this study this category covered at-tempts to modify the patient's or family's situation by provision of a corrective l i v i n g experience, such as inclusion i n a group, or changes of hospital routine. Direct Services: F. Supportive Help - Includes casework treatment through the use of relationship to support the strengths of the patient and/or relatives through tech-niques such as reassurance, permissive attitudes that re l i e v e g u i l t , and a protective relationship. The re-lationship i s used not to motivate change, but to sup-port the individuals acceptable existing aims and to protect them from undue pressure. G. Interpretation - Includes explanation of the outer as-pects of problems or situations, e l i -g i b i l i t y rules, medical procedures, implications of i l l n e s s , etc. It includes also c l a r i f i c a t i o n or pointing out on a rational discussion basis, attitudes, feelings and behaviour problems. Hi Counselling - As used i n this study, covered the use of relationship to motivate'or bring about change i n behaviour, through aiding the individual to see causes of behaviour, and to f i n d more satisfactory outlets for the unacceptable behaviour. Social Services Rendered The main focus of this study i s the assessment of the means used to help those veteran in-patients f o r whom soc i a l services are requested. In this part'of the study the s o c i a l services rendered on behalf of the group were examined - 62 -from the point of view of frequency and length of M.S.S.D. contacts, numbers of previous re f e r r a l s of the patients to M.S.S.D., and the frequency d i s t r i b u t i o n of the different types of services. Frequency of M.S.S.D. Contacts: The number and frequency of M.S.S.D. contacts with the patients, relatives and other persons, including medical s t a f f , other D.V.A. per-sonnel and community representatives (Table 6) shows the average number of interviews per case to be two point eight. The figures are based on the interviews actually recorded i n the M.S.S.D. f i l e s . These should be considered'only approxi-mate, since, i n a few instances, the actual number of contacts was not recorded but information concerning a number of i n t e r -views was summarized. Social workers on their rounds may have frequent, b r i e f contacts with patients known to them, but no record may be made of these when no sp e c i f i c service i s re-quested by the patient, although he may actually have gained some help from the interest of the worker. The figures i n d i -cate that patients were seen i n nearly a l l the cases studied, and that relatives were seen i n over half the cases. In view of the fact that a large percentage of the patients and their families l i v e d i n rural areas, the number and frequency of direct contacts with relatives i s proportionately high. Con-tacts were also had with persons other than relatives i n - 63 -Table 6. Number and Frequency of M.S.S.D. Contacts Persons Contacted Number Contacted Number of Int ervi ews Average Inter-views per Case Patients 41 88 2.14 Relatives 28 52 1.85 Others 36 89 2.47 Total 105 229 2.18 Source: sample of Medical Social Service case records. nearly three-quarters of the cases. It i s probable that a l l contacts with referring doctors may not be recorded as i n t e r -views because of the established practice of discussing the patient's medical condition and treatment planning with the attending physician unless time w i l l not permit this prior to the patient's discharge. It may be seen that the highest number of contacts per case was with persons other than the patient or rel a t i v e s . This fact further points up the social worker's use of resources and participation i n team planning. Length of M.S.S.D. Contacts: A study of patients i n DVA treatment i n s t i t u t i o n s * shows that over twenty per cent of a l l patients are i n hospital less than one month, and forty-three per cent are i n hospital less than three months. In the f i f t y cases examined, ten of these (20 per cent) were active with 1. WINFIELD, op.cit. - 64 -the M.S.S.D. less than one week. In eight of these, services were completed i n one day. In most instances these patients came or were referred to M.S.S.D. immediately prior to discharge. Of these ten cases, f i v e had economic presenting problems, three had presenting housing problems, one presented problems of per-sonality disorder and one needed help with a major problem of anxiety. The largest numbers of secondary problems i n this group were seen to be vocational and physical l i m i t a t i o n . Twenty-five of the cases (50 per cent of the group) were active more than one week but less than one month. Economic problems were the major reason f o r need of service i n eight of these, mental or personality disorder i n f i v e , and physical l i m i -tations i n f i v e . Economic problems were presented i n three cases, anxieties i n two, and vocational i n one. Secondary problems of anxiety were seen i n almcbst half these cases. The remaining f i f t e e n of the f i f t y cases were active one month or more. Five of these had major problems of housing. The remainder of this group had presenting problems divided a l -most equally in*the categories of economic, mental disorder, anxieties, and inter-personal relations. The secondary problems of this group were f a i r l y evenly divided. Previous Referrals: When patients or their families have been previously known to a social service department, certain types of services on behalf of the individuals can be - 65 -i n i t i a t e d and completed more quickly, since considerable know-ledge regarding the individuals and their situations w i l l have been obtained. Less exploration of the d i f f i c u l t i e s , strengths and resources f o r solving the problems may then be necessary. In the cases studied, forty-one of these had not been previously known to the M.S.S.D. Two cases had previously received ser-vices on one occasion. Two had been known twice before, and three had been given services three times i n the past. One veteran had been referred to M'.IS.S.D. for help on four previous occasions and one veteran had been referred on f i v e former occa-sions. Distribution of Services: An examination of the ser-vices rendered i n the cases studied showed that a t o t a l of 119 services were given. In one case the patient was discharged before any service could be given. According to the c l a s s i f i -cation of services, as direct or indirect i n nature, seventy-one of the services f e l l into the d i v i s i o n of indirect services, and forty-eight were considered direct. The d i s t r i b u t i o n of services, as shown i n Figure 4> points up supportive help as being the type of social service employed most frequently. This help was given i n t h i r t y - s i x of the cases and frequently accompanied other types of service. The second means most frequently used to help meet the problems of the veterans and their families was refer-r a l to other resources. A total of twenty-seven r e f e r r a l s were DISTRIBUTION OF SOCIAL SERVICES Explanation and Offer of Service Referral Economic Aid • Social Assessment Environmental Modification • Supportive Help Interpretation Counselling • IO 20 30 4 0 IO zo 30 AO Figure 4« Distribution of Social Services (Shaughnessy Hospital, 1956.) - 66 -made. A further breakdown of the r e f e r r a l s revealed that the highest number (14) were to community resources. Twelve re -f e r r a l s were made to Welfare Services and one to another D.V.A. hospital. Social assessment and diagnostic aid to assist the medical s t a f f i n treatment planning was a service given on behalf of the veteran and his family i n twenty-three of the c§ses examined. In sixteen cases explanation and offer of service was extended. Interpretation was one means used to help solve the problems i n ten of the cases. The types of social services extended infrequently were economic aid, en-vironmental manipulation and counselling. One of the integral services of a social service de-partment i n a medical setting i s that of acting i n a consulta-t i v e and teaching capacity to persons other than the c l i e n t group. Members of the department may participate i n conferences concerning a patient known to them or may be asked for advice regarding s o c i a l planning f o r particular patients by other mem-bers of the hospital s t a f f . While these have not been included i n the c l a s s i f i c a t i o n of services i n this study, i t was noted that these services were given i n s i x of the f i f t y cases studied. The Weighting of Services i n Relation to the Psychosocial Problems The d i s t r i b u t i o n of social services rendered i n r e l a -t i o n to the presenting and accompanying problems, as diagnosed - 67 -by M.S.S.D., i s shown i n Table 1. The h i g h e s t number of s e r -v i c e s were seen t o be g i v e n i n r e l a t i o n to problems o f a n x i e t i e s , w i t h s u p p o r t i v e h e l p b e i n g the method of casework s e r v i c e most f r e q u e n t l y used t o d e a l w i t h t h i s problem. S u p p o r t i v e h e l p was o f f e r e d more f r e q u e n t l y f o r accompanying problems of a n x i e t y than when t h i s was the p r e s e n t i n g d i f f i c u l t y . One of the main reasons f o r t h i s was t h a t when a n x i e t y accompanied problems, such as economic d i f f i c u l t y , and where r e f e r r a l was made t o another source t h e r e was l i t t l e o p p o r t u n i t y f o r the s o c i a l worker t o g i v e a more i n t e n s i v e s o r t of treatment such as i n t e r p r e -t a t i o n . The second h i g h e s t p r o p o r t i o n of s e r v i c e s was g i v e n i n r e l a t i o n t o problems of mental o r p e r s o n a l i t y d i s o r d e r . S o c i a l assessment and d i a g n o s t i c aid^: t o a s s i s t m edical B t a f f , was the type of s e r v i c e most o f t e n rendered i n r e l a t i o n t o t h i s p r e s e n t i n g problem. E x p l a n a t i o n and o f f e r of s e r v i c e and sup-p o r t i v e h e l p were g i v e n an equal number of t i m e s . I n t e r p r e t a -t i o n was employed i n two i n s t a n c e s where p r e s e n t i n g problems were i n t h i s c a t e g o r y . Where t h i s was seen t o be secondary, e x p l a n a -t i o n and o f f e r of s e r v i c e was g i v e n i n one i n s t a n c e and s u p p o r t i v e h e l p i n another. S e r v i c e s were o f f e r e d a s i m i l a r number of times i n r e l a t i o n t o economic and h o u s i n g problems. The most s t a t i s t i c a l l y s i g n i f i c a n t f i g u r e w i t h r e s p e c t to the nature of s e r v i c e s ' e m p l o y e d -68-Table 7. Distribution of Social Services in Relation to  Presenting and Accompanying Problems Problem ledical Social Services Rendered Total Services Explanation and Offer of Service Referral Economic Aid Social Assessment Environmental Modification Supportive Help Interpretation Counselling I. Economic P A II. Housing P A III. Vocational P A IV. Physical Disab- P i l i t y A 3 9 1 1 5 1 1 1 2 1 2 2 1 -9 -4 -1 - 2 1 - _ 2 - -2 - -18 18 3 12 V. Medical Treat- , P ment Anxieties A VI. Mental or Person- P a l i t y Disorder- A VII. Inter-personal P Relations A 2 2 1 4 2 1 1 2 1 - 1 -- 8 -7 5 -13 - -4 2 -1 - -3 1 2 3 2 -31 22 15 Total 16 27 3 23 2 36 10 2 119 Source: sample count of Medical Social case records. P Presenting Problem A Accompanying Problem - . 6 9 -in dealing with these problems is that referral to either Wel-fare Service or a community agency was the method employed most often in assisting with economic problems while social assess-ment as an aid to medical staff along with referral were most often required in relation to housing problems. Where these two problems were secondary, services were given only twice and in the same categories for each problem. Services related to difficulties in inter-personal relations were given an almost equal number of times where this was seen to be an accompanying difficulty as where it was seen to be the presenting problem. Services were given fifteen times in respect to this problem. The majority of these services were \ of a. direct nature. Supportive help was employed most often in helping with this difficulty. Interpretation and counselling were offered five times. When vocational problems were seen to be either a major or a secondary problem, services were rendered a propor-tionately small number of times, three in a l l . This can be accounted for, in large part, by the fact that all hospitalized veterans are interviewed by the Welfare Officers who have res-ponsibility for assisting veterans experiencing problems in relation to employment, unless the patient is medically unem-ployable and not eligible for assistance through D.V.A. re-sources. Ih these instances'the MiS.S.D. might be called upon to aid the patient at the time of his discharge with problems in this area. Services were offered i n re l a t i o n to problems of physical d i s a b i l i t y or li m i t a t i o n twelve times and were found to be most frequent i n the category of social assessment, f o l -lowed by supportive help and environmental manipulation. This l a t t e r method of social casework was not employed i n respedt to any other problems. Case I l l u s t r a t i o n s The following summarized examples of typic a l cases 1 provide further understanding of the application of different types of casework service i n respect to problems and situation of particular patients or families. The meeting of the needs presented i n the case summaries c a l l s f o r the use of different types of services i n a discriminating way. Case 44 i l l u s t r a t e s an instance i n which explanation and offer of services was given to a patient's r e l a t i v e , where i l l n e s s and hospitalization was seen to be a further disruptive factor i n an already disturbed family situation. Mr. A., age 69, a veteran of World War I, was admitted to Shaughnessy Hospital f o r the f i r s t time with a severe con-d i t i o n of "Arteriosclerotic heart disease" some two weeks prior to the r e f e r r a l to M.S.S.D. He and his wife owned their own home and were i n receipt of the maximum W.V.A. They had two adult children with whom the patient had good relations. The 1. The summaries were made from case records of M.S.S.D. of Shaughnessy Hospital. Identifying information has been removed i n order to safeguard c o n f i d e n t i a l i t y . patient's wife had gone to the d i s t r i c t o f f i c e of Veterans' Welfare Services to enquire whether any assistance would he available to help her purchase medicines for herself. Since she seemed to be emotionally, upset about the patient's i l l n e s s , i t was f e l t she should see the hospital social worker, and a telephone r e f e r r a l was subsequently made. Mrs. A. did not c a l l at M.S.S.D. as suggested but again returned to the d i s t r i c t o f f i c e , at which time she revealed that she was receiving p r i -vate psychiatric treatment. She seemed to have no recognition of her own mental disturbance but attributed her problems to poor physical health. The M.S.S.D. worker telephoned Mrs. A. who stated that she could not v i s i t the patient or discuss her situation with the medical social worker, i n spite of urging, because of her own health. She said the patient "could not go on being i l l because she needed him to care for her". Mr. A. died the day following this contact. The social worker noted i n the record that the wife w i l l have continuing problems, but as she did not wish to talk d i r e c t l y with M.S.S.D. the case should be closed. Undoubtedly Mrs. A. w i l l require the services of a community agency and w i l i encounter emotional problems be-cause of her dependency. She may require medical or psychiatric services from a community agency, since i t seems unlikely she c could continue to pay for private care on her limited income. - 72 -Case 4Qj i l l u s t r a t i v e of the social service depart-ment's use of community resources and of supportive help i n re l a t i o n to insecurities and problems of illness, i s the case of Mr. B. This seventy-two year old married veteran, i n re-ceipt of W.V.A., was referred to M.S.S.D.- by the attending doctor who requested social assessment i n connection with pos-s i b l e discharge of the patient. The family had been known to M.S.S.D. i n 1950 when a social assessment was requested, and i n 1954 when the patient was routinely seen at the time of a hospital admission. Considerable information was available from these previous contacts concerning the family r e l a t i o n -ships and previous social circumstances. The presenting prob-lem at this time was the patient's physical l i m i t a t i o n and need for special care. Mr. B. had been admitted to the hospital f o r the eighth time, with congestive heart f a i l u r e , some s i x months prior to r e f e r r a l . The patient also had a history of T.B. dating back f i v e years. Special precautionary measures needed to be taken i n order that the disease would not become more serious* or. I'be-transmitted to others. In the two weeks follow-ing r e f e r r a l , the patient and his wife were both seen once and these contacts revealed an accompanying problem of anxiety con-cerning the patient's medical condition and treatment planning. The social worker obtained the information that the patient and his wife l i v e d alone i n their own home which was a l l on one - 73 -l e v e l , thereby making i t unnecessary for patient to over-exert himself physically. The patient was noted to be careful i n his personal care and the couple took the added precaution of occu-pying separate sleeping quarters. A good relationship existed between patient and his wife, who was anxious to have him home. In addition to the supportive help given both the patient and his wife i n allaying their anxieties surrounding the possible need for continuing hospital treatment, the social worker ar-ranged for Mrs. B. to discuss the patient's condition with the attending physician. A contact was made with the V i c t o r i a n Order of Nurses who had previously known the family and who were able to contribute valuable information concerning the care the patient might receive i n the home, as well as to offer post-discharge services to ensure medical supervision and to provide the necessary injections which Mr. B. might otherwise have to receive at the hospital. The patient was discharged after this information was discussed with the doctors. An e a r l i e r r e f e r r a l of this case to M.S.S.D. would have given the social worker more opportunity to have aided i n allaying some of the anxieties and fears of the patient and of his wife. Case 24? this case i l l u s t r a t e s the employment of environmental manipulation, supportive help and interpretation to relatives, who were anxious about the treatment planning for patient. Mr. C , a 77 year old W.V.A. recipient, who l i v e d - 74 -with his wife i n their own home, had been admitted to hospital for the f i r s t time one day preceding r e f e r r a l and was being considered for i n s t i t u t i o n a l treatment. He required constant supervision because of his mental confusion. The patient's married daughter telephoned to express concern about planning for patient. She had recently been hospitalized and because she anticipated further hospitalization she was unable to as-sume responsibility f o r Mr. C.'s care. His wife, age 72 years, was unable to offer the extent of care and supervision which he required. Five contacts were had by M.S.S.D. with the patient's relatives and six with other persons, i n efforts to help the family accept their own i n a b i l i t y to continue caring for Mr. C. and to co-operate i n the treatment plan. Following recommenda-tion f o r i n s t i t u t i o n a l care f o r the patient and his transfer from an active treatment ward to the "Extension", both the patient's wife and daughter became unduly upset. They considered "appeal-ing the decision to place the patient on this ward". The worker notes that she interpreted "the need to place patients i n the most suitable environment", as well as arranging for the wife and daughter to discuss patient's care with the doctor. After this contact the worker notes that the daughter i s more accept-ing of the plan and acknowledges that the family i s more upset than the patient. In a l a t e r contact, the daughter expressed concern that Mrs. C. was insistent upon coming to the hospital - 75 -to assist with Mr. C.'s feeding. In co-operation with the ward sta f f , i t was possible, i n this particular instance, to adjust the environment i n order to permit the wife to gain some s a t i s -f a c t i o n and reassurance by contributing i n this way to the patient's care, since i t did not interfere with regular ward routine, and to help the daughter to see the mother's need to do t h i s . Case 23: this case i s an example of the social worker's employment of multiple direct services and social assessment, which aided the treatment team and the patient i n efforts toward rehab i l i t a t i o n , and i n the prevention of further social and emotional breakdown of the family. The methods used were sup-portive help, interpretation and counselling, over a period of six weeks. Segen contacts were had with the patient, two with r e l a t i v e s , and several with other members of the treatment team. The family had been known to M.S.S.D. on one previous occasion. Mr. D., a 34 year old married veteran of World War II, l i v e d i n a rural setting with his wife and three children, who ranged i n age from 2 to 7 years. He had been admitted to hospital f o r the seventh time and was diagnosed as being i n a "depressive state". He had been unable to work for a period prior to hospi-t a l i z a t i o n and was supporting himself and his family from the assets of a business which he had bought from his brother and resold about one year l a t e r . Because the patient believed the - 76 -s e l l i n g price had been too low, bad f e e l i n g existed between the brothers. The patient's wife f e l t the work required was too hard for the patient. Mr. D. had previously been committed f o r psychiatric treatment at Crease C l i n i c . He held some residual antagonism toward his wife for having signed the committal form. The patient contacted M.S.S.D. requesting aid i n l o -cating housing for his family whom he wished to bring to the c i t y . The worker notes the d i f f i c u l t i e s i n inter-personal r e l a -tionships as indicated by the patient's expressed doubts con-cerning paternity of the children and suspicions regarding r e l a -tives' a c t i v i t i e s . In subsequent interviews, the anxiety of both Mr. and Mrs. D. regarding the patient's i l l n e s s and prog-nosis were seen to be an additional d i f f i c u l t y . The efforts of the worker and doctor to discourage the patient's moving his family at this time were unsuccessful. Mrs. D., upon her a r r i -v a l , assumed that, since the patient had been responsible for bringing the family to the c i t y , he should arrange satisfactory accommodation, although he was ill-equipped to do t h i s . In subsequent interviews, both Mr. and Mrs. D. were aided, through discussion, to work out housing arrangements which would be satisfactory for both themselves and the children. Mrs. D. was able to supply information helpful to the medical s t a f f , con-cerning patient's recent behaviour. The social worker was able to help the wife understand the nature of the patient F | S i l l n e s s and to give her support i n her a b i l i t y to cope with some of the problems as well as to co-operate i n treatment recommenda-tions. In consultation with the doctor, both parents were counselled with respect to d i f f i c u l t i e s i n the marital and child-parent relations, a r i s i n g i n part from patient's i l l n e s s . The.case was closed following the patient's discharge from hospital. Case 15: the problem of inter-personal d i f f i c u l t i e s presented i n the circumstances of Mr. E., and accompanied by his anxieties related to his condition of physical d i s a b i l i t y , i l l u s t r a t e the social worker's use of a variety of resources, environmental modification and counselling. There were 15 con-tacts with the patient and seven with others, i n a period of 5 months. Mr. E., a 33 year old veteran of World War II, i n re-ceipt of W.V.A., had been transferred at his request from a distant DVA hospital to Shaughnessy. He was receiving treat-ment for "paraplegia of the dorsal spine, with decubitus ulcer". This condition, resulting from an accident, would severely handi-cap Mr. E. i n self-care and might lead to his confinement to a wheel-chair for the remainder of his l i f e . He had been separated f o r over a year from his 29 year old wife and four children, who ranged i n age from 12 to 4 years. The patient's relatives l i v e d i n another province. Mr. E. referred himself to M.S.S.D. with a request for help i n drafting a l e t t e r pertaining to divorce proceedings which he had i n i t i a t e d . He hoped to obtain custody of the two older children. A contact with the DVA hospital where the patient had formerly received treatment established the fact that there had been a long history of marital discord, with considerable psychiatric and casework service extended, and culminating i n the mutual decision that divorce would be the most satisfactory solution for a l l those concerned. Through subsequent counselling, and on the basis of the information concerning the patient's i n s t a b i l i t y and f a i l u r e to assume family responsibility, he was helped to recognize and accept the in a d v i s a b i l i t y of separating his family. His W.V.A. status i n relation to divorce presented some f i n a n c i a l complications. Referral to Welfare Services was made to assist i n c l a r i f y i n g and making f i n a n c i a l arrange-ments. The patient expressed his hope that he would be able to walk again. With the approval of the medical s t a f f , the soci a l worker supported the patient i n his desire to further this p o s s i b i l i t y . Arrangements were made for him to be re-ferred to the Western Society for Rehabilitation when his treatment at Shaughnessy would be concluded. Since the patient knew no one i n the ci t y , i t was further noted that his inclusion i n a group might prove b e n e f i c i a l . He was subsequently referred to, and became a member of, the Indoor Sports Club, thereby gaining the opportunity f o r social contacts and a c t i v i t i e s s u i t -able to his limitations. He was assisted also i n obtaining needed clothing. CHAPTER IV SOCIAL SERVICES AMD THE VETERAN IN-PATIENT This f i n a l chapter contains a review of the philo-sophy -underlying the practice of social casework i n a D.V.A. hospital, the findings of the study and some recommendations with reference to the practice arid study of so c i a l work i n Shaughnessy Hospital. In keeping with one area pf i t s function, the M.S.S.D. engages i n research with the aim of improving social services extended to the Veteran patient. The particular theme of this study was to attempt to determine, i n some measure, the kinds and weighting of social services i n r e l a t i o n to psycho-social problems. Because of the heterogeneous nature of the group of patients served by M.S.S.D., and the l i m i t a t i o n of time a v a i l -able to complete the project, i t would have been outside the scope of the thesis to explore the services rendered on behalf of the entire c l i e n t e l e . The study was, therefore, limited to an exploration of the services, and factors influencing these, i n relation to a group of f i f t y male in-patients referred to M.S.S.D. during the period January - June, 1 9 5 6 . - 80 -Philosophy and Setting The advancement of specialization i n the practice of medicine, and the treatment of the patient i n large i n s t i t u -tions i n the la s t decade, brought forth the need f o r the ser-vices of s t a f f who could bring to the doctor and the hospital administration, information concerning the patients' social circumstances. On this basis, at the beginning of the century, the practice of social work i n medical settings was f i r s t given impetus by The London Charity Organization i n England, and by Dr. Richard Cabot i n America. Social casework, as practised i n a medical setting, derives i t s basic philosophy and body of s k i l l s and knowledge from generic s o c i a l work i n i t s aim of helping individuals to achieve more sa t i s f y i n g adjustments-within themselves and to their environment. Since i t s early beginnings i n medical settings, social work has continued to extend i t s e l f i n co-operation with medicine, and other d i s c i p -l i n e s , towards the r e h a b i l i t a t i o n of patients to as f u l l a measure of physical, emotional and so c i a l well—being as pos-s i b l e . The changes i n the f i e l d of health and medical care have tended to influence the practice of social work within the i n s t i t u t i o n s . The concept of the meaning of i l l n e s s has broadened. With the increasing emphasis on the treatment of the whole person, there i s now an attempt toward integration of physical, social and emotional facets. Social workers are - 81 -taking more responsibility i n c l a r i f y i n g and i n p a r t i c i -pating i n the application of this approach. The influence of psychosomatic medicine and the emphasis upon the social and emotional restoration of the handicapped veteran brought forth the request f o r social service programmes to be added to D.V.A. reh a b i l i t a t i v e programmes shortly after World War I I . Rehabilitative programmes to assist veterans were f i r s t established prior to World War I, when the economic needs of disabled o f f i c e r s were recogniged by the payment of pensions by the government. Programmes were subsequently extended under the Department of Soldiers' C i v i l Re-establishment to include hospital accommodation, vocational re-training, pensions and other forms of assistance to service-disabled men. Under the Department of Pensions and National Health, and the succeeding Department of Veterans A f f a i r s , established to administer a l l l e g i s l a t i o n concerning veterans, r e h a b i l i t a t i v e measures and benefits have broadened to become one of the most comprehensive r e h a b i l i t a t i v e programmes ever established for veterans. Welfare Officers attached to Welfare Services Branch have re s p o n s i b i l i t y f o r ensuring that veterans are aware of a l l benefits to which they are entitled, and for assisting the veteran with s o c i a l problems which do not have a bearing on any medical condition f o r which he may be receiving treatment. - 82 -Medical Social Service, established i n Shaughnessy Hospital i n 1947 as part of the D.V.A. Treatment Services Branch, has responsibility f o r assisting with problems associated with the i l l n e s s or treatment of those veterans under D.V.A. ©edical care. Services are given on behalf of the patient at the doc-tor's request, or with his approval. The social workers i n D.V.A. hospitals thus enter into a collaborative relationship with other treatment person-nel, integrating their individual s k i l l s , prerogatives, and pro-fessional knowledge into the overall programme. They, thereby, contribute to the effectiveness of the tot a l team i n i t s interest of serving the patient and helping him to achieve the greatest possible r e h a b i l i t a t i o n . Review of the Main Findings The main focus of this thesis was an exploration of the psycho-social problems of the patient group (Chapter I i ) and of the services rendered by M.S.S.D. i n dealing with these needs and problems (Chapter I I I ) . It seems worthwhile to comment on the methods used and the d i f f i c u l t i e s encountered i n making such an exploratory sur-vey. In a setting such as a D.V.A. hospital, the situations of the M.S.S.D. c l i e n t group are affected by a large number of variable factors, such as the patients' sex, treatment rights and benefits, medical diagnosis, place of residence, etc. These variable factors present problems i n sampling, and i n establishing c r i t e r i a f o r the evaluation of services, because of the wide range and diverse nature of psychosocial problems. In order to ensure that there are factors common to the sample group, i t becomes necessary to l i m i t the study to a particular group of patients and to use broad categories i n c l a s s i f y i n g both problems and services. More complete and more sp e c i f i c c l a s s i f i c a t i o n s of both problems and services, as well as the '-application of rating scales, would ensure greater r e l i a b i l i t y of the survey results, and would permit a more accurate evalua-tion of the problems and the means of dealing with them. The cl a s s i f i c a t i o n s could be improved and further developed by the case Study method. Such an approach would also permit a closer examination of the ratios of problems and services per patient within different categories and groups. For this survey, information was obtained from the patients' d i s t r i c t o f f i c e and hospital f i l e s and from M.S.S.D. case records. Class i f i c a t i o n s were used to set up s t a t i s t i c a l tables showing the frequency of problems and services. Some d i f f i c u l t y was encountered i n establishing c r i t e r i a for evalua-t i o n and analysis of the subject matter because the records are not written with such a purpose i n mind. The summary type - 84 -recording often did not contain information regarding certain aspects of the patients' s o c i a l circumstances, attitudes or feelings. For study purposes, the presenting and accompanying problems were seen to be the major and secondary psychosocial problems with which the patient or family required help; the underlying problems as those deep-rooted experiences and other factors out of which the problems have developed. An attempt was made to determine how the persons most concerned with the patients' circumstances and treatment (the patient, family, doctor and social worker) viewed the problem and needs. An examination of the general characteristics of the patient group showed that a high proportion (36 per cent) were i n the younger age group (26 to 45)j a s compared to the average and median age of those receiving treatment i n D.V.A. i n s t i t u -tions. Sixty per cent were under s i x t y - f i v e years of age. About one half of the group were married. An additional twenty-four per cent were separated or divorced. Only three veterans were unattached or had no close r e l a t i v e s . Sixty per cent of the group had good relationships with at least one member of his family. The majority of the group had had at least public school education. More than half of the group (56 per cent) were r e t i r e d or steadily employed, while twenty-three per cent were medically unemployable. The remaining twenty-two per cent had potential employment problems. Over half of the group were - 85 -known to be l i v i n g on marginal or low incomes. Approximately one third of the patients owned their own homes, and more than half of them l i v e d i n the c i t y and therefore could take advan-tage of the resources available i n the urban community. The medical diagnoses, except that of psychoneurosis, corresponded proportionately to those of other patients receiving treatment i n D.V.A. i n s t i t u t i o n s . An exceptionally high percentage of patients referred to M . S . S . D . were i n this diagnostic group. It was also noted that t h i r t y per cent of the patients had had f i v e or more previous admissions to Shaughnessy. Two of the main factors bearing on services and on the prognosis f o r social r e h a b i l i t a t i o n are the process and reason f o r r e f e r r a l and the way i n which the patient and his family view their needs gnd situation. The majority of the study group (62 per cent) were referred to M . S . S . D . by the attending physician. Only six per cent of the patients reques-ted services of their own accord; eight per cent of the families requested help; and a very small number (2 per cent) were ob-tained by routine coverage. The largest proportion of ref e r r a l s was for assistance with discharge planning, for assessment of the patient's social background or environmental circumstances. A r e l a t i v e l y small number of the r e f e r r a l s (20 per cent) were fo r direct services to aid the family toward a better personal adjustment. - 86 -The patients saw the largest number of major problems i n the category designated as economic, while the re l a t i v e s saw more major problems i n re l a t i o n to housing and to their anxiety concerning the patient's medical diagnosis or treatment. Patients and their relatives recognized most need for help i n r e l a t i o n to secondary problems of vocational d i f f i c u l t i e s and anxiety. They considered the contributing factors to be mainly the patient's physical limitations or d i s a b i l i t i e s . The evaluation of problems seen by the doctor showed the greatest number of major ones i n the categories of economic;, housing and mental or personality disorder. They saw physical limitations, anxiety and vocational as the most frequent secon-dary problems. The most frequent underlying d i f f i c u l t y as seen by the doctors was i n the category of physical l i m i t a t i o n . The social workers' diagnoses of psychosocial problems, based on an evaluation of the patient's t o t a l situation - medical diagnosis, personality structure, social circumstances and family dynamics - revealed a t o t a l of 111 problems. The 56 presenting problems f e l l mostly into the categories of economic, housing, mental or personality disorder and anxiety. An almost equal number (55) of the secondary problems were seen to be mainly i n the categories of anxiety, vocational, physical l i m i t a t i o n and inter-personal relations. The highest proportion of under-, l y i n g d i f f i c u l t i e s was i n the c l a s s i f i c a t i o n of inter-personal relations. The most sign i f i c a n t difference between the soc i a l workers' assessment and that of the others was the greater num-ber of times the social worker saw a need for help to be given i n r e l a t i o n to anxiety and inter-personal relations. The assessment of M.S.S.D. services (rendered on the basis of the social workers' diagnosis, and dependent upon the cli e n t ' s wish f o r service as well as upon the doctor's recog-n i t i o n of needs and approval of the treatment plan) showed that a t o t a l of 119 services were given. Study of the frequency of contacts with patients and others, and of the length of time cases were active with M.S.S.D. indicated that an almost equal number of interviews were had with persons other than rel a t i v e s as compared with the number of interviews with patients per case. A s l i g h t l y lower number of interviews was had with r e l a t i v e s . The majority of cases were active with M.S.S.D. approximately one.month. The largest number of services were of an indirect nature, with r e f e r r a l of the c l i e n t to<..appropriate resources being the most frequent of these and social assessment the second most frequent. Explanation and offer of services was given sixteen times. Supportive help was given more often than any other type of service. This method was the one most often employed i n giving direct help to patients or their r e l a t i v e s . An intensive type of casework treatment was employed i n a pro-portionately low number of situations. - 88 -Evaluation of the weighting of social services i n rela t i o n to psychosocial problems revealed that services were given most frequently i n r e l a t i o n to problems of anxiety, f o l -lowed by mental or personality disorder, economic and housing. The least number of services was given i n r e l a t i o n to vocational d i f f i c u l t i e s , and i n r e l a t i o n to physical limitations. Support-ive help was given most often i n r e l a t i o n to problems of anxiety, mental or personality disorder and inter-personal relations. Referral to community agency or to welfare services was the method used most often to deal with economic problems. Social assessment was the service most often used i n r e l a t i o n to problems of housing and mental or personality disorder. Implications for Treatment Team and Community Rehabilitation i s essentially a team responsibility, whether that team i s operating i n a particular setting or i n the larger community. A l l resources existing i n f a c i l i t i e s within the i n s t i t u t i o n and community, and individual profes-sional operations contribute to the solution of the t o t a l prob-lem. It i s the professional and ethical r e s p o n s i b i l i t y of a l l concerned with treatment, i n a broad sense, to f i t and integrate t h e i r individual s k i l l s into the overall community scheme, so that their efforts may be most f r u i t f u l and the "best interests of the individuals served. The professional social worker's - 89 -responsibility i s to render appropriate and helpful social work services to cli e n t s within the functions and pol i c i e s of his employing agency, and to assist that agency i n f u l l e r understands ing of cl i e n t needs so that p o l i c i e s may be increasingly helpful to c l i e n t s . The M.S.S.D. has this responsibility as part j>f the DVA programme and team concerned with the re h a b i l i t a t i o n of veterans under DVA medical care, as well as to assist i n f i n d -ing a solution to psychosocial problems which the veteran or his family may be experiencing. Failure of any member of the treat-ment team to carry out his r e s p o n s i b i l i t y f o r ameliorating prob-lems, or for recognizing, and bringing to attention, the s i t u a -t i o n of those patients experiencing social or emotional d i f f i -c u l t i e s may result i n less effectiveness of the t o t a l r e h a b i l i -tative scheme. It may have f a r reaching consequences, not only for the patient himself, but for the wider community. The suc-cess of the re h a b i l i t a t i v e programme i s aleo dependent upon the cornmunity's provision of adequate resources for meeting the needs of DVA patients and the i r families, which cannot be met within the existing l e g i s l a t i v e provisionsl The i l l veteran, f o r example, who i s worrying about the loss of income to his family during his i l l n e s s , or about unharmonious relationships i n the home, may not respond favorably to medical treatment, thereby requiring his continued hospitalization. His prolonged absence - 9 0 -may lead to the "breakdown of family unity. If needed financial, health, recreational, family and child-guidance resources are not available to those families disabled by the absence of the i l l vet-eran, the total community may be affected by breakdown and dependen-cy of the other family members. The findings, i n relation to the particular group of pat-ients studied, pointed up some general and specific implications i n regard to the participation of M.S.S.D. in the DVA and community rehabilitative programme for the i l l and handicapped veteran. The most outstanding observation, generally, i s that M.S.S.D. services are being used for those hospitalized veterans with a f a i r poten-t i a l for rehabilitation; that i s , the younger patients with f a i r or good potentiality for returning to the community and those who have dependent wives and children. On the negative side, one needs to consider that there may be many older and possibly unattached veterans who could benefit from M.S.S.D. services, but whose si t u -ations are not coming to attention. The people i n later maturity who find themselves i n a setting i l l - s u i t e d to provide them with love and affection, and facing a future that appears to be without promise, may react with a feeling of panic or of despair. The Assessment and Rehabilitation unit, to which a social psychologist i s attached, gives services to the elderly patients hospitalized i n the domicilliary care unit. They might be helped also through the services of a caseworker to find more satisfactions i n daily - 91 -living, with, the ultimate better u t i l i z a t i o n of other rehabilit-ative resources. Another general observation with reference to the use of M.S.S.D. services, i s that most requests from medical staff continue to be i n the realm of a practical nature; that i s , for economic and discharge planning or as a diagnostic aid, with l i t t l e emphasis or recognition being given to the contribution which the social worker can make to the overall treatment plan i n direct, continous work with the patient or his family. When problems are anticipated re-garding after—care of a patient, an early referral to M.S.S.D. would provide the caseworker an opportunity for getting to know the patient and for planning with him and his family so that fewer problems would arise. A more valuable service could be offered to both the patient and family i n this way, and recurrent illnesses might be prevented. Recognition i s made of the social worker's a b i l i t y to evaluate the environmental factors, family relationships and their effects upon the patient. More recognition of her professional capacity to effect changes i n these,through casework treatment, would ensure better ser-vice on behalf of the patient, hospital and community. With reference to specific observations regarding M.S.S.D. services, i t may be seen by the frequency of contacts with patients, relatives and others, that communication between services and co-ordination on a family centered diagnostic and social treatment app-roach are seen as a key to improvement of the social situation of the patient. The relatively low number of contacts with patients raises - 92 -the question as to whether or not a more intensive kind of social treatment might.not be given to patients i n some of these instances. A certain number of them, who are desirous of service, continue to re-ceive medical treatment for a prolonged period after referral to M.S.S.D., e.g., those patients referred for social assessment. This would depend, in part, on the doctors* awareness of what the social worker can contribute i n direct work with the patient. Another more specific area with implications regarding the effectiveness of M.S.S.D. services, i s that of recording. The study-revealed that the records do not always bring out significant factors concerning the patients* social circumstances or other matters which have a direct bearing on their problems and on the need for service. Recommendations "The effectiveness of any form of remedial action rests upon comprehension of the f u l l context, of the problems, de-lineation of the objectives, recognition of the f u l l range of approaches required for reaching them and the integration of each approach with the total problem solving operation". The objective of making M.S.S.D. services as effective as possible, and available to a l l those patients and their families who are in need of casework help, i s a responsibility, not only of the i n -dividual caseworker, and M.S.S.D., but also of other treatment staff and of the hospital administration. 1. COCKERILL, Eleanor, "The Interdependence of the Professions in Helping People", Journal of Social Casework, Vol. 34> No. 9> Nov-ember, 1953. - 93 -The continuing support of administration i n advancing M.S.S.D. services and increasing staff, in order to provide for a broader pat-ient coverage and more continuous types of service to be given to those in need of help, i s essential to the functioning of M.S.S.D. as a part of the rehabilitative team. Administration can further contribute to better overall patient care, and more effective use of M.S.S.D., through continued provision for programmes of research, student and staff training, and most especially by providing for the inclusion of M.S.S.D. in the teaching programme of the hospital in medical ward rounds and interne orientation. This would serve to increase awareness of the social factors i n il l n e s s , to increase the co-ordination and integra-tion of efforts of the various team members, and to further more eff -ective use of M.S.S.D. The need for greater interpretation of soc-i a l services to medical staff was pointed up i n a previous study. 1 Doctors have a responsibility for recognizing and bringing to early attention of M.S.S.D. the situation of those patients whose family relations, environmental pressures, or social conditions may be presenting problems or potential d i f f i c u l t y , and thus enable the pat-ient to obtain maximum benefit from medical treatment. If social workers are to participate more f u l l y and contin-uously i n the long-term rehabilitative treatment of patients, and to 1. BARSKY, Anastasia N., Casework i n a Veterans' Hospital; An Analytical Study of Referrals from Doctors, Shaughnessy Hospital, 1953-1954, Master of Social Work thesis, University of British Col-umbia, 1954. give more intensive direct treatment services, i t seems essential that they find some other ways of interpretating to medical staff the kinds of services that they are professionally equipped to perform. Much i s done on a doctor-worker basis, as indicated by Miss Barsky,* but the need of some sort of general educational programme continues to be i n -dicated. A great deal could be accomplished also by improvement of recording techniques. The social worker's assessment of the total situation of the patient and his family, the psychosocial diagnosis, and the treatment needs should be clearly set down, whether they can be carried out or not. Social workers are equipped to deal with many of the psychological manifestations of patients* problems, as well as with the more practical areas of d i f f i c u l t i e s . Their carrying out of any service on behalf of patients i s dependent upon sufficient staff, early referral of cases, and co-operation with other hospital and community personnel. Some consideration might also be given to the keeping of f u l l e r M.S.S.D. records for particular groups of patients to f a c i l i t a t e research which might demonstrate the more effective use of M.S.S.D. Fuller recording of specific psychosocial factors would contribute to c l a r i f i c a t i o n and classification of social work methods, and would also lessen some of the d i f f i c u l t i e s encountered in making surveys of patients' needs and problems. Certain areas of possible future study were brought to att-ention i n the study of the services rendered i n meeting the problems of the patients. A closer examination of the resources available for 1. BAESKY, ib i d . - 95 -meeting needs might reveal areas for the development of further D.V.A. and community resources. These study findings indicated that there might he value i n a survey, for example, of the economic needs of younger veterans. A need i s also seen for additional examination of the basic factors underlying the social d i s a b i l i t y of the patients and their families. Study 1 of the psychosocial components of the problems of "hard-core families" has revealed important implications for agen-cies and communities regarding diagnosis, treatment planning and prev-ention. A study of the overall pattern of psychosocial and health factors operating in the situations of patients repeatedly referred to M.S.S.D. might provide information significant to their needs and treatment. A follow-up study of patients who had received M.S.S.D. casework services over a prolonged period of time might serve to dem-onstrate the outcome of more intensive types of casework service. Since considerable difference was noted i n the way patients and fam-i l i e s view their needs for social treatment, as compared to the doc-tors and social workers assessments, another area for f r u i t f u l study might be the preparation of the patient and the process of referral of clients to M.S.S.D. Conclusions Developing recognition of the social factors i n the rehab-i l i t a t i o n of the sick and handicapped veteran has led to the inclus-ion, and continuous expansion, of social services i n the treatment 1. MARCUSE, Berthold, Long-Term Dependency and Maladjustment  Cases i n a Family Service Agency, Master of Social Work thesis, Univ-ersity of British Columbia, 1956. - 96 -programmes of D.V.A. institutions. The social worker in these sett-ings must function within the framework of social work and medicine, and must accept the responsibility to develop her own a b i l i t y to es-tablish her unique contribution within the total treatment programme. This particular study obviously leaves many questions un-answered. It does give some ideas about the kinds of problems for which the M.S.S.D. i s requested to give service, what i s being done, and which services are most needed. Services and programmes cannot be rationally evaluated or improved without investigations of prac-tices related to need and to problem areas. It i s hoped that these findings w i l l stimulate others to undertake additional studies, and w i l l be of benefit, i n some small measure, to the patients and their families. - 97 -APPENDIX A: SCHEDULE FOE CASE ANALYSIS IDENTIFICATION: Case No. Regimental No. AGE: 18 to 25...26'to 45...46 to 65...66 to 75...76 & over... WAR: Prior to World War I...WW I... WW II... Korea... RELIGION: R.C....Prot....Hebrew...Other...No A f f i l i a t i o n . . . RACE: White...Indian...Negro...Oriental...Mixed...Not Known... MEDICAL INFORMATION: f> PENSIONABLE DISABILITY: 5-20...25-40...45-60...65-8O...85-100 TREATMENT CATEGORY: Section Diagnosis I CURRENT ADMISSION DATE: - No. of Previous Admissions.... PROGNOSIS: Improvement...Chronic...Recurrent...Terminal...Not Known... BACKGROUND INFORMATION: EDUCATION: Elementary...Secondary...University...Business... Technical... .Other... .Not Known..... EMPLOYMENT STATUS: Retired...Unemployed...Medically Unemployed... Occasionally Employed...Steadily Employed TOTAL MONTHLY INCOME: Pension. W. V. A USUAL LIVING CIRCUMSTANCES: Rural.... Urban.... No Fixed Address...Boarding...Housekeeping Room Sleeping Room...Apartment...Rented House...Own Home... Relatives Home...Domiciliary Care...Shack... MARITAL STATUS: Single...Married...Common-law...Separated... Widowed...Divorced...Not Known... DEPENDENT.SI Wife.. .Child(ren).. .Parent(s).. .Sibling( s).. .Other.... RELATIVES: Well Sick Dead E1LATI0NSHIPS WITH CLIENT: (good, f a i r , poor, indifferent) Mother .... Father Step-mother .... Step-father Siblings Children .... Wife APPENDIX A: (Continued) MEDICAL SOCIAL SERVICE: DATE OP REFERRAL: NO. of CONTACTS: Patient...Relative..Other.. NO. PREVIOUS REFERRALS: ... TIME ACTIVE: Days...Weeks...Months... SOURCE OF REFERRAL: Doctor...Other Hospital Staff...Other DVA Staff... Routine Coverage...Patient...Relatives.... Community... REASON FOR REFERRAL: Social History...Social Assessment... Economic Aid...Discharge Planning.... Personal & Social Adjustment... PROBLEMS: As seen by l ) Patient 2) Family 3) Doctor 4) Social Worker Presenting Accompanying Underlying Economic... Housing.... Vocational... • Physical Disability... Anxieties re Treatment... Mental or Personality Disorder Inter-personal Relations... SERVICES: INDIRECT: Patient Relative Hospital Personnel Referral Welfare Services... Other DVA Hospital. Community... Explanation & Offer of Service Social Assessment & Diagnostic Aid............ ....... ........ ............... Environmental Modification.. ....... Economic Aid.... DIRECT: Supportive Help.... • Interpretation Counselling........ • - 99 -APPENDIX B: BIBLIOGRAPHY Books CANNON, Ida M., On the Social Frontier of Medicine, Harvard Un-iversity Press, Cambridge, 1952. COOLEY, Carol H., Social Aspects of Illness, W. B. Saunders Co., Philadelphia and London, 1951. GOLDSTINE, Dora, Readings in the Theory and Practice of Medical Social Vfork, University of Chicago Press, Chicago, 1954. , Expanding Horizons in Medical Social Work, University of Chicago Press, Chicago, 1955. HAMILTON, Gordon, Theory and Practice of Social Casework, Columbia University Press, New York, 1951* HERSKOVITS, M. J., Man and His Works, A. A. Knopf, New York, 1948. MORRIS, Cherry, Social Casework i n Great Britian, Faher and Faher, London, 1950. ROBINSON, G. Canby, The Patient as a Person, The Commonwealth Fund, New York, 1939. UPHAM, Frances, A Dynamic Approach to Illness, Family Service Assoc-iation of America, New York, 1949* WEISS, Edward, M.D., and ENGLISH, 0. Spurgeon, M.D., Psychosomatic  Medicine, W. B. Saunders Ltd., London and Philadelphia, 1943. Articles, Documents, Publications, Statutes ANGELL, Stephen L., "Inter-Agency Communication The Mortar for Individual Services", Proceedings National Conference of Social Work, St. Louis, Mo., 1956. American Association of Medical Social Workers, "A Statement of Standards to be Met by Social Service Departments i n Hos-pitals, Clinics and Sanatoria", A.A.M.S.W., Washington, 1949. BOWERS, Swithun, O.M.I., "The Nature and Definition of Social Case-work: Part III", Journal of Social Casework, Vol. 30, No. 10, 1949. - 100 -BARSKY, Anastasia N., Casework i n a Veterans' Hospital; An Analy-t i c a l Study of Referrals from Doctors, Shaughnessy Hos-p i t a l , Master of Social Work thesis, University of B r i t -ish Columbia, 1954* CABOT, Richard C , "Hospital and Dispensary Social Work", (reprint) Expanding Horizons i n Medical Social Work, University of Chicago Press, Chicago, 1955* Canada, Medical Social Service General Policy, Circular Letter No. 138, King's Printer, Ottawa, 1947* , The Veterans' Charter, King's Printer, Ottawa, 1947* CLOHOSEY, Mary E.A.B., Social Implications of Re-Admissions of Veteran Patients to Shaughnessy Hospital, Master of Soc-i a l Work thesis, University of British Columbia, 1954* COCKERILL, Eleanor, "The Interdependence of the Professions i n Helping People", Journal of Social Casework, Vol. 34, No. 9> November, 1953. Community Chest and Council, Directory, Greater Vancouver Commun-it y Chest and Council Agencies, Vancouver, 1956. FIELD, Minna, "Role of the Social Worker i n a Modern Hospital", Journal of Social Casework, Vol. 34j No. 9 , November 1953. FROST, Rebecca, The Changing Emphasis i n the Function of the Med- i c a l Social Worker, Master of Social Work thesis, Univ-ersity of Southern California, American Association of Social Workers, Washington, D. C , 1955* HOLLIS, Florence, "The Techniques of Casework", Principles and  Techniques i n Social Casework, Family Service Assoc-iation of America, New York, 1950. Joint Committee on the Teaching of Social and Environmental Factors i n Medicine, Widening Horizons i n Medical Education, Har-vard University Press, Cambridge, 1948. MARCUSE, Berthold, Long-Term Dependency and Maladjustment Cases In  a Family Service Agency, Master of Social Work thesis, University of British Columbia, 1956. PATON, John, and WIEBE, John, Medical Social Service i n a Veteran's  Hospital Out-Patients' C l i n i c : A comparative Sample Study of Cases Referred and Not Referred for Social Ser-vice, Shaughnessy Hospital, Master of Social Work thesis, University of British Columbia, 1954* - 101 -REED, George A., The Placement of Adolescent Boys: A Survey-Beview of the Problems of Adolescent Boys i n Care of the Child-ren's Aid Society, Vancouver, B.C., Master of Social Work thesis, University„of British Columbia, 1953. RUBTJTOW, Leonora, B., "Medical Social Service", Expanding Horizons in Medical Social Work, University of Chicago Press, Chic-ago, 1955. WHITE, Grace, "Distinguishing Characteristics of Medical Social Work", Readings i n the Theory and Practice of Medical Social Work, University of Chicago Press, Chicago, 1954* WJJTFIELD, G. A., M.D., and WELLWOOD, L., "An Analysis of In-patients, Department of Veterans' Affairs, at Midnight, March 31 , 1955", Canadian Services Medical Journal, Vol. XIII, Queen's Prin-ter, Ottawa, 1956. WOOD, Walter S., Rehabilitation (A Combined Operation), Queen's Printer, Ottawa, 1953. 

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