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Homemaker service for tuberculous mothers : an analytical study of Vancouver's three-year special project Gilchrist, Margaret Dorothea 1952

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HOMEMAKER SERVICE FOR TUBERCULOUS MOTHERS An Analytical Study of Vancouver's Three-Year Special Project MARGARET DOROTHEA GILCHRIST Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK in the School of Social Work Accepted as conforming to the standard required for the degree of Master of Social Work School of Social Work 1952 The University of British Columbia TABLE OF CONTENTS i i . Chapter 1. The Impact of Tuberculosis Page The nature of tuberculosis. The "tuberculous personality". Dr. Wittkower's research. The tuberculous mother. 1. Chapter 2. Groping for a Solution Vancouver's resources for helping the mother with tuberculosis. Supervised Homenaker Service. Historical background of the special project. Extent and cost of t o t a l T.B.-Homenaker project......... 17* Chapter 3« The Problem of Evaluation Aims of the T.B •-Homenaker project. Earlier evaluations. Background of the present evaluation. 37. Chapter 4. Results of the Bating Scale - General Control data. Total evaluation. Circumstances under which service was given. Health evaluation. Supervised Homenaker Evaluation • 47. Chapter 5. Results of the Rating Scale - Casework Evaluation Function of casework. Client-worker relationship. Problems given casework consideration. Progress i n the solution of problems. Care of children • •• 69 Chapter 6 How Valuable was the Project? Gains in health. Contribution of the caseworker. Contribution of the Supervised Homemaker. Security of children. Recommendations re use of the caseworker. Focus of casework. Selection and placement of homemakers. Intake procedures 96. Appendices: A. A rating scale for evaluating Supervised Homenaker Service to families where the mother has tuberculosis. ...........117. B. Supplementary charts for Chapter 4».................... 128. C. Application forms for T.B.-Homemaker Servioe....» 134* D. Bibliography... 144-145 i i i TABLES AND CHARTS IN THE TEXT Charts Page Figure 1. Premorbid personalities of tuberoulous patients (Wittkower's classification) • 7 - 8 Figure 2. Personality and l i f e situation of tuberoulous patients suffering relapse (from Wittkower) ........ 12* Figure 3. Relationship between emotional reaction to tuberculosis and course of tha disease (from Wittkower).... • 14* Figure 4. Cost of Supervised Homenal© r Service January - June 1944> Family Welfare Bureau, Vaneouver ............. 25* Figure 5. Source and amount of refunds to Family Welfare Bureau for T.B.-Homemaker Service April 1949 - January 1952 i n c l . 32. Figure 6. Administrative costs of T.B.-Homenaker Service ••••• 32. Figure 7. Distribution of 58 T.B.-Homenaker families according to the cost of service per family • • • 33* Figure 8. Distribution of 58 T.B.-Homemaker families according to length of service 34* Figure 9. Monthly distribution of hours of T.B.-Homsmaker service • 36. Figure 10* Distribution of 42 T.B.-Homenaker families aocording to over-all evaluation 49* Figure 11. Distribution of 42 r.B.-Homemaker families according to year i n which service was started and over-all evaluation ......................................... 50. Figure 12. Movement scale for health progress of 29 patients on B.R.F. 57. Figure 13. Distribution of T.B.-Homenakers according to length of service i n each home 64. Figure 14. Suitability of Supervised Homemakers to needs of T.B. families 67* Figure 15. Warmth i n the client - caseworker relationship: movement scale for 42 T.B.-Homemakor oases ......... 74. Figure 16* Dependency i n the client - caseworker relationship: movement scale 75* i v Figure 17. Freedom to express h o s t i l i t y i n the client -caseworker relationship: movement soale 76. Figure ia. Average amount of growth i n olient-worker relationship •• 77 • Figure 19. Number of clients showing no growth i n client-worker relationship •• 77* Figure 20. Growth i n the olient's relationship with caseworker and with supervised homemaker 79* Figure 21. Proportion of T.B.-Homeiiaker clients who achieved satisfactory client-worker relationship ............ 79» Figure 22. Distribution of patieat^s problems given casework consideration, according to area of d i f f i c u l t y ..... 83» Figure 23. Distribution according to severity of a l l problems given casework consideration 85* ABSTRACT In Ap r i l 1949 the Family Welfare Bureau, i n conjunction with the Metropolitan Health Committee, and with the financial support of the Federal Department of Health, began a three-year project to provide supervised homemaker service to families where the mother had tuber<= oulosis* By the end of March 1952, fifty-nine families had been given service, forty-eight of these for a period longer than three months. These forty-eight families are the subject of this study* In order to evaluate the effectiveness of this special project, a rating scale was drawn up as an aid i n the task of measuring the results of the service provided* The rating scale was devised to assess three main aspects of the program - health improvement, super-vised homemaker service and casework service* Questions were of two kinds - those which asked for factual data about the families and about the service providedj and those of an evaluative nature, i n which an effort was made to assess change and growth i n the clients' attitudes and behavior between the opening and closing of the case* The questions were answered by agency caseworkers who knew the families ooncerneds nine workers completed forty-two rating scales i n sufficient detail for use i n this thesis* At the end of the rating scale, workers were asked to assess the value of the t o t a l service to the family i n question* On the basis of this over-all evaluation, each of the forty-two cases v/as placed i n one of three categories - the highly successful, the moderately successful, or the unsuccessful* The components of the entire rating scale have been tabulated and analyzed.in such a way as to highlight differences which seem significant between these three categories© The study leaves no doubt that the T.B.-Homemaker Project made a significant contribution to the physical and mental health of the families given service* However, on the basis of the agency's experienci certain tentative recommendations have been made with regard.to the role of the caseworker, the foous of casework, the selection and placement of homemakers, and intake procedure» v i . ACKNOWLEDGMENTS All branches of sooial work have made some contribution to this piece of research. The projeot which i t attempts to evaluate was the result of community organization. The casework aspects of T.B.-Homemaker Servioe are the foous of most of the study. The research design makes use of material and techniques developed by specialists in social work research. And there were elements of group work process in the participation of Family Welfare Bureau workers in the evaluation project. In particular the writer wishes to express her sincere appreciation: - to Miss M. McPhedran, Director of the Family Welfare Bureau, for her interest and her kindness in making available both the necessary material and the time of her staff, - to Mrs. E. Kenyon, Mrs. B. Mabee, Mrs. M. Cowper, Miss L. Carscadden and other members of the Family Welfare Bureau staff, without whose counsel and participation this project would not have been possible s - to Mrs. H. Exner and Dr. L.C. Marsh of the School of Social Work, for their penetrating criticism and patient understanding., CHAPTER I - THE IMPACT OF TUBERCULOSIS Tuberculosis was first reoognized as a disease entity by the Hindus as early as 1500 B.C.t i t has been a plague of the human raoe ever since* So often does i t go hand in hand with poverty, poor nutrition, f i l t h and overcrowding that its incidence is widely used as one of the indioes of sooial disorganization, along with suoh other statistics as the infant mortality rate; but i t also makes its insidious appearance in many homes whose socio-economic standards are quite adequate* It is characteristic of l i f e in a modern civilized community that more or less everybody comes in contact with the tuberole bacillus and that, in consequence, the population in general acquires a high degree of immunity against infection. The most recent thinking about the etiology of the disease assumes that a variety of factors, which a l l operate to lower a person's resistance, are responsible for the onset of manifestations of active tuberculosis in adult l i f e * At the turn of the oentury, the mortality from tuberculosis in the 1 United States of America was 202 per 100,000. In the intervening f i f t y years, inoreased opportunities for healthier living conditions, extensive programs of health eduoation and case-finding, and more effective and more available treatment methods, have combined to reduoe 1 2 the mortality rate to 36*4 in the U.S.A. and 31*2 in Canada. However, as recently as 1943# i t ranked seventh as a cause of death for the 1. Frances Upham - A Dynamic Approach to Illness Family Servioe Association of Amerioa - Hew York 1949 P.105. 2. Canada Year Book, 1951 (Figures for 1948) population of the U.S.A., and f i r s t as a oause of death in the age group 15 - 44. In the literature of the nineteenth century, tuberoulosis, then commonly known as consumption, was a favourite disease for the heroines of tragio or melodramatio novels* It was usually described as dramatic i n onset, "galloping" i n progress, and fa t a l * Today, thanks to the develop-ment and widespread use of mass ohest X-ray surveys, 70 per cent of the new cases discovered by this method are i n the minimal stage* The early symptoms of the disease - lack of energy, lack of appetitie, sleeplessness, i n a b i l i t y to oonoeatrate, emotionality - are so diffuse and non-speoifio that the actual diagnosis oomes as a great shook t o many patients* Among the commoner long-term Illnesses, tuberoulosis alone i s Infectious, requiring prolonged quarantine so that other members of the family and the oommunity may be protected from contagion* Most communities provide for the care of acutely i l l tuberculous patients i n state-financed sanatoria where no other disease i s treated* Management of such institutions ranges from the autooratio to the democratic: but even i n those which aim to make the l i f e of the patient as pleasant as possible, the necessary treatment includes many unpleasant and threatening features* It involves physioal separation from family and friends, with con-comitant feelings of sooial rejection: seeing your ohildren only through a glass screen, i f at a l l ; knowing that i f you kiss your spouse, you may infect him - i s this not, i n i t s e l f , a form of torture? Standard treatment for tuberoulosis includes a long period of bed-rest, often imposed long past the time when the patient actually feels i l l * This severe limitation of physical outlets for the release of emotional tension affects seme people more than others, but no 3. sanatorium patient is able to remain completely unaffected* Other commonly used forms of treatment - pneumothorax, thoracoplasty, phrenic crush, pneumoperitoneum - are surgioal in nature and call up in the patient rational and irrational fears related to earlier experiences* Another outstanding character1stio of tuberculosis io its recurrent nature* Recovery from an attack of primary tuberculosis represents victory only in the first battle with the germ* in a war that may last for years* The majority with manifest tuberculosis suffer relapses* Further-more, the relapses are usually more serious than the original attack* 1 This factor, plus the high mortality rate, help to make tuberculosis one of the most anxiety-produoing of a l l the long-term illnesses* In order to prevent relapse, patients must adapt themselves to a life-long "protected" regime which includes avoidance of unnecessary strain and physical exercise; proper nutrition; more than normal rest; and great oare of intercurrent illnesses, especially of the upper respiratory tract* A certain amount of oooupational readjustment is necessary in most oases* This may range a l l the way from seme sort of "industrial oonvalesoence" - a hardening-up period of lighter, part-time employment at a familiar job-to complete vocational retraining, or to a l i f e of unemployabillty* In summary, then* tuberculosis is a chronic disease which, by its nature, provokes severe anxiety; also,because of its duration and method of treatment, i t has tremendous emotional implications for the patient, 1. Pattison, Harry A* Rehabilitation of the Tuberculous Livingstone Press, Hew York 1942 " ~" " of which frustration, fear and a feeling of social rejection are the most outstanding* The "Tuberculous Personality11 Hippocrates reoognized tuberoulosis as "a disease influenced by 1 sentiment and by the conditions of weather, soi l and water"* Ever since his time, periodio attempts have been made to correlate tuberculosis with constitutional factors, mental disease, disorders of speech and writing, hypersexuality, unmet dependency needs and emotional trauma, to mention only a few. A number of generalizations concerning t he peculiarities of the tuberculous patient clutter the medical l i t era ture» contradiction contradicts contradiction, and the patient is desoribed as anything between an insane criminal and a saint too ethereal for this mundane world* 2 , Weiss and English point out the high inoidenoe of neurosis in persons suffering from tuberoulosis and suggest that the pre-morbid neurotic personality was probably a causative factor in the disease* They believe that neurotic habits related to eating, appetite and nutrition may be responsible for the underweight that frequently precedes tuberoulosisi or anxiety may prevent needed sleep and rest* However, they present no soientifioally tested evidence to support their theory* Dr. Leslie E . Luehrs, staff psyohiatrlst for the Community Service Sooiety of New Yrok, attempts a Freudian approaoh to the problemi 1. Quoted in "Emotional Factors and T.B." , Beatrice B. Berle - ' Psychosomatic Medicine Vol.X,„pp*366-71 2* E . Weiss & 0*S. English Psyohosomatio Medicine, W.B* Saunders -Second Edition 1949 - p.615 5 I believe that the tuberculous personality i s characterized by an almost equal urge toward aggression and toward passivity, toward livin g and toward dying, toward infantile dependence and mature independence. There i s usually a strong ego drive for achievement, but the impetus toward achievement, i s ohe«!kad> by a fear of his own aggression, or guilt about being too successful. As a result, he leaves a goal not reached, and retreats rapidly In the other direction of inactivity and dependency u n t i l his guilt about this adjustment starts the goal swinging again toward aggression...When the person i s releasing his aggression, his whole well-being adds to his resistance; but at the point where he begins t o retreat from his aggression, he lets down his general defences, inoluding his resistance to the disease, which then reasserts i t s e l f and helps carry him In the other direction toward passivity and dependence. 2 Berle points out that most analytio studies have been unaccompanied by c l i n i c a l and laboratory data on the course of the disease i n the individuals studied, and goes on to say* No progress oan be made i n the understanding of the relationship of emotional faotors and tuberoulosis unless the physiologio aooompaniments of emotional stress are included i n the detailed study of the problems of virulence, since this i s the only way in which the effeot of "undue emotional strain," recognized sinoe the third oentury as influencing the course of tuberculosis, oan be broken down into Its component parts. However, Dr. IWittkower's study of the psyohologioal aspects of " 3 tuberculosis seems to meet most of Miss Berle's exacting standards. On .a researoh fellowship from the National Association for the Prevention of Tuberoulosis, Dr* Wittkower, an. eminent B r i t i s h psychiatrist, spent two and a half years doing the original researoh upon which his slim, thoughtful volume i s based. Before drawing any conclusions/ Dr. Wittkower interviewed 785 tuberoulous patients for at least two hours each. The interview i n a l l oases, though by no means r i g i d l y standardized, comprised (1) a c l i n i c a l history (2) an assessment of the patient's reaotion to his 1. Quoted In Ruth 0* Cowell "Case Work with a Tuberoulous Young Woman" The Family Vol. XXVII No. 3 p. 96 2. EmotionaTFaotors and T»B. op.cit* 3.. A Psychiatrist .Looks at Tuberoulosis - Erio Wittkower M.D., -published by the National Association for the Prevention.of Tuberoulosis London 1949. illness, its treatment and its implications and (3) an assessment of his premorbid personality and his life-situation at the time of onset. The 785 patients interviewed represented a carefully seleoted random sample of Britain's tuberoulous population^ from the point of view of sex. marital status, social status, age on examination, and severity of tuberoulous lesion. 294 were sanatoria patients, 27 patients at village settlements$ 94 were at home, unfit for work. 235 were at work, 82 of them in village settlements, others in normal places of employment: 49 more were classified as f i t for work but were unemployed when interviewed. One of the questions which Br* Wittkower set out to answer was "what kind of a fellah" is predisposed to develop tuberculosis* He broke his enquiry down into three parts, designed to ascertain -A* Typioal features, i f any, of the premorbid personalities of tuberculous patientst. B. The effect of personality factors on the course of the disease:: and C* The relationship between reaction to illness and oourse of illness* His conclusions oan be summarized as follows:: ... A* Reconstruction of the premorbid personality in the 300 patients selected for this part of the study showed no uniformity. The best that Dr. Wittkower could do was to identify groups of individuals similar in their behavior pattern and in their basio conflicts* The groups isolated in this manner can be set out as follows FREQUENCY (In %>s) TYPE CURRENT BEHAVIOR PATTERN BASIC CONFLICTS 10 1.Overtly insecure a )over«-dependent 8 b) leaning 21 o)asserters of independence 27 I l a . Self-drivers b)Self-drivers in reverse "Overgrown children", poor sense of responsibility, very s e l f -centred, unable to tolerate frustrat-ion* Excessive need to be well-liked; agression either re-pressed or suppressed leads to anxietyt re-act disproport-ionately to frustration* Work hard to earn approvalJresent dependence on anyonet worriers* Severe sense of duty, often with overweening aimbitiousness • Need to impress others* Aggression channeled into work or against them-selves • Self-frustrating, self-damaging and self-humiliating trends esp* i n occupational f i e l d . Naroissistio immaturity« no anxiety* Experience of ohildhood rejections immature - s t i l l need parent substitutes* Defenoe mechanism for dependency needs and basio insecurity - feel rejected by parent figures. Overdeveloped super-ego -masochistic drives i no overt rebellion. Defenoe mechanism against over-developed super-ego. Figure li A Psychiatrist Looks at Tuberculoses lover) : 8. FREQUENCY" (in %'a) CURRENT BEHAVIOR PATTERN BASIC(OONFLICTS TYPE 12 III.Rebellious 13 IV.Conflict-harassed V.Misoellaneous Resentment of imposed authority» i n -calculable agressive behavior: shallow social contacts of nbooa*» > companion11 type. Inconsistent behavior - excessive sel f - c r i t i c i s m . Conscientious, ambitious - high standards. (Mental defectives, mentally i l l , or too l i t t l e material for classification) Lack of affect-ion plus over-controlling parents. Defence against need for affection* D i f f i c u l t y i n ooping with agressive and sexual thoughts -t e r r i f i o anxiety. Figurels Premorbid personalities of tuberculous patients - summary of (cont'd) classification used by Wittkower (op.cit.) and percentage distribution for 300 patients. Because of the type of classification whioh Dr. Wittkower uses, i t i s not easy to correlate his findings with the conjectures of Freudian 1 psychiatrists already quoted. His study provides impressive evidence to support the theory that the majority of those who develop tuberculosis have personalities whioh are either basically neurotic or characterized by marked neurotic oomponetss the 36 patients of type III comprise the only group whioh i s specifically, but not neoessarily, non-neurotio, and even some of these might well be classified as fixated at the oral-aggressive phase. However, i t would seem that only some 18% of his sample (the "over-dependent" and "leaning") f a l l without question into the "oral . . 2 fixation" category whioh Weiss and English imply i s typical of the 1. See pp (4-5) ~~ 2. See p. (4) 9» tuberculous, and that anal and oedipal maladjustments are at least equally frequent. From the point of view of overt behavior patterns, the largest single group are the 48/6 who drive themselves too hard out of a deep-seated heed for either social approval ("asserters of independence1) or self-punishment ("self-drivers")* Dr* Wittkower also attempted to disoover the extent to which emotional trauma immediately preceded the onset of tuberculosis, and may therefore be considered a precipitating, even i f not a strictly etiological factor* From this point of view, the l i f e histories of the 300 patients under investigation were submitted to careful examination* His findings are best expressed in his own words: It was found that In a considerable number of these patients, disturbing events of a specific nature preceded the onset of symptoms* However, to understand the real significance and relevance of these events, i t obviously matters l i t t l e what they were e.g. a demotion or the death of a member of the family, but rather what they were felt to be by the patient*•• namely, a rebuff, the loss of a supporting figure or the removal of a person who had been loved and hated at the same time* Application of this principle to the patients of the overtly in-secure and of the rebellious types shows that at the time of onset of their symptoms: 13 of the 31 patients of the over«dependent type were In a state of violent resentment of what they regarded as hardships: 20 of the 24 patients of the leaning type were emotionally disturbed by what they regarded as a rebuff, or by separation from, threat of losing, or aotual loss, of a supporting figure; 33 of the 62 self-asserters found themselves in a similar situations and 13 of the 36 patients of the rebellious type were disproportionately resentful of either imposed hardships or imposed authority* The situation is somewhat different with regard to the self-drivers (including the self-drivers in reverse) in whom, whatever other precipitating factors may play a part, the main emphasis must be placed on their self-damaging, self-frustrating and self-humiliating 1 0 . trends; and with regard to the representatives of the confliot-harassed type whose oonflicts over aggressiveness or over sexuality came to a climax previous to the onset of symptoms of tuberculosis because, in fact or in fantasy, they had done something which they felt they should not have done. 1 In brief, Dr. Wittkower considers these factors to be important only for the 51% of his sample whom he classified as insecure or rebellious, and demonstrably significant for only a l i t t l e more than half of these* Dr* Wittkower summarizes his psychopathological conclusions as follows It has been shown that an inordinate need for affeotion is an outstanding oommon feature of the premorbid personality of tuberoulous patients* This need for affection may be openly expressed, thinly disguised, well-ooncealed or flatly denied* Coupled with i t are conflicts over dependence* At the one end of the scale are individuals who adopt a receptive, parasitic or leech-like acquisitive attitude towards members of their family, If not to the world In general; at tfoe?other end are individuals who, by ostentations Insistence on Independence, reveal their inability to recognize and to admit their need for dependence* Between these two extremes lies the whole gamut of defences against admission of need for affection and dependence.... Individuals who develop tuberculosis seem to have In oommon an inability to deal adequately with their aggressive Impulses and are prone, though for varying reasons, and In different ways, to turn them against themselves* The advent of the illness seems to be the outcome of their self-destructive trends which may be extra-punitive or Intrapunitive In function... Situations which rouse aggressiveness or endanger the delicately poised security system of the patients often precede the onset of symptoms of tuberoulosis*•• The psychological mechanisms identified here, which is no way Invalidate the relevanoe of other etiological factors, such as adverse living conditions, offer some explanation as to why a person falls i l l and why he falls i l l when he does, but they f a i l to explain why he falls i l l with pulmonary tuberculosis* 2 3?. op. cit* p*107-108 .2<«. op. c i t . p.136-8 1 1 . In. the absence of a oontrol group, there is no way of knowing how much more frequently these characteristics ooour among people destined to contract tuberculosis than among the general population: however, to have these facts established is of tremendous importance to a l l who have oocasion to work with the tuberoulous* As for the other characteristics which have been ascribed to the "tuberoulous personality", most of them can be adequately explained on a reactive basis* The depressive mood of the tuberculous is a normal and adequate reaction to their illness; elation and euphoria, i f they occur, are defences against depression* Self-centredness, selfishness, suggestibility, are regressive phenomena common to many sufferers from chronic illness* Introspection, day-dreaming, intellectual preoccupation, are forms of behavior fostered by imposed muscular inactivity* Their tendency to break bounds together with their tendency to disoharge. themselves prematurely, seems to find an explanation in their confinement and isolation: i f the sense of confinement is aggravated by restrictive measures and by poor morale in the sanatorium, the rate of premature self-discharges rises significantly* • • B* To obtain evidence as to whether, and to what extent?, emotional factors affect the course of the disease, the case-histories of 68 patients who had had one or several relapses were grouped according to the patients1 personality types, and the l i f e situation previous to the onset of relapses was submitted to an analysis* The results of this study may be tabulated as follows: 12* TYPE FREQUENCY-/300 PATIENTS FREQUENCY -/68 RECURRENCES MOST FREQUENT CAUSE OF RELAPSE 1« Overt ly insecure a)over-dependent 31 2 b) leaning 24 3 overwork(5) c) asserters of 62 12 independence Ila)Self-drivers 80 19 overwork(ll) b)Self-drivers in reverse 7 5 masochism^.) III. Rebellious 36 9 riotous living (6); 17. Conflict-harrased 38 11 persistence and intensifiat-tion of conflict Figure 2s Personality and l i f e situation of tuberculous patients suffering relapse - adapted from Wittkower. From the above i t will be seen that patients of the over-dependent and leaning types seem to offer a good prognosist in Dr. Wittkower's words, "they are much too fond of themselves to expose themselves to undue risks"• At the other end of the soale, the continuing,masochistic behavior of the "self-drivers in reverse" serves to bring on. relapses at. an alarming rate. Self-asserters and self-drivers, on recovery, tend to overwork themselves or to take on unsuitable jobs, partly owing to their basic personality structure and partly owing to feelings of guilt over having defaulted in their duties though being i l l . About the conflicts harassed individuals. Dr. Wittkower says: 1 3 . Generally i t is probably true to say that the ohanoe of permanent, or at least of long-lasting recovery, in conflict-harassed individuals depends on whether or not the advent of the illness and their subsequent suffering adequately serve as a means of self-punishment and of atonement• 1 Contrary to his expectation, he found that disturbing events of a specific nature considerably less frequently preceded the ooourence of relapses than the onset of the disease* Thus emotional trauma, which preceded the onset of tuberculosis in 79 out of 153 patients in the insecure and rebellious categories* preceded relapses in only 4 out of 26 patients of these types* In summary, Dr. Wittkower says: The data strongly suggest that the speed and ohanoe of recovery of an individual depend to a great extent upon his personality, and that sometimes i t may be safer to assess a patient's prognosis on the basis of his personality and of his emotional conflicts than on the basis of the shadow on the (X-Ray) film* .2 C. To disoover what relationship, i f any, there is between the patient*8 reaction to his illness and the course of the disease, one hundred patients examined at King Edward Sanatorium, Midhurst, early in 1946, were followed up after two years* Their state of mind at the time of i n i t i a l examination was brought into relation with their clinical oondition at the time of follow-up} also with the: oourse of the disease at the time of i n i t i a l examination* The results of this study may be tabulated as follows: .1. Ibid* P.140 .2. Ibid. P.139 14. EMOTIONAL 1946 1948 REACTION Up-grade Down-grade, Arrested, Down-grade stationary improved stationary L i t t l e concerned 29 11 36 4 Severely concerned 13 18 24 7 Psychological defences 11 18 20 9 Figure 3? Relationship between emotional reaction to tuberoulosis and course of the disease - adapted from Wittkower - A Psychiatrist  Looks at Tuberoulosis It w i l l be noted that of those who were l i t t l e oonoerned i n 1946, 90$ had made a good recovery by 1948, compared with 30% of those who were severely concerned, and 20% of those who displayed psychological defences (e.g. defiance, over-cheerfulness, resentment, apathy). But i t also well to observe that three-fourths of the patients who were l i t t l e concerned i n 1946 had good reason for such an attitude, since they were on the up-grade t whereas of those who were severely concerned or using defence mechanisms, 36 out of 60 had to face the re a l i t y that their progress towards recovery was down-grade, fluctuating or stationary. In other words, i t i s d i f f i c u l t to determine whioh i s cause and which is effeot. The Tuberoulous Mother How does this apply to the situation of the mother who develops tuberoulosis? It has already been mentioned that one of the characteristics of this disease i s i t s contagious nature, whioh proscribes a l l close social contacts. This would be particularly disturbing for the young mother who is thus cut off from her husband and children* Dr. Wittkower's study 15-oonfirms this. 80$ of the married women in his group were severely upset by the i n i t i a l diagnosis, compared with 59% of the entire group who had this reaction. He also found a definitely significant correlation between marital status and concern about the disease. 41% of the married patients compared to 23% of the single patients expressed severe concern about their illness t this percentage rose to 53% for the married women. It is not merely a matter of ostraoism. Who is to take over her duties while she is "taking the cure"? Will the children get adequate oare and training? Will they grow away from her while she is in the sanatorium? If paid help is secured to run the home, how will the cost be met? If a relative is able and willing to help, how oan she ever be repaid for sueh long-term self-sacrifice? If i t is necessary to place the ohildren, will they ever understand and forgive her? : And what about marital relationships? Her husband married, her when she was in good-healthi how does he feel about a wife who has become a "chronic invalid"? or who, at best, must-always take extra, good oare of herself? The reassurance that she might get from physical demonstrations of affection is ruled out by the nature of the illness. Confinement in bed and in hospital increase her anxiety and tend to create depression while reducing outlets for emotional tension to an often intolerable minimum. Under these circumstances, minor and unintentional slights or disagreements can easily become major incidents in the eyes of the patient. At the same time, her husband's tension is also increased by such factors as additional responsibilities at heme and anxiety about his wife's illness: he too must cope with lack of usual satisfactions for his sexual drives. 16. The situation is not much easier upon the wife's return from hospital. She has grown accustomed to the protected environment of the hospital, and may continue to expect the same amount of oare at home. She may have changed while in hospital: under the influence of tuberculosis, reckless people have been known to become extremely careful of themselves* careful people reokless "because I haven't long to live"; cheerful people sometimes turn bitter and irritable, and sturdy oaks become clinging vines. The environment may also have changed considerably. A normally dependent husband may have grown to new stature, or conversely, may have broken under the strain of his wife's illness and his resultant extra responsibilities. Children likewise have grown older, and may have grown into new independence or new attachments. Some communities have worked out "sheltered workshops" and periods of industrial oonvalesoenoe for tuberculous patients returning to commercial employment. What about the similar needs of mothers returning to their homes and families? Ordinarily, patients reoeive optimum benefit from sanatorium oare some weeks or months before they are ready for "normal" routine: some need discharge when the only "exercise" allowed them is the familiar B.R.P. (bath-room privileges). In many oases, they look and feel reasonably well at this point, and there is a strong tendency for the environment to make demands upon them whioh they cannot meet without disobeying the doctor's instructions and endangering their recovery. How can wives and mothers be helped to ease themselves gradually back into their rightful role? 17 CHAPTER I I - GROPING FOR A SOLUTION In Greater Vancouver, as a matter of publ ic health praot ice , nurses of the Metropoli tan Health Committee make per iodic v i s i t s to homes where any member of the family i s known to have, or to have had, tuberculosis* Their purpose i s to see that patients carry out the doctor ' s recommendations and re turn regu la r ly to the nearest C l i n i c for oheok-up: and to interpret the need of other members of the family for frequent 1 X-rays , since recent researoh (notably the Cattaraugus County study) has demonstrated that the incidence of tuberoulosis i s as much as th i r t een times higher among the famil ies of the tuberoulous than among the general population* In the course of t h i s work, the nurses gradual ly beoame more and more concerned about the famil ies where the mother had contracted tuberculosis* The welfare of the ch i ld ren made i t essen t ia l that the heal th of t h i s group of patients be given highest p r i o r i t y * ye t , fo r the reasons out-l i ned above, these were often the people who found i t hardest to co-operate w i t h the dootors In treatment* Some of them, having been diagnosed, had been put on a Complete bed-rest program at home u n t i l a bed should be ava i lab le at the sanatorium* Others, w i t h a place awaiting them at the h o s p i t a l , had found I t d i f f i c u l t i f not impossible to take advantage of the f a c i l i t i e s ava i lab le because they had not been able to make sa t i s fac tory arrangements fo r the care of t h e i r home and chi ldren* A t h i r d large group was made up of women who 1* H.D. Chadwiok & A*S* Pope "Modern Attack on Tuberoulosis^ New York, The Commonwealth.Fund 1942. 18, had completed a period of sanatorium oare to ths point where the dis-advantages of institutional regimentation and separation from family and friends were outweighing the advantages of a protected and controlled environment, but who were s t i l l far from ready to assume their f u l l household responsibilities* Patients differed widely in their resources for meeting these situations* There were those with a sufficiently large inoome that they oould afford to hire a housekeeper privately for as long as necessary* However* even these families found that, exoept when employment was quite slack, i t was not easy to persuade a competent housekeeper to work in a tuberoulous home when she oould secure a position with no apparent risk of infection: or to stay long enough to give some continuity to family l i f e . There were others with relatives upon whom they oould oall for assistance. In many oases, there were real advantages in this, especially for the children. Initially at least, i t is less frightening to have grandma or Aunt label take oharge when mother is sick than to get used to a complete stranger or, worse s t i l l , a series of complete strangers* But relatives who may be genuinely glad to help out during confinement or short illnesses, often find very burdensome the length of time their assistance is needed in oases of tuberculosis, or become terribly concerned about its infectious nature* Furthermore (and again the time factor makes this especially important), any emotional strains in the previous relationship between the relative and the family tend to develop into major issues under the pressures of this type of situation* For example, a daughter may have ,had considerable difficulty in breaking a 19. hostile-dependent tie to her motiierj But with the help of an understanding husband and geographical separation, she suooeeds in emancipating herself to a satisfactory degree. Now that the daughter has developed tuberoulosis, her moths r comes to take over responsibility for her home and children,reactivating the dependency pattern of her ohildhood and a l l its oonfliots* Or perhaps the "good Samaritan" is a favored older sister, who has always known how to make the patient feel incompetent, and who relishes this opportunity to show her just how she should manage her home and children* In either of these cases, or a dozen similar ones, the situation provokes in the patient a large amount of anxiety and hostility which, out of gratitude to her benefaotor, she dare not express. If we accept Dr. Wittkower«s thesis that difficulty in handling feelings of aggression is characteristic of tuberculous patients, this factor assumes particular significance. Then too, a l l emotional considerations aside, what of the ecjonomio Implications of this type of solution? For families on marginal incomes, one more mouth to feed is no minor affair. And the benefactor Is ordinarily sacrificing the opportunity to earn money elsewhere, a faot of which she may remind the family in moments of anger, but which tends to further complicate the problem whether i t is mentioned or not* For those families who are enabled neither by adequate finances nor by kind relatives to make their own plans, the community has made some provision. Children who are suspeoted of having tuberoulosis oan be looked after in the Preventorium. For a limited number of children, arrangements oan be made through the Children's Aid Society for-non-ward foster-home placement. For others, foster day care may be the most 20. satisfactory arrnagement* Perhaps neighbors may keep a watchful eye on older school-age ohildren for the time elapsing between sohool dosing and father's return from work* For many of the situations coming to the attention of the metro-politan health nurses, these community resources seemed reasonably adequate* For example, foster home plaoement or institutional oare may 1 be the best possible plan for ohildren in certain age groups or for those from very deprived or disturbed homes* And some fathers are able to play both a father and a mother role over a considerable period of time, so that for the ohildren, foster day care or a neighbor's supervision is adequately supplemented by the feeling of security that comes from belonging to a strong-knit family unit* A l l four of these plans make heavy emotional demands upon both parents and children, demands whioh they are not always ready to meet. The children-are asked to adjust to a whole new regime at a time when their anxiety about mother's illness is apt to reactivate infantile dependency needs* In the oase of plaoement, this change frequently involves the loss of familiar surroundings and play-mates as well as acoeptanoe of new parent figure, new siblings, and of the new role played by their own father under these circumstances* The mother is asked to "give up" her ohildren at a time when her ego is seriously weakened by illness* unless her relationship with them is healthy and mature, this is extremely 1* For example, ohildren working through oedipal conflicts may find i t less threatening to "visit" away from home than to adjust to someone ooming right into their own home and "usurping" mother's plaoe, unless they feel that liking other adults is "disloyal" to their own parents* 21. d i f f i c u l t for her, especially i f she has guilt feelings about rejeoting them. Furthermore, i n praotioe, none of these provide an entirely satisfactory solution to the.problem of the convalescent mother needing help i n gradual resumption of home responsibilities. Actually, whatever plan i s made, the mother i s apt to be i n a serious predicament. I f the family get along well without her, her sense of adequaoy i s threateneds i f they don't, she may blame herself. Under the oiroumstanoes, i t i s hardly surprising that many problems arose. Some tuberoulous mothers were refusing hospitalization beoause they would not oonsider placement of their children and could make no alternative arrangements. Others were signing themselves out of sanatorium prematurely as plans that had been made broke down. Social workers and doctors i n the sanatoria were concerned about the degree of anxiety oreated i n many patients by the d i f f i c u l t i e s their ohildren and husbands were experiencing, and i t s deterrent effect en their health. Supervised Homemaker Servioe For mothers i n similar oiroumstanoes, but suffering from short-term illnesses, or needing hospitalization for confinement, surgery, or other treatment, the oommunity did provide an additional service. In 1938 the Family Welfare Bureau, Vancouver's private family agenoy, had taken the f i r s t steps towards establishing i t s Supervised Homemaker Service. In that year, following the example of other family agenoies i n Canada and the United States, the Family Welfare Bureau hired as "Mother Substitutes" three middle-aged women who were known to have successfully raised their own ohildren and who were then i n searoh of domestic employment. These were sent to manage the homes of agenoy clients under the following oiroumstanoest 22. a) when the mother was i l l , either in or out of the home; b) when the mother had deserted; c) when the mother was dead; and d) when the mother "needed instruction in home management". By 1949 , from these tentative beginnings, and out of twelve years of experience, a ful l fledged Supervised Homenaker Service had emerged, with a reasonably well-defined but flexible set of principles and practices. The essential features of this service as i t was in the spring of 1949 can be outlined as follows: l) Supervised Homemakers are staff members of the Family Welfare Bureau who go into the homes of clients to oare for children during the temporary absence or illness of the mother. Preferably, they are women between 35 and 65 years of age, in good physical and mental health, who have raised families of their own; who like people and have some insight into their behavior; who are competent household managers and plain cooks; and who are capable of working flexibly as a team with the caseworker to assist families accepted for service. Responsibility for appointing, instructing, paying and discharging these staff members is vested in one caseworker who is known as Supervisor of Homemakers. Training is carried out in two major ways -a) through monthly meetings of the homemaker staff with the Supervisor and selected speakers. These provide for disoussion of common problems and social contact between homemalsrs as well as training in different aspects of the job b) through individual supervision and support given to tiie homemaker by the district caseworker who is working with the family with which the 23. homemaker i s current ly placed. 2. Supervised Homemaker Service i s designed as an " inter im" or "supplementary" se rv ice . Servioe for more than three months to any one family can be provided only under exceptional circumstanoes and by specia l approval of the Agency board, on recommendation of the Supervised Homemaker Committee* 3. E l i g i b i l i t y of fami l ies fo r Supervised Homemaker Service i s deoided by the d i s t r i c t caseworker i n consul ta t ion w i t h the Supervisor of Homemakers, and i s based upon careful considerat ion of the fo l lowing fac to rs : a) a b i l i t y to pay. Service i s designed p r imar i ly for famil ies who cannot afford to pay f u l l cost of housekeeper of t h e i r own select ion* b) re la t ives* I t i s understood that a l l p o s s i b i l i t i e s of sui table help from re la t ives have been explored before app l i ca t ion i s made* c) s ize of family* Cases are not usua l ly acoepted where there i s only one c h i l d i n the home, and where the mother i s absent* d) medical advice* I f the Supervised Homemaker i s requested because of the mother's i l l n e s s , i t i s expeoted that the caseworker w i l l obtain a medical diagnosis and the doctor ' s advice as to the need and probable length of the servioe• e) type of i l l n e s s * Servioe i s not usua l ly given where there i s contagion or i n f ec t i on i n the home, or where the mother's i l l n e s s appears to be mental or emotional rather than physical* f ) type of care required* I f the mother needs f u l l nursing care i n the home such as cannot be given by a v i s i t i n g nurse* the case i s not usua l ly considered sui table for Supervised Homemaker Serv ice . Minor 24. nursing service con be considered under the guidance of the Victorian Order of Nurses. g) family constellation. Supervised Homemaker Service i s not considered suitable for the oare of ohildren without one responsible guardian i n the home. h) standard of l i v i n g . Adequacy of accommodation and equipment, standards of cleanliness and nutrition are taken into account when considering applicationss there are limits to the homemakers' resource-fulness i n coping with homes which are seriously sub-standard i n these respects. Family Welfare Bureau Experience with Long-Term Cases At the beginning of the service, there had been seme discussion of Its value as an alternative to long-term foster-home care of children i n families where the mother had died or was chronically incapacitated. But, on the one hand, the cost seemed prohibitive i n relationship to the over-all agenoy budget: and on the other hand, with expert homemakers at a premium, i t did not seem wise to t i e up any considerable number of them i n long-term eases. Furthermore, the total need i n this area was much greater than any private agenoy could possibly undertake to meet, especially since (in contrast to foster-home oare) there was no provision In the Vancouver area for public funds to help underwrite the cost. However, i n spite of i t s general adherence to a policy of giving only Interim and supplementary service, the Family Welfare Bureau had, from 1938 onwards, carried a limited number of longer-term cases on an experimental basis. By the end of November 1943, this type of service had been given to a total of twenty-three families. In four of these 25. families* the mother had heart disease: in three, "chest condition11: two were cancer oasest but the largest single group, and the most expensive per case, were the eleven families in which the mother had tuberculosis* There was no question that the service had been valuable, not only to the families concerned, but also to the agency, which began to learn some of the implications of long-tern oases: but the expense was prohibitive* One family was given service oyer a two-year period at a oost of $846.40* the total cost for the eleven families was $2,975.27» an average of over $270 per family* Or, to see the same same facts from another angle, look at the following statistics for the fi r s t six months of 1944: For a l l families For T.B. families Total cost $3,034.88 $1,064*00 Re imbur sement s 1,873*10 387*00 Net Cost $1,161*78 $ 676.60 Number of families served 50 3 Figure 4: Cost of Supervised Homemaker Servioe January-June 1944: Family Welfare Bureau, Vanoouver. In other words, one-third of the budget was used to give service to 6% of the clients receiving this type of service* Furthermore, costs per T.B. family oontinued to rise as longer periods of oare were given: so that inl946, 3»305s hours of servioe was given to seven families at a total oost of $1,790*05} and in the first seven months of 1947* five families cost the agency $1,921,21* It is not surprising therefore that in November 1944, the Family Welfare Bureau took the initiative in calling the first of a series of 26. inter-agency conferences to discuss the problem of meeting the need for homemaker service of families where the mother was tuberculous* Nineteen people attended this first meeting, representing the City Social Service Department, the Social Assistance Branch of the Provincial Department of Welfare, the Metropolitan Health Committee, the Tuberoulosis Control Division of the Provincial Department of Health, the Community Chest and Council, and the Children's Aid Society, as well as the Family Welfare Bureau. They were unanimous in feeling that homemaker service for low-inoome families where the mother had developed tuberculosis, was a constructive and necessary service* but there was no suoh agreement when i t came to deciding whose responsibility i t was to finance i t * A smaller, but similarly representative conference held in June 1945» came to some more definite suggestions about ways in which this need might be met* In the case of families which were eligible for Social Assistance, the cost of housekeeper service was to be shared, like other relief costs, on an 80-20 basis by the province and the municipality* Where the Family Welfare Bureau provided and supervised the homemaker, i t was to be reimbursed for the salary of the homemaker, but not for administrative costs, although this matter was not clarified until November 1945* There was s t i l l no provision for low-income families not eligible for Public Assistance. The conference had no immediate suggestions, except that perhaps the British Columbia Tuberculosis Sooiety might set up a special fund for this purpose, in conjunction with the looal club sponsoring the sale of Christmas Seals* The people present at this meeting also seemed to feel that qualified Hememakers with agenoy supervision were needed only in homes from which 27* the mother was absent: i t was suggested that when the mother was at home, a less responsible "housekeeper" working under the mother's direct° ion would be satisfactory, and that the local caseworker or the T.B. Social Servioe worker could give any incidental assistance required. For another eighteen months the Family Welfare Bureau continued to meet a small part of the need on basis of the June 1945 conference decisions. Then, in January 1947, i t decided as a matter of policy that i t would aooept no new oases of this type unless the f u l l oost of the service was underwritten by either a servioe club, one of the publio agencies, or some other souroe. It did not take this step hastily, or without exhausting a l l alternatives* Thus in November 1946, the Director wrote to the Executive Secretary of the Community Chest and Council, asking for the support of the Welfare Section in the agency's efforts to have the public departments assume financial responsibility for household help as part of medical treatment in oases of tuberculosiss and that these same department s be made aware of the preoedent established by the Dependents' Board of Trustees during the war years* The Council supported the agency's stand, agreeing that to meet the need was beyond the scope of private funds; and that provision should be made in some way from tax funds as a public health measure* But as no tax supported arrangement was made* the change of policy was carried out, with consequent hardship for several families* Historical Background of the Special Projeot Then, in 1948, two forces began to converge to change the state of affairs whereby medically indigent families with tuberculous mothers were ineligible for homemaker service* First the concern of the Metropolitan Health Nurses and the Tuberoulosis Social Servioe staff 28. about these families (whose plight was aggravated by the shortage of sanatorium bed8) crystallized into a oonviction that tax-supported household help was a v i t a l necessity. They gave every support to Dr. Stewart Murray, Senior Medical Officer of the Metropolitan Health Committee, i n his efforts to secure this type of service. Secondly, the Federal Department of Health and Welfare, under the leadership of Minister Paul Martin, had embarked upon a policy of financial assistance to the provinces for the purpose of raising standards of public health across the country. In the spring of that year, at Dr. Murray's request, the Metro-politan Health Nurses carried out a survey of the families known to them who required household assistance because the mother was tuberculous. They were asked to indicate what type of service was required, i n accordance with the following classifications -1} Homemaker - where the mother is out of the home, and a stable, mature, trained woman i s needed to take charge. 2) Housekeeper - where the mother i s i n the home and i s available to give direotion. 3) Extra Help - where the mother or the family i s able to do some of the work, but needs help with the heavier work a few hours a day or week. On the basis of this survey, which revealed forty-one families i n need of helps and the names of three additional families furnished by Tuberculosis Social Service Department, the total need was estimated as follows: 10 Homemakers # #100 per month $1000.00 16 Housekeepers @ $75 per month 1200.00 1664 Hours of Extra Help @. .65 per hour 1081.60 Total monthly cost $3,281.60 TOTAL ANNUAL COST $39,379.20 29. However, i n outlining the project, Dr. Murray suggested that, to begin with, only the most urgent cases should be dealt with: and requested the Federal government for an i n i t i a l grant of #12,000, on the basis of the following estimates: a) 5 homemakers at an approximate cost of $115 per month: Annual cost - $ 6,900 b) 5 housekeepers at an approximate cost of $75 per month: Annual oost - 4,250 o) Hourly domestic help averaging 1,200 hours per year at 65/ per hour 780 TOTAL ANNUAL COST $11,950 Part of his outline also suggests: As the Family Welfare Bureau has a servioe already established for homemakers i n the community, that they should be asked to provide service as mentioned above on requisition from the Metropolitan Health Department. Finally, on the 10th of March 1949, Dr. Murray was able to write to Miss M. McPhedran, Director of Family Welfare Bureau, as follows: You w i l l recall various interviews which we have had regarding the use of housekeeping and homemaking services with tuberoulosis oases in the Metropolitan Health Area, particularly i n Vancouver. Recently we have been advised by Dr. Hatfield that approximately $12,000 i s available for this purpose and I am now asking that you take this matter up with your Board as to whether or not your organization w i l l supply this servioe for which you would reoeive reimbursement from us along the lines suggested i n the attaohed outline of the material whioh went to Ottawa. Of course, you are aware that the funds for this servioe are supplied by the Federal Health Grants through the Provincial government, specifically the Division of Tuberoulosis Control, to ourselves. I am very anxious that you give us this co-operation as you are already i n the f i e l d and to me i t i s advisable to make the best use of suoh a well organized servioe as yourself rather than to oontemplate going into the f i e l d as a new venture on our own. By the beginning of A p r i l , 1949, a l l the necessary preliminaries had been completed, and the service was ready to swing into action. Under the chairmanship of Miss Hunter, Director of Publio Health Nursing, there 30. had been set up as inter-agency clearance committee known as the Technical Advisory Committee. On i t , the following interested groups were represented: Family Welfare Bureau Children's Aid Society City Social Service Department Metropolitan Health Committee Provincial Health Department„ Division of Tuberoulosis Control, Social Service Department. Social Welfare Branch - Vancouver District Victorian Order of Nurses To this Committee was entrusted responsibility for making policy with regard to homemaker service to families where the mother was tuberoulous; and for reviewing regularly a l l oases being finanoed through the special grant. It was agreed that a l l applications for servioe were to be first oleared with the patient's doctor, then sent by the Public Health Nurses to their Director: having approved them she was to forward them to the Family Welfare Bureau. Applications were then to be ohecked by the Supervisor of Homemakers, who would clear with whatever other social agencies were currently active with the family concerned. The next step in intake was to be a home vis i t by a social caseworker, the district worker of the Family Welfare Bureau assuming this responsibity i f no other agency was working with the family. New applications were to be disoussed at the meetings of the Technical Advisory Committee, planned for the first and third Wednesday of each month. However, there was also an unwritten understanding that this prooedure oould' be telesooped in the case of emergenoy situations. In the typewritten instructions drawn up by the Family Welfare 31. Bureau, and approved by the Technical Advisory Committee, the continuing division of responsibility between nurse and caseworker was defined as follows: The Public Health Nurse -1) is responsible for the supervision of the T.B. patient -amount of exercise, clinic recommendations, etc. 2) arranges for transportation to and from hospital for treatments i f the family is unable to provide i t 3) acts as consultant for a l l health problems in the family The Case Worker ~ visits the home before a Homemaker is plaoed there in order to explain the duties of the Hamenaker to the family, and later to supervise the homemaker in her work. She w i l l also act as consultant for a l l social problems in the family. A further unwritten responsibility of the caseworker was to interpret the needs of the family to the homemaker before her placemant. Prior to the formation of the Teohnical Advisory Committee, two meetings were held between representatives of the Metropolitan Health Committee, and the Family Welfare Bureau. The decision was made, based on the Family Welfare Bureau's experience that except for occasional "Charwoman" help, only one category of household help would be provided -the skilled homemaker. It was also agreed that the rate to be charged to the Metropolitan Health Committee by the Family Welfare Bureau for the i n i t i a l period would be $.75 per hour,, of which $.12 per hour represented overhead, inoluding oasework service. Extent and Cost of Total T.B.-Homemaker Project The special grant was renewed in April 1950, and inoreased to $21,000 for the years by the end of the project in Maroh 1952, approximat-ely $55,000 had been spent to give some 69,000 hours of homemaker service to a total of 59 families with 112 ohildren. The amount of service given ranged from two days to twenty-four months per client. 32.: In February 1952, the writer was asked, in her capacity as research student at the Family Welfare Bureau, to prepare a statistical report on the extent and cost of supervised homemaker service to families where the mother was tuberculous. The following graphs and tables are based on figures compiled at that time, and cover the period from April 1949 to January 1952 inclusive. One question of interest to other communities contemplating a similar service i s : "To what extent did the families concerned contribute to the cost of the service?" The answer i s : "To a very limited extent", as indicated in Figure 5 below: % of total refunded Source of refund to Family Welfare Bureau Amount of Refund Graphic Representation Metropolitan Health Committee Families served $52,915.22 1,780.50 96.8 % 3.2 % 1 ] Figure 5: Source and amount of refunds to Family Welfare Bureau for cost of T.B.-Homemaker Servioe to families where mother is tubercul-ous t April 1949 - January 1952 inclusive. A second question of almost equal importance i s : "How great were the administrative costs of the projeot?" This is, shown in the following table: Costs of Amount % of total cost Graphic Representation Homemakers1 salar: Casework and admini st rat i on •es $41,732.86 12,962.86 76.3% 23.7% r 1 Figure 6: Distribution between salaries and administration of the cost of T.B.-Homemaker project April 1949 - January 1952, inclusive. 33. Major items in estimated administrative oosts included: salary of the Supervisor of Homemakers, salaries of caseworkers and casework supervisions; clerical costs, bookkeeping and stenographic costs* Lesser items included rent, stationery, telephone, automobile, and miscellaneous expenses* Cn a per family basis, costs were distributed as follows: No* of families Range of costs Graphic Representation Quartiles Under $200 14 $200 - $399 6 $400 - $599 7 $600 - $799 6 $800 - $999 5 $1000-$1199 7 $1200-$1399 0 #1400-11599 1 $1600-11799 1 $1800-$1999 2 $2000-$2199 4 $2200-$2399 0 $2400-$2599 1 $2600-$2799 2 $2800-$2999 2 L0west $11*20 _ First quartile $183.60 Median $636 3rd quartile $1160 - H i g h O l&94.40 AVERAGE COST PER FAMILY -$943 Figure 7s Distribution of 58 T*B«-Homemaker families accoriding to the cost of service per family: April 1949 - January 1952, inclusive* 34 No. of months No. of families Graphio Representation Quartlies 2 4 5 6 7 8 9 10 12 14 15 19 20 21 22 23 24 Total 6 5 5 6 4 3 5 2 2 3 2 1 2 3 3 2 . 3 JL 58 families Lowest " l month 1st Quartile 4 months Median ~ 7 months 3rd Quartile " 19 months JHighest " 24 months Figure 8i Distribution of T.B. families according to number of months during which S.H. Service was given: April 1949 - January 1952 inclusive• 35. Figure 8 shows the distribution of T.B.-Homemaker families according to the number of months during which service was given. It is interesting to note that they f a l l roughly into three groups - those receiving service for less than 3 months, those served for 3-16 months, and those served for more than 18 months* In reading this figure, i t is well to remember that, in most of the long-term cases, full-time service was given for only about half of the total period. This fact is reflected clearly by a comparison of figure 7 with figure 8. The median length of service is seven months. The cost of seven months of full-time service would be approximately $1000: but the actual median cost is $636. Out of the fourteen families receiving service for nineteen months or more, only three were given.exclusively full-time service: out of a total of 298 months of servioe to clients in . this group, 155 months represent part-time service of less than 100 hours per month. It is also of interest to ask how many families per month were given T.B.-Homemaker Servioe. The agenoy's average monthly caseload of this group of clients was as follows: April 1949 - March 1950: 11 clients per month. Range 2-19 April 1950 - March 1951: 20 clients per month. Range 16 - 24 April 1951 - January 1952: 20 clients per month. Range 14 - 24. Servioe was given to this number of families per month without employing more than twelve supervised homemakers at any one time. This was possible partly because of normal turnover in the T»B.-Homemaker caseload; partly because, with a number of families receiving only part-36 time se rv ice , some homemakers could meet the needs of two or more fami l ies each. The number of hours of servioe per month provided by the agency, are summarized i n the table which fo l lows : Month 1949-50 A p r i l May June Ju ly August September October November December January February March 156 337.5 949 1096.5 1553.75 1571.5 1520 1866.5 2236.75 3168 1978 2534.25 * TOTAL 17,960.5 MONTHLY AVERAGE 1,498 1950-51 1951-52 2133.5 2476 2514 3071.75* 2149.75 1928 2157.5 2289 2025.25 2211 1760 / 2570 /* 27,295 2,274.5 1734.75 / 1767 / 1716 / 2234 * 2349 2391.75 2965.75 2894.75 2517.25 2234 22,804.25 2,280 Figure 9c Monthly d i s t r i b u t i o n of hours of supervised homemaker service i n T . B . hemes: A p r i l 1949 - January 1952 i n c l u s i v e . * includes holiday pay for hone makers / a c t u a l hours of servioe reduced because of fear that the grant might be discontinued i n March 1951* 37 CHAPTER III - 5EHE PROBLEM Of EVALUATION Neither the Technical Advisory Committee nor any of i t s member groups ever drew up a complete o f f i c i a l statement of the aims of Supervised Homenaker service t o f ami l i e s where the mother is tuberculous. This does not mean that there were no de f in i t e aims: the imp l i ca t i on i s rather that a l l of the people involved i n the project were so imbued w i t h a common philosophy of service that they f e l t no need to s p e l l i t out* Some of the basic assumptions oan be read between the l i ne s of the D i r ec to r ' s reports to Family Welfare Bureau annual meetings and the accompanying s t a t i s t i c s * For others, i t i s necessary t o turn to the p o l i c y deoisions of the Teohnical Advisory Committee, and the Family Welfare Bureau statements about the general purposes of homemaker servioe* P u l l i n g together mater ia l from a l l o f these sources, i t seems possible t o draw the fo l lowing conclusions: 1* The primary aim of the servioe was t o a s s i s t the mother to achieve the greatest pqssible degree of health* This involved a continuing, co-operative re la t ionship between the pa t ien t , the dootor, the nurse, the homemaker and the s o c i a l worker* Their d i s t i n c t i v e r e s p o n s i b i l i t i e s can be defined b r i e f l y as fo l lows : (a) Doctor - t o diagnose and treat the patient - to make recommendations about h o s p i t a l i z a t i o n , d i s -charge, and oonvalesoent oare, inc luding homemaker se rv ice , exercise and follow-up treatment (b) Nurse - to ac t as l i a i s o n between doctor and patient - to a s s i s t the patient and her family t o make arrange-ments to car ry out -the doc tor ' s recommendations 38 - to aot as consultant for a l l health problems i n the family - to ins t ruc t the homemaker i n precautions neoessary i n working wi th T*B* patients (c) Homemaker - to make i t possible for the patient to fol low the doctor ' s ins t ruc t ions by assuming such of her household duties as the doctor recommends - to carry out heal th precautions recommended by nurse and dootor .(d) Caseworker- to supervise and support the homemaker i n the . . performance of her duties - to use her professional r e l a t ionsh ip t o help the patient to understand and accept the impl ica t ions of her i l l n e s s , inoluding the recommendations of nurse and dootor, and the services of the homemaker 2* A secondary aim, of almost equal importance, was to hold the family together during the o r i s i s orsated by the mother's i l l n e s s * Respons ib i l i ty i n t h i s area f e l l c h i e f l y upon the shoulders of the homemaker and the caseworker, as fo l lows : (a) Homemaker - to make possible optimum secur i ty for the oh i ldren by caring for them i n t h e i r own home - to r e l i eve the anxiety of the patient and her husband insofar as i t was focussed i n t h i s area (b) Caseworker- to become aware of the strengths and weaknesses of eaoh family as she ca r r i es out her duties around intake and around supervision of the homemaker «=> to use t h i s awareness to a s s i s t the homemaker to carry out her duties - to help the family to accept and use the homemaker to best advantage - insofar as the family aooepts i t , to give casework service to i t s various members wi th the aim of improving family re la t ionships and the personal adjustment of husband, wife and ohi ldren 39 Earlier Evaluation The "T.B.-Homemaker Project" was a milestone in the history of the Family Welfare Bureau. Never before had the agenoy been responsible for the expenditure of such a large sum of money on such a small group of families in so short a period of time. This was a pilot project for the entire North American continent; as far as the agenoy oould discover, no other community had ever before been able to provide homemaker service on such a wide soale to families where the mother had tuberculosis. It is not surprising then that there was, from the beginning, a great emphasis on evaluation. Every time i t was necessary for the Technical Advisory Committee to make a deoision about a particular case, both caseworker and nurse evaluated the ourrent situation, and other workers who knew the family contributed additional information and interpretation* There were also periodic attempts at overall evaluation* For instance, prior to the Annual Meeting of tiie Family Welfare Bureau in March 1950, workers were asked to evaluate the results of the projeot, and a report was drawn up whioh reads in part as follows: EVALUATION (18 families) Definite Improvement:- Health 9 Sooial 9 Partial Improvementj- Health 4 Sooial 7 No Improvement:- Health 5 Social 2 SOCIAL PROBLEMS WHICH COMPLICATED THE HOMEMAKER SERVICE ' (80 problems in 27 families) f: i-Family Relationships:- Between husband and wife 9 Between parents and ohildren 10 13 families Personality Adjustments:- Adults 13 Children _j> 14 families Adjustment to the Homemaker:- Patient 10 Husband 10 Children f 14 families 40 Economic Factors 14 families Cultural Factors 4 families Housing 2 families A year later. Miss M* McPhedran, Director of the Family Welfare Bureau, devoted a considerable section of her Annual Report to a more analytic evaluation:-This experiment has shown us that: ( l ) Social problems exist i n varying degrees of severity, which, i f not resolved, prevent the mother from benefitting to the f u l l by the help of the homemaker* (2) Parents who have sound basio family relationships are able to participate i n planning with the health authorities and the sooial worker and t o be co-operative with the homemaker. Conversely, we have found that the mothers who have signed themselves out of hospital against the doctors* orders, have not been able to use the homemaker servioe constructively. (3) Progress i s slow i n the group where there are many sooial and health problems other than tuberoulosis. There may be evidence of eventual family breakdown, or insecurity of the children, or marginal physical neglect. This group has reoeived the largest proportion of both homenaker and casework service. We have been able t o h e l p some of these families, and we think, therefore, that a limited number from this group should be a part of any, homemaker program where the mother has tuberoulosis* Acceptance for this form of treatment should depend on careful evaluation of the entire family situation, including health problems and personal relationships* (4) Certain patterns of behavior can be discerned i n the great variation'of individual behavior shown* Tense, highstrung, :anxious women seem to have a tremendous drive to get well, and find i t most d i f f i o u l t to aooept bed-rest restrictions* Some of these have been unable to give up the responsibility for household tasks to anyone else* Attempts to have them adhere s t r i o t l y to exercise orders increase their anxiety, and, i n some instances, we hava had to dis -continue idie servioe* The other extreme i s the passive, dependent woman who tends to l e t the homemaker take over entirely the management of the household and the training of the ohildren* We have encountered h o s t i l i t y i n our efforts to help these women grow up emotionally, and assume responsibility* On the whole, they have been helped through the casework relationship, i n combination with the homemaker's help.*.. (5) We have found that s k i l l e d casework services must be a part of the treatment plan i n the majority of families i f we are to help the various members to a better sooial and personal adjustment, and to 41. better health. There seems to have been relatively greater improvement in health problems than in the social situations, partly because social i l l s respond more slowly to treatment; and partly beoause, at f i r s t , we were not sufficiently realistic, and thought that the fact of having a homemaker in the home would relieve inner as well as outer pressures. In April 1952, a different type of evaluation was attempted by Mrs. £• Kenyon, a senior caseworker on the staff of the Family Welfare Bureau, who since October 1951 had been carrying a specialized caseload consisting mainly of T.B.-Homemaker cases. On the basis of her experience, she wrote in an article for "The Social Worker": It seems to me that, at least at the beginning of the project, we tended to see, on the one hand, the urgency of the need for service purely from the health point of view; and, on the other hand, countless personality problems which required our skilled handling. Between those two needs of our clients, we (i.e. the caseworkers) were somewhat lost; the focus of our service was blurred, and the lack of response or the hostility of the client tended to make us discouraged and angry... Assuming then that the caseworker's role is to help the client to make the best possible use of the/Supervised Homemaker Service in order that she may recover and take: her rightful place in the family and in the community, we now need to think of ways in which that purpose oan be best achieved. In my experience, a meaningful relationship with the mother, resulting in some change in her old pattern of behavior, is reached, in the majority of oases, at a point of crisis. Sometimes this crisis occurs prior to the place-ment of the homemaker, but more often i t takes place later, either when i t is administratively necessary to change a homemaker, or when reduction of hours of service is indicated because of the improvement in the mother's health... The importance of the caseworker's s k i l l in handling the mother's outburst at the point of crisis cannot be over-estimated. All the warmth and acceptance given the client during the i n i t i a l contact will be of l i t t l e value i f the caseworker beoomes threatened when the mother dares to reveal her "bad" self... Although I believe that in the majority of cases of tuberculosis where Supervised Homemaker Servioe has been provided i t has been possible to help the mother in a manner similar to that of the D. case (quoted to illustrate the hypothesis outlined above), some , tuberculous mothers are too upset emotionally to be able to make use of that type of casework service. In our limited experience we found that those mothsrs' lack of response even at points of 42 c r i s i s was ind ica t ive of t h e i r great d i f f i c u l t y i n r e l a t i ng to the caseworker* These were a l so the cases i n which there was least physical improvement* Consequently they involved a p a r t i c u l a r l y long period of homemaker service as w e l l as a d i f ferent type of casework t r e a t m e n t » • • On the basis of our oaxperienes^ during the past three years we are now attempting to evaluate the Supervised Homemaker Service fo r tuberoulous mothers* Although i t i s not possible at present to reach ove ra l l conclusions, we do know that there i s a large group of mothers who can be helped to recover faster and probably to avoid relapses through the provis ion of the servioe* To that group belong such dependent mothers as Mrs* D*, as w e l l as the tense, seemingly independent o l ien ts whose struggle centres around t h e i r struggle t o accept t h e i r dependency needs* With regard to the group of tuberculous mothers too emotionally up-set to use the service cons t ruc t ive ly i n order to recover, i n a few oases we d id s t a b i l i z e the home and give the ohi ldren much needed secur i ty by the placement of the homemaker* While from the s o c i a l standpoint i t i s usua l ly more constructive to help oh i ld ren stay w i t h t h e i r own parents provided the s i t u a t i o n i s not des t ruct ive for them, the purpose of the federal heal th grant would need t o be broadened i n order to continue g iv ing Supervised Homemaker Service i n those cases* As long as the objective of the service i s to hasten the mother's recover, i t seems sound to provide homemaker service only to the f i r s t two groups of c l i e n t s * 1 However, no ef for t had been made to tes t s c i e n t i f i c a l l y the hypotheses i m p l i c i t i n the reports by Miss MoPhredran and Mrs* Kenyon, or to evaluate the t o t a l program i n a comprehensive fashion, and to draw from the agency's experiences conclusions which might be useful to other communities contemplating se t t ing up s i m i l a r services* Background of the Present Evaluation In the academic year 1951-52, the wr i t e r was given a student research 2 placement at the Family Welfare Bureau* As one of her assignments, she 1* Casework Aspects of Supervised Homemaker Servioe to Mothers w i t h  Tuberculosis "The Soc ia l Worker" Volume 20 Number 5, A p r i l 1952s published by the Canadian Associa t ion of Soc ia l Workers* 2* Like the casework or group-work placement, the research placement Involves 400 hours of f i e l d work i n a s o c i a l agenoy, under the j o i n t d i r e c t i o n of two supervisors, one designated by the agency, the other by the School of Soc ia l Work* This i s separate from, and i n add i t ion t o , the thesis requirement for the degree of Master of Soc i a l Work* 43 was askad i n January 1952 t o undertake a report of the spec ia l T*B*° Homemaker project* One of the questions which she set out to answer was "How valuable was the project? 1 1 The impl icat ions of t h i s question proved to be so numerous and var ied that i t has now become the core of t h i s thes is* In an effor t to answer t h i s question w i t h greater p rec i s ion and ob j ec t i v i t y than the agency had done previously , the ra t ing scale was drawn up which i s reproduced i n Appendix A* I t i s divided in to three major sect ions , corresponding wi th the three major aims of the service -A* Health Evaluat ion B* Supervised Homemaker Evaluat ion C. Casework Evaluat ion In add i t ion , a fourth sect ion attempts an ove ra l l r a t ing of the value of t o t a l service to each fami ly , and asks for information about circumstances under which service was provided and discontinued* A l l three sections include questions of two types - those which ask for spec i f i c information about such matters as s o c i a l and heal th s ta tus , amount and t iming of servioe , changes of personnel: and "movement"  questions of an evaluative nature, which attemp to measure growth and change i n a t t i tudes , behavior and re la t ionsh ips* Before the r a t i n g soale was drawn up, careful consideration was given to a l te rna t ive methods of evaluation* For instance, a l l of the c l i e n t s included i n t h i s study were interviewed by a caseworker a minimum of nine times} some as many as f o r t y - f i v e times* During the course of these interviews, much material of a " s o c i a l h is tory" type came out, so that i t would have been possible to attempt a psychosocial diagnosis of 44 each o l i e n t and to relate sucoess to t h i s f a c t o r * However, i t never became agency polioy t o secure a " s o c i a l history" before providing home-maker service* Furthermore, the science of sooial casework has now reached the stage of development where i t should be possible f o r q u a l i f i e d practitioners to assess t r e a t a b i l i t y on the basis of current adaptation, rather than being completely dependent upon detailed knowledge of the c l i e n t ' s past experiences* Therefore, although t h i s type of approach was considered, i t was not adopted* A major contribution to the s c i e n t i f i c progress of casework has been made by Drs* Hunt and Kogan and t h e i r associates at the I n s t i t u t e of Welfare Besearoh, Community Service Sooiety of New York, i n the develop-ment of t h e i r Movement Scale f o r evaluating the r e s u l t s of s o o i a l oase-1 work* I t defines movement as "the change that appears i n an i n d i v i d u a l o l i e n t and/or his environmental s i t u a t i o n between the opening and closing of his oase"* I t breaks down types of evidence of movement into four categories -(1) Adaptive e f f i c i e n c y - changes i n the effectiveness of functioning i n any area, including new s k i l l s i n planning or i n the use of community resources..and new habits of s o c i a l behavior* (2) Disabling habits and conditions - such phenomena as a l t i t u d e s , personality t r a i t s and behavior i n i m i c a l to good sooial relationships; delinquencies, symptoms of neurosis or psychosis, disabling anxiety, basio c o n f l i c t s of motivation, bad health*^Frequently changes i n t h i s area appear to be but one side of a c o i n , the other side being a new adaptive e f f i c i e n c y * (3) Verbalized attitudes or understanding - evidence from what the c l i e n t says that his attitudes toward or his understanding of himself, other people, or his s i t u a t i o n or soma aspect of i t has changed* 1» J . MoV* Hunt and Leonard S» Kogan - Measuring Results i n Sooial  Casework - A Manual on Judging Movement - New lorx l^bu, namily" Servioe Association of Amerioa 45 (4) Environmental oiroumstanoes - change i n the c l i e n t ' s s i t u a t i o n or environmental circumstances, including such things as h i s phys ica l environment, h is eoonomio ciroumstances, and h is s o c i a l environment (for example, behavior toward a o l i en t by other members of his fami ly , boss, fe l low workmen, neighbors). Thus, ohanges i n l ) 2) or 5) by one member of the family may beoome a change i n 4) for other members. For each oategory, a scale has been erected, w i t h seven in te rva l s representing approximately equal amounts of change, four representing improvement, three de te r io ra t ion : and for each i n t e r v a l of the sca le , an anchoring i l l u s t r a t i o n has been provided. I t s use requires that eaoh oase to which i t i s appl ied must be "processed" - that i s , summarized i n such a way as to h igh l igh t development i n eaoh of the four categories . Serious consideration was given t o the p o s s i b i l i t y of applying the Hunt-Kogan Scale to the ent i re group of cases. However, t h i s idea was abandoned for two major reasons -a) the i m p o s s i b i l i t y of t r a i n i n g workers in the use of the Movement Soale, because of lack of time and lack of personnel:- and the authors speoify that i t s v a l i d i t y and r e l i a b i l i t y depend upon consistency i n applying the scale , gained through t r a i n i n g . b) the fact that the Scale i s only the f i r s t step i n answering the question that the agenoy and the w r i t e r f e e l i s of major importance -"What type of o l i en t s can be given greatest help through t h i s spec ia l ized servioe ?" However, use was made, i n the r a t ing soale f i n a l l y developed, of two basic oonoepts adopted by Hunt and Kogan af ter careful prel iminary study -a) that the concept of movement i s an in t eg ra l oomponent of casework philosophy i n that oase-workers aim to help t h e i r o l ien ts behave more happily and e f f e c t i v e l y » r e l a t i ve to t h e i r previous functioning rather than to have them f i t some i d e a l i s t i c pattern of s t a t io „ per fec t ion . 46 b) that casework judgment i t s e l f - even without the instrumentation of methodically developed scaling devices - i s a f a i r l y reliable measuring tool...There i s no evidence for a decrease in the r e l i a b i l i t y of the instrument (the Hunt-Kogan Scale) when workers use i t with their own oases, nor i s there any apparent tendenoy for workers to over or under-rate movement for their own clients. . Admittedly, the workers i n this project realised that movement judgments were going to be made for their clients by one or more independent judges• Evaluation Prooedure After thorough disoussion at a staff meeting and a t r i a l application of a draft scale to five oases, workers i n the Family Welfare Bureau were asked to apply the revised scale to oases with whioh they were familiar. Nine workers participated i n this part of the project, and an effort was made to evaluate a l l forty-eight of the T.B.-Homemaker cases which had 2 been given service for more than three months. Three oases oould not be rated because, for geographical reasons, a l l casework services had been provided by the Provincial Department of Welfare. In three more instances, the rating soales were not completed, i n sufficient d e t a i l t o be used. The following.chapters then are based on forty-two oases - not a sampling or cross-section, but almost the entire group of long-term oases. 1. ibid - PP. 7 and 25 2. One worker, who s i x months earlier had been given a specialised case-load made up mostly of oases of t h i s type, completed twenty of the rating scales. A seoond worker evaluated eleven oases with whioh she was familiar either personally or through having supervised the worka* giving servioe to the family. The writer rated three families on the basis of the agency's records. The other six workers each evaluated their own cases. 47. CHAPTER IV - RESULTS OF THE RATING SCALE - General To be s t r i c t l y soientifio, experimental social researoh requires a control group, , Results obtained without one are valid only for the group studied: not un t i l similar results are secured by study of a similar group at another time or place, or the same group at another time, can general conclusions be drawn with any degree of confidence. With the hope that anotter student of research may, at sometime in the future, be prompted to undertake a similar study to this evaluation, certain s t a t i s t i c a l data necessary for setting up a control group were collected as part of the rating scale - data about the housing, income, size of family and ages of children i n the families under consideration. This i s tabulated i n Appendix B. Out of the 42 families under consideration, 33 received monthly incomes of $150-249 per month. In a very real sense, the range of income was limited by the terms under which service was given - those who could afford to hire housekeepers privately were not e l i g i b l e . One family with an income of over $300 per month was included because of heavy indebted-ness. When the special grant was discontinued, they managed to secure their own domestic help and seemed actually better pleased with this arrangement, although the mother's dependency needs were such that she was at f i r s t quite hostile when tha agenoy withdrew service. Of the five cases i n the lowest income bracket, three were among the agenoy*s most successful cases: of these three, two were widows on pension, and the third was a woman whose husband had deserted her. Eleven of the nineteen cases where total service was evaluated by the workers as "unquestionably of tremendous value" had incomes of $200-249 per month. 48 In evaluating housing, workers were asked to take into consideration space, equipment and sanitation* The soale was set up as a continuum, with three points defined on a five-point scale* Workers were free to mark i t at whatever point they felt came closest to describing actual housing conditions: only five homes were oheoked at unmarked points on the soale. As would be expected, 35 out of the 42 hones were rated as "generally satisfactory" ©r better: families with severe housing problems were automatically eliminated by the conditions of service* In only one of the families where total service was "unquestionably of tremendous value" was housing less than "generally satisfactory"* Out of the six families whose housing "left nothing to be desired", five were considered highly successful* It is perhaps more of a surprise to learn that in only 11 out of the 42 families under consideration were there more than two children*. A glance at figure 3 in Appendix B indioates that the largest single group of families receiving servioe were the seventeen who had two children eaoh* There is no apparent explanation for this faot, and no significant correlation between the size of families and the success of servioe in this project* Nor is there any observable relationship between the ages of the ohildren and the effectiveness of T.B.-HOBBmaker Servioe. There were a total of 86 children in the families given servioe for more than three months: approximately half of them were pre-sohool children, and only seven were in the adolescent group. Total Evaluation One of the main purposes of the entire research projeot was to try to determine the differences between families who are able to make 49 constructive use of Supervised Homemaker Servioe when the mother has tuberoulosis, and those who are not* Therefore, one of the key questions on the Rating Scale read "How valuable do you feel the total servioe was to this family? M This question was deliberately placed on the last page of the Rating Scale, so that workers would answer i t only after the careful analytic consideration of each oase required to complete the rest of the Rating Scale* During the succeeding pages of this researoh report, referenoe w i l l frequently be made to this over-all evaluation* The oode letters, their definition, and the number of oases i n each category, are indicated i n the following table: Code Description Freq-uency Graphic A B Unquestionably of tremendous value Some d i f f i c u l t i e s , but generally valuable So many d i f f i c u l t -ies that value i s questionable 19 12 11 FigurelO: Distribution acoording to over-all evaluation of 42 T*B.-Bomemaker families* A break-down of the 42 cases according to the year i n which servioe was commenced and the over-all evaluation i s most interesting* It shows very clearly how the agenoy has learned by experience to select for T.B*-Homemaker Service the families whioh are best able to benefit by i t * In figure 11 notice how the A-group grows from 5, or 36% of the cases begun April 1949 - March 1950, to 8, or 67% of the cases started 1951-52: while the C-group shrinks from 6, or 30% of the first-year cases, to one 50 or Q% of the most recent group. Fiscal Year Code Freq-uency Graphic 1949-50 A B C 1950-51 4 3 6 6 1951-52 C A 4 8 Figure "ft: Distribution of. T.B •-Homenaker families according to year i n which service was started and over-all evaluations. Circumstances Under Whioh Servioe Was Given Long-term T*B.-Homemaker Service was provided to meet quite a variety of situations* The largest single group of the 42 oases under consideration were the 22 families given service after the mother's d i s -charge from hospital, while she was convalescingt half of the oases i n this group were considered highly successful* A homemaker was placed with 11. families while the mother was i n the sanatorium* In most oases, the homemaker either commenced her duties before the mother l e f t , or stayed on after her return, or both* These were therefore, among the mosb expensive oases carried by the agency* 5 out of the 11 were classified 51 in the A-group. Service was provided to five women whose tuberculosis was arrested, but who were threatened by a further breakdown beoause of the physical strains associated with pregnancy. A l l of the families given service under these ciroumstances f e l l into the A- or B-group, making i t the most successful category examined in this study*: further-more, these were relatively short-term cases. With the remaining five cases, the agency was less successful. Three of these were patients who were nominally "awaiting hospital bed"t one was a patient who was in hospital when the homemaker was fi r s t placed, but who signed herself out against medical advice to "take the cure" at home: the last was a mother with quiescent tuberculosis who the dootors considered needed a period of bed-rest beoause of extending lesions. These facts are summarized and tabulated in Appendix B. On the basis of this material, i t w i l l be noted that, in the experience of the Family Welfare Bureau, the most successful cases were those: - where the mother with arrested tuberculosis needed domestic help to prevent a breakdown during pregnancy - where the mother discharged from hospital needed "tapered" service as she gradually resumed her household duties - where the mother about to enter hospital was unable to make other arrangements to keep her family together* Of these three groups, the fi r s t is the least expensive per case, and the third is the most expensive. The average number of hours of homemaker service for each successful (A-group) case in each category is as follows: m pregnant 487 hours, - convalescent 1,542 hours - hospitalized 1,962' hours 52 Gut of the 42 oases studied, 14 were given part-time servioe only: 13 were given tapered service; and 15 were given full-time servioe* There was a high correlation between the type of service and the worker's over-all evaluation. Only 4 out of 14 part-time service cases were rated as "unquestionably of tremendous value", compared with 8 out of 15 f u l l -time servioe and 7 out of 13 tapered service. This may be partly because, on the whole, less oasework service was given to clients receiving only part-time homemaker service* An outstanding characteristic of families able to make constructive use of T.B.-Homemaker Service was their eagerness to avail themselves of i i t . Workers were asked to evaluate the attitude of olients i n this respect on a five-point soale with three marked points -/ — 7 7 7 — 7 Very eager Some ambivalence, No desire-applied for service mostly r e a l i s t i o under pressure Out of 19 clients i n the A-group, 15 were described as "very eager for service", and none f e l l below the mid-point of the scale. In the C-group, on the other hand, 6 out of 11 olients f e l l at or below the mid-point t and even of the two described as "very eager f o r service", but subsequen-t l y unable to benefit by i t , one really wanted just a char-woman, and the other was eager to "get her share" of a tax-supported service* There i s also a high correlation between the anxiety of the mother about the care of her home and children, and her oapaoity to use T.B.-Homemaker Service. The rating scale f o r this characteristic was set up as follows: 53 / 7 —7 T 7 Completely para- A lot of Considerable Tendency to Unrealistio lyzed or disorgan- anxiety, out anxiety, avoid facing optimism ised by anxiety of proportion mostly r e a l - r e a l i t y to the actual i s t i c and situation under control Only one client i n the A-group was described i n i t i a l l y as having a "tendency to avoid facing reality" i n this area, and with casework help she moved to the centre or norm of the soale. By comparison, 6 out of 11 clients i n the C-group had t h i s euphoric attitude to start with. When service was discontinued, there were only 3 clients i n the C-group whose attitude towards the care of their home and children during their illness could be f a i r l y described as "considerable anxiety, mostly r e a l i s t i c and under oontrol." These findings are i n accordance with current casework theory, which maintains that, i n the client-worker relationship, the client's anxiety can become a positive force for constructive change; and that, conversely, laok of anxiety tends to foreshadow lack of capacity for growth. Certainly, the predicament i n which the tuberculous mother finds herself i s sufficient oause for anxiety that "unrealistic optimism" seems almost pathological* Health Evaluation Medical research has proved, beyond the shadow of a doubt, that the less far advanced the tuberculous infeotion, and the more "co-operative" the patient, the better his chances of making a relatively complete recovery from this disease. The findings of this study are i n general accordance with this concept. One item i n the health evaluation section of the rating scale asked for the date of the patient's f i r s t tuberculous breakdown. On the basis of information given under this heading, i t appears that, out of the forty-54 two long-term oases studied, t h i r t y of the women were suffering or convalescing from their f i r s t tuberculous breakdown. Of the remaining twelve, six, i t is true, f e l l into the A-group. But three of these can-not be considered cases of recurrent tuberculosis i n the true sense, since homemaker service was given to prevent a further breakdown during pregnancy. In two more instances, successful thoracoplasty had given the mother new hope for complete recovery from an otherwise disoouraging relapse. Three of the twelve women i n t h i s category f e l l into the C-groupj one had suffered with chronic tuberculosis since, her teens; one had been hospitalized several times for therapeutic abortions and for attacks of asthma; and the third had had her f i r s t breakdown eight years previously. The remaining three cases of recurrent tuberculosis f e l l into the B-group. The majority of women i n a l l three groups - twenty i n a l l - had 1 tuberculosis which was classified as active, improved at the beginning of servioe. There were thirteen oases of active pulmonary tuberculosis, 1 eight arrested, and one instanoe of tubercular peritonitis. Details of distribution of the forty-one cases of pulmonary tuberculosis acoording to the a c t i v i t y of the disease at the beginning of homemaker service are shown i n Figure 7 in Appendix B. Of the thirteen active cases, a l l five i n the A-group progressed at least to active, improved during the course of servioe* only two of the C-group made similar gains. A l l four women i n the B-group whose tuberculosis was active were awaiting hospitalization when service was commenced. 1. Classification i n accordance with pamphlet "Diagnostic Standards" published by the National Tuberculosis Association 1950. 55 Twenty-one of the pulmonary tuberculosis patients, including thirteen of the most successful oases, had moderately advanced lesions when the agency made its first contaot* None of the mothers in the A-group had  far-advanced lesions. There were only thirty-eight oases in which accurate information was available about the period of time the mother had spent in hospital* This data is summarised in Figure 8 In Appendix B. It will be noted that 14 out of 19 patients in the A-group had spent ten months or more in sanatoria, whereas only 3 out of 8 of the C-cases and 4 out of 11 of the B-cases had been hospitalized for this length of time* Without knowing the circumstances of hospital discharge in each case, i t is impossible to interpret the significance of this apparent correlation between a relatively long period of hospital oare and ability to make constructive use of homemaker service* Ordinarily, one would expect the longer period of hospitalization to indicate a more severe attack of the disease* However, in this case, one wonders whether i t means a greater degree of co-operation with the medical authorities, or a longer period of dependency whioh makes i t easier for the mother to accept her subsequent dependency upon homemaker and oaseworker during her convalescence* The Family Welfare Bureau gave servioe to sixteen mothers whose sputum was positive at some point during contact* Half of these were awaiting hospitalization, and this condition was therefore to be expected* Of the eight patients who had left the hospital with positive sputum, or whose sputum became positive again after disoharge, five were in the C-group: and only two of these five improved to the point where sputum became negative* The agency's experience is in line with medioal research 56. whioh indicates that prognosis is poorest for patients who leave 1 hospital with positive sputum. Of the forty-two tuberoulosis patients who are the focus of this study, twenty-nine were on bed-rest or had only bathroom privileges (B.R.P.) when supervised homemaker service commenced. However, the graph below indicates clearly that members of the A-group are distinguished by the greater amount of improvement i n exeroise status• The average amount of improvement for the entire A-group is 2.2 points on the scale: for B- and C-groups, i t i s .9 points. 1. See, for instance, figures on survival and recurrence rates quoted by Upham, A Dynamic Approach to Illness pp.Il6-118» Ten years after leaving Altro, the sheltered workshop operated i n the Bronx, New York, by the Committee for the Care of the Jewish Tuberoulous, 76% of those discharged with positive sputum had suffered a recurrence of the disease, compared with 30^ of those discharged with negative sputum« 57. Code Frequency Graphic Representation of Movement A 11 : 8 X X X X X 10 Exercise status — X X X X X L B.R.P. -only L. Less than one hour daily JL One hour daily 2 months Z 1. Two hours Ordin-daily for ary 2 months living conditions Figure 12: Movement chart for a l l T.B.-Homemaker oases on "bath-room privileges only" at commencement of service. Soale based on classification recommended by the National Tuberoulosis Association - "Diagnostic Standards: 1950 Edition". Each line or X represents one case: X means "no improvement". 58. One of the questions on the rating soale asked about the extent to which the mother followed medical instructions. At the beginning of the service, thirteen women were desoribed as "constantly breaking (reoommend-ed medical) routine". Two of these were in the A-group, five in the B-group, and six in the C-group. There were six more patients whose habits were considered less than satisfactory in this respect. By the end of agenoy oontaot, a l l clients in the A-group were following medical instructions in a satisfactory ways but four olients in the B-group and nine out of eleven olients in the C-group oontinued to disregard medical  advice more or less flagrantly. Up to this point, the rating scale is on pretty firm ground. The actual health gains were measured and recorded by competent medical authorities. In answering the question about the extent to which the mother followed medical instructions, the oaseworker had as evidence in each case the homemaker's observations, and the homemaker was in the home enough of the time to know what was really happening. But when i t comes to the more subjective question about the patient's attitude to her illness, the limitations of the rating soale become more apparent. One end of the scale is marked "extremely unrealistic - denies, exaggerates, extreme anxiety or rage." According to the workers, thirteen olients - almost a third of the total - had, at the beginning of agenoy oontaot, attitudes best described by this phrase. This figure 1 corresponds closely to Dr. Wittkower«s analysis, in which he desoribed the emotional reaction of 29 out of 100 patients to their illness as "psychological defences". The other end of the soale, however, is marked "quite realistio considering severity of illness", and for this there is I» A Psychiatrist Looks at Tuberoulosis, op.cit. 59. no similar check. Furthermore, with no manual of d i r e c t i o n s , no i l l u s t r a t i v e anchors, i t i s quite possible that t h i s item meant some-thing different f o r each of the nine workers using the scale, although the fact that two of the workers between them rated 32 out of the 42 cases serves as somewhat of a corrective to t h i s trend. There i s another source of possible error that must be taken into consideration i n t h i s and other s i m i l a r items on the rating scale. This i s the fact that most of the evidence upon which the caseworker's judgment was based was the c l i e n t ' s v e r b a l i z a t i o n . This raises an interesting question - to what extent was the c l i e n t free to express her r e a l feelings? This depends upon a variety of factors, among which are casework s k i l l and the type of client-worker relationship which has been achieved. Furthermore, when an agency i s providing service f o r which no s a t i s f y i n g substitute can be secured elsewhere, thBre i s tremendous pressure upon the c l i e n t to behave i n the way i n which she thinks i t s representative expeots or w i l l approve. However, bearing i n mind these l i m i t a t i o n s , i t s t i l l seems possible to conclude that a stubbornly u n r e a l i s t i c attitude towards t h e i r i l l n e s s i s characteristic of patients unable to benefit by T.B.-Homemaker service. A l l but four of the entire group of forty-two oases were given casework help i n accepting" t h e i r i l l n e s s : but when service was discontinued, only  one o l i e n t in'the C-group had achieved an attitude which the worker oould v describe as "moderately r e a l i s t i c " . By contrast, 15 out of 19 A-group patients were considered to be quite r e a l i s t i o i n t h e i r a t t i t u d e . In the B-group, the majority of the c l i e n t s showed improvement i n t h i s area. Six out ofdrwelve mothers achieved a s a t i s f a c t o r y degree of realism* and of the s i x who began by denying, exaggerating or raging at t h e i r i l l n e s s , 60* five were able to improve their attitude with casework help. A speoific aspect of the patient's attitude to his illness i s his desire to recovers for some clients, tuberculosis seems to represent the aoting out of an unoensoious desire for self-destruction. The rating scale attempted to assess the extent to which a healthy desire to get well ooinoided with constructive use of T.B.-Homemaker service. In the C-group, only two olients were considered by the worker to r e a l l y want to get well i n spite of occasional periods of discouragements three women i n this group deteriorated to the point where their determination to destroy themselves became evident to the worker. In the A-group, a l l . clients reached the point where the desire to get well predominated. In the 5-group, in only four cases was there any question of the patient's wish to recover. i n summary then, these seem to be the characteristics, i n the f i e l d of health, of the client able to make most constructive use of.T.B.-Homemaker service -1) she is suffering or convalescing from her f i r s t tuberculous breakdown: or, her tuberculosis arrested, she needs greater rest because of the physical strains of pregnanoys or, i f her illness i s recurrent, radical surgery such as thoracoplasty has been recommended. 2) i f convalescent, she has spent the f u l l time i n hospital recommended by competent medical authorities, and has not "signed herself out" against their advice. 3) unless awaiting hospitalisation, she has negative sputum. 4) her lesions are not far advanced. 5) she i s generally will i n g and able to follow medical instructions • 6* her attitude to her illness i s free from extreme anxiety, extreme rage or.,unrealistic denial: in spite of occasional periods of dis-couragement, she seems really eager to get well again. 62. Supervised Homemaker Evaluation Obviously the effectiveness of supervised homemaker service i n any home depends in large measure on the personal qualifications of the home-maker and the extent to which she i s able to meet the physical and emotional needs of the family to which she is assigned. This is even c" more important in long-term cases, such as homes where the mothsr i s tuberculous, than in short-term emergencies. The matter of "s u i t a b i l i t y " i s quite complex: i t varies from family to family, and, as the patient's health condition improves, i t changes periodically for any one family. An agency giving mostly short-term homemater service tends to put a pie mi urn upon the homemaker who i s flexible and competent, and who can go into any of a variety of homes to take complete oharge. F l e x i b i l i t y and competence continue to be important qualifications for homemakers where the mother has tuberculosis, but other factors also emerge, as the Family Welfare Bureau learned. Chief among these are the following: a) The capacity of the homenaker to work as part of a professional team with the caseworker, the nurse and the doctor i s of even greater importance i n long-term than i n short-term cases, b) The homemaker who "takes over" completely when the tubercular mother is at home i s sometimes a considerable threat to the convalescent patient. The T.B.-Homemaker needs to be able to adjust to the individual mother's desire and a b i l i t y to remain mistress i n her own home, and to encourage the mother to assume increasing responsibility as her health and strength permit. 63e c) The T.B.-Homemaker needs to be able to understand and aooept the pa t ien t ' s expression of h o s t i l i t y , not as a personal a t tack, but as a natura l concomitant of tuberculosis and i t s continuous, severe f rus t r a t ions . d) When hours of service are being reduced, the homemaker needs to be able to help the mother to accept these l i m i t a t i o n s . e) The homemaker should be able t o carry on the form and standards of oare and d i s c i p l i n e to which the oh i ldren are aooumstomed, deputizing fo r the mother rather than competing w i t h her . Over a period of years, both the Supervisor of Homemakers and the veteran members of the homemaker s t a f f had become accustomed to short-term homemaker placements. This may be one of the reasons for the pract ice which the Family Welfare Bureau adopted of moving homemakers from one home to another every s i x months or so . (However, i t was never a conscious reason aocording to the Supervisor of Homemakers.) The pract ice was based pa r t l y on the changing needs of the f a m i l i e s , p a r t i c u l a r l y of the tuberculous mother. The woman who, when f i r s t discharged from h o s p i t a l , needed a mother figure as homemaker, frequently required a more objective r e l a t ionsh ip when the servioe was being reduced: the family which could make good use of a homemaker who would take complete charge i n the mother's absence, needed a di f ferent q u a l i t y of servioe upon mother's r e tu rn . I t was based pa r t l y upon the needs of the homemakers: i n some hemes, phys ica l and emotional s t ra ins were such that the homemaker was unable t o "take i t " for any great length of t ime; i n others, the homemaker found i t d i f f i c u l t t o maintain her ro le as an agenoy employee i f l e f t i n one home i n d e f i n i t e l y . I t was based p a r t l y 64. upon the need of the agency to preserve and develop the f l e x i b i l i t y of it s homemakers by providing them with a variety of different experiences. In practice, homemakers were changed much more frequently than once every six months, as the following table d e a r l y shows* Months of Service Freq-uency Under one 25 1 - 3 57 4 - 6 27 7 - 9 11 10-12 8 Over 12 2. TOTAL 130 Graphic Representation A - 9 B - 9 A - 19 A - 16 C - 7 B - 22 C - 16 B - 7 A-3 B-4 A - 6 B-2 e-4j c - 4 A- J C-l LJ JU Figure 13s Distribution of T.B•-Homemakers according to length of service in each home. On the average, homemakers were i n fact moved once every three-and-a-half months. However, there i s a significant difference between the A-group and the B- and C-groups in rate of turnover. In the A-group, ths average period of service for each homemaker was 4*3 months per family, compared for 2.8 months for the B-group and 3.1 months for the C-group« This does not correlate significantly with the type of homemaker (which w i l l be discussed subsequently), but i t seems to be related to capacity of the mother to establish a mutually satisfactory relationship with the homemaker. According to the agency's records, i n the A-group, only one out of 19 clients had serious d i f f i c u l t y in t h i s area: whereas 5 out of 12 clients in the B-group and 7 out of 11 ollents i n the C-group needed 65 casework help with this problem* It also reflects the fact that, i n the beginning, when there were fewer successful cases, and when the capabilities of new homemaker staff were not well-known, the agency-tended to change homemakers at the client's request* Later, workers learned that quite often a complaint about a homemaker reflected the client's emotional disturbance rather than the homemaker*s limitations, and attempted to work through d i f f i c u l t i e s while retaining the.same homemaker i n the home* As has been mentioned e a r l i e r , this was the Family Welfare Bureau's f i r s t major experience i n providing long-term homemaker servioe* In order to get the project under way as rapidly as possible, the agenoy had to double i t s homemaker staff within a period of two or three months, and there was considerable turnover and experimentation before i t f i n a l l y secured a group of reliable women with the special qualifications out-lined at the beginning of t h i s section* This situation created some d i f f i c u l t i e s i n the qualitative parts of the homemaker section of the rating scale* For example, one of the questions asked "By what type of supervised homemaker was servioe given?"* The three marked points of the five-point scale were* "By S*H* about whom agenoy has questions and doubts", "By average S*H* whose effect-iveness varies from case to case", and "By outstanding, flexible home-maker." There was not time to chart the variety of evaluations given to each individual homemaker, but the writer noted i n casual observation that a homemaker desoribed by one worker as "outstanding" would quite li k e l y be rated "average" by another:, and some of the workers themselves pointed out that although the agency now realizes that a particular homemaker was inadequate, she was placed i n t h i s specific home i n good 66. f a i t h at a time when she was considered quite competent. For t h i s reason, no use has been made of the answers t o t h i s p a r t i c u l a r question. One s p e c i f i c aspect of the homemaker*s s u i t a b i l i t y i s her capacity to work as part of the agency-medical team: the r a t i n g scale attempted to look into the relationship of t h i s q u a l i f i c a t i o n t o the success of t o t a l service. Measured i n terms of weeks, 30% of servioe i n the B-group, 15% of service i n the A-group, and 4% of service i n the C-group was given by homemakers described by the workers as "preferring t o work completely on her own". I t i s possible that some cases i n the B-group might have been rated "highly successful" had there been closer co-operation between caseworker and homemaker, since nine out of twelve of the B-group homemakers who were evaluated as not adequately meeting the needs of the f a m i l i e s they served, f e l l into the "independent" category. More than ha l f of a l l service i n the 42 cases under considerat-ion was given by homemakers described as "working as a team wit h the caseworker on a 50-50 basis." Of greater importance was the question on the rating scale asking about the extent to which each p a r t i c u l a r homenaker f i t t e d the physical and emotional needs of the family given servioe. Like other q u a l i t i t i v e questions, t h i s one has a wide margin of e r r o r . However, even allowing f o r t h i s , i t i s apparent that families i n the A-group were given super-vised homemaker service better suited to t h e i r needs. Of the 130 separate placements whose duration i s charted i n figure 13» 11 were of too short duration f o r evaluation. The remaining 119 were distr i b u t e d as follows: 6 7 . Evaluation of Homemaker Coda Freq-uanoy Graphio Representation Very poor choice Average suit a b i l i t y Extraordinarily well suited A B C A B C A B C A B C A B C 6 10 2 3 2 5 10 11 11 15 9 3 20 8 4 Figure 14: Suitability of Supervised Hon»makers to needs of T»B. families - distribution of 119 ratings aooording to over-all evaluation of oases* 68. It w i l l be noted that only 16% of supervised homemaker placements for the A-group were rated as "very poor choice"1, compared to 30% for the B-group and 28% for the C-group: whereas.37% of placements for the A-group were considered as "extraordinarily well suited" to the family's needs, compared to 20% i n the B-group and 16% i n the C-group. This would seem to be, i n part, related to the more complex needs of families i n the B-and C-groups, and their greater d i f f i c u l t y i n establishing with the case-worker a sufficiently close relationship that she would become aware of those needs. When i t i s remembered that the proportion of oases i n the C-group decreased from year to year, this pattern i s also a measure of the extent to which the agency learned by experience to f i t the homemaker to the needs of the family. In summary then, i t would appear that T.B .-Homemaker cases were most successful:-a) when changes of homeaialBr were kept to a minimum; b) when the homemaker "worked as a team with the caseworker on a 5 0 - 5 0 basis"? c) when the agency knew enough about both the homemaker and the family to make placements in accordance with the family's physical and emotional needs. 69 CHAPTER VI - RESULTS GF THE RATING SCALE - CASEWORK EVALUATION From the beginning, casework was an integral part of services given to T.B •-Homemaker families. It was different i n focus from the family-casework service normally provided by the Family Welfare Bureau: the agency was asked by the public health nurse to provide the mother with homemaker service, not to help her with problems of personality adjustment or inter-family relationships. However, the role of the caseworker emerged with increasing c l a r i t y as the service progressed* It became apparent that her major function was to help the tuberculous mother make the best possible use of homemaker service i n order to recover her health and resume her rightful place i n the family and the community* This involved such varied ac t i v i t i e s as assessing the capacity of the family to use homemaker service: serving as a bridge between family and agency as one homemaker succeeded another: interpreting family needs to the homemaker, the nurse, sometimes the doctor, and then, in reverse, interpreting the actions and recommendations of these professional people to families who were sometimes tooupset to oomprehend them f u l l y the f i r s t time* But even though the focus of casework differed, the requirements for successful oasework remained* I f casework services were going to help the client to make the best possible use of homemaker service, i t was s t i l l essential that the olient be capable of establishing a relationship with the worker. Furthermore, those of the family's problems whioh interfered with constructive use of homemaker service must be accessible to casework treatment. 7 0 . Client-Worker Relationship In the rating scale, a serious effort was made to take both of these factors into consideration. It was assumed that, as a minimum basis for oasework, the olient should be capable of establishing a relationship which i s : -a) warm enough to permit generally relaxed discussion with the worker around problems related to provision of concrete services; b) dependent enough that he i s able to accept the caseworker's participation i n making decisions and resolving problems which arise around concrete services; c) secure enough that he i s free t o express his h o s t i l i t y overtly . to the worker when circumstances arise which give him good reason for anger. It was also assumed that, i n most instances, the relationship would be relatively superficial to begin with, but that i t would develop depth* warmth and security through a succession of regular face-to-faoe inter-views. Therefore workers were asked to indicate the characteristics of their relationship with the olient at the beginning and end of agency contacts Since the father was Interviewed at least once i n every case where he was alive and liv i n g with the family, this information was requested for both parents. However, from the point of view of the amount of casework service, i t soon became dear that oontaot with the father i n these cases had tended to be relatively brief and superficial. .Out of 39 fathers, 22 were seen less than five times, and only 6 were seen more than ten times. The range was from one to twenty interviews, and the average f i v e . The mothers, on the other hand, were given much more extensive and intensive service. Only 3 were interviewed less than ten times, and 7 71. were seen on more than t h i r t y occasions. The range was from two to 1 forty-five interviews, with the median eighteen and the average twenty interviews par c l i e n t . Therefore the analysis which follows i s based upon the caseworkers1 evaluation of her developing relationship with the tuberculous mother. This i s one of the more subjective secions of the rating scale. Its v a l i d i t y may well be questioned, since workers have been asked to judge a relationship i n which they are deeply involved. The fact that i t has not yet become standard practioe i n casework recording to make a periodic analysis of the nature of the client-worker relationship increases i t s margin of error. Feeling somehow to blame i f no adequate relationship was formed, some workers may have been tempted, to see growth where no growth oocured: or, conversely, to judge the client as incapable of relating, rather than to look equally for deficiencies i n their own 2 casework s k i l l s . Furthermore, i n this study i t was not possible to use the most effective counter-check for this danger - the careful differential diagnosis of the stage of psychosexual development reached by the olient, which would be the major determinant of the type of inter-personal relationships he is capable of forming. 1. One olient for whom the rating soale was incomplete was seen 65 times in addition to numerous telephone calls© 2. The hazard i s particularly great i n the " h o s t i l i t y " part of the quest-ion. The question i t s e l f would have been less ambiguous had i t read "Was the client-worker relationship sufficiently secure that the olient f e l t free to express h o s t i l i t y and criticism?" and had a l l the scale intervals been marked, somewhat as follows: r 7 7 7 — 7 No overt Great anxiety Free expression More h o s t i l i t y Continuous expression when hostility.of h o s t i l i t y on than the real barrage of of h o s t i l i t y i s expressed r e a l i s t i c bases situation h o s t i l i t y warrants 72. It w i l l also be remembered that, i n her ar t i c l e cn "Casework Aspects of Supervised Homemaker Service for Mothers with Tuberoulosis", Mrs. Kenyon pointed out the great importance of the caseworker's a b i l i t y to encourage and accept the mother's expression of h o s t i l i t y . A possible implication of this i s that not a l l of the workers assigned to this group of clients had this s k i l l or recognized i t s importance: possibly some of the mothers rated as "no overt expression of ho s t i l i t y " were forced to repress their feelings by the limitations of the caseworker. Furthermore, the rating scale was not sufficiently refined to take into account d i s -placed h o s t i l i t y , directed perhaps towards the homemaker, the medical authorities, or other members of the family. However, the question was retained, for three major reasons -a) the crucial importance of tha client-worker relationship i n oasework, and the need to make some attempt, however primitive, to measure i t ; b) the faot that a l l workers using the scale had professional t r a i n -ing and therefore some self-awareness and some understanding and aoceptanoe of the extent to which limitations of the client's personality can prevent his f u l l use of casework helpj c) the results themselves, which, as w i l l presently appear, were in line with current casework theory. The question about relationship was broken down into three sections, to correspond with the three characteristics of a client-worker relation-ship outlined above - warmth, dependency and h o s t i l i t y . The scale for each quality was divided into five equal intervals, with the f i r s t , third and f i f t h point clearly marked by a descriptive phrase. The quality i t -self was conceived as a continuum, and the workers were thus free to mark the scale anywhere along i t s length. In tabulating the results, each quality for eaoh olient was 73. represented by a straight line, its starting point describing the relationship at the beginning of oasework service, and its termination showing the relationship at the close of agenoy oontaot* Thus the length of the line indioates the amount of movement or growth on the part of the olient* In the graphs for dependency and for freedom to express hostility, the norm is at the centrev i t has therefore been necessary to indicate the direction of growth by varying the type of straight line* The amount of growth possible is smaller in these two graphs than in the one portraying warmth* 74. Freq-uency Code Graphic Representation of Movement P T SCALE - - - -Very superficial relationship T T Good relationship generally relaxed discussion around illness & service ~7 Very close relationship -discusses most intimate problems freely A 19 B 12 C 11 X X Figure 15s Warmth in the client-caseworker relationship: movement scale for 42 T.B.-Homemaker cases. Each line or X represents one olient. A l l movement is from left to right: X equals "no movement"« 75. Code Freq-uency Grajphio Representation of Movement SCALE A r Leaves a l l decisions to caseworker 19 T T T Participates in making decisions on flexible basis —7 Terribly threatened by any invasion of independence X X X 12 X X 11 X X X X Figure 16s Dependency in the client-caseworker relationships movement scale for 42 T.B.-Homemaker oases. Each line or X represents one client.. means movement from left to right means movement from right to left X means "no movement" 76 Code Freq-uency Graph!o Representation of Movement SCALE r — No overt expression of h o s t i l i t y 19 7 7 Free expression of h o s t i l i t y on re a l i s t i c basis T Continuous barrage of ho s t i l i t y X X X X B 12 X X X 11 X X X X Figure 17f Freedom to express ho s t i l i t y i n the olient-caseworker relation-ship: movement scale for 42 I *B*-Horns maker cases* Each line or X represents one client* Means movement l e f t to right •••••» Means movement right to l e f t XXXX Means no movement 77. ' Just a glance at the three graphs indioates immediately one of the outstanding characteristics of the C-group - their lack of growth i n the client-worker relationship. I f we add up from the graphs the total amount of movement for a l l olients, grouping them i n accordance with their over-a l l evaluation, and divide the total for eaoh group by the number of clients i n that group, we have an index of movement which varies significantly. Here i t is i n summary: Code olients Warmth Dependency Hostility A .19 1.6 1.7 1.2 B 12 1.2 1.0 1.0 C 11 .8 .3 .5 Figure 18r Average amount of growth i n client-worker relationship, as measured by the Rating Scale: 42 T.B.-Homemaker oases. Or, to state the same facts i n a different way, the following proportions of clients showed no growth whatsoever i n their relationship with the caseworker, and are thus represented by X on the movement soale: " 'fe$89ra^ T!' No growth Mo growth in " No growth i n Code Group. . i n Warmth Dependency Hostility A 19 1 3 5 B 12 0 3 3 C 11 3 7 5 Figure 19: Number of clients showing no growth whatsoever in olient-worker relationship: 42 T.B,-Homemaker oases. Nor i s there any significant correlation between the amount of case-work servioe given and the client's growth i n relationship. For^instance, i f the number of casework interviews given t o the thirteen olients showing no movement i n dependency i s compared with the number given.to the .78. thirteen clients showing the greatest amount of movement, we find that the no-movement group received an average of 17 interviews per client (range 9-37), while the group showing greatest growth in relationship 1 received an average of 22 interviews per client (range 10-45). Furthermore, this lack growth in inter-personal relationships showed up as well in the relationship between the client and the supervised homemaker. For purposes of comparison, a "relationship profile" was drawn up for a l l eleven clients in the C-group and for a random group of eleven clients in the A-group, giving two groups of equal size. In each profile were summarized the characteristics of the client's relationship with both homemaker and oaseworker. Since most families were given service by at least three different homemakers, the possibility of personality olaeh as a major factor in inhibiting growth is thereby minimized. The results of this comparison with regard to growth can be summarized as follows: 1. The recent study of case movement in New York Child Guidance Clinics has shown that there is significantly greater success among cases receiving more than twenty interviews compared with those receiving twenty or less. In this group of twenty-six oases, three of the "no-movement"' cases were interviewed more than twenty times, compared .with six oases in the group showing greatest growth. 79. Characteristic Code Relationship with 0 Amount .5 1 of movement 2 3 4 Total movement (11 clients) Dependency A . Caseworker G 0 7 3 1 17 points A Homemaker 3 0 5 3 11 points C Caseworker 7 1 3 3.5 points C Homemaker 9 1 1 2.5 points Freedom, to A Caseworker 3 0 4 3 1 14 points express hostility A Homemaker 3 0 1 4 3 21 points C Caseworker 7 1 2 0 1 5*5 points G Homenaker 6 1 2 1 1 8 points Figure 20s Growth in the client's relationship with caseworker and with supervised homemakers comparison of 11 cases in C-gmnxwith 11 cases in A-group - T.B.-Homenaker service. Booking again at the three basic graphs, another pattern quickly beoomes apparent - the way in which, in the A-group, a l l lines move towards and approximate the norm, which is the right-hand side of the "warmth" graph, and the centre of the otter twos while in the C-group there is a centrifugal tendency. The following table shows this aspect more clearly: Code Size of Group Satisfactorily warm relationship Satisfactory degree Enough securityti of dependence express hostility A 19 17 19 15 B 12 6 4* • • • > 6 C 11 4 2 0 / Figure 21s Proportion of T.B.-Homemaker clients who achieved satisfactory client-worker relationship by the end of agency contact. * 4 out of the 12 were threatened by dependency:: the other 4 remained over-dependent / 9 out of the 11 repressed their anger: the other 2 confronted the worker with a constant barrage of hostility 80. This pattern i s also born out by the profiles showing elient-homemaker relationship. When the agenoy discontinued service, a tendency to distrust and dominate the homemaker characterized 4 out of 11 olients i n the C-group compared to none of the clients i n the A-group: and normal freedom to express h o s t i l i t y towards the homemaker was achieved by 1 out of 11 olients i n the C-group oompared to 7 out of 11 olients i n the A-group. However, i t i s important to note that these differences were not readily apparent at the beginning of the agency's contact. Of the 42 cases under consideration, 22 began with a superficial worker-client relationship: 6 A-group 8 B-group 8 C-group 15 were i n i t i a l l y threatened by dependency: 5 A-group 5 B-group 5 C-group 25 were unable at f i r s t to express their h o s t i l i t y : 10 A-group 8 B-group 7 C-group In conclusion then, i t can be very clearly seen that supervised homemaker service oannot be used constructively by clients who are unable, over a three-month period of service, to develop a satisfactory relation-ship with either the caseworker or the homemaker« It i s obvious that, as a diagnostic tool for screening out applicants who are "poor risks", this criterion i s too time-consuming and costly to . be practical. It may have some use i n eliminating marginal cases after a probationary period of service: this w i l l be discussed i n the concluding chapter of this study. The major significance of this conclusion i s that no miraculous change occurs when the olient i s a mother suffering from 81. tuberculous: her capacity to use the service whioh is offered depends in large measure upon her capacity'to establish Inter-personal relationships. Problems given Casework Consideration: As part of the evaluation project, workers were asked to indicate a l l problems given casework consideration, their severity, and progress made in their solution* At first glance, this section of the rating scale seems to be on solid ground* At the Family Welfare Bureau, sooial workers are expected to mark routinely on the statistical card for each client "problems given individual consideration by caseworker" and "evaluation at closing"• The routine evaluation involves placing the case in one of three categories:-1) Servioe enabled family or individual to handle situation better* 2) Service did not enable family or individual to handle situation . better* 3) Unable to evaluate* & Also, in the course of planning the length and intensity of treatment, it is necessary for them to evaluate, at least tentatively, the serious-ness of the presenting problem and its likelihood of responding to case-work: this process usually involves at least two people - the sooial worker and her supervisor* In other words, in completing this section of the rating scale, workers were merely asked to carry through, in slightly different form, a process with which thay were familiar« This section of the rating scale also has certain strengths in its basic approach* The importance of a periodic diagnostic evaluation of the olient has been generally acoepted by sooial workers on this oontineht, in theory i f not always in practioe* But there is an insidious danger 82. latent in this approach - the tendency to label certain elients as "oo-operative", others as "untreatable", without taking into sufficient consideration that the most co-operative of clients is apt to have some difficulties so deeply entrenched behind defence mechanisms that they are inaccessible to casework treatment, while the most untreatable of clients may well have some problem of recent origin and reactive nature which is capable of responding to realistic casework with limited goals. .Perhaps wider application of the concept used in the rating soale - that of evaluating the severity or treatability of the problem for the client -may serve as somewhat of a corrective far this latent danger. However, the validity of tie casework evaluation is limited by the lack of anchoring illustrations and detailed Instructions for using this part of the rating scale. The margin of error is somewhat reduced by the , fact that two workers between them completed 32 out of the 42 oases. It is obvious that the soale needs considerable refinement before wider use can be made of i t . But within these limitations, the soale does give valuable clues to significant differences between clients able to make constructive use of T.B.-Homemaker servioe and those who are poor risks. During the course of the T.B.-Homemake r project, casework considerat-ion was given to 238 individual problems. For 156 of these, the olient was the mother. ; I f we consider only these 156 problems, there was no significant difference between ths three groups of olients in terms of the number of problems presented: these averaged 5.5 per olient in the A-group, 4.1 per olient in the B-group, and 5.7 per client in the C-group. Nor were there any major differences in the areas in which problems occured. Six of these areas were listed on the rating soale, with an 83. opportunity for workers to make their own additions. The problems most frequently encountered i n a l l three groups were the mother's reaotion to her illness and the mother's personality adjustment. Inability to accept the necessary limitations of the service provided by the agency was the next most frequent souroe of difficultyt then child-parent relationships, marital relationships and relationship with the supervised homemaker, i n that order. The following table shows the distribution of problems among clients i n the three different categories. No. of clients presenting this problem Area of d i f f i c u l t y A-group B-group C-group TOTAL , Reaotion to illness 15 12 9 36 Limitations of servioe 10 9 8 27 Relationship with Supervised 6 5 6 17 Homemaker Marital Relationship 8 5 4 17 Child-parent Relationship 13 6 5 24 Personality adjustment 14 12 9 , 35 TOTAL 55" 49. 4T TJo' Figure 22s Distribution of patient's problems given casework considerat-ion, according to area of difficulty:: 42 T.B .-Homemaker oases (Problems discussed with other members of the family are omitted•) Workers were also asked to indioate the relative severity of each problem given casework consideration. This was the question i n the rating scale that perhaps suffered most from lack of anchoring i l l u s t r a t -" ions and detailed directions. The soale i t s e l f was set up as follows: LSuperficial,due 2. Chiefly reaction to 3.Rooted i n 4,Very deep- 5.Suspe-chiefly to lack unusual environ- defenoe mechan- seated, cted of information mental stress isms, but requiring psychotio capable of psycho- reaction change with therapy for intensive case- movement work relationship 84. * There were two immediate indications of its weakness, once the tabulation of the completed scales was undertaken. The f i r s t was the faot that only 6 problems out of a total of 238 were described as "superficial, due chiefly to laok of information." When questioned about this, several of the workers using the soale agreed that almost every olient had had some misconceptions about conditions, of servioe, and many questions to ask, especially during the intake process. However, they had not considered that these were "problems given casework consideration" and had there-fore neglected to include them under the appropriate heading. The second weakness was more serious. In spite of the faot that a l l five points on the "severity of problem" scale were defined, almost a third of the 238 problemsrated were placed at unmarked points on the scale. This seems to suggest both that the scale itself needs refining and rewording, and that workers need more help than was available to them in this instance, in exact classification of the problems with which they are dealing. However, even making allowances for these limitations, the pattern that emerged from the answer to this question was so clear-cut that i t seems to have some significance. Of the total number of problems presented by families in the A-group, 7Q% were considered to be of the type capable of modification through casework treatment (1-3 on the scale), while for the B-group the figure in 53%$ and for the C-group, 2A%» A glance at the table on the following page will amplify and clarify these figures. 85. Severity of problem (lode Freq-uency graphic Representation 1.Superficial, due chiefly to lack of information 2.Chiefly reaotion to unusual enrironmental stress A B A 5oRooted i n defence mechanisms but capable of change with intensive case-work relation-ship B 4.Very deep-seated, requiring psychotherapy for movement 5.Suspected psychotic reaction 3 0 3 26 10 2 10 11 4 32 19 c 6 A. 8 B 9 C 13 ft. 8 B 15 Z 21 i 1 3 11 3 10 •"1 T Figure 23: Distribution, according to severity, casework considerations T.B.-Homemake of problems given r cases* 86. Once again, our conclusion seems to be a common-sense one, in accordance with the practice and theory of oasework. If the family, has problems which are so deep-seated that they cannot be helped through oasework, i t is most unlikely that i t will derive maximum benefit through provision of T.B.-Homemaker service. Progress in the solution of problems In setting up the rating soale, i t was assumed that there are three degrees of movemant that oan result from a client-caseworker relationship. Ideally, there should be progress in the solution of the problem itself -for instance, marital tension should be reduced, the client should begin to follow the doctor's instructions. But failing this, a lesser degree of growth can be indicated verbally by the client's inoreased awareness of the nature and extent of his problem, and by his emerging desire for help. These were both considered to represent a lowering of defence mechanisms whioh may be the starting point for treatment now, or which may make i t possible for him to use help at a later date. It was not recognized until the scales had been completed and the results tabulated, that a verbalization of increased awareness of difficulties is sometimes an intellectual defence against change rather than a lowering of defences in preparation for change. Workers were asked to indicate progress in the solution of problems under each of the above headings. The soale for solution of the problem itself was set up as follows: / "7 ~T 7 7 Problem dominates Problem oreates Problem not Some aspsots Total prob-many aspects of difficulties in basically of problem lem client's l i f e some areas resolved, but basically basically under control resolved resolved 87. Out of ths> 238 problems listed, i t was indicated that 157 made progress of one point or more on this scale. If we oonsidsr that increased awareness and/or increased desire for help are also progress, then there was some movement for 78% of a l l problems given oasework consideration in the course of the project. According to the tabulated results of the rating scale, i t would appear that, even with clients whose problems were considered to be of an equal degree of severity, there was unequal movement toward their solution; and these differences corresponded with the over-all-;success of the case. For instance, 57 problems were described as "rooted in defence mechanisms, but capable of change with intensive casework relationship". Of these, 32 were ascribed to olients in the A-group, 19 to B-group, and 6 to C-group. In group C, only one out of six olients made any progress whatsoever in the solution of his problems with the others, there was absolutely no movement even in awareness or desire for help. By comparisei, there was not one problem of this degree of severity ascribed to olients in the A- and B-groups whioh did not respond to oasework by some sort of modification. Out of 32 problems of A-group olients, 28 responded by growth in a l l three areas - awareness, desire for help, and progress in the solution of the problem. In the B-group, the actual situation improved in 18 out of 19 instances* However, considerable caution needs to be exercised in the interpretation of this. The fact that there were only five problems listed in the above oategory as not responding to treatment makes one suspeot a certain degree of rationalization on the part of the workers* In actual faot, with a olient who is unable to relate, or who lacks anxiety or desire to change, even an informational or reactive problem 88. . may prove impervious to treatment. >Furthermore, i n this projeot, the focus was such that workers were expected to concern themselves chiefly with problems interfering with optimum use of homem&kdr servioe, although the family casework servioes of the agency were also interpreted to these clients as a matter of course. Therefore one would expect a much higher percentage of non-movement than was i n fact recorded. It i s possible that workers tended to rate as "very deep-seated, requiring psyohotherapy for movement", d i f f i c u l t i e s which they were unsuccessful i n treating: for this group of problems, the non-movement percentage increases sharply to In conclusion, and i n spite of the limitations of the rating soale* there seems to be an adequate basis for assuming that the tuberculous mother able to make best use of homemafesr service i s one: a) who i s able to develop, with at least one member of the agency staff, a relationship whieh i s characterized by warmth, some dependency, and freedom to express h o s t i l i t y ! and b) whose problems, upon careful diagnosis, do not appear to be so deep-seated that they cannot be helped through casework at the point where they impinge upon her constructive use of homemaker servioe. Care of Children As has been stated previously* one of the major aims of the projeot was to provide optimum security for the children. I t was assumed that^ i f the children were suffering under the type of care provided, the visible indications would be one or more of the following: - generalized unhapplness - no freedom to express h o s t i l i t y or, alternatively, inadequate control over their hostile impulses 89. - regressive behavior, including psychogenic illness - sooial withdrawal. Therefore one section of the rating scale was designed to measure the effectiveness of T.B.-Homemaker servioe i n these terms. The four significant questions under this heading were phrased as follows: Happiness / T " Children always seem unhappy Aggression 7 7 r Normally oheerful, but with spells of whining and petullanoe 7 Unusually sunny disposition r T Chronic A great deal aggressive of attention-behavior of seeking pathologioal behavior severity Regression — i 7 — : ? Normal amount Some aggression, No of aggression, usually accomp- aggressive usually on anied by anxiety behavior reaotive level / 7 Major, e.g. severe enuresis, psyohogenio illness Social withdrawal / Minor, e.g. thumb-suoking / / No regressive behavior / Extremely with-drawn - prefers to be alone T T T 7 etc. (from Rating Scale) It was also assumed that the oaseworkers would have vivid f i r s t -hand pictures of the needs and personalities of the individual children as they came into care and as they reacted to different homemakers. However, as the rating scales were oompleted, i t became olear that this 90. assumption was only partially valid. There were 14 ohildren out of the total group of 86 about whom the workers knew so l i t t l e that they made no attempt to describe their personalities in the analytioal terms of the scale: most of these were infants. Out of the 28 families with more than one child, there were only eleven in whioh individual ohildren in the same family were described as having different personal reaotions to the homemaker experience: there was a strong tendency on the part of the oaseworkers to see the ohildren of eaoh family as a group. Only 8 ohildren in four families were noted as reacting differently to different homemakers. There seem to be several reasons for this state of affairs. In the first place, the T.B.-Homemaker project was focussed largely upon the tuberoulous patient. Family agenoies do have a traditional tendenoy to ooncentrate upon parents, and to try to solve ohildren1s problems by helping parents to meet their needs more adequately. In this instance, this tendency would be reinforced by the fact that the project was financed through the federal and provincial departments of health, and that the primary aim of the servioe was to enable the mother to recover from tuberculosis. The welfare of the children, though recognized as important, was secondary: this was not a child-focussed service. Part of the difficulty may also be a distorted reflection of ourrent trends in the theory and practioe of children's work. Of recent years, there has been so much emphasis upon the more difficult and time-consuming skills of play interviewing and play therapy that some sooial workers are left with the impression that these are the only techniques for making direot contact with younger children. The relatively simpler but important skills of assessing a child's needs through observing him 91. in his own horns and through oarrying on simple conversations with him seem to be somewhat neglected* Whatever the reasons, i t does seem that, on the whole, caseworkers had a somewhat nebulous picture of the ohildren given care in this projeot* In addition to their own often casual observations, their chief sources of information were the mother and the homemaker* However, neither of these oan be considered impartial witnesses* Especially at intake, the mother would tend to paint the rosiest possible picture of her ohildren in order to persuade the agenoy to provide a homemaker to look after them* At a later date, i f disturbed and threatened by the homemaker, she might tend to exaggerate their difficulties as a means of expressing her hostility towards the homemaker and of bolstering her own self-esteem* The homemaker's limitations in this respeot were of a different order, but none the less severe* In the f i r s t place, few of the home-makers had an opportunity to remain in one home for any considerable length of time - the average period of service was 3s- months. The experience of child-caring agencies with foster-home placement suggests that this is too short a period for the child to feel free to "be himselfn or for the homemaker to get to know him except in a relatively superficial way* In the second place, she saw the ohildren In reaction to herself, a stranger in their home, and for same of them a usurper, a threat, a rival. She would tend to measure them according to her own standards* Some homemakers tended to see conforming children as the desirable norm, and discouraged expression of hostility or regression to infantile habits* Others were more flexible, more sensitive to the inner needs of children in their care, more able to help them express their feelings* 92. In the third place, she saw the children at a time when they had already undergone one or more disturbing experiences - mother's gradual decline in health and final breakdown, mother's apparent rejection as she was unable for a long time to kiss and fondle them, perhaps also plaoement with relatives or in a foster home during mother's hospitalizat-ion* Eaoh child's reaction to these immediate disturbing experiences was, as i t were, a veneer, under whioh lay his total personality structure, built up through the years, layer by layer, out of the complex inter-action of his biologioal organism with his psychosocial environment* To separate his basic from his reaotive conflicts would challenge a highly skilled diagnostician* The homemakers were warm-hearted, interested, but untrained* One would not expeot them, for instance, to be aware of the subtle, irrational anxiety of a child who saw mother's illness and his own subsequent unbappiness as punishment for some perfectly normal hostility whioh he had expressed towards mother in a moment of anger and frustration. These reservations must, a l l be borne in mind in interpreting the results of this section of the rating scale, which is summarized in the following pages. At the beginning of agenoy contaot, according to the rating scale: - 23 children lacked normal cheerfulness - 27 ohildren were displaying a disproportionate amount of ^aggressive, attention-seeking behavior - 10 children lacked freedom to express hostile feelings - 28 ohildren were showing some regressive symptoms - 15 children were somewhat withdrawn in sooial contacts Beoause the homemakers wanted their young charges to be as happy and 93. healthy and successful as possible, and found their task easier when the ohildren conformed, they naturally devoted a good deal of their time and energy to helping the youngsters become "better adjusted". That these efforts had their effeot is indicated by the following figures, which show the status of the sans group of children at the termination of homemaker service! - 11 children lacked normal cheerfulness - 7 ohildren were displaying a disproportionate amount of aggressive, attention-seeking behavior-- 15 ohildren were showing some regressive symptoms - 7 children were somewhat withdrawn in social contacts . In some cases, these apparent gains may represent repression of normal feelings, which In the long run is damaging from a mental health point of view. In many cases, the symptoms of insecurity represented the child's short-term reaction to mother's illness and the resultant family disruptions their modification is the happy result of the servioes of the homemaker, who helps to relieve immediate fears and strains and to bring order to the household - in other words, with the help of the homemaker, the child regains his former feeling of security. However, the rating ssale was not sufficiently refined to differentiate between 1 real and apparent gains. It is interesting to note from the above figures the unanimous failure of the ten children who "lacked freedom to express hostile feelings" to respond to the warm care of the homemake rs by greater 1, In two or three instanoes brought to the writer's attention, the homemaker was able to form with a rejected child a relationship which proved to have therapeutic value in modifying deep-seated disturbances. 94. . capacity to express normal feelings of anger through agressive behavior. A further perusal of the rating scales shows that not one of the ten ohildren with this symptom changed in any way during the oourse of services i f they were withdrawn and shy, they remained withdrawn and- shyj i f they chewed their finger nails or wet the bed, they oontinued to do so. Five of these children came from two families where servioe was least successful: this was the kind of behavior expected of the children, although the inter-personal relationships of both of the fathers and of one of the mothers were characterized by excessive hostility. The other five ohildren belonged to four families where service was considered most successful: in three of these four, this was the family pattern of behavior - neither parent was able to express hostility with normal freedom. There were nine families in whioh according to the rating scale, the "movement" of one or more of the ohildren was in a negative direction. One five-year-old boy, heretofore an only child, showed minor regressive symptoms at the birth of a sibling. Two small sons of irresponsible parents with a serious marital difficulty, became unoontrollably aggress-ive when their mother returned from hospital and began to favor one over the other. Two adolesoents suffered in the bands of a homemaker who found i t hard to work with children in this age group, although their younger siblings became happier and more outgoing during the same period. In one instance, a six-year-old boy developed an aoute anxiety reaotion when a homemaker became emotionally disturbed during the week that she was placed in his home. A family of three exceptionally outgoing, happy-go-lucky l i t t l e boys became unhappy and repressed under a rigid, controll-ing homemaker, but lost their anxiety when a more congenial mother deputy 95. was found* The other three cases were similar - children who developed temporary symptoms of insecurity under one homemaker lost them under her successors* Only four of the twelve children in these nine families failed to regain their original statuss four moved on to apparently better adjustment* In summary, in spite of the limitations of the rating scale, there does seem to be an adequate basis for concluding that most of the home-makers did a fine job of meeting the physioal and emotional needs of the children entrusted to their care* 96. CHAPTER VI - HOW VALUABLE WAS THE PROJECT? The data in the foregoing chapters leave l i t t l e room for doubt about the value of the T.B.-Homemaker project. The harmonious teamwork between doctor, nurse, homemaker, and social worker seems to have made a substantial contribution to the physical and mental health of this group of tuberculous mothers and to the security and happiness of their families. Moreover, i t is not easy to visualize any alternative type of service which would have served their individual needs so satisfactorily. From the point of view of health alone, only 9 out of the 42 patients failed to make measurable progress. In most cases, progress was shown as improvement in exercise status, rather than in the form of more dramatic transition from active to arrested tuberoulosis. However, at the.present stage of treatment of the tuberculous, exercise status is the simplest index of the doctor's estimate of the patient's total well-beings therefore gains in this area would seem to Indicate that the project adequately f u l f i l l e d its primary purpose - to assist the mother to achieve the greatest possible degree of health* * It is too soon yet to know how many of these patients will suffer from another tuberculous break-down: the recurrence percentages are unfortunately high. However, the results of the rating soale would seem 1. It is interesting to note that not a l l of the cases In which S.H. servioe failed to produce health improvements were classified as having "so many difficulties that value is questionable". Four out of the nine were evaluated as belonging to the B-group, because of other gains made by the tuberculous mother or members of her family* 97. to indicate that, i n the course of receiving homemaker service, the majority of tuberculosis patients were given substantial help i n achieving a reasonably r e a l i s t i c attitude toward their i l l n e s s , and sufficient acceptance of medical authority that they can follow recommended routines satisfactorily* Unless i t is presumed that this growth i s purely transitory, i t i s to be hoped that these new habits and attitudes w i l l help the patient to live within the limitations imposed by his residual i l l n e s s i n such a way as to avoid self-induced relapses; and w i l l assist him to co-operate with medical personnel i n the treatment of apparently idiopathic recurrences of the disease* There i s another important respeot i n which we may conclude, even more tentatively, that provision of T*B«-Homemaker Service has improved the prognosis of some of these patients* It w i l l be remembered that Dr. Wittkower concluded that the personality of the tuberoulous patient was oharaoterized by "an inordinate need for affection.... conflicts over dependence••. and i n a b i l i t y to deal adequately with their aggressive impulses." Because of lack of research i n this f i e l d , we do not yet have an adequate scientific basis for determining the extent to whioh the deepened interpersonal relationships which characterize intensive oasework treatment, are carried over into everyday l i v i n g . Yet every practicing caseworker has had experiences which oonvinoe him that there is consider-able carry-over. And belief i n the non-transitory nature of the results of successful oasework i s part of the rationale upon whioh the modern practice of social work i s founded* This being the case, there i s perhaps an adequate basis for conclud-ing that, for at least a small group of olients, the oasework aspects of the T.B.-Homemaker Project helped to satisfy certain emotional needs , 98. 1 considered characteristic of the tuberculous. To the extent that psychic factors are considered important in the etiology of tuberculosis, to that extent the servioe may be considered to have improved the health prognosis of these patients. For example, according to the rating scale, ten clients were able to develop a relationship of more than average warmth with the case-worker; and of these ten, nine made such satisfactory progress that they f e l l into the A-group. Evidently these patients were able to accept their own need for affection and to grow through its partial satisfaction in the olient-caseworker relationship. With regard to dependency, sixteen olients apparently entered the casework relationship with an attitude described as "greatly threatened by any invasion of independence". This is a smaller proportion of the , total group than the 48% whose pre-morbid personalities Dr<> Wittkower classified as "asserters of independence" or "self-drivers";; but i t is s t i l l quite high, considering that, at least in the case of convalesoent patients, many of their dependency needs had been partially and temporarily satisfied during hospitalization. Seven of these sixteen were able ultimately to "participate in making decisions on a flexible basis". At the other end of the scale were eight olients who "left a l l decisions to the caseworker" s three of these also reached the optimum mid-point of the "dependency scale". It would seem that these ten clients at least were given substantial help in solving the "oonfliots over dependence" mentioned by Dr. Wittkower. 1. "Casework aspects" would include, for a few oases, some services ~"~" rendered by the public health nurse and/or the homemaker, as well as by the caseworker. However, the rating scale concerned itself primarily with the client-caseworker relationship perse. 99. What of the "inability to deal adequately with their aggressive impulses" which Dr, Wittkower concluded was the third personality characteristic of tuberoulous patients? This perhaps is the most important point of the threes for i t is the orux of most psyohosomatic theory that illness represents hostility turned inwards. Furthermore, the limitation of physical movement and the social ostracism connected with tuberculosis add substantially to the total amount of frustration experienced by the patient while reduoing healthy outlets for expression of the resultant anger. Under these circumstances, one cannot but feel great concern about the basio personality adjustment of the seven patients who, even after three months or more of casework and homemaker servioe from the Family Welfare Bureau, and, in some oases, considerable assistance from the social worker in the sanatorium, s t i l l seemed incapable of any overt expression of hostility. Only one member of this group was considered to have made the best possible use of T,B,-Homemaker service. The prognosis does seem better for another group of seven patients who were init i a l l y desoribed as incapable of any overt expression of hostility, but who eventually achieved "free expression of hostility on a realistic basis." One would hope that the experience of having their hostility aooepted by both caseworker and homemaker may lessen their need to turn i t inward in the form of illness. The T.B.-Homemaker projeot would also appear to have been reasonably successful in achieving its secondary goal - to hold the family together during the crisis created by the mother's illness. During the three-year period, workers of the Family Welfare Bureau, in conference with publio health nurses, had oooasion to refuse many applications 100. 1 for servioe, A few families were tentatively accepted, but service was discontinued within three months. In addition to these, there were ten families out of the forty-two uhder consideration, from whom T.B.-Home-maker Servioe was ultimately withdrawn because of their inability to use 2 i t constructively. In most of these, the tuberculosis patient was an emotionally disturbed woman who had also found i t difficult or impossible to benefit by the sanatorium regime. There are few miracles in human relationshipss and even the combination of skilled services provided to this group of olients did not sucoeed in accomplishing the impossible. But for the majority of the families given T.B.-Homemaker Service, direct casework assistance was undoubtedly a major factor in making possible the achievement of this secondary goal. It has already been 3 noted that 233 problems were given "individual oasework consideration", in addition to the "informatlonalM ones whioh most workers failed to include in the rating scale. There was apparently some movement for 78% of a l l problems disoussed, and for 157 of them, actual progress in the solution of the problem itse l f . The rating scale, Upon which these . figures are based, was of course only a rough measuring instruments and no comparable figures are available. Yet this would appear to be quite a good standard of service, particularly when i t is noted that for 156 of the problems given casework consideration, the olient was the 1. Applications withdrawn or rejected amounted to about one-third of a l l tuberculosis applications received. Refusal was usually on the basis of information received from the Tuberoulosis Sooial Servioe Department and/ or from other agencies whioh had known the family for some time, and felt that some other community resource would better meet its needs. Rejections were reviewed by the Technical Advisory Committee. 2. Two of these were listed as "Family unable to accept conditions of servioe - voluntary withdrawal". 3. See Chapter V. 101.. tuberoulous mother, whose ego strengths were at a low ebb beoause of her i l l n e s s . Failure to make progress i n the solution of problems appears to be more closely related to the intensity of the client-caseworker relation-ship than to the client's ego strengths. Of the 52 problems where there was no movement, half were those discussed with fathers seen fewer than six times by the agency caseworker. In addition to i t s contribution to "holding the family together during the c r i s i s created by the mother's i l l n e s s " , this direct oasework service seems able to stand on i t s own merits as a real contribution to the mental health and happiness of this group of c l i e n t s . That so much should have bean achieved i s a tribute to the s k i l l of the oaseworkers. Few olients asked directly for assistance with marital problems, ohild-parent relationships or personality adjustment: and many found i t d i f f i c u l t , especially at f i r s t , to understand how the caseworker f i t t e d into the picture at a l l . This was especially trying for social workers accustomed to work i n a voluntary family agency which had been moving for a considerable period out of the f i e l d of concrete services towards greater and greater concentration on oasework treatment. However, i t would be completely unfair to attribute a l l the gains made by the client to the caseworker who saw her once a week. Especially when we speak of the way in which the service helped to meet the emotional needs of the tuberoulous mother for affection, dependency and help i n expressing h o s t i l i t y , we must not forget that i t was the supervised home-maker who carried muoh of t h i s responsibility. In this integrated approach, the caseworker not only gave general casework services, but also supervised the homemaker, Interpreting to her the needs of the family and the significance of various problems which she encountered i n working with 102, i t s members* In the last analysis, however, i t was the homemaker who had to meet the various immediate situations as they arose* To the extent that she met them i n a constructive fashion, the family benefitted;; when she acted unwisely, the family suffered* There were.two factors which tended to make i t d i f f i o u l t for the homemakers to oarry out these responsibilities* Both w i l l be discussed i n more detail later, and are only mentioned here i n passing* The f i r s t was the practice of moving homemakers so frequently that the median length of servioe was under three months and the average only three-and-a-half months* The second point was that, particularly i n the early months of the experiment, homemakers were too often thrust into an emergency situation before sufficient information about the family had been secured to make a wise placement, or even to determine whether homemaker servioe was the best solution to the family's problem* . Over two other oircumstanoes of servioe, the agenoy had less control. One of these was the speed with whioh the projeot was begun* This made i t necessary for Family Welfare Bureau to double i t s homemaker staff within a three-month period, and sometimes resulted inalittle-known homemaker being sent to a little-known home* The other was the laok of any research or even narrative account of long-term homemaker service which made clear the specific personal qualifications required for this kind of work* Laoking t h i s , the Family Welfare Bureau tended at f i r s t to hire new staff members of the type who had proved satisfactory for short-term service, and only gradually learned to differentiate between the two* Under these conditions, the fact that only eighteen homemaker place-ments over the three-year period were rated as patently unsatisfactory 103. would seem to be quite a high level of servioe. The Family Welfare Bureau considers that a great deal of the credit for this i s due to i t s policy of making the homemakers fee l an indispensable part of the agency's professional s t a f f . The fact that homenakers oould consult freely with both the d i s t r i c t worker and their Supervisor when d i f f i c u l t i e s arose, undoubtedly served to keep them on the job i n situations which would probably have prompted an "independent" housekeeper to leave. Some of them came to take a pride i n t h e i r oapaoity to handle disturbed people and disturbing situations. It requires only a l i t t l e imagination to approoiate the unhappy plight of any child when his mother breaks down with tuberculosis. When she follows medical instructions not to kiss or.fondle him, i t may appear to him like rejection or punishment. When she i s whisked off to hospital, he may feel that she has deserted him. The change i n his normal routine made necessary by her long illness i s apt to disturb him. He w i l l sense the anxiety of his parents and react to that i n his own way. Under these circumstances, there i s bound to be an increase i n his own feelings of fear and anger, and i t i s only natural that these w i l l be reflooted i n his behavior, however well-adjusted he i s , and whatever plans are made for his care. In addition, on the basis of currently accepted theories of psycho-sexual development, i t would be expected that provision of supervised homemaker servioe might create speoial d i f f i c u l t i e s for certain children. Those i n the oedipal stage of development are particularly vulnerable when a stranger comes into their own home to play a mother role. For the g i r l , i t means that father not only puts her own mother ahead of her i n his affections (a faot which she is coming, perhaps grudgingly, to accept 104. beoause of her love for mother); but that he i s also giving to a strange soman some of the attention whose t o t a l i t y she craves for herself* The boy may see his mother's desertion as punishment for his desire to possess her* Adolesoents would appear to be another especially vulnerable group* They are normally i n an ambivalent state of rebellion against authority and against adults who represent authority* When mother becomes i l l with tuberculosis, the situation becomes very d i f f i c u l t , especially for the teen-age g i r l * In the reactivation of the oedipal oonflict which characterizes adolescence, she may see mother's illness as an opportunity to take mother's place as well as to prove that she oan play an adult role* To be deprived of this opportunity by a complete stranger who i s apt also to try to control and direct her i s an experience that some adolescents should not be expected to faoe<> However, these factors were given very l i t t l e consideration when decisions were being made about provision of homemaker servioe i n the course of this projeot* Workers at the Family Welfare Bureau tended to take i t for granted that children would be more secure i n their own homes than i n available foster homes* They f e l t that the agency's greatest contribution to the welfare of the ohildren was indirect - through improving the mother's health, and through helping parents and homemakers to a greater understanding of the children's needs, and greater f l e x i b i l i t y and resourcefulness i n meeting these within their own home* . There wow no effort to dodge the speoial problems presented by certain age groups* Furthermore, long-term T«B»-Homemaker service was given to some families where the children had suffered considerably i n the hands of immature, inconsistent parents* 105. Under these oiroumstanoes, the faot that only twelve ohildren were desoribed as growing more insecure during the agency's contact would seem to represent a high standard of service* As a matter of f£ot, when one considers the traumatic experiences to which these children had been and were being subjeoted, i t i s their laok of negative movement which causes concern* However, i t i s reassuring to note that 38 out of the 72 children showed at least minor regressive symptoms at sometime during the agency's oontaot, and that 34 exhibited attention-seeking behavior* Furthermore, the accuracy of this part of the evaluation is limited by weaknesses i n the rating scale which have already been discussed* In other words, there seems to be adequate reason to belive that for most of the children, T.B.-Homemaker service was a oonstruotive experience, and represented the best type of oare available in this community at this time.' However, i n any pioneer undertaking, mistakes are inevitablet deoisions are made which seem wise at the time, and only experience proves them otherwise. The T.B.-Homemaker projeot was no exception to this rule* Some of the lessons which the Family Welfare Bureau learned during the three-year period are general i n nature, and would have made the service more valuable to most of the families concerned* The f i r s t of these has to do with the qualifications of the caseworker. Social workers dealing with tuberculous patients, whether i n the sanatorium or i n projects of this type, do need to have a thorough understanding of their speoial emotional needs* In particular, they must know what the illness means to the patient (a factor which i s l i k e l y to vary tremendously from oase to case) and to have particular s k i l l i n accepting and i n ooping with the olient's expression of h o s t i l i t y , what-106. ever its target. They also need to he able to help the olient to accept limits. Over and above these general qualifications, the caseworker in this type of project needs above average diagnostic s k i l l s . In order to evaluate the capaolty of the client to make constructive use of supervised homemaker servioe. she must be able to unravel from the tangled skein of visual and verbal evidence, behavior which is indicative of serious, deep-seated emotional disturbance from behavior which represents a relatively healthy expression of feelings engendered by the illness and its attendant environmental disturbances. Furthermore, she must have sufficient conviction about her diagnosis to use i t as a basis for firmly refusing service to clients whose needs she feels oertain will be better met through other community resources. She must be prepared to act where necessary in spite of considerable pressure from the health agency making the original referral and, in this oase, administering the grant. Her capacity to set limits firmly but kindly will further be necessary around . such matters as hours of homemaker service, choice of homemaker personnel, and financial contributions on the part of the family© There will surely be no quarrel with the statement that not a l l sooial workers possess these skills to an equal extent. One of the lessons of the Vancouver project would seem to be that the social workers assigned to this type of service should be those on the agency staff who are especially competent in these areas - diagnosis, capacity to set limits and to accept hostility, and sufficient consciousness of function that they oan maintain a consistent role in a complicated inter-disoiplinary approach. 107. The second lesson,very closely related to the f i r s t , has to do with the focus of the oasework. Mrs. Kenyon, in her article on "Casework 1 Aspects of Supervised Homemaker Servioe for Mothers with Tuberculosis", summarized one aspect of the agency's experience in the following way: It seems to me that, at least at the beginning of the projeot, we tended to see, on the one hand, the urgency of the need for service purely from the health point of view, and, on the other hand, countless personality problems which required our skilled service* Between those two needs of our clients we were somewhat lost; the focus of our service was blurred, and the lack of response or the hostility of the client tended to make us discouraged and angry... We were asked by the nurse to provide Supervised Homemaker Service for the mother, not to help her with her personality problems. In her i n i t i a l contact with the mother, the caseworker as the representative of a family agency has the responsibility to interpret to the client not only the homemaker service but also other functions of the agency such as helping people with marital and parent-child relationship problems. But i f we have real respect for the client's right of self-determination, we must allow the mother to decide whether or not she wishes to use those services...The question then arises -— what should the caseworker's approach be i f the mother does not seem to want the homemaker service and yet needs i t desperately from a physical standpoint? I do feel strongly that the caseworker must believe that the tuberculous mother, although temporarily dependent, is s t i l l in charge of her own destiny and that ultimately, the choice between using help in order to recover, and refusing that help, belongs to the mother and not to the caseworker*..o The caseworker's role is to heip the client make the best possible use of the Supervised Homemaker Service in order that she may recover and take her rightful place in the family and in the community., There is however a further aspect which seems to deserve careful consideration. The results of the rating Scale left no doubt that the Vancouver project was fooussed primarily-upon the tuberculous mother. On the whole, only "difficult" husbands were given any considerable 2 . amount of casework servioe. The needs of the children too were definitely 1. Op. c i t . 2. Only five of them were seen for more than 10 interviews* 108. secondary to those of the mother. This was natural enough, considering the special oiroumstances of the Vancouver project. In the f i r s t place, the service was financed through a health grant, and there was never any doubt that its primary aim was the improvement of the mother's health. In the second place, the agency was making every effort to keep administrative costs to a minimum^  and to have extended casework services to fathers and children on an equally intensive basis would have entailed a considerable inorease in costs. Furthermore, at the point of intake, which would have been the logical time to make a careful study of the needs of individual children in each family, there was often considerable pressure from both the public health nurse and from the family to have the servioe provided with a l l possible despatch. However, considering the difficult role that the father in each of these families was called upon to play, and the importance of his relationship to the patient and the children, i t would seem that in most cases he could have made good use of consistent, supportive casework assistance. In some cases this was provideds in many others, i t was offered but rejected. The writer is convinced that the servioe would have been even more successful i f , within the limits of client self-detenaination, more effort had been made to include the father equally within the orbit of oasework services,focussing the discussion upon his difficult role and his own anxieties. The agency's role with regard to the ohildren would also have to be carefully defined i f the service became more child-fooussed, and ohanges in this area would tend to slow up intake procedure. It is true that short-term homemaker service to meet emergency situations defeats its own purpose i f intake procedures are too complicated and rigid. But is is a 109. different matter when what is contemplated is expensive, long-range service during an illness which has taken some: time tu> develop and which will require even more time to cure. In this situation, surely both public health nurses and families could be helped to understand the agency's need to know as much as possible about the children so that a sound decision could be made about the provision of service, and so that a homemaker could be assigned in accordance with their needs as well as the mother's. And i t does seem likely that this would, in the long run, be an economical expenditure of time, tending to reduce unnecessary changes of homemaker, and increase the security of the children. The third lesson has to do with the choice and placement of home-makers. It has already been pointed out that the qualifications of home-maker staff for long-range service of this type are not identical with those required for short-term servioe. On the basis of Family Welfare Bureau experience, the chief differences would seem to be as follows: a) The capacity of the homemaker to work as part of a professional team with the caseworker, the nurse and the doctor is of even greater importance in long-term than in short-term oases. b) The homemaker who "takes over" completely when the tuberoular mother is at home is sometimes a considerable threat to the convalescent patient. The T.B.-Homemaker needs to be able to. adjust to the individual mother's desire and ability to remain mistress in her own home, and to encourage the mother to assume increasing responsibility as her health and strength permit. c) The T.B.-Homemaker needs to be able to understand and accept the patient's expression of hostility, not as a personal attack, but as a natural ocncomitant of tuberculosis and its continuous, severe frustrations. 110. d) When hours of service are being reduced, the homemaker needs to br able to help the mother to accept these limitations. e) The homemaker should be able to carry on the form and standards of care and discipline to which the children are accustomed, deptuizing for the mother rather than competing with her. Because of the difficulty of building up a staff with these potentialities, i t would seem preferable to develop this type of service more gradually than was possible in the Vancouver situation. The fact that the project was so much more successful in its last year than in its first would seem to be related in part to the fact that the agenoy by this time had learned what type of women made successful homemakers in tuberculous homes, and had built up a highly skilled staff of whose strengths and limitations i t was well aware. However, the Family Welfare Bureau's experience lends l i t t l e support to the practice which i t followed of moving homemakers frequently. Although there were perhaps some occasions when the homemaker was glad to be relieved of a difficult situation, there must have been many more where the practice meant that just as she was getting to know one family well, she was transferred. From the point of view of the families concerned, the situation was even more trying, especially for the children. During the period of their mother's illness, they would be dependent upon the homemaker for emotional as well as physical satisfactions:: but a succession of homemakers gave them l i t t l e opportunity to develop the kind of relation-ship which would enable them to derive much security. For the tuberculous mothers too, i t must have been very trying to adjust to one stranger after another, no matter how well qualified the individual homemaker. 111. Of course the long-term placements have their own difficulties j the homemakers themselves have commented, in their staff meetings, that i t is harder for them to keep their relationships with the family professional and to maintain their own sense of identity with the agency. Problems 1 seem to arise most frequently around the matter of confidentiality and the constructive handling of client 1s sooial inviataions after the service relationship has been terminated. Administratively too there are serious difficulties when the same agency is using a single homemaker staff to to provide both short-term and long-term service. However, the soundest policy would seem to be to make every effort to leave the homemaker in each home as long as she is satisfying the real needs of the family. This would include some situations where family, or homemaker, or both, are asking for a change, and where real casework s k i l l is required to assess the total situation and to help both homemaker and client to work through difficulties, perhaps finding some other solution than change of homemaker. In emergency situations where a suitable home-maker is not immediately available, i t is suggested that a temporary home-maker be used with interpretation similar to that used when placing a child in a temporary foster home. In order to reduce to a minimum the difficulties attendant upon long-term placements, the agency will probably need to exert additional effort in two directions. In the selection and training of homemakers, emphasis will have to be laid upon their capacity to work as part of the agency or inter-agency team. The agency will also have to give continued support and direction to its caseworkers so that they are able to help both homemaker and client to work through the 1. Tuberculosis patients do tend to maintain friendships which.they have formed during hospitalization, and many of the clients given servioe in this project knew one another. It seemed natural for them to use the home-makers as a means of communication, and difficult for the homemakers to -handle such requests. 112e problems (such as over-identification and confidentiality) which seem to arise more frequently i n long-term than i n short-term placements. As stated previously, these three lessons are general i n nature, and their application would tend to make the total service of greater value to a l l c l i e n t s . But there s t i l l remains the hard core of eleven families where, after the provision of T.B.-Homemakers Service for three months or more, the agency concluded that there had been "so many d i f f i c u l t i e s that value i s questionable". A careful examination of these does not suggest that their status would have been materially changed by improve-ments i n any of the three areas already discussed. At f i r s t glance, as a matter of fact, the eleven cases seem t o have l i t t l e i n common, except the faot that the agenoy did not really get to know them u n t i l many months of expensive service had been given. This leads us inevitably t o a closer examination of the intake procedures used for this projeot. Obviously, the sooner the workers are able to obtain a clear diagnostic picture of the family, the sooner they are able to make a wise decision about the provision of service. It seems equally obvious that an application for supervised homemaker service soarcely calls for a complete social history i n the Child Guidance Clinic tradition. Yet, between the two extremes of insufficient information and the client's complete l i f e history, i t was d i f f i c u l t for nurses and social workers alike to determine what factors were significant and necessary before the decision was made to accept the case f o r service. For many of the clien t s , no suoh problem aroses i t was clear from the beginning that they were either "good risks" or quite Impossible clie n t s . But between these two extremes lay many doubtful cases where i t 11-3 « was very difficult to make a decision. The fourth lesson then, based on the agency's experience and on the results of the rating soale, has to do with intake procedures. As has already been mentioned, i t was ordinarily the public health nurse who first- told the patient about the service and completed a preliminary application cn her behalf. In Appendix C will be found a copy of the application form devised by the Metropolitan Health Committee for this prupose. It was made out in duplicate, one copy being kept on the files of the Metropolitan Health Committee and the other being forwarded to the Family Welfare Bureau. Ordinarily i t was supplemented by considerable discussion both before and after the caseworker made her first visits. The social worker was responsible for completing the agency's regular application form for homemaker service, inwhioh there is considerable emphasis upon the family's financial eligibility. Social workers who had known the family contributed pertinent information at the monthly meetings of the Technical Advisory Committee. There was a noticeable lack of uniformity in the preliminary casework procedures, especially at the beginning, and much learning by t r i a l and error as the project continued. On the basis of these experiences, an intake outline for T.B.-Homemaker applications has been drawn up by the writer and is reproduced in Appendix C. This differs from the previous forms in several important respects. In the f i r s t place, i t is meant to be used in much the same way as the outlines frequently used for social histories - i t is a guide to information which is important rather than an application form for a business transaction. In the second place, i t is suggested that nurse and social worker work flexibly as a team to complete the intake procedure , 114. dividing responsibility as seems convenient for each oase, rather than each having her own "form" to f i l l i n * The increased length of the suggested intake form is more apparent than r e a l . It incorporates s t a t i s t i c a l information about children, housing, finances and source of referral from the Family Welfare Bureau application form; data about the mother's health from the Metropolitan Health Committee form: makes more specifio questions previously asked about the family's situation and willingness to co-operate. The sections on the husband, the children and family relationships cover information which was frequently, but not always secured by the caseworker in her preliminary interviews and are intended to lend a l i t t l e more uniformity and focus to. this part of the process* The chief innovations are the section entitled "Mother's Hospital Record", and some of the questions under the heading of "Mother's Health"* The reasons for these must be obvious to the careful reader* It has already been pointed out that most of the failures i n this project were families where the mother was emotionally disturbed* But i t was evident from the rating scale that i t was not always easy, on the basis of intake interviews alone, to distinguish women whose disturbance was deep-seated from,those who were reacting to a deeply disturbing environmental situation* However, most of the seriously disturbed women had also made a relatively poor adjustment while i n the sanatorium, and tended to have d i f f i c u l t y i n following medical instructions when discharged: some of them signed themselves out of hospital against medical advice* Furthermore, mothers who were suffering from their f i r s t tuberculosis breakdown and whose illness was not too f a r advanced tended not only to be better patients i n the sanatorium but also 115. to make better use of T.B.-Homemaker Servioe. Therefore, to know the pa t ien t ' s health h i s to ry and the s ign i f ican t aspects of her hosp i ta l record i s very relevant, and serves some of the same purposes as a soo ia l h i s to ry or as t r i angu la t ion i n surveying - i t provides a check upon the caseworker's diagnostic impressions. The revised form i s a lso designed to serve a purpose for which i t s predecessors were never intended. Assuming that the recommendation of long-term homemaker placements i s carr ied out, i t becomes more than ever important to place the r igh t homemaker i n the r i gh t home. Some of the information requested, w i th regard to such items as housekeeping standards, ch i ld ren ' s i n d i v i d u a l needs, fa ther ' s in teres ts and hobbies, dominant member of the family , i s intended to give the Supervisor of Homemakers a s u f f i c i e n t l y v i v i d picture of the family that she can v i s u a l i z e which of her s t a f f w i l l f i t i n bes t . I t i s not suggested that an app l ica t ion be refused jus t because the pa t ien t ' s i l l n e s s i s recurrent , jus t because there are d i f f i c u l t i e s i n in t e r - f ami ly re la t ionsh ips , jus t because the mother i s unable t o form more than s u p e r f i c i a l personal r e l a t ionsh ips , jus t beoause the husband i s being u n r e a l i s t i c , jus t because one or more members of the family are. not enthusiast ic about homemaker se rv ice . But, considering the experience of the Family Welfare Bureau, i t would seem advisable that where several of these factors are present, careful study should be given t o the ent i re s i tua t ion before making a d e c i s i o n . I t has been noted that one of the factors which correla tes most h ighly wi th capacity to benefit by the service i s the c l i e n t ' s capacity to form a sound re la t ionship w i t h the caseworker. I t has l ikewise been noted that i t i s not possible t o make a f a i r judgment i n t h i s area i n 116. less than three months. Bearing t h i s i n mind, i t i s recommended that, i n doubtful cases, the agency consider a po l i c y of providing service f o r a probationary period of, three months, at the end of which the entire s i t u a t i o n w i l l be c a r e f u l l y reassessed, w i t h special emphasis upon the c l i e n t ' s capacity to r e l a t e . In conclusion then - when a l l the evidence i s i n , the verdict i s cle a r . Not only was Vancouver's three-year T.B.-Homemaker project valuable i n i t s e l f t but i t also seems to have demonstrated the need and the p r a c t i c a l i t y of t h i s type of service i n other communities, as the best way of meeting the needs of certain families where the mother develops tuberculosis. APPENDIX A A RATING SCALE FOR EVALUATING THE SUCCESS OF SUPERVISED HOMEMAKER SERVICE IN HOMES WHERE THE MOTHER IS TUBERCULAR. NAME* 118. CHILDREN; Name and birthdate FATHER; Occupation Inoome: HOUSING: (consider space, equipment, sanitation) / r r 7 7 Very inadequate Generally satisfactory Leaves nothing to be desired A - HEALTH EVALUATION Date of f i r s t T.B. Diagnosis Dates of hospitalization, i f any ON SCALES BELOW, INDICATE BY X THE STATUS OF THE PATIENT AT BEGINNING OF S.H. SERVICE, AMD BY 0 STATUS. OF THE PATIENT AT END OF S.H. SERVICE. (X) MEANS NO CHANGE. 3. Lesions: 7—— r —7 —7 —7 Minimal Moderately Far advanced advanced 4. Activity: Inactive 7 Active 5. Sputum: 1 1 9 ' Positive Negative 6* Exeroiss status: r T B.R.P. only Following medioal instructions Less than one hour daily 7 r One hour daily Two hours daily 2 mos. or more 2 mos0 or more ~ 7 Ordinary living conditions / Constantly breaks routine 8. Attitude to illness: 7" —~7~™ Generally f o l l o w 8 T — 7 Follows rigidly / T Extremely unrealistio (e.g. denies, exaggerates, extreme anxiety or rage) Desire to recover: 7 7 Moderately realistic (e.g. generally satisfaotory-diffioult in one or two areas) 7 Quite realistic considering severity of illness r Seems determined to k i l l herself 7 Sometimes dis-couraged, but really wants to get well 7" 7 Determined to recover regardless of difficulties B - SUPERVISED HOMEMAKER EVALUATION 120. 1* Date S* Ho service commenced* 2* Dates of change of -S*H« 3* Dates when S.H. service was reduced* 4* Date when S*H* service terminated* 5* Initially, how eager was the family to secure S« H* service? ( IF FATHER AND MOTHER DIFFERED, RATE EACH SEPARATELY) r T T T 7 Mother No desire -applied under pressure T Some ambivalence mostly "realistio T 6* By what type of supervised hamemaker was service given? (IF MORE THAN ONE, RATE EACH SEPARATELY - SH.H. 1, S.H., 2, e t c ) / T By S* H* about whom agenoy has questions and doubts 7 By average S*H* whose effectiveness, varies from case to case 7" Very eager Father —~7 By outstanding flexible S* H* 7* How well suited do you consider supervised homemaker was to the needs (physical and emotional) of this family? (IF MORE THAN ONE, RATE EACH SEPARATELY - S.H. . 1, S*H. 2, etc.) / Very poor choice T 7~ Average suitability T 7 Extraordinarily well suited 8* Relationship between patient and Supervised Homemaker (INDICATE BY X RELATIONSHIP AT BEGINNING OF SERVICE, AND 0 RELATIONSHIP AT END OF SERVICE. . IF MORE THAN ONE. S.H., RATE EACH SEPARATELY) . a» Responsibility . . ' T T 7 r T T T 7 r Leaves everything to S.H. b. Hostility 7 ~ Tendency to leave things to S.H. 7 Shares responsibility flexibly with S.H. as health permits ~7 Tendenoy to distrust and dominate S.H. 7 Quite unable to delegate any responsibility r T 7 r T T T 7 / Quite unable to express any hostility or oriticism T 7~ Occasional hostility & oriticism, usually on realistic level T 7 Extremely hostile endless criticism 9. Relationship between caseworker and supervised homemaker: (RATE EACH S.H. SEPARATELY) r S.H. prefers to work completely on her own T ——-j-S.H. works as team with caseworker on 50/50 basis T 7 S.H. is very dependent on caseworker for direction 10. family*s expression of anxiety with regard to oare of home and children* (MARK SEPARATELY FOR FATHER AND MOTHER, USE X AT BEGINNING OF SERVICE, 0 AT END. ) 122. / 7 7 7 "7 Completely paralyzed A lot of anxiety, Considerable anxiety, Tendency to avoid Unrealistic or disorganized by out of proportion mostly r e a l i s t i c and facing reality optimism anxiety to the actual under oontrol situation 11. Care and security of children (MARK SEPARATELY FOR EACH CHILD IF KNOWN, USE X AT BEGINNING OF a. Physical care SERVICE, 0 AT END.) T T 7 r T T 7 / Children generally dirty and unkept b« Happiness r r r Children always seem unhappy 7 Children often dirty and unkept T T T T Children generally clean and well cared f o r T r T 7 Normally cheerful, but with spells of whining and petulance T 7 Children clean and well oared for at a l l times 7 7 — 7 Unusually sunny disposition c»o Aggression 123. / / J Chronic aggressive behavior of patho-logical severity T —r~ — 7 A great deal of attention-seeking behavior T T T T T T 7 7 7 Normal amount of Some aggression Absolutely no aggression, usually usually aocompanied aggressive on reactive level by anxiety behavior d» Regression r r r Major e«g. severe enuresis or psychogenic illness T T T T T 7 — " Minor e»g© thumb-sucking T T 7 7 7 No regressive behavior e» Social withdrawal / : ~ 7 7 : 7 7 /= 7 7 ~ " 7 ~ 7 / —7 7— : ~ 7—~ 7 Extremely with- Considerable Some areas of d i f f i - Forms warm Usually takes initiative drawn - prefers withdrawal - finds oulty, but generally relationships in establishing warm to be alone i t hard to form warm and outgoing readily social relationships social relationships o C -' EVALUATION OF CASEWORK SERVICE 124. Number of interviews with patient - • Number of interviews with husband Number of interviews with supervised homemaker ! 1. Nature of relationship with caseworker. (INDICATE SEPARATELY FOR FATHER AND MOTHER. X INDICATES STATUS AT BEGINNING OF SERVICE. 0 INDICATES STATUS .AT END OF SERVICE. ) ... a«. Warmth r T T T 7 Mother Very superficial relationship b. Dependency T T 7 Good relationship -generally relaxed discussion around illness and service / Father Very oloss relationship discusses most intimate problems freely r r Leaves a l l decisions to caseworker T No overt expression of h o s t i l i t y T T o. Hostility /— T T T 7~—~ Participates i n making decisions on flexible basis T 7" T T T T Free expression of ho s t i l i t y on r e a l i s t i c basil "7 Mother 7 Father Terribly threatened by any invasion of independence "7 Mother "7 Father Continuous barrage of h o s t i l i t y 2. In the chart on the last page, you are asked a» to indicate a l l major problems given casework consideration b. to designate as client eaoh person with whom the problem was disoussed o. to estimate the seriousness of the problem to that particular client d. to evaluate unmerically the progress made in the solution of each problem Please use the following scales for your guidance in completing the chart* A. Severity of the problem r — 1.Superficial, due ohiefly to laok of information T T 2.Chiefly reaction 3.Rooted in defence to unusual environ- mechanisms but mental stress capable of change with intensive ~ 7 — 1 4.Very deep-seated 5.Suspeoted requiring psycho- psychotic therapy for move- reaction ment B. Client's awareness of the problem oasework relationship /" T 1.Completely unaware 2. C. Desire for help 7 3o Partially aware T 7 5.Totally aware / 1.Quite unable to accept help in this area D. Movement 2. T 7 » Able to aooept help when i t is offered T 7 5.Takes initiative in asking for help directly r 1.Problem d ominates many aspects of olient's l i f e 7 7 T, — 2.Problem oreates 3.Problem not basically 4oSome aspects difficulties in resolved, but under of problem some areas control basioally resolved 7 5.Total problem basically resolved 126. Area of d i f f i c u l t y Client A Severity Awar B eness C Desire for help D Movement From To From To From To Reaotion to illness„ Reaotion to limitations of servioe Relationship with S.H. Marital relationship Child-parent relationship Personality adjustment Other (specify) 1 ': - -D - GENERAL 127 • !• How valuable do you feel the total servioe was to this family? 7 7 7 Unquestionably of tremendous value Some difficulties, but generally valuable So many difficulties that value is questionable Of no value whatsoever 20 What were the circumstances under which S.H. service was given? (Check whioh) a. Mother awaiting hospital bed b. Mother in hospital Co Mother discharged from hospital - convalescent d. Mother on bed rest at home as alternative to hospitalization e. To prevent break-down when mother pregnant f. Other (speoify) 3. What were the circumstances under which S.H. servioe was discontinued? (Cheok whioh) a. Mother well enough to manage without help b. Family able to make satisfactory alternative plan c. Family unable to make constructive use of servioe - servioe withdrawn by agenoy d. Family unable to accept conditions of servioe - voluntary withdrawal e. Environmental factors made i t impossible to continue servioe (Housing, sanitation, equipment, etc.) f • Family moved g. 24 - month limit reached h. No further funds available i . Other (speoify) APPENDIX B SUPPLEMENTARY CHARTS FOR CHAPTER IV Page Figure 1. Monthly income of 42 T.B.-Homenaker families 129. Figure 2 . Housing of 42 T.B.-Homemaker families 129. Figure 3. Number of children in 42 T.B.-Homemaker families 130. Figure 4 . Ages of children in" 42 T.B.-Homemaker families. 130. Figure 5. Circumstances under which T.B.-Home-maker Service was given 131« Figure 6. Eagerness of families for T.B.-Home-maker Service. 132* Figure 7. Activity of mother's tuberoulosis at commencement of service 133. Figure 8. Length of mother's hospitalization; 42 T.B.-Homemaker families 133. 129* Range Frequency Graphic Representation Under $150 per month $150-199 per month $200-249 per month $250-299 per month & over per month Total 14 19 1 42 2 Figure 1: Income of Families Receiving T»B.-Homemaker Servioe for More Than Three Months Classification Frequency Graphic Representation Very inadequate Generally satisfactory Leaves nothing to be desired Total 0 1 4 16 2 11 0 6 42 J figure d: Housing or families receiving x«B,-ttomemafcer service ror more than Three Months 130, Number of Children Frequency Graphic Representation None One ' Two Three Four •-.Five. Total !3 17 6 4 1 42 families 3 1 1 J Figure 3: Number of Children in Families Reoeiving T.B.-Homemaker Service for More Than Three Months Age Range Frequency Graphic Representation 0-2 years 3-5 years 6-11 years 12-15 years Total 19 25 35 7 86 children 1 1 Figure 4: Ages of Children in Families Receiving T.B.-Homemaker Service for More Than Three Months 131. Service given while mother Code Freq-uency Graphic Representation - convalescent hospitalized (care during, and/or before and after) pregnant (oare during and/or after) - awaiting hospital bed - other A B C A: B C A B B C B* C/ 11 5 6 5 4 2 4 1 1 2 1 1 2 Figure 5s Distribution of T.B.-Homemaker cases according to over-all evaluation and oiroumstanoes under.which service was given. * mother with quiescent T.B. needed bed-rest because of extending lesions, /mother, in hospital when service commenced, signed herself out to "take the cure" at home. 132, Classification Code Freq-uency Graphic Representation Very eager for servioe Some ambivalence, mostly realistic No desire-applied under pressure A B C B C A B C B C 15 3 2 3 3 1 2 2 IT Figure 6t Distribution of families given T.B.-Homemaker Service, according to over-all evaluation and mother's desire for service. 133. Activity Code Freq-uenoy Graphic Representation Arrested Active, improved Active B C A B C A B C 3 1 9 5 6 5 4 4 Figure It Distribution of T.B.-Hornsmaker cases according to activity of disease at beginning of services (Scale based on classification recommended by National Tuberculosis Association "Diagnostic Standards" - 1950 Edition.) Months of hospitalization Code Freq-uency Graphic Representation Under 5 5 - 9 10 - 14 15 - 19 A B C A B C A B C A B C 1 2 0 4 5 5 6 1 2 8 3 1 1 Figure b: D i s t r i b u t i o n or 30 T»B.-Homemaker cases according to t o t a l time spent i n tuberoulosis h o s p i t a l . APPENDIX C REFERRAL FORMS FOR T.B.-HOMEMAKER SERVICE j ^ g e 1) Referral Forma used by Metropolitan Health Committee........ 135» 2) Application Form used by Family Welfare Bureau ....*•• 136* 3) Recommended Intake Outline for T»B.-Homemaker Applications•• 138« REFERRAL FOR SUPERVISED HOMEMAKER (TB) 155 Name Address Diagnosis.. ..Any other health conditions (specify)... • Exercise. • Sputum. Reason homemaker requested Type of service required - Resident.............Full Time.............. Part Time (specify) • Approximate length of service required...... SUMMARY OF HOME CONDITIONS Members of Household Birth Sex Relationship Occupation or Remarks Housing (Number of rooms, type, location, general condition, sanitation) Attitude, intelligence, cooperation (patient and family) home atmosphere, economio status, etc. S.S* Index Approved for considerations Director of Public Health Nursing Signature of nurse REFERRAL FORM FOR SUPERVISED HOMEMAKER SERVICE OF THE FAMILY WELFARE BUREAU OF GREATER YANCOUVER Rate.. Case #. 136. 1. NAME.... 2. ADDRESS. 3. REG. 4. FAMILY: .TELEPHONE. First name .UNIT Birthdate Birthplace Place of work or auhuul Father: Mother: Children! Others: 5. Referred for S.H. Service by: 5B. State Problem: 6. HEALTH OF MEMBERS OF FAMILY Family doctor or clinic V.O.N, care Religion & Church connections. Previous S.H. Service: 7* HOME: No. of rooms, sleeping arrangements- for S.H., standards & equipment, including washing facilities: Family relationships, attitudes to S.H. Service of both parents and older children, behaviour, etc. Why originally known to agency: 8. Monthly income & Resources Earnings of father Earnings of mother... Contributions of ch....... Family Allowance .......... Other sources. TOTAL Monthly expenses: Food.. Fuel Rent & payments Water... Clothing. Taxes.......... Insurance Incidentals.... Electricity •• Medicines. Telephone Others ......... TOTAL Bank account & other negotiable assets: Payment for S.H. expected: Amount.... Source < Outstanding debts: Name Total amount now owing Montly payments 137. 9. HOME PLAN DURING S.H. SERVICE: (1J Responsibility to be taken for food money . and shopping by: (2) Arrangements for week-end leave for S.H.... (3) Responsibility for the ohildren (4) Children's duties.. • • (5) Duties of the father or other person responsible in the home (6) Resident or non-resident Hours of duty suggested (7) Approximate length of time required Agency Signature of Worker 10. SERVICE RENDERED: Date service commenced Total cost....... .•.Completed.. Reimbursements .Name of Homemaker. i..Bal.owing....... 138, INTAKE OUTLINE FOR T.B.-HOMEMAKER APPLICATIONS Introductions In order to make a wise decision about applications for long-term T.B.-Homemaker Service, it- is necessary for the Family Welfare Bureau to have as much information as possible about the family to be served. The following questions have been carefully chosen because, in the agency's experience, they have a close relationship with the extent to which the family can benefit from the placement of a homemaker. Your co-operation in completing this form will be very muoh appreciated. It is suggested that the public health nurse secure as much of the necessary information as possible, and that the caseworker complete i t in the course of her preliminary visits. The form is intended to be a flexible outline, not a rigid questionnaire* NAME • ADDRESS • REG. # TELEPHONE FAMILY First name Age Place of work or school Father Mother: Children: Others in the household ... HOUSING (consider number of rooms, sanitation, standards of housekeeping, and equipment, inoluding washing faci l i t i e s ) . FINANCES: Family inoome and resources Monthly expenses Income of father. Contributions of children... Family Allowance. Other sources.... TOTAL Food.......... Electricity. Rent or Telephone... payments........... Insurance... Taxes. Clothing.... Fuel Health Water........ Other.. TOTAL. Bank account and other negotiable assets: Outstanding debts: Total amount now owing Monthly payments Name of creditor 139« MOTHER'S HEALTH; Date of first T.B. diagnosis. ..Dates of a l l hospitalization for tuberculosis..............o Present situation (Is mother awaiting hospitalization, in hospital, pregnant, convalescent, etc.?)..... < Re most recent breaMown; Date...........Souroe of in for nation .Doctor Health condition at beginning of breakdown (Type of infection, lesions, activity, sputum) Treatment recommended• * Circumstances of discharge from hospital.< Health condition when discharged from hospital (lesions, activity, sputum, exercise status)....... ...*.....«• At the present time, to what extent is patient following medical instructions?. • What is patient's attitude to her illness* MOTHER'S HOSPITAL RECORD: (if known) Notes During the course of a lengthy stay in hospital, the attitudes*and behavior of tuberculosis patients frequently undergo a marked change. You are therefore asked to indicate by X the mother's status at the time* of admission to hospital, and by 0 her status at discharge. Each "Scale" is continuous, and may be marked at any point. Personal relationship with doctors, nurses, people in authority: / 7 7 Very hostile or Generally Extremely suspicious co-operative submissive Personal relationships with other patients: r ~—7~ —7 7 Extremely with- Finds i t hard Generally warm Takes initiative drawn - "lone wolf " to make and outgoing in social situations friends Attitude to illness itself: r— — — 7 "7 Denies, exaggerates, Generally Very mature and extreme fear or rage satisfactory intelligent (Indicate which) Breaks rules at every opportunity. Complaines, but usually complies Seems to welcome these During hospitalization, did-any incidents arise which may have a bearing on patient's application for T.B.-Homemaker Service? If so, explain briefly. FAMILY RELATIONSHIPS: 141 • S«S.I.Registrations Date Active? Not at a l l Lgency consulted (check which) Telephone | Personally Have any of the problems for which the family sought agency assistance any bearing on the present application? If so, explain briefly. Have you noticed any signs of difficulty in inter-family relationships? Who seems tovplay the dominant role in the family? What do you consider to be the outstanding strengths and weaknesses of the Family? How would you describe the home atmosphere? What help have relatives given in the present situation? What is their attitude to mother's illness? How much influence do they have on this family? HUSBAND: Occupation. .Educational level Health : Hobbies and interests...... Attitude to wife's illness...... Response to increased responsibilities made necessary by wife's illness Estimate of intelligence, co-operativeness, emotional maturity.... Personality traits or habits which should be taken into consideration in the present application 142* CHILDREN: To what type of routine and discipline have the children in this family been accustomed?......* How have the children been cared for during the mother's illness up to the present time? •• How have they reacted to their mother's illness and its attendant disturbances ?. Have they been told that a homemaker may come in to assist their mother?...........What is their reaction?... • What type of homemaker do you consider would best meet the needs of the children in this home? Indicate as far as you can the individual needs and speoial problems of each of the children. Try to include such factors as the following: health, food dislikes or allergies, sleep disturbances, enuresis, fears, unusual habits, aggressiveness, relationships with parents and adults in authority, relationships with siblings and playmates, school adjust-ment, hobbies and recreational intersts* 143. PLANS FOR SUPERVISED HOMEMAKER SERVICE: How eager is the "family to secure S.H. Service?... Estimate of family's capacity and willingness to work co-operatively with both homemaker and caseworker. • « Type of service required: (underline) resident, non-resident, full-time, part-time Hours of duty Approximate length of time required suggested Duties of father Duties of mother Duties of children Arrangements for week-end leave for S.H Arrangements for family's financial contribution to cost of service SOURCE OF REFERRAL: Service recommended by (Physician) Application completed by: Publio Health Nurse ...District Social Worker Agency. Date application completed....... Approved for consideration: Director of Public Health Nursing Accepted for Service ....... Signature Date APPENDIX D  BIBLIOGRAPHY Books Alexander, Franz, Studies in Psyohosomatio Medicine, Ronald Press, New York 1948. Elledge, C.H., The Rehabilitation of the Patient, J.B. Lipinoott Co., New York 1948. Pattison, Harry A., Rehabilitation of the Tuberculous, Livingstone Press, New York 1942. Siltzbaoh, Louis E., Clinioal Evaluation of the Rehabilitation of the  Tuberoulous, New York Tuberculosis and Health Association, New York, 1944* Upham, Frances, A Dynamic Approaoh to Illness - a Sooial Work Guide, Family Servioe Association of Amerioa, New York 1949* Weiss, Edward, and English, 0. Spurgeon, Psyohosomatio Medioine, W.B. Saunders Co., New York, Second Edition 1949* Hunt, J.M., and Kogan, Leonard S., Measuring Results in Social Casework -a Manual on Judging Movement, Family Service Association of America, New York 1950. Wittkower, Eric, A Psychiatrist Looks at Tuberoulosis, National Associat-ion for the Prevention of Tuberculosis, London 1949. Articles Albee, George W., "Psyohologioal Concomitants of Pulmonary Tuberoulosis", American Review of Tuberculosis, Volume 58, pp.650-661 Berle, Beatrice B., "Emotional Factors ani Tuberculosis - A Critical Review of the Literature", Psychosomatic Medioine, Volume X, pp.366-71 Black, Alice L,, "Some Factors Affecting the Vocational Rehabilitation of Tuberculous Patients", Smith College Studies in Sooial Work, Volume XI, pp.286-321. Benjamin, J.D., Coleman, J.V., and Hornbein, R., "A Study of Personality in Pulmonary Tuberoulosis", American Journal of Orthopsychiatry, Volume XVIII, No. 4, pp.701-707. Berman, Jean and Leo, "The Signing Out of Tuberculosis Patients", The  Family, April 1944, pp.67-73. Brooke, Mary S., "The Psychology of iho Tuberculous Patient", Journal of  Social Casework, February 1948, pp.57-60 Coleman, J.V., Hurst, A., and Horribein, R o , "Psychiatric Contributions to the Care of Tuberoulous Patients", Journal of the American Medical  Association, Vol.135, No. 11, pp.699-702. Fraenkel, Marta, "Some Tentative Results of a Study of Housekeeping Service for Chronic Patients", Welfare Council of New York City Bulletin, May 23rd, 1941. Harz, J., "Tuberoulosis and Personality Conflicts", Psychosomatio Medicine, Volume VI, pp.17-22. Streoker, E.A., et a l . "Mental Attitudes of Tuberoular Patients", Mental Hygiene, October.1938, pp.529-43. 

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