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The effectiveness of case work treatment in a team approach to rehabilitation of rheumatoid arthritis… Hunt, Donna George 1953

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THE BgFEGTIYEHESS Of CASE WORK TREATMENT IN A TEAM APPROACH TO REHABILITATION OF RHEUMATOID ARTHRITIS PATIENTS (RHEUMATIC DISEASES PROJECT, RHEUMATOID ARTHRITIS SERIES, CANADIAN ARTHRITIS AND RHEUMATISM SOCIETY BRITISH COLUMBIA DIVISION) by DONNA HUNT Toesis Submitted in Partial Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WOHC in the School of Soeial Work, Accepted as conforming to the standard required for the degree of Master of Sooial Work School of Sooial Work. 1953 The University of British Columbia. i i TABLE OF CONTENTS Page Chapter 1. A Medical Experiment i n the Treatment of  Rheumatoid A r t h r i t i s Rheumatoid A r t h r i t i s and the mystery of Cortisoneo The Rheumatic Diseases Project sponsored by the Canad-i a n A r t h r i t i s and Rheumatism Society of B r i t i s h Columbia, a medical experiment. "The patients selected f o r the Project," general d e s c r i p t i o n . Focus of present study.... 1 Chapter S» The Team Approaoh to R e h a b i l i t a t i o n The team; The role of the s o o i a l worker within the team and i t s l i m i t a t i o n s . Some t h e o r e t i c a l assumptions of casework methods; d i r e c t and i n d i r e c t treatment de-f i n e d . Methods of evaluation of casework services; Method 1, Some casework c r i t e r i a of t r e a t a b i l i t y ; C r i -t e r i a i n d i c a t i n g d i r e c t treatment; C r i t e r i a i n d i c a t i n g environmental or i n d i r e c t treatment. Method 2, The ra t i n g scale f o r measuring movement•• <> 13 Chapter 3. T r e a t a b i l i t y ; Some Casework C r i t e r i a C r i t e r i a i n d i c a t i n g d i r e c t treatment, i l l u s t r a t e d by the oase of Mr. Z. C r i t e r i a i n d i c a t i n g environmental or i n d i r e o t treatment i l l u s t r a t e d by the case of Mrs. XC. Contra-indioations f o r either d i r e c t or i n d i r e c t t r e a t -ment i l l u s t r a t e d by the case of Miss A......... 0.......... 89 Chapter 4« An Approaoh to the Measurement of Movement The r a t i n g scale as a yardstick of movement. Move-ment defined. Upward movement described i n terms of Mr. Z„ Downward movement i l l u s t r a t e d by the case of Mr. R. No-movement i l l u s t r a t e d by the oase of Mr. L. The conoepts of the r a t i n g scale. The patients a b i l i t y to make constructive use of a casework r e l a t i o n s h i p i l l u s t r a t e d by Groups 1, 2 and 3. The effectiveness of d i r e c t treatment. The effectiveness of i n d i r e c t t r e a t -ment • • o . . o . . . . . . . . 8 • » • • • • e o • • o . • • • . • . • . . . e o » . 45 Chapter 5. Toward Maximum Helpfulness Tne case of Mrs. 0, a r e a l i s t i c approaoh to t r e a t -ment. Limitations of the treatment role o f the s o c i a l worker. Vocational guidance and the s o c i a l worker. i i i Page Team planning for maximum helpfulness needed. Some general conclusions and suggestions for planned treat-ment. The case of Mrs, D, a planned approaoh to treatment and illustrative of realistic social diag-nostic evaluation. Planning the reality of the team approach, responsible leadership "by the Doctor, sound social diagnostic evaluation,, integration of the phy-siotherapist, conferences, consultative psychiatric services, need for interpretation, preparation of the patient for referrals and planned total treatment...,,,,,, 66 Appendices: A, The rating scale for evaluating case work services,,.• 88 6* Charts in the Text. Chart 1, Age distribution, marital status and number of children of patients. Chart 3 . Comparative chart of movement,-achieve-ment of goals and criteria. Chart 3 . Illustration of movement score, Mr, Z. Chart 4 . Illustration of movement score, Mrs. 6 , Chart 5 , Illustration of movement score, Miss M...... 9Q C • Bibliography, • • • • 96> i v ABSTRACT The Canadian A r t h r i t i s and Rheumatism Society, B r i t i s h Columbia D i v i s i o n has envisaged research as an important and i n t e g r a l part of i t s objectives and i n February 1951 embarked upon an intensive study of the usefulness of cortisone i n long-term medical treatment of the rheumatic diseases, including a series on Rheumatoid A r t h r i t i s . A comprehensive program of medical treatment has been put int o e f f e c t , i n c l u d i n g the ser-vices of s o c i a l workers. I t i s e s s e n t i a l l y a team approach to the aim of physical r e h a b i l i t a t i o n and a return to g a i n f u l employment. The present study i s directed to the evaluation of the case work treatment offered to those patients selected to par t i c i p a t e i n the Rheumatic Diseases Project, Rheumatoid Arth-r i t i s Series on Cortisone Therapy. Within a predominantly medical setting the function of the case worker has been consid-ered from the viewpoint of what i s expected of her by the med-i c a l profession and what might be expected from her as a professional s o c i a l worker. Two methods of assessment were employed both based on evaluation of each case according to selected case work c r i t e r i a and the premise that effectiveness of treatment depends upon the appropriate use of s k i l l s i n r e l a t i o n to the degree of t r e a t -a b i l i t y of the patient. The f i r s t approach made use of the available case records as f a r as possible. The second was the device of a Rating Scale devised f o r the purpose and completed by a group of s o c i a l workers f o r each patient worked* with. The goals aimed at by the Medical Committee responsible for the project were stated as "physical r e h a b i l i t a t i o n and a return to g a i n f u l employment". Medically the cortisone therapy was successful i n e f f e c t i n g enough physical improvement fo r a patient to become p o t e n t i a l l y employable. S o c i a l l y r e s u l t s were discouraging because emotional d i f f i c u l t i e s and the non-avail-a b i l i t y of suitable positions prevented the actual return of many patients to g a i n f u l employment. The Long-standing personality problems, characterizing t h i s group of patients, precluded the use of intensive case work techniques i n roughly 75%,of- the cases. The evidence i s that face-to-face interviewing involving the s k i l l e d use of r e l a t i o n s h i p i s not appropriate and that supportive technigues designed.to prevent further d e t e r i o r a t i o n , alone are relevant f o r the majority. Sound s o c i a l diagnostic evaluations with the use of appropriate treatment methods are e s s e n t i a l . I t i s suggested V the r e a l i t y of the team approach should he made ava i l a b l e , and that more use should be made of s o c i a l -work s k i l l s i n the s e l -ective screening of applicants f o r r e h a b i l i t a t i o n , and that the contributions of s o c i a l work i n the t o t a l team plan merits deep-er exploration. vi ACKNOWLEIDGEMEOT I wish to express my appreciation of the kind assistance of Dr. C. E. Robinson and those s o o i a l workers who made t h i s study possible and made v a l -uable contributions to the development of the mat-e r i a l presented, I wish also to thank Dr. Leonard C, Marsh f o r h i s patience and help i n the in t e g r a t -ion of contents, and the s t a f f members of the Can-adian A r t h r i t i s and Rheumatism Society whose co-op-eration and in t e r e s t made i t a very pleasant under-taking. THE EFFECTIVENESS OF CASE WORK TREATMENT IN A TEAM APPROACH TO REHABILITATION OF RHEUMATOID ARTHRITIS PATIENTS (RHEUMATIC DISEASE PROJECT, RHEUMATOID ARTHRITIS SERIES, CANADIAN ARTHRITIS AND RHEUMATISM SOCIETY BRITISH GOLUIfBIA DIvTBION) CHAPTER I A Medical Experiment in the Treatment of Rheumatoid Arthritis^  Rheumatoid Arthritis and the mystery of Cortisone. The word "rheumatism" refers to the pains and aches of the muscles and joints that result from a good many causes, including a large and miscellaneous group of diseases and disorders of the supporting tissues of the body. Specifically, i t accounts for several kinds of arthritis, rheumatoid, osteoarthritis, arthritis due to injury and infections, gout, rheumatic fever, and rheumatic diseases of the tissues other than the joints. Two types of arthritis, rheumatoid and osteoarthritis (a joint disease due to the wear and tear of old age) acoount for about seventy per cent of a l l eases of rheumatic disease. 1 From an eoonomio aspect, rheumatoid arthritis is the most serious of the arthritides in that this disease i s most prevalent in the younger age groups when productivity and l i f e expectancy are at the highest level. There are in -deed grave social implications in terms of economic and human wastage in the fact that eighty per cent of a l l patients are between the ages of twenty-five to f i f t y years, with the peak at thirty-five to forty years. It should indeed be a matter of concern to the community at large that three times as many 1 Primer on the Rheumatic Diseases, prepared by a Committee of the American Rheumatism Association, 1950. - 2 -patients come from families with incomes under $1,000. as among families with incomes of $3,000. or more. It i s a disease which continues for. months or many years and, unless early medical treatment i s instituted, crippling and deform-ity result, with the patient becoming bedridden or confined to a chair• No single factor has been found which can adequately account for the production of rheumatoid arthritis* Many theories of oausation have been proposed but none has with-stood cri t i c a l evaluation. There i s , however, fairly general agreement among authorities on the disease as to certain predisposing or precipitating factors. 3 Among these may be mentioned physical and emotional shook the latter probably more frequent and exposure to dampness, rain or cold. Weiss has commented that "there i s good reason to believe that a significant relationship exists between l i f e stress and the disease of arthritis with environmental stress, especially poverty, grief and family worry being more than a chance faoti-or in the onset and exacerbations of rheumatoid a r t h r i t i s " . 4 Constitutional or hereditary influences, while not well understood8 seem to have a bearing in the genesis of rheum-atoid arthritis as well as unfavorable sooial factors such as 2 Primer on the Rheumatic Diseases, prepared by a Committee of the American Rheumatism Association, 1950. 3, 4 Weiss, Edward and English, O.S., Psychosomatic Medicine. Saunders, 1943. - 3 -poverty* overcrowding In the home and poor housing conditions* Because there is a convergence of many influences in the genesis of the disease, there i s no "speoifio" which can be alone relied upon, whether i t be vaooine, diet, drug or physiotherapeutic agent, to effect a cure* Successful treat-ment can be carried out only through the co-operative effort of patient, physician, nurse, social worker and physiother-apist* The outcome is determined, however, to a great extent by the adequacy of treatment during the early stages of the disease* It depends on the doctor*s knowledge and whether doctor and patient w i l l submit to the requirements of logical therapy, or whether they wi l l angle constantly for some quick wsure-cure" * The rigorous discipline imposed by rheumatoid arthritis must be accepted, and the patient must have the de-sire and the w i l l to get well* He must guard against tension lest he wear himself out, and much depends upon his ability to accept help in the complexities of his emotional l i f e * It has been estimated that one in twenty persons S are affeGted by arthritic diseases and that there is hardly any therapeutic process that has not been utilized in their treatment. The discovery in the United States, by P*S* Hench and his coworkers in 1949, that cortisone, a steroid hormone secreted by the adrenal cortex, profoundly affected the course 5 Public Affairs Pamphlet #166, Arthritis and the Miracle Drufis* Dominion Government. 6 Hench, P.S. and Others, "Review of American and English Literature of Eeeent Years", Ninth Rheumatism Review. Medical Association of America* of rheumatoid arthritis, has stimulated great interest in the study of a l l forms of arthritis, a study that in the past was not Intensive. The main result of cortisone seems to be a relief of pain, swellings and lnflamatlon of the joints, but i t i s not yet known why and how the hormone works. Freedom from pain usually lasts only so long as the medication is given and frequently side effects are produced. In Canada research into rheumatoid arthritis and other rheumatic diseases has been emphasized by the Canadian Arthritis and Rheumatism Society. A comprehensive program of education and treatment has been envisaged including as one of i t s six stated objectives that of research, expressed simply as "assisting in examination of any proposed methods 7 of prevention, treatment or cure". The British Columbia Div-ision of the Canadian Arthritis and Rheumatism Society has been particularly interested in determining the usefulness of cort-isone in the long-term treatment of the rheumatic diseases, and early in the year 1951 allocated funds for such a project, with one section directed to the intensive medical study of rheumatoid arthritis. The present study however is concerned only with one aspect of this project and the effectiveness of the casework services offered to the patients selected for i t . 7 Health and Welfare Publications (Dominion Government) Issue. April. 1951, Issue "Arthritis", Special Supplement, March, 1948. 8 In subsequent references to be known as "The Society". - 5 -The Rheumatic Diseases Project: Rheumatoid A r t h r i t i s Series 9 on Cortisone Therapy. In deference to the fact that public money was being used i t was decided by t h i s Society that the patients selected to p a r t i c i p a t e i n the experiment would be chosejd, from two categories. The f i r s t was to be persons of low i n -come receiving treatment through outpatient h o s p i t a l c l i n i c s i n Vancouver, and the second, those whom i t seems possible t o r e h a b i l i t a t e and return to usefu l employment. Rates of income are determined by the regulations governing the p o l i c i e s of h o s p i t a l outpatients departments, since t h e i r f a c i l i t i e s are used to provide necessary c l i n i c examinations and medical treatment. To be e l i g i b l e a patient may not have more than one hundred d o l l a r s per month as a single person, one hundred and t h i r t y d o l l a r s per month as a married person with one c h i l d . The use of a s l i d i n g scale allows a maximum income of two hun-dred and f i f t y d o l l a r s per month including savings and bonds up to fi v e hundred d o l l a r s . The Society has always emphasized need of treatment rather than a b i l i t y to pay f o r i t , so that a few patients are accepted d i r e c t l y on the recommendation of private physicians and i n these cases s l i g h t l y higher earnings are permitted. A C l i n i c a l Research Committee (Cortisone and A.C.T.H. Committee) under the leadership of Dr. R.B. Kerr, professor at 9 In subsequent references to be known as "The Project" or "The Rheumatio Diseases Project". the Sohool of Medicine of the University of British Columbia with the Medical Director of the Canadian Arthritis and Rheumatism Society in the capacity of secretary of the group was established to supervise the project* It consists of eight doctors who are also members of the British Columbia Medical Association Arthritis Committee and acting in an ad-visory capacity, i t i s responsible for the selection of the patients and the general policies with respect to the Rheum-atic Diseases Project* Any doctor practicing in British Col-umbia, whether a private physician or a clinic doctor, may request the inclusion of his patient, but he must submit an application which is reviewed, and a decision made as to the patient's e l i g i b i l i t y . For the sake of uniformity in assess-ing the experiment, a comprehensive set of forms concerning medical diagnosis, treatment and progress reports are main-tained and issued to doctors whose patients have been admitted. Duplicate records of medical reports and social oase histor-ies are filed at the Canadian Arthritis and Rheumatism Soc-iety, British Columbia Division, offices in the interests of data for medical research. Regular clinics are held by the doctors, and a procedure of frequent examination of patients is maintained with careful follow-up by physiotherapists and social workers. Medical treatment includes physiotherapy, hydrotherapy and the services of an orthopoedle nurse provided from the staff of the Society to the hospitals of St. Paul*s and the Van-oouver General who allow spaoe and equipment for these pur-poses* Facilities are also available at the Western Society for Rehabilitation for those patients requiring an extensive period of physical rehabilitation in residence, and often i n -cludes patients living outside the Greater Vancouver area* Each patient, when admitted to the Project, must sign a state-ment relieving the Society of responsibility for poor results or side effects produced by this hormone* The medical treat-ment and i t s doubtful aspects are carefully explained to him and he makes his own decision as to whether or not he wishes to undertake i t * Once he has begun he i s expected to continue for a twelve-month period of time, and may enter the exper-iment at any time on the reoommendation of his doctor* Case work services are considered an Integral part of the treatment plan in many eases* In addition to the use of social workers from the Medical Social Service Departments of the hospitals for those attending outpatients clinics, a qualified social worker i s employed by the Society to provide this aspect of treatment to those patients receiving care at the Western Society for Rehabilitation. The f i r s t patient was admitted to the Project, February 1st, 1951, and by May in the same year there were included a total of thirty-three patients, twenty-eight adults and five ohildren* The adult group oonslsted of fifteen females and thirteen males whose ages ranged from twenty-three years to sixty-two years* The evaluation of the casework services offered to the patients participating in the Rheumatoid Arthritis Series of the project was limited to the study of twenty-three adult oases for the following reasons* Of twenty-eight re-ferrals for casework services* two patients were referred to the Vancouver Family Welfare Bureau for specialized family service* one was assessed as having no problems requiring casework treatment, and two patients so recently entered the project that they could not be evaluated* The five children on the Juvenile Rheumatoid Arthritis Series were not referred for casework services by their doctors* The Patients selected for the Project: Chart I, Appendix B illustrates the age distrib-ution, marital status, and average number of ohildren belong-ing to each patient, as well as the duration of rheumatoid arthritis and the age of each patient at the onset of tho disease* Hard work a l l their lives as members of large, poverty-stricken families, necessitating their leaving school at an average age of twelve to fourteen years, appears with monotonous regularity among the ©as® histories of this group of twenty-three patients* Before the onset of rheumatoid arthritis, however, they would seem to represent a fairly typical cross-section of the average "working-man" population. Occupations f a l l , in the case of the men, IntoXthe^kil'led labour group, and include electricians, farmers, an X-ray technician, and a university student* The average education i s grade eight for both men and women* The husbands of the married women f a l l , too, into the skilled labour group, with the single and widowed women doing domestic and waitress work, with one single woman being a stenographer* The majority of these patients seem to have been severely dominated by one or other of their parents* They showed a marked desire to please, with a tendency to be over-ly respectable, and were very socially conscious of the good opinion of others* This very general picture would, of course, indicate a seriously undermined self-esteem which seemed to be well defended by the bright, courageous appear-ance presented by most of them* On the whole, the twenty-three patients superficially appeared to be an independent group, who had considerable conflict about authority and were resistive to a meaningful oasework relationship which would help them change their present patterns of behaviour* Th® female group had had rheumatoid arthritis for an average of nine years, with the duration of the disease distributed from three years up to twenty years* The male group averaged 6.9 years, with a range from two years to f i f -teen years* Since the average age at the onset of the disease would be 38*1 years for the women and 38*1 years for the men, It can readily be seen that the emotional effects of such a crippling and painful disease cannot be underestimated, since i t occurred at an age when a man might reasonably be expected to be at his peak of productiveness, and a woman well estab-lished in a career or marriage. The precipitating oauses of the rheumatoid arth-r i t i s oomdition could not be definitely ascertained from the recorded material on f i l e , but a general surrey of the pat-ients receiving treatment seems to indioate early emotional and environmental deprivation having an accumulative effects in conjunction with severe emotional trauma* Xn partial substantiation of this statement i t may be noted that the two widows involved gave* as the cause of their arthritic con-dition, the death of their husbands; two of the separated wom-en gave the shock of an unhappy marriage; the widower, the death of his wife and loss of his job; one male separated, the desertion of his wife; and one man his marital problem at home* It might also be pointed out that seven other members of the total group were given help with poor marital relationships* and the remaining patients were suspected of having marital difficulty. It can readily be seen that the sooial problems and the medical difficulties of the rheumatoid arthritis patient are a challenge to a program of rehabilitation in view of the dearth of concrete knowledge as to cure and prevention* It i s an area f u l l of speculation, particularly in view of the characteristic personality patterns presented by these pat-ients and, above a l l * one where medical research has long been overdue* The focus of the present study i s an evaluation of the present program of case work services offered to those 11 patients selected to participate in the Rheumatic Diseases Project, essentially a medical experiment* There are en-couraging implications in the fact that a l l available re-sources and services have been brought together in a combined attack: on the medical-social problem of arthritis* There are discouraging aspects in the emphasis in the program upon purely physical rehabilitation to combat a disease which carries with i t such serious sooial and economic implications, and where i t i s known that the psychosomatic aspects of arthritis cannot be ignored* The evaluation proposes to examine how the sooial worker is able to function as a professional person, and a member of a therapeutic team in a medical project, which i s a major concern of caseworkers in a medical setting* Why she is expected to and does f u l f i l l a certain role i s of f i r s t im-portance in assessing the effectiveness of her services* There are indications of profound difficulties for the medical sooial worker because the nature of her contribution i s not fully understood by her team-mates* It is reasonable to assume that what she does as a case-worker in the total approach to the rehabilitation of the patient wi l l influence the future use of her services and her status within the team* The suc-cess of casework services must of neoessity be determined by the psychosocial problem presented and the use made of avail-able techniques. In short, the use the patient i s able to make of the services offered depends on the diagnostic s k i l l possessed by - 12 the caseworker followed by discriminate use of treatment techniques* The opportunity to act on this premise must he permitted i f the caseworker i s to he effective in the art of helping people* The team members must recognize the limit-ations of her profession and she must accept them* There i s good reason to believe that confusions existed within the Rheumatic Diseases Project with the consequent wastage of human and material resources* Poorly focussed services are not only damaging to community understanding and appreciation of a program but are also prejudicial to social work i n the effort to obtain rightful recognition from other professional groups* Thus, the major concern of this evaluation is how problems were met by the social worker and what the results of oasework treatment were within the limitations of this particular medical setting and those of the profession* CHAPTER II The Team Approach to Rehabilitation* The approach to the treatment of these viotims of rheumatoid arthritis is basically team planning with each member of the team having a speoifio function* The dootor i s the head or the direotor of the team* for he i s responsible for the over-all plan of treatment* Under his leadership the physiotherapist, the sooial worker and any other staff members of hospital or Society assisting in the patient's cure, con-tribute individual skills in the total plan of rehabilitation* The physiotherapist carries out, much like the nurse, the physical remedial and preventive regimen prescribed by the doctor according to his diagnosis of the patient* Rheum-atoid arthritis is a painful, crippling disease, and unless early remedial treatment is begun, serious deformity often results* The Role of the Sooial Worker within the Team; To the social worker, the doctor refers those pat-ients whom he considers emotionally disturbed or to have prob-lems which do not f a l l within the framework of physical care and yet may be impeding satisfactory progress* It is well known that tension and worry may be responsible for exacerb-ations of the disease and relief from such often causes re-missions of symptoms* The Rheumatic Diseases Project was primarily thought of as a medical experiment and the sooial worker, therefore, - 14 -has no part in the seleotion of patients for rehabilitation and does not participate in the conferences held by the Medical Committee for this purpose* It was considered that since every patient would not require ease work treatment a l l ad-missions for the Rheumatoid Arthritis Series on Cortisone Therapy would not need to be referred* The individual case i s referred by the doctor after he has undertaken the experiment, and screening is done at the point the physician recognizes his patient's need of case work treatment* Individual con-sultations between doctor and sooial worker are sometimes held, but, the usual procedure i s that of a written report from the sooial worker to the doctor* It is assumed that the physician is responsible for the preparation of his patient for oase work treatment* The social worker deals with many medical men since admissions to the project includes those patients recom-mended by private physicians and those receiving treatment through the outpatient's departments of the two hospitals* Gases are distributed among seven sooial workers according to the clinic attended and the Canadian Arthritis and Rheumatism Sooiety's sooial consultant* The sooial worker's role, within the setting of the Rheumatic Diseases Project, i s governed by each individ-ual doctor's concept of what she does as a member of the team In relationship to his patient* For the purposes of this study, however, her function as a oase worker was determined according to accepted basic principles and practices of pro-15 -fesslonal sooial work* With the exception of one worker, who had had considerable experience in the field of medical sooial work, fifteen cases were carried by social workers who had completed two years of training at the University of British Columbia School of Sooial Work and six were carried under supervision by four students completing their second year of training* It i s not unreasonable to assume that ac-cepted professional case work methods would be followed and could therefore be evaluated according to oertain standards of practice* Preliminary analysis of the case recordings of the twenty-three rheumatoid arthritis patients studied, revealed that the case worker had been assigned one well-defined role* This may briefly be stated as, a provider of concrete services, including assistance in obtaining financial aid, contacts with regard to employment opportunities, obtaining hobby materials and small personal comfort allowances* It became apparent, however, that she had also acoepted a second role, that of a dealer in emotional problems, recognizing as a professional person, the psychosocial nature of a l l problems* It i s inter-esting to note, in this respect, that without exception every referral of the twenty-three oases was made on the basis of concrete services by the doctors, with the social worker re-commending continuing treatment for emotional factors where such disturbances were worked with* Study of the social diag-nosis of the problems, in terms of the techniques used in their - 16 -solution, made i t obvious that the ease worker was not only concerned with relieving the immediate problem brought ot her attention, but where possible, because of the patient's recog-nition and participation, attempted to modify basic diffic u l t -ies and complications. Some Theoretical Assumptions of Casework Methods; The two major methods of treatment used by the social worker consistently employed in varying degrees and stated according to Gordon Hamilton's definitions 1 were: (1) Environmental manipulation or indlreot treatment which in-cludes " A l l attempts to correct or improve the situation in order to reduce strain and pressure, and a l l modifications of the living experience to offer opportunities for growth or change; the emphasis is on situational modification. Growth and change may be stimulated through any creative situation as well as through interviewing". (2) Direct treatment, "a series of interviews carried on with the purpose of inducing or reinforcing attitudes favourable to maintenance of emotion-al equilibrium, to making constructive decisions, and to growth or change. The term also includes psychological support"• m It was recognized at the outset that personality ad-justment may be attempted by either method or a combination of both. The requisite conditions for treatment of any type, 1, Hamilton, Gordon, Theory and Practice of Social Case  Work. 2nd ed., revised, Columbia University Press, 1951. - 17 however, were that the patient himself wished to change and that he would pursue whatever course of treatment would help M m either to change, or to modify his attitudes and behaviour patterns* He had also, to a greater or lesser degree, to ac-cept his responsibility to effect a change. The term treat-ment, then, was defined according to Gordon Hamilton's def-g inition, "the sum of a l l activities and services directed towards helping an individual with his problem". The techniques of ease wort are determined by the objectives of the oase worker, which in turn, are affooted by the problem presented by the patient* It was assumed, there-fore, that the effectiveness of casework treatment oould best be evaluated by the consideration of these components of the ease work process in relationship to one another* Inherent in this approaoh i s the concept of treatability* The degree to which the personality organization oan be changed and how  much modification of attitude and behaviour oan be achieved, by working with the relatively healthy part of the patient's ego with respect to his real external situation, are always basle case work questions* Treatment to be effective must be based on a diagnostic evaluation, a professional judgement de-s fined by Gordon Hamilton as "the understanding of the psycho-social problem brought by the olient and his functioning with regard to his problem, his capacities and the availability of 2, 3 Hamilton, Gordon, Theory and Practice of Social Case  Work. 2nd ed*, Revised, Columbia University Press, 1951* - 18 outer and Inner resources. It Is this personality evaluation and characterization which determines treatability, success or failure, constructive and destructive factors i n the prog-nosis of a case"* The accomplishment of the objectives of case work treatment i s based on aocepted techniques or practices evolv-ing from the use of the ease work relationship* This relation-ship i s different from any other human relationship, in that i t * s purpose is therapeutic, The main characteristic of i t is that there must be one in the experience who wished to be helped - the patient-and one who wishes to help - the case worker* The ease work relationship is made up of acceptance, permissiveness and active support* The patient oan be sus-tained and to a degree stimulated to change by i t s construct-ive use, but the extent depends upon the kind and quality of his emotional need and it s place in the harmony of the per-sonality* The problem must be defined and an estimate made of the patient's capacity to deal with i t in fact* Its struct-ure, etiology and the elements in relationship must be under? stood* From the outset the oase worker must assess the kind and extent of help i t i s reasonable to offer or expect* From the assumptions just expounded, two approaches were made to accomplish an evaluation of the effectiveness of the oase work services offered to the twenty-three patients on the Rheumatic Diseases Project* Both were based on a diag-- 19 -n e s t l e e v a l u a t i o n o f e a c h e a s e a n d t h e p r e m i s e t h a t t h e s u e -e e s s o f t r e a t m e n t d e p e n d s u p o n t h e a p p r o p r i a t e u s e o f e a s e w o r k s k i l l s i n r e l a t i o n t o t h e d e g r e e o f t r e a t a b i l i t y o f t h e p a t i e n t . T h e s e m e t h o d s a r e n o w c o n s i d e r e d u n d e r t h e h e a d i n g o f " M e t h o d s o f E v a l u a t i o n " . M e t h o d s o f E v a l u a t i o n M e t h o d I: Some C a s e W o r k C r i t e r i a o f T r e a t a b i l i t y . T h e f i r s t a p p r o a c h w a s c o n c e r n e d p r i m a r i l y w i t h e s t -a b l i s h i n g t h e p a t i e n t ' s c a p a c i t y t o m a k e c o n s t r u c t i v e u s e o f t h e o a s e w o r k r e l a t i o n s h i p . A n a t t e m p t w a s made t o a s s e s s t h e b a l a n o e o f d e s t r u c t i v e a n d c o n s t r u c t i v e f o r c e s i n t h e p a t i e n t ' s e x p e r i e n c e s , b o t h p a s t a n d p r e s e n t . T h e f o l l o w i n g f a c t o r s w e r e t a k e n i n t o a c c o u n t w i t h t h i s o b j e c t i v e i n v i e w , ( a ) E m o t i o n a l a n d p h y s i c a l s t a b i l i t y i n c h i l d h o o d a n d t h e p r e s e n t f a m i l y u n i t , ( b ) N e g a t i v e a n d p o s i t i v e h e a l t h f a c t -o r s , ( o ) L o n g i l l n e s s , ( d ) G e n e r a l a n d s p e c i a l c a p a c i t i e s , ( e ) E m o t i o n a l t o n e o f f a m i l y e x p e r i e n c e s , ( f ) E c o n o m i c a n d c u l t u r a l i n f l u e n c e s , ( g ) S a t i s f a o t o r i n e s s o f s o o i a l e x p e r -i e n c e s , ( h ) E d u c a t i o n a l i n f l u e n c e s , ( i ) S e l f i n s i g h t ( i n t h e s e n s e o f u n d e r s t a n d i n g o f s e l f a n d p r o b l e m s w i t h t h e a b i l -i t y t o b e r e s p o n s i b l e a n d s e l f - c r i t i c a l . ) B e c a u s e o f t h e i n a d e q u a c i e s o f r e c o r d e d d e t a i l i t w a s d i f f i c u l t , i n b e t t e r t h a n h a l f t h e o a s e s , t o o b t a i n a n y b u t t h e m o s t s u p e r f i c i a l p e r s o n a l i t y d e s c r i p t i o n s . A n e x a m p l e o f a t y p i c a l f o r m u l a t i o n o f s o o i a l d i a g n o s i s i s t h e f r e q u e n t l y 20 repeated phrase that "this patient is a rigid, unyielding per-son who oannot use a case work relationship"• Little oonorete information was recorded to substantiate such a statement* Early l i f e experiences or histories of these patients were vague and inconclusive permitting l i t t l e scope for accurate research and creating conjecture as to the preoelpitating causes of the present onslaught of the disease of rheumatoid arthritis and previous accumulative ezperienoes leading up to i t * Little oonorete Information could be gained from the re-cording concerning the patients former employers and the community* Ourrent problems, however, were more thoroughly dealt?- with by the case workers and for this reason criteria •4-borrowed and adapted from Carl R* Rogers were established to determine not only the level of treatability of the patient hut the focus of treatment* The following are the casework oriteria selected: Criteria Indicating Direct Treatment: 1* The patient i s under enough stress or tension to talk about his problems and to try to find a solution to his oonfliots* 2* The patient is able to cope with! this situation* 3« There i s an opportunity for the patient to express the con-flicting tensions whioh have created his problem in planned contacts with the case worker* 4 Rogers, Carl R*, "When i s Counselling Indicated", Counselling and Psychotherapy. Houghton Mifflin Company, 1942, Ch. I l l * - 21 4« The patient wants help* He oonseiously recognizes his need for i t * It i s realized that help ©an be given without this ©ondition being f u l f i l l e d but the likelihood of success-ful direct treatment i s greater i f the patient wants help* SV The patient is reasonably emotionally independent of close family control* 6* The patient i s reasonably free from excessive instabilit-ies* particularly of an organic nature* 7* The patient possesses adequate intelligence for coping with his l i f e situation, with an intelligence rating of dull -normal or above* 8* patient i s of suitable age-old enough to deal somewhat independently with l i f e , and young enough to retain some elas-t i c i t y of adjustment* In terms of chronological age this might mean roughly from ten to sixty years* Criteria Indicating EnvlT^ ^ w f t w b a l or Indirect Treatment; 1* The component factors of the patient's adjustment situation are so adverse that even with changed attitudes and insight, he could not cope with i t * 2* The patient i s inaccessible to oase work in that reasonable opportunity and effort f a l l to discover any means by which he can express his feelings and problems* 5* Effective environmental treatment i s simpler and more efficient than a direct approach* 4* The patient i s too young or too old, too dull or too un-stable for a direct type of case work treatment* - 22 -I t w a s n o t e d t h r o u g h o u t t h e e x a m i n a t i o n o f m e t h o d s o f t r e a t m e n t , t h a t w h i l e r e s o u r c e s a n d t e c h n i q u e s w e r e e m p l o y e d i n c o m b i n a t i o n t h e p r e p o n d e r a n t e m p h a s i s i n n i n e t e e n o f t h e t w e n t y - t h r e e o a s e s w a s o n d i r e c t t r e a t m e n t * O n l y f o u r p a t i e n t s w e r e t r e a t e d e x c l u s i v e l y b y i n d i r e c t m e t h o d s , t w o b e c a u s e t h e y h a d n o n e e d o f r e l a t i o n s h i p a s a c o r r e c t i v e e x p e r i e n c e , a n d t w o , b e c a u s e t h e y w e r e c o n s i d e r e d t o h a v e b a s i c p e r s o n a l i t y p r o b l e m s s o s e v e r e t h a t d i r e c t t r e a t m e n t w a s p r e c l u d e d . I t i s o b v i o u s t h a t e v e r y p a t i e n t d o e s n o t r e q u i r e d i r e c t t r e a t m e n t a n d t h a t t h e s o l u t i o n o f p r o b l e m s b r o u g h t t o t h e a t t e n t i o n o f t h e o a s e w o r k e r * S t u d y o f t h e b a l a n c e o f d e s t r u c t i v e a n d c o n s t r u c t -i v e f o r c e s i n t h e p a t i e n t s e x p e r i e n c e s i n d i c a t e d t h a t t h e r e w a s a n o v e r b a l a n c e o f d e s t r u c t i v e f a c t o r s i n t h e p a t i e n t ' s p a s t e x p e r i e n c e s w h i c h w o u l d n e g a t e e m p h a s i s u p o n d i r e c t t r e a t m e n t e x c e p t o n a n e x p e r i m e n t a l b a s i s * T y p i c a l c a s e m a t e r i a l d e s c r i b i n g c h a r a c t e r i s t i c p a t i e n t s s e l e c t e d f e j r t h e p r o j e c t a n d i l l u s t r a t i n g t h e c r i t e r i a e m p l o y e d w i l l b e f o u n d i n C h a p t e r I I I * M e t h o d 2: T h e R a t i n g S c a l e f o r M e a s u r i n g M o v e m e n t . S i n c e p r o c e s s r e c o r d i n g w a s n o t f o l l o w e d i n t h e m a j o r i t y o f t h e c a s e s , t h e o a s e w o r k e r - p a t i e n t r e l a t i o n s h i p w a s o f t e n u n c l e a r * F r e q u e n t l y i t w a s d i f f i o u l t t o l e a r n , e x -c e p t o n t h e b a s i s o f c o n j e c t u r e , h o w a n d w h y t h e p r o b l e m a r o s e a n d w h a t w a s b e i n g d o n e a b o u t i t * I t w a s a t t h i s p o i n t t h a t 5 A p p e n d i x A * , T h e R a t i n g S o a l e * S3 -T h e R a t i n g S c a l e f o r E v a l u a t i n g t h e E f f e c t i v e n e s s o f C a s e W o r k S e r v i c e s o f f e r e d t o R h e u m a t o i d A r t h r i t i s P a t i e n t s w a s e n v i s -a g e d a s a m o r e v a l i d a p p r o a o h t o t h e p r o b l e m s I n v o l v e d i n w o r k -i n g w i t h t h e a r t h r i t i c p a t i e n t a n d t h e e v a l u a t i o n o f t h e s u c -c e s s o f t r e a t m e n t s e r v i c e s b e i n g o f f e r e d * R e c o g n i t i o n w a s made o f t h e f a c t t h a t l a p s e s i n r e c o r d e d m a t e r i a l d i d n o t n e c -e s s a r i l y m e a n a l a c k i n s e r v i c e s * B r i e f l y , t h e R a t i n g S c a l e h a d a d u a l p u r p o s e . I t w a s d e s i g n e d t o n o t o n l y m e a s u r e t h e p a t i e n t f s o a p a o i t y t o g r o w o r c h a n g e w i t h i n t h e o a s e w o r k p r o -c e s s b u t a l s o a t t e m p t e d t o m e a s u r e t h e a m o u n t o f s u c h m o v e -m e n t * A s w i t h t h e c r i t e r i a p r e v i o u s l y d e s c r i b e d i t w a s a n e f f o r t t o e s t a b l i s h t h e a b i l i t y o f t h e p a t i e n t t o m a k e c o n -s t r u c t i v e u s e o f t h e c a s e w o r k p r o c e s s a n d o n w h a t l e v e l o f s e r v i c e * T h i s t i m e h o w e v e r , t h e o p i n i o n o f t h e c a s e w o r k e r d e a l i n g w i t h t h e p a t i e n t w a s u s e d * T h e R a t i n g S c a l e c o n s i s t e d o f t w o s e c t i o n s , a n d a s e r i e s o f f i v e p o i n t s c a l e s * S e c t i o n 1 i n c l u d e d t h e a t t i t u d e s a n d r e a c t i o n s o f t h e p a t i e n t t o h i s p h y s i c a l o o n d i t i o n a n d S e c t i o n S t h e b e h a v i o u r p a t t e r n s o f t h e p a t i e n t w i t h i n t h e c a s e w o r k r e l a t i o n s h i p * ^ h e o b j e c t i v e w a s t o e s t a b l i s h t h e p r o b l e m , c o n c r e t e o r b a s i c , t h e p a t i e n t ' s a b i l i t y t o a c c e p t h e l p w i t h i t , a n d t o o b t a i n t h e o a s e w o r k e r ' s o p i n i o n o f t h e s u c c e s s o r f a i l u r e o f h e r c a s e s * E a c h i n d i v i d u a l s c a l e w a s a n a t t e m p t t o m e a s u r e t h e v a r i o u s f a c t o r s i n t h e P a t i e n t ' s p e r -s o n a l i t y w h i c h made i t p o s s i b l e o r i m p o s s i b l e f o r h i m t o m a k e 6 T o b e k n o w n i n s u b s e q u e n t r e f e r e n c e s a s " T h e R a t i n g S c a l e " * £4 -effective us© of direct treatment - a method based on skilled use of relationship since this case work service was emphas-ized i n nineteen of the twenty-three eases* The Rating Scale was distributed to the eight dif-ferent sooial workers working with the oases to be completed* Three of the workers were master's students from the School of Social Work who carried a total of six eases with the re-mainder handled by regular staff members attached to St* Paul's Medical Social Service Department, the Vancouver General Hos-pital Sooial Service Department, and the Canadian Arthritis and Rheumatism Society* It was explained as fully as possible to each worker completing i t and individual discussions were held with those who found fiifficulty in answering the various sections and assistance given when requested, i t might be noted here that the greatest area of difficulty in completing the Rating Scale appeared to be in the Section concerning "Severity of the Problem" and in completing the chart on page 3* Discussion around this problem with the workers i n -dicated that the majority felt that the l i f e experiences of the patients suggested deep-rooted personality difficulties which eould not be changed but did not preclude movement in the case in other areas such as improved environmental conditions* The chart was designed to suggest this* A further cheek was imposed by the correlation of the results of the parts "Degree 7 Appendix A, The Rating Scale, Part 2, Section A* - £5 -8 t o W h i c h T r e a t m e n t G o a l s w e r e A c h i e v e d " a n d " D e g r e e t o W h i c h 9 C a s e w o r k i s r e s p o n s i b l e f o r t h e M o v e m e n t s h o w n i n t h e C a s e " . I n t h i s w a y t h e p r o g r e s s o f t h e p a t i e n t w i t h a d j u s t m e n t s o t h e r t h a n c h a n g e i n p e r s o n a l i t y p a t t e r n s w a s a l s o i n d i c a t e d . I n t h e a n a l y s i s o f t h e a m o u n t o f m o v e m e n t a o a s e m a y s h o w * f a c t o r s s u c h a s , t h e o v e r - a l l a m o u n t o f e f f o r t t h e w o r k -e r p u t i n t o t h e c a s e a n d t h e s k i l l a n d t e c h n i q u e s u s e d w e r e t h o u g h t t o b e i m p o r t a n t i n t h e e v a l u a t i o n o f t h e s e r v i c e s o f f e r e d t o t h e p a t i e n t * O v e r - a l l e f f o r t w a s p r i m a r i l y t h o u g h t o f a s t h e a m o u n t o f t i m e s p e n t o n t h e e a s e a n d t h e n u m b e r o f a r e a s o f d i f f i c u l t y t r e a t e d w i t h i n a g i v e n s o c i a l d i a g n o s i s t o c r e a t e a b e t t e r a d j u s t m e n t o f t h e p a t i e n t * S k i l l w a s r a t e d o n t h e b a s i s o f t h e d i a g n o s i s b y t h e w o r k e r o f t h e p r o b l e m d e a l t w i t h a n d t h e m e t h o d s o r t e c h n i q u e s u s e d t o r e a c h h e r g o a l * I t i s r e c o g n i z e d t h a t t h i s p r e m i s e m a y n o t b e v a l i d i n t e r m s o f a c c u r a t e m e a s u r e m e n t o f m o v e m e n t * b u t f o r t h e p u r p o s e s o f t h i s s t u d y t h e s e a s p e c t s w e r e c o n s i d e r e d i m p o r t a n t a s p a r t o f t h e c a s e w o r k p r o c e s s i n t h e s u c c e s s o r f a i l u r e o f a c a s e * T h e w o r k e r s w e r e a l s o a s k e d t o s c a l e t h e i r o p i n i o n s a s t o t h e d e g r e e t o w h i c h t h e y f e l t e a s e w o r k w a s r e s p o n s i b l e f o r t h e 10 m o v e m e n t s h o w n i n t h e c a s e , i n a n e f f o r t t o o b t a i n some i n -d i c a t i o n o f w h e t h e r o r n o t p h y s i c a l i m p r o v e m e n t , s i n c e a l l t h e 8 I b i d , F a r t 3, p * 3*, p a g e 24. 9 I b i d , F a r t 4, p * 4* 10 I b i d , F a r t 4, p * 4* - 26 patients are on a course of cortisone treatment, may have been a factor in changing patterns of behaviour* Relief from the extreme pain and discomfort of rheumatoid arthritis after long years of almost continual suffering was thought to be a factor i n movement which could not be discounted* The relief i s sometimes so dramatic that some effort to evaluate this aspect had to be made* The answers to this part were oorrel-11 ated with the section on Health Evaluation taking into ah* count the amount of improvement in the activity of the disease* how the patient followed medical instructions, his attitude to his Illness and his desire to recover while undergoing ease work services* 1 2 The nature of the relationship of the patient with 13 the worker as an element in ease work treatability was scaled in terms of the three factors, warmth* dependency and hostile-ity as determinants in the patient's capacity to make "use of the ease work process* Warmth was considered as the quality of feeling* or feeling tone of the patient toward the case-worker* dependency and hostility as the way or manner the pat-ient makes his decisions and handles his relationships within his given situation* The severity of the problem* the patient's awareness of i t and his desire for help with his difficulty 1 4 11 Appendix A* The Rating Scale. 12 Ibid, p*l* 13 Ibid, p. 2* 14 Ibid* - 27 were considered elements that also entered into the patient's capacity to establish a oase work relationship and therefore into the success or failure of the process* With referenoe to the scale evaluating the severity 15 of the problem i t may be noted that the problem is constant in many respects* For example* i t i s possible for a patient to have a severe emotional problem and yet. i f he has the ability to form a case work relationship he i s often capable of growth or change* Conversely, a superficial problem would show no movement with a limited capacity of relationship, in-dicating that deeper personality disturbances existed* Whether such a difficulty would be dealt with by the oase worker would depend on the patient's awareness of i t and his desire for help* In short, diagnosis based on the patient*s ego strengths and level of maturity would suggest the basis of treatability* The interpretation of the material gathered by the methods described here are of necessity the thinking of the researcher and of course open to question* In an effort to achieve as much ob jeotivity as possible in the evaluation of oase work services the worker's ratings of their own eases were combined with the researcher's viewpoint to establish the conclusions finally arrived at* It may be argued that the workers had unconscious motivations in their responses 15 Ibid, p* 3*, page 26. 28 -a n d w e r e s u b j e c t i v e i n t h e w a y t h e y a n s w e r e d t h e q u e s t i o n s p o s e d , b u t t h i s o b s t a c l e , i f f o l l o w e d t o i t l o g i c a l c o n c l u s -i o n r e a c h e s a b s u r d i t y * I t e a n n o t b e s u r m o u n t e d i n v i e w o f t h e f a c t t h a t t h e o a s e w o r k p r o c e s s i s b a s e d o n r e l a t i o n s h i p , w h i c h i n s p i t e o f t h e p r o f e s s i o n a l d i s c i p l i n e o f t h e q u a l i f i e d a n d e x p e r i e n c e d o a s e w o r k e r a l w a y s c o n t a i n s a n e l e m e n t o f t h e s u b j e c t i v e * T h e m e t h o d s u s e d t o r a t e r e l a t i o n s h i p a n d t h e f a c t -o r s i n v o l v e d i n i t m a y b e q u e s t i o n e d , b u t s i n c e a u t h o r i t i e s i n t h e o a s e w o r k a n d r e s e a r c h f i e l d s a r e s t i l l s t r u g g l i n g w i t h t h e d i f f i c u l t y o f f i n d i n g a v a l i d m e a s u r i n g s t i c k i t c a n o n l y b e s u g g e s t e d t h a t t h e m e t h o d s o f a s s e s s m e n t u s e d i n t h i s s t u d y b e c o n s i d e r e d a r e a s o n a b l e a p p r o a c h t o a n e w a n d a l m o s t u n e x -p l o r e d a r e a o f s o c i a l w o r k * I n a n y e v a l u a t i o n some s t a n d a r d o f m e a s u r e m e n t m u s t b e p o s t u l a t e d a g a i n s t w h i c h t o d r a w c o n -c l u s i o n s , a n d a l l t h a t c a n b e s t a t e d i s t h a t c e r t a i n i n f e r -e n c e s m a y b e d r a w n f r o m a g i v e n h y p o t h e s i s w i t h i n a p r e s c r i b -e d s e t o f c i r c u m s t a n c e s * T h i s i s v e r y p r o b a b l y a s s c i e n t i f i c a s s o o i a l w o r k o r a n y o t h e r p r o f e s s i o n c a n b e a t t h i s t i m e * D e s c r i p t i v e o a s e m a t e r i a l i l l u s t r a t i n g t h e u s e o f T h e R a t i n g S c a l e a n d t h e c o n c e p t o f m o v e m e n t i s c o n t a i n e d i n C h a p t e r I T * P a t i e n t s c h a r a c t e r i z e d a r e t y p i c a l s e l e c t i o n s f r o m t h e g r o u p p a r t i c i p a t i n g , i n t h e R h e u m a t i c D i s e a s e s P r o j e c t * CHAPTER III Treatability: Song Casework Criteria. Treatability was examined on the basis of selected c r i t e r i a 1 and results point to the conclusion that treatment based on Inadequate diagnostic evaluation does influence the success or failure of a case* Success or failure, in the sense the words are used here, means merely how much a patient was helped to make effective use of services offered to him having regard to his capacity to do so* A simple method of scoring was employed for the purpose of easy calculation* One point was allowed for each of the criteria f u l f i l l e d , and a zero score for a condition that oould not be met* An i n -ability to achieve a total score made i t doubtful i f the patient could be treated on that level of case work services* Criteria for direct treatment added up to eight points while indirect treatment totalled only four points* The total re-sults for a l l the oases studied are summarized in Chart II, Appendix B • It should be noted that the conditions set up as oriteria for treatability are merely tentative and do not cover a l l the conceivable situations which arose* Their pur-pose was to indicate the primary focus only* It i s obvious that in many oases direct and indirect methods would be used in combination, but i t was assumed that there would be a preponderant emphasis on one or the other techniques* 1 Rogers, Carl R., "When i s Counselling Indicated", Counsel- ling and Psychotherapy. Houghton Mifflin Company, 1948* - 30 -M r * Z , f o r e x a m p l e , a g e d t w e n t y - t h r e e y e a r s * w a s a b l e t o m a k e e f f e c t i v e u s e o f i n d i r e c t a n d d i r e c t t r e a t m e n t w i t h t h e p r i m a r y f o c u s o n t h e l a t t e r m e t h o d . H e p a r t i c i p a t e d i n t h e o a s e w o r k p r o c e s s o v e r a p e r i o d o f t e n m o n t h s w i t h a t o t a l o f f o r t y p l a n n e d w e e k l y i n t e r v i e w s o f a p p r o x i m a t e l y o n e h o u r ' s d u r a t i o n e a c h . P r e v i o u s e x p e r i e n c e s o f M r . Z r e v e a l e d t h a t h e h a d a l w a y s f e l t r e j e c t e d b y h i s f a t h e r * a h a r d - w o r k i n g , d o m i n e e r i n g m a n w h o d r o v e h i m s e l f a n d h i s f a m i l y u n m e r c i f u l l y t o m a k e h i s b u s i n e s s a s u c c e s s . H e p r e s e n t e d a p a t t e r n o f a r i g i d y o u n g m a n w i t h t e r r i f i c " d r i v e " , w h o d e e p l y r e s e n t e d M r . Z , S r . , b u t w a s u n a b l e e i t h e r t o a d m i t h i s a n g e r o r e x -p r e s s i t , a n d w h o h a d s t r u g g l e d d e s p e r a t e l y f o r h i s f a t h e r ' s a p p r o v a l b u t n e v e r r e o e i v e d a n y d e m o n s t r a t i o n o f i t . H i s m o t h e r c o n t r o l l e d h i m t o o , b u t i n a n o v e r - i n d u l g e n t w a y , c r e a t -i n g g u i l t f e e l i n g s w h e n h e d i d n o t w i s h t o a c c e d e t o h e r d e -m a n d s u p o n h i m . H i s o n l y s i s t e r r e l a t e d t o h i m i n m u c h t h e same w a y a s h i s m o t h e r , b u t h e w a s a b l e t o e x p r e s s h i s r e s e n t -m e n t t o w a r d h e r m o r e o v e r t l y * H i s f a t h e r ' s s u d d e n d e a t h , a n d t h e f a c t t h a t h e w a s u n a b l e t o r e a o h h i s b e d s i d e b e f o r e t h e e v e n t , d e e p l y a f f e c t e d M r * Z , p a r t i c u l a r l y w h e n i t w a s r e p o r t e d t o h i m t h a t h i s f a t h e r h a d c a l l e d i n c e s s a n t l y f o r h i m a n d s e e m e d t o w a n t t o l e t "M™ k n o w t h a t h e d i d c a r e . S h e b u s i n e s s h i s f a t h e r h a d o w n e d a n d i n w h i c h M r * Z h a d w o r k e d s i n c e t h e a g e o f s i x t e e n , b e o a m e h i s , a n d h e o o n t i n u e d t h e p a t t e r n o f s t r e n u o u s l a b o r a t h y p e r -t e n s i v e s p e e d l a i d d o w n b y t h e d e c e a s e d . M a r r i a g e a t t h e a g e - S l -o t t w e n t y - o n e y e a r s t o a d e p e n d e n t , r a t h e r f r i v o l o u s n i n e t e e n y e a r o l d g i r l w h o w a s d e e p l y a t t a o h e d t o h e r m o t h e r , a n d t h e b i r t h o f a b a b y s o o n a f t e r , © o n t i n u e d t o p a v e t h e w a y t o I l l n e s s , M a r i t a l f r i c t i o n a n d i n t e r f e r e n c e f r o m r e l a t i v e s o n b o t h h u s b a n d ' s a n d w i f e ' s s i d e s , ( M r * Z a l s o b e i n g u n a b l e t o b r e a k h i s t i e s t o h i s m o t h e r w h o d i s a p p r o v e d o f h i s c h o i c e o f a w i f e ) e n d e d i n M r s * Z * s d e s e r t i o n w h i l e h e w a s a w a y o n a t r i p * R e a c t i n g w i t h e m o t i o n a l i n t e n s i t y t o t h i s n e w s , M r * Z d r o v e c o n t i n u o u s l y f o r s e v e r a l d a y s a n d n i g h t s t o r e a c h h i s home* O n a r r i v a l h e b e g a n t o f e e l i l l , w e n t t o b e d a n d f o u n d t h a t h e w a s s o s t i f f a n d f u l l o f p a i n t h e n e x t d a y t h a t h e w a s u n a b l e t o g e t u p * A f t e r a p e r i o d o f h o s p i t a l i z a t i o n , M r * Z w a s o f f e r e d e a s e w o r k t r e a t m e n t a n d a c c e p t e d i t , r e c o g n i z -i n g t h a t h e h a d a p r o b l e m , a l t h o u g h u n a w a r e o f t h e d e e p - r o o t e d n a t u r e o f i t * T h i s c a s e w i l l n o w b e d e s c r i b e d i n i l l u s t r a t i o n o f t h e u s e m a d e o f c r i t e r i a t o e s t a b l i s h t h e p r i m a r y f o o u s o f t r e a t m e n t * I * O r i t e r i a I n d i c a t i n g D i r e c t T r e a t m e n t * 1* T h e p a t i e n t l a u n d e r e n o u g h s t r e s s o r t e n s i o n t o - b a l k  a b o u t h i s p r o b l e m s a n d t o t r y t o f i n d a s o l u t i o n t o h i s c o n - f l i c t s . I t i s o b v i o u s t h a t M r . Z n o l o n g e r h a d t h e a b i l i t y S R o g e r s , C a r l R . , " W h e n i s C o u n s e l l i n g I n d i c a t e d " , C o u n s e l - l i n g a n d P s y c h o t h e r a p y . C h a p t e r I I I , H o u g h t o n M i f f l i n C o m p a n y , T h e O a s e o f M r . Z . 3 8 t o o o p e w i t h t h e s t r e s s a n d s t r a i n o f e n v i r o n m e n t a l a n d e m -o t i o n a l p r e s s u r e s * H e h a d u n d e r g o n e t w o t r a u m a t i c e z p e r i e n o e s o v e r a p e r i o d o f t w o y e a r s - t h e d e a t h o f h i s f a t h e r a n d t h e d e s e r t i o n o f h i s w i f e a f t e r c o n s i d e r a b l e f r i c t i o n b o t h w i t h h e r a n d h e r r e l a t i v e s * A c o n t r o l l e d p e r s o n a l l h i s l i f e , h e w a s r i g i d a n d u n a b l e t o e z p r e s s h i s a n g e r h a v i n g l e a r n e d t o b o t t l e u p h i s r e s e n t m e n t f o r f e a r o f d i s a p p r o v a l * H i s d e s i r e t o e o n t i n u e h i s f a t h e r ' s p a t t e r n O f h a r d w o r k a n d a n e x e m p l a r y l i f e o f s t e m d i s c i p l i n e t o o b t a i n t h e l o v e o f h i s f a m i l y a n d s o o i a l a p p r o v a l , h a d e n d e d i n f a i l u r e * T h e o n l y r e c o u r s e h e h a d t o e x p r e s s h i s i n h i b i t e d a g r e s s i o n * w h e n w o r k f a i l e d * a n d t o f u l f i l l h i s d e e p d e p e n d e n c y n e e d s , w a s t h r o u g h p s y c h o g e n i c r h e u m a t o i d a r t h r i t i s * M r * Z ' s a n x i e t y a n d t e n s i o n , c r e a t e d b y h i s f e a r o f c r i p p l i n g a n d b e i n g u n a b l e t o c a r r y o n t h e p h y s i c a l a c t i v i t y h e h a d a l w a y s b e e n a c c u s t o m e d t o , t h e p a i n o f t h e l o s s o f h i s f a m i l y , p a r t i c u l a r l y h i s s o n w i t h whom h e i n d e n t l f i e d , t h e f e a r o f d o m i n a t i o n b y h i s m o t h e r w h o b e g a n t o t a k e o v e r h i s l i f e d u e t o h i s i l l n e s s a n d d e p e n d e n c y u p o n h e r a n d t h e d e -t e r i o r a t i o n o f h i s b u s i n e s s , b e c a m e g r e a t e n o u g h t o e n a b l e h i m t o b e g i n t o e x p r e s s h i s f e e l i n g s a b o u t h i s p r o b l e m s w i t h i n a h e a l i n g o a s e w o r k r e l a t i o n s h i p * H i s d e s i r e t o e o n t i n u e h i s b u s i n e s s w a s f r u s t r a t e d b e e a u s e o f h i s p h y s i c a l i n c a p a c i t y a n d h e g r a d u a l l y b e c a m e a w a r e t h a t h e w a s n o w u n a b l e t o d r i v e h i m -s e l f a n d m u s t o o p e w i t h h i s b a s i c p r o b l e m s o f m a l a d j u s t m e n t t o a c h i e v e h i s g o a l o f s o o i a l a p p r o v a l a n d s u c c e s s * 8* T h e p a t i e n t i a a b l e t o c o p e w i t h h i s s i t u a t i o n . H e h a s e n o u g h s t r e n g t h o r c a p a c i t y t o t a k e a c t i o n t o a l t e r h i s l i f e c o u r s e a n d t h e s i t u a t i o n i s t o some e x t e n t c h a n g e a b l e * T h e r e a r e a l t e r n a t i v e s a t i s f a c t i o n s a n d a l t e r n a t i v e w a y s o f d e a l -i n g w i t h t h e s i t u a t i o n p o s s i b l e * M r . Z d e m o n s t r a t e d g o o d a v e r a g e a b i l i t y * T h r o u g h h a r d w o r k h e h a d b e e n e x p a n d i n g a n a l r e a d y a d e q u a t e b u s i n e s s , h a d some s a v i n g s a n d w a s p r o v i d i n g f o r h i s m o t h e r a n d o w n f a m i l y o n a d e o e n t l e v e l * H e w a s a s t a b l e , r i g i d y o u n g p e r s o n w h o h a d l i t t l e t i m e f o r l e i s u r e a n d r a r e l y d e v i a t e d f r o m h i s g o a l o f b e i n g a s u c c e s s f u l b u s i n e s s m a n * A t t w e n t y - t h r e e y e a r s h e h a d a c c o m p l i s h e d a g r e a t d e a l , w a s r e s p e c t e d i n h i s c o m m u n i t y , h a d n o s o c i a l l y c e n s u r a b l e h a b i t s a n d l i v e d o n a n a v e r a g e s o c i a l s c a l e * M r . Z * s c o n s i d e r a b l e d r i v e a n d b a s i e i n t e l l i g e n c e made i t p o s s i b l e f o r h i m t o a l t e r h i s g o a l s b e -c a u s e o f h i s i l l n e s s w h e n h e r e c o g n i z e d t h a t h e m u s t * F r e e f i n a n c i a l l y , s i n c e h i s w i f e d i d n o t d e m a n d s u p p o r t a n d a s s i s t -e d b y h i s s i s t e r a n d m o t h e r w h o w e r e o v e r s o l i c i t o u s i t i s t r u e , b u t n o n e t h e l e s s i n t e r e s t e d a n d s y m p a t h e t i c , h e h a d t h e p o w e r w i t h i n h i m s e l f a n d i n h i s e n v i r o n m e n t t o c o p e w i t h t h e s i t -u a t i o n a n d t o c o n t r o l i t * 5* T h e r e i s a n o p p o r t u n i t y f o r t h e p a t i e n t t o e x p r e s s t h e  c o n f l i c t i n g t e n s i o n s w h i c h h a v e c r e a t e d h i s p r o b l e m i n p l a n - n e d c o n t a c t s w i t h t h e c a s e w o r k e r * A d e q u a t e f a c i l i t i e s w e r e a v a i l a b l e f o r r e g u l a r w e e k -l y I n t e r v i e w s w h i c h w e r e c a r r i e d o n t h r o u g h o u t a t e n m o n t h - 3 4 -p e r i o d * A c o u r s e o f t r e a t m e n t w a s p l a n n e d w i t h M r * Z , w i t h c o n t a c t s d i r e c t e d t o t r e a t m e n t o f h i s e m o t i o n a l p r o b l e m s i n r e l a t i o n t o h i s m a r i t a l s i t u a t i o n * f e e l i n g s a r o u n d h i s f a t h e r a n d m o t h e r i n c o m b i n a t i o n w i t h s p e c i f i c h e l p w i t h r e g a r d t o v o c a t i o n a l r e t r a i n i n g i n v i e w o f some c r i p p l i n g * n e c e s s a r y i n t e n s i v e p h y s i o t h e r a p y a n d f i n a l l y j o b p l a c e m e n t * 4. T h e p a t i e n t w a n t s h e l p * H e c o n s c i o u s l y r e c o g n i z e s h i s n e e d f o r i t * I t i s r e a l i z e d t h a t h e l p c a n b e g i v e n w i t h o u t t h i s c o n d i t i o n b e i n g f u l f i l l e d b u t t h e l i k e l i h o o d o f s u c c e s s -f u l d i r e c t t r e a t m e n t i s g r e a t e r i f t h e p a t i e n t w a n t s h e l p * M r * Z w a n t e d t o t a l k a b o u t h i s p r o b l e m s a n d s o o n n o t e d d u r i n g c a s e w o r k c o n t a c t s t h a t w h e n h e d i s c u s s e d p r o b -l e m s b o t h e r i n g h i m t h a t h i s a r t h r i t i c s y m p t o m s b e g a n t o s u b -s i d e * R e l i e f o f t e n s i o n w i t h t h e a t t e n d a n t r e l a x a t i o n m a d e h i m a w a r e o f b a s i c p e r s o n a l i t y p r o b l e m s w i t h w h i c h h e r e q u e s t -e d p s y c h i a t r i c h e l p * H e g r a d u a l l y b e c a m e a w a r e o f d e p e n d e n c y n e e d s w h i c h h e w a s e x p r e s s i n g t h r o u g h h i s a r t h r i t i c s y m p t o m s * W i t h i n t h e a c c e p t i n g r e l a t i o n s h i p w i t h t h e c a s e w o r k e r h e w a s e n a b l e d t o e x p r e s s h i s r e s e n t m e n t a g a i n s t h i s p a r e n t s a n d w i f e , h i s f e a r s o f d e f o r m i t y a n d t h e l o s s o f p h y s i c a l a c t -i v i t y * A c o n s c i o u s d e s i r e f o r h e l p a t t h e b e g i n n i n g o f o a s e w o r k t r e a t m e n t made i t p o s s i b l e f o r h i m t o f o l l o w t h r o u g h t h e c o u r s e o f t r e a t m e n t p l a n n e d * 5* T h e p a t i e n t i s r e a s o n a b l y e m o t i o n a l l y i n d e p e n d e n t o f c l o s e •pAirrny a p n t r o l * S p a t i a l l y M r * Z w a s i n d e p e n d e n t o f h i s f a m i l y d u r -- 3 5 -i n g t r e a t m e n t , l i v i n g a p a r t f r o m t h e m * E m o t i o n a l l y h e w a s s t i l l d o m i n a t e d b y h i s m o t h e r a n d t h e c a r r y - o v e r o f h i s f a t h -e r ' s p a t t e r n s a n d d e e p l y h a r t b y h i s w i f e ' s d e s e r t i o n * H e w a s , h o w e v e r , r e s e n t f u l e n o u g h o f t h e w h o l e s i t u a t i o n t h a t h e w a s a b l e t o e x p r e s s h i s a n g e r a n d t o make a n e f f o r t t o o o p e w i t h t h e s e p r o b l e m s * @V T h e p a t i e n t i s r e a s o n a b l y f r e e f r o m e x c e s s i v e i n s t a b i l -i t i e s , p a r t i c u l a r l y o f a n o r g a n i c n a t u r e * A s w a s n o t e d p r e v i o u s l y , M r * Z w a s a s t a b l e , c a p a b l e p e r s o n w i t h a c o n t r o l l e d b u t s o l i d f a m i l y b a c k g r o u n d a n d s u f -f e r e d n o o r g a n i c i n s t a b i l i t i e s i n t h e s e n s e o f m e n t a l a b e r -r a t i o n s * T h e d i s e a s e o f r h e u m a t o i d a r t h r i t i s w i t h i t s p a i n a n d p o s s i b i l i t i e s o f c r i p p l i n g a n d i n e v i t a b l e e x a c e r b a t i o n s a n d r e m i s s i o n s , c r e a t e d a d i f f i c u l t p h y s i c a l p a t t e r n , b u t u n d e r c o r t i s o n e t h e r a p y h e r e s p o n d e d w e l l , g r a d u a l l y l e a r n i n g t o c o n -t r o l h i s i l l n e s s * T h e d i s e a s e h a d n o t y e t b e c o m e a c h r o n i c c o n d i t i o n a n d i t s d u r a t i o n w a s o f o n e y e a r a t t h e t i m e e a s e w o r k t r e a t m e n t w a s o f f e r e d * 7* T h e p a t i e n t p o s s e s s e s a d e q u a t e i n t e l l i g e n c e f o r c o p i n g  w i t h h i s l i f e s i t u a t i o n * w i t h a n i n t e l l i g e n c e r a t i n g o f d u l l - n o r m a l o r a b o v e * M r * Z w a s o b v i o u s l y o f g o o d i n t e l l i g e n c e * H e w a s a b l e t o c o m p l e t e h i s G r a d e 21 a t s i x t e e n y e a r s i n s p i t e o f a f t e r - s c h o o l w o r k i n h i s f a t h e r ' s b u s i n e s s , a n d w a s a b l e t o c o m p l e t e a t e c h n i c i a n ' s c o u r s e d u r i n g e a s e w o r k t r e a t m e n t r e -q u i r i n g a b o v e - a v e r a g e a b i l i t y * - 36 -8* The patient Is of suitable age—old enough to deal some-what independently with l i f e , and young enough to retain some elastloity of adjustment* In terms of chronological age this might mean roughly from ten to sixty years* Mr* Z was twenty-two years of age when treatment began* With his drive* awareness of his problems and desire for help in aooepting change* he was not yet rigid enough to preclude growth in m a t t i n g a better adjustment to his l i f e situation* He was young enough to benefit by further tech-nical training whioh made future profitable employment pos-sible and to make new adaptations in terms of leisure and social relationships* viewed within his framework, i t was found that of the twenty-three rheumatoid arthritis patients studied, nine were considered potentially treatable on a direct treatment level* It was noted previously that nineteen patients were given services with emphasis upon direct treatment, whioh would suggest either an experimental approach or that there was inadequate sooial diagnosis and evaluation of construct-ive and destructive forces in the patient*s l i f e experience* The latter view is favoured sinoe the ten cases who were un-treatable on a direct basis, but given such services, were found to have had l i f e experiences of a crippling emotional g nature, particularly with regard to factors 1, 2, 3, 4, and 3 Refer to Chapter II, p* 19, fir s t paragraph* 37 5 with some doubt of number* Q, 6 Chronologically, a l l were of suitable age* Emotionally they presented a picture of rigidity and psychological adapt-ation to the state of being i l l * A further check was imposed upon those oases where indirect or environmental treatment was indicated according to the following criteria illustrated by the oase of Mrs* X* This patient* a woman of forty years* had been i l l with rheumatoid arthritis for six years* She was f i r s t re-ferred for oase work treatment over three years ago by her doctor, who considered that she needed help with a poor fam-i l y situation which was aggravating her physical condition* Her husband was working at an inadequately paid job after be-ing unemployed for a number of years* A backlog of debt had been built up whioh he, being a conscientious person, was re-ducing by small installments* He was resistant to his wife being admitted to hospital for treatment and suffered himself from asthma and ulcers* Mrs* X describes Mr* X as "selfish, demanding and mean"* Relationships with her two adult child-ren, living in the home, and two school age, were f u l l of con-f l i c t and accentuated by her husband's poor attitude toward her, according to Mrs* X* The patient was also deaf and thought that her family took advantage of this* She had a fear of pregnancy and rejected sexual relations, which further aggravated the marital discord* The social worker had several interviews with Mrs* X at this time, but the case was closed - 38 -until she was referred again a year later by her doctor for ease work help* Onoe more she was interviewed several times and the oase closed* Mrs* X herself, upset and depressed* earns back to the social worker a year later requesting help with her problems, saying that, "Someone haft to do something for her—she didn't know what, but she had come to the end of her rope***5 II* Oriteria Indicating Environmental or Indirect Treatment4, I V The component factors of the patient's adjustment s i t - uation are so adverse that even with changed attitudes and  insight, she could not cope with i t * Destructive experiences in the family or sooial group or a destructive environment, added to own inadequacies in health, abilities and competen-cies, make adjustment very unlikely, unless the environmental setting i s changed* Inadequate income, debts which her husband Insisted upon paying, two adult children whom she resented, because she was unable to control them, and they did not provide the financial support so needed, two sohool-agers whom she was un-able to manage physically and in terms of discipline, along with poor marital relationships made her environment impossible* Fear of leaving her children in another's care, a severe crip-pling arthritic condition, made i t impossible for her to ac-cept help and yet physically she was unable to manage a house-4 Rogers, Oarl R., Phd. Oriteria; Adapted from Counselling  and Psychotherapy. Chapter III, "When i s Counselling Indicated", "Some Basic Questions", Houghton Mifflin Company, 1 9 4 2 . - 39 hold* 2* The patient is inaccessible to oasework in that reason- able opportunity and effort f a i l to discover any means bv  which he oan express his feelings and problems* Over the three year period Mrs. X was interviewed eighteen times by two sooial workers. Eight of these inter-views were concentrated over the latter six months. Excerpts from the case-record wil l illustrate this criteria. "While Mrs. X has an understanding between her difficulties at home and her illness, she has no insight into the part she plays in these difficulties. She projects a l l of the responsibility for these unto her husband and sees herself in a"martyr role"* "While Mrs* X seemed to gain considerable release from ten-sion in talking about these things, i t i s questioned whether she could use a oase work relationship constructively. She appears to be a very disturbed person, but quite rigid, with no insight into the need for change in herself. She resisted the idea of regular interviews, perhaps because of this, but is willing to be seen from time to time". "She panics at the suggestion that her husband be seen". In short, Mrs. X did not want help with basic personality problems—she had settled for arthritis. 3* Effective environmental treatment is simpler and more  efficient than a direct approach* Environmental or indirect treatment was made avail-able through the Family Welfare Bureau when Mrs. X went to 40 the hospital and home-maker service was provided* Necessary dentures were obtained for Mrs* X* Toward the end of the oase work services a period of treatment at the Western Re-habilitation Centre was arranged which considerably improved Mrs* X*s physical condition and strengthened the family situation* 4. The patient i s too young or too old* too dull or too un- stable for a direct type of case work treatment* Mrs* X may not be considered too old at the age of forty, chronologically speaking, but emotionally her problems have been so long outstanding that direct treatment may be considered unfeasible* Psyohiatrio referral was made during the fi r s t year of contact with the social worker but such treatment was unsuccessful* Mrs* X was described as "an im-mature, dependent person demanding the undivided attention of the worker"• Her husband was interviewed and found "cap-able of functioning quite well in regard to his wife and the home situation i f he were supported in doing i t " • The mar-riage was considered to be one "of neurotic dependency"* Both Mr* and Mrs* X "are basically deprived, immature and thus dependent people"* Mrs* X when she did have flare-ups of her arthritic condition "insists that the sooial worker do some-thing, but wil l not participate in planning"* Mr. X is "hos-t i l e and uncooperative^'but "when he was helped on the basis of his own needs he became more co-operative"* It becomes obvious throughout the case-record that - 41 Mrs* X prefers to be thought of as a martyr* and says, "Life i s so miserable that she doesn't even want to get well*" The sooial worker desorlbed the relationship thusly, "Mrs X did not relate to me on anything but a superficial basis* She used me to meet her requests for physical assistance and sup-port through acceptance* reassurance and warmth* |he cannot tolerate limits or interpretation"• Again the social worker records, "It i s very difficult for her (Mrs* X) to accept the worker's relationship with Mr* X and his attempts to co-operate* She prefers to Interpret him to the hospital staff as a punish-ing, depriving person, who i s at the root of her illness"* It i s apparent that Mr* X's resistance to his wife's receiving hospitalization was overcome very readily in one Interview and i t i s to be regretted that he did not receive the direct treatment he could have accepted through a referral to a separate worker or different agency offering such ser-vices* It was noted throughout the case histories of the pat-ients studied that the approach to treatment was predominantly patient-centred and exploration of the family unit for pos-sible strengths seriously neglected* Six patients of the total group were found to be capable of nmTHwg effective use of indirect or environmental treatment* In one of these the social diagnosis suggested some doubt that this method would be constructive but an ex-perimental approach was indicated* When i t i s considered that direct treatment was emphasized in every ease i t can only 42 -be reiterated that inadequate sooial diagnosis and evaluation was consistently apparent* The following case is ill u s t r a t -ive of those patients with personality disturbances so severe that n e i t h e r type of oasework treatment was effective* Contra-Indications for either Direct or Indirect Treatment* Miss A was an obvious example of those patients who were unable to make constructive use of either type of case work treatment but where services should probably be offered when and i f requested by them* Seven patients stand within this category, according to the oriteria applied* Again dir-ect treatment was emphasized in four oases with three being offered indirect treatment on the level they were able to make use of i t * •  Miss A, age thirty-eight years, was referred to the oase worker by her doctor for vocational guidance and was Interviewed ten times over a period of six months* She made major Improvement while on cortisone therapy, in spite of breaking physiotherapy regimes through an inability to agree with the physiotherapist* Beginning treatment as an active oase of rheumatoid arthritis of ten years duration, she arrived at an arrested stage of the disease at the termination of this study* During the period of time Miss A, unapproach-able in the extreme, was offered case work treatment, the ease worker was not able to establish any more than a very superficial relationship and to obtain any information which would assist her in helping Miss A with her problem* This - 43 -patient was terribly threatened by any invasion of independ-ence and responded to proffered services and interpretations of the help the case worker could give her with polite but firm rejection* She could not* however* express hostility to the caseworker and having almost completely lost her abil-ity to function within her environment because of her person-ality problem, i t was impossible for her to make any adapt-ation which would Improve her situation or to take employ-ment* It i s interesting to note that Miss A i s character-ized as a "rigid, unyielding person with a schizoid person-ality" who i s "aware of her tendency to schizophrenia but states that she does not wish help with her problem"* There is no doubt that Miss A i s untreatable from the viewpoint of her emotional problems because of her inability to Involve herself in a oase work relationship, and to participate in their solution* Because of her personality problem i t i s con-jectural whether or not she will be able to make effective use of concrete services offered* It could be said that ease work treatment in this case was ineffective since Miss A was unable to obtain employment and the oase worker was unable to establish rapport, but, invlew of the suspected psychotic reaction which rejects a l l relationship, supportive help, i f and when she can accept i t , i s a l l that oan be offer-ed to this patient* The over-emphasis upon direct methods of oasework - 44 -treatment with patients unable to make use of sueh tech-niques points to two conclusions. One is that services offer-ed to patients on the Project have been ineffective and the other that those services they are capable of using have not been made available to them* It follows that human and mat-erial wastage are the only results of sueh efforts and that there is an urgent need for sound planning on behalf of the patient and the community* CHAPTER IV An Approach to the Measurement of Movement Perusal of t h e s iting Scale 1 will make i t apparent that a norm was established for each individual scale as a minimum criterion below or above whioh direot treatment was considered unwarranted unless on an experimental basis* (A) Movement defined; Movement was rated from the date of the beginning of oase work treatment for each Individual patient to the termination of this study May 20, 1952* Movement was defined essentially as change* in the sense of a growth process* either through the utilization of resources or relationship or both* It Included improvement or change for the better in the sooial situation of the patient* physically or emot-ionally, and the modification of behaviour and attitudes to promote positive, healthful growth of personality* A move-ment soore was conceived as upward movement or change, and downward movement or deterioration during oase work treatment* Sinoe rheumatoid arthritis patients present many of the aspects common to a chronic disease condition, (particularly that of weak ego structures) i t was recognized that the ohroniclty of the illness in many oases may be found in the personality of the patient rather than in the environment* Accordingly, consideration was given to the oase work aim of preventing 1 Appendix A* "The Rating Scale" • 46 -further breakdown or deterioration through environmental and emotional pressures by means of supportive treatment (a supporting of strengths and existing aims without the ex-pectation of change*) Mrs* X and Miss A, desoribed in Chapter III* represent those eases where further deterior-ation or breakdown was prevented* It became apparent that such oases may demonstrate a no-movement score and for the purpose of determining the focus of treatment, in this respeot, Seotlon B of the rating scale, Farts 1, 2, 8 and 9 were utilized to establish this objective. The example of Mr* L to be elaborated shortly, i s iillustrative of those oases where no-movement occurred either physloal or emotional* It was recognized that a pat-lent may deteriorate or break down during oase work treatment thus producing a downward movement score during the process* An effort was made to establish the reasons for deterior-ation through an analysis of the diagnostic evaluation of the oase, in relation to the techniques used in the solution of the problems presented by the patient* It was assumed, in this respeot, that the inoompetenoe of the worker may be a factor, as well as the severity of the disturbance presented* The example of Mr* R to be presently desoribed is the one patient who deteriorated under oase work treatment and i l l -ustrates a downward movement score* Upward Movement; Mr* Z, previously discussed in Chapter II, demon* 47 -st rated the highest upward movement score of the twenty-three patients studied sinoe he was able to make effective use of resources and relationships to change his behaviour patterns and to improve his social situation* He is charact-erized as presenting ailong-standing neurotic pattern of be-haviour which eventuated in almost complete personality dis-organization and the precipitation of an attack of rheumatoid arthritis through the emotional trauma of his wife's desert-Ion of him at the beginning of case work treatment* At the termination of services Mr* Z had been enabled to obtain suitable employment* his marital relations had improved* he was better able to oope with the domination of his mother and sister* and along with major physical improvement* with re-gard to disease, he was able to control exacerbations of symptoms* Most important of a l l * not only had he become aware of his basic conflict but he i s able to take the i n i t -iative in requesting and accepting help with personality structure through psychiatric assistance* The oase work techniques employed were environmental modification, psycho-logical support and clarification indicating a high degree of s k i l l on the part of the worker and a relatively strong ego on the part of Mr* Z* Downward Movement; Diagnostic evaluation indicated that Mr* R had long-standing basic problems of a psychoneurotic nature, hairing been characterized as such and hospitalized because of a psy-- 48 • ©hotio episode several years before oase work services were offered to Mm, while a patient in the Rheumatic Diseases Project* For many years deeply dependent upon his wife, he was unable to withstand the shock of her death and the loss of his employment occurring almost simultaneously, and deter-iorated to Irrationality and the beginning of rheumatoid arthritis which soon totally incapacitated him* Several months of treatment based on environmental and psychological support enabled Mr* R* to make better ad-justments to his sons and to begin to cope with his business affairs* This period of upward movement, however, did not continue and again this patient became psychotic, present-ing a picture of complete regression physically and emotion-ally with a slight hold on reality* Examination of the tech-niques employed in relationship to the problems brought to the attention of the case worker suggested that through the us e of interpretation of unconscious material in an effort to produce insight into his difficulties and an awareness of the nature and extent of his feelings, a psychotic reaction was precipitated* A perusal of the background of Mr* R* reveals a dependent person with a weak ego structure already once diag-nosed as psychoneurotic* It is known that the psychotic per-sonality i s unable to bear the pain of insight without a long period of ego strengthening, and then only, in a specially structured relationship, usually in the domain of the clinical psychiatrist* It can only he concluded that the case worker had overstepped the limits which her professional equipment had prescribed for her* Mo-Movement; Mr* L, age forty-one years, is a character disorder verging on the psychopathic who finds in his illness, the answer to his unconscious desire to be dependent due t o early childhood deprivations in the affectional area* Mr* L i s characterized as a sullen, unrealistic, controlling, complete-l y unresponsive person* He was referred for ease work treat-ment because of his lack of response to medical therapy and his disagreeable personality which made i t almost impossible for his Doctor and the Physiotherapist to continue treatment with him* Mr* L was unable to make adequate use either of medical or oase work services being totally engrossed in the disease of rheumatoid arthritis* He was unable to form any but the most superficial relationships to either the case-worker, other patients, the doctor or any other members of the staff* This limitation was so pronounced that he was almost totally friendless in the community as well* Narciss-is t i c in the extreme, he talked continously on the toplo of his arthritic condition and resented the medication given other patients for fear there might not be enough left to cure him* A glance at his past history made i t dear that Mr* 50 L had received so l i t t l e affection and so few of his early basic needs had been met, that i t was necessary for Mm to seek only satisfaction in himself* The fourth youngest of fourteen ohildren of a poor Welsh fisherman living in a bleak* sparsely populated section of the country* he was early ex-pected to shift for himself* At the age of twelve when he had reached the fourth grade* he was told by his harsh and domineering father* whom he greatly feared , that he was too stupid to continue at school and that he would have to go with him on fishing trips to row the boat* His mother* immersed in caring for her large brood, of children* had l i t t l e time for any of them and she i s remembered as a weak, worn-out woman* too tired to care very much how her son was faring* Mr* L worked for two years in close, but unpleasant contact with his father, who constantly undermined his self-confidence, and finally left home to be employed as a seaman* He was not happy i n this work but continued on the boats until his f irst attack of arthritis made i t necessary for him to leave* Soon after he began to recover, he married a woman much older than himself who mothered him as the spoiled boy she considered him to be* Such a marriage might have been the solution to Mr. L's effeminanoy needs, sinoe he enjoyed house-hold tasks and his dependency upon his wife's financial sup-port, but unable to relate on a warm enough level to satisy her maternal need, either through ohildren or himself, estran-gement soon took place* Mr* L was unable to oope with any of 51 bis problems and may be considered an inadequate personality* He can only revert to his arthritic condition for he has wall-ed himself off from everyone because he feels that he can count on no one but himself and "what's the use anyway, for no one really cares". In terms of relationship, he is able to give so l i t t l e that he cannot be helped with his emotional problems on a direct treatment level and i t is doubtful i f psycho-therapy would benefit him because of his basic inability to establish an enabling relationship. Direct treatment was attempted over a period of seven months with sixteen inter-views, including one with his wife. The duration of the dis-ease was six years, suggesting a chronic condition. Mr. L's severe personality problems and rejection of proffered case work services in any area over this length of time would seem to make regular face to face interviews with this patient, as was done in this oase, completely unjustifiable. Diagnostic evaluation over several interviews should have indicated the possibilities of treatment and the patient's inherent right to self-determination respected. Social diagnostic evaluation of Mr. R and Mr. L i n -dicates that these patients are untreatable except on a limited level of concrete environmental modification, i f even in this area in the oase of Mr. L$ in terms of ease work sk i l l s . Both are ineffective oases when the motive for referral by the doctor, that of gainful employment, is considered. Neither patient had the prerequisites for direct treatment - the cap-acity for self-help, the wish to change and to improve their situation. These elements in Mr* Z made i t possible for him not only to solve reality problems but to move on to help with his basic neurotic conflict. This may be called effective case work, since through a combination of environmental man-ipulation and direct interviewing treatment, Mr. Z was enabled to change his behaviour and attitudes within his social s i t -uation and therefore to function more constructively in a l l areas. Authorities on the subject of human behaviour have generally agreed that every so-called normal person or ment-ally healthy individual, may, i f unfavourable pressures are sufficiently numerous and persistent, display symptoms of ab-normal or deviate behaviour. There are irreducible basic human needs which may be considered; (1) the need to main-tain physical well-being, (2) the need to feel of worth and importance (the need for personal recognition), and (3) the need for security, for the love and affection of one's f e l l -ows, and for comfort and safety (a striving to have a warm and satisfying relationship with other people). Ho one of normal intelligence is able to confine his activities to the f u l -fillment of only one or two of these needs and maintain an integrated personality. Undue frustration or overbalance of 2 Thorpe, Louis P. and Barney Katz, Phd., The Psychology of  Abnormal Behaviour. The Ronald Press Company, Hew Yoric, 1948. these complementary needs produces neurotic, psychosomatic and other symptoms of maladjustment* Rheumatoid arthritis creates concrete problems for the individual afflicted with i t since i t is a disease usually of long duration, often creating severe deformity and occurr-ing as i t does, generally, at the productive years of l i f e * There is no doubt that such illness, with i t s real threat of dependency with consequent loss of self-esteem and the inev-itable new adjustments that must be made, such as change of employment, often a realignment of familial roles and curtail-ment of physical and sooial activity because of the very nature of the disease, superimposes a considerable burden upon the adaptative mechanisms of the personality* Dr. Weiss states that, "emotional stress under suoh conditions may so deplete the arthritic patient's normal defences that his capacity for adaptation to usual environmental stresses is lost. It is not to be wondered at that, in many advanced crippled oases, there is a ohronio psychological adaptation to the state of being orippled* 3 Medical treatment often includes hospitalization at the onset of the disease for a period of weeks or months and surgical procedures, and physiotherapy is instituted for the prevention of deformity or its correction* It, therefore, becomes important for the patient to establish within himself 3 Weiss, Edward and English, O.S*, Psycho somatic Medicine. Saunders, 1943* - 5 4 emotional adjustment to the requirements imposed by the dis-ease* Being compelled to suffer cannot help but arouse anger but the expression of i t may also be the outlet for long-standing grudges that the patient may otherwise have kept to himself* The almost universal stoicism and optimism noted throughout the twenty-three oases studied would suggest a chronic state of inhibited aggression or control of hostile impulses which would indioate a general predisposing person-ality factor* Emotional factors are expressed through a t t i t -udes* behaviour and verbalization* so that i t is possible for the oase worker to see the patient in his situation* as well as his problem* through these aonsoious feelings, needs and drives* The patient gives the meaning which the situation holds for him and this becomes the starting point for treat-ment* The Concepts of the Rating Scalet In order to obtain a more precise description of the patient's reaction to his illness than was available in the ease recordings, Section A, Health Evaluation of the Rating 4 Scale s i was devised to embrace a series of questions, with an extreme attitude at each end of each scale, for the purpose of arriving at the meaning of Illness to each patient and his feelings around It* It was assumed in this regard, that the patient would very likely reveal a pattern of behaviour in re-4 Appendix A* The Rating Seale* - 5 5 latlonshlp to his illness similar to that which he adopted in meeting other reality situations or problems* This assumption was substantiated* Since relief from the symptoms of rheumat-oid arthritis is often dramatic, due to cortisone therapy, the amount of improvement in the activity of the disease was con-sidered of possible importance as an ally in the strengthening of ego structure with the attendant result of a greater cap-acity to cope with confronting problems because of a new con-stellation of events* Section B, Evaluation of Casework Ser vice, parts 1 5 and 2, was designed to formulate essentially, the treatabil-i t y of the patient or client in terms of his capacity to make effective use of the base work relationship* In this respect the patient's ability to relate to people, to make decisions to alter his situation and to express his resentment at his situation enough to want to change or alter i t , were a l l con-sidered factors which made i t possible for him to make use of a oase work relationship in the solution of his problemse It included basically an evaluation of the strengths and cap-acities of the personality to accept help and some indication of the resistances to assistance* To help a patient express his feelings is a test of the case worker's s k i l l i n creating an enabling atmosphere 5 Ibid*, page 5 4 6 Appendix A* "The Rating Scale"« 56 since, i t i s possible to overcome resistances and to enable the patient to accept help* S k i l l , however, may be futile i f the inner and outer resources of the patient are meagre. Thus, an effort was made to measure the severity of the problem pre-sented and the prognosis for the success of direct treatment insofar as the patient consciously recognized his problem and 7 wanted help with i t . Problems within the skills of the case worker were considered concrete problems requiring practical services, such as, Information, job placement and other environmental situations. Also included were those where the patient was aware of personality difficulties creating problems for him, which could be modified through a case work relationship, such as difficulty in obtaining employment because of conflict with authority, marital discord etc., feelings around illness and in relationship to necessary medical regimens. Problems out-side the limits of case work techniques were considered those requiring psychotherapy for movement defined as "any inter-8 viewing procedure carried out by a psychiatrist". Suspected psychotic reactions were also assumed to require the services of a psychiatrist for movement. Treatment sometimes may be successful without a 7 Ibid, Section 6, Part 2, Subsection A,B, and 0., page 55. 8 Ooleman, Jules V . , M.D., "Distinguishing Between Psycho-therapy and Oasework", Principles and Techniques in Sooial  Oasework. Selected Articles, 1940-1950, Family Service Association of America. - 57 eonsoious desire for help, but, there i s much more chance of i t s success i f the patient is under stress, eager for help and able to talk about his problems* Treatment is powerless to deal with problem-creating forces whioh are not in some way brought into the case work relationship* Basic minima9 indicating the patient's capacity to make effective use of a oase work relationship with regard to direct treatment were established by the researcher, below which, this method was considered inappropriate* Tabulation of the results of the Bating Scale was done numerically for the purposes of simplification, the total score of both sections yielding the amount of movement for each patient and his capacity to make effective use of direct and indirect methods of ease work treatment* The norm at point three on each scale represented a total of thirty-eight points* ¥ha Patient's Ability to make oonstruatilveeUEsekof a casework relationship; Groups 1. 2 and 5* The twenty-three patients participating in the Rheumatoid Arthritis Series on Cortisone Therapy, Rheumatic 9 Appendix A, Section B, Page 2, Subsection 1, A, B, 0* Basio Minima: A* W A R M T M: A relationship warm enough to permit generally relaxed discussion around oonorete problems* B* DEPENDENCY: The patient is comfortable enough with his own dependency needs to be able to share and accept the case work-er's participation in making decisions and resolving problems which arise around the provision of oonorete service* 6* HOSTILITYs The patient is secure enough that he is free to express hostility overtly when circumstances arise which give him good reason to be angry* Diseases Project, studied, were divided Into three groups according to the severity of the problem presented and the oase work relationship established with them for the purposes of treatment at the termination of oase work services* The three divisions were designated as Group 1, those patients having a "good relationship—generally relaxed dis-cussion around illness and service, " whose problems were rated by the oase worker as "rooted in defense mechanisms but capable of change with Intensive (direct treatment) case work relationship"; Group 2, those with a "very olose relationship— -discusses most problems freely and whose problems were rated as "very deep-rooted, requiring psychotherapy for movement, including suspected psychotic reaction"; Group 3, represented those patients who had a "very superficial relationship" and whose problems were considered "superficial due chiefly to lack of information", and "chiefly reaction to unusual environmental stress"* 1 1 Considered from the viewpoint of the primary foous of the two methods of treatment employed in the services offer-ed to these groups the following conclusions were arrived ats The Effectiveness of Direct Treatment: In nineteen oases direct treatment was emphasized 10 Refer to Chart II - Comparative Scores of Movement, Achievement of Goals and Criteria - Appendix B • 11 Appendix A* "A Rating Scale", Sections, Part 1, Subsect-ions A, B, C* Part 2, Subsection A* 59 -with the Rating Scale, indicating that only six patients had the oapaoity to make effective use of this service* It may be noted that, according to criteria of treatability previous-l y outlined, in Chapter III nine patients (including Group 1) f e l l within this category, although latitude in determining treatability accounted for three doubtful diagnostic eval-uations, according to the conditions applied* These patients averaged a total of sixteen interviews over a period of eight months and ranged from two interviews over a period of two months to forty interviews during a ten month period* Consid-ering the small degree of movement achieved, i t may well be wondered at, in view of the diagnostic evaluation, why this group of patients was not given a more intensive course of treatment* More service was given to Group 2 than either Group 1 or Group 3, who averaged thirty interviews over a period of ten months, with a scatter from three interviews to forty-five interviews over a twelve month period* It i s difficult to understand the emphasis upon face-to-faoe interviewing, direct treatment, with these pat-ients, obviously considered by the oase workers beyond their scope of treatment, except on an experimental basis* Movement according to the Rating Scale was so small that i t could be barely rated* Group 3, presented a more realistic approach to treatment aimed at basic change within the personality struct-60 -lire of the individual patients* This group averaged sixteen Interviews over a period of seven months, with a scatter of two interviews over a two month period to forty-two interviews over a twelve month period* Physical Improvement was made in a l l eases, exclus-ive of three patients each, in Group 2 and Group 3 respect-i v e l y * Average ages and duration of the disease of rheum-atoid arthritis for each group was as follows: Group 1 - ages 83 years to 49 years, included four males and two females* Duration of disease 8 years* Group 8 - ages 89 years to 44 years, included five males and two females* Duration of disease 7 years* Gyoun 3 - ages 33 years to 49 years, included four males and six females* Duration of disease 9 years* The long duration of rheumatoid arthritis in each ease would suggest a chronic state of illness with a l l the psychological implications of any ohronlo condition* Physical improvement seemed to make no appreciable change in the pat-ient's capacity to make effeotlve use of ease work services, in spite of the fact, that seventeen patients were physically rehabilitated enough to be employable, eight on a full-time and nine on a part-time basis* Five of these patients were housewives enabled to care for their homes* It is self-evident that these patients had to be redirected to lighter physical and less skilled labor than hitherto performed* It can only be concluded, therefore, that the sev-61 -erity of the problems presented by seventeen of the twenty-three patients participating in the Rheumatic Diseases Project, were sueh that they were unable to make constructive use of a cor-rective case work relationship* There is no doubt that treat-ment i s powerless to deal with problem-creating forces which are not in some way brought into the oasework relationship* It i s * indeed* questionable* i f the primary focus of the ease worker should eontinue to be direct treatment but rather that her s k i l l and effort should be redirected to a group of patients who have the capacity to make use of such methods* The Effectiveness of Indirect Treatments Included in the indirect method of oase work treat-ment i s the goal of rehabilitation as defined by the Clinical Research Committee responsible for the Rheumatic DiseaseslPre-ject, "physical rehabilitation and gainful employment"* The treatment ©T oase work goals listed <Jm the Rating 1 2 Scale, f e l l into five categories, and the number of patients receiving concrete services and help with reality problems were as follows: 1* Job placement and vocational counselling - 9 patients* 2* Help in accepting Illness, i t s limitations and medical treatment - 15 patients* 3* Help in relieving anxiety and tension in relation to i l l -ness and fear of financial and personal dependency - 10 patients* 4* Help in the resolution of marital conflict or the family situation or problems - 8 patients* 12 Appendix A* Section B, Part 1, and Section B, Part 2* 3* The development of self-awareness in its relationship to illness and personality difficulties - 3 patients* As oan be seen, this group received help i n various combinations of service, with the greatest amount of assist-ance being given in the f i r s t three categories* The percent-i l e average scores according to the degree to which treatment goals were achieved as rated by the oase workers were as 13 follows: 1* Job placement and vocational counselling - 29 # achievement* 2* Help in the acceptance of illness, i t s limitations and medical treatment - 57*3$ achievement* 3* Help in relieving anxiety and tension in relation to i l l ness and fear of financial and personal dependency - 48$ achievement* 4* Help in the resolution of marital conflict or the family situation or problems - 50$ achievement* 5* The development of self-awareness in i t s relationship to Illness and personality difficulties - 71.0$ achievement* The degree to which the workers felt that case work was responsible for the upward movement shown in these areas, as averaged, is 22.74$, This would indicate, again, that the severity of the basic emotional problems encountered by the oase worker in this group of patients, were such, as to pre-clude a high rate of change in any area where service was offered* The seven oases indicating a primary focus of direct treatment made the largest gains, in terms of the goals of treatment aimed at by the case worker, averaging 68*1$ aehieve-13 Appendix A* Section B, Part 3, - 63 -ment of goals, with oase work responsibility averaged at 37*8$* Goals 1, 2 and 3 were emphasized by oase workers with nine of the patients in this group, with one falling within goals 4 and 5 as well* fen of the thirteen oases requiring psychotherapy for movement had goals 1, 2 and 3 as the oase worker's aim, with two suspected psychotic reactions falling within these goals, indicating the use of social and support-ive therapy* One of the latter had goals 4 and 5 as his case worker's aim* Since no consideration was given by the Clinical Research Committee responsible for the selection of patients for the Rheumatic Diseases Project, to personality factors, as determinants in the level of rehabilitation of each patient, the results of the program, from the viewpoint of gainful em-ployment, are discouraging, in contrast to the physical im-provement made* The case worker in her role of vocational guidance assisted five male patients to obtain employment out of a total of thirteen physically able to work* light of these men made major physical gains* When i t is remembered, however, that diagnostio evaluation demonstrated that sixteen patients were able to make possible use of indirect treatment, with only a possible mnylmum of nine patients able to make effective use of such services, such results are understand-able* Seven of the twenty-three cases were incapable of making effective use of either type of treatment acoording to the oriteria applied* - 64 It can only be oonoluded, when i t is noted that in twelve of the sixteen oases direct treatment was the primary foous, that the role of the case worker as a provider of con-crete services has been neglected* This is illustrated by the faot, that of the eight oases where marital problems were listed as a goal of case work treatment, only seven interviews were held with relatives, and in only two oases, were refer-rals made to other agencies offering family services* Con-tacts by the case worker with employers or agencies offering specialized employment services were negligible* It i s obvious throughout, on one hand that the caseworker has attempted to deal with emotional problems beyond the scope of present sooial work techniques and neglected the problems she is equip-ped to work with* This accounts for the general lack of up-ward movement of the patients on the Rheumatic Diseases Pro-ject* On the other hand, i t is apparent that emotional d i f f -iculties beyond the scope of oasework skills have been referred to her by the doctor* The lack of understanding and the aware-ness of the contribution she has to make by the medical pro-fession and the sooial worker herself is demonstrated by the ineffectiveness of the oase work services offered to the Rheumatoid Arthritis patients bn the Project. Such breakdowns in the team approach to rehabilit-ation are responsible for the patients inability to make con-structive use of those services they are capable of responding to in the majority of oases* Characteristic personality 65 patterns desoribed have olarified the difficulties of a chronic disease, with a l l that that term implies, in conjunction with severe emotional problems* There Is a real need for the soo-i a l worker to determine her area of competence on the solid foundation of sooial diagnostic evaluation i f she is to make her services appropriate and effective* CHAPTER -Y Toward. Maximum Helpfulness The patient sets the pace for his rehabilitation and in this study i t cannot be emphasized too strongly, that where case work treatment goals were current problems and con-crete services, their achievement was relatively high* The case of Mrs. 0 exemplifies a realistic approaoh to treatment and the use of indirect methods. The Case of Mrs. 0. Mrs. C, a young married woman of thirty-six years, with two school-age children, was able to respond to case work treatment when i t was offered to her and to take i n i t -iative in requesting help with concrete or praotioal problems, she became aware of, through an enabling relationship. She did not believe in talking about her feelings "for fear people would oonsider her a bore", had exaggerated feelings of duty and a nagging sense of responsibility. With an acute con-science, she was a controlling person with many nervous manner-isms, so f u l l of tension and anxiety that during interviews she was often on the verge of tears and was extremely guarded in discussion. Her husband, a salesman, was away from home a great part of the time so the total responsibility for her children f e l l upon her shoulders and she nagged at them con-sistently, creating within her family an atmosphere of tension and unhappiness. - 67 -Vaguely aware, at f i r s t , that something was the matter with her attitudes, she was able to move toward an under-standing of the emotional factors in her illness and to try to work through her problems• Mrs. 6's first attack of rheumatoid arthritis had occurred at the birth of her second child* She did not wish added responsibility and dependency but felt guilty because of her rejection of this l i t t l e g i r l * An aged aunt who had raised her whom she deeply resented, complicated the situation again* The old lady needed care and further emotions of guilt were aroused because Mrs* G did not wish to have her aunt in her home; thus were created more inner tension and a second arth-r i t i c attack* Her own unmet needs for dependency had stirred up conflict whioh had long ago become deep-rooted in defence mechanisms noted in her exaggerated sense of responsibility and extreme control, with illness again a protection* Her past history illustrates the accumulative effect of many factors eventuating in chronic disease* Mrs* G was the second child in a family of four and had taken responsibility for her sisters and brothers at an early age* Her father was alcoholic and after considerable marital conflict deserted the family when she was about six years of age* Her mother was bedridden for the last three years of her l i f e , dying when Mrs* C was ten years of age* There-upon, she was sent to live with the aunt previously mentioned, who was very strict and overworked her considerably* She left - 68 -her aunt's home at seventeen years of age, and was employed as a domestic until her marriage. Supportive therapy enabled Mrs. C to express her hostility towards her Aunt and to accept her feelings around this area. She has been helped to be more comfortable with her dependency needs and to move from relating on a very superfic-i a l and well guarded level to a good relationship with the oase worker and generally relaxed discussion around illness and service. Treatment has enabled her to be less anxious to the point of giving up some nervous mannerisms, and to make a be-ginning in the direction of more satisfying adaptations with-in her environment. Mrs • 0*s basic personality problems have been untouched, but she i s more comfortable within her i l l -ness, and because she has the capacity to relate she i s able to accept help in other aveas of current problems with her children and her finances and to reach for i t as her awareness increases. Oase work has continued with Mrs. C over a period of twelve months and sixteen interviews. She has made major physioal improvement within this time under medical treatment, the duration of the disease being six years. This oase along with the others previously describ-ed exemplify patterns of personality whioh appear typical of the rheumatoid arthritic patient. The need to control, the rigidity of defences and the deep dependency needs whioh cannot be admitted to consciousness result in an almost compulsive person. The seventeen patients who were listed as requiring - 69 -psychotherapy for movement f e l l between Mr. L's personality characteristics and Mrs. C, again forming the patterns out-lined, hut in varying degrees. Many did not have the eapaeity to relate or the desire for help that Mrs. 0 had and yet were not so extreme in their rejection of people as Mr. L was. I t can readily be seen that ease work must be a long term, con-tinuing process with these patients, for defences are so well established, and ability to relate so limited that a strong supportive relationship is necessary for even the most super-f i c i a l upward movement, quite apart from basic change in per-sonality structure. It i s doubtful i f available casework re-geuroes can go beyond assisting the pa tlent to be more com-fortable within his illness and the provision of concrete en-vironmental services and help with practical problems. Limitations of the Treatment Role of the Sooial Worker: Limitations are placed upon the treatment role of the case worker by the nature of the mental or psychological dysfunctioning. Psychoses for the most part present an absol-ute limit, while neurotic maladjustments can be influenced under general criteria such as the severity of the disturbance, the length of i t * s duration and the client's age.1 It was evident that the younger patients whose per-sonalities were basically healthy showed the greatest capac-ity to use case work services to make better adaptations, and 1 Appendix B. Refer to Chart III, Mr. Z; Chart IV, Mrs. B; and Chart V, Miss M. - 70 offered the best possibilities for rehabilitation* Those whose ego structures were weak, such as prepsychotic, psychotic, Infantile character structures and severe neurotics, oould be protected from undue pressure which could contribute to a break-down, and were sometimes helped to grow through the experien-ce of more adequate functioning* This, of course, raises the question whether case work treatment should be geared to a program of the prevention of breakdown or to that of dynamio rehabilitation* Both concepts are valid from the viewpoint of sooial work, but with limited services the necessity for a definite goal with a well defined agency function would seem to be appropriate* It may not be amiss to stress the point that the largest amount of effort and the greatest number of face to faoe interviews were concentrated upon those seventeen patients whose basic personality problems were severe enough to require psychotherapy for upward change or movement* It is obvious that supportive therapy, rather than a deeper level of relationship aimed at change in behavior, is the only justifiable process with these oases since i t is a limited treatment and designed to maintain present strengths* The six patients whose problems were severe but who came within the scope of intensive case work may well have benefitted from the use of direct treatment, but i t is noted that to less than half was this treatment made available* This group was accorded, on the average, - 71 l i t t l e better than two interviews per month over a period of seven months* It would seem, therefore, that i f selective ease work must be practiced, as i s indicated, then greater emphasis should be placed on those patients able to use a greater depth of relationship to change behavior than on those whose basic personality problems cannot be modified except by the specialized services of a psychotherapist. This i s most glaringly apparent in the total lack of ease work treatment offered to the children or their families participating in the Rheumatic Diseases Project, Juvenile Rheumatoid Arthritis Series. The fact that none of them were referred by their doctors would indicate a serious dearth of interpretation by the social worker and of understanding of the emotional comp-lications of illness on the part of the physician. It cannot be denied that the majority of the twenty-three patients studied f a l l within the climacteric age group where the instincts might be expected to stimulate a new but last climax and where the ego has less chance to prevail and has difficulty in keeping balance. The generalized picture obtained from recording on f i l e would lead one to believe that the current distress has i t s roots in long-standing maladjust-ments, not just in present reality pressures. This in turn suggests that the Rheumatic Diseases Project patients are poor prospects for rehabilitation in any sense but the physical. The problem of oase work i s some personal or environ-mental unsettlement, and i t s aim a new settlement. From this - 72 -viewpoint only six patients of the twenty-three were able to make a new settlement, while the remaining seventeen patients have yielded to unsurmountahle harriers to the realization of their desires. Vocational guidance and the Sooial Worker; "Return to useful employment" was part of the social thinking of the Clinical Research Committee who envisioned the Cortisone experiment with rheumatoid arthritis patients selected from the low-income brackets. Job placement or vocat-ional counselling was considered the case worker's function, and i t may be noted in this respect that a l l those who were medically f i t to work, either f u l l time or part time, includ-ing eight men and two women, were referred to the social worker on this basis. Of the eight men, four were able to work part time with jobs available for two of them; and four were able to work f u l l time, with jobs available for two. The two women both had employment, and sinoe the remaining eight women were housewives with families they would not be taking gainful em-ployment in any oase. Five of these were able to do their housework part time, while three women had improved enough to do i t f u l l time. It should be stated at this point that vocational guidance of the rheumatoid arthritis patient is a particular problem for the sooial worker because of the deformities suf-fered by the majority of them whioh requires redirection into lighter employment, with few resources available for retrain-- 73 -ing in the community, The sooial worker i s , consequently, dependent upon the individual employer for job placement, and he usually sees his prospective employee in terms of dollars and cents and whether or not i t is profitable to employ a handicapped person* The sooial worker must also take into account the disease itself, which imposes limitations in plan-ning for the patients who are often subject to remissions of symptoms while on cortisone and exacerbations when off medi-cation, which may mean they are not ready for employment at the time the job is available for them* Thus she must wait to be oertain of the physical improvement before she begins to find a suitable plaoement for the patient* The age factor also enters into the total picture, since most of the patients in the male group are between forty-one and forty-nine years and have been totally unemployed over a period of several years* Only those few employers who have types of business where an older, partially disabled man oan be satisfactorily fitted in, will consider them* Competition, with the preference given in most i n -dustries to the handicapped Seoond World War veteran, also, makes vocational plaoement more difficult for the sooial work-er* Emphasis has been placed upon the use of the resources of the Special Placement Division of the National Employment Ser-vice by the Society, which would seem to be a sound method of coping with the problem* Even so, the employment of five men and two women out of a total of thirteen employables, in view 74 -of the added efforts of tthe sooial worker, is a matter of concern* Sheltered workshops geared to vocational training may well he the answer in this respect, in combination with pressure exerted upon governmental departments and in-dustry* Expansion of the program to include case work serioes to children with rheumatoid arthritis and their families* taking into oonderation their potential employability and the prevention of human wastage, may well be one step toward easing this situation in the future. It is obvious that the emphasis of the program has been to "get the arthritio patient back to work"* There is a pressing need for a dynamic philosophy of rehabilitation in the sense of Kenneth Hamilton's definition which includes gainful employment* The ultimate aim of rehabilitation should be,"the restoration of the handicapped (individual) to the fullest physical,i mental, sooial, vocational and 3 economic usefulness of which they are capable*" It might be said that six patients of the group studied are well on their way to being rehabilitated* The 2 Hamilton, Kenneth A*, Counselling the Handicapped in the Re- habilitation Process. Chapter 1, A General View, Definition of Terms* "Rehabilitation i s creative. It aims to define, develop and utilize the assets of the individual. Its purpose i s to re-store competitive ability, independence, and self-determination. It seeks to utilize a l l the available resources, both within the Individual and within the community, toward this end .P. Ronald Press, New York, 1946. 3 "Symposium of National Counoil on Rehabilitation", New York. May 25, 1942. Definition adopted by the National. Council. ' - 75 remaining seventeen may nave been prevented from further deterioration through the provision of services and a strong supportive oase work relationship* It therefore becomes ap-parent that from the aspect of social rehabilitation the Rheum-atic Diseases Project, has been unsuccessful* From the view-point of medical research and an experiment in the limitations of oase work treatment with a seleot group of patients i t has been an unqualified success* There i s no doubt that the prevention of family dis-ruption and individual breakdown i s a sooial economy, compared with institutionalization and the plaoement of children* These patients are well enough to live in the community and part-icipate in certain aspects of adequate sooial functioning• There i s , however, a strong case for a preventive program for children and young adults, rather than the present concentrat-ion on the chronic older adult patient* A concrete philosophy of rehabilitation is necessary, i f the goal i s thought of in the total sense, and not merely from the physical aspect* The decision has to be made as to whether the program i s to be the prevention of social and fam-i l y breakdown in the chronic oase, or directed to improved functioning of the individual patient through changes in basic personality patterns* Adequate sooial diagnosis of the prob-lems presented by the patients should be made before they are taken on the Project* Such an evaluation would include the severity of the emotional disturbances, their duration, an - 76 -evaluation of ego strengths, the stage of maturity of the pat-ient and his ability to grow through a casework process. Team Planning for Maximum Helpfulness; Some general Conclusions: Sinoe the social worker is a specialist in this field she should be included, at least in an advisory oapaoity, on the Clinical Research Committee selecting the rheumatoid arthritis candidates for cortisone therapy. The sooial worker has a real contribution to make with the chronic patient who has advanced to a stage of rigidity, in both disease: process and emotional attitudes, so that the condition has become irreversible. Her understanding of the emotional elements can gssist the physician to distinguish these patients from those who are more treatable, and to determine the appropriate level of medical and sooial treatment. For patients with neurotic tendencies, the concentra-tion upon physical i l l s , examinations, frequent clinic v i s i t s , may produce greater rather than less disability. A more dir-ectly palliative and alleviatlve type of treatment would often, not only be the most appropriate treatment for such patients, but would also release effort for work with more hopeful oases where treatment must be more limited and to contribute a medical-social perspective to the program of medical care. These contributions that the social worker i s able to make, however, must rest on a firm base of sound practice in individual oases. The social worker must be clear as to 78 her appropriate scope and focus* Speciflo conclusions to he drawn from this study are that more emphasis should he placed on sooial diagnosis, screening out those patients unable to be rehabilitated and concentrating effort upon those who are able to benefit by the program offered* Evaluation ©f the patient's problem over a period of three to five interviews should i n -dicate the inherent possibilities of the primary focus of treat-ment where difficulties are apparent* Preliminary survey of the group problems that oan be dealt with within the resources available* in combination with individual assessment much on the lines followed in psychiatric screening, would cut down on the numbers taken on the Rheumatic Diseases Project whose mal-a&gpta&ions are untreatable by the oase worker* The Oase of Mrs* D. A Planned Approaoh to Treatment; An example of realistic diagnostic evaluation may be found in the oase of Mrs* D, age thirty-five years, recently referred from an outside point to the Society by her dootor for further medioal treatment under the Rheumatoid Arthritis Series, His referral suggested that poor home relationships were con-tributing to her illness* Plans were made in conference between the medical director and the sooial counsellor to have Mrs. D admitted to the Western Rehabilitation Centre for therapy* These were care-fully explained to this patient by the Medioal Director and the total treatment program was interpreted, not only from the view-point of the physical aspects but including in the etiology of rheumatoid arthritis the effects of stress and worry upon the oourse of the disease* The suggestion was made that case work services were available to assist her in the solution of problems with which she wished help* Several interviews with Mrs* D confirmed the tent-ative diagnosis of the case worker that this patient was f u l l of anxiety, strongly defensive and reacting negatively to pressures and heavy responsibilities at home, with four young children to care for and an ailing husband unable to provide adequate economic resources for his family* Marital conflict, overwork at a job beyond her physical strength to assist f i n -ancially to pay for the home and provide for the children, had a l l conspired to break down Mrs* D's health* Over compensation through a cheerful smiling front, had kept her at work, in spite of intense suffering* During f i r s t contacts with the case worker she was only able to relate on a superficial lev-el, but demonstrated a capacity to move toward warmth with a desire for help with concrete problems concerning future plans* Positive feelings toward her family and a real determination to get well indicated a fundamentally healthy personality* Reassessment of the case after three interviews with clarification of the services case work oould offer verified the fact that Mrs* D oould accept and wanted help. In her own words she expressed herself as follows: Tou get too close to a problem when you are thinking about i t yourself. It helps to have another person's viewpoint and to know what some-80 -one else thinks* You get thinking you're about the size of an niokle, and then when you talk i t over with someone you get reassured*n It was apparent that the oase worker had focussed on immediate problems and evaluated the ego strengths that Mrs* D had to accomplish their solution* Severe environmental stress along with illness had weakened Mrs* D's considerable strengths* The oase worker, however, using supportive techniques did est-ablish an enabling relationship, which resulted in a positive reaction to total treatment and Mrs* D's recognition of part of her basic personality problem, an unconscious need to suffer, and self sacrifice expressed simply by her, "I know I've always kept up longer than I should have". It need not perhaps be pointed out that a well pre-pared referral for case work services from the Doctor, a team approach, with realistic diagnostic evaluation of sooial problems has made i t possible for Mrs. D to be rehabilitated within her maximum capacity. Planning the Reality of the Team Approach: Because of limited resouroes, i t is obvious that i t i s impossible to treat everyone, and a team approach i s necessary for the most effective use of the time, effort and s k i l l now utilized. Emphasis upon diagnosis before the patient is taken on the Project, and i f this is impossible, then at least, regular conferences with the doctor before the case is referred for oase work services i s necessary. This would en-able the social worker to interpret her role and the functions - 81 ~ she can implement in relation to the problems presented. Evaluation after a period of time, in conjunction with the doc-tor, would reinforce his understanding of the impact of emot-ional difficulties as they affect the giving and receiving of casework services, whether they heron a eo&orete problem level, or with deeper personality difficulties. This of course, would presuppose an awareness on the doctor's part of his role as head of the team, and his willingness to have regular confer-ences with the social worker to consider the patient as a whole person. Another great gap in the team approach is found with the physiotherapist, who plays a major role in her relation-ship to the patient, and should be encouraged to make more imaginative use of her s k i l l in terms of -varying monotonous routines through creative use of methods. She sees- him regular-ly and gives him much support in his battle with remedial and preventive regimens. She works closely with the doctor, but with the use of rigid routines may reinforce the patients a l -ready rigid personality patterns which the case worker may be helping him relax as part of her treatment plan. The physio-therapist should be included in the total team planning for she has much to offer in terms of knowledge of the patients a t t i t -ude to his illness. Conferences made up of the three members of the staff who are carrying out the program of rehabilitation seem essential to make effective use of the various skills i n -volved. 8£ -Apart from regular conferences concerning individual oases within the Vancouver General Hospital, St, Pauls*s Hosp-i t a l and the Canadian Arithritis and Rheumatism Society, a pool-ing of knowledge and experience would he of benefit in periodic meetings of the total groups involved in working with the arthritio patients, including the doctors and a l l staff members contributing their services to the program* Such meetings would not only stimulate Interest, but solutions to common grobjlems.acould be co-operatively worked out* Individual interpretation to individual doctors and physiotherapists by the sooial worker is valuable, but there i s s t i l l a need for concerted action so that a l l may function to capacity for the benefit of the patient* It might also be suggested, (in view of the seventeen members of the Rheumatoid Arthritis Series who are unable to make effeotive use of direct treatment) i f i t is felt that help with their problems should be included in the program set up by the Society, that the case worker limit her time and effort to social and supportive therapy* The necessary s k i l l to work with these patients might be obtained through the services of a psychiatrist psychoanalytically oriented. Con-sultative services are valuable, but unless such oases are carried by the sooial worker under the psyohiatrist's regular supervision upward change can be expected to be nebulous* It is recognized that resources in this field are extremely lim-ited, and again the common problem would have to be worked out 83 -through conferences designed toward a solution of such d i f f -iculties with the psychiatrist. The ideal situation, of course, would be to have these oases undertaken by a staff psychiat-r i s t , but in lieu of this, oases carried by the sooial worker under his continuing supervision and consultation would make services more effective. The inclusion of a psyohiatrlst i n an advisory capacity on the Clinical Research Committee sel-ecting candidates for the Rheumatic Diseases Project would facilitate the choice of those able to benefit to the greatest extent i n a program of total rehabilitation. From the oaseworker*s viewpoint, i t is obvious that the burden of interpretation of the needs of the patient to the doctor and the physiotherapist, is hers. With current problems of understaffirig and heavy caseloads i t is important that she be given the opportunity to be more selective in the oases carried. This Implies more s k i l l f u l diagnostic techniques, and the ability to see the program as a whole rather than from the viewpoint only of the individual patient. With the distrib-ution of patients throughout three separate centres i t is necessary to provide some means of getting together for the purpose of making more effective use of oase work s k i l l s . Regular conferences of a l l the sooial workers would assist in this respect, for i t i s important to share a common phllosopy and understanding of what the oase worker has to offer the arthritic patient within the medioal setting. The time of a social worker employed for the purpose of co-ordinating efforts - 84 -in this direction would toe well spent. It is noteworthy that in only eight cases of the twenty-three studied were relatives, husbands and wives of the patients interviewed, with whom there were a total of thirteen interviews, varying from one to three. It has also been indicated throughout the material analysed that concrete problems and practical services have not been the oase worker's major consideration. Since patients Indeed have families, i t i s suggested that the family rather than the single patient should be the unit of focus. More emphasis upon family diag-nosis might assit the patient to be more comfortable within his dependency* particularly in view of the marital problems presented by the group* Again this means that the patient must be seen as a whole person in a l l his human relationships, for support extended to other members of the family unit often leads to healthier family relationships. It may be assumed, also, that physical improvement does account for superfical upward movement in the ability to accept services, since oase work does not take the total credit* Because i t i s noted that effort has chiefly been directed to services relating to the illness i t s e l f and i t s aoeptance, i t i s obvious that the disease beoomes a ohronio factor whioh cannot be ignored in the oase work process* The illness imposes certain limitations whioh must be given priority consideration, and demands from the social worker a function essentially that of enabling the patient to use what the doctor has to offer and 85 to focus upon effecting change in the environment, as the pat-ient's opportunity to maintain his balance may be either en-hanced or seriously limited by the influence of factors within i t * The chronic nature of the disease of rheumatoid arthritis and i t s often long duration with a l l the implications of re-duced ego strengths, feelings of inadequacy and lack of self-esteem which a chronic condition presents, makes i t essential that the social workers should oonsider that they are making a significant contribution to the well-being of the patient through s k i l l f u l manipulation of the environment, rather than feeling that such services are of lesser importance because they are foeussed upon effecting change in the environment. Understanding the problem of basic adjustment with which the patient is dealing is a responsibility in order that suoh services, around employment, for example, may bring max-imum helpfulness to the patient. The dynamic significance of such environmental services are unquestionable, and need not be relagated to a minor position among the various ways of giving help. Many patients, as has been shown in this study, do need help in mobilizing their inner and outer resources in order to accommodate themselves to the real threat to seourity which illness brings. Emotional support, although the patient may not consciously be aware of his need for i t , to help him maintain his total economy on a basis less oostly to himself and others, i s indeed a significant contribution of the case worker. 86 -Equally important, however, is a thorough knowledge and use of material resources available* There is a need to hold the patient within the appropriate area in whioh he and the sooial worker can fruitfully work together, and i f he is unable to make progress there, to realize that the problem is beyond medioal sooial oase work. This again brings in the problem of referral whioh has already been dealt with, but i t should be pointed out that four-teen oases out of twenty-three did not know that they were being referred to the case worker, nor why. The other nine oases had a vague idea that i t was in connection with job placement and other practical services. Preparation by the doctor in a l l but three oases indicated his lack of awareness of the total function-ing of the social worker. He sees her role as a vocational counsellor and the provider of oonorete servioes, and there is a necessity for a better understanding of oase work treatment on his part. Knowledge of her skills would also be f a c i l i t -ated through round table discussion and a co-ordination of effort on behalf of the patient. It is suggested that a total treatment plan should be worked out for eaoh individual at the point he i s oonsidered for the Project with enough flex i b i l i t y allowed to suit his varying needs as treatment progresses. Revaluation of the plan in regular conferences when needed would be of value. To recapitulate, i t can only be said from the view-point of this study of the rheumatoid arthritic patients part-87 -loipating in the Rheumatic Diseases Project, that the great lack has "been the team approaoh to the problem of their rehab-ilation* The sooial worker has a philosophy and techniques to accomplish this goal, not shared for the most part by the Clinical Research Committee sponsoring the experiment* There is a need for a more clearly focussed program, based on a well-defined goal of rehabilitation, approached through concerted action by staff members* The doctor must assume his f u l l res-ponsibility as head of the team, for the patient is his client, to make most effective use of the services the oase worker has to offer as a member of the team* She has demonstrated that she has much to contribute, both from the aspect of concrete services and deeper emotional distress* However, in order to make the most effeotive use of her treatment s k i l l s i t is nec-essary for her to have the co-operation and understanding of the medioal profession, to make a coordinated effort to give total service to a whole patient* Struo turing the program cannot be her complete responsibility within this medioal setting, and there must be mutual agreement as to the goal to be aohieved and the methods of accomplishment. The team's dilemma as now best to serve the patient, oan be resolved by team work* Case workers, however, must accept the philosophy that oase work is indeed "the sum of a l l activities and ser-vices directed towards helping an individual with his problem".' 4 Hamilton, Gordon, Theory and Praotioe of Sooial Case Work 2nd ed*, Revis ed, Columbia University Press, 1951* 88 -A P P E N D I X A. - 89 -> A RATING SCALE FOR EVALUATING THE SUCCESS OF CASE WORK SERVICED OFFERED to RHEUMATOID ARTHRITIS PATIENTS File No. Children Sex Age Age Marital Status Sex 4, ~ ! A - HEALTH EVALUATION 1. Date of onset of a r t h r i t i s , or duration of illness 2. Dates of hospitalization, i f any, or duration of stay in treatment centre_ • On scales below, indicate by nX" the status of the patient at beginning of case work servioe, a»d bv "0" status of the patient at end of case work service. "K/O" means no change... 3. ACTIVITY! r—~ • lactive DEGREE OF INCAPACITY OR HANDICAP; (1) Bedridden (2) Wheel Chair (3) Able to walk about (4) Able io work: Full time (Housework or job)Part time (5) Is there a job available to go to? - Yes • No 5 . FOLLOWING MEDICAL INSTRUCTIONS;. —7 Arrested 7 Active PARTS OF BODY AFFECTED; » .. ... » o V 0 « • * . . Arms : Legs Other parts • • • • • o » • • » • « • • tt • • • 0 0 • Follows ri g i d l y 6. ATTITUDE. TO ILLNESS; j , y, Generally follows 7 -7 Extremely unrealistic (e.g. denies, exaggerates, extreme anxiety or rage) 7. DESIRE TO RECOVER; 7 7 -*~ Moderately r e a l i s t i c (e.g. generally satis-factory-difficulty in one or two areas) 7 Constantly breaks routine 7 Quite r e a l i s t i c /— Tt 7—7 7 7"—— 7. Determined to Some ambivalence Seems' deter-recover regardless of generally healthy mined t o , k i l l d i f f i c u l t i e s attitude herself or himself B - EVALUATION OF CASE WORK SERVICE Number of interviews with patient...........,..-.........,*...,.........,.... Number of months treated «•...... Number of interviews with wife, husband or relatives. Date of change of case worker ( i f any)......,............ ......... - 8 -1. Nature of relationship with base worker* (indicate separately for father, mother and sooial worker) "X" indicates status at beginning of service, "0" indioates status &t end of service, A, WARMTH| 7 Very superficial relationship B. DEPENDENCY* 7 7 7 ~ 7 — — Good relationship generally relaxed,discussion around illness and service /' ./• 7 Very close relation-ship, discusses most problems freely. / —' T Leaves a l l decisions to case worker 7 ^ T Participates in making decisions on flexible basis 7 Terribly threat-ened by an invasion of independence. 0, 'HOSTILITY! 2. 7 Continuous barrage of h o s t i l i t y 7 — 7 —7 T~ No overt expression Free expression of ho s t i l i t y on rea l i s t i c basis In the chart following, you are askeds a. to indicate ALL MAJOR problems given casework consideration, b. to designate as client, each person with whom the problem was discussed, o, to estimate the seriousness of the problem to that particular client, d. to evaluate numerically the progress made in the solution of each problem. A» SEVERITY OF THE PROBLEM? / 7 7 7 — 7 Superficial, due Chiefly reaction Rooted in defence Very deep rooted Suspected chiefly to lack * f to unusual envir- mechanisms but requiring psycho-psychotic 1 information onmental stress oapable of change therapy for move-reaction with intensive case. ment work relationship B, CLIENT AWARENESS OF.THE PROBLEM: 7 Quite aware OM DESIRE FOR HELPI T 7 Able to face with case work help T - . / ^ Takes i n i t i a t i v e in asking for help D. MOVEMENT» T 7 Able to accept help when i t is offered r T 7 Completely un-aware even when brought to his or her. attention* 7 Quite unable to accept help i n any area. Client completely immobilized or disorganized by problem —7 " 7 Problem not basically resol-ved, but under control ~ 7 Problem completely resolved, AREA OP DIFFICULTY -3-Client A Severity B Aware f rim From ness "CO To e Desire for Help D Movement From To From To Reaction to illness Reaction to limitations »f service Relationship with S. W. Marital Relationship Child-parent relationship Personality disorder i 'Other (Specify) 1 1 1. Please l i s t treatment or case work goalsj 2 , Check off the technique you used to achieve them (please add i f necessary) TECHNIQUES. T~. Environmental modification; (modification of physical or social and human environment, modification and modifying attitudes) by DIRECT ACTION. .... 2. Psychological support; jclient-worker interview - encouraging client to talk freely and express feelings, relieving anxiety and feelings of guilt, promoting client's confidence in his a b i l i t y to handle his situation adequately). SUPPORTIVE TREATMENT. .... 3. Clarification, (counselling - helping client to understand himself, his environment and/or people with whom he is associated - intellectual un-derstanding with some Emotional content, client becomes aware of his own feelings, desires and attitudes.) .... 4. Insight. (On a therapy level, client relives his current and past emotionsj deep level feelings which are not deeply repressed), 3. DEGREE TO WHICH TREATMENT GOALS WERE ACHIEVED; /5 Not achieved ____ , P a r t i a l l y achieved Half achieved - r ~ Achieved in most areas 7 100 Fully Achieved 4. DEGREE TO WHICH CASE TORE IS RESPONSIBLE FOR, THE...MOVEMENT... SHOWN IN ,THE CASEt ^ 7^ 5 /so — ~ M '/loo Not: responsible Partially Half Mostly Totally responsible responsible responsible responsible 5.. OVER-ALL AMOUNT OF EFFORT EXPENDED ON THE CASE. (Increasing amounts of effort.}. /TT" JT. ' ' /3 . * /4. 75. Minimal Slightly more Average amount More than High or full than minimal average amount amount 6., Difficulty, of the .client's problem from the technical stani point of getting suocess in treatment. (Increasing difficulty of problem). A — — / 2 ~n : — ~ 7 " r 75 No difficulty Slight Difficult very Impossible difficulty difficult 7. Is this a case where the change in the client would have occurred without case work BUT oasework has increased the rapidity of the ohange? Yes No 8, Has deterioration been prevented without evidence of upward movement? Yes No 9, Have services (such as financial)., environmental, etc.) been rendered without evidence.of movement? Yes No . REFERRAL* (Please check off).. 1. Did the patient know he was being referred for case work treatment? Yes No 2. Did the patient know why he was referred for casework service? Yes No ' 3. Who prepared the patient for referral? Doctor Social Worker_ 4. Are cases referred in conference or consultation with the Doctor? Regularly Occas ionally Not et a l l 5 . Did evaluation of case work treatability come BEFORE or AFTER :'v.TA< i l Referral? - ©0 A P P E N D I X B. CHAE.T I M A l _ C PATIENTS (13) FETMALE PATIFNT5((0) iiHiiiiiiiimmiiiii 1 iinHimimiiiiniiii i i « r f ^ * » » S * » 7 » * ' e « W W J 1 4 ) « i 7 J » « M I W W 353S.JHT* D « J 7 3 f M At VdS. MAJOf t lTY 33 To 41 V«Si «t M A R I T A L STATUS 5 1 SePARATro l 1 W t O o W F O 2 Z. ©IN6LE 2 AvCRAGr . M O M B e * • Z9 Ye*Tto1M05 AGE" fcA«6E S YE6. To 25YC& AVEO-A6C A6e SCHOOL. A a e 6 * >(*S. Of* eneuMATOio AcrHems 3 W VRS. AVEeAfcF A6f A T e*srr of D ISEASE 32. J VK2>. G a o U P l (6 F ^ T l B N T f c ) G R O U P a (7 P A T I E N T S ) G R O U P S (lO P A T I E N T S ) f l o -i r 25 U So to IB MS| n So -lo-CO -0 -10 3 tav/mar MoviMrxr AtwivrwrNT or 6oAia P o m s ep MoVEMB«y AOMvaMrtrr eraema i i »e»iT*ieiA(«: -*n-.*-ra>) D I R E C T TR*Atrvir»*T" INBICATCD HOT L AcMicvertnrr of « O A W r < 4 VceiTSRlA(7 P A T I E W T S ) I M O I C A T K O A« fR.I»XAl«.y P O C U 6 i. c e i r a u A (7PAriB»*tri nee"Ax«»i»>»T oisii_y Aft PeowS VERY CLOSC ( t f iLATlOMSMlP-0>«CUSbaT6 M O S T pi«oet^Ma peeeuy. c o o o D I S ^ U S S I O K I A < U U > J C iu»if»6 f %eeu>cr\ * T T E > O C E - M r C H A > J J 4 n 6 B U T C A P A d U f S » M A U « < r W I T H iMTrNftiVff C A S I T -W o f c J C < t t i . ATlo»i*v» iP . »oPC<tPi« - ' *U Cjtr cMtffPuy To M*ac O F ,*Jroe*iAno»J cHiBin.y K k A e T r o N T o o»Joe»oAu VrK.y c i . o t . E - <eL«Tio»isHip- oi«ce>e*ses 0o«PEcrx?o •B«>V*»toTtc Cjs.»<rpo»J. S M i P . euptt^itiAi. ftt.An'fao)' ft«v»r«.,TV o»r na-ogL^ . y * * y fsyci-'p-rHfi-e.APy Move M**JT 9 S O o P K T C O P»yCHoT>C. »ze ACTIO*}. Chart III - 98 Suspected Psychogenic Arthritis Due to Emotional Trauma. I Health Evaluation Beginning of Casework Services Stipulated End May 20/58 win, A y JS\JM\JLO Movement Aotivity of Disease Active Arrested 2 Following Medical Instructions Follows Rigidly No change 0 Attitude to Illness Moderately realistic Quite realistic 1 Desire to Recover Determined to recover regard-less of d i f f i c -ulties No change 0 II Nature of Relation-A* Warmth Superficial relationship Very close relationship, discusses most problems freely 4 B. Dependency Leaves most discussions to caseworker Participates in making decisions 2 C* Hostility No overt expression Almost free expression on realistic basis 2 III the Severity of Problem Rooted in defence mechanisms but oapable of change with intensive casework relationship A* Client's Aware-ness of Problem Able to face with casework help No change 0 B. Desire for Help Able to accept help when i t is offered No change 0 Oi5 Movement Client almost oom- Problem pletely immobil- almost ized or disorganized resolved by problem 2 Number of interviews - 40» Number of months treated - 10 months* Duration of illness - 18 months* 13 points Chart IV - 9« -Neurotic Personality - Mrs. B. Aged 41 years I Health Evaluation Beginning of Casework Services Stipulated Movement End May 20/5S Activity of Disease Active Minor improve-ment 1 Following Medioal instructions Generally follows No change 0 Attitude to illness Moderately realistic Quite realistic 1 Desire to Reoover Determined to recover regard less of d i f f i c -ulties Some ambivalence, generally healthy attitude 1 II Nature of Relation-ship with Caseworker A* Warmth Very superfioal relationship Good relation- ] ship, generally relaxed discussion around illness and service  B • Dependency Terribly threat-ened by any invasion of independence Participated in making decisions on a flexible basis 0. Hostility No overt expression Some expression III Severity of the Problem A« Client's Aware-ness of Problem Very deep rooted, requiring psychotherapy for movement Completely unaware, Improvement, even when brought some awareness to her attention B. Desire for Help C • Movement Quite unable to accept help in a ny area  Immobilized in some areas Number of interviews - 18 Number of months treated - 7 months Duration of illness - 5 years Able to accept help in some areas Problem not basically resolved, but under control 10 points Chart V Psychoneurotic. Infantile Personality Structure. Miss M. 57 years* Indirect Treatment Indicated as Primary Focus I Health Evaluation Beginning of Stipulated Movement • Casework Services End May 20/52  Activity of Disease Active Active, minor improvement 1 Following Medical Instructions Constantly breaks routine Breaks routine less 1 Attitude to Illness Extremely unrealistic Less extremely unrealistio 1/2 Desire to Recover Seems determined to k i l l herself Seems less determined to k i l l herself 1 H Nature of Relation-ship with Caseworker A. Warmth Very superficial relationship Slight improve ment in very superficial relationship 1/2 B. Dependency Leaves a l l decisions to caseworker No improvement, leaves a l l dec-isions to case-worker 0 0. Hostility Continuous barr-age of hostility No improvement 0 H I Severity of the Problem Very deep rooted, requiring psychotherapy for movement A« Client's Aware-ness of Problem Completely unaware even when brought to her attention , No improvement 0 B. Desire for Help Quite unable to accept help in any area No improvement 0 C • Movement Client completely Immobilized or disorganized by basic problem No improvement 0 Number of interviews - 42. 4 points Number of months treated - 12 months. Duration of illness - 12 years. 96 -A P P E N D I X 0. - 92 -BIBLIOGRAPHY Books Alexander. Franz and French, Thomas M., Studies In Psy-° dhosomatio Medioine, Ronald Press Company, 1948. "Joints and Skeletal Muscles", Part VII. "Preliminary Report on a Psyohosomatic Study of Rheum-atoid Arthritis", hy Adelaide M. Johnson, M.D., Louis B. Shapiro, M.D., and Franz Alexander, M.D. Dunbar, Flanders, Emotions and Bodily Changes. New York, Columbia Universi'iy Press, 1946. Dunbar, Flanders, Mind and Body. New York, Rendon House, 1947• Family Service Association of America, Principles and  Techniques In Sooial Casework. Selected Articles, 1940 - 1950. ~ G i l l i n , J. L., Sooial Pathology. 3rd ed., Appleton, Oentury, Crofts Inc., New York, 1946. Hamilton, Gordon, Theory and Practice of Sooial Oase Work. End ed., Revised,' Columbia University Press, 1951. Hamilton, Kenneth A., Counselling the Handicapped in the  Rehabilitation Process. The Ronald Press, New York, 1946. Richardson, Henry B., Patients Have Families. Common-wealth Fund, New York, 1945. ' Thorpe, Louis P., and Katz, Barney, The Psychology of  Abnormal Behavior. The Ronald Press Company, New York, 1948. Weiss, Edward, and English, O.S., Psychosomatic Medioine. W. B. Saunders Co., Philadelphia, London, 1943. Articles and Pamphlets. A Committee of the American Rheumatism Association, Primer on the Rheumatic Diseases. American Medioal Association, Chicago, Illinois, Copyright, 1949. 96 -Articles and Pamphlets. Bartlett. Harriet M . , "Some Aspects of Sooial Casework in a Medical Setting", Prepared for Committee on Funct-ions. American Association of Medical Sooial Workers. Chicago, 1940* — - — -Canadian Arthritis and Rheumatism Society, British Columbia Division, Miscellaneous memeographed material. Cocke r i l l , S., "New Emphasis on an old concept of Med-icine", Journal of Social Casework. January 1947. Dominion Government, Health and Welfare Publications. Issue, April 1951. Issue, "Arthritis", Special Supplement, March 1948. Margolis, H.M., M.D., JOurnel of Sooial Work. "Rheumatoid Arthritis", January 15297 « — - — Margolis, H.M., M.D., "The Care of the Patient with Rheum-atoid Arthritis", The Family. January 1945. Upham, Frances, A dynamic approach to Illness, American  Association of Medical Social Workers. "A Statement of Standards to be met by Medical Sooial Service Depart-ments in Hospitals and Clinics. 

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