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The role of the medical social worker in the treatment of epilepsy : an exploratory study of cases from… Rabinovitch, Gertrude 1952

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THE ROLE OF THE MEDICAL SOCIAL WORKER IN THE TREATMENT OF EPILEPSY  An e x p l o r a t o r y study o f cases from the S e i z u r e C l i n i c o f the Vancouver General Hospital.  by Gertrude R a b i n o v i t c h  Accepted as conforming t o the standard r e q u i r e d f o r the degree of Master of S o c i a l Work  S c h o o l o f S o c i a l Work  1952 University of B r i t i s h  Columbia  Abstract  M e d i c a l s c i e n c e has done much t o b r i n g e p i l e p s y out of the realm of mysticism and misconception, i n t o the a r e a of normal and n a t u r a l d i s e a s e s ; but many persons s u b j e c t t o s e i z u r e s experience d i f f i c u l t y i n t h e i r attempts to l i v e as o t h e r s do. I t i s the purpose of t h i s t h e s i s t o examine the ways i n which medical s o c i a l work can h e l p them achieve t h i s end. The s e t t i n g - u p and the purpose o f the S e i z u r e C l i n i c o f the Vancouver General H o s p i t a l i s d e s c r i b e d . An examination of the s o c i a l s i t u a t i o n s o f f i f t y - t h r e e persons who were r e f e r r e d t o the s o c i a l worker d u r i n g a p e r i o d of seventeen months, f o r v a r i o u s k i n d s of h e l p , r e v e a l s the problems which e p i l e p s y p r e s e n t s t o t h i s group of people. There are numerous examples of d i f f i c u l t i e s a s s o c i a t e d w i t h (a) p a r e n t a l a t t i t u d e s , (b) s o c i a l r e l a t i o n s h i p s , (c) employment, and (d) marriage. The m a t e r i a l i n d i c a t e s - c l e a r l y , t h a t b l a n k e t statements r e g a r d i n g " e p i l e p t i c s " i n g e n e r a l , are u n f a i r and untrue.' Each i s an i n d i v i d u a l who r e q u i r e s h e l p w i t h h i s p a r t i c u l a r difficulties. A n a l y s i s of the cases r e v e a l s t h a t the m e d i c a l s o c i a l worker can c o n t r i b u t e t o the treatment of e p i l e p s y by (a) e n a b l i n g the p h y s i c i a n to understand the p a t i e n t s s o c i a l . s i t u a t i o n as i t a f f e c t s h i s medical c o n d i t i o n and h i s a t t i t u d e toward medical treatment; (b) c o r r e c t i n g the p a t i e n t ' s misconceptions toward h i s i l l n e s s , a l l e v i a t i n g a n x i e t y r e g a r d i n g treatment, and g e n e r a l l y e n a b l i n g him t o o b t a i n the g r e a t e s t b e n e f i t from m e d i c a l treatment; (c) h e l p i n g the p a t i e n t understand and accept h i s handicap; (d) h e l p i n g p a r e n t s develop healthy, a t t i t u d e s toward handicapped c h i l d r e n , i n o r d e r t h a t they may be prepared to assume the r e s p o n s i b i l i t i e s o f adulthood; te) f a m i l i a r i z i n g persons i n the community with the f a c t s r e g a r d i n g e p i l e p s y and thus e v e n t u a l l y r e d u c i n g the stigma a s s o c i a t e d w i t h the i l l n e s s . The casework methods used by the s o c i a l worker i n c l u d e , ( a ) m o d i f y i n g the environment, (b) p s y c h o l o g i c a l support, (c) c l a r i f i c a t i o n , and (d) i n s i g h t . There i s s u f f i c i e n t evidence i n t h i s study t h a t m e d i c a l s o c i a l work can i n v a r i o u s ways and t o v a r y i n g degrees, h e l p e p i l e p t i c persons to be u s e f u l members of the communities i n which t h e y l i v e .  Acknowle dgement s  To Dr. N.L. Auckland, who has shown continued i n t e r e s t i n the establishment o f a constructive programme f o r the d i a g n o s i s , treatment and r e h a b i l i t a t i o n o f persons, handicapped by e p i l e p s y , I should like  t o express my thanks.  H i s kindness i n e x p l a i n i n g  both t h e s o c i o l o g i c a l and medical a s p e c t s o f t h i s i l l n e s s has been o f immeasurable a s s i s t a n c e .  I should  l i k e t o express a p p r e c i a t i o n t o Miss E l e a n o r B r a d l e y , A c t i n g D i r e c t o r of the S o c i a l S e r v i c e Department o f t h e , Vancouver General H o s p i t a l , f o r t h e encouragement she has g i v e n .  I should a l s o l i k e to express my thanks t o  Dr. L.C. Marsh, A c t i n g D i r e c t o r of the School o f S o c i a l Work, of t h e U n i v e r s i t y o f B r i t i s h Columbia, not o n l y for  h i s c o n s t r u c t i v e c r i t i c i s m , but a l s o f o r the i n t e r e s t  he has shown i n t h i s  project.  Table of Contents  THE ROLE OF THE MEDICAL SOCIAL WORKER IN THE • TREATMENT OF EPILEPSY  Chapter  I  S e i z u r e C l i n i c - Ah:Experiment . i n Co-operation Teamwork i n the treatment o f e p i l e p s y ; h i s t o r i c a l f a c t o r s i n f l u e n c i n g present day t h i n k i n g ; d e s c r i p t i o n o f the ' S e i z u r e C l i n i c ; purpose of the' t h e s i s ; method used i n o b t a i n i n g c a s e - m a t e r i a l for analysis.  Chapter.II  The M e d i c a l Aspects o f E p i l e p s y  ...  D e f i n i t i o n o f e p i l e p s y , kinds o f s e i z u r e s , and d i a g n o s t i c procedures used i n e s t a b l i s h i n g a d i a g n o s i s ; m e d i c a l and s u r g i c a l treatment; the p h y s i c i a n ' s r e s p o n s i b i l i t y i n the management o f the i l l n e s s . Chapter I I I  Can the M e d i c a l S o c i a l Worker Help the S e i z o r e d C h i l d ?  21  General, problems which e p i l e p s y p r e s e n t s t o the c h i l d r e n i n t h i s study; s p e c i f i c problems o f the p r e s c h o o l c h i l d , the c h i l d a t t e n d i n g s c h o o l , and the c h i l d o f s c h o o l age who i s not a t t e n d i n g s c h o o l ; kinds of •• r e f e r r a l s made t o the s o c i a l worker and t h e h e l p p r o v i d e d .  Chapter IV  Can the M e d i c a l S o c i a l Worker Help the A d u l t Who i s S u b j e c t to S e i z u r e s  45  D i f f i c u l t i e s of s i n g l e persons i n r e l a t i o n to p a r e n t a l a t t i t u d e s , s o c i a l r e l a t i o n s h i p s , employment, and f e e l i n g s toward marriage; d i f f i c u l t i e s of persons whose s e i z u r e s began b e f o r e marriage and a l s o those of persons whose s e i z u r e s began a f t e r marriage; r e f e r r a l s to the s o c i a l worker and the h e l p provided. Chapter V  M e d i c a l S o c i a l Work - An Essent'a^l f o r the S u c c e s s f u l Treatment of E p i l e p s y .............. 75 D e f i n i t i o n of " s u c c e s s f u l treatment"; casework methods d e f i n e d i n terms of (a) modifying the environment, (b) p s y c h o l o g i c a l support, (c) c l a r i f i c a t i o n , and (c) i n s i g h t ; c o n c l u s i o n s r e g a r d i n g the r o l e of the m e d i c a l s o c i a l worker i n the treatment o f e p i l e p s y i n the s e i z u r e c l i n i c and a l s o i n any other m e d i c a l s e t t i n g .  Diagrams  Diagram 1  Diagram 2  I l l u s t r a t i o n o f the l o b e s o f the b r a i n  13  M a r i t a l status of e p i l e p t i c persons i n the study  46  Tables  Table 1  Table 2  Kinds of R e f e r r a l s t o the S o c i a l Worker  37  Kinds o f R e f e r r a l s to t h e S o c i a l Worker  66  Chapter I  SEIZURE  CLINIC  AN EXPERIMENT IN GO-OPERATION  F o r t o o many y e a r s , t h e treatment o f e p i l e p s y has been regarded as the r e s p o n s i b i l i t y  o f the medical p r o f e s s i o n a l o n e .  However, with t h e t r e n d toward  specialization  and t h e r e c o g n i t i o n  t h a t no one person c o u l d equip h i m s e l f t o t r e a t  t h e numerous  phases o f a l l i l l n e s s e s , the i d e a o f "teamwork* amongst v a r i o u s p r o f e s s i o n a l people, i n c l i n i c s o r i n h o s p i t a l s was i n i t i a t e d . A l s o , with an i n c r e a s i n g acceptance o f "psychosomatic  medicine",  t h a t i s t h e study o f t h e i n f l u e n c e of b o t h t h e mind (psyche) and body (soma) i n i l l n e s s , m e d i c a l s o c i a l work g r a d u a l l y g a i n e d acceptance as one o f the p r o f e s s i o n s which c o u l d c o n t r i b u t e t o the t o t a l understanding o f t h e p a t i e n t .  E p i l e p s y i s an i l l n e s s  which appears t o be as much a s o c i a l problem.as i t i s a m e d i c a l problem, and i t i s t h e r e f o r e . w o r t h w h i l e t o examine the extent t o which medical s o c i a l work can c o n t r i b u t e t o i t s treatment. The degree t o w h i c h e p i l e p s y has been and continues t o be a s o c i a l problem,, has been g r e a t l y i n f l u e n c e d by t h e f o l k l o r e and s u p e r s t i t i o n s which, f o r c e n t u r i e s , have been a s s o c i a t e d with i t .  E a r l i e s t h i s t o r i a n s speak o f i t as a ••Sacred Disease ..,  a v i s i t a t i o n o f the gods".  I t s causes have been " e x p l a i n e d " i n  terms o f vapours, the i n f l u e n c e o f t h e moon, and t h e s e x u a l  2 misbehaviour o f the parents o f persons s u b j e c t to s e i z u r e s the p a t i e n t h i m s e l f .  and  P r i o r t o the f i r s t h a l f o f the l g t h  treatment c o n s i s t e d o f remedies with a s u p e r s t i t i o u s These i n c l u d e d the g e n i t a l s o f s e a l s , charms and I s o l a t i o n of the p a t i e n t was  connotation.  amulets.  recommended s i n c e he was  a menace t o s o c i e t y and the f a m i l y group.  century,  considered  I s o l a t i o n took the  form o f c u s t o d i a l care i n mental i n s t i t u t i o n s o r s p e c i a l colonies.  Despite  the e f f o r t s o f such men  B.C.), Thomas W i l l i s  as H i p p o c r a t e s  (460-378  ( 1 6 2 1 - 7 5 ) , John Hughling Jackson .(.1835-1911),  Hans Berger (  -1941)» and W.G.  of the great men  who  Lennox, t o mention only a  few  have c o n t r i b u t e d to t h e u n d e r s t a n d i n g o f  e p i l e p s y , a great d e a l more i s r e q u i r e d to b r i n g i t out o f  the  realm o f m y s t i c i s m and m i s c o n c e p t i o n , i n t o the realm o f normal and n a t u r a l d i s e a s e s .  For t h e n , and  o n l y then, can treatment o f  e p i l e p s y be e f f e c t i v e . The  seizure c l i n i c  i s a nebulous term d e s c r i b i n g a  p r o j e c t of the Vancouver General. H o s p i t a l , i n which a v a r i e d programme g r a d u a l l y evolved t o t a l well-being  out o f a growing concern f o r the  of the person r e q u i r i n g treatment f o r e p i l e p s y .  F o r m e r l y , because o f the numerous d i f f i c u l t i e s a s s o c i a t e d w i t h t h i s i l l n e s s and the community^ l a c k of r e a d i n e s s  t o assume  r e s p o n s i b i l i t y toward the person w i t h e p i l e p s y , treatment at the O u t p a t i e n t s was  1  Department of the Vancouver General H o s p i t a l  c o n f i n e d , p r i m a r i l y , t o the a d m i n i s t r a t i o n of drugs by  members of the m e d i c a l p r o f e s s i o n .  Although i n d i v i d u a l , attempts  were made by p h y s i c i a n s t o t r e a t the s o c i a l and  psychological  3  handicaps of the i l l n e s s , the organization of the. seizure c l i n i c i n June 195© was the f i r s t co-operative attempt i n B r i t i s h Columbia to treat i t s numerous aspects.  Through the efforts  of three Vancouver physicians, who were associated with the neurology clinic.of the Outpatients' Department, funds were obtained from a mental hygiene grant of the Federal Government to carry out the programme of the c l i n i c .  The grant provided  for an electroencephalographic machine, a f u l l time social worker, a stenographer and. an occupational therapist who would.both work half time.  The objective of the programme was the "diagnosis,  treatment and.rehabiiitation of patients referred",^  The  function of the medical social worker was defined as follows: Referral to the social worker will, come from the doctors in the c l i n i c . The worker w i l l compile social histories by interviewing patients and their relatives. He w i l l carry on education re the illness with families, employers and associates and work closely with the patient to influence his. attitude toward his illness. 2  It i s obvious from this that the c l i n i c was founded on an acceptance of the psychosomatic approach and of the need for "teamwork" in the treatment of epilepsy. It i s a c l i n i c in which the profession of social work i s considered an essential part of a comprehensive programme. The Outpatients' Department of the Vancouver General Hospital provides medical treatment for those persons i n the community, who cannot, through lack of financial resources, obtain medical care on a,private basis. Each year, out-door ^ i 1 and 2 taken from minutes of one of the f i r s t organizational meetings held.June 9» 1950,  medical treatment i s provided for approximately 7060 patients who have met the e l i g i b i l i t y requirements,. Medical treatment i s available to: (a) a single person earning up.to $100 per month, (b) two persons earning.up to $130 per month. (c) three persons earning up to $150 per month. Twenty-five dollars i s allowed for each additional member of the family u n t i l a maximum income of $250.00 per month i s reached, A family may have savings amounting to $500.00, Persons whose medical care can be provided through company medical schemes are ineligible for treatment at.the Outpatients Department, However, 1  i f treatment for a particular condition i s not provided by the company plan, and the patient i s otherwise e l i g i b l e , treatment i s available through the Outpatients' Department,  Consideration i s  given to the patient's social situation i n those instances where the income i s just beyond the e l i g i b i l i t y requirements. Patients are referred to the Outpatients Department by 1  physicians i n private practice.  Patients referred by the social  agencies of Vancouver are also, accepted for treatment,. The procedure of sending a patient through the department begins with an examination of the patient by an interne.  The patient i s then  sent to the c l i n i c which can best provide for his treatment. In addition to the volunteer efforts of physicians, service i s provided, by a paid staff of resident internes, graduate nurses, nurses' aides, social workers, pharmacists, dieticians, laboratory technicians, clerks and. stenographers.  The teaching programme  for nurses, social workers, dieticians and technicians adds to  5 the s e r v i c e provided The  by t h e O u t p a t i e n t s  Seizure C l i n i c  i s s i m i l a r t o , but i n many r e s p e c t s  d i f f e r e n t from t h e o t h e r c l i n i c s  i n the Outpatients'  I t may use the f a c i l i t i e s p r o v i d e d t i o n i t . p o s s e s s e s the r e s o u r c e s grant.  Department,  1  for a l l clinics,  Department, but i n a d d i -  made p o s s i b l e by t h e f e d e r a l  W i t h i n t h e s t r u c t u r e of t h e H e a l t h Centre f o r C h i l d r e n ^  i s a c l i n i c providing, treatment f o r c h i l d r e n w i t h e p i l e p s y . Although t h i s i s n o t i n theory  considered  a part of the seizure  c l i n i c , i t i s so i n p r a c t i c e .  The n e u r o l o g i s t , t h e s o c i a l worker  and t h e stenographer from the s e i z u r e c l i n i c have assumed a measure.of r e s p o n s i b i l i t y i n . the c l i n i c Centre f o r C h i l d r e n . volunteer  An a d d i t i o n a l n e u r o l o g i s t and. neuro-surgeon  their service to t h i s The  Outpatients'  Department f o r the treatment of e p i l e p s y , s e r v e d as f o r t h e new c l i n i c .  r e o r g a n i z a t i o n o f the c l i n i c regular clinics  Outpatients' A clinic  clinic.  neurology c l i n i c , a l r e a d y e s t a b l i s h e d i n t h e  the f o u n d a t i o n  The  o f neurology a t t h e Health  Through t r i a l and e r r o r , t h e  r e s u l t e d i n t h e f o l l o w i n g framework.  i n neurology are h e l d one day a week i n the  Department and i n t h e Health  Centre f o r C h i l d r e n .  i n neuro-surgery i s h e l d each Saturday morning., i n t h e  Outpatients' operation,  Department.  D u r i n g t h e f i r s t year o f t h e c l i n i c ' s  a case-conference type o f c l i n i c was heU on Saturday  mornings f o r t h e d i s c u s s i o n o f a p a t i e n t whose problem was d i f f i c u l t 3  The H e a l t h Centre f o r C h i l d r e n p r o v i d e s out-door care f o r c h i l d r e n up t o the age of s i x t e e n y e a r s . The e l i g i b i l i t y r u l e s which apply t o t h e O u t p a t i e n t s ' Department, a l s o apply i n t h e centre.  6 and whose medical i n v e s t i g a t i o n had been thorough. p a t i e n t was was  not p r e s e n t ,  he was  informed, b e f o r e  Although the  the  h e l d , t h a t h i s problems would be d i s c u s s e d by a group  were i n t e r e s t e d i n h e l p i n g him.  from the s e i z u r e c l i n i c .  A l s o , any  twofold. medical,  The  interne, physician, public was  interested  purpose of t h i s conference  Through d i s c u s s i o n an attempt was  made to e v a l u a t e  was the  p s y c h o l o g i c a l a n d . s o c i a l f a c t o r s i n each, s i t u a t i o n .  F o l l o w i n g t h i s , a s u i t a b l e p l a n o f treatment was As the c l i n i c p r o g r e s s e d , the the i l l n e s s became more o b v i o u s . gradually introduced.  An  r e l a t i v e s of p a t i e n t s was  outlined.  problems a s s o c i a t e d w i t h  Consequently, i n n o v a t i o n s  e d u c a t i o n a l meeting f o r parents i n i t i a t e d when i t was  i n f l u e n c e of unhealthy p a r e n t a l a t t i t u d e s .  the  p a t i e n t s should  Out  t h e i r common problems.  t o meet and  as  s o l u t i o n to that  discuss  When s e v e r a l p a t i e n t s themselves expressed  t h i s d e s i r e , a " p a t i e n t ' s group" was purpose of t h i s group was  organized  twofold:  as an  (b) t o provide  and r e c r e a t i o n a l a c t i v i t i e s .  experiment.  (a) t o i n f o r m the members  about t h e i r c o n d i t i o n and t h e ways cff meeting the a s s o c i a t e d w i t h i t , and  no  negative  of these meetings came the s u g g e s t i o n  a l s o have the o p p o r t u n i t y  that  Group d i s c u s s i o n s ,  w e l l as i n d i v i d u a l i n t e r v i e w s , seemed to be the best t h i s problem.  were and  recognized  amount of d i r e c t h e l p , t o p a t i e n t s c o u l d counteract  contacts  neurolo-  s o c i a l worker  h e a l t h nurse or s o c i a l worker i n the community who i n the p a t i e n t , c o u l d a t t e n d .  who  T h i s group i n c l u d e d the  g i s t , the neuro-surgeon, the p s y c h i a t r i s t and the  The  conference  problems  the members w i t h  social  In summary, the S e i z u r e C l i n i c seeks to provide the  t o t a l well-being  of the person with e p i l e p s y i n the  for  following  ways: (a) through the c o - o p e r a t i v e the c l i n i c s t a f f ;  e f f o r t of every member o f  (b) through the establishment and s u p e r v i s i o n of a s u i t a b l e m e d i c a l regime i n the c l i n i c s of neurology at the O u t p a t i e n t s ' Department and the H e a l t h Centre f o r C h i l d r e n ; (c) through an e v a l u a t i o n of the p a t i e n t ' s p s y c h o l o g i c a l - and s o c i a l s i t u a t i o n , and suggested treatment, f o r i t ; (d) through an e d u c a t i o n a l programme f o r p a t i e n t s , parents and i n t e r e s t e d members o f the community. Assuming t h a t the f u n c t i o n of the medical worker i s dependent upon the s o c i a l and  social  p s y c h o l o g i c a l problems  p e c u l i a r t o a p a r t i c u l a r i l l n e s s , i t i s the purpose o f t h i s t h e s i s to examine the r o l e of the medical s o c i a l worker i n the of epilepsy.  In order  t o achieve t h i s end,  a group of  treatment case-  h i s t o r i e s were s e l e c t e d f o r a n a l y s i s from the t o t a l c a s e - l o a d the  s o c i a l worker a s s o c i a t e d w i t h the S e i z u r e C l i n i c ,  e n t i r e group of p a t i e n t s r e f e r r e d t o the forms of h e l p , s i x t e e n were c o n s i d e r e d study f o r two  reasons.  Of  of  the  s o c i a l worker f o r v a r i o u s  inappropriate f o r t h i s  F i r s t , a number o f p a t i e n t s f e l l i n t o a  group about whom l i t t l e was t i o n seemed t o be the r e s u l t  known.  The  scantiness  o f the  informa-  of the p a t i e n t ' s f a i l u r e t o keep  c l i n i c appointments, h i s antagonism.toward r e f e r r a l t o the worker, or his.unexpected departure.from Vancouver,.  The  social  patients  whose s e i z u r e s were not diagnosed as e p i l e p t i f o r m were a l s o e x c l u d e d from t h i s study s i n c e t h e i r problems appeared, t o d i f f e r  f r o m those a s s o c i a t e d with e p i l e p s y .  Apart from the s i x t e e n  cases  which were not c o n s i d e r e d s u i t a b l e , f i f t y - t h r e e cases were found to have s u f f i c i e n t d e t a i l t o present a c l e a r p i c t u r e o f the patient's s o c i a l  situation.  A p r e l i m i n a r y e x p l o r a t i o n of the c a s e - h i s t o r i e s f o r t h i s study r e v e a l e d t h a t the problems of the e p i l e p t i c d i f f e r e d from those o f the e p i l e p t i c a d u l t .  A l s o , the  selected child  service  rendered by the medical s o c i a l worker, of n e c e s s i t y v a r i e d i n accordance w i t h the k i n d s of s i t u a t i o n s w i t h which the r e q u i r e d and requested h e l p .  patient  For t h i s reason, f o l l o w i n g a  p r e s e n t a t i o n of the medical a s p e c t s of e p i l e p s y , the method planned i s t o d e p i c t the problems p e c u l i a r t o an e p i l e p t i c  c h i l d and the  h e l p the medical s o c i a l worker can p r o v i d e (Chapter I I I ) . From t h i s i t i s p o s s i b l e t o a n a l y z e f u r t h e r the ways i n which the m e d i c a l s o c i a l worker can be of h e l p w i t h the problems which the e p i l e p t i c a d u l t must f a c e (Chapter I V ) . problems r e v e a l i n g themselves can be drawn as t o the way the treatment o f e p i l e p s y .  F i n a l l y , from the  specific  i n the sample eases, c o n c l u s i o n s  medical s o c i a l work can p a r t i c i p a t e i n  Chapter II  THE MEDICAL ASPECTS OF EPILEPSY  Medical research s t i l l has a great deal to contribute to the understanding of epilepsy. Because of the lack of scientific evidence, there are numerous opinions regarding the nature of the i l l n e s s , the factors to consider i n establishing a diagnosis, the definition and classification of seizures and the appropriate measures to use i n treatment.  It i s beyond the scope of this  thesis to present i n detail, the various points of view or to evaluate the benefits of each.  However, i t i s essential to have  some basic knowledge of the medical aspects of epilepsy i f the social implications of the illness are to be understood. One writer on the subject, Dr. E.M. Bridge considers epilepsy, "less as a disease in the l i t e r a l sense than as a symptom consisting of sudden and recurrent lapses of consciousness often associated with convulsive movements," He goes on: "The symptom results from a disturbance i n the functional state of nerve cells within the brain, but the disturbance i t s e l f may be set i n motion by a variety of diseases and by different types of factors i n the individual."4 4  Dr. Bridge therefore, considers i t necessary to  Bridge, Edward M., M.D., Epilepsy and Convulsive Disorders i n Children. McGraw-Hill Book Company Inc., New York, Toronto, London, 1949, p. 9.  10 determine the r e l a t i v e importance o f (a) h e r e d i t y , defect,  (c) p h y s i o l o g i c a l d i s t u r b a n c e s ,  (b) s t r u c t u r a l  (d) p e r s o n a l i t y maladjust-  ments and environmental s t r a i n s , i n e s t a b l i s h i n g a d i a g n o s i s o f epilepsy. be  I f treatment i s t o be thorough, each o f these f a c t o r s must  considered. The  importance o f h e r e d i t y i n e p i l e p s y has caused a great  d e a l of controversy  and a great d e a l . of unhappiness..  I n the p a s t ,  too much emphasis has been p l a c e d upon i t . Research has shown t h a t , i n some cases of e p i l e p s y , t h e h e r e d i t y f a c t o r i s s i g n i f i c a n t . In o t h e r s , i t i s of no s i g n i f i c a n c e .  In s t i l l others,  i t i s only  one  of many f a c t o r s w a r r a n t i n g c o n s i d e r a t i o n .  I t i s accepted by  the  a u t h o r i t i e s i n t h i s f i e l d , that convulsive  d i s o r d e r s are s e v e r a l  times more p r e v a l e n t  among the r e l a t i v e s o f people w i t h e p i l e p s y  than among those o f n o n - e p i l e p t i c i n d i v i d u a l s .  Dr. W.C,  Lennox  estimated t h a t the chance o f an e p i l e p t i c i n d i v i d u a l producing an e p i l e p t i c o f f s p r i n g i s approximately one i n f o r t y .  He a l s o concluded  from an a n a l y s i s o f 675 electroencephalograms, made of. twins both normal and e p i l e p t i c and o f parents and other near r e l a t i v e s o f e p i l e p t i c s , "that e p i l e p s y per se, i s not i n h e r i t e d , but a p r e d i s p o s i t i o n may be, "^ B r a i n i n j u r y i s thought t o be of s i g n i f i c a n c e i n a p p r o x i mately f i f t y per cent of a l l cases o f e p i l e p s y .  Organic damage t o  t h e b r a i n may r e s u l t from i n j u r i e s a c q u i r e d before or during 5  the neonatal period, vascular  b i r t h , at b i r t h  o c c l u s i o n , head trauma and  Lennox, W i l l i a m C,, M.D., Marriage and C h i l d r e n f o r E p i l e p t i c s . Pamphlet r e p r i n t e d from Human F e r t i l i t y . Vol..10, No, 4, Dec. 1945.  11 o t h e r c o n d i t i o n s and litis,  diseases.  c e r e b r a l degenerative  and tumor, and  syphilis.  The  l a t t e r group i n c l u d e s encepha-  d i s e a s e s , l e a d encephalopathy, abcess  I t i s thought that the dead nerve  r e s u l t i n g from c e r e b r a l i n j u r y , or the  cells  scar t i s s u e t h a t r e p l a c e s  the c e l l s , do not themselves become f o c i of abnormal, d i s t u r b a n c e s . R a t h e r , the l i v i n g nerve c e l l s around the s c a r t i s s u e , which have been subject to abnormal, c o n d i t i o n s , a r e thought to become, the of explosive discharges.  centres  M e d i c a l r e s e a r c h has not as y e t p r o v i d e d  a  comprehensive e x p l a n a t i o n f o r the I r r i t a b i l i t y of c e l l s , which r e s u l t s i n b u r s t s of e l e c t r i c a l discharges and which manifest  themselves i n  the form of an e p i l e p t i c s e i z u r e . Dr. B r i d g e uses the term " p h y s i o l o g i c a l f a c t o r " t o a " v a r i e t y of i n f l u e n c e s t h a t a f f e c t the e p i l e p s y by  describe  precipitating  s e i z u r e s or by augmenting the tendency toward c o n v u l s i v e types  of  reactions".^*  are  Whereas the f a c t o r s of h e r e d i t y and b r a i n i n j u r y  f i x e d i n terms of t h e i r c o n t r i b u t i o n to the c a u s a t i o n , the l o g i c a l f a c t o r s are of a f l u c t u a t i n g n a t u r e . the onset  o f menstruation,  physio-  I n f e c t i o n and  fever,  the s l e e p c y c l e , d i s t u r b e d f l u i d r e g u l a -  t i o n , c h r o n i c f a t i g u e , and emotional  disturbances:  f a c t o r s are c o n s i d e r e d i n the category  a l l of  these  of f l u c t u a t i n g phenomena.  E n v i r o n m e n t a l p r e s s u r e s and p e r s o n a l i t y maladjustments are a l s o fluctuating factors. emotional  I t i s a well-accepted  s t a t u s of the p a t i e n t , h i s p e r s o n a l i t y , and the  which are brought t o bear upon him, i n f l u e n c e the frequency 6  concept t h a t the  i n some i n s t a n c e s not  pressures only  o f s e i z u r e s but a l s o p r e c i p i t a t e t h e i r  B r i d g e , Edward M., M.D., E p i l e p s y and C o n v u l s i v e D i s o r d e r s i n C h i l d r e n . McGraw-Hill Book Company Inc.,' New York, T o r o n t o , London, 1949, p. 1 0 5 .  12 initial  appearance. As s t a t e d p r e v i o u s l y , t h e r e has been a g r e a t  controversy  regarding  the c l a s s i f i c a t i o n o f t h e t y p e s o f s e i z u r e s .  No one s e t o f c l a s s i f i c a t i o n s i s acceptable i n t e r e s t e d i n t h i s p a r t i c u l a r aspect The  deal o f  t o a l l physicians  v  o f t h e p r a c t i c e of m e d i c i n e .  terminology o f Dr. E.M. B r i d g e has been employed i n t h e f o l l o w -  ing description of seizures.  The term " f o c a l s e i z u r e " i s d e s c r i p -  t i v e of t h e s e i z u r e which i s i n i t i a t e d i n s p e c i f i c areas o f t h e brain.  The s e i z u r e u s u a l l y b e g i n s i n the same, way w i t h l i m i t e d and  s p e c i f i c p o r t i o n s o f the b r a i n i n v o l v e d . may or may not f o l l o w .  A generalized  convulsion  The terms " e s s e n t i a l e p i l e p s y " o r " i d i o p a t h i c  e p i l e p s y " apply t o s e i z u r e s which have no. c o n s i s t e n t point o f origin.  T h i s term i n d i c a t e s t h a t i t has been i m p o s s i b l e  evidence of s t r u c t u r a l damage t o the b r a i n . research,  i t i s known t h a t c e r t a i n p o r t i o n s  responsible f o r specific bodily functions.  to obtain  As a r e s u l t o f m e d i c a l of the b r a i n a r e Therefore,  the p o r t i o n  or p o r t i o n s o f the b r a i n from which t h e e l e c t r i c a l d i s c h a r g e s f o r t h , determine t h e form which t h e s e i z u r e s t a k e . pass through s e v e r a l stages.as t h e discharge portions o f the b r a i n .  burst  The s e i z u r e may  spreads over v a r i o u s  The lobes o f the b r a i n with some  explanation  o f the f u n c t i o n o f s p e c i f i c a r e a s , are i l l u s t r a t e d on page 13 (Diagram 1). Many s e i z u r e s , whether major or minor, b e g i n w i t h an "aura", o r warning, of t h e approaching s e i z u r e .  Some p h y s i c i a n s c o n s i d e r i t  important, f o r purposes o f treatment, t o - l o o k upon t h e aura as a  13  CENTRAL FISSURE OF ROLANDO  Diagram 1 Examples:  (a) i f t h e e l e c t r i c a l d i s c h a r g e s a r i s e i n - the o c c i p i t a l , a r e a o f the b r a i n , t h e seizure, begins w i t h the p a t i e n t seeing " l i g h t s dancing" o r " f l i c k e r i n g s t a r s " . (b) i f the e l e c t r i c a l d i s c h a r g e s a r i s e i n the upper p o r t i o n o f the temporal l o b e , the p a t i e n t may e x p e r i e n c e a s e n s a t i o n o f sound a l t e r i n g , becoming f u r t h e r away or l o u d e r .  f o r m of s e i z u r e .  They b e l i e v e t h a t t h e p a t i e n t who  warnings, but p r e s e n t s no c l i n i c a l  experiences  symptoms, s h o u l d have h i s medica-  t i o n i n c r e a s e d t o the p o i n t where even the warnings no l o n g e r manif e s t themselves.  The warnings i n d i c a t e that there i s abnormal  e l e c t r i c a l a c t i v i t y which must be suppressed i f complete c o n t r o l o f s e i z u r e s i s t o be achieved.  The aura may  take v a r i o u s forms and i s  dependent upon the s i t e of o r i g i n o f the abnormal e l e c t r i c a l discharge.  The p a t i e n t may have a vague f e e l i n g of f e a r , d i z z i n e s s ,  14 f a i n t n e s s , or s e n s i t i v i t y i n c e r t a i n areas o f the body.  Approxi-  mately f i f t y per cent of a l l major s e i z u r e s b e g i n w i t h an The  p a t i e n t l o s e s consciousness and becomes r i g i d .  t o n i c stage, because o f c o n t r a c t i o n s from h i s c h e s t , the p a t i e n t may  During t h i s  of muscles which f o r c e the a i r  u t t e r the " e p i l e p t i c . c r y " .  r i g i d i t y changes to r a p i d j e r k i n g movements, which become ly  slower.  Bleeding  t i g h t l y clenched  may  jaws.  E v a c u a t i o n of the b l a d d e r or bowel spasm o f muscles.  interference i n breathing  may  the  The  progressive-  r e s u l t i f the tongue i s caught between  r e s u l t during the i n i t i a l  ashen c o l o u r .  aura.  may  For t h i s same r e a s o n ,  cause the p a t i e n t t o become a b l u e  An i n c r e a s e i n the f l o w o f s a l i v a may  occur  or  during  s e i z u r e and when r e g u l a r breathing, begins a g a i n , the f a m i l i a r  " f r o t h i n g at the mouth" appears. a r e l a x e d s t a t e o f exhaustion. occur when the s e i z u r e has  The  patient gradually sinks into  Vomiting and  ended.  headache f r e q u e n t l y  Although t h e p a t i e n t i s u s u a l l y  l e t h a r g i c o r confused and wishes t o . s l e e p , o c c a s i o n a l l y he i s a b l e • to c a r r y on immediately a f t e r the The  seizura  seizure j u s t described  occurs.  i s the  one which the  person v i s u a l i z e s when the word " e p i l e p s y " i s mentioned. there are numerous other t y p e s of e p i l e p t i c s e i z u r e s .  The  average However, following  a r e the more common minor s e i z u r e s , which o c c u r . (a) P e t i t mal s e i z u r e s . These c o n s i s t of sudden p e r i o d s of s t a r i n g , l a s t i n g o n l y a few seconds.. I f there are any muscular movements they are c o n f i n e d t o t w i t c h i n g of the e y e l i d s and face or m i l d rhythmical, j e r k i n g s of the hands and arms. (b) Minor motor s e i z u r e s . These b e g i n with r i g i d i t y , but no c o n v u l s i v e movements,follow. Sometimes consciousness i s o n l y d u l l e d . Confused and i r r a t i o n a l a c t i o n s may occur. When the s e i z u r e i s over, t h e r e i s l i k e l y to be a t r a n s i e n t p e r i o d of d i s o r i e n t a t i o n , d u l l n e s s or headache.  15 (c) A k i n e t i c s e i z u r e s . These are c h a r a c t e r i z e d by a sudden l o s s o f p o s t u r a l c o n t r o l . In young c h i l d r e n , o n l y the head and upper e x t r e m i t i e s are involved.. I f the e n t i r e body i s a f f e c t e d , the p a t i e n t s u d d e n l y . f a l l s and,almost immediately g e t s up. I f consciousness i s l o s t , i t i s of very short d u r a t i o n . (d) Myoclonic s e i z u r e s . These are s e i z u r e s i n which s i n g l e c o n t r a c t i o n s of muscles occur without l o s s of consciousness. The p a t i e n t has no awareness o f the i n i t i a t i o n of the c o n t r a c t i o n s and no c o n t r o l over them....... i . e . an arm may suddenly be j e r k e d out t o one s i d e . The p a t i e n t i s aware o f i t s occurrence but can do nothing to stop it. (e) Psychic e q u i v a l e n t s or so c a l l e d psychomotor a t t a c k s . - These are s e i z u r e s i n which the p a t i e n t suddenly performs some h i g h l y c o - o r d i n a t e d but i r r e l e v a n t a c t i o n t h a t ends a b r u p t l y without r e c o l l e c t i o n . To a i d i n the establishment f o l l o w i n g d i a g n o s t i c procedures may  of a d i a g n o s i s of e p i l e p s y , t h e  be c a r r i e d out a f t e r a medical  h i s t o r y has been_obtained and a thorough n e u r o l o g i c a l examination done • (a) X-ray o f the s k u l l . These X-rays r e v e a l any i t i e s i n the development of the s k u l l ,  abnormal-  (b) Subdural puncture. In c h i l d r e n , l e s s than two y e a r s of age, who have c o n v u l s i o n s , p r o g r e s s i v e enlargement of the head, and unexplained vomiting, one might suspect the presence of a blood c l o t between the b r a i n and i t s c o v e r i n g s . The d i a g n o s i s i s e s t a b l i s h e d by i n s e r t i n g a needle through the " s o f t spot" or f o n t a n e l o f the baby's head and f i n d i n g , bloody, f l u i d . (c) The electroencephalogram (E.E.G.). T h i s i s a r e c o r d o f the e l e c t r i c a l a c t i v i t y of the b r a i n . I t i s used to determine the nature and p o s s i b l e cause of the s e i z u r e s . F r e q u e n t l y i t i s h e l p f u l not only i n . determining the k i n d of m e d i c a t i o n which s h o u l d be administered but a l s o i n d e c i d i n g whether or not i n c r e a s e s or decreases i n m e d i c a t i o n are warranted. (d) Pneumo-encephalogram. T h i s i s a s u r g i c a l procedure - used t o determine the l o c a t i o n and nature of c o n d i t i o n s w i t h i n the b r a i n which may be c a u s i n g s e i z u r e s . I t i s used p r i m a r i l y t o determine whether or not surgery i s indicated.  16  (e) Lumbar puncture. Many o r g a n i c d i s e a s e s of the b r a i n - produce a l t e r a t i o n i n the composition of the s p i n a l f l u i d , the examination of which may l e a d t o a d i a g nosis, i.e. syphilis. F o l l o w i n g the establishment of a d i a g n o s i s , attempts  are  made t o c o n t r o l the s e i z u r e s with the use of v a r i o u s a n t i - c o n v u l sants.  • *  (a) Bromides. These are e f f e c t i v e i n some p a t i e n t s who have o n l y major s e i z u r e s . With the advent o f newer, more e f f i c i e n t m e d i c a t i o n s , i t s use has g r a d u a l l y decreased. Cb) r  P h e n o b a r b i t a l . I t i s c o n s i d e r e d one of the most e f f e c t i v e and cheapest of a n t i - c o n v u l s a n t s . . I t s main disadvantage i s t h a t i f taken i n l a r g e doses, i t may cause the p a t i e n t t o become extremely s l e e p y .  ,  (c) D i l a n t i n , I t has proven q u i t e s u c c e s s f u l , both alone and i n combination w i t h other drugs, i n c o n t r o l l i n g s e i z u r e s . The t o x i c r e a c t i o n s may take the form of u n s t e a d i n e s s , double v i s i o n , and inflammation o f the gums. D i l a n t i n and p h e n o b a r b i t a l are c o n s i d e r e d t o be the mainstay of medical t r e a t - . - ment s i n c e they are the cheapest drugs and t h e y have proven themselves t o be the most e f f e c t i v e i n a c h i e v i n g c o n t r o l o f major s e i z u r e s . (d) Mesantoin and t h i a n t o i n . These are r e c e n t a d d i t i o n s to the a n t i - c o n v u l s a n t drugs. S i n c e these medicines have a tendency t o i m p a i r the f o r m a t i o n of white blood c e l l s , monthly blood counts should be taken. Some p a t i e n t s develop r a s h e s . a s a r e s u l t of a s e n s i t i v i t y t o the m e d i c a t i o n s . (e) T r i d i o n e and paradione. These are e f f e c t i v e i n the c o n t r o l o f p e t i t mal s e i z u r e s . The s i d e r e a c t i o n s may take the form of " g l a r e " and impairment of the f o r m a t i o n o f white blood c e l l s . ( f ) Phenurone. I t i s one of the most r e c e n t a d d i t i o n s t o the a n t i - c o n v u l s a n t drugs. I t i s thought t o be u s e f u l i n g a i n i n g c o n t r o l o f psychomotor s e i z u r e s . I t should o n l y be used with p a t i e n t s who can be c l o s e l y observed f o r s i d e r e a c t i o n s . S u r g i c a l - t r e a t m e n t of e p i l e p s y i s c o n s i d e r e d a p p r o p r i a t e  17 for  only a small portion of p a t i e n t s *  I f the s e i z u r e s  a s e r i o u s handicap and m e d i c a l treatment has considered.  is  any  f a i l e d , surgery  However, i t i s undertaken o n l y i f the  area i s d e f i n i t e l y l o c a l i z e d and  jeopardize  i s not  the p a t i e n t ' s Dr.  i s then  epileptogenic  can be e a s i l y reached.  p o s s i b i l i t y that e x c i s i o n might r e s u l t . i n other  d i s a b i l i t i e s , surgery  constitute  I f there neurological  done u n l e s s f a i l u r e to do so would  life.  Douglas T. Davidson, J r . , c o n s i d e r s the  p r i n c i p l e s as b a s i c i n the medical treatment of  following  epilepsy,?  1, H a l f o f the b a t t l e of therapy i s e n l i s t i n g and. maint a i n i n g c o o p e r a t i o n o f the p a t i e n t . F i r s t we e x p l a i n t o the p a t i e n t or h i s p a r e n t s t h a t w h i l e a p a r t i c u l a r drug i s v e r y l i k e l y t o be h e l p f u l i n c o n t r o l l i n g h i s p a r t i c u l a r type of s e i z u r e , we cannot p r e d i c t i t s e f f i c a c y w i t h c e r t a i n t y , nor can we determine the exact dosage beforehand. We s t r e s s need f o r c l o s e teamwork between doctor and p a t i e n t over a p e r i o d of months i n order to d i s c o v e r the b e s t medicine or combination of medicines and the o p t i m a l dosage. We point out that many d i f f e r e n t drugs are a v a i l a b l e today, t h a t a medicine which helps i n n i n e cases may f a i l i n the t e n t h , and e s p e c i a l l y t h a t f a i l u r e w i t h one o r more drugs may be f o l l o w e d by success w i t h another drug, • .... • 2, Maintenance o f f a i r l y constant systematic drug l e v e l s , through d i v i d e d doses and d a i l y a d m i n i s t r a t i o n , 3, Abrupt withdrawal of a n t i - c o n v u l s a n t m e d i c a t i o n i s avoided when p o s s i b l e because o f the danger of p r e c i p i t a t ing s t a t u s epilepticus° or d i s t r e s s i n g i n c r e a s e i n s e i z u r e frequency. 7  8  Davidson, Douglas T., J r . , M.D., "New L i g h t on an Old D i s o r d e r " , L e c t u r e s d e l i v e r e d at I n s t i t u t e s on E p i l e p s y , Tampa and Miami,A p r i l 1930. Dr. Davidson p r a c t i c e s at the. N e u r o l o g i c a l I n s t i t u t e , the C h i l d r e n ' s M e d i c a l Center, Boston, Mass, S t a t u s E p i l e p t i c u s .. a term used to denote a c o n t i n u i n g s t a t e of unconsciousness and c o n v u l s i o n s . Consciousness may remain l o s t f o r hours o r even days. There i s danger t h a t the p a t i e n t may die from exhaustion u n l e s s r a d i c a l . m e a s u r e s a r e i n s t i t u t e d .  IS 4. When used, a. g i v e n drug i s g i v e n to the p o i n t of e i t h e r completely c o n t r o l l i n g s e i z u r e s or o f p r o d u c i n g t o x i c s i d e e f f e c t s . The t h e r a p e u t i c dose i s o n l y . s l i g h t l y lower than that which produces toxicity; 5. Any unpleasant r e a c t i o n i s to be c o n s i d e r e d r e p o r t e d immediately. Since t o the  if  and  the. c o n t r i b u t i o n of the medical s o c i a l worker  treatment of e p i l e p s y i s g r e a t l y i n f l u e n c e d by  adequacy of medical treatment, to c o n s i d e r  the  the  physician's  r e s p o n s i b i l i t y i n the management of t h i s i l l n e s s , would seem t o be i m p o r t a n t .  I t begins with the r e c o g n i t i o n t h a t  extensive  n e u r o l o g i c a l t r a i n i n g i s r e q u i r e d i f the i l l n e s s i s t o adequately t r e a t e d .  be  Much damage has been done by the p h y s i c i a n  .  whose l a c k of u n d e r s t a n d i n g o f e p i l e p s y has r e s u l t e d i n an a t t i t u d e of "Too you."  The  bad,  but  p h y s i c i a n who  there  i s n o t h i n g which can be done f o r  f a i l s to r e c o g n i z e  suggests to parents t h a t the c o n v u l s i o n  the i l l n e s s  i s due  "worms", "which your c h i l d w i l l outgrow", has i n j u s t i c e to the p a t i e n t and bility  h i s parents.  it.  and  done a  It i s his  great responsi-  uses modern  supervising  medications  r e l i e v e the p h y s i c i a n o f h i s r e s p o n s i b i l i t y t o the  h i s parents.  or  o f e p i l e p s y and.in t r e a t i n g  Undertaking surgery when necessary and  do not  to "teething"  to send the p a t i e n t t o the p h y s i c i a n who  procedures i n e s t a b l i s h i n g a d i a g n o s i s  and  Dr. Davidson, i n h i s address a l r e a d y  patient  quoted,  v e r y e f f e c t i v e l y o u t l i n e s the p h y s i c i a n s r e s p o n s i b i l i t y t o parents: A c c u r a t e d i a g n o s i s and s k i l f u l p r e s c r i p t i o n of a n t i e p i l e p t i c m e d i c a t i o n s are an e x c e l l e n t b e g i n n i n g i n the treatment of the s e i z u r e d c h i l d j but we have a d d i t i o n a l responsibilities. The parents' concept o f e p i l e p s y almost i n v a r i a b l y r e q u i r e s r e o r i e n t a t i o n and c o r r e c t i o n .  19 They want d e s p e r a t e l y to know what t o do when the c h i l d . h a s a s e i z u r e . They need t© be t o l d r e p e a t e d l y and i n v a r i o u s ways t h a t the term e p i l e p s y r e f e r s o n l y to the f a c t o f r e c u r r e n t s e i z u r e s , t h a t e p i l e p s y may be present i n grades o f s e v e r i t y , t h a t e p i l e p s y i s u s u a l l y not complicated by mental d e f e c t o r by i n s a n i t y e i t h e r at i t s onset or l a t e r i n i t s course, t h a t the prospect o f a s e i z u r e ending f a t a l l y i s i n f i n i t e s i m a l , t h a t the outlook i s f o r a f u l l normal l i f e i f the c h i l d i s n o r m a l l y endowed a t the onset of s e i z u r e s , t h a t time as w e l l as m e d i c a t i o n tends to b r i n g an end t o the s e i z u r e s , and t h a t pleasant p h y s i c a l and mental a c t i v i t y i s a v i t a l p a r t o f the treatment. N  The  p h y s i c i a n ' s r e s p o n s i b i l i t y t o the p a t i e n t i s t o a  l a r g e degree determined by the age o f h i s handicap.  The  of the p a t i e n t and.the  very young c h i l d wants t o f e e l t h a t he i s  a c t u a l l y p a r t i c i p a t i n g i n the treatment, and by h i s parents and  extent  the d o c t o r ,  being.manipulated  A c h i l d ' s questions  i l l n e s s need to be answered t h o u g h t f u l l y and understanding o f , and p r e p a r a t i o n t h i s i l l n e s s are t h e r a p e u t i c  not  regarding  honestly,  since  f o r problems a s s o c i a t e d with  measures e s s e n t i a l t o the  o f u n s a t i s f a c t o r y behaviour and  his  a t t i t u d e s i n adulthood.  prevention The  p a t i e n t , whether a c h i l d or an a d u l t , whose e m o t i o n a l balance i s considered  t o be s e r i o u s l y disturbed,, r e q u i r e s the h e l p of a  skilled psychiatrist,^ The is  a d u l t p a t i e n t wishes to b e l i e v e t h a t h i s p h y s i c i a n  i n t e r e s t e d i n him not merely as "another e p i l e p t i c " , but  as an i n d i v i d u a l w i t h h i s i n d i v i d u a l problems.  rather  An i n d i v i d u a l  approach suggests t h a t treatment then becomes an extremely time consuming venture, 9  Nevertheless,  the p a t i e n t whose, s e i z u r e s  are  I t i s beyond the scope o f t h i s t h e s i s to present the psychodynamics of e p i l e p s y or the p s y c h i a t r i c treatment of the seizured patient.  20 e v e n t u a l l y c o n t r o l l e d , but whose emotional s t a t u s i s so unbalanced t h a t he cannot accept the r e s p o n s i b i l i t i e s o f every day  living,  can h a r d l y i n the o p i n i o n o f the. w r i t e r , be c l a s s i f i e d as an, example of. s u c c e s s  1 0  i n the treatment o f epilepsy,.  r e a s o n , the p h y s i c i a n who  i s i n t e r e s t e d i n the t o t a l  of the person w i t h e p i l e p s y r e c o g n i z e s  For  this  well-being  that,  No s i n g l e p h y s i c i a n , no matter how w e l l t r a i n e d , i s capable of p o s s e s s i n g a l l the s k i l l s necessary f o r the p h y s i c a l , emotional and s o c i a l needs of l a r g e numbers o f e p i l e p t i c c h i l d r e n . Some are so w e l l a d j u s t e d t o l i f e s i t u a t i o n s t h a t simple a t t e n t i o n to p h y s i c a l needs enables them to h u r d l e the more s e r i o u s o b s t a c l e s and t h e r e a f t e r t o be s e l f - s u f f i c i e n t and serene. In o t h e r s t h i s i s not enough, and i n s t i l l another group the p h y s i c a l a s p e c t s of the problem.are o n l y a minor p a r t o f the t o t a l . Who should be r e s p o n s i b l e f o r the study and treatment of the many complex s i t u a t i o n s t h a t a r i s e ? C e r t a i n l y the s o l u t i o n l i e s not w i t h any one group but i n a c o o r d i n a t i o n of the e f f o r t s and a b i l i t i e s o f a l l , ! 1  There i s evidence of the acceptance of t h i s concept i n the s e i z u r e c l i n i c .  With r e g a r d  to the p a r t i c u l a r c o n t r i b u t i o n  o f the m e d i c a l s o c i a l worker, the p h y s i c i a n s s e r v i c e which can i n some cases be p r o v i d e d  have r e c o g n i z e d t o those  whose p r o g r e s s i n m e d i c a l treatment i s i n f l u e n c e d by p s y c h o l o g i c a l problems.  the  patients social  I n the chapters which f o l l o w , t h e r e  and are  i n d i c a t i o n s o f the c o n t r i b u t i o n which the p h y s i c i a n can make t o t h e treatment o f s o c i a l f a c t o r s , j u s t as t h e r e are i n d i c a t i o n s of the  c o n t r i b u t i o n s which the s o c i a l worker can make t o the  medical  treatment. 10  11  F o r the purpose of t h i s t h e s i s , " s u c c e s s f u l treatment of e p i l e p s y " suggests t h a t the p a t i e n t has gained c o n t r o l o f h i s s e i z u r e s , i s a b l e t o support.himself and meet l i f e ' s f r u s t r a t i o n s with, a measure, of calmness and o b j e c t i v i t y , B r i d g e s , Edward M., M.D., E p i l e p s y and Convulsive D i s o r d e r s i n C h i l d r e n . McGraw-Hill Book Company Inc., New York, Toronto, "  London, 1949» p,  462,  Chapter I I I  CAN  THE MEDICAL SOCIAL WORKER HELP THE SEIZURED CHILD?  A f u l l and p r o d u c t i v e adulthood i s the wish most parents have f o r t h e i r c h i l d r e n .  S a t i s f a c t i o n of a c h i l d * s need f o r l o v e  and s e c u r i t y , and encouragement i n meeting the day-to-day  problems  of  c h i l d h o o d , prepare him f o r the. more demanding r e s p o n s i b i l i t i e s  of  adulthood..  For the s e i z u r e d . c h i l d , p r e p a r a t i o n f o r adulthood  i s a more complex t a s k which few parents seem adequately to ing  assume.  F r e q u e n t l y , t h e i r own  prepared  f e a r s and misconceptions r e g a r d -  the i l l n e s s , prevent t h e i r handicapped  youngsters from  satis-  f a c t o r i l y proceeding through the necessary stages of emotional growth i n t o mature adulthood.  Therefore, help f o r the s e i z u r e d  c h i l d must be c o n s i d e r e d not o n l y i n terms o f d i r e c t h e l p t o the p a t i e n t , but o f i n d i r e c t h e l p through h i s p a r e n t s .  In the present  study, the c a s e - h i s t o r i e s of f o u r t e e n c h i l d r e n r e v e a l s a t y p i c a l range of the d i f f i c u l t i e s which e p i l e p s y p r e s e n t s i n c h i l d h o o d . P a r e n t a l a t t i t u d e s toward the H e a l t h Centre f o r C h i l d r e n , p a r e n t a l a t t i t u d e s toward  e p i l e p s y and i t s treatment, and p a r e n t a l  a t t i t u d e s toward  the s e i z u r e d c h i l d , a l s o f a l l i n t o t h i s group of  general considerations. It for  i s w e l l t o remember t h a t a l l the c h i l d r e n  selected  t h i s study a t t e n d the Health Centre f o r C h i l d r e n , which, as  22 s t a t e d p r e v i o u s l y , has c e r t a i n e l i g i b i l i t y requirements.  In other  words, the parents of the f o u r t e e n c h i l d r e n l i v e w i t h i n a v e r y l i m i t e d income.  The  extent t o which f i n a n c i a l s t r e s s i n f l u e n c e s  p a r e n t a l a t t i t u d e s toward handicapped measure.  children, i s d i f f i c u l t  However, i t seems l i k e l y t h a t concern over  matters c o u l d add l i t t l e i n g of p a r e n t s .  to  financial  t o the g e n e r a l good humour and  understand-  A l s o , although attendance a t an o u t p a t i e n t s '  c l i n i c f r e e s parents of the f i n a n c i a l r e s p o n s i b i l i t y of the  illness,  many parents have adverse r e a c t i o n s toward a c c e p t i n g h e l p from a "free c l i n i c " .  A g a i n , t o measure the extent to which t h i s  influ-  ences p a r e n t a l a t t i t u d e s toward medical t r e a t m e n t , i s d i f f i c u l t . However, comments made by the parents o f the c h i l d r e n ,  suggest  t h a t i t does i n some i n s t a n c e s , a f f e c t m e d i c a l treatment.  There  are parents who  cannot  f e e l t h a t d o c t o r s who  v o l u n t e e r t h e i r time  be i n t e n s e l y i n t e r e s t e d i n t r e a t i n g the c h i l d r e n who clinic.  There are other parents who  come t o the  b e l i e v e t h a t because the  s e r v i c e i s f r e e , t h e i r c h i l d r e n are b e i n g used f o r experimental purposes.  Many parents are unable t o b e l i e v e t h a t t r i a l and  i s the o n l y way  i n which the c o r r e c t dosage f o r c o n t r o l o f s e i z u r e s  can be determined.  A l s o , there are parents who,  because o f p r i d e ,  experience both g u i l t and resentment about h a v i n g t o accept medical c a r e .  free  T h i s expresses i t s e l f i n t h e i r f a i l u r e t o keep  c l i n i c appointments and a l s o i n t h e i r a t t i t u d e toward the child.  error  unwell  These p o i n t s r e g a r d i n g the i n f l u e n c e of p a r e n t a l a t t i t u d e s  r e s u l t i n g out of attendance  at an out-door  c l i n i c , have been  e x p l a i n e d i n order t o make c l e a r , t h a t the impressions f r o m an examination  o f case r e c o r d s of the p a t i e n t s who  gained attend t h i s  23  t y p e of c l i n i c , may  not h o l d t r u e f o r p a t i e n t s who  ment on a p r i v a t e b a s i s .  1 2  receive treat-  There i s no q u e s t i o n t h a t many o f the  problems a s s o c i a t e d w i t h e p i l e p s y c o n s t i t u t e a burden t o a l l economic s t r a t a s of s o c i e t y .  However, c e r t a i n aspects o f the  i l l n e s s a r e probably more burdensome t o the group of people i n the lower income b r a c k e t s . Since the measuring  of a t t i t u d e s i s d i f f i c u l t and  cannot  be completely o b j e c t i v e , no d e f i n i t e c o n c l u s i o n s have been reached r e g a r d i n g the a t t i t u d e of parents toward  epilepsy.  However, from  the comments made when p a r e n t s were f i r s t r e f e r r e d t o the medical s o c i a l worker, impressions were f o r m u l a t e d i n terms o f , (a) i n d i f f e r e n c e toward the i l l n e s s ,  (b) concern about i t but acceptance  the r e s p o n s i b i l i t i e s a s s o c i a t e d w i t h i t , and  (c) complete  of  rejection  o f the m e d i c a l d i a g n o s i s and f a i l u r e t o assume r e s p o n s i b i l i t y i n the treatment  process.  No attempt was  made to d i s c o v e r the extent  t o which t h e parents were f a m i l i a r w i t h e p i l e p s y p r i o r t o the onset of s e i z u r e s i n t h e i r own  c h i l d r e n , and i t i s t h e r e f o r e i m p o s s i b l e  t o determine whether or not t h i s has any bearing on t h e i r o f the d i a g n o s i s .  Of the s i x cases where t h e r e was  acceptance  known t o be a  h i s t o r y of e p i l e p s y i n near r e l a t i v e s , f o u r of the parents seemed t o be i n category (c) w i t h the remaining two I n t h e seven cases where t h e r e was 12  cases i n c a t e g o r y ( b ) .  no known h i s t o r y o f e p i l e p s y ,  I t i s perhaps important t o p o i n t out t h a t the impressions o f the w r i t e r are not e n t i r e l y the r e s u l t of an o b j e c t i v e a n a l y s i s of the case r e c o r d s o f t h i s study. Her o p i n i o n s have been c o l o u r e d by her experience as medical s o c i a l worker i n the s e i z u r e c l i n i c f o r a p e r i o d of seventeen months. i  24 t h e number o f parents i n category ( c ) t o t a l l e d f o u r .  Two parents  seemed t o be i n category (b) and o n l y one i n category ( a ) . I n the f o u r t e e n t h case, the p a t i e n t ' s mother p e r i o d i c a l l y  experienced  " f a i n t i n g s p e l l s " which were c o n s i d e r e d h y s t e r i c a l r a t h e r than e p i l e p t i f o r m i n nature.  In t h i s case t h e parents were completely  r e j e c t i n g o f t h e d i a g n o s i s . ^These f i g u r e s i n d i c a t e t h a t i n n i n e o f the f o u r t e e n c a s e s , t h e parents were not a c c e p t i n g o f the d i a g n o s i s . Nor were they a b l e t o assume the r e s p o n s i b i l i t y o f c o n s t r u c t i v e l y p a r t i c i p a t i n g i n the treatment.  The f o l l o w i n g cases are presented  to i l l u s t r a t e t h e ways i n which t h i s r e v e a l e d i t s e l f . (a) Johnny i s a 14 year o l d boy whose grand mal s e i z u r e s began a t the age o f 7. From t h a t time u n t i l he was almost 13, Johnny and h i s p a r e n t s , i n t h e i r search f o r a "wuick c u r e " , f r e q u e n t e d t h e o f f i c e s o f numerous p h y s i c i a n s and c h i r o p r a c t o r s . Treatment i n c l u d e d inadequate s u p e r v i s i o n o f a n t i - c o n v u l s a n t drugs, " p i l l s from a d o c t o r i n Chicago", a most u n i n t e r e s t i n g and u n p a l a t a b l e d i e t , severe d i s c i p l i n e and a l s o c h i r o p r a c t i c "adjustments". When the s c h o o l nurse was f i n a l l y able to convince Johnny's parents o f t h e a d v i s a b i l i t y o f t a k i n g him to t h e Health Centre f o r C h i l d r e n , he was d e s p e r a t e l y i n need o f adequate medical treatment. Because o f the frequency o f h i s s e i z u r e s and t h e i n s t a b i l i t y o f h i s home environment, Johnny was p l a c e d i n the c h i l d r e n ' s ward o f the Vancouver General H o s p i t a l f o r a p e r i o d of t h r e e weeks. With numerous changes i n h i s m e d i c a t i o n , t h e number o f s e i z u r e s was reduced, but not completely stopped. When Johnny r e t u r n e d t o h i s home, arrangements were made f o r him t o be seen a t r e g u l a r i n t e r v a l s a t the H e a l t h Centre f o r C h i l d r e n , H i s mother complained about t h e frequency of h i s appointments and the i n c o n venience i t was c a u s i n g her. H i s medicine was blamed f o r h i s a g g r e s s i v e behaviour and h i s "stupidity". Interviews with the mother seemed always t o be d i r e c t e d toward d i s c u s s i o n o f h e r own i l l n e s s e s and t h e e f f e c t of Johnny's i l l n e s s upon her. The f a t h e r d i d n o t appear p a r t i c u l a r l y i n t e r e s t e d i n the i l l n e s s o r i t s treatment.  T h i s case i l l u s t r a t e s the harm which can be done when parents do not r e c e i v e adequate medical advice s e i z u r e s , and w i l l not  at t h e onset o f the  consequently b e g i n t h e i r search f o r treatment which  l a b e l t h e i r c h i l d an e p i l e p t i c .  The  emphasis p l a c e d upon  the i n c o n v e n i e n c e s caused by the i l l n e s s i n d i c a t e s an i n a b i l i t y or unwillingness  on the p a r t of the p a r e n t s to c o n s t r u c t i v e l y p a r t i c i -  pate i n treatment. (b) Jimmy i s a t h r e e year o l d youngster whose myoclonic s e i z u r e s began at the age of one y e a r . A year l a t e r , d u r i n g a high f e v e r caused by measles, he had h i s f i r s t generalized convulsion. Although the E.E.G, t e s t was/Within normal l i m i t s , from the d e s c r i p t i o n g i v e n /by the mother, the doctor concluded t h a t the c h i l d had e p i l e p s y and t h e r e f o r e p r e s c r i b e d r e g u l a r doses o f a n t i - c o n v u l s a n t drugs. The need f o r r e g u l a r i n t a k e of the medication was e x p l a i n e d t o the mother who seemed q u i t e w i l l i n g to c a r r y out the physician's advice. A month l a t e r , when Jimmy was again brought i n t o the c l i n i c by h i s mother, she asked the doctor i f i t was necessary f o r Jimmy to take the medicine s i n c e the E.E.G. t e s t was normal. F u r t h e r d i s c u s s i o n r e v e a l e d t h a t her husband d i d not l i k e to see the c h i l d t a k i n g medicine and l a b e l l e d an " e p i l e p t i c " i f he r e a l l y d i d not have e p i l e p s y . She-was r e a s s u r e d about t h i s and i t was suggested t h a t the s o c i a l worker v i s i t the home f o r the purpose o f e x p l a i n i n g e p i l e p s y and i t s treatment t o the f a t h e r . The home v i s i t r e v e a l e d t h a t Jimmy was an unhappy l i t t l e boy who because of h i s n e g a t i v i s t i c b e h a v i o u r , was c o n s i d e r e d by r e l a t i v e s to be somewhat strange. The f a t h e r commented t h a t he d i d not wish to have the youngster l a b e l l e d an " e p i l e p t i c " because, "the f o l k s would then be able to say t h a t they always knew there was something wrong w i t h him". I t was a l s o l e a r n e d d u r i n g t h i s v i s i t t h a t Jimmy's g r e a t grandmother, on h i s mother's s i d e a l s o had e p i l e p s y . F o l l o w i n g t h i s v i s i t , Jimmy's c o n d i t i o n was again e x p l a i n e d t o the f a t h e r by the p h y s i c i a n . I t seemed t h a t he was more a c c e p t i n g of the d i a g n o s i s and a l s o more w i l l i n g f o r Jimmy t o take the medication. However, s e v e r a l months l a t e r when Jimmy began s t u t t e r i n g , the parents reduced h i s m e d i c a t i o n and remarked t o the doctor t h a t they knew the medication was r e s p o n s i b l e f o r the stutter.  26 T h i s case i l l u s t r a t e s s e v e r a l i n t e r e s t i n g p o i n t s i n g p a r e n t a l a t t i t u d e s toward e p i l e p s y .  I t should  regard-  be mentioned  t h a t t h e r e l a t i o n s h i p between mother and f a t h e r appeared somewhat strained. the  The  f a t h e r , i n i n d i r e c t ways, seemed t o be a t t r i b u t i n g  c h i l d ' s i l l n e s s to the f a c t t h a t there was  e p i l e p s y on h i s w i f e ' s the d i a g n o s i s  s i d e o f the  family.  a history of  His r e f u s a l to accept  seemed a s s o c i a t e d w i t h an i d e a t h a t something  "wrong" w i t h the c h i l d ' s i n t e l l e c t u a l . a b i l i t y . to be  This i s believed  so by a l a r g e number of misinformed people.  i n d i c a t e t h e i r i n a b i l i t y t o accept the  Many parents  d i a g n o s i s by r e f u s i n g to  f o l l o w the p h y s i c i a n ' s a d v i c e regarding- medication and a l s o blaming the medication f o r a c h i l d ' s u n d e s i r a b l e  behaviour.  case c l e a r l y i l l u s t r a t e s , t h a t d e s p i t e numerous reassurances explanations  by both s o c i a l , workers and  because o f t h e i r own  was  p h y s i c i a n s , many  by This and  parents,  inner c o n f l i c t s cannot i n t e l l i g e n t l y assume  t h e i r r e s p o n s i b i l i t y i n t h e treatment of  epilepsy.  (c) Mary i s a seven year o l d g i r l whose p e t i t mal s e i z u r e s began.when she was f o u r y e a r s o f age. P r i o r to her attendance a t the H e a l t h Centre f o r C h i l d r e n , she was t r e a t e d i n Toronto by persons a p p a r e n t l y not a l l i e d w i t h the m e d i c a l p r o f e s s i o n . The mother, who s t a t e s t h a t she i s a graduate i n metaphysics and w e l l informed i n a l l phases o f medicine, speaks of the c h i l d ' s former treatment i n terms of "wave l e n g t h s " , "bowel o b s t r u c t i o n s " , and " u n s u i t a b l e d i e t " , Mary's s e i z u r e s p e r s i s t e d u n t i l a p p r o p r i a t e m e d i c a t i o n was. p r e s c r i b e d . Although the mother f r e q u e n t l y comments on the amount of medicine Mary i s t a k i n g , she n e v e r t h e l e s s f e e l s o b l i g e d t o f o l l o w the doctor's advice because she i s a b l e t o see the b e n e f i t s of the medicine. In one of the group d i s c u s s i o n s , she commented t h a t p r i o r t o her attendance at, the c l i n i c , she would not use the term " e p i l e p s y " when d i s c u s s i n g Mary's i l l n e s s . She c o n s i d e r e d these episodes  27  " f a i n t i n g s p e l l s " , which, were not a t - a l l s i m i l a r to the e p i l e p t i c s e i z u r e s w i t h which she was familiar. Because t h i s mother, i n the o p i n i o n of the w r i t e r , i s v e r g i n g on a p s y c h o s i s ,  i t i s perhaps i n a p p r o p r i a t e to, use  case as an example of p a r e n t a l a t t i t u d e s toward e p i l e p s y .  this Never-  t h e l e s s i t i l l u s t r a t e s the tendency on the p a r t o f parents t o "shop" f o r treatment from anyone.who w i l l not l a b e l t h e i r c h i l d epileptic.  I t i s a l s o an e x c e l l e n t example o f how  parents,  an  in  t h e i r r e f u s a l to accept the i l l n e s s , w i l l r e f u s e to c a l l i t by i t s proper name. (d) Teddy i s a f o u r y e a r o l d youngster whose major s e i z u r e s began two y e a r s ago. He i s the youngest c h i l d and the o n l y boy i n a f a m i l y of t h r e e c h i l d r e n . There i s a h i s t o r y of e p i l e p s y on the f a t h e r ' s s i d e of the f a m i l y and the f a t h e r hims e l f had " f a i n t i n g s p e l l s " as a c h i l d . Teddy's s e i z u r e s have been c o n t r o l l e d f o r over a y e a r . Because of t h i s , h i s mother r e f u s e s to come i n t o the c l i n i c except t o have the p r e s c r i p t i o n refilled. She agrees to see the doctor o n l y when she i s t o l d t h a t the p r e s c r i p t i o n w i l l not be r e f i l l e d u n l e s s Teddy i s seen by a d o c t o r . On one of these occasions a r e f e r r a l was made t o the m e d i c a l s o c i a l worker on the b a s i s t h a t the p a r e n t s needed h e l p i n understanding e p i l e p s y . When t h i s was d i s c u s s e d w i t h the mother, she very e m p h a t i c a l l y s t a t e d t h a t she knew a l l there was t o know about e p i l e p s y and t h a t as f a r as she was concerned her son was a w e l l and h e a l t h y boy. Since the amount of i n f o r m a t i o n  available i n this  case  i s extremely b r i e f , i t i s d i f f i c u l t to a s c e r t a i n the reasons f o r t h e mother's a t t i t u d e . o n l y son, may The  The  way  i n which she  spoke about him  as  her  i n p a r t e x p l a i n her r e f u s a l t o see the boy's handicap.  h i s t o r y of e p i l e p s y i n her husband's f a m i l y may  a l s o be  a  23 factor.  In any  event, t h i s case c l e a r l y i l l u s t r a t e s a r e f u s a l  on the p a r t of a parent t o accept  a d i a g n o s i s of e p i l e p s y t o  the  p o i n t where she cannot b r i n g h e r s e l f to see a p h y s i c i a n o r t o openly d i s c u s s the i l l n e s s .  One  might be i n c l i n e d t o t h i n k  her  tendency t o consider her c h i l d e n t i r e l y w e l l , a p o s i t i v e q u a l i t y , were i t not f o r her obvious a n x i e t y about h i s h e a l t h . In examining the a t t i t u d e s of the parents c h i l d r e n , an attempt was  made t o discover the extent  a t t i t u d e s were i n f l u e n c e d by the i l l n e s s . p a t t e r n of p a r e n t a l o v e r - p r o t e c t i v e n e s s .  toward these t o which t h e i r  S i x cases evidenced a I n two  cases,  the  i l l n e s s seemed t o f o s t e r p a r e n t a l f e e l i n g s o f d i s l i k e f o r t h e child.  The  a t t i t u d e s of parents  toward the remaining s i x c h i l d r e n  d i d not appear to be p a r t i c u l a r l y i n f l u e n c e d by -t'he c h i l d ' s i l l n e s s . F a i l u r e to d e t e c t evidence of the i n f l u e n c e o f the i l l n e s s upon p a r e n t a l a t t i t u d e s , i n some i n s t a n c e s was p i c t u r e of the f a m i l y s i t u a t i o n .  due  to an  incomplete  In the o p i n i o n o f the w r i t e r ,  these f i g u r e s have l i t t l e meaning because of the smallness  of  the  numbers, the degree of s u b j e c t i v i t y which o f n e c e s s i t y e n t e r s i n t o an e v a l u a t i o n of t h i s s o r t , and the l a c k o f s c i e n t i f i c method a v a i l a b l e f o r measuring " a t t i t u d e s " .  However, the i n d i v i d u a l  s i t u a t i o n s promote i n t e r e s t i n g s p e c u l a t i o n r e g a r d i n g  parental  a t t i t u d e s toward e p i l e p t i c c h i l d r e n . Whether or not p a r e n t a l a t t i t u d e s were c l a s s i f i e d  as  o v e r - p r o t e c t i v e depended upon the answers t o the f o l l o w i n g questions. (1) Do the parents i n s i s t upon having the youngster w i t h i n . - view a t a l l times, r e g a r d l e s s of the extent t o which the s e i z u r e s have been c o n t r o l l e d ?  29 (2)  Do the parents r e s t r i c t the a c t i v i t i e s which the p h y s i c i a n f e e l s the youngster can do? i.e p l a y i n g w i t h other c h i l d r e n , r e f u s i n g t o permit them t o r i d e a b i c y c l e , e t c .  (3) Are the parents a b l e t o accept permanent separat i o n from the c h i l d where i n s t i t u t i o n a l c a r e has been recommended by the p h y s i c i a n ?  (4) Are the parents i n c l i n e d t o meet the c h i l d ' s every whim?  (5) Are the parents c o n s t a n t l y l o o k i n g f o r symptoms o f i l l h e a l t h i n the c h i l d ? The  f o l l o w i n g cases a r e presented t o i l l u s t r a t e the manner i n  w h i c h the parents r e v e a l e d t h e i r o v e r p r o t e c t i v e n e s s t o g e t h e r w i t h an e x p l a n a t i o n of the p o s s i b l e reasons f o r t h e i r  attitude.  (a) Bobby i s a s i x y e a r o l d , m e n t a l l y r e t a r d e d youngster whose s e i z u r e s began a t the age o f s i x months. He has not l e a r n e d t o p l a y w i t h other c h i l d r e n and at present spends h i s time p l a y i n g alone or with h i s p a r e n t s . The parents are unable t o r e c o g n i z e t h a t Bobby w i l l never be l i k e other normal c h i l d r e n and t h a t the o v e r - i n d u l g e n t environment at home w i l l make i t more d i f f i c u l t f o r him t o accept i n s t i t u t i o n a l care i n the f u t u r e . Because o f the extent o f h i s mental handicap i t does not seem l i k e l y t h a t o t h e r plans can be made f o r him. Undoubtedly h i s being an o n l y c h i l d i n p a r t e x p l a i n s the a t t i t u d e of the p a r e n t s . However, the f a c t that h i s c o n d i t i o n i s a t t r i b u t e d to a b i r t h i n j u r y and t h a t h i s mother was almost f o r t y years of age at the time o f h i s b i r t h , would seem t o be of g r e a t e r s i g n i f i c a n c e . G u i l t f e e l i n g s oyer pregnancy a t t h a t l a t e date may e n t e r i n t o the t o t a l p i c t u r e . (b) Benny i s a s i x t e e n year o l d boy who i s i n t h e moron group o f g e n e r a l i n t e l l i g e n c e . The s e i z u r e s which f i r s t o c c u r r e d a t the age o f f i f t e e n are now c o n t r o l l e d . He has been an " a i l i n g " c h i l d s i n c e i n f a n c y . Benny l i v e s w i t h a n - a l c o h o l i c f a t h e r and an o v e r - i n d u l g e n t step-mother. Placement i n Woodland School has  3P been suggested t o these parents, b u t they have not been a b l e t o accept it.--3. Nor are they a b l e t o o f f e r any suggestions r e g a r d i n g f u t u r e plans f o r Benny. H i s e x i s t e n c e a t home c o n s i s t s o f an i r r e g u l a r r o u t i n e o f e a t i n g , s l e e p i n g and " p l a y i n g with t h e boys". He has been g i v e n no r e s p o n s i b i l i t y f o r household t a s k s . He i s n o t able t o f i n d any form o f employment. I n t h e o p i n i o n o f t h e mother he i s n o t able t o work because o f h i s h e a l t h . She c o n s i d e r s him a "good boy", but f i n d s h i s constant demands f o r money, somewhat o f a problem. The f a t h e r ' s a t t i t u d e o f i n d i f f e r e n c e seems t o be the r e s u l t o f h i s concern w i t h h i s own problems. A l s o , from h i s past behaviour, i t seems l i k e l y t h a t he i s the type of person who r e f u s e s t o f a c e a d i f f i c u l t s i t u a t i o n . The step-mother's a t t i t u d e toward Benny seems t o have been i n f l u e n c e d by her .status i n her own family situation. She speaks o f " a l s o . h a v i n g been t h e 'black sheep' i n the f a m i l y " . F o r t h i s reason, she s t a t e s t h a t she a p p r e c i a t e s how Benny f e e l s . She speaks of t h e inadequacies i n her marriage and i t seems l i k e l y t h a t c a r i n g f o r Benny i s one of h e r few p l e a s u r e i n l i f e . (c) Joan i s a f o u r year o l d c h i l d whose p e t i t mal s e i z u r e s began at the age o f two. P r e v i o u s l y , she was permitted t o p l a y with o t h e r c h i l d r e n only i f her e l d e r b r o t h e r was w i t h her. Her mother i s c o n s t a n t l y watching f o r symptoms o f a s e i z u r e . I n many r e s p e c t s t h e mother's conc e r n i s on a r e a l i t y b a s i s , s i n c e she seems l e s s anxious t o have Joan by her s i d e now t h a t the number o f s e i z u r e s i s d i m i n i s h i n g , (d) Jimmy has a l r e a d y been mentioned on page 2$, Although he i s p e r m i t t e d t o p l a y with o t h e r c h i l d r e n , he must always be w i t h i n c l o s e d i s t a n c e of e i t h e r h i s mother or f a t h e r . Since t h e onset 13  Woodland School accepts persons whose mental a b i l i t y i s below average i n t e l l i g e n c e . P r o v i s i o n i s made f o r formal e d u c a t i o n . However, more emphasis i s p l a c e d upon e d u c a t i o n i n the d a i l y r o u t i n e s o f l i v i n g , i n o r d e r t h a t those who l i v e t h e r e may be b e t t e r a b l e t o care f o r themselves. P r o v i s i o n i s a l s o made f o r t r a i n i n g i n the v a r i o u s t r a d e s . These r e s o u r c e s t o g e t h e r w i t h the r e c r e a t i o n a l f a c i l i t i e s p r o v i d e d , make f o r contentment on the p a r t o f a l a r g e p o r t i o n of t h e s c h o o l ' s population.  31 of t h e s e i z u r e s , t h e parents have not spent an evening t o g e t h e r away from home. Although he has not had a s e i z u r e i n s e v e r a l months, they a r e f e a r f u l o f him having a s e i z u r e i n the presence o f a strange b a b y - s i t t e r . The mother's a t t i t u d e toward Jimmy suggests g u i l t f e e l i n g s on her p a r t . She s t a t e s she found i t d i f f i c u l t t o be good t o him because he was a "whiney, u n a t t r a c t i v e and d i f f i c u l t " c h i l d . The.onset o f the. s e i z u r e s seems t o have brought h e r g u i l t f e e l i n g s to.the f o r e and i n some ways she seems t o be p u n i s h i n g h e r s e l f by b e i n g e x c e s s i v e l y concerned about Jimmy, The h i s t o r y o f e p i l e p s y i n h e r f a m i l y may also, be a determining f a c t o r . The f a t h e r appears t o be an immature person who i s more concerned w i t h what h i s parents w i l l t h i n k about Jimmy, than he i s w i t h Jimmy's w e l f a r e . In the two cases where the d i s l i k e f o r t h e c h i l d r e n was q u i t e obvious, t h e r e were i n d i c a t i o n s t h a t the i l l n e s s alone d i d not i n i t i a t e these f e e l i n g s .  I n both cases the p a r e n t s had  numerous problems o f t h e i r own and as a r e s u l t c o n s i d e r e d t h e r e s p o n s i b i l i t y o f the i l l n e s s more than they c o u l d endure. one  In  case the mother expressed her r e j e c t i o n o f the youngster by  having her p l a c e d i n the Crease C l i n i c . ^ 1  I n t h e o t h e r case,  i n s t i t u t i o n a l care was suggested t o the p a r e n t s , but they were not a b l e t o accept i t .  T h e i r g u i l t r e s u l t i n g out o f t h e i r  r e j e c t i o n o f him, seems t o be t h e b a s i s f o r t h e i r i n a b i l i t y t o make these p l a n s .  He remains  a t home, and i s f r e q u e n t l y reminded  t h a t he i s a problem t o h i s f a m i l y and p a r t i c u l a r l y h i s mother. The parents o f t h e c h i l d r e n i n t h e s i x remaining 14  cases  Grease C l i n i c ... i s a treatment c e n t r e f o r m e n t a l l y d i s t u r b e d people who a r e c o n s i d e r e d to be l i k e l y t o respond t o p s y c h i a t r i c treatment w i t h i n a p e r i o d o f f o u r months. At t h e end o f t h i s time, the p a t i e n t i s e i t h e r d i s c h a r g e d o r moved t o the b u i l d i n g s w i t h i n the P r o v i n c i a l Mental H o s p i t a l .  32.  ,  r e v e a l e d a t t i t u d e s which d i d not appear t o be i n f l u e n c e d by the child's illness.  One  mother speaks o f her son as h a v i n g the same  q u a l i t i e s o f c h a r a c t e r as her husband from whom she i s separated. Penny, who  i s now  she i s now  at the age where she i s a s k i n g q u e s t i o n s about her  n a t u r a l mother.  s i x , i s d i s l i k e d by her f o s t e r mother, because  The f o s t e r mother, who  mother, r e s e n t s t h i s .  She  s t a t e s t h a t she can see a l l the n e g a t i v e  q u a l i t i e s of h e r s i s t e r i n Penny, her and i n t e r e s t e d i n her p r o g r e s s . who  i s the s i s t e r of the n a t u r a l  Sherry's parents seem fond of On t h e other hand, her mother,  h e r s e l f comes from a broken home, i s so concerned a b o u t . r a i s i n g  well-behaved,  obedient  most unreasonable.  c h i l d r e n , t h a t a t times her demands are  In two  of the t h r e e remaining cases, the  p a r e n t a l a t t i t u d e s seemed reasonably h e a l t h y . i m p r e s s i o n gained from one i n t e r v i e w was  In the t h i r d , the  one o f i n d i f f e r e n c e on the  part of the mother. In summary, i t may  be noted t h a t i n 57% of the  s t u d i e d , the a t t i t u d e s of parents seemed t o be i n f l u e n c e d by the c h i l d ' s i l l n e s s .  cases  specifically  Parental, o v e r p r o t e c t i v e n e s s  and d i s l i k e or r e j e c t i o n were the most n o t i c e a b l e q u a l i t i e s .  The  group i n which the a t t i t u d e s o f parents d i d not appear to be p a r t i c u l a r l y i n f l u e n c e d by the i l l n e s s , c l e a r l y i l l u s t r a t e s way  the  i n which p e r s o n a l problems i n f l u e n c e p a r e n t a l a t t i t u d e s .  can be no doubt t h a t t h i s f a c t o r i s of importance groups as w e l l .  i n the o t h e r  There two  Because of the extent t o which p a r e n t a l a t t i t u d e s  i n f l u e n c e c h i l d r e n , the a t t i t u d e s o f the p a r e n t s of the i n t h i s study have been d i s c u s s e d i n q u i t e some d e t a i l .  children  33 Let us now presents  c o n s i d e r some o f the problems which e p i l e p s y  t o c h i l d r e n w i t h i n the s p e c i f i c  categories of the  s c h o o l c h i l d , the c h i l d a t t e n d i n g s c h o o l and the c h i l d o f  preschool  i  age who  i s not a t t e n d i n g s c h o o l .  These c a t e g o r i e s were s e l e c t e d  s i n c e examination of the m a t e r i a l r e v e a l e d t h a t although were many problems common t o a l l c h i l d r e n who  have e p i l e p s y ,  n e v e r t h e l e s s the d i f f i c u l t i e s o f the c h i l d r e n a t t e n d i n g were q u i t e d i f f e r e n t from those which p r e s e n t e d c h i l d r e n who  were not a t t e n d i n g  The  first  category  there  school  themselves t o  school.  c o n s i s t s of a group o f f o u r c h i l d r e n .  I t has not been p o s s i b l e t o determine the f e e l i n g s of t h e c h i l d r e n toward t h e i r handicap. questioned fell  Only one  c h i l d , who  her mother about her i l l n e s s .  so much more than other c h i l d r e n .  a t t i t u d e s seem to be the most important  has a k i n e t i c s e i z u r e s ,  She wondered why  With t h i s group, p a r e n t a l feature.  Since t h i s  a l r e a d y been d i s c u s s e d , no a d d i t i o n a l d i s c u s s i o n i s The  necessary.  Because t h e r e i s g r e a t v a r i e t y i n the type  s e i z u r e s and the measure of c o n t r o l achieved, the c h i l d r e n present  few  similar qualities.  i s t h a t none o f the c h i l d r e n have expressed  of  the s i t u a t i o n s of The  one  common f e a t u r e  t h e i r f e e l i n g s about  S e v e r a l attempts have been made t o d i s c u s s  e p i l e p s y w i t h the o l d e r c h i l d r e n p a r t i c u l a r l y , but as y e t have shown no i n t e r e s t i n becoming f a m i l i a r w i t h i t . probably  has  s i x c h i l d r e n a t t e n d i n g school, range i n age from s i x  t o sixteen years.  their illness.  she  of s i g n i f i c a n c e .  they  This i s  I t i s d i f f i c u l t t o determine whether  t h i s i s the r e s u l t o f t r u e d i s i n t e r e s t , r e f u s a l t o accept the  fact  3h t h a t they a r e handicapped, o r a tendency on the part o f p a r e n t s to  i n s t i l i n t h e c h i l d r e n the f e e l i n g t h a t i t i s an u n d e s i r a b l e  topic o f conversation.  I n two o f t h e s i x cases the c h i l d r e n each  attended the c l i n i c once, thus p r e v e n t i n g t h e establishment  of a  r e l a t i o n s h i p which c o u l d e v e n t u a l l y l e a d t o a d i s c u s s i o n on e p i l e p s y w i t h e i t h e r the p h y s i c i a n or the m e d i c a l s o c i a l worker. Impressions  o f t h e s c h o o l adjustment o f t h e c h i l d r e n were based  upon comments made by t h e p a r e n t s , t h e c h i l d r e n and i n t h r e e instances, the school teacher.  None o f t h e c h i l d r e n mentioned  being t e a s e d by o t h e r c h i l d r e n about t h e i r s e i z u r e s .  Only two  c h i l d r e n seem t o be happy and making s a t i s f a c t o r y p r o g r e s s i n school.  L i t t l e i s known about Danny o r Kenny who attended t h e  c l i n i c on only one o c c a s i o n . at  Danny d i d not seem t o be happy e i t h  home or i n s c h o o l , but t h e reasons  ascertained.  f o r t h i s c o u l d n o t be  Kenny j u s t began a t t e n d i n g s c h o o l and seems t o be  keeping up w i t h the other c h i l d r e n .  However he cannot be con-  s i d e r e d happy i n h i s s c h o o l s i t u a t i o n s i n c e he i s backward about p a r t i c i p a t i n g in. group a c t i v i t i e s . and making average grades,  Penny, who i s i n grade s i x  does n o t l i k e s c h o o l because she f e e l s  t h a t the other c h i l d r e n do not l i k e her. an e x p l a n a t i o n f o r this» expresses.strong  She i s not a b l e t o f i n d  S i n c e s h e . i s an unhappy l i t t l e g i r l who  f e e l i n g s of w o r t h l e s s n e s s ,  i t i s not surprising  t h a t she f e e i s t h i s way about, her s c h o o l s i t u a t i o n .  The cases o f  Mary and Tony s h a l l be e x p l a i n e d i n g r e a t e r d e t a i l because t h e i r s c h o o l experiences  seem t o have been i n f l u e n c e d , t o a marked  degree, by t h e i r medical c o n d i t i o n .  33(a) Mary began s c h o o l at the age o f s i x y e a r s , - However, because of the frequency o f her p e t i t mal s e i z u r e s , she was compelled to l e a v e s c h o o l o n l y a few days a f t e r she began. The f o l l o w i n g y e a r , she e n r o l l e d a g a i n , her s e i z u r e s now w e l l c o n t r o l l e d . T h i s time i t was not her s e i z u r e s , but her behaviour which presented a problem. Her-attention span was b r i e f and her work h a b i t s poor. U n l e s s the t e a c h e r was at her elbow, she was unable t o complete her assignments. The o t h e r c h i l d r e n f r e q u e n t l y complained t o the t e a c h e r about Mary h a v i n g hurt them. She was i n c l i n e d t o be rough w i t h the c h i l d r e n and at times enjoyed b i t i n g them. F i n a l l y she was p l a c e d i n a s p e c i a l c l a s s where i t was f e l t she would be a b l e t o r e c e i v e the a t t e n t i o n she craved.15 O r d i n a r i l y , she would not be cons i d e r e d an a p p r o p r i a t e candidate f o r a. s p e c i a l c l a s s because,her i n t e l l e c t u a l a b i l i t y appears t o be beyond t h a t of most students i n s p e c i a l c l a s s e s . I t i s d i f f i c u l t t o a s c e r t a i n how much of Mary's behaviour i s due, e i t h e r d i r e c t l y or i n d i r e c t l y , t o her i l l n e s s , and how much i s the r e s u l t o f her mother's behaviour. Comments r e g a r d i n g the mental s t a t u s of Mary's mother have been made on page 27» In any event, Mary continues t o be a problem i n school. (b) Tony i s a s i x t e e n year o l d boy who i s now t a k i n g h i s grade t e n . He managed t o complete h i s lower grades w i t h a minimum of e f f o r t but i s now experiencing difficulty. Recent t e s t s i n d i c a t e d t h a t h i s i n t e l l e c t u a l a b i l i t y was s l i g h t l y below the average. However, i n the o p i n i o n o f the w r i t e r , t h i s does not e n t i r e l y e x p l a i n h i s present d i f f i c u l t y . T h i s past year has been the f i r s t y e a r , s i n c e the onset o f psychomotor and p e t i t mal s e i z u r e s f i v e y e a r s ago, t h a t Tony has been f r e e of s e i z u r e s . Although he refuses to discuss h i s feelings.about his i l l n e s s , t h e r e i s evidence t h a t he r e s e n t s i t , p a r t i c u l a r l y s i n c e he has a t w i n b r o t h e r who i s completely w e l l . A l s o , because of h i s handicap, Tony's mother has set down more r e s t r i c t i o n s f o r him t h a n f o r h i s brother. T h i s may have i n t e n s i f i e d h i s f e e l i n g s of resentment and a l s o f o s t e r e d i n f e r i o r i t y f e e l i n g s . I t does not seem l i k e l y t h a t any youngster can do h i s best a t s c h o o l when h i s i n n e r f e e l i n g s are i n constant t u r m o i l . 15  S p e c i a l c l a s s e s are p r o v i d e d i n many o f the Vancouver s c h o o l s f o r c h i l d r e n who are i n t e l l e c t u a l l y handicapped. The number of c h i l d r e n i n these c l a s s e s i s fewer than i n the r e g u l a r classroom and the c u r r i c u l u m i s i n l i n e w i t h t h e i r c a p a b i l i t i e s .  i  36 The group o f children.who  a r e o f s c h o o l age, b u t a r e  n o t a t t e n d i n g s c h o o l c o n s t i t u t e a problem i n terms o f f u t u r e p l a n n i n g f o r them.  I n each o f the f o u r cases, the parents have  not been a b l e t o f a c e t h i s problem i n a r e a l i s t i c manner. case placement i n t h e Crease  I n one  C l i n i c has s e r v e d as a temporary  measure.. However, t h i s type o f care w i l l n o t meet.Janey's needs i n the future.  The t h r e e other c h i l d r e n , i n the o p i n i o n s o f the  d o c t o r s , r e q u i r e i n s t i t u t i o n a l , c a r e . H o w e v e r , the parents p r e f e r t o d e l a y placement i n an i n s t i t u t i o n u n t i l a b s o l u t e l y necessary.  Johnny's case, which has a l r e a d y been d i s c u s s e d i n  s o m e . d e t a i l , s h a l l . b e presented,to encountered  i l l u s t r a t e the d i f f i c u l t i e s  i n p l a n n i n g t h e f u t u r e o f a. mentally handicapped  youngster. (a) Johnny, who i s now f o u r t e e n y e a r s of age, has been out. o f s c h o o l f o r a y e a r . He was a problem t o t h e t e a c h e r s f i r s t because o f the frequency o f h i s s e i z u r e s . L a t e r , when c o n t r o l o f s e i z u r e s was a c h i e v e d , he was a problem because o f h i s i n a b i l i t y to absorb the m a t e r i a l presented t o him i n a special class. A l s o , h i s a g g r e s s i v e and uncont r o l l e d behaviour, caused them a g r e a t d e a l o f concern. When Johnny, because of. h i s s i z e , outgrew the s p e c i a l c l a s s i n t h e p u b l i c s c h o o l , i t was d e c i d e d t h a t he d i d n o t have s u f f i c i e n t a b i l i t y t o go i n t o the s p e c i a l c l a s s i n . t h e j u n i o r h i g h s c h o o l s . T h e r e f o r e placement i n Woodland School was d i s c u s s e d w i t h t h e p a r e n t s . They v i s i t e d t h e s c h o o l , and decided i t was not the p l a c e f o r t h e i r son. A t p r e s e n t , Johnny remains a t home and h e l p s h i s mother w i t h t h e housework. Because o f h i s 16  T h i s would seem an a p p r o p r i a t e p l a c e t o p o i n t out t h a t o f t h e f o u r t e e n c h i l d r e n i n t h i s study, i n s t i t u t i o n a l c a r e , because o f mental r e t a r d a t i o n , has been recommended f o r only t h r e e c h i l d r e n . T h i s i s not i n keeping w i t h t h e v e r y common b e l i e f t h a t a l l persons w i t h e p i l e p s y a r e s u i t a b l e c a n d i d a t e s f o r a mental i n s t i t u t i o n or an i n s t i t u t i o n f o r mentally r e t a r d e d persons. The one c h i l d who was p l a c e d i n a mental i n s t i t u t i o n . s h o w e d symptoms o f mental i l l n e s s p r i o r t o t h e onset of s e i z u r e s .  37 c h i l d i s h behaviour, h i s f a t h e r , who i s a p a i n t e r , i s not attempting t o teach him h i s own t r a d e . He s t a t e s t h a t Johnny might d e s t r o y a " p a i n t j o b " t h a t had a l r e a d y been completed. He plans to-find-„ employment f o r him as a " t r u c k l o a d e r when he i s a few y e a r s o l d e r " . Perhaps t h i s i s the answer, but w i t h Johnny's need f o r constant s u p e r v i s i o n , one might be i n c l i n e d t o wonder. Having examined the d i f f i c u l t i e s which e p i l e p s y t o the f o u r t e e n c h i l d r e n and t h e i r p a r e n t s , t o now c o n s i d e r the help p r o v i d e d i s p r e s e n t e d t o i n d i c a t e the kinds  i t seems  f o r them.  presents  appropriate  The f o l l o w i n g t a b l e  of r e f e r r a l s which were made  t o the medical s o c i a l worker i n the s e i z u r e  clinic.  S o c i a l h i s t o r y requested  7  I n t e r p r e t a t i o n of e p i l e p s y to p a r e n t s  4  I n t e r p r e t a t i o n of e p i l e p s y t o p a t i e n t  1  Help parents accept i n s t i t u t i o n a l  care  for patient  1  Help p a r e n t s accept m e d i c a l treatment To f a m i l i a r i z e the s c h o o l t e a c h e r r e p a t i e n t ' s c o n d i t i o n and the k i n d of help he r e q u i r e d Help mother i n the d i s c i p l i n i n g o f her c h i l d  •  1  1 •  1  Table I  The f i g u r e s i n t h i s t a b l e , although i n s i g n i f i c a n t i n terms o f numbers, n e v e r t h e l e s s points.  bring t o light several interesting  Note t h a t the numbers do not add up t o f o u r t e e n .  In  some i n s t a n c e s , the p h y s i c i a n s t a t e d more than one reason f o r r e questing  h e l p f o r the p a t i e n t .  Note a l s o that the l a r g e s t number  3S o f r e f e r r a l s was patient.  based upon a d e s i r e f o r i n f o r m a t i o n about the  T h i s suggests t h a t the medical  most r e c o g n i t i o n as an " i n v e s t i g a t o r " .  s o c i a l worker r e c e i v e d While t h i s may  t r u e when the c l i n i c f i r s t began, i t i s not so today.  have been As  the  m e d i c a l s o c i a l worker gained knowledge o f both the medical s o c i o l o g i c a l aspects of the i l l n e s s , her f u n c t i o n i n the g r a d u a l l y changed.  Too,  and  clinic  as the p h y s i c i a n s became more f a m i l i a r  w i t h the kinds o f h e l p p r o v i d e d by the medical s o c i a l worker, t h e r e were changes i n the nature  of t h e i r r e f e r r a l s .  Regardless  type of request made, the h e l p g i v e n depended upon the  o f the  particular  needs o f the p a t i e n t , the s k i l l of the medical s o c i a l worker, and the a b i l i t y of the p a t i e n t and h i s parents to use the s e r v i c e available. D i r e c t h e l p t o the c h i l d r e n i n the sample has been extremely  limited.  Some h e l p i s p r o v i d e d f o r the o l d e r c h i l d r e n  i n meeting t h e i r environmental needs.  A l s o , whenever p o s s i b l e ,  t h e y are encouraged t o d i s c u s s t h e i r f e e l i n g s toward t h e i r and any other problems they may a d o l e s c e n t s are extremely  have.  handicap  However, because many  s e c r e t i v e and s u s p i c i o u s o f the motives  o f o t h e r s , e s t a b l i s h m e n t . o f a case~work r e l a t i o n s h i p which would eventually, l e a d to a d i s c u s s i o n of. a t t i t u d e s a n d . f e e l i n g s , has been extremely  slow.  A l s o , the m a j o r i t y o f the o l d e r c h i l d r e n i n  t h i s group are i n t e l l e c t u a l l y handicapped and c o u l d i n a l l probab i l i t y g a i n l i t t l e from t h i s type of d i s c u s s i o n .  Since young  c h i l d r e n are r a r e l y able t o v e r b a l i z e t h e i r f e e l i n g s ,  indirect  methods must be used, both t o d i s c o v e r t h e i r c o n f l i c t s and t o h e l p  39  them w i t h t h e s e . a t h e r a p i s t who a child's play.  T h i s can be accomplished i n a p l a y s i t u a t i o n by has been t r a i n e d t o understand the symbolism  of  In some c l i n i c s , the t h e r a p i s t i s a s o c i a l worker  whose t r a i n i n g has been d i r e c t e d along t h e s e l i n e s .  Whenever t h i s  type of case work s e r v i c e i s o f f e r e d , p r o v i s i o n i s made f o r the s o c i a l worker to c o n s u l t w i t h a p s y c h i a t r i s t who guide t h e t h e r a p i s t . of  i s equipped t o  F o l l o w i n g the establishment o f a d i a g n o s i s  the c h i l d ' s c o n f l i c t s , the t h e r a p i s t can, by means of p l a y , h e l p  t h e c h i l d work through h i s d i f f i c u l t i e s .  The s o c i a l worker i n the  s e i z u r e c l i n i c i s not equipped to p r o v i d e t h i s type of h e l p t o emotionally disturbed c h i l d r e n . for  Also, psychiatric  consultation  p l a y therapy i s not a v a i l a b l e to the s o c i a l worker.  For these  reasons the emphasis i n working w i t h these c h i l d r e n has been d i r e c t e d toward r e l i e v i n g environmental p r e s s u r e s and m o d i f y i n g parental attitudes.  Janey's case i s an example of the type of  h e l p which has been p r o v i d e d f o r c h i l d r e n . (a) Janey was f i r s t brought to the H e a l t h Centre f o r C h i l d r e n by her e l d e r s i s t e r who sought advice r e g a r d i n g Janey's s e i z u r e s and a l s o her "strange behaviour". The s e i z u r e s which f i r s t appeared two y e a r s ago and had been c o n t r o l l e d by phenob a r b i t a l , reappeared when Janey. stopped t a k i n g her m e d i c a t i o n . She was d e s c r i b e d as a s u l l e n youngster who r e f u s e d t o p l a y with other c h i l d r e n and who f a b r i c a t e d reasons f o r not l e a v i n g the house. She l o c k e d h e r s e l f i n the bathroom f o r three hours t o a v o i d having t o keep her c l i n i c appointment. On s e v e r a l o c c a s i o n s as she and her s i s t e r t r a v e l l e d over one of the Vancouver b r i d g e s , she spoke o f wanting t o jump o f f the b r i d g e . She c o u l d g i v e no e x p l a n a t i o n f o r wanting to do t h i s other than t h a t she had an urge t o do so. F o l l o w i n g the i n i t i a l examination, i t was d e c i d e d t h a t Janey should be p l a c e d on the p s y c h i a t r i c ward f o r purposes o f o b s e r v a t i o n . I t was at t h i s p o i n t t h a t a r e q u e s t f o r a s o c i a l h i s t o r y came to the medieal s o c i a l worker. There f o l l o w e d a  40 s u c c e s s i o n of i n t e r v i e w s w i t h Janey, her and both her p a r e n t s .  sister,  I t was l e a r n e d t h a t Janey, the second youngest o f f o u r daughters, was a product of a broken home. When she was approximately f o u r y e a r s of age, her f a t h e r j o i n e d the armed s e r v i c e s and s i n c e t h a t time has been absent from the home. Janey's mother i s l i v i n g i n a common-law r e l a t i o n s h i p w i t h a man who has r e f u s e d t o accept the f i n a n c i a l r e s p o n s i b i l i t y of the c h i l d r e n . S i n c e the two o l d e r daughters are married, Janey's mother has been a b l e t o p r o v i d e f o r the n e c e s s i t i e s of the two younger daughters by h o l d i n g a p a r t time j o b . Janey's mother speaks q u i t e f r e e l y about her p r e f e r e n c e f o r Janey's younger s i s t e r . She d e s c r i b e s her as a more l i k e a b l e , outgoing youngster who i s l e s s o f a worry t o her. She s t a t e s that Janey has always been, a strange c h i l d . When she was very young she r e f u s e d t o p l a y with other c h i l d r e n and spent much o f her time p l a y i n g i n her own l i t t l e w o r l d of make-believe. As she grew o l d e r , she continued t o have d i f f i c u l t y i n her r e l a t i o n s h i p s w i t h o t h e r s . The onset o f s e i z u r e s seemed t o r e i n f o r c e t h i s p a t t e r n . She was i n constant f e a r o f having a s e i z u r e i n the presence of o t h e r s . . She a p p a r e n t l y stopped s c h o o l f o r t h i s same reason. The p l a n f o r her t o h e l p her.mother with the housework d i d not prove s a t i s f a c t o r y . Janey r e s e n t e d i n s t r u c t i o n but was not capable o f c a r r y i n g out her r e s p o n s i b i l i t i e s without constant reminders. Most of her time was spent day-dreaming o r r e a d i n g comic books. S h o r t l y b e f o r e her adm i s s i o n t o the h o s p i t a l , she went to l i v e w i t h her o l d e r s i s t e r w i t h the understanding t h a t she was t o h e l p her w i t h the housework. Janey's three week s t a y i n the h o s p i t a l seemed t o be a p l e a s u r a b l e experience f o r her. She made f r i e n d s e a s i l y and a t times was q u i t e outgoing and a g g r e s s i v e . She seemed to t h r i v e on the a t t e n t i o n she was g e t t i n g . There were few i n d i c a t i o n s o f her tendency t o daydream, although the o c c u p a t i o n a l t h e r a p i s t n o t i c e d t h a t her a t t e n t i o n span was b r i e f . She seemed q u i t e contented i n her p r o t e c t e d e n v i r o n ment and c o n t i n u e d her p a t t e r n of r e f u s i n g to f a c e the o u t s i d e world. Upon d i s c h a r g e from the h o s p i t a l , p l a n s were made t o have Janey p l a c e d i n the Crease C l i n i c f o r a temporary p e r i o d . The medical s o c i a l worker's c o n t r i b u t i o n t o the treatment programme f o r t h i s p a t i e n t took v a r i o u s forms w i t h a minimum amount o f d i r e c t h e l p t t o Janey. The s o c i a l h i s t o r y c o n t r i b u t e d t o the doctor's  41 understanding o f Janey's t o t a l s i t u a t i o n . I t was q u i t e e v i d e n t t h a t t h e r e was no one i n t h e f a m i l y who c o u l d g i v e her the understanding and h e l p she r e q u i r e d . Due t o the l a c k o f f a c i l i t i e s i n t h e h o s p i t a l , t h e medical s o c i a l worker a c t e d as t h e r e s o u r c e person i n a r r a n g i n g f o r psychol o g i c a l t e s t s t o be done a t t h e C h i l d Guidance Clinic. She a c t e d as l i a i s o n between t h e h o s p i t a l and the d i s t r i c t s o c i a l worker who was t o do the f o l l o w - u p o f the case and see t o i t t h a t p l a n s f o r Janey's admission t o the Grease C l i n i c were c a r r i e d o u t . D i r e c t h e l p was g i v e n t o Janey on a s u p e r f i c i a l level. D i s c u s s i o n s r e g a r d i n g admission t o t h e h o s p i t a l , the r o u t i n e o f t h e ward, t h e psychol o g i c a l t e s t s , d i s c h a r g e p l a n s and e v e n t u a l p l a c e ment i n the Grease C l i n i c probably s e r v e d a t h e r a p e u t i c purpose. The worker v i s i t e d Janey f r e quently and took h e r out f o r walks on the h o s p i t a l grounds© Her c o n v e r s a t i o n s c o n s i s t e d p r i m a r i l y o f d e s c r i p t i o n s o f her numerous, and probably makeb e l i e v e , b o y f r i e n d s . On only one o c c a s i o n d i d she c a s u a l l y mention her f e e l i n g s r e g a r d i n g h e r i l l ness. She t a l k e d about i t i n c o n n e c t i o n w i t h wanting t o stay i n bed i n the mornings s i n c e most o f h e r s e i z u r e s o c c u r r e d a t t h a t time. She added t h a t she w o r r i e d about h a v i n g s e i z u r e s i n f r o n t of o t h e r s . At t h i s p o i n t t h e b e n e f i t s of m e d i c a t i o n were e x p l a i n e d t o h e r w i t h t h e i n t e n t i o n o f h e l p i n g her r e a l i z e t h a t c o n t r o l , o f the s e i z u r e s might h e l p h e r overcome her f e a r o f meeting people. Recognizing t h a t the p a t t e r n e x i s t e d p r i o r t o the onset o f s e i z u r e s , there i s some q u e s t i o n about her a b i l i t y t o b e n e f i t from t h i s d i s c u s s i o n . During her e n t i r e stay i n h o s p i t a l , Janey f a i l e d to express her f e e l i n g s toward h e r younger s i s t e r or her mother. She spoke of them o n l y i n pleasant terms and a t times seemed t o be f a n t a s y i n g about her s t a t u s i n the home. I t seemed i m p o s s i b l e t o e s t a b l i s h a n y t h i n g o t h e r than a s u p e r f i c i a l r e l a t i o n s h i p with h e r s i n c e she f r e q u e n t l y appeared t o be out o f touch w i t h r e a l i t y . Although Janey enjoyed her stay i n h o s p i t a l , t h e e x t e n t t o which she b e n e f i t t e d from h e r experience,- other than to gain c o n t r o l o f her s e i z u r e s , i s questionable. Janey's case i l l u s t r a t e s the way i n which medical  social  work can p r o v i d e a s e r v i c e which i s i n d i r e c t l y b e n e f i c i a l t o the patient.  Background i n f o r m a t i o n o f the p a t i e n t ' s s o c i a l  situation  42  adds t o the physician's understanding o f the p a t i e n t as a person, t h u s e n a b l i n g him.to  use the psychosomatic  approach not o n l y i n  e s t a b l i s h i n g a d i a g n o s i s , but a l s o i n c a r r y i n g . o u t treatment* The m e d i c a l . s o c i a l worker's awareness of community r e s o u r c e s , p r o v i d e s another form of i n d i r e c t h e l p .  I n Janey's case, one  agency i n the community p r o v i d e d a s e r v i c e which helped e s t a b l i s h a d i a g n o s i s , and a second agency c o n t r i b u t e d by s e e i n g t o i t t h a t the p h y s i c i a n ' s recommendations were c a r r i e d o u t .  There are  numerous examples i n t h i s sample, of agencies such as the C h i l d r e n ' s A i d S o c i e t y , . t h e M e t r o p o l i t a n H e a l t h Committee, and the V o c a t i o n a l S c h o o l , c o n t r i b u t i n g t o the treatment programme of the c h i l d r e n . The medical s o c i a l worker who  i s f a m i l i a r w i t h both the  t r u t h s and a l s o the common misconceptions r e g a r d i n g e p i l e p s y can do much to modify p a r e n t a l a t t i t u d e s toward i t .  The w e l l - i n f o r m e d  p a r e n t has fewer f e a r s and as a r e s u l t i s more able to h e l p the s e i z u r e d c h i l d develop h e a l t h y a t t i t u d e s toward h i s handicap. the s e i z u r e c l i n i c , numerous methods have been employed t o parents.  Pamphlets,  In  educate  o b t a i n e d from the N a t i o n a l E p i l e p s y League o f  America, are d i s t r i b u t e d among the parents. a v a i l a b l e f o r t h e i r use.  Books a r e made  The f o l l o w i n g case i l l u s t r a t e s how  an  e p i l e p t i c c h i l d can b e n e f i t from i n c r e a s e d u n d e r s t a n d i n g on the p a r t of h i s parent. (a) When Tony was f i r s t r e f e r r e d t o the H e a l t h Center f o r - C h i l d r e n f o r medical treatment, h i s mother was extremely concerned about h i s h e a l t h . S i n c e she was separated from her husband, t h e r e s p o n s i b i l i t y o f the i l l n e s s was h e r s a l o n e . Although she seemed an i n t e l l i g e n t woman, she b e l i e v e d that e p i l e p s y appeared  43 i n seven y e a r c y c l e s , and t h a t once i t appeared, nothing c o u l d be done u n t i l the seven y e a r s were completed. She was convinced the m e d i c a t i o n Tony was t a k i n g was harmful and she blamed i t f o r h i s i n c r e a s i n g d i f f i c u l t y i n s c h o o l . Because o f the frequency of h i s a t t a c k s , she c o n s i d e r e d i t necess a r y to r e s t r i c t h i s a c t i v i t i e s . Tony was a most unhappy youngster. He was extremely q u i e t and shy i n s c h o o l , but a c t e d out h i s h o s t i l e f e e l i n g s at home. As changes were made i n the m e d i c a t i o n , the frequency of the s e i z u r e s decreased and g r a d u a l l y stopped. Tony's mother then became more able t o d i s c u s s h i s i l l n e s s on an o b j e c t i v e , r a t h e r than an emotional b a s i s . She r e c e i v e d an e x p l a n a t i o n of the d i f f e r e n t kinds o f a n t i - c o n v u l s a n t drugs used i n the treatment o f e p i l e p s y and the s i d e r e a c t i o n s which c o u l d be expected. Changes i n m e d i c a t i o n were e x p l a i n e d both t o Tony and to her. She was made t o f e e l that her h e l p was r e q u i r e d i n the treatment, and a l s o that others were i n t e r e s t e d i n h e l p i n g her share the r e s p o n s i b i l i t y o f her son's i l l n e s s . From the evening group d i s c u s s i o n s she l e a r n e d how other parents f e l t about e p i l e p s y . Some of her own f a n t a s t i c b e l i e f s , expressed by some members of the group, were d i s c o u n t e d a n d . r i d i c u l e d , not by the p r o f e s s i o n a l people p r e s e n t , but by other p a r e n t s . The i d e a of t r e a t i n g Tony as a normal c h i l d was p l a n t e d i n her mind. A l s o , from comments made by p a r e n t s , whose grown up c h i l d r e n r e c e i v e treatment f o r e p i l e p s y , she r e c o g n i z e d the importance o f planning f o r h i s f u t u r e . As her u n d e r s t a n d i n g - o f e p i l e p s y and i t s problems became.clearer, her a t t i t u d e toward Tony changed considerably. She i s now t r y i n g to see him as a w e l l c h i l d whose p o t e n t i a l i t i e s must be e x p l o r e d t o the f u l l e s t i n order t o make up f o r h i s h a n d i caps. Formerly, i t was her ambition f o r him to enter the p r i e s t h o o d . For t h i s reason she p l a c e d too much emphasis upon the attainment o f marks which were beyond Tony's c a p a b i l i t i e s . The t e n s i o n r e s u l t i n g out of t h i s was a n e g a t i v e i n f l u e n c e upon him. When the r e s u l t s o f the p s y c h o l o g i c a l t e s t s were e x p l a i n e d t o h i s mother, she commented t h a t t h e r e d i d not seem t o be any p o i n t i n pushing Tony beyond h i s c a p a b i l i t i e s , and t h a t i t would be best to d i r e c t h i s t r a i n i n g along the l i n e s which were best s u i t e d f o r him. In a r e c e n t c o n v e r s a t i o n , Tony's mother commented on the change i n h i s a t t i t u d e . He i s doing b e t t e r work  44 i n s c h o o l and p l a n s t o continue f o r as l o n g as he i s a b l e . He p a r t i c i p a t e s i n numerous s c h o o l a c t i v i t i e s , i s l e s s moody and appears t o be h a p p i e r i n every way. I t seems l i k e l y t h a t t h e chances o f happiness i n adulthood f o r Tony, a r e g r e a t e r now than when h i s mother f i r s t brought him to the H e a l t h Centre f o r C h i l d r e n . From t h e m a t e r i a l p r e s e n t e d i n t h i s c h a p t e r , i t may be c o n c l u d e d t h a t the c h i l d r e n i n t h i s study, have more than t h e average number o f d i f f i c u l t i e s .  There i s evidence a l s o , t h a t  their  m e d i c a l c o n d i t i o n i s not s o l e l y r e s p o n s i b l e f o r t h e e x t e n t o f t h e i r problems.  Financial insecurity, unsatisfactory  relationships  between p a r e n t s , and p a r e n t a l ignorance o f the b a s i c needs o f c h i l d r e n may be c o n t r i b u t i n g f a c t o r s i n t h i s p a r t i c u l a r  sample.  In some i n s t a n c e s , the i l l n e s s presented d i f f i c u l t i e s i n terms o f p a r e n t a l a t t i t u d e s toward  e p i l e p s y and the s e i z u r e d c h i l d , p a r e n t a l  a t t i t u d e s , r e g a r d i n g the acceptance  of f r e e m e d i c a l treatment and  a l s o , a b i l i t y o f p a r e n t s t o i n t e l l i g e n t l y p a r t i c i p a t e i n the treatment.  Examination o f t h e cases r e v e a l s t h a t w i t h h e l p from  t h e p h y s i c i a n and t h e medical s o c i a l worker, over prolonged p e r i o d s o f time, p a r e n t a l a t t i t u d e s c o u l d be m o d i f i e d t o the extent where some parents c o u l d probably c o n t r i b u t e a g r e a t d e a l toward the achievement o f happiness seizured c h i l d .  -  and m a t u r i t y i n adulthood, f o r the  Chapter IV  CAN THE MEDICAL SOCIAL WORKER HELP THE ADULT WHO IS SUBJECT TO SEIZURES?  Is  happiness, and m a t u r i t y i n meeting  the respon-  s i b i l i t i e s o f adulthood a r e a l i t y f o r the person with, e p i l e p s y ? F o r many the answer i s "no", f o r some "yes", and f o r o t h e r s , "perhaps".  Although t h e r e may be some t r u t h i n the c u r r e n t  b e l i e f t h a t persons with e p i l e p s y are i n c a p a b l e o f becoming and remaining worthwhile members o f a community, examination o f the s o c i a l s i t u a t i o n s o f the t h i r t y - n i n e a d u l t s i n t h i s  study,  c l e a r l y i l l u s t r a t e s that b l a n k e t . statements r e g a r d i n g " e p i l e p t i c s p e r se", a r e n o t a p p l i c a b l e . istic  Indeed, because o f the i n d i v i d u a l -  c h a r a c t e r i s t i c s o f t h e members o f t h e group, attempts a t  a n a l y s i s of c l e a r l y d e f i n e d c a t e g o r i e s o f p a t i e n t s proved unproductive.  F o r t h i s reason, t h i s chapter i s not t o be a s t a t i s t i c a l  s t u d y o f the a d u l t s i n t h i s group, but r a t h e r a g e n e r a l d e s c r i p t i o n of  problems which e p i l e p s y p r e s e n t s t o t h e a d u l t s who seek  m e d i c a l treatment Hospital, attempt  a t the s e i z u r e c l i n i c o f t h e Vancouver G e n e r a l  A l s o , because o f t h i s i n d i v i d u a l i s t i c  q u a l i t y , no  has been made t o present a s t a t i s t i c a l e v a l u a t i o n o f the  r e s u l t s o b t a i n e d from the h e l p p r o v i d e d by t h e m e d i c a l s o c i a l worker i n the c l i n i c .  Again, w i t h t h e h e l p o f ease  t h e d e s c r i p t i o n i s t o be g e n e r a l .  illustrations,  46 Examination o f t h e case m a t e r i a l r e v e a l e d t h a t although t h e r e were problems common to a l l a d u l t s w i t h e p i l e p s y , those o f t h e s i n g l e persons d i f f e r e d i n many r e s p e c t s from those o f the m a r r i e d group.  T h e r e f o r e , t h e problems which e p i l e p s y presents  t o a d u l t s s h a l l be d i s c u s s e d i n terms o f these two c a t e g o r i e s . Women  Men  Diagram 2  Diagram 2 i n d i c a t e s t h e m a r i t a l s t a t u s o f both the men arid women i n the sample©  Since 68% o f the s i n g l e persons i n t h i s group  a r e between t h e ages o f seventeen and t h i r t y y e a r s , i t i s p o s s i b l e t h a t a number w i l l marry i n the f u t u r e . would probably s t i l l persons do n o t marry.  However, the s t a t i s t i c s  suggest t h a t t h e l a r g e s t p o r t i o n o f e p i l e p t i c Assuming t h a t the women who a r e a t present  engaged t o be married, s h a l l marry, and the men who a r e s e p a r a t e d f r o m t h e i r wives a r e not l i k e l y t o marry, the s t a t i s t i c s  indicate  47 t h a t a h i g h e r percentage o f men than women remain s i n g l e .  17  Of t h e f o u r men who are m a r r i e d , a l l but one developed epilepsyf o l l o w i n g marriage.  I n t h e case o f t h e e i g h t women, only one  developed e p i l e p s y f o l l o w i n g marriage. marriage may be r e s p o n s i b l e  for this.  The f i n a n c i a l aspects o f I n our present s o c i e t y , t h e  male i s expected t o assume t h e f i n a n c i a l r e s p o n s i b i l i t i e s o f t h e household.  Therefore,  the handicapped male, who i s i n a c o n s t a n t  dilemma about t h e permanency o f h i s j o b , i s u n l i k e l y t o assume t h e r e s p o n s i b i l i t i e s of marriage.  The women, on t h e other hand,, may see  marriage as a s o l u t i o n t o t h e i r employment problems.  The placement  o f f i c e r s o f t h e N a t i o n a l Employment S e r v i c e have observed t h a t men are more w i l l i n g than women, t o accept a f e l l o w employee who has epilepsy.  T h i s suggests t h a t men a r e l e s s d i s t r e s s e d by t h e s i g h t  o f a s e i z u r e , t h a n women.  Whether o r not t h i s i n f l u e n c e s t h e  development o f s o c i a l r e l a t i o n s h i p s which e v e n t u a l l y l e a d t o marriage, i s d i f f i c u l t t o a s c e r t a i n .  P r i o r t o a discussion of the  problems which e p i l e p s y p r e s e n t s t o the m a r r i e d person w i t h  epilepsy,  l e t us examine t h e s o c i a l s i t u a t i o n s o f the s i n g l e members o f t h i s group. The  s i n g l e person encounters t h e g r e a t e s t number o f  d i f f i c u l t i e s i n terms o f s o c i a l r e l a t i o n s h i p s and employment. Parental three 17  a t t i t u d e s have been d i s c u s s e d  a t great  length  and t h e r e f o r e r e q u i r e no f u r t h e r e l a b o r a t i o n .  i n chapter  However, t h e i r  :  The three s i n g l e g i r l s who a r e engaged to be m a r r i e d have been i n c l u d e d i n the group o f married e p i l e p t i c persons. Analysis of t h e eases i n d i c a t e d t h a t the problems which e p i l e p s y p r e s e n t s t o them are s i m i l a r t o those o f m a r r i e d persons whose s e i z u r e s began p r i o r t o marriage.  48 influence  upon the  employment and the discounted. t e c t i o n and friendships. world.  The  The  establishment of h e a l t h y a t t i t u d e s  toward  development o f s o c i a l r e l a t i o n s h i p s must not  c h i l d who  has  l i v e d i n an  be  environment of overpro-  dependency, i s i l l - e q u i p p e d , as an a d u l t , t o seek out Nor  can he meet the f r u s t r a t i o n s o f the  c h i l d who  i s the product of a c o l d and  environment, becomes a s u s p i c i o u s . a n d a n t a g o n i s t i c a b i l i t y to accept the  rejecting adult.  l e s s d e s i r a b l e , as w e l l as the  q u a l i t i e s of his friends, i s l i m i t e d . f r i e n d s t o f a l l i n w i t h h i s way  business  F a i l u r e on the  His  desirable part  of  o f t h i n k i n g i s immediately i n t e r -  p r e t e d as an i n d i c a t i o n of t h e i r d i s l i k e f o r him.  A l s o , t h i s group  experience d i f f i c u l t y i n a c c e p t i n g d i r e c t i o n from employers. Again, c r i t i c i s m i s i n t e r p r e t e d unfairness.  In s h o r t , the  as an i n d i c a t i o n o f d i s l i k e and  person who  has  lacked  sympathy  and  u n d e r s t a n d i n g i n c h i l d h o o d , seems unable t o view the behaviour motives of f r i e n d s , f e l l o w employees, and  and  employers, on a r e a l i s t i c  basis. For the  s i n g l e persons i n t h i s study, d i f f i c u l t y i n s o c i a l  relationships reveals  i t s e l f i n the f o l l o w i n g ways.  (a) The person spends a l l h i s time at home w i t h h i s f a m i l y because he f e e l s t h a t no one who knows about h i s handicap w i l l want to be h i s f r i e n d . His a t t i t u d e i s f r e q u e n t l y the r e s u l t of former unpleasant e x p e r i e n c e s . (b) The person e s t a b l i s h e s f r i e n d s h i p s but these are - not l a s t i n g . He i s somewhat n e g a t i v i s t i c w i t h the r e s u l t t h a t few people want to c a r r y on w i t h the friendship. A l s o , because of h i s s u s p i c i o n and impatience w i t h o t h e r s , he sees no p o i n t i n cont i n u i n g w i t h the f r i e n d s h i p . There i s a l s o the group of people who have not been i n any one p l a c e l o n g enough t o a c q u i r e l a s t i n g f r i e n d s h i p s . Because  49 o f employment d i f f i c u l t i e s , they a r e c o n s t a n t l y on t h e move, (c) The person i s unable t o share f r i e n d s . Because o f h i s d i f f i c u l t y i n f i n d i n g people who understand and accept him, he i s i n c l i n e d t o " l a t c h on"*to the person who shows him f r i e n d l i n e s s . F r e q u e n t l y t h i s leads to a d i s s o l u t i o n o f the f r i e n d s h i p . Although a l l o f the twenty-eight persons appear t o be experiencing  d i f f i c u l t y i n their social relationships, i n ten  c a s e s , these d i f f i c u l t i e s do not appear t o be p a r t i c u l a r l y associated with t h e i r medical c o n d i t i o n .  For example, one boy  who s t u t t e r s s e v e r e l y , i s extremely backward about p l a c i n g i n a s i t u a t i o n where he w i l l be meeting new people.  himself  Another member,  who f e e l s t h a t h e r f a m i l y i s l o o k e d down upon by members o f t h e s m a l l community i n which she l i v e s , r e f u s e s t o make any attempts : t o seek new f r i e n d s h i p s .  The i m p l i c a t i o n s o f the i l l n e s s  seem  l e s s d i s t r e s s i n g t o t h i s group o f t e n p a t i e n t s , than t o t h e remaining e i g h t e e n .  There a r e those who are l e s s i n c l i n e d t o  c o n c e r n themselves with t h e i r handicap because t h e i r s e i z u r e s a r e now more o r l e s s c o n t r o l l e d . remain a t home.  Four persons are employed, and two  They each have t h e i r a c q u a i n t a n c e s , many o f whom  are unaware o f t h e f a c t t h a t they have e p i l e p s y .  The f o u r whose  s e i z u r e s have n o t been as w e l l c o n t r o l l e d , do n o t appear t o be p a r t i c u l a r l y p e r t u r b e d by t h e e f f e c t o f t h e i r s e i z u r e s upon e i t h e r t h e i r s o c i a l r e l a t i o n s h i p s or'employment. illustrative  The f o l l o w i n g case i s  o f the p a t i e n t who has made h i s own p e c u l i a r a d j u s t -  ment to h i s handicap. (a) Mr, R, who i s f o r t y - f o u r y e a r s o f age has had - epilepsy since infancy. Although h i s major s e i z u r e s occur as f r e q u e n t l y as f o u r o r f i v e times a month, he i s l a x about t a k i n g h i s  50 m e d i c a t i o n . He a l s o a c c e p t s a l c o h o l whenever an acquaintance consents t o buy him a d r i n k . Twenty y e a r s ago, Mr. R. was t o l d by the doctors i n t h e Mayo C l i n i c a t Rochester N.Y., t h e r e was nothing which c o u l d be done f o r him. I t was suggested, a c c o r d i n g t o Mr. R., that he l i m i t h i s a c t i v i t i e s and p l a n not t o work f o r t h e remainder o f h i s l i f e . Mr. R. has f o l l o w e d t h e advice o f t h e doctor's. .Despite the f a c t t h a t a g r e a t e r measure o f c o n t r o l of s e i z u r e s has been achieved,. Mr. R. i s c o n v i n c e d t h a t n o t h i n g can be done f o r him. S i n c e h i s m a t e r i a l needs are s p a r i n g l y s u p p l i e d by t h e s o c i a l a s s i s t a n c e cheque he r e c e i v e s , and h i s s o c i a l needs seem t o be met, Mr. R. i s c o n t e n t . D i f f i c u l t i e s i n s o c i a l r e l a t i o n s h i p s seem t o be more d i s t r e s s i n g to the r e m a i n i n g eighteen  s i n g l e persons.  Some a r e  unable t o make any attempts i n e s t a b l i s h i n g s o c i a l r e l a t i o n s h i p s . They have completely withdrawn from s o c i e t y .  Another group can  speak about t h e i r f e e l i n g o f "not belonging",  and f o l l o w i n g one  or two u n s u c c e s s f u l The  attempts, r e f u s e t o exert themselves f u r t h e r .  t h i r d group c o n s i s t s o f outgoing persons who made attempts t o  make f r i e n d s , but a r e not l i k e d by others because of t h e i r aggressive  behaviour. The  first  i n only one r e s p e c t .  group c o n s i s t s o f e i g h t persons who a r e s i m i l a r They seem to have adopted an a t t i t u d e o f ,  "Nobody l i k e s me o r wants t o be ray f r i e n d . " f e e l i n g seems q u i t e d i f f e r e n t i n each. t h i s group are mentally  The b a s i s f o r t h i s  A number o f t h e persons i n  r e t a r d e d and have as c h i l d r e n , been  t o a great' d e a l o f t e a s i n g .  subject  Withdrawal i s a s u i t a b l e escape.  A l s o , because o f t h e i r i n t e l l e c t u a l handicap and the frequency o f t h e i r s e i z u r e s , p a r e n t s have kept them c l o s e by t h e i r s i d e . Consequently, they l a c k confidence o u t s i d e world.  i n t h e i r a b i l i t y t o meet t h e  One p a t i e n t has completely withdrawn from r e a l i t y  51 and l i v e s i n a f a n t a s y w o r l d . to  Another two have been  committed  the P r o v i n c i a l Mental H o s p i t a l i n s t a t e s of d e p r e s s i o n .  o t h e r s remain a t home, complain of t h e i r unable t o do a n y t h i n g about i t .  The  l o n e l i n e s s , but are  The f o l l o w i n g ease d e s c r i b e s the  l o n e l i n e s s c h a r a c t e r i s t i c o f t h i s group of a d u l t s . (a) Miss S. i s an a t t r a c t i v e t w e n t y - s i x year o l d g i r l who was f i r s t i n t r o d u c e d t o the s o c i a l worker approximately two y e a r s ago. At that time a request was made t o h e l p Miss.S. f i n d employment. S e v e r a l months l a t e r , when Miss S. was brought i n t o the h o s p i t a l , having attempted s u i c i d e , g r e a t e r e f f o r t was e x e r t e d i n attempting to understand Miss S . ' s total situation. I t was l e a r n e d t h a t Miss S. i s the e l d e s t c h i l d i n a f a m i l y o f two. The o t h e r c h i l d i s a boy, f o u r y e a r s her j u n i o r . Her parents are e l d e r l y people who seem q u i t e r i g i d i n t h e i r i d e a s . M i s s S. was a s i c k l y c h i l d and as a r e s u l t encouraged t o remain c l o s e t o home. Even p r i o r to the onset o f major s e i z u r e s , a t the age o f t h i r t e e n , Miss S. had few friends. She was i n c l i n e d t o be backward and shy. F o l l o w i n g the onset of s e i z u r e s , some o f her c l a s s mates c o n s i d e r e d her mad and r e s e n t e d her presence i n s c h o o l . However, she c o n t i n u e d her s t u d i e s , ranked i n the upper h a l f of the c l a s s and completed her grade eleven examinations. By t h i s time a g r e a t e r measure o f c o n t r o l of s e i z u r e s had been achieved. * The f a m i l y then moved and Miss S. o b t a i n e d a p o s i t i o n as a s a l e s c l e r k i n a l a d i e s ' c l o t h i n g s t o r e . S i n c e she had a f a i r l y l e n g t h y warning p r i o r t o the onset of a s e i z u r e , she was a b l e to remove h e r s e l f t o the back o f the s t o r e on the r a r e occasions when a s e i z u r e o c c u r r e d . Her employer, though sympathetic and understanding encouraged her t o stop working and when the f a m i l y moved a g a i n , seemed t o welcome M i s s S.'s d e p a r t u r e . Miss.S. then o b t a i n e d a p o s i t i o n as a c l e r k i n one o f the department s t o r e s . S e v e r a l months l a t e r she was asked i f she would l i k e t o work as a c a s h i e r . Miss S. was s u c c e s s f u l i n t h i s job and from her Mother's d e s c r i p t i o n , seemed q u i t e happy and c o n t e n t . Miss S. was f r e e of s e i z u r e s f o r t h r e e y e a r s when she stopped t a k i n g her m e d i c a t i o n upon the s u g g e s t i o n of a man who was l i v i n g i n t h e i r home. He s a i d he was a h e r b a l i s t and t h a t the herbs he would g i v e her would be l e s s harmful t o  52  her than the "dope".she was t a k i n g . They would a l s o b r i n g about a c u r e . M i s s S. was at work when the f i r s t s e i z u r e i n t h r e e years o c c u r r e d . She was asked to g i v e up her j o b . Her medical c o n d i t i o n was again soon under c o n t r o l . However, the damaging.effect of t h i s experience upon her p e r s o n a l i t y development, c o u l d not be as e a s i l y r e p a i r e d . As Miss S. experienced,more and more d i f f i c u l t y i n o b t a i n i n g employment, she became more r e l u c t a n t t o apply f o r j o b s . She became i n c r e a s i n g l y despondent and p r e f e r r e d t o remain i n her room, sewing or s t a r i n g i n t o space. Since she was convinced t h a t no one l i k e d her, she r e f u s e d t o go anywhere, where she might meet young people. T h i s case i l l u s t r a t e s the d i f f i c u l t i e s i n s o c i a l r e l a t i o n s h i p s which are both d i r e c t l y and i n d i r e c t l y caused by illness.  With t h i s g i r l ,  i t seems l i k e l y that the i l l n e s s merely  i n c r e a s e d the magnitude of an a l r e a d y e x i s t e n t problem. a t t i t u d e s have c o n t r i b u t e d much to t h i s g i r l ' s present culties.  The  Parental diffi-  mother has been extremely o v e r p r o t e c t i v e and  unconsciously  an  has  r e i n f o r c e d the i d e a t h a t people are f e a r f u l  becoming f r i e n d s w i t h persons who  have e p i l e p s y .  of  Encouragement  i n h e l p i n g her overcome these f e e l i n g s , would have been more constructive.  The  d e t a i l s of t h i s case have been presented  i l l u s t r a t e many of the The n e g a t i v e mentioned.  The is  other problems a s s o c i a t e d w i t h e p i l e p s y .  i n f l u e n c e of p a r e n t a l a t t i t u d e s . h a s a l r e a d y been The  be discounted. o f being  to  "one  damage done by Miss S.'s  s c h o o l experience  Acceptance of one's school-mates and the of the gang"- i s important t o an adolescent  e f f e c t of having  cannot  feeling girl.  to g i v e up a j o b , d e s p i t e one's c a p a b i l i t i e s ,  d i s t r e s s i n g to a young-girl.  Heart-breaking  t h a t , r e g a r d l e s s o f t h e i r experience  a l s o , i s the  w i t h t h i s i l l n e s s and  fact  the  53 s u c c e s s which has been achieved  i n m e d i c a l treatment, b o t h the  parents and the p a t i e n t are so w i l l i n g t o take the a d v i c e "quack" who  o f f e r s them a  The  any  "cure".  second group o f p a t i e n t s are those who  expended more e f f o r t i n e s t a b l i s h i n g f r i e n d s h i p s , and achieved  of  a measure of success.  seem to have have  However, they cannot be  as happy, contented, out-going p e r s o n s .  The  described  f o l l o w i n g cases  i l l u s t r a t e the d i f f i c u l t i e s in,, s o c i a l r e l a t i o n s h i p s which t h i s group meets. (a) Miss X. i s a twenty-seven y e a r o l d g i r l whose . s e i z u r e s began i n i n f a n c y . As a c h i l d she l i v e d . i n an extremely p r o t e c t e d , and at the same time, r e j e c t i n g environment. L a t e r , she spent s e v e r a l years i n a mental i n s t i t u t i o n because her p a r e n t s , who were s e p a r a t e d , r e f u s e d to care f o r h e r . F o l l o w i n g her d i s c h a r g e from the h o s p i t a l , she came t o Vancouver and s i n c e t h a t time has h e l d s e v e r a l jobs as a messenger g i r l . P e r i o d i c a l l y she l o s e s her job because o f s e i z u r e s . M i s s X. cannot comfortably p a r t i c i p a t e i n group a c t i v i t i e s , because she f e e l s " d i f f e r e n t " . However, she does have one o r two c l o s e f r i e n d s . Since she has had l i t t l e experience i n e s t a b l i s h i n g c a s u a l f r i e n d s h i p s , she t r i e s too h a r d to a c q u i r e the f r i e n d s h i p of the few people whom she t h i n k s are a c c e p t i n g her. She s t a t e s h e r s e l f , t h a t she does not l i k e t o share her f r i e n d s . (b) M i s s L. i s a twenty-seven y e a r o l d Chinese g i r l - - whose s e i z u r e s began at the age of s i x t e e n y e a r s . P r i o r t o the appearance of the s e i z u r e s , Miss L. had p o l i o m y e l i t i s which l e f t her w i t h weakness i n her l e f t l e g and hand. Although Miss L . s s e i z u r e s are now c o n t r o l l e d , she i s most concerned and ashamed o f her i l l n e s s . Her c u l t u r e p a r t l y e x p l a i n s this. E p i l e p s y i s viewed w i t h h o r r o r by the Chinese people, who c o n s i d e r i s o l a t i o n and o s t r a c i s m the o n l y method of coping w i t h i t . Miss L. h e r s e l f , has many s u p e r s t i t i o n s about i t . For example, she' b e l i e v e s t h a t anything or anyone who i s a s s o c i a t e d w i t h her i s d e s t i n e d f o r d e s t r u c t i o n . She a t t r i b u t e s the death of two of her t e a c h e r s , to the f a c t t h a t they took a s i n c e r e i n t e r e s t i n her. 1  .  54 Miss L . i s a most ambitious g i r l . Despite her handicaps, she has h e l d a j o b as a c l e r k i n a g r o c e r y s t o r e , s t u d i e d her e n g l i s h p u b l i c s c h o o l grades by correspondence and i s now t a k i n g a b u s i n e s s course. She i s kept busy working a n d s t u d y i n g and s t a t e s t h a t she has no time f o r e r e c r e a t i o n . However, she does have some f r i e n d s and i n the past has had s e v e r a l b o y f r i e n d s , none of whom know about h e r e p i l e p s y . (c)  Miss J . , who i s t h i r t y - o n e y e a r s o f age has had e p i l e p s y s i n c e i n f a n c y and has been f r e e o f s e i z u r e s f o r approximately two y e a r s . As a c h i l d she l i v e d an extremely s h e l t e r e d l i f e and was n o t p e r m i t t e d t o l e a v e t h e home without b e i n g accompanied by a member o f h e r f a m i l y . As an a d o l e s c e n t she had no f r i e n d s other than a former s c h o o l t e a c h e r who was many y e a r s h e r s e n i o r .  ,  I n more recent y e a r s , as t h e frequency o f s e i z u r e s decreased, Miss J . was encouraged t o seek the f r i e n d s h i p o f o t h e r s . She j o i n e d s e v e r a l c l u b s , such as t h e Y.W.C.A. and the Weaver's G u i l d . Although she attended r e l i g i o u s l y , and people were l e a s a n t , she a c q u i r e d the f r i e n d s h i p o f none, he was looked upon a s being d i f f e r e n t from the o t h e r s . I n h e r search f o r f r i e n d s h i p , she began f r e q u e n t i n g the neighborhood bowling a l l e y and dance h a l l . She has made s e v e r a l acquaintances which her parents do n o t c o n s i d e r d e s i r a b l e . Although she i s anxious t o s a t i s f y h e r need f o r s o c i a l r e l a t i o n s h i p s , she d i s t r e s s e d by t h e constant "nagging" of h e r p a r e n t s .  f  The t h i r d group o f persons who experience d i f f i c u l t y i n s o c i a l r e l a t i o n s h i p s a r e those who a r e n o t l i k e d by o t h e r s because of  t h e i r aggressive, n e g a t i v i s t i c a t t i t u d e .  Mr. F.'s case i s  i l l u s t r a t i v e of t h i s pattern. (a) Mr. F. i s now t w e n t y - s i x y e a r s o f age. H i s major s e i z u r e s began a t the age o f s i x y e a r s , and although he has been f r e e o f s e i z u r e s d u r i n g f a i r l y l e n g t h y p e r i o d s throughout h i s l i f e , complete c o n t r o l o f s e i z u r e s has n o t been a c h i e v e d . Mr. F. was s u b j e c t t o a great d e a l o f t e a s i n g and abuse d u r i n g h i s s c h o o l y e a r s . He r e f u s e d t o a t t e n d s c h o o l because o f t h i s , upon the completion o f t h e f i f t h grade. He e x p e r i e n c e d r e j e c t i o n a t home.  55 His immediate r e a c t i o n t o any form o f f r u s t r a t i o n , took the form o f a temper tantrum. T h i s p a t t e r n p e r s i s t s and as a r e s u l t Mr. F. has few f r i e n d s . H i s a t t i t u d e seems t o be one o f , "Nobody l i k e s me or shows me any c o n s i d e r a t i o n J t h e r e f o r e , why should I be c o n s i d e r a t e o f o t h e r s . " The  cases used to i l l u s t r a t e the d i f f i c u l t i e s  encountered  i n s o c i a l r e l a t i o n s h i p s , p o i n t out the i n d i v i d u a l q u a l i t y of these difficulties.  Although s i m i l a r c h a r a c t e r i s t i c s of withdrawing  from s o c i e t y , or the development of n e g a t i v i s t i c a t t i t u d e s  may  appear i n a number of cases, the b a s i s f o r the development  of  these p a t t e r n s i s r a r e l y s i m i l a r . p a r e n t a l a t t i t u d e s , experiences  Handicaps other than e p i l e p s y ,  i n s c h o o l and  employment, c u l t u r a l  p a t t e r n s , and the type and frequency o f s e i z u r e s , a l l seem to determining  factors.  The m a t e r i a l suggests a l s o t h a t the  members of the.group who  older  have been s u b j e c t t o - s e i z u r e s f o r many  y e a r s , have t o a g r e a t e r extent accepted adjustment to i t . The  be  t h e i r handicap and made an  m a j o r i t y o f the persons i n t h i s group none-  t h e l e s s , are extremely unhappy about t h e i r l a c k of f r i e n d s . Employment f o r the e p i l e p t i c persons i n t h i s group, c o n s t i t u t e s a major problem.  Of the twenty-eight s i n g l e persons  i n the sample, only f i v e have been f a i r l y s t e a d i l y employed. even they have experienced years.  d u r i n g the past two  years.  of her own.  E i g h t people  and t h i r t e e n have not worked at a l l The men  who  have been employed have  l i t t l e t r a i n i n g - f o r s p e c i a l i z e d jobs.  as l a b o u r e r s .  two  r e c e n t l y r e c e i v e d money f o r  engaged i n a b u s i n e s s  have worked s p a s m o d i c a l l y  had  p e r i o d s o f i d l e n e s s d u r i n g the past  A s i x t h person .whose parents  o i l r i g h t s , i s now  But  The  m a j o r i t y have worked  Others have been employed as a hardware c l e r k , h o t e l  56 c l e r k , w a i t e r , logger and p o r t e r on a boat. f a c t o r y worker, messenger g i r l ,  The p o s i t i o n s o f  s a l e s c l e r k , ward a i d and house  maid, have been h e l d by the women who  have worked.  In most  cases, d i s m i s s a l accompanied the occurrence o f a s e i z u r e .  In  o t h e r s i t u a t i o n s , seasonal l a y - o f f s , which are f r e q u e n t i n the u n s k i l l e d employment f i e l d , were r e s p o n s i b l e f o r the d i s m i s s a l . I n some i n s t a n c e s , d i s s a t i s f a c t i o n w i t h the j o b , r e s u l t e d i n t h e p a t i e n t ' s r e f u s a l t o continue w i t h i t . p a t i e n t s , who  In the group of t h i r t e e n  have not worked during the past two  y e a r s , t e n do  not know what i t means to work or t o be f i n a n c i a l l y independent, A p a r t i a l e x p l a n a t i o n f o r t h i s i s t h a t n i n e o f the t e n p a t i e n t s are i n t e l l e c t u a l l y handicapped.  There are few f a c i l i t i e s i n  B r i t i s h Columbia, f o r the employment o f m e n t a l l y r e t a r d e d  persons.  Miss Y, the t e n t h person, i s not i n t e l l e c t u a l l y handicapped, but she does not have the use o f her l e f t  s i d e and has been t r e a t e d  as an i n v a l i d f o r many y e a r s .  S i x o f the t e n persons  s u b j e c t t o frequent s e i z u r e s .  T h i s has a l s o been a  are  still  determining  f a c t o r i n t h e i r i n a b i l i t y to undertake or f i n d employment. three people who  a t one  time e x p e r i e n c e d f i n a n c i a l independence  are at present unemployed f o r reasons a t i o n and frequency  The  of seizures.  One,  other than mental r e t a r d due t o a m e d i c a l c o n d i t i o n  o t h e r than e p i l e p s y , i s c o n s i d e r e d p h y s i c a l l y u n f i t f o r employment. The  second whose s e i z u r e s are now  c o n t r o l l e d i s so unsure o f  h i m s e l f , t h a t he makes an unfavourable In a d d i t i o n to h i s own  impression before employers.  e f f o r t s , the e f f o r t s of the N a t i o n a l  Employment S e r v i c e , have proven u n p r o d u c t i v e . p r e s e n t s an i n t e r e s t i n g employment problem.  The  third  case  57 (a) Mr. C. has been unemployed f o r a p e r i o d of f o u r - y e a r s , f o l l o w i n g b r a i n surgery done on an emergency b a s i s . S h o r t l y afterwards, t h e f i r s t s e i z u r e occurred, Mr. C. had p r e v i o u s l y h e l d jobs as a c l e r k i n a h o t e l and w a i t e r i n a b e e r - p a r l o u r . He was c o n s i d e r e d a capable employee. At present Mr. C, r e c e i v e s s o c i a l a s s i s t a n c e amounting t o $40.00 per month, l i v e s i n a t h i r d r a t e h o t e l , and eats most o f h i s meals w i t h h i s sisters. I n many r e s p e c t s he seems q u i t e content w i t h h i s l o t . He speaks o f h i s f e a r s o f undert a k i n g the k i n d o f work he has always done, because of the r i s k o f h a v i n g s e i z u r e s i n p u b l i c . Periodi c a l l y , when he has been f r e e o f s e i z u r e s f o r two or three months, he begins t o wonder i f he i s w e l l enough t o undertake a j o b . On s e v e r a l such o c c a s i o n s , on h i s way t o apply f o r a j o b , Mr. C. has had a s e i z u r e . The a n x i e t y a s s o c i a t e d w i t h employment seems t o b r i n g on s e i z u r e s . Examination o f t h e employment e x p e r i e n c e s o r l a c k o f experience of t h i s group o f p a t i e n t s , i n d i c a t e s t h a t a l a r g e number who are unemployed c o u l d work i f g i v e n t h e o p p o r t u n i t y . There a r e those who, because o f t h e i r l i m i t e d i n t e l l e c t u a l  ability,  the frequency of s e i z u r e s , t h e i r l a c k o f t r a i n i n g , t h e i r f e e l i n g s of i n s e c u r i t y i n meeting t h e o u t s i d e world and t h e i r l a c k o f f a i t h i n t h e i r a b i l i t y r e s u l t i n g out o f r e p e a t e d f a i l u r e s , cannot be employed i n the r e g u l a r labour market. d i f f i c u l t i e s which e p i l e p s y presents  These then, a r e t h e  to t h e s i n g l e persons  seeking  employment. P r i o r . t o a d i s c u s s i o n o f t h e problems which e p i l e p s y presents  to married persons, perhaps a d e s c r i p t i o n o f the f e e l i n g s  of t h e s i n g l e persons toward marriage would be i n order.  A large  number of both male and female p a t i e n t s express t h e i r d e s i r e t o be m a r r i e d .  The men, more than the women, speak o f t h e improb-  a b i l i t y of t h i s .  Although they t a l k about wanting t o marry and t o  53 " s e t t l e down the way  other people do", they cannot see  ever accomplishing t h i s . or t o f i n d a mate who  themselves  T h e i r i n a b i l i t y to h o l d . a steady job  w i l l be understanding and a c c e p t i n g of t h e i r  medical c o n d i t i o n , are mentioned  as. h i n d e r i n g f a c t o r s .  I t should  perhaps a g a i n be noted, t h a t the s e t t i n g from which the p a t i e n t s f o r t h i s study were s e l e c t e d , has i n f l u e n c e d the nature of t h e sample.  There would seem t o be a preponderance  of persons who  are  more l i k e l y to be unemployed, and l e s s a b l e to assume t h e respons i b i l i t i e s o f marriage.  The g i r l s seem more h o p e f u l about  chances o f marriage, but t h e r e are some who  their  wonder i f i t i s f a i r  to expect another person to share the r e s p o n s i b i l i t i e s o f t h e i r handicap.  Those whose s e i z u r e s are c o n t r o l l e d , have the  of d e c i d i n g when and how  t o d i s c u s s t h e i r medical c o n d i t i o n w i t h  members of the o p p o s i t e sex who Miss L., whose s i t u a t i o n was problem to work out.  problem  have shown an i n t e r e s t i n them.  d e s c r i b e d on page 53,  had  this  Because of her understanding o f the f e e l i n g s  o f C h i n e s e people toward e p i l e p s y , she decided not t o i n f o r m her male f r i e n d s about her i l l n e s s and simply r e f u s e d t h e i r p r o p o s a l s o f marriage.  Most o f the p a t i e n t s w i t h whom t h i s p o i n t was  dis-  cussed agree t h a t the p r o s p e c t i v e mate must be informed, r e g a r d l e s s o f the r i s k of t h e i r r e f u s a l t o accept the r e s p o n s i b i l i t y o f the i l l n e s s .  In summary, i t may be concluded t h a t the m a j o r i t y  o f the s i n g l e persons i n t h i s study would l i k e t o be m a r r i e d . However, some q u e s t i o n i t s a d v i s a b i l i t y and o t h e r s seem to have accepted i t s i m p r o b a b i l i t y .  Authorities in this f i e l d  agree,  t h a t marriage f o r the person w i t h e p i l e p s y must be d e c i d e d on an individual  basis.  59 Examination o f the c a s e - h i s t o r i e s o f t h e m a r r i e d persons i n t h i s study suggested d i s c u s s i o n o f the d i f f i c u l t i e s which e p i l e p s y p r e s e n t s t o :  (a) those persons who were s u b j e c t t o  s e i z u r e s p r i o r to marriage, and (b) those persons whose s e i z u r e s first  appeared a f t e r marriage.  The f i r s t  group c o n s i s t s o f e i g h t  persons and i n c l u d e s t h r e e s i n g l e g i r l s who a r e engaged t o be married.  There i s o n l y one man i n t h i s group.  The second  c o n s i s t s o f f o u r persons and i n c l u d e s only one woman. f a c t t h a t t h e r e i s a preponderance  group  The v e r y  o f men i n one group and o f  women i n the second group suggests that, the d i f f i c u l t i e s . e n c o u n t ered by these two groups a r e i n many r e s p e c t s d i s s i m i l a r . The mature persons i n the f i r s t  group probably r e a l i z e d  t h a t happiness and success i n marriage was t o a l a r g e extent dependent handicap. let  upon the a t t i t u d e o f the p r o s p e c t i v e mate, toward t h e S i n c e the m a j o r i t y o f persons i n t h i s group a r e women,  us c o n s i d e r some o f the q u e s t i o n s the e p i l e p t i c woman might  ask h e r s e l f b e f o r e d e c i d i n g upon marriage w i t h a p a r t i c u l a r person. (1) What does my f u t u r e mate know about e p i l e p s y ? What does he f e e l about i t ? W i l l t h e occurrence of a s e i z u r e be u p s e t t i n g to him? (2) Can he, and i s he w i l l i n g to assume t h e f i n a n c i a l r e s p o n s i b i l i t y o f my i l l n e s s ? (3) What does he t h i n k about having c h i l d r e n ? Will he be f e a r f u l about t a k i n g the r i s k o f producing an e p i l e p t i c c h i l d ? Does he c o n s i d e r my s e i z u r e s s u f f i c i e n t l y w e l l c o n t r o l l e d t o enable me t o care f o r a c h i l d ? A n a l y s i s o f the case h i s t o r i e s o f t h e e i g h t p a t i e n t s suggest t h a t little  d i s c u s s i o n r e g a r d i n g the handicap o c c u r r e d p r i o r t o the  marriage.  The f o l l o w i n g cases a r e p r e s e n t e d t o i l l u s t r a t e  some o f  60 t h e d i f f i c u l t i e s which can r e s u l t  out of t h i s .  (a) Mrs. J . m a r r i e d an american s o l d i e r a t the age o f twenty-one y e a r s . She has been m a r r i e d f o r approximately t h r e e y e a r s and has l i v e d s t e a d i l y w i t h h e r husband f o r l e s s than a y e a r , s i n c e h i s d i s c h a r g e from t h e army. Although she has not openly expressed d i s s a t i s f a c t i o n w i t h h e r marriage, t h e r e a r e i n d i c a t i o n s o f unhappiness. Examination o f h e r developmental h i s t o r y suggests t h a t Mrs. J . was probably not ready t o assume the r e s p o n s i b i l i t i e s o f marriage. Mrs. J . i s the second youngest o f a f a m i l y o f f o u r c h i l d r e n who were r a i s e d by a widowed mother. There i s a long h i s t o r y o f i l l n e s s e s i n the f a m i l y . At t h e age o f t h i r t e e n , Mrs. J . developed e p i l e p s y and because of t h e s i d e r e a c t i o n s of her medicine stopped s c h o o l a t t h a t time. She s t a t e s t h a t she remained at home, because o f t h e f r e q u e n c y of s e i z u r e s , d u r i n g the g r e a t e r p a r t of her a d o l e s cence. Her mother was h e r c h i e f companion. O c c a s i o n a l l y , h e r young b r o t h e r took her t o a movie o r a dance. As she approached her t w e n t i e s , ' a g r e a t e r measure of c o n t r o l o f s e i z u r e s was a c h i e v e d and she was a b l e t o f i n d a temporary j o b . She a l s o made more attempts to mingle w i t h young people. I t was a t t h i s time t h a t she met her husband. Since Mrs. J . has not spoken about h e r reason f o r marrying her husband, t h e r e i s no way o f knowing this. The f a c t that she had few f r i e n d s , t h e glamour o f a uniform, t h e s e c u r i t y o f f i n a n c i a l support, may have been d e t e r m i n i n g f a c t o r s . She speaks o f her husband as an easy-going, c h e e r f u l , ood-natured person. Her mother however, d e s c r i b e s im as s e l f i s h and i r r e s p o n s i b l e . I n her o p i n i o n he has i n d i c a t e d h i s i r r e s p o n s i b i l i t y i n h i s h a n d l i n g of* f i n a n c i a l matters, h i s a t t i t u d e toward her daughter's i l l n e s s , and h i s behaviour toward his child. She s t a t e s t h a t he has d i s c u s s e d plans f o r d i v o r c e w i t h f r i e n d s , but has n o t mentioned i t to h i s wife.  f  P r i o r t o the marriage, Mrs. J . ' s i l l n e s s was e x p l a i n e d t o Mr. J . by her d o c t o r . Mr. J . i n d i c a t e d t h a t , s u p e r f i c i a l l y at l e a s t , he understood and was w i l l i n g t o assume the r e s p o n s i b i l i t i e s a s s o c i a t e d with i t . Mrs. J . comments t h a t the s e i z u r e s , which now occur approximately once a month, do n o t seem to cause him any a n x i e t y . However, Mrs. J . i s h e r s e l f q u i t e d i s t u r b e d about them because of t h e  61 d i f f i c u l t i e s she i s encountering w i t h h e r s i x t e e n month o l d daughter. S i n c e the c h i l d becomes most upset when a s e i z u r e o c c u r s , Mrs. J . i s a n x i o u s l y a w a i t i n g t h e time when the c h i l d w i l l be o l d enough t o understand and accept an e x p l a n a t i o n o f the i l l n e s s . I t seems p o s s i b l e that Mrs. J . f e e l s g u i l t y about having had a c h i l d s i n c e she arranged t o be s t e r i l i z e d immediately a f t e r i t s birth. Her a t t i t u d e toward the youngster i s also suggestive of t h i s . She w o r r i e s e x c e s s i v e l y about the youngster's h e a l t h and seems to need reassurance t h a t she has not produced an i m p e r f e c t l y endowed c h i l d . There i s no evidence to i n d i c a t e t h a t e i t h e r Mr. or Mrs. Jones thought about t h e i m p l i c a t i o n s o f t h e i l l n e s s upon t h e i r o f f s p r i n g . Nor was t o o much thought g i v e n to the • s i g n i f i c a n c e o f t h e i l l n e s s i n r e l a t i o n to t h e i r own happiness. Mrs. J . may have seen marriage as a s o l u t i o n t o the d i f f i c u l t i e s she encountered as a s i n g l e person*..-* The extent t o which t h i s has proven s u c c e s s f u l i s q u e s t i o n a b l e . S i n c e her husband's d i s c h a r g e from t h e army, he has not been a b l e t o f i n d steady employment. Nor i s he able t o take her w i t h him t o t h e U n i t e d S t a t e s and thus b e n e f i t from the g r a t u i t i e s made a v a i l a b l e t o him from h i s war e x p e r i e n c e . Immigration r e g u l a t i o n s prevent her entrance i n t o the U n i t e d S t a t e s . Consequently, her search f o r f i n a n c i a l s e c u r i t y has n o t been met. Although she has the companionship of her husband, she has few f r i e n d s . Her e a r l i e r experience has not taught her t h e a r t of g e t t i n g a l o n g w i t h o t h e r s . Nor i s her husband a p a r t i c u l a r l y s o c i a b l e person. She has the added r e s p o n s i b i l i t y of a c h i l d , who at times causes her a great d e a l ' of worry. Also,the s h a r i n g o f r e s p o n s i b i l i t i e s , which she probably expected i n marriage has not m a t e r i a l i z e d . She has t h e r e f o r e r e g r e s s e d t o her former p a t t e r n o f depending upon her mother. I n s h o r t , marriage does not seem to have met Mrs. J.'s needs. She seems to have made l i t t l e progress i n her a b i l i t y to meet t h e problems o f adulthood. Mrs. I . who i s now twenty-three, has had both major and minor s e i z u r e s s i n c e she was-ten y e a r s of age. She spent f i v e y e a r s o f h e r l i f e i n t h e P r o v i n c i a l Mental H o s p i t a l and when she was s u c c e s s f u l i n e s c a p i n g from the i n s t i t u t i o n , she determined t o marry. I t s h o u l d be n o t e d t h a t she was i n s t i t u t i o n a l i z e d because o f h e r s e i z u r e s and not h e r mental s t a t u s .  62 C o n s i d e r i n g Mrs. I.'s background and her present emotional s t a t u s , i t seems l i k e l y t h a t the o n l y type of person t o whom she would a p p e a l , would be a person who was h i m s e l f immature. Mrs. I . married a man who has had a "nervous breakdown". He has always had d i f f i c u l t y i n o b t a i n i n g employment and as a r e s u l t cannot p r o v i d e f o r the b a s i c necess i t i e s o f the household. When Mrs. I.'s c h i l d was born, she s t a t e d she always wanted a c h i l d , "of my very own, so t h a t I might g i v e i t the t h i n g s I missed as a c h i l d " . Because of the f i n a n c i a l i n s e c u r i t y i n the home, the immaturity of both the p a t i e n t and her husband, and the frequency of Mrs. I.'s s e i z u r e s , one would q u e s t i o n the l i k e l i h o o d of any c h i l d o b t a i n i n g the s e c u r i t y which i s i t s r i g h t . I t seems probable t h a t i n t h i s p a r t i c u l a r case, the p a t i e n t has been i n t e n t upon meeting her own emotional needs with l i t t l e c o n s i d e r a t i o n of the r e s p o n s i b i l i t i e s o f adulthood or parenthood. More emphasis has been p l a c e d upon p o i n t i n g out the i m p l i c a t i o n s of the i l l n e s s to the t h r e e g i r l s who be m a r r i e d and the one g i r l who Miss F. who  married w i t h i n the l a s t y e a r .  i s engaged t o be married has g i v e n some thought  i m p l i c a t i o n s of her i l l n e s s . how  are engaged t o  Although t h e r e i s no way  t o the  of knowing  t h i s w i l l a f f e c t h e r marriage, i t seems probable t h a t the  chances o f happiness  i n marriage are g r e a t e r f o r her than the  persons whose s i t u a t i o n s have been d e s c r i b e d . (c) M i s s F. has known her f i a n c e f o r approximately a - year and has been engaged f o r two months. She has not made d e f i n i t e p l a n s f o r her marriage s i n c e she i s w a i t i n g t o see the measure o f c o n t r o l which can be achieved w i t h the new m e d i c a t i o n which i s b e i n g tried. She and her f i a n c e have d i s c u s s e d the f i n a n c i a l r e s p o n s i b i l i t y of her i l l n e s s and he f e e l s t h a t he i s a b l e t o assume t h i s r e s p o n s i b i l i t y . In d i s c u s s i n g the a d v i s a b i l i t y of having c h i l d r e n they agreed that they wished t o have c h i l d r e n d e s p i t e the r i s k o f producing an e p i l e p t i c c h i l d . They r e c o g n i z e d t h a t s i n c e her a b i l i t y to l o o k a f t e r a c h i l d would depend upon the frequency o f her s e i z u r e s , they would be wise t o be sure about t h i s before p l a n n i n g f o r a c h i l d .  two  63 Arrangements have been made f o r the f i a n c e t o d i s c u s s Miss F.'s c o n d i t i o n w i t h her p h y s i c i a n and a l s o f o r him t o have an E.E.G. t e s t . The r e s u l t s o f the t e s t w i l l be h e l p f u l t o t h e . p h y s i c i a n i n a d v i s i n g them r e g a r d i n g h a v i n g children.1° Miss F.»s f i a n c e has read s e v e r a l books, and i s p l a n n i n g t o a t t e n d the evening meetings i n o r d e r t o f a m i l i a r i z e h i m s e l f w i t h the f a c t s about e p i l e p s y . He seems fond o f Miss F. and s i n c e r e l y i n t e r e s t e d i n doing what i s b e s t f o r her. The m a t e r i a l i n t h i s sample does not p r o v i d e c o n c l u s i v e evidence r e g a r d i n g the a d v i s a b i l i t y o f marriage epilepsy.  f o r persons  with  F i n a n c i a l problems a r e present i n v a r y i n g degrees i n  each o f the e i g h t cases.  However, t h i s i s to be expected i n t h i s  sample.  M a t u r i t y and r e a d i n e s s t o assume the r e s p o n s i b i l i t i e s o f  marriage  seems l a c k i n g i n the m a j o r i t y o f t h e members o f the group.  C o n s i d e r a t i o n f o r the r e s p o n s i b i l i t i e s a s s o c i a t e d w i t h t h e i l l n e s s seems a l s o t o be l a c k i n g . married e p i l e p t i c persons  However, measuring the l o t o f the a g a i n s t t h a t of t h e s i n g l e persons, i t  seems l i k e l y t h a t the former group have a c h i e v e d a g r e a t e r degree of happiness.  y  The person who develops  e p i l e p s y f o l l o w i n g marriage,  experiences the f e a r s and p r e j u d i c e s w e l l known t o t h e s i n g l e epileptic  person.  However, h i s problems are somewhat  different.  His mate i s there i n some cases t o h e l p share h i s - d i f f i c u l t i e s and i n o t h e r s t o magnify them.  18  I n the case of a man, meeting the  Persons who do not present c l i n i c a l symptoms o f s e i z u r e s , may n e v e r t h e l e s s have an abnormal E.E.G. t r a c i n g . S i n c e both parents c o n t r i b u t e t o t h e i n h e r e n t q u a l i t i e s o f an o f f s p r i n g , i t i s advantageous to know whether both p a r e n t s , or o n l y one may be t r a n s m i t t i n g t o the c h i l d , the p r e d i s p o s i t i o n t o seizures.  64  f i n a n c i a l r e s p o n s i b i l i t i e s of an e s t a b l i s h e d household r e a l concern.  The a t t i t u d e s of c h i l d r e n toward the  parent can a l s o be d i s t u r b i n g . to  i s a very-  handicapped  The f o l l o w i n g cases are  presented  i l l u s t r a t e these p o i n t s . (a) Mr. L., who i s t h i r t y - s i x y e a r s o f age developed e p i l e p s y a t the age of twenty-seven. P r i o r t o the development o f s e i z u r e s , he was employed as a c i v i l i a n t e l e g r a p h i s t i n the R.C.A.F. D e s p i t e frequent p e t i t mal s e i z u r e s , he was a b l e to c a r r y on w i t h h i s job f o r some time. However, when the major s e i z u r e s began, he was compelled to g i v e i t up. Mr. L. has had e x t e n s i v e surgery s i n c e t h a t time and as a r e s u l t has a v i s u a l handicap i n a d d i t i o n to the e p i l e p s y . O b t a i n i n g employment has been most d i f f i c u l t . His wife holds a p a r t time job t o supplement the h e l p they o b t a i n from Mr. L.* s p a r e n t s . Mr. L.'s w i f e i s a sympathetic, woman who has g i v e n h e r husband and support he needs. Although at the same time he r e s e n t s the must depend upon h e r .  understanding the encouragement he a p p r e c i a t e s i t , extent to which he  (b) Mr. A., who i s f o r t y - s i x y e a r s of age, had h i s f i r s t s e i z u r e two y e a r s ago d u r i n g a p e r i o d o f f i n a n c i a l s t r e s s f o r the f a m i l y . S i n c e t h a t time s e i z u r e s have o c c u r r e d only when he was w o r r i e d , o r when he l e t h i m s e l f run out of m e d i c a t i o n . A l though he has been f r e e of s e i z u r e s f o r a p e r i o d o f e i g h t t o n i n e months, he has not been able t o f i n d work. The f a m i l y continues t o r e c e i v e s o c i a l assistance. The a t t i t u d e s of Mrs. A. and the c h i l d r e n have been d e t r i m e n t a l to Mr. A.'s g e n e r a l f e e l i n g of w e l l b e i n g . Mrs. A. knows l i t t l e about e p i l e p s y and u n f o r t u n a t e l y i s more prone t o b e l i e v e the f o l k t a l e s a s s o c i a t e d w i t h i t , than the t r u t h . Both she and the c h i l d r e n f e a r the s e i z u r e s and have succeeded i n making Mr. A. f e e l t h a t h e . i s a strange b e i n g who I s not possessed o f a l l h i s senses. In the p a s t , Mrs. A. has i n s i s t e d upon managing the a f f a i r s of the f a m i l y . Consequently, Mr. A. who was b a s i c a l l y a dependent person, depended upon her perhaps more than the average husband depends upon h i s w i f e . As a r e s u l t , Mr. A. has found h i s w i f e ' s present a t t i t u d e toward him d i s t r e s s i n g and beyond h i s comprehension.  0  65  (c) Mr. B.., t h i r t e e n y e a r s ago, at the age o f t h i r t y , - - had h i s f i r s t major e p i l e p t i c s e i z u r e . He had been m a r r i e d f o r s e v e r a l y e a r s and had a t h r e e y e a r o l d son. Having completed a u n i v e r s i t y course i n agronomy, he was employed as a s c h o o l t e a c h e r i n a small town i n the i n t e r i o r of B r i t i s h Columbia. S i n c e the s e i z u r e s f i r s t appeared o n l y at n i g h t , he was able to c a r r y on w i t h t h i s job f o r s e v e r a l years. He was i n constant f e a r t h a t someone would f i n d out about h i s i l l n e s s . The f i r s t occurrence o f a s e i z u r e i n the c l a s s - r o o m r e s u l t e d i n h i s discharge. From then on, a s e r i e s of jobs and periodic dismissals followed. As the number of d i s m i s s a l s i n c r e a s e d , Mr. B.'s p e r s o n a l i t y became i n c r e a s i n g l y u n p l e a s a n t . Consequently some o f h i s d i s m i s s a l s were not the r e s u l t of s e i z u r e s , s i n c e t h e r e were times when he was f r e e of s e i z u r e s f o r a lengthy p e r i o d , but r a t h e r h i s n e g a t i v i s t i c manner. The f e a r of d i s c o v e r y and a l s o h i s f e e l i n g s r e g a r d i n g . t a k i n g jobs which he c o n s i d e r e d beneath him, i n part e x p l a i n h i s b e h a v i o u r . Mr. B.'s wife although understanding of her husband's i l l n e s s , i s . q u i t e n a t u r a l l y d i s t r e s s e d about it. P r i o r t o the b i r t h o f t h e i r second c h i l d , she was p a r t i c u l a r l y anxious about the h e r e d i t y aspect of the i l l n e s s . At the age o f t h r e e , the youngster had a s e i z u r e during an i l l n e s s . Although d i s t u r b e d b y - i t , - s h e r e f u s e d to accept the p o s s i b i l i t y o f a d i a g n o s i s of e p i l e p s y . In a d d i t i o n to t h i s worry, and concern about t h e i r f i n a n c i a l i n s e c u r i t y , Mrs. B. has the added r e s p o n s i b i l i t y o f e x p l a i n i n g the , i m p l i c a t i o n s o f the i l l n e s s to the c h i l d r e n . They do not understand t h e i r f a t h e r ' s frequent p e r i o d s o f i r r i t a b i l i t y , o r the reason why t h e i r parents l i v e a restricted social l i f e . They are c o n s t a n t l y reminded of the i n f l u e n c e o f t h e i r behaviour upon t h e i r father's health. Consequently, the t e n s i o n i n the household seems to be at a high p i t c h at a l l t i m e s . These three  cases c l e a r l y i l l u s t r a t e the  unhappiness^hich  e p i l e p s y b r i n g s to f a m i l i e s .  For some f a m i l i e s , i t s appearance  introduces  For  s e r i o u s problems.  seriousness  o t h e r s , i t merely i n t e n s i f i e s  the  o f e x i s t i n g problems.  Presentation  o f the s o c i a l s i t u a t i o n s o f the s i n g l e  m a r r i e d persons i n t h i s study, has  i n d i c a t e d the magnitude and  and the  66 d i v e r s i t y of problems which present themselves t o e p i l e p t i c persons.  The r e a c t i o n s o f t h e members o f t h i s group t o t h e i r  handicap,  i s so v a r i e d , t h a t i t seems l o g i c a l t o assume t h a t the  h e l p they are g i v e n must be p r o v i d e d on an i n d i v i d u a l i s t i c b a s i s . Examination  o f t h e k i n d s o f r e q u e s t s f o r h e l p which have come t o  the medical s o c i a l worker i n the s e i z u r e c l i n i c , and the h e l p p r o v i d e d v e r i f i e s t h i s assumption.  Table 2 i n d i c a t e s t h e kinds o f  r e q u e s t s f o r h e l p made t o the medical  s o c i a l worker.  S o c i a l h i s t o r y requested  ."  Help p a t i e n t w i t h emotional  17  problems  •  12  Help p a t i e n t f i n d employment  £  I n t e r p r e t e p i l e p s y t o parents o r r e l a t i v e s  3  Help p a t i e n t o b t a i n f i n a n c i a l h e l p  2  M e d i c a l h e l p f o r p a t i e n t requested from s o c i a l agency i n the community  2  F o l l o w up o f p a t i e n t upon discharge from h o s p i t a l  2  Help p a t i e n t accept medical treatment  1  Help p a t i e n t f i n d r e c r e a t i o n a l o u t l e t s Help c h i l d r e n understand  .........  parent's i l l n e s s  1 1  Table 2  With t h i s group o f p a t i e n t s , as w i t h the' c h i l d r e n , the g r e a t e s t number o f r e f e r r a l s were made i n terms o f requests f o r i n f o r m a t i o n about t h e p a t i e n t .  I n many i n s t a n c e s i t served as t h e  i n i t i a l step i n e s t a b l i s h i n g a casework ' r e l a t i o n s h i p which r e s u l t e d  -  67 in  the p r o v i s i o n of v a r i o u s  kinds o f h e l p t o t h e p a t i e n t .  The  emotional problems of the twelve p a t i e n t s f o r whom help was r e quested, were v a r i e d . illness,  P a r e n t a l a t t i t u d e s , f e e l i n g s r e g a r d i n g the  and an u n s a t i s f a c t o r y m a r i t a l s i t u a t i o n were f r e q u e n t l y  t h e reasons f o r the p a t i e n t ' s a n x i e t y . the c h i l d r e n , help has been p r o v i d e d need, t h e resources  With t h i s group, as w i t h  on t h e b a s i s of the p a t i e n t ' s  a v a i l a b l e t o meet these needs, and the  p a t i e n t ' s a b i l i t y t o use the s e r v i c e a v a i l a b l e .  The casework  r e l a t i o n s h i p w i t h t e n of t h e t h i r t y - e i g h t p a t i e n t s was concluded following the i n i t i a l diagnostic interviews. the  I t was decided  that  s e r v i c e given had met t h e p a t i e n t ' s immediate need and a l s o  t h a t the p a t i e n t c o u l d probably g a i n l i t t l e work r e l a t i o n s h i p .  The extent  from a c o n t i n u i n g  case-  o f the p a t i e n t ' s d e t e r i o r a t i o n , h i s  s a t i s f a c t i o n w i t h h i s s i t u a t i o n , and t h e l e n g t h o f h i s i l l n e s s were determining f a c t o r s .  S e r v i c e to t h i s group o f people c o n s i s t e d o f :  (a) O b t a i n i n g a s o c i a l h i s t o r y f o r t h e use of t h e physician. (b) A c t i n g as l i a i s o n between agency i n t h e community and the p h y s i c i a n ... i . e . C h i l d r e n ' s A i d S o c i e t y , N a t i o n a l Employment S e r v i c e , C i t y S o c i a l S e r v i c e Department. (c) Arranging f o r p a t i e n t ' s committal t o the P r o v i n c i a l . Mental H o s p i t a l ... d i s c u s s i n g plans w i t h r e l a t i v e s who were d i s t u r b e d by t h e n e c e s s i t y of such p l a n n i n g . (d) E n a b l i n g p a t i e n t t o v e r b a l i z e h i s f e e l i n g s about a s p e c i f i c problem which presented i t s e l f and h e l p i n g decide upon the a l t e r n a t i v e s a v a i l a b l e to him i n meeting the d i f f i c u l t y , (e) D i s c u s s i n g e p i l e p s y with p a t i e n t ' s r e l a t i v e s , thus . a l l e v i a t i n g some of t h e i r a n x i e t i e s about the patient's condition. The  f o l l o w i n g case i s one which was f o l l o w e d by the  68  • t  m e d i c a l s o c i a l worker, only long, enough t o e s t a b l i s h a d i a g n o s i s o f the p a t i e n t ' s s o c i a l  situation.  (a) Mr. K. whose s e i z u r e s began a t the age of e i g h t e e n , - i s now f o r t y - o n e y e a r s o f age. He l e f t home s h o r t l y a f t e r the onset of s e i z u r e s and s i n c e t h a t time has wandered. He s t a t e s t h a t he has to have a s e i z u r e about twice a y e a r , " i n order to r e l i e v e the pressure i n my head." W e l l i n advance, he i s aware of when t h i s i s l i k e l y t o o c c u r and g i v e s up h i s job t o prevent having the s e i z u r e on t h e j o b . He i s not c o n s c i e n t i o u s about t a k i n g h i s medication and i s r e l u c t a n t t o g i v e up a l c o h o l . He has been a d v i s e d by the p h y s i c i a n , that t h e s e i z u r e s c o u l d be comp l e t e l y c o n t r o l l e d i f he c o u l d be c o - o p e r a t i v e about the medication and the a l c o h o l . F o l l o w i n g s e v e r a l d i s c u s s i o n s with Mr. K., i t was obvious that although he blames the s e i z u r e s f o r h a v i n g to c o n s t a n t l y seek out new j o b s , he works a t a job o n l y long enough to meet h i s immediate needs. He enjoys a l c o h o l and a l s o h i s wandering l i f e . C o n t r o l o f s e i z u r e s would n e c e s s i t a t e changes i n t h e p a t t e r n o f l i f e which he has e s t a b l i s h e d f o r himself. He does not seem prepared t o do t h i s at t h i s stage o f h i s l i f e . I n t h i s c a s e , the m e d i c a l s o c i a l worker c o n t r i b u t e d t o the treatment by b r i n g i n g t o the p h y s i c i a n , i n f o r m a t i o n which i n c r e a s e d h i s u n d e r s t a n d i n g o f Mr. K.'s t o t a l s i t u a t i o n . Since Mr. K. i s q u i t e content with the adjustment he has made to h i s handicap, i t seems p o s s i b l e t h a t e f f o r t s t o c o n t r o l the s e i z u r e s , would be more d i s t r e s s i n g t o him than t o l e t him have h i s s e i z u r e s . The  f o l l o w i n g cases a r e presented t o i l l u s t r a t e the  v a r i e t y o f s e r v i c e s made a v a i l a b l e t o the r e m a i n i n g twenty-eight patients. (a) Mr. B.'s s i t u a t i o n i s b r i e f l y d e s c r i b e d on page 65. The p h y s i c i a n , i n r e f e r r i n g Mr. B. t o t h e medical s o c i a l worker, suggested that e f f o r t s be made t o f i n d employment f o r Mr. B. F o l l o w i n g a two month w a i t i n g p e r i o d , during which time Mr. B. was a b l e t o o b t a i n temporary employment, he was f i n a l l y p l a c e d i n a j o b by t h e s p e c i a l placement d i v i s i o n o f the N a t i o n a l Employment S e r v i c e . Mr. B. was r e l i e v e d t o l e a r n t h a t although h i s employer was informed o f h i s handicap, he was n e v e r t h e l e s s  69 w i l l i n g t o accept him. Except f o r t h e i n i t i a l i n t e r v i e w , t h e r e were few o p p o r t u n i t i e s t o t a l k w i t h Mr. B. s i n c e he was,employed o r busy seeking employment. Mrs. B. who was t a k i n g her young daughter t o the H e a l t h Centre f o r C h i l d r e n was i n t e r v i e w e d on numerous.occasions. She commented on the h e l p she experienced out of.being, able t o d i s c u s s her husband's i l l n e s s w i t h another, person who seemed to understand. The few acquaintances they have, know n o t h i n g about h e r husband's i l l n e s s . . I n t h e past she found h e r s e l f t e l l i n g "white l i e s " i n o r d e r t o be sure t h a t no one found out about i t . Because d i s c u s s i o n of e p i l e p s y i s u p s e t t i n g t o Mr. B., she has kept her thoughts t o h e r s e l f . At times she f e l t the burdens o f h i s i l l n e s s were more than she c o u l d endure. On one o c c a s i o n she commented t h a t , " I t i s a n i c e f e e l i n g .to,know t h e r e a r e others who a r e i n t e r e s t e d and w i l l i n g to share the r e s p o n s i b i l i t y w i t h you." Steady employment f o r Mr. B., attendance a t t h e evening group meetings,, together w i t h t h e r e assurance Mrs. B. o b t a i n e d out o f the d i s c u s s i o n s w i t h t h e s o c i a l worker, have brought about a change of a t t i t u d e on the p a r t o f Mrs. B. She h e r s e l f s t a t e s , because she i s l e s s anxious about keeping h e r husband's i l l n e s s a s e c r e t , and a l s o about the p o s s i b i l i t y o f her c h i l d r e n - d e v e l o p i n g e p i l e p s y , the g e n e r a l atmosphere a t home has improved. In t h i s case t h e medical s o c i a l worker p r o v i d e d d i r e c t h e l p t o t h e p a t i e n t by o b t a i n i n g t h e s e r v i c e o f an agency i n the community. Indirectly, Mr. B. b e n e f i t t e d from the change i n a t t i t u d e on the p a r t o f h i s w i f e . Interviews with t h e s o e i a l worker not o n l y served t o i n c r e a s e h e r unders t a n d i n g o f e p i l e p s y , but also, t o serve as a s a f e t y - v a l v e f o r her pent-up f e e l i n g s . ,Miss J.'s s i t u a t i o n i s d e s c r i b e d on page 54. When Miss J . was f i r s t i n t r o d u c e d t o the m e d i c a l s o c i a l worker, she was a withdrawn, and r e s e n t f u l person who was completely dominated by h e r f a m i l y . S e v e r a l i n t e r v i e w s o c c u r r e d b e f o r e Miss J . f e l t s u f f i c i e n t l y c o n f i d e n t . i n t h e s o c i a l worker t o v e r b a l i z e h e r f e e l i n g s about her handicap and t h e p r o t e c t i v e , a t t i t u d e o f her p a r e n t s . She was encouraged t o t h i n k of ways she might enable her parents t o understand h e r need t o be more independent , When an o p p o r t u n i t y presented i t s e l f , the s o c i a l worker e x p l a i n e d t o the p a r e n t s how many  70 handicapped persons needed encouragement i n t r y i n g t o meet the problems o f adulthood with l i m i t e d h e l p from o t h e r s . She added t h a t i n c h r o n i c i l l ness, p a t i e n t s were i n c l i n e d to c l i n g t o o t h e r s f o r support, because of t h e i r l a c k of c o n f i d e n c e i n t h e i r own a b i l i t y . Throughout the months t h a t f o l l o w e d , both Miss J . and her parents r e q u i r e d reassurance about Miss J.'s attempts at independence. Miss J . has become a d i f f e r e n t person. Formerly, she was withdrawn, s u b s e r v i e n t , and inwardly r e s e n t f u l . At p r e s e n t , she i s o u t g o i n g , aggress i v e and a t times openly h o s t i l e . In many r e s p e c t s she i s a h a p p i e r person. However, she r e q u i r e s help i n meeting her d i f f i c u l t i e s w i t h a g r e a t e r measure of o b j e c t i v i t y and calmness. Formerly, by remaining at home, she r a r e l y had o c c a s i o n to f a c e an uncomfortable s o c i a l s i t u ation Now she must l e a r n t o cope w i t h such a s i t u a t i o n without becoming d i s c o u r a g e d or openly h o s t i l e . A l s o , s i n c e her parents are e l d e r l y people who probably are l i m i t e d i n t h e i r a b i l i t y t o change, Miss J . r e q u i r e s h e l p i n d e c i d i n g what concessions she w i l l have t o make i f she i s to l i v e c o m f o r t a b l y i n t h e i r home. ;  9  This case i l l u s t r a t e s the way i n which the medical s o c i a l worker, although p r o v i d i n g l i t t l e i n the way of m a t e r i a l or environmental h e l p to persons w i t h e p i l e p s y , can n e v e r t h e l e s s g i v e them t h e encouragement and support necessary t o h e l p them h e l p themselves. T h i s p a r t i c u l a r p a t i e n t benef i t t e d from the medical s o c i a l worker's attempts to h e l p the p a r e n t s g a i n more understanding of the p a t i e n t ' s needs.'- T h i s case a l s o i l l u s t r a t e d how a l o n g term r e l a t i o n s h i p must be c a r r i e d on i f s a t i s f a c t o r y changes i n a t t i t u d e s are t o o c c u r . M i s s J . has gone from one extreme t o t h e other and i t may take months and perhaps years before she i s able t o adopt a "middle way". (c) Miss F.'s plans f o r marriage are d e s c r i b e d on - page 6 2 . A year ago, when Miss F. who had a t t e m p t e d . s u i c i d e , was brought t o t h e p s y c h i a t r i c ward of the h o s p i t a l s her p h y s i c i a n r e q u e s t e d the medical s o c i a l worker's h e l p i n o b t a i n i n g the c o - o p e r a t i o n of both t h e p a t i e n t and her p a r e n t s . He had known them i n p r i v a t e p r a c t i c e f o r approximately s i x y e a r s , and found i t i m p o s s i b l e t o g a i n t h e i r i n t e l l i g e n t p a r t i c i p a t i o n i n treatment.  71 The i n i t i a l i n t e r v i e w s w i t h each o f the parents was e x p l a i n e d on the b a s i s o f wanting to d i s c u s s w i t h them, the way i n which the d o c t o r , t h e medical s o c i a l worker and they c o u l d h e l p t h e i r daughter become a h a p p i e r person. D i s c u s s i o n with t h e parents r e v e a l e d the f o l l o w i n g i n f o r m a t i o n r e g a r d i n g t h e p a t i e n t ' s background. Miss F., t h e e l d e s t o f t h r e e daughters was r a i s e d i n a home where t e n s i o n a r i s i n g out o f an u n s a t i s f a c t o r y m a r i t a l adjustment, e x i s t e d f o r many y e a r s . As a s m a l l c h i l d , Miss F. was c o n s i d e r e d very grown up f o r her y e a r s . She was extremely t i d y about h e r s e l f and extremely w i l l i n g t o h e l p w i t h the household t a s k s . J u s t b e f o r e t h e onset o f both major and minor s e i z u r e s a t the age o f t h i r t e e n , Miss F. vowed t h a t she would do n o t h i n g f o r anyone i n t h e household. Both h e r parents were working and seemed t o be depending upon her to , do; the h o u s e - c l e a n i n g . Miss F. f e l t t h a t the mother favoured the s i s t e r , two y e a r s h e r junior. She was c o n s i d e r e d t o be c a p a b l e , a t t r a c t i v e and more l i k e a b l e . The t e n s i o n e x i s t i n g i n the home was m a g n i f i e d manyfold by the onset o f Miss F.'s s e i z u r e s . D e s p i t e the attempts o f t h e p h y s i c i a n , n e i t h e r Miss F. n o r her parents c o u l d be convinced o f t h e b e n e f i t s d e r i v e d out o f t h e m e d i c a t i o n . The s e i z u r e s p e r s i s t e d and Miss F. began e x p e r i e n c i n g more and more d i f f i c u l t y i n s c h o o l . S i n c e the m a j o r i t y of h e r s e i z u r e s were o f the p e t i t mal type, her t e a c h e r s were n o t aware of her handicap. She p r e f e r r e d not t o t e l l them anything about i t . F i n a l l y f o l l o w i n g an argument with h e r s c h o o l p r i n c i p a l who was t r y i n g to d i s c o v e r the explanat i o n f o r i n c r e a s i n g d i f f i c u l t y , she d e c i d e d t o stop s c h o o l . She then made s e v e r a l attempts t o work, but was asked t o l e a v e a f t e r h e r f i r s t s e i z u r e o c c u r r e d . The time she spent a t home was devoted t o l i s t e n i n g t o r e c o r d s , r e a d i n g books o r simply day-dreaming. She made fewer attempts t o see h e r f r i e n d s o r to make new a c q u a i n t a n c e s . She became more and more convinced o f h e r worthl e s s n e s s and f i n a l l y a f t e r a q u a r r e l w i t h her f a t h e r , o f whom she i s extremely fond, she attempted s u i c i d e by t a k i n g an overdose o f medication. Miss F. had t o f i r s t be convinced o f the s o c i a l worker's s i n c e r e i n t e r e s t i n h e l p i n g h e r , b e f o r e she would permit h e r s e l f t o be a n y t h i n g but a n t a g o n i s t i c . No attempts were made to impose  72  any s o r t of h e l p upon her* I t was not l o n g b e f o r e she was d i s c u s s i n g her f e e l i n g s r e g a r d i n g her i l l n e s s , her parents, employment and s o c i a l r e l a t i o n s h i p s . She c o u l d see h e r s e l f as a l i a b i l i t y r a t h e r than an a s s e t t o s o c i e t y and f o r t h i s reason c o u l d see nothing but unhappiness f o r h e r s e l f i n the f u t u r e . When h e r unpleasant past experiences were d i s c u s s e d a t l e n g t h , she was encouraged t o t h i n k about t h e f u t u r e . D i s c u s s i o n o f the d i s s e n t i o n between h e r p a r e n t s , r e s u l t e d i n a r e a l i z a t i o n on her p a r t , there was l i t t l e she c o u l d do about i t , except t o do her p a r t i n making t h e home as pleasant and comfortable as p o s s i b l e . Because the o t h e r s were e i t h e r working or going t o s c h o o l , she decided t h a t she c o u l d c o n t r i b u t e most by doing the house-keeping. T h i s was t o be her j o b u n t i l she c o u l d f i n d employment out i n the business w o r l d . Because the f a m i l y was i n f i n a n c i a l s t r e s s , attendance a t the Outpatient C l i n i c was d i s c u s s e d w i t h Miss F. and her parents. Her own p h y s i c i a n continued t o see her on an o u t p a t i e n t b a s i s . R e l i e v i n g h e r parents of t h i s o b l i g a t i o n helped M i s s F. f e e l t h a t she was l e s s a r e s p o n s i b i l i t y t o her parents. Miss F. met some o f t h e other g i r l s who a t t e n d the c l i n i c and i n t h i s way gained a d d i t i o n a l understanding o f the way o t h e r s a d j u s t e d t o t h e i r handicap. She g r a d u a l l y r e a l i z e d t h a t i n some r e s p e c t s she was more f o r t u n a t e than o t h e r s . When t h e group f o r p a t i e n t s was begun, M i s s F. was keenly i n t e r e s t e d i n i t s o r g a n i z a t i o n s i n c e she f e l t that g i r l s l i k e h e r s e l f could gain a great d e a l by meeting and d i s c u s s i n g common problems. She s a i d she thought she c o u l d h e l p o t h e r g i r l s , overcome some o f the i d e a s she once had. As her understanding o f e p i l e p s y i n c r e a s e d , she became more c o - o p e r a t i v e about t a k i n g her medication. T h i s together w i t h an i n c r e a s i n g measure o f happiness, r e s u l t e d i n a marked decrease i n the frequency of p e t i t mal s e i z u r e s and complete c o n t r o l of.major s e i z u r e s . D e s p i t e M i s s F . s e f f o r t s , and that o f the s p e c i a l placement d i v i s i o n o f the N a t i o n a l Employment S e r v i c e , s u i t a b l e employment has not been found f o r her. T h i s seems i n p a r t r e l a t e d t o a l a c k o f confidence i n her a b i l i t y t o do t h e k i n d of work she would l i k e t o do, and her f e e l i n g t h a t c e r t a i n jobs are,, u n d e s i r a b l e . However, she has decided t o make every e f f o r t t o find.some form o f employment p r i o r t o h e r marriage, t o prove to h e r s e l f t h a t she can h o l d a job. T  The  medical s o c i a l worker c o n t r i b u t e d t o the treatment  73 programme f o r t h i s p a t i e n t by f i r s t h e l p i n g t h e p a r e n t s g a i n more understanding o f t h e i r daughter's needs. evening meetings  Attendance a t t h e  i n c r e a s e d t h e i r understanding o f e p i l e p s y , and  r e s u l t e d i n a g r e a t e r w i l l i n g n e s s t o p a r t i c i p a t e i n treatment. Mr. F., who a t f i r s t was extremely a n t a g o n i s t i c ,  periodically  comments on the change i n h i s daughter's o u t l o o k toward l i f e .  At  one p o i n t he had commented t h a t , "No doctor can t e l l me a n y t h i n g I don't know about e p i l e p s y , day."  I l i v e w i t h i t twenty-four hours a  I t was he who suggested t o Miss F.'s f i a n c e that he d i s c u s s  Miss F.'s c o n d i t i o n w i t h the doctor b e f o r e t h e i r marriage. a l s o brought him t o the evening meetings. his  He  The d o c t o r , because o f  u n d e r s t a n d i n g o f the t o t a l f a m i l y s i t u a t i o n , has taken more  time t o e x p l a i n the i m p l i c a t i o n s of the i l l n e s s both t o t h e p a t i e n t and her parents.  Consequently,  success i n treatment seems more  l i k e l y than i t was when Miss F. was f i r s t brought i n t o t h e hospital.  T h i s case suggests t h a t medical s o c i a l work can c o n t r i bute t o the treatment o f e p i l e p s y by: (a) G a i n i n g i n f o r m a t i o n f o r t h e d o c t o r ' s u s e . (b) H e l p i n g the p a t i e n t express h i s f e e l i n g s , thus e n a b l i n g him t o view s i t u a t i o n s more r e a l i s t i c a l l y . (c)  G i v i n g the p a t i e n t the encouragement and support he needs.  (d) H e l p i n g parents understand the i l l n e s s and the p a t i e n t i n o r d e r that they might p a r t i c i p a t e i n treatment i n a more i n t e l l i g e n t manner. (e) G i v i n g the p a t i e n t the environmental h e l p he needs whenever community r e s o u r c e s a r e a v a i l a b l e . From the many cases i l l u s t r a t i n g t h e problems a s s o c i a t e d  74 w i t h e p i l e p s y , and the k i n d o f h e l p provided, i t may be concluded t h a t medical happiness  s o c i a l work can h e l p some e p i l e p t i c  persons  achieve  and m a t u r i t y i n meeting the r e s p o n s i b i l i t i e s o f a d u l t -  hood and i n t h i s way become and remain worthwhile members o f t h e i r community.  '  Chapter V  MEDICAL SOCIAL WORK - AN ESSENTIAL FOR THE SUCCESSFUL TREATMENT OF EPILEPSY  '  S u c c e s s f u l treatment o f e p i l e p s y , as p r e v i o u s l y  des-  c r i b e d , " i m p l i e s that the person subject t o s e i z u r e s has gained c o n t o l o f h i s s e i z u r e s , i s able t o support h i m s e l f  and t o meet  l i f e ' s f r u s t r a t i o n s ) w i t h a measure o f calmness and o b j e c t i v i t y . " (p. 20)  The c o n t r i b u t i o n o f the s o c i a l worker i n a c h i e v i n g  g o a l l i e s i n the r e l a t i n g and  this  o f s o c i a l f a c t o r s to medical f a c t o r s ,  i n the treatment o f p a r t i c u l a r s o c i a l problems a s s o c i a t e d  epilepsy,,  with  B a s i c to t h e e x e r c i s e o f medical s o c i a l work i n t h e  treatment o f e p i l e p s y i s , (a) knowledge of the m e d i c a l a s p e c t s o f the i l l n e s s ,  (b) understanding o f the s o c i a l and p s y c h o l o g i c a l  problems which t h e i l l n e s s p r e s e n t , resources diagnosing  (c) knowledge o f community  which may be h e l p f u l t o the p a t i e n t and (d) s k i l l i n the extent  o f t h e p a t i e n t ' s d i f f i c u l t i e s and the k i n d  of h e l p he can best use.  No attempt has been made i n t h i s study to measure i n s t a t i s t i c a l terms, the extent  t o which the medical s o c i a l worker  c o n t r i b u t e s t o the s u c c e s s f u l treatment o f e p i l e p s y . reason, one might question  For t h i s  the v a l i d i t y o f the statement  regarding  the need o f a medical s o c i a l worker i n a programme s t r i v i n g t o achieve "success".  The case h i s t o r i e s which have been presented  76 g i v e ample evidence.  Given a f u l l e r e x p l a n a t i o n o f the  terms  "help" and " s e r v i c e " ,  used so f r e q u e n t l y i n t h i s t h e s i s ,  little  doubt can remain as t o the c o n t r i b u t i o n m e d i c a l s o c i a l work can make f o r t h a t m a t t e r , not o n l y i n the treatment o f e p i l e p s y the s e i z u r e  c l i n i c , but i n any m e d i c a l  in  setting.  I n e p i l e p s y as i n a l l i l l n e s s e s ,  treatment  of  social  f a c t o r s i s dependent  upon the p a t i e n t ' s  T h e r e f o r e , the f i r s t  r e s p o n s i b i l i t y o f the m e d i c a l s o c i a l worker  i s t o be aware of the p a t i e n t ' s  medical c o n d i t i o n .  p h y s i c a l h e a l t h and to work  c l o s e l y w i t h the p h y s i c i a n i n e n a b l i n g the p a t i e n t out of medical t r e a t m e n t .  The p r o f e s s i o n a l r e l a t i o n s h i p between  p a t i e n t and s o c i a l worker i s d i f f e r e n t between the p a t i e n t  to g e t the most  and the p h y s i c i a n .  from t h a t which e x i s t s S o c i e t y has p l a c e d the  p h y s i c i a n i n an a u t h o r i t a t i v e p o s i t i o n ; and r e g a r d l e s s  of  understanding d i s p l a y e d by the p h y s i c i a n , many p a t i e n t s , p a r t i c u l a r l y those a t t e n d i n g a "free  the and  c l i n i c " are r e l u c t a n t  to  q u e s t i o n the p h y s i c i a n about matters which are causing them c o n c e r n . The s o c i a l worker, whose s t a t u s i s  much l e s s a u t h o r i t a t i v e ,  who has more time to devote t o the  d i s c u s s i o n o f problems  r e l a t i n g to the i l l n e s s ,  and  f r e q u e n t l y gains i n f o r m a t i o n which  h e l p f u i t o the p h y s i c i a n i n c a r r y i n g out the m e d i c a l  is  treatment.  F o r example, the p h y s i c i a n may i n t h i s way d i s c o v e r t h a t a patient's  negativistic  attitude  r o u t i n e t e s t s , the d i a g n o s i s ,  i s the r e s u l t o f f e a r s r e g a r d i n g  medication or t h e p r o g n o s i s .  The  p h y s i c i a n c a n , by a simple e x p l a n a t i o n a l l a y such f e a r s ,  and  therefore obtain greater  The  patient  c o - o p e r a t i o n from the p a t i e n t .  i n t u r n b e n e f i t s more from the m e d i c a l t r e a t m e n t .  77  The tendency  on the p a r t o f s e v e r a l p a t i e n t s i n t h e  s e i z u r e c l i n i c , t o d i s r e g a r d the p h y s i c i a n ' s a d v i c e r e g a r d i n g m e d i c a t i o n , i s an e x c e l l e n t example of how l a c k o f c o - o p e r a t i o n i n treatment stood.  can be overcome when reasons f o r t h i s p a t t e r n a r e under-  Only a f t e r a f a i r l y  lengthy p e r i o d had e l a p s e d , and  p a t i e n t s were a t l a s t convinced o f t h e s o c i a l worker's s i n c e r e i n t e r e s t i n h e l p i n g them, would they v e r b a l i z e t h e i r r e g a r d i n g t h e i r handicap. p a t t e r n became obvious.  feelings  At t h i s time the reasons f o r t h i s In some i n s t a n c e s , n e i t h e r the p a t i e n t  n o r the parents c o u l d accept the d i a g n o s i s , and as a r e s u l t saw • no reason f o r t a k i n g the m e d i c a t i o n .  Those p a t i e n t s who had  p r e v i o u s l y attended c h i r o p r a c t o r s , and had been warned o f the e v i l s of "dope", had ambivalent  f e e l i n g s about t a k i n g medicine.  Some p a t i e n t s had not been t o l d that i t was important t o have a d e f i n i t e amount of m e d i c a t i o n i n the b l o o d stream a t a l l times as a p r e v e n t a t i v e a g a i n s t s e i z u r e s , and t h e r e f o r e c o u l d n o t see the reason f o r r e g u l a r i t y i n t a k i n g t h e medication.  Many p a t i e n t s d i d  not understand the t r i a l and e r r o r method i n v o l v e d i n determining the amount of m e d i c a t i o n necessary t o c o n t r o l s e i z u r e s .  Some  f e l t t h a t the p h y s i c i a n d i d not know what he was doing and was merely experimenting w i t h them.  There were p a t i e n t s who were not  aware of t h e newer medications a v a i l a b l e f o r the treatment o f e p i l e p s y and who, because of t h e i r e a r l i e r experiences w i t h a n t i convulsant drugs, were i n c l i n e d t o f e e l they were of. l i t t l e v a l u e . Marked improvement i n a t t i t u d e s toward medication was  observed  when e x p l a n a t i o n s were made and r e a s s u r a n c e s g i v e n by the s o c i a l worker and the p h y s i c i a n who had become aware o f the reasons f o r  t h e p a t i e n t s ' delinquency. The  medical s o c i a l worker, because o f h i s r e l a t i o n s h i p  w i t h the p a t i e n t , has regarding  an e x c e l l e n t o p p o r t u n i t y  medical treatment.  to g i v e reassurance  Many p a t i e n t s , as w e l l as  expressed a p p r e c i a t i o n f o r h a v i n g had the o p p o r t u n i t y someone who  appreciated  'ment, permitted time r e a s s u r e d  relatives,  to t a l k with  t h e i r "mixed-up" f e e l i n g s r e g a r d i n g  them t o d i s c u s s these f e e l i n g s , and them about the f u t u r e .  at the same  For many, t h i s was  d i f f e r e n t from e a r l i e r experiences i n t h e i r search  treat-  quite  f o r medical  treatment of e p i l e p s y . Informing the p h y s i c i a n of the p a t i e n t s ' to g i v e up way  unwillingness  s e i z u r e s - whether conscious or otherwise - i s another  i n which medical s o c i a l work can c o n t r i b u t e t o m e d i c a l t r e a t -  ment.  Although most p a t i e n t s i n the s e i z u r e c l i n i c v e r b a l i z e d a  d e s i r e f o r c o n t r o l of s e i z u r e s , there were i n d i c a t i o n s of f e a r t o what t h i s would mean to some p a t i e n t s whose i l l n e s s was standing.  They had made t h e i r own  handicap and  p e c u l i a r adjustment t o  c o n t r o l of s e i z u r e s would mean g i v i n g up  dependency upon r e l a t i v e s and  a l s o the community.  of  as long  their  their  For the  first  time i n t h e i r l i v e s , they would be expected t o behave i n a manner b e f i t t i n g an a d u l t . p a t i e n t s has who  The  physician's  awareness o f t h i s f e a r i n  resulted i n concentration  were b e t t e r able to use  were p e r m i t t e d  of e f f o r t upon the  the s e r v i c e o f the  clinic.  patients  The  others  t o " d r i f t " i n medical treatment u n t i l s u c h time as  they showed a more p o s i t i v e approach toward treatment. p h y s i c i a n a l s o r e i n f o r c e d the  The  s o c i a l worker's e f f o r t s t o enable  79 t h e persons who  need t h e i r s e i z u r e s , t o see the b e n e f i t s t o be  gained from independence.  With encouragement and support, some  p a t i e n t s are more able t o g i v e up s e i z u r e s ; and i n t h i s way become more c o - o p e r a t i v e i n medical treatment.  they  A l l o f these are  ways i n which medical s o c i a l work can help p a t i e n t s r e c e i v e the g r e a t e s t b e n e f i t from m e d i c a l  treatment.  In a d d i t i o n to h e l p i n g w i t h m e d i c a l treatment, s o c i a l work i s a l s o concerned w i t h the adjustment make t o t h e i r s o c i a l s i t u a t i o n s .  medical  which p a t i e n t s  The case h i s t o r i e s which have  been presented i l l u s t r a t e the problems which e p i l e p s y p r e s e n t s w i t h r e g a r d to f a m i l i a l and s o c i a l r e l a t i o n s h i p s , e d u c a t i o n and employment. i n meeting  The types of h e l p g i v e n by the medical s o c i a l worker these problems,  have of n e c e s s i t y been i n f l u e n c e d by  the a c t u a l needs o f p a t i e n t s ,  the k i n d s of h e l p t h e y seek,  their  a b i l i t y to use casework treatment and the s k i l l o f the medical s o c i a l worker.  As s t a t e d p r e v i o u s l y  have been g i v e n .  both d i r e c t and i n d i r e c t h e l p  F o r t h e c h i l d r e n of t h i s study, casework h e l p  has been p r i m a r i l y of an i n d i r e c t n a t u r e .  T h i s has a l r e a d y been  e x p l a i n e d i n terms of a l a c k of r e s o u r c e s i n u s i n g p l a y therapy as a means of d i r e c t treatment  of c o n f l i c t s i n c h i l d r e n .  Although  casework methods employed i n h e l p i n g a d u l t persons w i t h e p i l e p s y have been more d i r e c t , n e v e r t h e l e s s i t seems l i k e l y t h a t the  -  a d u l t s have a l s o b e n e f i t t e d most from the i n d i r e c t h e l p g i v e n . The f o l l o w i n g examples are presented t o i l l u s t r a t e the methods o f s o c i a l casework as d e f i n e d by Miss F l o r e n c e H o l l i s . ^ 1  19  T h i s and succeeding q u o t a t i o n s are taken from H o l l i s , F l o r e n c e , "The Techniques, of Casework." J o u r n a l o f S o c i a l Casework, Family S e r v i c e A s s o c i a t i o n of America, June  1949, p. 235-244.  80 (a) M o d i f y i n g the, environment. This r e f e r s to "steps - taken by the caseworker t o change the environment i n the c l i e n t ' s f a v o r by the worker's d i r e c t a c t i o n - . . . I t i s undertaken by the caseworker o n l y when environmental p r e s s u r e s upon the c l i e n t are beyond the l a t t e r ' s c o n t r o l , but can be m o d i f i e d by the caseworker, or when such p r e s s u r e s are more l i k e l y t o y i e l d t o change when handled by the worker than by the c l i e n t h i m s e l f . " I n the s e i z u r e c l i n i c ,  t h i s method has been used a g r e a t  d e a l , and p a r t i c u l a r l y i n r e l a t i o n t o modifying the a t t i t u d e s o f p a r e n t s toward e p i l e p t i c o f f s p r i n g .  The o v e r p r o t e c t i v e p a t t e r n s  o f Miss J's parents have been m o d i f i e d t o some extent as a r e s u l t o f the implementation of t h i s method by the s o c i a l worker (Chapter IV).  Attempts  to modify the environment  by d i s c u s s i o n s w i t h  s c h o o l t e a c h e r s (Chapter I I I ) and placement  o f f i c e r s of the  N a t i o n a l Employment S e r v i c e (Chapter IV) are o t h e r examples of t h i s casework method. (b) P s y c h o l o g i c a l support. T h i s i s designed t o " r e l i e v e a n x i e t y and f e e l i n g s o f g u i l t , and to promote the c l i e n t ' s c o n f i d e n c e i n h i s a b i l i t y to handle h i s s i t u a t i o n adequately. A l s o i n c l u d e d i n p s y c h o l o g i c a l support i s the d i r e c t encouragement of a t t i t u d e s t h a t w i l l enable the c l i e n t t o f u n c t i o n more r e a l i s t i c a l l y as w e l l as more c o m f o r t a b l y . " T h i s i s a c h i e v e d by "encouraging the c l i e n t t o t a l k f r e e l y and express his' f e e l i n g s about h i s s i t u a t i o n ; e x p r e s s i n g sympathetic understanding o f the c l i e n t ' s f e e l i n g s and acceptance of h i s b e h a v i o r ; i n d i c a t i o n of the caseworker's i n t e r e s t i n the c l i e n t , h i s d e s i r e to h e l p ; e x p r e s s i o n o f the worker's c o n f i d e n c e t h a t a way can be found t o improve the s i t u a t i o n , confidence i n the c l i e n t ' s a b i l i t y t o s o l v e h i s d i f f i c u l t y , to make h i s own d e c i s i o n s ; i n d i c a t i o n o f . the worker's r e s p e c t f o r and a p p r o v a l o f steps the c l i e n t has taken or i s p l a n n i n g where these a t t i t u d e s are r e a l i s t i c a l l y warranted." P s y c h o l o g i c a l support and a l s o environmental support were  81 u s e d by the s o c i a l worker i n h e l p i n g Miss F. f e e l t h a t l i f e was worth l i v i n g and that she c o u l d be an a s s e t , r a t h e r than a l i a b i l ity  t o s o c i e t y (Chapter I V ) . (c)  C l a r i f i c a t i o n . "The dominant note i n c l a r i f i c a t i o n i s understanding — understanding by t h e c l i e n t o f hims e l f , h i s environment, and/or people w i t h whom he i s a s s o c i a t e d ... T h i s understanding may range i n q u a l i t y from a simple i n t e l l e c t u a l process o f t h i n k i n g through matters that a r e uncomplicated by s t r o n g emotion, t o a deeper comprehension o f a t t i t u d e s and f e e l i n g s o f c o n s i d e r a b l e emotional content." "Sometimes t h e caseworker makes d i r e c t i n t e r p r e t a t i o n s concerning the e f f e c t o r s i g n i f i c a n c e o f the c l i e n t ' s a c t i o n s o r r e a c t i o n s or o f those o f o t h e r s w i t h whom he i s a s s o c i a t e d . More o f t e n , the worker merely asks q u e s t i o n s o r comments on i n c o n s i s t e n c i e s and i n a p p r o p r i a t e emotions. Always the e f f o r t i s t o h e l p t h e c l i e n t t o t h i n k more c l e a r l y , t o r e a c t more r e a l i s t i c a l l y , and t o p l a n more w i s e l y . " T h i s method has not been used e x t e n s i v e l y by t h e s o c i a l  worker i n t h e s e i z u r e c l i n i c .  Only a s m a l l number o f p a t i e n t s  seemed t o have t h e a b i l i t y o r the d e s i r e f o r t h i s understanding. However i t was used w i t h Miss F. (Chapter IV) and a l s o Miss L. (Chapter IV) who, as a r e s u l t have been able t o see t h e i r more r e a l i s t i c a l l y and t o p l a n more w i s e l y . In in  situations  .„  attempting t o h e l p Miss I . whose case was presented  p a r t , t h i s method was used but without  success.  Although Miss I .  v e r b a l i z e d a d e s i r e t o g a i n understanding o f h e r s e l f and t h e reasons f o r d i f f i c u l t i e s i n i n t e r p e r s o n a l r e l a t i o n s h i p s and employment, the understanding gained has been p u r e l y on an intellectual level.  She does not seem t o have t h e a b i l i t y t o use  t h e understanding gained, i n c o p i n g w i t h the f r u s t r a t i o n s she meets.  32  (d) I n s i g h t . " I n s i g h t development i n v o l v e s c a r r y i n g u n d e r s t a n d i n g t o a deeper l e v e l than t h a t d e s c r i b e d in clarification." "To achieve i n s i g h t , c u r r e n t and past emotions must be r e l i v e d i n a t h e r a p e u t i c atmosphere i n order t h a t some o f the a f f e c t may be d i s c h a r g e d and i n order that i r r a t i o n a l i t i e s may be brought so c l e a r l y to the s u r f a c e t h a t they can be r e c o g n i z e d , a t f i r s t i n the s a f e t y o f the treatment s i t u a t i o n and l a t e r in real l i f e t h e purpose of t h i s development of i n s i g h t i s t o i n c r e a s e the c l i e n t ' s understanding of h i m s e l f and h i s s i t u a t i o n so t h a t he can manage h i s l i f e more r e a l i s t i c a l l y , with, l e s s a n x i e t y and h o s t i l i t y , and l e s s use o f d e s t r u c t i v e defence mechanisms." T h i s method o f s o c i a l casework has o n l y on r a r e been used i n the s e i z u r e c l i n i c .  occasions  A l a c k o f d e s i r e on the part of  p a t i e n t s f o r t h i s deeper understanding of themselves, l a c k o f skill  on the part of the medical s o c i a l worker, and the absence o f  p s y c h i a t r i c c o n s u l t a t i o n are the reasons f o r t h i s . Examination o f the problems which e p i l e p s y presents t o the persons i n t h i s study, and a n a l y s i s o f t h e h e l p p r o v i d e d by the medical s o c i a l worker a s s o c i a t e d w i t h t h e c l i n i c have r e s u l t e d in  the f o l l o w i n g c o n c l u s i o n s  r e g a r d i n g t h e r o l e o f the m e d i c a l  s o c i a l worker i n the treatment of e p i l e p s y : (a) The medical s o c i a l worker has a c o n t r i b u t i o n t o make i n h e l p i n g t h e p h y s i c i a n understand the p a t i e n t ' s s o c i a l s i t u a t i o n as i t a f f e c t s h i s medical c o n d i t i o n and h i s a t t i t u d e toward medical treatment. (b) The medical s o c i a l worker can do much t o h e l p p a t i e n t s - o b t a i n the g r e a t e s t b e n e f i t from medical treatment by c o r r e c t i n g misconceptions toward the i l l n e s s , by a l l e v i a t i n g a n x i e t y r e g a r d i n g treatment, and by encouraging p a t i e n t s r e g a r d i n g the f u t u r e . (c) The medical s o c i a l worker has a r e s p o n s i b i l i t y i n h e l p i n g parents develop h e a l t h y a t t i t u d e s toward handicapped o f f s p r i n g . Since people are l e s s f e a r f u l o f those t h i n g s which they understand, g i v i n g p a r e n t s  83 an understanding of e p i l e p s y , i s the f i r s t step toward the development of h e a l t h y a t t i t u d e s i n p a r e n t s . Making them f e e l t h a t the s o c i a l worker and the p h y s i c i a n are w i l l i n g to share some of the r e s p o n s i b i l i t i e s o f the i l l n e s s , decreases t h e i r burden w i t h the r e s u l t t h a t they are more a b l e t o g i v e the c h i l d the necessary encouragement and support. I t i s e s s e n t i a l , i f d i f f i c u l t y i n adulthood i s t o be minimized, to encourage parents t o permit c h i l d r e n to p a r t i c i p a t e i n most of the a c t i v i t i e s which are p l e a s u r a b l e to c h i l d r e n who are not handicapped by seizures. Parents need h e l p i n r e a l i z i n g t h a t overindulgence and o v e r p r o t e c t i o n can be as handicapping to a c h i l d as e p i l e p t i c s e i z u r e s . The parent who i s w e l l - i n f o r m e d r e g a r d i n g e p i l e p s y , who does not f e a r i t yet r e c o g n i z e s the problems which i t p r e s e n t s , can do much t o h e l p a handicapped c h i l d develop h e a l t h y a t t i t u d e s which w i l l enable him t o meet the . r e s p o n s i b i l i t i e s of adulthood w i t h m a t u r i t y . (d) The m e d i c a l s o c i a l worker can c o n t r i b u t e t o the t o t a l w e l l - b e i n g of the a d u l t p a t i e n t , by h e l p i n g him understand and accept h i s d i a g n o s i s . E s t a b l i s h m e n t o f a warm and f r i e n d l y r e l a t i o n s h i p may help the p a t i e n t f i r s t t o v e r b a l i z e h i s a n x i e t y and h i s f e a r s ; and, i n some cases, may e v e n t u a l l y r e s u l t i n g r e a t e r unders t a n d i n g o f h i m s e l f and h i s r e a l i t y s i t u a t i o n . Reduction of environmental pressures and i n n e r conf l i c t s may r e s u l t i n a decrease of the frequency of seizures. (e) The m e d i c a l s o c i a l worker has a r e s p o n s i b i l i t y , not only i n b e i n g aware of community r e s o u r c e s , but a l s o i n f a m i l i a r i z i n g the community w i t h the f a c t s r e g a r d i n g e p i l e p s y . The stigma a s s o c i a t e d w i t h t h i s i l l n e s s can o n l y be overcome, when i t i s b e t t e r understood. In  c o n c l u s i o n , a few comments must be made r e g a r d i n g the  f u n c t i o n o f the m e d i c a l s o c i a l worker i n the p a r t i c u l a r s e t t i n g o f t h i s study.  The cases presented suggest that the m a j o r i t y of  persons i n t h i s study have more d i f f i c u l t i e s than might be from p a t i e n t s who practice.  expected  seek m e d i c a l treatment from p h y s i c i a n s i n p r i v a t e  For them, attempting t o meet the immediate needs of  34 f o o d , s h e l t e r and employment i s one o f t h e major r e s p o n s i b i l i t i e s of t h e s o c i a l worker.  U n f o r t u n a t e l y , there are few community r e -  sources i n Vancouver which can be used f o r these purposes. Perhaps, t h e r e f o r e , t h e s o c i a l worker can p r o v i d e the g r e a t e s t s e r v i c e to the p a t i e n t s o f t h i s c l i n i c , by s t r i v i n g t o e s t a b l i s h an e d u c a t i o n a l programme about at r e h a b i l i t a t i o n  epilepsy.  I t seems l i k e l y t h a t  o f persons s u b j e c t t o s e i z u r e s w i l l prove  attempts unpro-  ductive u n t i l  the community becomes aware of the d i f f i c u l t i e s o f  this illness,  the t r u t h s about i t s nature, and the success which  can be a c h i e v e d i n medical treatment.  F o r t h e m a j o r i t y o f the  a d u l t s r e f e r r e d t o i n t h i s study, i t seems l i k e l y o f s u c c e s s f u l treatment a r e very s m a l l .  t h a t the chances  F o r t h i s reason i t i s the  o p i n i o n o f t h e w r i t e r t h a t the g r e a t e s t emphasis s h o u l d be p l a c e d upon t h e treatment of both medical and s o c i a l i l l s  o f the c h i l d r e n .  E a r l y c o n t r o l o f s e i z u r e s , t o g e t h e r w i t h t h e development o f h e a l t h y a t t i t u d e s toward the handicap, w i l l undoubtedly r e s u l t difficulties  i n fewer  i n adulthood.  I t was the wider purpose  of t h i s t h e s i s t o throw  light  on t h e f u n c t i o n o f t h e m e d i c a l s o c i a l worker i n t h e treatment o f epilepsy.  Although cases were s e l e c t e d from a s p e c i f i c  setting,  there can no l o n g e r be any doubt a s t d the c o n t r i b u t i o n medical . s o c i a l work can make t o t h e treatment of e p i l e p s y i n any s e t t i n g . Undoubtedly,  e p i l e p s y must be c o n s i d e r e d a s o c i a l problem as w e l l  as a medical problem;  and the combined e f f o r t s , o f many p r o f e s s i o n a l  and l a y persons w i l l be needed i f t h e many men and women s u b j e c t t o s e i z u r e s a r e to become and remain u s e f u l members o f t h e communities i n which they  live.  Bibliography-  Books Bridge,  Edward M., M.D., E p i l e p s y and Convulsive D i s o r d e r s i n C h i l d r e n , McGraw-Hill Book Company, New York, Toronto, London, 1949*  Hock, P a u l H., M.D., e d i t e d by Knight, Robert P., M.D., E p i l e p s y , P s y c h i a t r i c Aspects of Convulsive D i s o r d e r s , Greene & S t r a t t o n . New York. 1947. Proceedings of the 3 6 t h meeting o f the American P s y c h o p a t h o l o g i c a l A s s o c i a t i o n , h e l d i n New York C i t y , May 194^ Lennox, Wm.  G., M.D., Science & S e i z u r e s — New L i g h t on E p i l e p s y and M i g r a i n e , Harper & B r o t h e r s , New N York, 1941.  P e n f i e l d , ¥. and E r i c k s o n , T.C., E p i l e p s y & C e r e b r a l L o c a l i z a t i o n , Charles G. Thomas, P u b l i s h e r , Baltimore, 1941. Putnam, Tracy, M.D., Convulsive S e i z u r e s , How t o Deal With Them. A Manual f o r P a t i e n t s , T h e i r F a m i l i e s and F r i e n d s , J.B. L i p p i n c o t t Company, P h i l a d e l p h i a , London, Montreal. Temhin, D,, The F a l l i n g S i c k n e s s , B a l t i m o r e , 1945. •  A r t i c l e s and Bradley,  The  Johns Hopkins  Press,  Pamphlets  C h a r l e s , M.D., "Treatment of a Convulsive C h i l d i n a C h i l d r e n ' s P s y c h i a t r i c H o s p i t a l " , R e p r i n t e d from The Nervous C h i l d , V o l . 6, No. 1, 1947.  36  Gumrnins, Jean, "The F a m i l y as a F a c t o r i n t h e E p i l e p t i c ' s S o c i a l Adjustment", J o u r n a l o f S o c i a l Casework, Nov. 1949, p. 334-337, Family S e r v i c e s A s s o c i a t i o n o f America. D a v i d s o n , E L a b e l , Thomas, Joan, "A S o c i a l Study o f E p i l e p t i c P a t i e n t s " , J o u r n a l o f S o c i a l Casework. Nov. 1949, p. 330-334, Family S e r v i c e s A s s o c i a t i o n o f America. Davidson, Douglas T., M.D., "New L i g h t on an O l d D i s o r d e r " , The N e u r o l o g i c a l I n s t i t u t e , The C h i l d r e n ' s M e d i c a l Center, Boston, Mass., L e c t u r e d e l i v e r e d a t I n s t i t u t e s on E p i l e p s y , Tampa & Miami, A p r i l 1930. " E p i l e p s y - No D i s g r a c e " , Health B u l l e t i n o f t h e B r i t i s h Columbia Department o f Health & Welfare, June & J u l y 1930, from F l o r i d a H e a l t h Notes. F r a z i e r , Mrs. F r a n c i s , Rockower, Mr. L.W., " V o c a t i o n a l R e h a b i l i t a t i o n of t h e E p i l e p t i c and the M e n t a l l y Retarded", F e d e r a l S e c u r i t y Agency, O f f i c e o f V o c a t i o n a l R e h a b i l i t a t i o n , Washington, D.C., March 1943. The  Green L i g h t : N a t i o n a l A s s o c i a t i o n t o C o n t r o l E p i l e p s y , Inc., V o l . 1, No. 3, May 1946.  H i b b a r d , Bement F., "Are E p i l e p t i c s Employable", N a t i o n a l A s s o c i a t i o n to C o n t r o l E p i l e p s y , I n c . , Sept. 13, 1945, E x c e r p t s from a t a l k by B.F. Hibbard g i v e n before t h e S t a t e o f Main E d u c a t i o n a l Dept. Division of Vocational Rehabilitation. H a l l i s , F l o r e n c e , "The Techniques of Casework", J o u r n a l o f S o c i a l Casework. Family S e r v i c e A s s o c i a t i o n o f America, June 1949, p. 235-244. " I n s t i t u t e on E p i l e p s y " , Arranged by the H e a l t h & A u x i l i a r y D i v i s i o n of the Community Chest & C o u n c i l , w i t h the Health & Welfare E d u c a t i o n Group of Vancouver, May 3, 1943, Issued by t h e P r o v i n c i a l Department of H e a l t h , B r i t i s h Columbia. Kanner, Leo, M.D.*, "The E p i l e p t i c Person a t Home", A r t i c l e a v a i l a b l e from the N a t i o n a l E p i l e p s y League, Inc., 130 North Wells S t r e e t , Chicago 6, I l l i n o i s . * P r o f e s s o r of C h i l d P s y c h i a t r y , Johns Hopkins M e d i c a l S c h o o l , B a l t i m o r e , Maryland.  87  Kanner, Leo, M.D.*, "The Epileptic Child i n School". * Professor of Child Psychiatry, Johns Hopkins Medical School, Baltimore, Maryland. Lennox, Margaret A., M.D., Mohr, Jennie, Ph.D., "Social and Work Adjustment i n Patients with Epilepsy", The American Journal of Psychiatry, Volume 107, Number 4, Oct. 1950, The American Psychiatric Association, 1500 Greenmount Avenue, Baltimore 2, Md. Lennox, W.G., M.D., "Mental Hygiene and the Epileptic", Reprinted from The Bulletin of the Massachusetts Society for Mental Hygiene. Nov. 1944. Lennox, W.G., M.D., "The Petit Mal Epilepsies", Their Treatment with Tridione, Reprinted from The Journal of the American Medical Association, Dec. 15, 1945. •-• Lennox, W.G.., M.D., "Marriage and Children for Epileptics", Reprinted from Human F e r t i l i t y . Vol. 10, No. 4, Dec. 1945. Lennox, W.G., M.D., Cobb, Stanley, M.D., "The Employment of Epileptics", American Epilepsy League, Inc. Minutes of one of the f i r s t organization meetings of the Seizure Clinic of the Vancouver General Hospital, June 1950. "Medical Social Work", Social Work Year Book. 1949, Margaret B. Hodges, Editor, Russel Sage Foundation, Pinanski, Joan, "Social Service and Seizures", Information about Epilepsy for the Social Worker, February 21, 1946, Prepared by the National Epilepsy League. Randall, Guy C., M.D. and Rogers, Will C., Ph.D., "Group Therapy for Epileptics", The American Journal of Psychiatry, Vol. 107, Number 6, Dec. 1950, The American Psychiatric Association, 1500 Greenmount Avenue, Baltimore 2, Md. Rice, Elizabeth P., "Generic & Specific i n Medical Social Work", Journal of Social Casework, Family Services Association of America, April 1949, p. 131-134.  88  T u r v e y , S.E.C., M.D., " E p i l e p s y " , A Radio T a l k sponsored by the Greater Vancouver H e a l t h League, A p r i l 1942. l a h r a e s , Herbert, " E p i l e p s y - The Ghost i s Out o f t h e C l o s e t " , - P u b l i c A f f a i r s Pamphlet, No. 98. Yahraes, Herbert and D i x i e , "You'd Never Know Our Daughter i s an E p i l e p t i c " , C o l l i e r ' s . November 26, 1949.  Theses Bo.wkett, Mary Frew, The S o c i a l Worker i n t h e Treatment Team, T h e s i s submitted f o r the Master's Degree, u.B.C., 1951.  

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