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Social problems of a group of patients with psychogenic illness Zuckerberg, Asta 1947

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4 SOCIAL PROBLEMS OF A GROUP OF PATIENTS WITH PSYCHOGENIC ILLNESS by Asta Zuckerberg A thesis submitted i n p a r t i a l fulfilment of the requirements for the degree of MASTER OF SOCIAL WORK in the Department of Social Work The University of Br i t i s h Columbia September, 1947 n*7 its' (Up. i SOCIAL PROBLEMS OF A GROUP OF PATIENTS WITH PSYCHOGENIC ILLNESS by Asta Zuckerberg Vancouver, B.C * September,1947 ABSTRACT OF THESIS SOCIAL PROBLEMS OF A GROUP OF PATIENTS WITH PSYCHOGENIC ILLNESS The social problems of a group of fifty-three patients with psycho-genic illness are analyzed and interpreted i n this study. The patients were a l l those with at least one somatic complaint referred to the Social Service Department of the Royal Alexandra Hospital, Edmonton, Alberta, during the period from October 1944 to July 1946. The patients were found to have two main types of problems, those associated with their environment, and those associated with their emotion-a l condition* The environmental problems were those associated with employment, finances, war, school, immigration, housing, and miscellaneous . conditions. The emotional problems were those associated with the patients' attitude to i l l n e s s j relationships with other personsj with their own emotional development; with their feelings about matters pertaining to sex; and witha number of miscellaneous feelings* In a l l these groups, there were forty-six different problems studied* There was a t o t a l of 550 individual problems among a l l the patients, with an average of 10*57 problems per patient* Of these, 126 were environmental problems, with an average of 2*7 environmental problems per patient* The average number of emotional problems per patient was 7*3, with, .a t o t a l of 424 such problems. There were thirteen groups of problems among the environmental and emotional problems* The most frequent problems were those associated with illn e s s * These were found i n a l l patients. The next most frequent group was of problems associated with the patients' relationships with others, 98.11$ of the patients having problems here. 88.68$ of the patients had problems associated with their emotional development. 64.15$ of the patients had problems associated with employment. The same number of patients had problems arising from their attitude to matters pertaining to sex. 43.39$ of the patients had problems associated with financesj 30.19$, with warj 26.41$, with school; 26.41$, with immigration; 11*32$, with housing; 41.52$, with miscellaneous situations; and 35.81$, with miscellaneous feelings. The large numbers of problems among the patients emphasixes the need for medical casework treatment for hospital patients. A brief description of the nature of medical social work and of the setting i n which these problems arose, i s given. Descriptive and s t a t i s t i c a l material being summarized i n 9 tables. Interpretation of social work and medical terminology i s given whenever the meaning of these terms appeared obscure. An example of the type of social history, from which information for this study was obtained, and a table summarizing a l l the problems are given i n the appendices. Reading material used i n the study i s l i s t e d i n the bibliography. TABLE OF CONTENTS CHAPTER I PURPOSE, SCOPE AND METHOD 1 CHAPTER I I THE MEDICAL SOCIAL WORKER'S APPROACH TO THE PROBLEMS . . . 4 M e d i c a l S o c i a l W o r k . The S e t t i n g o f t h e P r o b l e m s . CHAPTER I I I ENVIRONMENTAL PROBLEMS 12 1 . P r o b l e m s A s s o c i a t e d w i t h Employment 14 2. P r o b l e m s A s s o c i a t e d w i t h F i n a n c e s . . . . . . . . 16 3 . P r o b l e m s A s s o c i a t e d w i t h S c h o o l 17 4. P r o b l e m s A s s o c i a t e d w i t h War 19 5 . P r o b l e m s A s s o c i a t e d w i t h I m m i g r a t i o n • 20 6 . P r o b l e m s A s s o c i a t e d w i t h H o u s i n g 21 7 . O t h e r P r o b l e m s 22 CHAPTER I V EMOTIONAL PROBLEMS 23 1 . P r o b l e m s A s s o c i a t e d w i t h t h e P a t i e n t s ' A t t i t u d e s t o t h e i r I l l n e s s 2. P r o b l e m s A s s o c i a t e d w i t h P e r s o n a l R e l a t i o n s h i p . . . 3. P r o b l e m s A s s o c i a t e d w i t h t h e P a t i e n t s ' E m o t i o n a l D e v e l o p m e n t . . . . • 4. P r o b l e m s A s s o c i a t e d w i t h t h e P a t i e n t s ' F e e l i n g s a b o u t Sex . . . . . . 5 . ' P r o b l e m s A s s o c i a t e d w i t h O t h e r F e e l i n g s . . . . . . CHAPTER V APPRAISAL 48 APPENDIX A . P s y c h o s o m a t i c H i s t o r y 51 APPENDIX B . T a b l e 9 - The Number and P e r c e n t a g e o f P a t i e n t s w i t h E a c h P r o b l e m . 57 25 29 36 45 46 BIBLIOGRAPHY 58 TABLES 1. The Distribution of the Patients According to Age Groups 9 2. Incidence of Complaints with Reference to the Various Organ-systems 10 3. The Number and Percentage of Patients with Problems Associated with Certain Environmental Conditions ' 12 4» The Number and Percentage of Patients with Problems in Each Occupation 1 5 . 5. The Number of Patients According to the Number of Groups of Problems . . . . . . . . 24 6. The Number and Percentage of Patients with Problems Associated with Each Group of Emotional Conditions 24 7. The Number and Percentage of Patients Having Problems Associated with Each Type of Relationship . . . 29 8. The Number of Patients Having Problems Associated with Various Emotional Problems • 37 9. The Number and Percentage of Patients with Each Problem . . . 57 1 CHAPTER I  PURPOSE, SCOPE AND METHOD Purpose • The purpose of this study i s to analyze and interpret the social problems of fifty-three general hospital patients who suffered from physical ailments which were primarily psychogenic. This type of i l l n e s s i s one which has a high degree of environmental and emotional factors i n i t s i n i t i a l development and progress, and as such, requires particular diagnosis and treatment. With the intense, specialization of modern medical practice i t has become d i f f i c u l t for the doctor to have the time and training to study this aspect of the patient's problems and assist i n solving them. He can, however, refer the patient to a person specially trained for this, i.e., the medical social worker. The importance of the role of the medical social worker has been described by the American physician, Dr. H.M. Margolis, as follows: With greater recognition of the social and emotional factors i n ill n e s s , there came naturally greater acceptance of the social worker and her help.... We depend on her largely for an objective picture of the patient's social setting, his relationship with the family group, i t s socio-economic as well as i t s emotional resources. We recognize that she often has the equipment and the inclination to help the patient to under-stand the early emotional conflicts that are a basis for existing emotional illnesses. As a result of this growing awareness of the value of medical social 1. Margolis, H.M. the Psychosomatic Approach to Medical Diagnosis and  Treatment. Journal of Social Casework, v.27, December iy4°, pp. 298,299. work, hospitals i n western Canada have shown an interest i n the establishment of such departments. Prior to 1945, pioneer work had already been done in this direction i n six hospitals in British Columbia, namely, the tuberculosis sanitaria in Vancouver, Victoria and Tranquille, 2 -y^ g Crippled Children's and General Hospitals in Vancouver, and the Royal Jubilee Hospital in Victoria. 3 i n Alberta, however, the only work of that nature was carried out in the Royal Alexandra Hospital where the information for this study was obtained. The Social Service Department in this hospital has-been considered outstanding due to the s k i l l of i t s social worker. It is f e l t , therefore, that the material contained i n this study may be of interest and assistance to administrators and staffs of newly formed departments by indicating what, types of environmental and emotional problems may be expected among patients with psychogenic disorders. Although some of the social problems studied here are peculiar to the l o c a l i t y and time most of the problems are representative of a l l hospital patients suffering from illnesses of this type. Scope This study covers the social problems of fifty-three patients at the Royal Alexandra Hospital, Edmonton, Alberta, who were referred to the Social Service Department from October 1S44, at which time the department •was established, to July 1946, when the data for this paper was gathered. This group includes a l l patients with at least one somatic complaint, referred by their physician for study and social treatment because they 2. Department of the Provincial Secretary, British Columbia. Report on Hospital Statistics and Administration of the "Hospitals Act", 1945. 3. Provincial Board of Health, British Columbia, Annual Report, 1945* considered the patients' environmental and emotional problems influential in the development of their illness and deterrent factors i n their recovery. Method Most of the material for this study was obtained from the psychosomatic or social histories compiled by the social worker at the Royal Alexandra Hospital following her interviews with patients, and i n some instances members of their families. These histories described the patient's childhood and.cultural background, his present family relationships and livi n g conditions, and his feelings and attitudes. This enabled her to direct attention to what she judged to be the chief disturbing factors. Obviously the information varied considerably with each case and there was no standardization i n the form of these records, an example of which may be found i n Appendix A. Psychosomatic histories and accompanying face-sheets, containing brief data such as the patient's age, sex, birth-date, nationality, symptoms and diagnosis were v i r t u a l l y the only case-records kept by the department. Lack of any c l e r i c a l staff prevented the social worker from recording each interview i n detail which i s preferable in this type of work. For ease i n analyzing the above material i t has been f e l t necessary to make some sort of division and the problems have been separated a r b i t r a r i l y into those which are predominantly (a) environmental and (b) emotional. D i f f i c u l t y has been encountered i n achieving this since both are inter-related. However, those which appeared to arise principally out of external circumstances were included i n the f i r s t group: those principally due to the patient's attitude, i n the second. CHAPTER II THE MEDICAL SOCIAL WORKER'S APPROACH TO THE PROBLEMS Medical social work i s carried on i n a hospital as a service to the patient, the physician, the hospital administration and the community. Its purpose i s to help meet the problems of the patient which aggravate his medical condition. These problems f a l l roughly into two groups, those of an environmental nature such as poor housing or prolonged poverty and those of an emotional nature associated with the individuals' feelings and attitudes, as, for instance, a sense of insecurity or unsatisfactory relationship with parents. The problems of a patient are met by a social worker by a variety of methods, dealing directly with the sick person or indirectly through others working toward his recovery. The American Association of Social Workers has outlined the means by which this i s done i n i t s description of the to t a l functions of medical social service departments. They are as follows: 1. The practice of medical social casework. 2. The development of the medical social program within the medical institution. 3. Participation i n the development of the medical social program i n the community. 4. Participation i n the educational program for professional personnel. 5 . Medical social research. * 4. A Statement of Standards to be Met by Medical Social Service Departments i n hospitals and Clinics. The American Association of Medical Social Workers, New York, 1940. The f i r s t of the above, the practice of medical social casework, was carried on to the greatest extent at the Royal Alexandra Hospital. In general, this branch of the work involves dealing directly with the patient and his problems.and requires f i r s t of a l l , a thorough study of the situation i n which the patient lives or has lived, i . e . his work, housing, family relationships and emotional development. The social worker(in future referred to as "her" to distingush from the patient referred to as "him") may achieve this by being, f i r s t of a l l , t r u l y understanding and sympathetic to the patient who comes to rely on the worker as a person he can trust with his innermost thoughts and feelings. Once he has found that these, no matter how reprehensible they may" s.eem, w i l l be met without shock or censure, he is able to unburden himself. His treatment begins as he talks and unravels his tangled memories and emotions. Once the medical social worker has a clear picture of the patient's problems, she can start to help him with the most pressing of them. For example, a patient who has just developed some alarming symptoms and has been admitted to hospital might find his confusion about the nature of his illness particularly disturbing. After the social worker has discussed with him his concern about such things as — what his diagnosis i s , how the symptoms came about, and what kind of treatment he may expect, she may proceed to help him with his other worries. This may be achieved my making him aware of the causes of his anxiety and offering concrete suggestions as to how to effect a solution of problems concerning the financial state of his family during his il l n e s s , his work, his relationship with his wife, or feeling of insecurity i n his daily contacts. To work out these d i f f i c u l t i e s may take varying lengths of time depending on the seriousness of the problem, the response of the patient to treatment, the s k i l l of the social worker, and the frequency and length of interviews between the patient and social worker. In some cases a patient may be greatly helped by two or three interviews: in others he may require assistance for a year or more: occasionally he may require supportive treatment indefinitely. Although at the Royal Alexandra Hospital, most attention was paid to social casework treatment, the other functions l i s t e d by the American Association of Medical Social Workers, and noted in reference 4, were also carried out as time and f a c i l i t i e s permitted. For example, there was an encouraging development of the medical social work program i n the hospital. F i r s t l y , the social worker demonstrated her usefulness to the patients with the most obvious social problems. As she did this, she heightened the awareness of the physicians and hospital staff of the patients' problems. As requests for social work assistance are made through the physicians and the hospital staff the broadening of such a program can only be achieved by a growth i n this understanding of the social problems. The social worker took part, too, i n the development of social and health programs in the community. This often involved i n i t i a t i n g as well as continuing with an active part i n certain public projects such as the better co-ordination of social agency functions,slum clearance or cancer fund campaigns. To some extent, she carried on an educational program for professional personnel, i.e. social workers, physicians and nurses. She supervised social work students placed in her department by a school of social work, participated i n cl i n i c s for internes and gave lectures to student nurses. Medical social research was not- done to any extent. Although this study is an example of medical social research and was done i n that department, it"was done extraneously, and not as part of the responsibility of that office. The Setting of the Problems The Royal Alexandra Hospital is a 500 bed hospital situated near downtown Edmonton. It is.owned by the c i t y , controlled by a board of directors and administered by a superintendent who i s a physician himself. Serying as a teaching hospital for the University of Alberta, i t i s staffed by graduate resident physicians and undergraduate internes. The hospital also has a training school for nurses. The institution offers no free hospitalization or treatment. The only care given there.for which patients do not pay, is maternity care which is paid for by the province, and indigent care, paid for by the municipalities who place their patients there. Daily rates for hospitalization range from $3.00 to $6.00. The Social Service Department was set up i n the f a l l of 1944. Its office, located on the f i r s t floor of the hospital near the main entrance and admitting office, i s easily accessible to doctors and patients. The services of the social worker are free and available to a l l patients on referral from their physician, nurse or interne. As there was only one social worker i n this hospital to deal with the many problems among the patients, there was l i t t l e opportunity for the social worker to continue contact with the patient after his discharge. In a few cases the contact was continued for a short time by means of home v i s i t s , but the majority of c i t y patients needing continued casework treatment after discharge were referred to the Edmonton Family Welfare Bureau. Patients from the - 8 -country d i s t r i c t s received no further help, as there are no agencies offering casework services i n Alberta outside the c i t i e s of Edmonton and Calgary. In order to secure a clearer view of the social problems discussed i n this study, i t i s of value to know a l i t t l e of the patients and where they lived. They were a l l residents of the province of Alberta whose geographical location makes i t particularly suitable for grain growing, mixed farming, stock raising, lumbering, mining and the fur trade. Much of the prairie land was taken by early settlers for homesteading. During the latter part of the nineteenth century and the beginning of the twentieth century, immigrants from a l l parts of continental Europe and Great Britain came out to this land of promise, so much publicized by the Canadian railway companies. In addition to those coming from Europe, people from the United States and eastern Canada moved out to "sunny Alberta". The population of the province i s thus made up chiefly of people of British, French, German, Ukrainian and western Slavic descent. Edmonton, the capital c i t y of the province, with a population of over 100,000 and situated on the banks of the northern branch of the Saskatchewan River, i s a trading centre for northern and central Alberta. During the war years there was a large influx of population. In the c i t y and the surrounding country were numerous Royal Canadian Air Force training stations. The United States Army Air Force base and that for the construction of the Alaska Highway were both i n Edmonton. About a half of the patients covered i n this study lived i n this city, and the remainder were from the small towns and country d i s t r i c t s of the province. Of the group of patients, twenty-seven were women, and twenty-five, men. A large number of the women were housewives. The remainder were i - 9 -clerks, domestics* students and unemployed. Details of the patients' occupations are given i n Chapter 3, section 2. The age distribution ranged from eight to sixty years, with the largest group of the patients, fourteen, i n the 31-40 year group, which also was the mean age group. The following table indicates the distribution according to age. T a b l e 1 The Distribution of the Patients According to Age Groups. Age group Number of patients 1-10 years 2 11 - 20 years 7 21 - 30 years 11 31 - 40 years 41 - 50 years 9 51 - 60 years f 4 61 - 70 years 6 Total 53 The illnesses, which were a l l predominantly psychogenic, were diagnosed as follows; psychoneurosis, 18 patients; mucous c o l i t i s , 4 patients; abdominal pain (ulcer symptoms), 3 patients; 2 patients with each of the following, neurosis, anxiety state, nervous exhaustion, - 10 -rheumatic heart disease, anorexia nervosa, scleroderma, Reynaud's disease, diabetes mellitusj one patient with each of involutional melancholia, globus hystericus, reactive depression, conversion hysteria, anxiety neurosis, simple syncope, hysterical state, pruritus ani, a r t h r i t i s , auricullar f i b r i l l a t i o n , duodenal ulcer, i r r i t a b l e bowel and skin condition. Host of the patients complained of symptoms associated with organ-system. A knowledge of the symptoms helps to give a more complete picture of the patients' physical conditions. The table below indicates the number of patients who complained of symptoms i n the various organ-systems. Table 2 The Incidence of Complaints with Reference to the Various Organ-systems Organ-systems Number of patients Gastro-intestinal 23 Central nervous 18 Cardiovas cular 10 Locomotor 10 Genito-urinary 9 Endocrine 4 Respiratory 2 Skin 2 Total 78 It may be noted that a large number of patients had symptoms with reference to the gastro-intestinal tract. Among patients whose illness i s so closely tied up with their emotions this can be expected since the abdomen, due to i t s sensitivity to nervous strain, has come to be calle d •'the sounding board of the emotions". Complaints i n the central nervous system were also frequent. This i s to be expected, as disorders ' affecting this part of the body, such as fainting, headache, dizziness and feelings of weakness, i f without organic cause, are an expression of the patient's anxiety. 5. Weiss, Edward and English, 0. Spurgeon, Psychosomatic Medicine, W.B. Saunders Co., Philadelphia and London, 1943, pp.438Q450 CHAPTER I I I ENVIRONMENTAL PROBLEMS It i s interesting to note that of the fifty-three patients studied i n the Royal Alexandra Hospital, a l l were disturbed by some environmental situation, either of the past or present. For purposes of analysis, the problems arising out of these circumstances were considered as follows: those associated with employment, finances, war, achool, immigration, housing and miscellaneous conditions. The number and percentage of patients having problems i n each one of 'these groupings i s given below. Table 3 -The Number and Percentage of Patients with Problems Associated with Certain Environmental Conditions • Environmental Number of Percentage of Condition patients patients Employment 34 64.1 Finances 23 43,4 War 16 30.2 School 14 26.4 Immigration 14 26.4 Housing 6 11.3 Miscellaneous 21 39.6 - 13 -There was a tot a l of 126 problems associated with environmental situations, making ah average of .2.7 such problems per patient. Certain of these situations were unalterable since they had occurred i n the past or were a result of circumstances beyond the control of the patient and the social worker; as, for example, prolonged periods of financial insecurity during the depression, years of heavy farm work, loss of a member of the family i n the war, an unsatisfactory school l i f e and disappointment on immigration to Canada. By the time a patient i s hospitalized, conditions such as those described above have already exacted their t o l l on his physical and mental health. Here the social worker may assist him to make these occurrences less harrassing. She i s prepared to be a sympathetic listener to his resentment and self-pity at continued deprivation. This may be the f i r s t opportunity he has ever had to unburden his troubles. Merely talking about his bitterness may help a patient to r i d himself of i t . I f the social worker i s able to help him understand how these hardships and worries have been affecting him he may c«me to realize that his attacks of stomach pain coincided with strenuous farm labor or that he really has never been happy since leaving his home i n Europe and his illness has run parall e l to t h i s . He might then find i t possible to develop a new philosophy of meeting d i f f i c u l t situations. Other environmental problems were the result of situations which may be altered, such as, unsuitable employment, debt, confusion over the ways of the adopted country, poor housing or absence of a member of the family in the army* As an example of the problem there i s the case of unsuitable employment, where the well-trained mechanic doing unskilled labor on a railway section gang and as a consequence suffering from a sense of - 14 -frustration. With encouragement and the active assistance of the social worker he may find work for which he has greater aptitude. Here the social worker i s of real value indeed. i 1. Problems Associated with Employment Problems associated with employment were encountered i n thirty-four pr 64.2$ of the patients. The problem faced by the largest group, seventeen i n number, was that their work was either too heavy physically or involved more responsibility than they were able to assume. This was• particularly noticeable among housewives, fourteen of the twenty-five studied belonging to this category. The other three patients were a farmer and two men engaged i n aeronautics. Six patients found the occupations i n which they were engaged unsuitable for other reasons such as having been trained for work with more prestige and higher wages, or lacking training and inclination for their work. The amelioration t of such situations i s of particular importance because the mental and physical strain of dissatisfaction, heavy work, and too much responsibility cause a vicious circle which may go on u n t i l the victim f i n a l l y collapses. Lack of stable employment, during the d i f f i c u l t depression years were found to have an effect on five patients and repeated farm losses through f i r e , flood, crop failure and poor markets, on seven. These were events of the past and, as such, were unalterable. In these cases however, as mentioned before, i t i s the job of the so c i a l worker to attempt a satisfactory adjustment of the patient's attitude towards them. A sense of failure i n connection with their work was found to have worried six patients, four of whom f e l t their military service rejection intensely. The other two patients who thought they had failed were a clerk who was transferred to a lesser position and a man who was retired after a series of positions each one of decreasing importance. It i s interesting to examine the types of employment of those having occupational d i f f i c u l t i e s , although the sample i s too small to draw any conclusions about the relationship between occupations and problems therein. As i s illustrated i n the table below, a l l those who were engaged in aeronautics, domestic service or who were unemployed had problems connected with their work. Five of the six farmers, two of the three clerks, seventeen (68$) of the twenty-five housewives, both of those i n aeronautics and the music teacher also f e l l i n this category. Table 4. The Number and Percentage of Patients with Problems i n Each Occupation  Occupation Total number of patients Patients with problems Number Percentage Housewife 25 17 68 Student 7 4 57.1 Farmer 6 5 83.3 Unemployed 4 4 100 Clerk 5 2 66.7 Aeronautics 2 2 100 Railway section-man 2 .1 50 Mechanic 1 - — School teacher 1 1 100 Domestic 2 2 100 53 34 . 64.2 - 16 •* 2. Problems Associated with Finances Certain of the problems associated with finances were connected with lack of employment and repeated farm losses, principally the result of the depression years. Of the twenty-three patients having serious past or present financial d i f f i c u l t i e s , twelve had undergone at least prolonged periods of financial insecurity, and three extreme poverty and hardship. It can quite easily be understood that the patient's present illness is linked to these problems because physical deprivation and mental strain are bound to have an effect on the health and happiness of a patient. It was concluded that this was certainly a factor in the instance of a fifty-nine year old Polish housewife who underwent much hardship in Europe during the f i r s t World War. Soon after she and her husband came to Canada to l i v e on a homestead, drought and depression struck and eventually resulted i n actual want for this family. This woman began to have stomach pain whenever she worked hard or was faced with additional trouble and a short time before she came into hospital experienced abdominal pain and symptoms simulating a heart attack while she was worrying about a crop failure. These physical manifestations were f e l t to be a result of her prolonged struggle with d i f f i c u l t i e s and were diagnosed as reactive depression. (Case 15.) Only nine patients were deeply concerned with the effect of their illness on their financial situation; s ix because of the loss of income through i l l n e s s , and three because of debts incurred for farm machinery and medical treatment. This number i s small because the study was made during the war years when there was f u l l employment and good returns - 17 -for farm produce. Also, less than half of the patients were bread-winners and six of those were farmers whose families could continue to operate the farm while the man was i n hospital* At this time immediate financial problems were not noticeable with this group of patients, but they can be expected to be more important in ordinary times. Naturally the seriousness of the illness and the length of hospitalization may be' expected to influence them to a considerable degree. If there is provision for i t i n a state or hospital, assistance to the patient with financial problems i s i n the scope of the medical social worker. This may relieve to some extent the anxiety and physical deprivation which can easily prevent the recovery of a patient from a psychogenic i l l n e s s . If such help is given by a social worker who i s sensitive to the feelings of the person who becomes financially dependent, she can make the acceptance of assistance much less disturbing to him. She i s aware, too, of the need to prevent him from becoming overly dependent and bring him gradually to become self-sufficient as soon as his condition permits. 3. Problems Associated with School Fourteen of the patients had some problems which were a result of their school l i f e . Ten patients had found school either too d i f f i c u l t , or unpleasant for other reasons. Feeling this way, some commenced to avoid regular attendance by frequent illness at an early age. For example, a twenty-six year old man, who was diagnosed as having diabetes mellitus, found school d i f f i c u l t at the early age of six years. He avoided i t by being i l l . He was sick f i r s t , with rheumatism, which was followed by - 18 -a series of injuries through accidents, and i n his early twenties, . hyperglycoemia, and f i n a l l y diabetes. (Case 19• ) Two of these ten patients who found school d i f f i c u l t were attending high school when they became i l l and i t was f e l t by their physician that the worry and strain resulting from this situation were contributing factors to their sickness. One, a sixteen year old boy under considerable tension f e l t unable to cope with thevwork and to l i v e up to his parents 1 wish that he should be a b r i l l i a n t scholar. Unable to face failure, he .began to avoid examinations by being i l l and eventually developed duodenal ulcers. (Case 34.) The other patient, a g i r l of seventeen, was worried and doing poor school work. It was f e l t that this was not because of innate a b i l i t y but because of her concern over the home situation. This resulted in truancy, further anxiety, and f i n a l l y , fainting attacks i n school. In addition, she complained of headaches, dizziness and backache. (Case 20.) These are disorders of the central nervous system and are regarded as being expressions of anxiety.^ Because of illness,four patients had been forced to leave school permanently and two of them, children with rheumatic heart disease. Two more had been unable to attend school as long as they wished because of the distance from their home to the school and because they were needed to help with work at home. Both f e l t this lack of education keenly, particularly one who had a responsible c i v i l i a n position with the A i r Force and was professionally and socially i n the company of people to whom he f e l t inferior. Among other factors, this was f e l t to contribute to .the development of this symptoms which were diagnosed as i r r i t a b l e bowel. (Case 46.) 6. Weiss, Edward and English, 0. -Spurgeon, Psychosomatic Medicine, W.B. Saunders Co. Philadelphia and London 1943, pp.438-450* - 19 -Approximately one-quarter of those studied had problems associated with school, which were as keen as those connected with employment and finances. Where the patient's school l i f e was a thing of the past, the social worker could only attempt, to change his attitude to i t j where he was s t i l l a student, she could do much more. He might be made to understand how he i s reacting to the situation, why i t i s unpleasant for him and what can be changed i n i t . She might also interpret the student's d i f f i c u l t i e s to his teachers and parents. For example, i n Case 34, where the parents were urging the boy to become a b r i l l i a n t scholar, an important part of the social worker's task lay i n bringing to the realization of the parents that they were setting an impossibly high scholastic standard for the boy and that i t would be wiser for him not to concentrate a l l his energies on his studies. 4. Problems Associated with War As the patients studied were i l l during the years 1944, 1945 and 1946, they had certain problems associated with the war which would not have been as numerous or as prominent i n peacetime. Sixteen, or about 30% of the patients were troubled by some events brought about by the war. Nine persons were affected by the absence of a member of a family i n the services, both through anxiety about him, and the increased responsibility for the home and family. For example, the onset of symptoms of a heart disorder i n one patient was thought by the doctor to result from her i n a b i l i t y to accept the responsibility of managing the home, and caring for the children after her husband went overseas. This situation, together with anxiety about his safety, - 20 -contributed to this illness which provided her with an acceptable reason to request the return of her husband on compassionate grounds. (Case 38.) The loss of a member of the family as a result of the war was a disturbing factor to four patients. Case" 20, for example, describes a young woman suffering from nervous exhaustion which manifest i t s e l f in headache, dizziness and fainting. She became noticeably more i l l after receiving news of the overseas death of her brother to whom she was closely attached. This also served to a rouse s t i l l more antagonism toward her father whom she held responsible for the enlistment of this brother. Three patients expressed concern over relatives l i v i n g in war zones in Europe, namely, Yugoslavia, Italy and the Ukraine. Although i t might be expected that the number of patients with such problems might be a l i t t l e higher i n Alberta, where immigrants from Europe make up such a large percentage of the population, the emergence of such a problem can be anticipated i n any part of Canada during wartime. 5. Problems Associated with Immigration Fourteen of the twenty patients of European descent had d i f f i c u l t i e s associated with immigration. Eight had d i f f i c u l t y in speaking English and f e l t themselves to be foreigners. Learning an entirely new way of l i f e , doing work they thought to be menial or mingling with people who were, i n their opinion, social inferiors resulted i n unhappiness which was f e l t by the physician to be an important contributory cause to the illness of three patients. One of them was a woman from a wealthy Italian family which had retired i n South Africa after l i v i n g i n a rich - 21 -farming area i n Italy, where the father had been a road building contractor. Leaving this l i f e , she came to Canada and married a homesteader i n northern Alberta. She was unable to adjust to the.heavy farm work, cold climate and the separation from her parents and developed abdominal and genito-urinary symptoms which have continued for fifteen years.. (Case 18.) Children bf immigrants had some problems associated with their adjustment to Canadian l i f e and the resultant conflict with their families' cultural patterns. There were two such patients, both young i g i r l s . The Hungarian father of one of them demanded old world servitude and hard work from her which was not i n keeping with the freedom allowed her fellow students. This made her self-conscious and fearful of appearing different from them. (Case 42.) 6. Problems Associated with Housing Problems arising out of poor and overcrowded housing were of significance to six patients. They resulted from the shortage of accommodation rather than the i n a b i l i t y to pay for better housing. Two of the patients were l i v i n g with their husbands' parents and feeling the effect of crowding aid strain. The others were l i v i n g i n small, inconvenient suites and rooms. Since the population of the city where this study was made swelled markedly, with subsequent overcrowding, during the war years, i t i s at f i r s t glance surprising that the number of patients affected was so small. This i s explained, however, by the fact that only one half of the patients were city residents.. Of the remaining twenty-six patients l i v i n g - 22 -on farms and small towns i n Alberta, none spoke of inadequate housing as being one of the problems. 7. Other Problems Twenty-one patients were bothered by other individual situations and occurrences. Four of them were unhappy because of physical defects, one being lame, the second overweight, the third, short of stature, and the fourth,\a'stammerer*:-, other situations disturbing the patients were as follows: change i n religious a f f i l i a t i o n s , s t e r i l e marriage, impending legal action, daughter's running away from home, a sister's marriage to a best friend, son's marriage, quarrel with a friend, sister's rape, v i s i t to the city, leaving home for the f i r s t time, childbirth, abortion, lack of knowledge about sex relations and reproduction, absence of a husband while he worked evenings, the marriage of a friend, VE Day celebrations, and the observation of a post-mortem. As most of these situations are not remediable, i t i s with the problems and attitudes which they, bring out i n the minds of the patients that the social worker would have to deal. CHAPTER IV , EMOTIONAL PROBLEMS It appears, from the psychosomatic histories of the Royal Alexandra Hospital that problems of an emotional nature were larger i n number than those related to environment. The resultant maladjustments caused fears, anxieties and dissatisfactions which, expressing themselves through the autonomic nervous system, contributed to the dysfunction of certain organs. ' Everyone has experienced at one time or another the physical manifestations of emotional strain, has had "goose pimples" at a movie " t h r i l l e r " , upset digestion or urinary frequency before examinations, or heart pounding from fright. With psychogenically i l l people, the . anxiety and fear have been so constant as to have established such symptoms permanently and have even, i n prolonged cases, led to actual structural change of certain organs. The problems arising from the above have been divided, for ease i n handling, into the five following groups: those associated with the patients* attitudes to i l l n e s s , their relationships with other persons, their own state of emotional development, their f eelings regarding sex, and those of miscellaneous character. A l l the patients had ^ .'difficulties which could be included i n two or more of the above classifications. Seven patients had problems i n two groups only but the largest number of patients, (twenty-one) had problems in four. See Table 5. - 24 -Table 5 Number of Patients According to the Number of Groups of Problems Number of Patients Number of Problems per Patient 7 2 15 5 21 4 10 5 The number and percentage of patients having problems associated with each group i s shown i n the following table* Table 6 The Number and Percentage of Patients with Problems Associated with Each Group with Emotional Conditions  Emotional Conditions Patients Number Percentage Attitude to illness 53" 100 Feelings associated with relationships 52 98*1 Emotional development 47 88.7 Feelings about sex 33 62.3 Miscellaneous feelings 19 35*8 - 25 -The t o t a l number of problems associated with emotions among a l l the patients was 424. The smallest number of d i f f i c u l t i e s per patient was' two, with only one patient having this number. The largest number of emotional problems per patient was thirteen, two patients having this number. The average number of problems associated with emotions was 7.5 per patient. This i s an interesting and possibly a significant figure as compared with the average of 2.7 environmental problems found i n the previous chapter. 1. Problems Associated with Attitudes towards Illness Illness i t s e l f was naturally a complicating factor for a l l the patients and a part of the cycle of cause and effect, being the end result of the problems and the source of further d i f f i c u l t i e s . However, attitudes associated with poor health which the patients had acquired were contributing factors to their present ailments or hindrances to their recovery. These feelings had frequently been built up over many years and sometimes were the result of the patients* own physical reactions i n the past or of the di s a b i l i t i e s of members of their families. The social worker found that a l l patients had disturbed thoughts i n this regard or very strongly established patterns of reaction to i l l n e s s . Much of her assistance i n such situations lay i n the discussion with the patients of what their real feelings were toward illness and how these caused their symptoms aid prevented their amelioration. Each and every one of the patients was perplexed by his misunder- • standing and incorrect conception of his i l l n e s s . Many of them had gone from doctor to doctor, receiving varied and hurried explanations of their d i s a b i l i t y and numerous kinds of treatment and drugs. In the strange - 26 -surroundings of the hospital they had, perhaps, undergone further extensive examinations to be f i n a l l y told there was no apparent physical cause for their complaint* In the rush of the complicated system of a modern hospital i t i s d i f f i c u l t for a physician to find the time to talk over i n detail the diagnosis and possible reason for the illness and u n t i l they have an opportunity to see the social worker, patients often l i e i n bed picturing every sort of imaginable horror conjured up by snatches of conversation overheard i n the examining room, stories of other patients and of visitors and "old wives tales" hea£d i n childhood. With the guidance of the doctor the social worker i s able to explain f i r s t , the exact physical findings, then attempt to help the patient see how his various problems and anxieties operate to cause the physical dysfunctions of which he complains* This frequently requires some time as i t i s necessary for the patient himself to come to the conclusion that his problems were causing physical disturbances, which is d i f f i c u l t for anyone to do* Thirty-three patients were particularly disturbed by fears of their symptoms and of death. With most of them, i t was a case of panic at the onset of such disorders as sudden abdominal pain, heart palpitations or shortness of breath. Several patients disclosed to the social worker that they were t e r r i f i e d that such manifestations might be the result of cancer or heart disease. Sometimes this fear was suggested by the fact that they had seen someone else with such a diagnosis. In case 3, for example, a thirty-eight year old man suffering from abdominal and prostate pain, was obsessed by the idea that he might have cancer, partly because a neighbor with similar complaints had died from that illness a short time before. Closely associated with such reactions to symptoms was the fear of death which was expressed by several patients. In Case 53, which has been mentioned previously, the woman was afraid she would die before she was able to r i d herself of her sins. In some instances the illness was complicated by the patient's resentment at i t s manifestations or the medical treatment required. For example, the i r r i t a t i n g and embarrassing symptoms of pruritus ani and neurodermatitis caused such feeling i n the sixty year old mechanic who suffered from i t . (Case 14.) In Case 32, the patient, a thirty-five •year old housewife complaining of severe, backache had undergone a spinal tap as part of the medical examination. Probably because there had been insufficient explanation of the importance and mechanism of the operation before i t was carried out, she was extremely upset by i t . Twenty-three patients had damaging attitudes to illness because of prolonged poor health, to which they b u i l t up certain resultant reactions In some cases this was a firmly entrenched pattern of meeting d i f f i c u l t situations by il l n e s s . This led to tenacious clinging to their physical disorder in seventeen patients wAo really did not wish their symptoms removed and consequently were almost untreatable. In Case 8, for example the social worker f e l t that the young woman suffering from anorexia nervosa did not wish to have removed the escape which this provided her. She had been unwell most of her l i f e and found more satisfaction i n this sheltered situation than i n facing l i f e with i t s uncertainties. In twenty-five instances, illness or bereavement i n the family led to certain disturbing conditions. With some patients the loss of a parent i n childhood had naturally affected their personality development and attitude to sickness and death. For exaple, i t was f e l t that some of the factors influencing the formation of anorexia nervosa i n a seventeen year old g i r l were her father's repeated digestive disorders and interest i n various special diets. The g i r l , was very close to her father so there was naturally some identification with him. (Case 6.) Her disorder, "which involved an i n a b i l i t y to eat to the extent that she lost an alarming auount of weight was considered to be associated with family concentration on foods and the patient's identification with the father. 7 In another instance, the fact that the patient had seen another person with a part i a l paralysis had led to her sudden i n a b i l i t y to move one side. She was i n hospital only two days, the symptom being completely removed the morning following the discussion of her problems and how they contributed to her d i s a b i l i t y , which was diagnosed as conversion hysteria. Fear that their illness might effect their family relationships was expressed by three women patients. The twenty-eight year old woman i n Case 7, for example, was unduly concerned that her poor health, which caused her to be i r r i t a b l e , would eventually spoil the happy relationship she had with her husband. Part of her psychoneurosis was expressed by a severe pre-menstrual tension which found i t s outlet i n quarrels with her husband and scolding of the children. 7.. Waller, John V., Kaufman, M. Ralph, and Deutsch, Felix, Anorexia  Nervosa; a Psychosomatic Entity. Psychosomatic Medicine, Vol. 2, pp.3 - 16, January 1940. - 29 -2. Problems Associated with Personal Relationships. Problems disturbing an almost equal number of patients were those which were associated with their relationships with other persons. Fifty-two, or 98.11$ of the patients had problems of this kind. Some of these were results of relationships in the past such as with parents i n childhood and others were aroused by existing relationships, as be-tween husband and wife. The five types of relationships i n which there were d i f f i c u l t i e s were those between the patient and his parents, between the patient and spouse, between the patient and siblings, between the patient and his children and between the patient and other persons. The number and percentage of patients having problems associated with each type of relationship i s indicated i n the following table. Table 7 The Number and Percentage of Patients Having Problems Associated with each Type- of Relationship Type of relationship Number of patients Percentage of patients a. Patient and parents 46 86.7 b. Patient and spouse. 18 33.9 c. Patient and siblings 14 26.4 d. Patient and children 14 26.4 e. Patient and others 8 15.1 30 -a. Relationship with Parents. Forty-six patients had problems resulting from unsatisfactory relationships with parents. It i s understandable that this group was large because of the tremendous influence of the child-parent bond on subsequent personality development. Where this was faulty, as with those patients whose maladjustment found i t s expression i n psychogenic il l n e s s , i t i s natural to find a high proportion (86.7$) of them who had a poor relationship. The most frequent complaint the patients,made to the social worker was that they were not wanted or loved by one or both parents. This rejection made them antagonistic to their parents, and guilty and anxious about that feeling which they could not express. The anxiety, together with other problems they had, appeared i n many cases to contribute to the formation of physical symptoms. Case 35 i s an example of a lack of parental affection and i t s results. Mrs. M. was a thirty seven year old housewife with three children, l i v i n g i n a lumber camp where she cooked for her husband's twenty-five employees. She was one of five children, repeating often that she was an "unwanted child" rejected by a l l the family. At the age of fifteen years she was forced by her family to marry a man much older than herself i n order that they might be r i d of her. She said that her husband had attempted to k i l l her several times, which, she. f e l t , did not worry her parents.. However, she f i n a l l y divorced him and married a man of her own choice. She had had almost a lifetime of i l l n e s s , somewhat exaggerated by her, as the hospital records did not always agree with her statements. During the present hospitalization she complained of ar t h r i t i s i n a l l the joints, diagnosed as a "psychoneurotic state". Recently much has been, written i n medical literature .of the importance of emotional factors i n the development of ar t h r i t i c symptoms. Dr. James L. Halliday states that psychoneurotics often develop a symptom complex of aches, pains, and stiffness and that the nature of the problem cannot be properly understood without psychological investigation to supplement the physical findings. He says that people with "psychoneurotic rheumatism" are sore and s t i f f symbolically, as they are "sore" about things and " s t i f f " with aggression turned inward. ® Mrs. M's stiffness and soreness appeared to have developed i n such a way. When parental rejection was accompanied by discord between the mother and father, further conflict was aroused because of the division . of loyalty to both parents. The following case i s given as an il l u s t r a t i o n of the effect of such a situation. Frances was an eight year old g i r l hospitalized for rheumatic heart disease. She was the eldest of three children born i n quick succession during the depression years. There was much discord between the parents which resulted i n the mother planning to divorce the father on his.return from overseas. She never had wanted Frances, and alternately spoiled and scolded the child. When the child was removed from this tense situation and placed i n a foster home, her physical condition improved but deteriorated whenever the child went home for weekends. 8. Halliday, James L., Psychosomatic Medicine and the Rheumatism  Problem, The Practitioner, London, V. 152, pp.b-15, January 1943. Situations where the patients f e l t their parents had been s t r i c t rather than rejecting were frequent. For example, Case 24 describes a thirty-nine year old woman patient who had grown up i n a highly religious and r i g i d home atmosphere. As a result, she overstressed the value of "goodness" and gentil i t y , and when she was faced with unpleasant responsibilities she expressed her revulsion by developing diarrhea. In some cases the patients remained too strongly attached to a parent of the opposite sex. This hindered them from reaching emotional maturity and independence. Sometimes this was accompanied by a desire to be li k e that parent and this further hindered their functioning i n the role of their own sex. A 30 year old woman patient, who was very attached to her -father, had considerable conflict between acting l i k e a boy, to please her father, or a domesticated daughter, to please her mother. This led to physical disturbances which prevented her from functioning adequately as a wife and mother. (Case 52.) Some patients t r i e d to r i d themselves of this too strong t i e by running away from home at an early age. Case 17 describes a sixty-five year old man who i n youth had run away from home and, as a consequence, was experiencing a feeling of guilt which was a part of his symptoms of involutional melancholia. b. Relationship with Spouse. Eighteen patients (33.9$) had problems associated with their relationship with their husband or wife. It i s interesting to note that fourteen of them also had poor relationships with their parents, making -33 -.78 the coefficient of correlation between the incidence of marital problems and poor relations with parents i n childhood. Fear of losing the affection of the marital partner was expressed by several patients. A man emotionally upset when his wife became friendly with other men developed ulcer symptoms. As he was not sure of her affection for him he became fearful of losing her altogether. His symptoms were similar to those he had had at the time of his divorce from his f i r s t wife. (Case 4.) Quarrels, lack of understanding and resentment'toward the husband or wife were the bulk of the problems of the patients i n this category. An example of such a condition was that of a thirty-eight year old man, (Case 3), who.resented what he f e l t to be his wife's exploitation of him and her failure to give him emotional support he needed for his inward security. His resentment was further intensified by the fact that she was more sexually demanding than he. As a result of his anxiety he suffered from abdominal and prostate pain. In Case 25,. a woman patient was irked by her husband's inefficiency i n his work while she herself was very quick and meticulous. This i r r i t a t i o n no doubt contributed to the development of mucous c o l i t i s , from which she suffered. c. Relationship between Patient and Siblings Fourteen patients had problems associated with their relationship with their siblings. The disturbing feelings of antagonism and jealousy conflicted with those of affection toward the sibling. For example, a forty-one year old woman patient spoke of much antagonism toward a sister - 34 -who was the favourite of the family and was more beautiful than she. Even when this sister was f a t a l l y injured and her death mourned by a l l the family, she f e l t jealous of the attention paid her. Also, less robust than her brothers and sisters, the patient remembered the teasing and ridicule to which they had subjected her. (Case 5.) Another patient noticed that the onset of her symptoms usually coindiced with the arr i v a l of her sister from another city. She was envious of this sister's carefree l i f e and resentful of her sister's intolerant attitude to her i l l n e s s , which consisted of severe headaches, fainting spells, fatigue and backache. (Case 32.) d. Relationship with Children. Feelings about relationship with their children c aused d i f f i c u l t i e s for fourteen patients. Most of these feelings were associated with the parents' rejection of their children. This basic rejection aroused anxiety and conflict between the real attitude toward the child and the sense that they should have more affection toward i t . Fear, resulting from a lack of knowledge about the care of their children, disturbed several mothers. For example, a forty year old woman patient with a three year old daughter, born after many years of marriage, had ambivalent feelings toward the child, based on the fact that she had never wanted to have a child. The anxiety reaction manifested i t s e l f i n backache and ringing i n the l e f t ear. (Case 26.) In Case 11, a young woman of eighteen was disturbed because she had ambivalent feelings toward her child and f e l t she lacked sufficient knowledge about the care of i t . With some patients, i t was an over-attachment to their child which caused their d i f f i c u l t i e s . For example, a- woman's feeling that her daughter should stay with her and had no right to a l i f e of her own, resulted i n emotional disturbance and f i n a l l y illness when the g i r l ran away from home. (Case 42.) In Case 15, a woman patient was very upset by the oncoming marriage of her sop, to whom she was overly attached. Shortly after he told her of his plans she developed symptoms simulating a heart attack which had no organic basis. e. Relationship with Other Persons Eight patients had problems associated with their relationship with' other persons. Five of them had d i f f i c u l t y i n establishing a close relationship with anyone and for the most part were lonely and without friends. A-thirty-nine year old farmer who lived alone was unable to relate to others and had almost no friends. He had half-heartedly advertised for a wife i n a newspaper and was unsuccessful i n his endeavour. (Case 47..) An i n a b i l i t y to relate to members of the opposite sex caused problems to three patients. In Case 6, for instance, the patient, a seventeen year old g i r l , was unable to establish normal relationships with boys her own age. This feeling toward members of the opposite sex was one of her many problems which led to the anorexia nervosa from which she suffered. - 36 -3. Problems Associated with the Patients' Emotional Development. The term "emotional development" i s used here to denote the usual attitudes, feeling tone and reaction patterns of a patient. These patterns are a result of the sum t o t a l of the person's environmental and hereditary influence. Many problems among the individuals referred to the social worker at the Royal Alexandra Hospital were associated with the degree of the patient's emotional growth. Forty-seven patients (88.7$) had problems associated with their emotional development. Since this i s a part of a l l the disturbing factors i n the patient's l i f e i t i s interesting to examine the correlation. Forty of the forty-seven patients having inadequacies i n their emotional development also had d i f f i c u l t i e s associated with their relationships to their parents. Thus, in this group of patients, the coefficient of" -correlation between poor relationships with parents and disturbing emotional development i s .85. The coefficient of correlation between faulty emotional development and unhappy relationship with the marital partner i s .89. The largest number of patients had d i f f i c u l t i e s associated with their feelings of insecurity, guilt and inadequacy. A sense of dependency, resentment and i n a b i l i t y to assume responsibility aroused anxiety i n a smaller number of patients. The number of patients having problems associated with various emotional conditions are given i n the table which follows. Table 8 The Number of Patients Having Problems Associated with various Emotional Conditions Emotional Conditions Number of Patients a Insecurity 16 b Guilt IS 0 Inadequacy 12 d Dependency 11 e Resentment 8 f Inability to assume responsibility 8 g Perfectionist tendencies 7 h Over-conscientiousness 6 1 Emotional immaturity 6 j Emotional flattening 6 ik Feeling against authority 4 '1 Emotional rigidity 4 m Meticulousness 4 n Aggression 3 Total problems 110 - 38 -Many of the above feelings are experienced i n varying degrees by everyone* It is only when they become too aoute, numerous and disturbing to the:- person's normal functioning in society that they became problems* They may then result i n anxiety and physical dysfunction over which the patient has no control* a* Insecurity The term ""insecurity11 is used here to denote the patient's feeling of unsureness, particularly in relation to the esteem and affection held for him by others* Fifteen patients/had problems arising from this source* A forty-one year old man had symptoms which were associated with his extreme fear of losing his wife, this fear growing out of his own feeling of insecurity*(Case 4)* Another patient, a thirty year old woman, was very unsure of her husband's affection for her because of her own insecurity* This feeling was actually a carry-over from her unsureness in regard to her parents* affection for her, and was a contributing factor to her psychoneurotic anxiety state which expressed i t s e l f i n nervousness, dizziness and fainting*(Case 22)* b* Guilt Guilt feelings are those which make the person uncomfortable because he feels he has done wrong, either i n thought or action* Fifteen patients discussed suoh feelings with the "social worker* Most of them were associated with their attitude toward other persons, religious beliefs or sex behaviour* In Case 25, fori example, a twenty-nine year old housewife had not been loved by her moth er as a ohild* For this reason she experienced much guilty resentment toward the mother and her expression of this resulted i n mucous oolitis* Another woman patient's chief worry was - 39 -her feeling that she had sinned against the teachings of her church by using contraceptives* Her illness she considered to be a punishment for her sins, perhaps to be followed by death and eternal damnation*(Case 53)* An example of guilt associated with sexual behaviour was that of a nineteen year old boy who was anxious over masturbation, imagining that • indulgence in i t would lead to impotence* This was associated with a speech blocking which he referred to as "speech impotence*" (Case 31)* c* Inadequacy Although a sense of inadequacy i s often associated with emotional insecurity, i t i s used here as a feeling of inability to cope with same particular task* Some of this may be real, as i n the .case of a person lacking aptitude and training for a job: some of i t may be imaginary, particularly where i t is the result of inward insecurity and laok of confidence* For example, a man employed as a civi l ian flying instructor felt that he was not able to do the job properly* This was further intensified by the fact that he lacked the formal education of his . associates* His anxiety state was expressed i n dizziness and headache, diagnosed as hyperventilation* (Case 50)* Case 48 illustrates the situation of inner insecurity engendering a sense of inadequacy* The patient, a young woman of twenty-eight, felt unable to oope adequately with the care of her home and family* Prior to her marriage, she was employed i n a store where she suffered from the fear of making errors* When under pressure she suffered from palpitation, dyspnoea and numbness of the hands and wrists* d* Dependency - 40 -Dependency leads to problems i n a patient when i t i s so strong that i t hinders his normal functioning as a self •sufficient person or arouses strong conflicts through his desire to be free of the bond* Eleven patients had such d i f f i c u l t i e s * In Case 39, for example, a twenty-one year old g i r l was overly-dependent on her family* As a result, she was very disturbed when she l e f t home to take a position i n another c i t y and subsequently became i l l , complaining of vision blur, nausea and headache* In another patient, a sixteen year old high school boy, the conflict was between his dependence on his parents and the need to assert himself as an independent adult*| This contributed to the development of his duodenal ulcer symptons-* (Case 34)* e* Resentment By the term "resentment"* we mean feelings of antagonism, whether expressed or not, and some of the problems studied here stemmed from the i n a b i l i t y of the patient to express his resentment toward persons or situations* There were eight such oases* One individual had suffered much through his own illness and those of his family* He had worked extremely hard on his farm and lost much through drought, erop failure and f i r e * He was resentful of a fate whioh had exposed him to suoh hardship but instead of expressing this feeling, he kept i t within himself for years with a resulting martyr-like attitude to l i f e culminating i n bronchial asthma and gastric ulcers* (Case 27)* - 41 -f* Inability to Assume Responsibility The inability to assume a large amount of responsibility i n regard to work or aotions was a disturbing factor to eight patients* This was a source of worry to one young farmer who had grown up without having to shoulder responsibility for any of his actions* He married a g i r l who had become pregnant by him before marriage* When he became badly i n debt on the farm which his parents had given him, he deserted his wife and family suddenly and remained away for several months* Troubled by the feeling that he would never be able to assume adequately the responsibilities expected of him, he suffered from abdominal pain similar to ulcer symptons* g* Perfectionist Tendencies In this paper the term, "perfectionist tendencies" i s used to denote that feeling which makes a person demand of himself and others an unattain-able standard of performance and behaviour* The struggle for such perfection resulted i n problems for seven patients* For example, an elderly man wanted to have everything i n l i f e clean and orderly* Employed for a time as a hotel detective, he was disturbed by the conduct of many of i the hotel guests, and began to suffer from irritable bowel symptons about this time* (Case 28) h* Over-conscientiousness Persons whose conscience, or sense of duty, drove them to do, chiefly for others, more than was normally expected of them are classed here as being "over-conscientious*" This i s closely related to the perfectionist - 42 -tendencies already described* Six patients had problems as a result of this striving* Case 7 i s an example* The patient, a young woman of a warm and affectionate nature, became extremely upset when she was unable to meet the material or emotional needs of others* She suffered from menstrual disor-ders, palpitation, weakness, dyspnoea and vision blur as a consequence* 1* Emotional Immaturity Emotional immaturity includes feelings of over-dependence, insecurity, inability to assume responsibility, to relate to persons of the opposite sex, to work under persons, i n authority and a l l those feelings whioh hinder the person's functioning as a balanced adult* Most of the patients had seme of these difficulties, which are actually indications of degrees of emotional immaturity* However , i t was not until they appeared to have almost a l l the symptons of immaturity that they were included i n this group* There were six suoh patients* One was a woman of twenty-one years* She became very unhappy and i l l when she left her parents to move, together with her husband and child, to another city* She was very dependent, insecure, unable to assume responsibility for the care of her child and to have satisfactory sexual relations with her husband* Her condition was diagnosed as a chronic anxiety state whioh found expression i n abdominal pain, headaches, dizzy spells, dysmenorrhia and dyspareunia* (Case 43)* j * Emotional Flattening The term "emotional flattening" i s used here to indicate the inability to show an emotional response where i t would ordinarily be expected* Sometimes this i s the result of fear of being hurt through responding I - 43 -emotionally* An extreme reaction of this sort i s associated with a schizoid personality* There were six patients with varying degrees of emotional flattening* One of them, for example, was a bachelor of thirty-nine who came to Canada alone* He lacked the a b i l i t y to relate i n a friendly manner to others and showed no feeling -when talking of his friends, his work of his family i n Europe* Because of his i n a b i l i t y to respond to anyone the social worker was unable to help this man*(Case 47)* k* Feeling Against Authority The feeling of resentment toward persons i n authority and the i n -a b i l i t y to aooept instructions from suoh persons was found to cause d i f f i c u l t y for four patients* This attitude toward authority was, i n most cases, i n conflict with the patients' needs for dependence* For instance, an elderly man exhibited this attitude to a marked degree with regard to the government, the doctors and his employers* At the same time he was rather dependent and needed someone to lean on*(Case 40)* Such feelings are described by Flanders Dunbar to be a part of the personality pattern 9 of the diabetic patient* 1* Emotional Bftgidity i An i n a b i l i t y to have any depth of feeling toward anyone or anything 9* Dunbar, Flanders, Psychosomatic Diagnosis, Paul B* Hoeber, Ino* (Medioal Book Department of harper and Bros*; Hew York and London* 1945, pp* 498* - 44 -is the interpretation given here to "emotional rigidity*" There were four patients with problems of this sort* For example, i n Case 45 as a result of emotional rigidity, a sixty-one;-! year spinster had few friends and was unable to relate to people* It further contributed to her arthritic symptons whioh were an expression of her tension* She was akin to the type of person Halliday desoribes^as likely to develop the symptons - emotionally 10 restricted, set i n his or her ways and ideas and with a high sense of duty* m* Metioulousness A very strong need for neatness and order in their surroundings result-ed in anxiety for four patients* One of them was a fifty-seven year old housewife whose metioulousness in . regard to the details of her surround-ings drove her to fear of involuntary soiling while she suffered from mucous colitis* Associated with her neurotic desire for cleanliness was her attitude toward sex, whioh she considered degrading (Case 1.)* n» Agftression A markedly disturbing amount of overt hostility i n a patient is referred to her as "aggression*" There were three patients with pronounced feelings of this sort* One particularly aggressive farmer of thirty-eight, who was also very impulsive, had, i n the past, been quick to engage i n fights* At the time of his hospitalisation for abdominal pain he was 10* Halliday, James L*, Psychosomatic Medicine and the Rheumatism Problem* The Practitioner, v* 158', pp* 6-15*, January, 1943* - 45 -remorseful over having severely beaten an Indian, (Case 5)* 4 * Problems Assoolated with the Patients' Feelings about Sex The feelings of a person with regard to sex are related to his emotional development* These feelings are discussed i n a separate section, however, because of the large number of patients having a conflict i n regard to sexual matters* A total of thirty-three patients had problems i n this field* Twenty-nine of the patients had what was classified as a "sex conflict, 1* which means the existence of a problem i n connection with his functioning in the role of an adult person of his own sex* This was expressed i n impotence, frigidity, dyspareunia and other maladjustments in sexual relations* Case 29 illustrates suoh a situation* The patient was a thirty-eight year old housewife who was shy and immature i n discussing sexual matters* She was frigid and used malaise as an excuse to avoid sexual relations* It was felt that her complaints of headache and pains were the result of this co nflict* A further example i s that of a middle-aged man who was psychogenioally impotent and had a deep sex conflict* He had outstanding physical strength and was very disturbed by his lack of sexual prowess* He suffered from prostate and abdominal pain* (Case 29*) Another patient, a forty-five year old woman, during twenty years of marriage, vomit ted after eaoh act of intercourse* This reaction regarded as symbolio of feelings of revulsion 11 felt by the patient* 11* Dunbar, Flanders* Emotions and Bodily Changes* Third Edition* Columbia University Press, itew York, 1946* pp*3ll« - 46 -In a few cases there seemed to be sexual conflict i n the patient because of his complete repression i n matters pertaining to sex. (Case 47, which was mentioned previously, illustrates this* The patient was a man of thirty-nine who showed considerable emotional flattening and appeared to have repressed everything to do with sex* Some of the patients* conflicts were centred around the use of contraceptives* For example, a thirty-nine year old woman who stressed her wishes for w g e n t i l i t y n and ladylike things was very upset over the use of contraceptives, considering them "not n i c e # w (Case 24)* Ten patients* problems were associated with their fear of pregnancy* The patient i n Case 43, for example, was so fearful of pregnancy that she avoided sexual intercourse altogether* This fear of conception was an expression of her sexual immaturity which was a part of the emotional immaturity discussed i n Section 3* There were two patients who told the social worker they werS disturbed by the conflict between their religious teachings and the use of contra-ceptives* Case 26 illustrates this situation* The patient was a forty year old woman who f e l t guilty because she had practised a form of contraception against the teachings of her church* Being very fearful of child-bearing, she was f r i g i d and complained of backache, which was diagnosed as anxiety state* 5.Problems Associated with Other Feelings .' i Nineteen patients had problems associated with other feelings, none of which were of primary importance to the patients or i n the development of their symptons* Six patients were very lonely* Ten had fears of such things as wind, thunderstorms, loud noises, water and ridicule* One of - 47 -the others f e l t unwanted by her husband's family, another was very worried about her mother's health and another was upset because so few souls were saved to go to Heaven. CHAPTER V APPRAISAL The analysis of the problems of this relatively small group of ' patients has brought to light several outstanding features, which, i t i s f e l t , may also appear among other hospital patients with psychogenic i l l n e s s . These features are brought out i n the summarizing table i n Appendix B. In examining this table, a particularly significant fact i s that a l l the patients lacked an understanding of their i l l n e s s . Linked closely with this were the fears, associated with i l l n e s s , expressed by 62.27$, and destructive attitudes resulting from previous illness expressed by 43.39$. These facts alone indicate the urgent need for a skil l e d social worker to discuss with sick people their diagnosis, treat-ment and the factors contributing to their symptom formation. This i s required not only by those with psychogenic i l l n e s s , but by a l l hospital patients who do not have a clear conception of their diagnosis and medical treatment. Poor relationships with parents, the second item i n the table, was revealed by a l l but 14$ of the patients. About 86 $ complained of th i s . Nothing could point more clearly to the necessity of assisting parents to give their children the affectional security so essential to their development into adequately functioning adults. Without this, l i k e these patients, i t i s possible that they w i l l develop into a i l i n g psychoneurotics who find their satisfaction and escape i n aches, pains and dysfunctions. When they are i n hospital, disabled by the manifestations of their malad-,449 -justraent, they cannot recover u n t i l their anxiety has appreciably diminished. Here there i s need for a s k i l l e d social worker to deal with the maladjustments herself, or point out the need for psychiatric treatment. The need for assistance i s further indicated by the large proportion of patients having poor relationships with their marital partner, and the ' s t i l l larger proportion (over half) of patients with a sex conflict. The large aggregate of patient-problems (550) i n this group of fifty-three patients again demonstrates the indispensability.of social treatment for hospitalized persons. Since a l l such problems are f e l t to be causes contributing to psychogenic il l n e s s , the patients cannot f u l l y recover u n t i l the d i f f i c u l t i e s are solved i n a satisfactory manner. If the anxieties are not recognized or resolved and the patient i s told by the doctor that there i s nothing organically wrong with him that his illness i s "just nerves", and he had better stop worrying he i s l e f t with no alternative but to go from doctor to doctor i n search of an answer. The numbers of such patients are large, some doctors estimating them to be one half of their total clientele. It seems reasonable to believe that the maintenance of social' service departments i n hospitals would be a financial economy to the patient and the community at large, shortening the period of hospitalization and reducing income loss. Although many of the patients with these types of problems may be helped by social work treatment i n a hospital, there are many who w i l l also require occasional after-discharge help when they are confronted with d i f f i c u l t i e s . This makes apparent the need for social agencies which give such services. In many instances, they could assist i n preventing the recurrence of the patient's breakdown and hospitalization. - 50 -When a person has developed the physical symptoms of a psychogenic disorder, his emotional d i f f i c u l t i e s are already acute. Intensive ^ remedial therapy i s then necessary. But i f his emotional maladjustment can be diagnosed and treated, on a preventive level, before the c r i s i s has developed, not only can the patient be spared unnecessary mental and physical suffering, but an economy i n case work services can be effected. These preventive services should begin i n childhood before the seeds of future disturbances have sprouted. With this end i n view, the importance of adequate child welfare and family case work services i n the community cannot be over-stressed. Although an awareness of the inter-relation of social problems and physical health i s growing among the medical profession and the general public, i t i s the duty of medical social workers to quicken that awareness through their community contacts and educational programs. As the over-whelming consequence and costs of ignoring the problems which result i n illness are grasped by the general public, there i s bound to be a demand for more family and medical casework services i n the community. With the increasing number of social workers being trained i n both fields there i s reasonable assurance that this need can be met. - 51 APPENDIX A Psychosomatic History Social Service Notes: Re: Mr. M.B.. Age 41 (Address) Service of Dr. S. Referred: July 5, 1946. Mr. B. was admitted to Hospital 28/6/46 suffering from pains suggestive of stomach ulcers. Medical findings, including x-ray, were negative for organic damage, and he was referred to social service for psychosomatic history, and assistance with social and emotional problems upsetting him. History: Mr. B« was born i n Hungary, (a part.which then became Jugoslavia, and then later was incorporated into Roumania) i n 1905. He has told me nothing of childhood, but he gives the impression of having had good education and other opportunities of the more privileged classes i n that country. His father died of gas poisoning i n the First Great War, and his mother of some gynecological condition, when she was 48. He has 1 brother and 3 sisters alive, and f a i r l y well, as far as he knows. They were i n the old country during the past War, and suffered acutely. The brother, he understands from the guarded communication he has had within the last monthvor so, was i n a concentration camp, as were also some of his other relatives, and his wife's aunt and her Jewish husband. He has worried considerably about them, during the years of silence, when unable to get word of them, but i s greatly relieved to know that they are s t i l l alive and well, since he has had letters from them a l l during the last couple of months. It was not possible to judge the emotional relationship with these siblings i n our limited conversation about them. - 52 -The patient came to Canada i n 1928, at 25 years, - a step for which he .gave me no reasons. He did farm work for about one month, did not l i k e i t , and began wandering i n search of more congenial work. He got a job as section labourer with a> .railway company and did very well for the f i r s t couple of years, but with the depression, work became more and more irregular. He married i n 1932, and shortly after lost his regular job. There were constant fights over finances with the necessarily reduced income, and his wife did not seem to be able to adjust herself to this reduction. It was i n 1932 that we have record of his f i r s t i l l n e s s . He was i n Hospital for appendectomy and adhesions to intestines. He was well for some months following surgery but i n 1933-4 had symptoms diagnosed as duodenal ulcers, and was told by Dr. S. that this was a result of anxiety. He was not willing to believe that such real pain could result from worry, and went down to Mayo Cli n i c , where a diagnosis of 'nervous indigestion' was given, but no explanation of how 'nerves' could cause such pain and d i s a b i l i t y . His symptoms seem to have commenced about the time his wife became pregnant of the child, a 1son, born i n 1934. He was not earning much, and was worried about the added expenses and lessened income, and his wife became more and more demanding. There were frequent fights, and the year following the birth of the child she began to go out occasionally with other men. He secured a divorce (I think i n 1936 or 37) on grounds of adultery, he retaining custody of the child, whom he placed i n a foster home. He had d i f f i c u l t y financing the divorce, foster home charges, and trying to pay on medical and hospital b i l l s , but nevertheless managed to save enough for a t r i p babk to Jugoslavia i n the spring of 1939. While back among his own people he met and married his present wife, - 53 -15 years younger than he. She was the niece of some friends, l i v i n g with them and caring for a youngster about the age of his son^ and he f e l t she would make an admirable substitute mother for the child, then 5 years old. They were married rather hurriedly as they had been warned by the B r i t i s h Consul to get out of the country immediately, and just got out before the outbreak of the war. Communication with both his relatives and hers was cut off almost immediately, and she, who had grown up i n a large city, among relatives and i n comparatively cultured surroundings, found herself i n a small Alberta mining town, married to an intelligent but rather domineering man many years her senior, with a ready-made family of one for her to look after. She and the youngster, now 12, get along smoothly and seem fond of each other. Mr. B. says she has been an excellent mother, and very good housekeeper. He also says "she i s not dumb. She learned English very quickly and learns other languages just as easily", and she seems to be well liked i n their community. He feels, I think, that she i s too well liked, and that she likes everyone and i s too friendly. She loves music and dancing, and wants to go to every party i n the town. She also wants pretty clothes and other expensive f r i v o l i t i e s , and for everything she wants, she won't take no for an answer, but coaxes and cajoles u n t i l her husband f i n a l l y gives i n , hating himself for being such a weakling, knowing that he i s making a mistake, but unable to put up with her wheedling. He does not l i k e to go to some of the 'rough parties' at the local dance h a l l , but goes ivith her once or twice a month, while she wants to go frequently. He resents seeing her dance with some of the tough customers there, and i s extremely jealous of her popularity among the group i n town which he does not approve. He says "she comes of good family, and should not enjoy being with such people. There are only half a dozen families i n the town f i t for us to - 54 -associate with". He i s s t i l l just a section worker on the railroad, but does not l i k e to have to associate socially with his fellow workers, and thinks himself above them. After considerable digging, the patient f i n a l l y admitted to me (and to himself) that his present symptoms began when his wife went off for the week-end to Lake View with another gi r l - o f questionable reputation, and some sailors. He t r i e d to think i t just a g i r l i s h prank, a mistake i n judgment and discretion that could be overlooked, but others began to talk and say "Oh, i f I were her husband, I'd just throw her out". She said she was sorry, and wheedled him into forgiveness, but, he says, "If she says she i s sorry, why doesn't she act i t ? Why does she have to continue to want to go out, and dance, and have good times? Perhaps I'm not good enough for- her, eh?" There has been no repetition of the week-end, but he lives i n daily terror of something happening which w i l l force him again, i n order to save his pride, to break up his home. He does not want to do this, and frets continually about how he can force her to his way of l i f e , without making her kick over the traces completely. To some extent, I f e l t that his illn e s s actually had a purpose i n i t , as a weapon to bring her to heel. The similarity to the picture of about 10 years ago, when he had ulcer symptoms f i r s t , and when he was worried about his f i r s t wife's i n f i d e l i t y - which she blamed on her desire to have a good time which he could not then afford to give her because of irregularity of employment -has been heightened by the fact that he has been unemployed now for about 5 months, a result of an accident i n which he hurt his right arm and shoulder. While he recounted the story of his treatment, prolonged-convalescence, and the puzzlement of the doctors that his arm did not - 55 respond to treatment, I f e l t that again his non-recovery perhaps had a purpose, even i f almost unconscious. While he was i n hospital his stomach symptoms cleared up, except for flare-ups when his wife came to v i s i t him and did not arrive at the exact moment specified. I believe •. he was also on compensation, as long as the arm incapacitated him. But compensation i s not equal to earnings, and his wife began to complain of their reduced income, and the things she could not have, and his old conflict of whether to say a l l " the things he wanted to say to her, and run the risk of losing her, or to bottle them up, and lose his own self respect, and the respect of the community for letting her get away with things, again became acute. I have advised him to get back to work as soon as possible, to lessen the financial strain, and get him busy so that he w i l l not be hanging around home a l l day, building up a wall of l i t t l e . resentments to add to his present oversupply. Mr. B. asked me to see his wife and explain to her, as I had to him, the cause of his symptoms. He also wanted me to t e l l her that she must not annoy him so that he would not have to develop real ulcers. I said that I would be glad to see his wife, and try to get her side of the picture, so that i t might be possible to help them towards better mutual understanding and co-operation. He wired her, asking her to come into town, but then did not t e l l her to keep the appointment made • with this department. I f e l t that he had lost his courage, for fear she presented too unfavorable opinion of him to us, and that he could not face that p o s s i b i l i t y . He blamed this failure to keep the appointment on our department, at f i r s t , although we had no-.way of seeing her unless he gave her word of the appointment, but was later able to see something of why this occurred. He has never been able to. accept blame himself readily - 56 -and finds i t hard to believe that i t i s often more painful to have resent-ment poison your system, than to admit yourself i n error. Mr. B. lias a deep lying feeling of i n f e r i o r i t y and insecurity which has made him a b i t aggressive,- impulsive, and belligerent. He has, how-ever, an underlying sense of justice and the a b i l i t y to see other people's point of view i f this i s explained sufficiently objectively to rouse his interest, without immediate emotional blocking. It i s not going to be easy for him to change his way of meeting l i f e , but his intelligence has accepted the cause of most of his d i f f i c u l t i e s , and he i s w i l l i n g to attempt the change. He has dogged determination i n his make-up, and i t i s possible that i n our interviews he got enough insight into himself and his problems to help him for some time to come.- I wish i t had been possible to talk with his; wife, as that might have been of value both to her and to him. (Signed) 9/7/46. - 57 APPENDIX B Table 9. The number and percentage of patients with each problem " Number of Percentage of Problem patients patients  100 86.66 62.27 56.60 47.17 . 43.39 47.52 35.81 33.96 32.07 30.19 28.30 26.41 26.41 22.64 22.64 20.75 20.75 18.87 18.87 16.98 15.09 15.09 15.09 13.21 13.21 11.32 11.32 11.32 • 11.32 11.32 11.32 11.32 9.44 35.Illness interfered with school attendance.., 7.54 7.54 7.54 7.54 7.54 5.56 . 5.56 5;56 • 5.56 5.56 3.77 3.77 - 58 BIBLIOGRAPHY Bartlett, Harriett M., Emotional Elements i n Illness: Responsibilities  of the Medical SociaTWorker, The Family, v o l . 21, pp. 59-47, Ap r i l , 1941. Bryson, Elizabeth, The Psychosomatic Approach i n Gynaecological Practice, The Practitioner, London, 1945, v o l . 55, pp. 378-384. "~ Carleton, W.T., Gastro-intestinal Tract Disturbances, Navy Medical Bulletin, Washington, 1945, vol . 44, pp. 538-548. Cobb, Stanley S., Technic of Interviewing a Patient with a Psychosomatic  Disorder, Medical Clinics of North America, W.B. Saunders Co., Philadelphia, pp. 1210-1216, Sept. 1944. Deutsch, Felix, Emotional Factors i n Asthma and Other Allergic Conditions, mimeographed by the American Association of Medical Workers, Washington, 1941. Deutsch, Felix, Social Service and Psychosomatic Medicine, mimeographed by the American Association of Medical Social Workers, Washington, . 1941. "." ' Deutsch, Helen, Psychology of Women, 2 vols., Grune and Stratton, New York, 1944. Dunbar, Flanders, Emotions and Bodily Changes, Third Edition, Columbia University Press, New York, 1946. Dunbar, Flanders, Psychosomatic Diagnosis, Paul B. Haeber Inc., Medical Book Division of Harper and Brothers, New York, 1943• Dunbar, Flanders, The Psychic.Component i n Disease (from the Point of View of the Medical Social Worker's Responsibility), Bulletin of the Medical Social Workers, Washington, vol. 10, pp.69-80, August, 1937. Ebert, Virginia B., Casework Services to Children with Rheumatic Heart  Disease, The Family, v o l . 22, pp. 9-14, March, 1941. English, Oliver S. and Pearson, Gerald H., Emotional Problems of Living, W.W. Norton and Co., New York, 1945. Friedman, Jacob H., The Attitude of the Psychoneurotic Toward Scientific  Contraceptive Advice, Journal of Nervous and Mental Diseases, Coolidge Foundation, New York, 1943, vol. 98, pp.396-413. Halliday, James L., Psychosomatic Medicine and the Rheumatism Problem, The Practitioner, 1943, vol . 152, pp. 6(r Hinsie, Leland E., The Person i n the BodVj W.W Norton and Co. Inc., New fork, 1945. - 59 - -Hertzmann, Jeanette, Casework i n the Psychosomatic Approach, Journal of Social Casework, vol. 27, pp. 299-507, January, 1946. Jones, Chester M., Functional Gastro-intestinal Disturbances, Medical Clinics of North America, W.B.- Saunders Co., Philadelphia, pp. 1154-1163, September, 1944. Lewis, Aubrey, The Psychological Aspects of Indigestion, The Practitioner, London, 1943, vol . 152, pp. 257-260. Lundberg, George Andrew, Social Research, Longmans, Green and Co., London, 1929. Margolis, H.M., The Psychosomatic Approach to Medical Diagnosis and Treat- ment, Journal of Social Casework, vol. 27, pp. 291-298. Richardson, Henry B., Patients Have Families, Commonwealth Fund, New York, 1945. ' Richardson, Elizabeth, An Adventure i n Medical Social Work, vol . 14, pp. 2-4, 27, June, 1945. Robinson, G. ,Canby, The Patient as a Person,Commonwealth Fund, New York, 1939. Simon, Bernece K., Social Casework i n a Medical Setting, The Social Service Review, v o l . 20, pp. 362-373, Sept. 1946. Waller, J. Kaufman, R., Deutsch, Felix, Anorexia Nervosa; a Psychosomatic  Entity, Psychosomatic Medicine, sponsored by the Committee on Problems of Neurotic Behaviour, Division of Anthropology and Psychia-try, National Research Council, The Williams and Watkins Company, Baltimore, vol.2, pp. 3-16, January, 1946. Webb, Beatrice and Sydney, Methods of Social Study, Longmans, Green and Company, London, 1932. Weiss, Edward and English, Oliver S., Psychosomatic Medicine, Saunders, Philadelphia and London, 1943. p Young, Scientific Social Surveys and Research, Prentice a a l l , Inc., New York, 1939.' Zillboorg, Gregory, Psychosomatic Medicine- a Historical Perspective, Journal of Nervous and Mental Disease, 1943, v o l . 98, pp.414. / 

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