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Rheumatic heart disease : the meaning of this illness to patients and their families - a study of male… Rykiss, Ben 1952

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c /RHEUMATIC HEART DISEASE: THE MEANING OF THIS ILLNESS  TO PATIENTS AND THEIR FAMILIES A Study of Male Adult Patients With Rheumatic Heart Disease Admitted to Shaughnessy Hospital (1948 - 1951) by BEN BYKTSS Thesis Submitted i n P a r t i a l Fulfilment •of the Requirements for the Degree of 'MASTER OF SOCIAL' WORK i n the School of S o c i a l Work 'Accepted as conforming to the standard required for the degree of,Master of S o c i a l Work School of S o c i a l Work 19_52 'The University o f - B r i t i s h Columbia ( i i ) TABLE OF CONTENTS page Chapter 1. Introduction Purpose of the study. The concept of the patient-as-a-whole. Background of s o c i a l work practice i n a medical se t t i n g . Emergence of the treatment team. Psychosomatic medicine. Research method used 1 Chapter 2. S o c i a l and Personal Implications Incidence of s o c i a l pressures:" Case examples. Personality patterns: Case examples - p a s s i v i t y , aggressiveness 18 Chapter 3. Case Work With Rheumatic Heart Patients Levels of case work treatment. The use of envir-onmental manipulation. The use of psychological sup-port and c l a r i f i c a t i o n 38 Chapter 4. Family Implications The effect on parents and s i b l i n g s : Case example-the domineering mother. The e f f e c t on marriage part-ners: Case examples - sexual incompatibility, imma-t u r i t y versus dependency. The effect on children: Case examples - the "separation experience". Case work with families: Case example - the patient's wife..59 Chapter 5. Conclusions and Recommendations Findings: The i n t e r r e l a t i o n s h i p between s o c i a l and personal problems and physical i l l n e s s * The role of the s o c i a l worker i n a medical se t t i n g . Recommendations: St a f f requirements. Resource re-quirements. The need for more research. Adequate use of recording. Prevention 79 - Appendices A. Medical Aspects of Rheumatic Heart Disease 96 B. Bibliography 101 (iv) ABSTRACT The purpose of this study has been to determine, (1) whether there is a connection between a patient's s o c i a l and personal background and his s u s c e p t i b i l i t y to rheumatic heart disease, (E) whether emotion^producing conditions a f f e c t the development and l a t e r recurrences of t h i s disease, (3) what the r e l a t i o n s h i p i s between s p e c i f i c s o c i a l and personal pressures and the course of a rheumatic heart patient's i l l n e s s , and (4) what the s o c i a l worker can contribute towards a l l e v i a t i n g these emotion-produc-ing conditions a f f e c t i n g the patient's i l l n e s s . Because of the l i m i t a t i o n s encountered, e.g. incomplete s o c i a l h i s t o r i e s , i t has not been possible to determine the f i r s t of these. A l l patients (25) with rheumatic heart disease who were re-ferred for medical s o c i a l service at Shaughnessy h o s p i t a l through a four-year period (1947-1951), have been selected for t h i s study. An analysis of a l l available records of various branches df the department of veterans' a f f a i r s interested i n the welfare of these patients, has been made. Material selec-ted has been confined to three broad areas i n the patients' l i v e s , (1) early personality formation, (2) s o c i a l and personal stress surrounding the onset, and (3) s o c i a l services employed i n a l l e v i a t i n g emotional stress of patients and t h e i r f a m i l i e s . The findings of t h i s study indicate that an ever-increasing cycle of s o c i a l problems affect the rheumatic heart patient, following the onset of his i l l n e s s . Economic d i f f i c u l t i e s form the major source of emotional stress, and these i n turn a f f e c t and are affected, by the earning capacity of p h y s i c a l l y - l i m i t e d , chronically-diseased patients. There are indications of per-sonality factors reacting upon the a b i l i t y of the patients to accept the l i m i t a t i o n s of t h e i r i l l n e s s and the demands of mature adulthood. Although t h i s study concerns i t s e l f only with war veterans, the majority of the findings are applicable to a l l patients a f f l i c t e d with rheumatic heart disease. Included here are, (1) the need for adequate resources, e.g. f i n a n c i a l grants, convalescent centres, suitable housing, l i g h t employment and r e t r a i n i n g programmes, (2) the need for more s o c i a l workers as well as professionally trained s o c i a l workers to insure proper use of available resources, (3) the need f o r more research not only with a l l rheumatic heart patients but with a l l forms of chronic i l l n e s s , and (4) the need for preventive measures e.g. through education, and early diagnosis and treatment of s o c i a l and personal problems. Problems r e s u l t i n g from increased f i n -a n c i a l grants given to veteran patients undergoing h o s p i t a l care, and l i m i t a t i o n s i n medical s o c i a l service recording under the department'of veterans' a f f a i r s , are two s p e c i f i c findings which are mainly applicable to the veteran. (v) . ACKNOWLEDGMENTS Grateful acknowledgment to Mrs. C. Mc A l l i s t e r , Director, Medical S o c i a l Service, Shaughnessy ho s p i t a l , i s made for her aid i n star t i n g t h i s project. I wish to express deep apprecia-ti o n to Miss G. Reid and Mr. J. J. Young, of the Medical S o c i a l Service s t a f f , Shaughnessy hospital, for th e i r contributions through case discussions. I am p a r t i c u l a r l y indebted to Dr. L. C. Marsh and Miss A. G. Black, School of Social Work, University of B r i t i s h Columbia, for the time and thoughtful help they have given i n the f i n a l assembling of the material. I am also i n -debted to Dr. J. A. Traynor, for his h e l p f u l suggestions concern-ing the medical aspects of rheumatic, heart .disease. I acknowledge the invaluable help of Miss L. McNee, Medical Records department, Shaughnessy h o s p i t a l , for her int e r e s t and aid i n bringing related reading material to my attention. Also, I wish to acknowledge the services of Miss T. White, as well as Miss L. McNee, Medical Records department, Miss G. Jones and Mrs. E. A. White of the C l e r i c a l s t a f f of Medical S o c i a l Service, Shaughnessy hospital, i n f a c i l i t a t i n g the process of case selec-t i o n . F i n a l l y , I am completely indebted to my wife and secretary, Mrs. Fay Rykiss, for her long and arduous months of patient t o i l , constant support, and sincere understanding - for without her, this study could never have been completed. (vi)... RHEUMATIC HEART DISEASE: THE MEANING- OF THIS ILLNESS TO PATIENTS AND THEIR FAMILIES Study of Male Adult Patients With Rheumatic Heart Disea Admitted to Shaughnessy Hospital (1948 - 1951) CHAPTER 1  INTRODUCTION a For several centuries rheumatic fever has been recognized but misunderstood disease. At f i r s t i t was thought to a f f e c t only the joi n t s of the body, but i t was not u n t i l the late eighteenth and early nineteenth centiurles that damage to the heart was observed. Even afte r more advanced discoveries were made, for many years a r t h r i t i s was considered to be the essen-t i a l feature of rheumatic fever and heart involvement merely a "complication". I t is'only recently that c a r d i t i s has assumed i t s proper place as the most important of the rheumatic i n f e c -1 t i o n s . One recent study estimates that ninety per cent of the de-2 f e c t i v e hearts i n children are'rheumatic i n nature. I t i s also estimated that rheumatic heart disease i s the second most prevalent form of heart disease i n adults, ( i . e . t h i r t y per cent). About ninety per cent of the disease occurs i n patients before they reach f i f t y years of age, and deaths are most prevalent within the f i r s t four decades. At l e a s t 75 per 3 cent of a l l RHD patients have one or more recurrent bouts of disease. In an age where the young breadwinner finds i t 1 William D. Stroud, Diagnosis and Treatment of Cardiovas- cular Disease, Vol. 1, 3rd ed., pp. 70-71. 2 R. L. C e c i l , "Rheumatic Heart Disease", Textbook of Medi-cine, pp. 1185-1192. 3 For convenience, the abbreviation RHD i s used as a substi-tute for the term rheumatic heart disease. (2) d i f f i c u l t enough to maintain h i s economic equilibrium, the add-ed burden of a chronic i l l n e s s , together with the prospect of short l i f e span, presents a serious problem for i n d i v i d u a l s , t h e i r f a m i l i e s , and society. Although much research on the medical aspects of t h i s d i s -ease has been done, 1 s t i l l the perfect treatment programme has not been found. As the medical profession has gained increased recognition of the need to examine the " t o t a l " patient, there has been a greater awareness that physical medicine i s not the complete solution to t h i s pressing problem. More work: s t i l l needs to be done i n the r e l a t i v e l y unknown areas of the s o c i a l and emotional influences a f f e c t i n g the course of a patient's i l l n e s s . In t h i s respect, some research has been done on the emotional factors contributing to causation and care of rheuma-t i c disease i n children, yet very l i t t l e written material of a sim i l a r nature i s available on the male adult RHD patient. The purpose of t h i s present study, i s to add something to the greater understanding of the s o c i a l and emotional factors of RHD i n male adults. This study seeks to determine, (1) whether there i s a connection between an RHD patient's s o c i a l and personal background and h i s s u s c e p t i b i l i t y to RHD, (2) 1 For a summary of the medical aspects involved i n Rheumatic Heart Disease, refer to Appendix A. 2 Elizabeth Richardson i n her a r t i c l e , "A S o c i a l Worker Looks at Psychosomatic Medicine", Canadian Welfare, pp. 20-25, e s t i -mates that approximately 85 per cent of rheumatically diseased children show signs of emotional upsets. (3) whether emotion-prodticing conditions a f f e c t the development and l a t e r recurrences of t h i s disease, (3) what the s p e c i f i c r e l a -tionship i s between these s o c i a l and personal factors and the course of an RHD patient's i l l n e s s , and (4) what the s o c i a l wor-ker can contribute towards a l l e v i a t i n g these stresses and s t r a i n s a f f e c t i n g the patient's i l l n e s s . The value to the RHD patient of such a project i s unquestion-able, for any research which i s directed towards the ameliora-t i o n of h i s i l l n e s s serves t h i s purpose. To the patient's "family" - his r e l a t i v e s , friends and other community members -insight into the " t o t a l " reactions of the patient, should cre-ate new l i g h t on the part they play i n encouraging or hampering causation and treatment. To the rest of society, there i s a need for such a study, not only from the standpoint of pure en-lightenment, but also from the economic advantage which i s gained. The aid which i s given the male adult allows him to function more-adequately as the breadwinner of h i s family. He i s then better able to become a contributing member of society rather than one who must constantly remain dependent upon otji-ers for the physical and emotional well-being of himself and his family. Unfortunately the t o t a l acceptance or understanding of concomitant causes other than the purely physical by the public i n general, i s far from complete. Part of the blame for t h i s i s due to the lack of research a l l o t t e d to the s o c i a l sciences. Whereas vast sums of money have been spent to bring the f i e l d of s c i e n t i f i c medicine to the position i t i s today, public apathy has allowed inves t i g a t i o n into the s o c i a l aspects of (4) disease to lag far behind. In Canada, as well as i n other countries, the stigma connected with mental incompetence has greatly affected t h i s lack of development. Any c h r o n i c a l l y - i l l person who can admit to himself that he i s unable to face r e a l i -ty and seeks escape from his s o c i a l and emotional problems throu-gh various physical manifestations, undergoes an extremely "pain-f u l " mental process. On the other hand, more s o c i a l acceptance i s gained by such a person when he has been pronounced medically unfi t through no f a u l t of his own. Further acceptance i s given to his unfortunate encumbrance by the necessary attention doc-tors, nurses, etc., provide. The case of the RHD patient des-cribed i n Chapter 3, i s a good example of t h i s enigma. 1 The Patient - As - A Whole Before an assessment of the meaning of i l l n e s s to RHD pat-ients and th e i r families can be made, some c l a r i f i c a t i o n on what i s meant by the terms i l l n e s s and disease, i s necessary. I l l n e s s has been defined by Flanders Dunbar, "as the deviation from health or from a state i n which a l l natural a c t i v i t y and functions are performed f r e e l y and e f f i c i e n t l y without pain or discomfort". Disease, on the other hand, i s the "abnormal state of the body r e s u l t i n g from harmful e f f e c t s of the proces-2 ses, injurious substances or accidents". From these d e f i n i -tions i t follows that i l l n e s s i s the subjective or a f f e c t i v e 1 See p. ( 49 }. 2 Flanders Dunbar, Emotions and Bodily Changes, 1946, i n t r o . to 3rd edition, p. SIX. (5) reaction of the i n d i v i d u a l , whereas disease i s the objective observable reaction. As C. G. Robinson has pointed out, i l l -ness, therefore, i s greater than disease because i t can exist 1 with or without objective recognition by others. Involved here, i s an awareness of the t o t a l environmental and hereditary forces which aff e c t the i n d i v i d u a l with RHD or any other disease. This multiple approach to i l l n e s s i s what i s meant by the term, the patient- - as - a whole. The i n d i v i d -ual meaning which his i l l n e s s holds for him, must be examined and treated i f the e f f e c t of the disease i s to be completely understood. The way he f e e l s as a r e s u l t of his disease, i s more than a recognition or observation of physical signs. The RHD patient who continues to work at strenuous employment because he i s unable to accept the diagnosis of his doctors, i s an example of t h i s . Not only i s i t necessary to consider the need for physically l i m i t i n g his a c t i v i t y here, but con-sideration must also be given to such complicating factors, as t h i s patient's inner need to gain approval through displays of physical prowess, his i n a b i l i t y to f i n d or perform less strenu-ous kinds of work, the immediate f i n a n c i a l debts which i l l n e s s has created, the physical needs of his family, etc. As a further point .of consideration, since a patient suffer-ing from a chronic disease i s a member of a family and of soc-i e t y , he i s not only being affected by them but they i n turn are affected by him. Therefore, i t i s reasonable to expect 1 George C. Robinson, The Patient As A Person, p. 3-4. (6) that they too w i l l need to be "understood" before the t o t a l reaction-pattern surrounding the disease i s known. The b e l l i -gerent attitude of the wife of an RHD patient who ;is forced to assume the position as breadwinner of the family, or of friends, employers, etc., who cannot understand the need for a long con-valescent period for an RHD patient who 'looks" perfectly healthy, are more common i l l u s t r a t i o n s of t h i s . Background of Medical S o c i a l Work Practice The recognition of the need to evaluate the patient-as-a whole, i s one of the basic elements of s o c i a l work practi c e . The development of t h i s more-complete approach, of course has not been confined to the profession alone, but has resulted from advances made i n the l a t e nineteenth and early twentieth century by several i s o l a t e d d i s c i p l i n e s . The profession of s o c i a l work as i t i s recognized and practiced today, i s one which s o c i a l workers have incorporated from the contributions a l l i e d s o c i a l sciences such as psychiatry, anthropology, s o c i -ology, etc., have been making. As a r e s u l t , newer s k i l l s i n understanding and treating human behaviour have been developed by the s o c i a l worker, so that the emotional as well as the en-vironmental problems of the i n d i v i d u a l are being given consi-deration. To understand how s o c i a l work i n a h o s p i t a l s e t t i n g emerged as a specialized branch of the general s o c i a l work f i e l d , con-sideration must be given to the developments which have also occurred i n the f i e l d of medicine. As the role of the general p r a c t i t i o n e r gave way to the demands for s p e c i a l i z a t i o n at the (7) beginning of the twentieth century, vast storehouses of medical knowledge began to accumulate. Yet, despite t h i s tremendous advance towards medical perfection, the purpose for which i t had been designed, appeared to be the elimination of disease, rather than the amelioration of the condition of the i n d i v i d u a l suffering from t h i s disease. In recent years, many doctors have begun to r e a l i z e that impersonal s c i e n t i f i c analysis of i s o l a t e d sections of the human anatomy has not been s u f f i c i e n t . The general p r a c t i t i o n e r , without a l l the specialized knowledge of today, at least knew his patient as a member of a family and a community. There were times when h i s treatment of the "whole" patient, was more e f f e c t i v e than the medicine he had at h i s d i s -posal. As the awareness of the need to base diagnosis and treatment on the patient-as-a whole began to take hold, the contribution of the general p r a c t i t i o n e r became more evident. However, a return to t h i s form of medical practice appeared impractical i n view of the need for s p e c i a l i z a t i o n which increased medical knowledge demanded. Instead, there arose a growing demand fo r s o c i a l workers who could help the doctors understand and treat the s o c i a l aspects of the patient's i l l n e s s . Most important here at f i r s t , was the follow-up service which s o c i a l workers could do for a patient whose doctor had prescribed s p e c i f i c con-valescent treatment measures inaccessible to the patient. The r o l e of the s o c i a l worker i n a medical se t t i n g has con* tinued to expand, since such a position was f i r s t created i n 1904 1 M. A. Dennis, "Medical S o c i a l Work", Canadian Welfare, p. 31. 18J As s o c i a l workers moved into the medical f i e l d , they too found i t necessary to broaden t h e i r s k i l l s , for i t was soon learned that "environmental manipulation" was not the f i n a l answer to a patient's problems. By t h i s time, advances i n psychiatric thinking were opening up new channels for understanding the "whole" patient. The incorporation of psycho-social s k i l l s necessary to treat the emotional disturbances displayed by pat-ients, added to the value of the s o c i a l worker i n a h o s p i t a l s e t t i n g . Recognition by the medical profession of the need f o r t h i s l a t t e r function to be performed by s o c i a l workers, i s s t i l l unaccepted to a great extent. Emergence of the Treatment Team Drawing from the general body of s o c i a l work knowledge, medical s o c i a l workers^- continually revised t h e i r methods of therapy. While development i n t h i s f i e l d had much to gain from the advance of case work practices i n related f i e l d s of s o c i a l work, i t became evident that a difference i n approach would be necessary because of the type of se t t i n g i n which medical soc-i a l work was being performed. The method of handling emotional problems of patients within the framework of a h o s p i t a l s e t t i n g and without the co-operation of doctors, nurses, d i e t i c i a n s , etc., who came i n more frequent contact with the patient, appear-ed i n s u f f i c i e n t . I f i t was to be the p a t i e n t - a s - a whole who was to receive treatment, then due consideration had to be given to 1 S o c i a l workers who perform t h e i r services i n a medical set-t i n g . (9) the part played by each member of the h o s p i t a l s t a f f interested i n the patient's recovery. For example, one of the records used i n t h i s study indicated that an RHD patient was continually becoming upset because he f e l t the h o s p i t a l s t a f f was "against him" and was punishing him by t h e i r " r i g i d " demands. Consulta-t i o n with the nurses and attendants involved, revealed that pa-t i e n t was constantly misinterpreting the requirements of hospi-t a l routine. Because the h o s p i t a l s t a f f , i n the performance of th e i r d a i l y tasks, were not aware that the patient did not un-derstand what was expected of him, they f e l t that the patient was just a chronic complainer. As a r e s u l t of these s t a f f con-sultations, the members of the treatment team understood why the patient had acted as he did, and were then i n a better posi-tion, to avoid future emotion-provoking incidents. At the same time, the s o c i a l worker was able to interpret to the patient the reason for the actions of the h o s p i t a l staff, so that he no longer became upset by t h e i r requests. In many instances i t was easy to see where overzealous wor-kers would create resentment from nurses, d i e t i c i a n s , etc. Too . often there appeared to be much overlapping of services rendered. As the process of s p e c i a l i z a t i o n extended to each of these pro-fessions, i t was necessary for each of them to recognize the r e s u l t i n g narrowing of service t h i s produced, i n much the same way as the medical profession had done. For example, whereas nurses had formerly administered earnestly, although u n o f f i -c i a l l y , to the patient's s o c i a l needs outside of the h o s p i t a l , i t became d i f f i c u l t to accept the s o c i a l worker who was now -taking over th i s f i e l d of endeavour. Some nurses mistakingly • (10) f e l t t h e i r role i n the h o s p i t a l might be taken over completely i f such practices were to continue. This problem of s e t t i n g boundaries of service, has extended to a l l the growing s p e c i a l -i s t s i n the h o s p i t a l , i . e . occupational and physio-therapy, die-t e t i c service, etc., and i s one which today, i s s t i l l not corn© pletely resolved. Since treatment of the patient i s ca r r i e d on i n a medical setting, i t was only natural that the doctor as the leading s p e c i a l i s t i n t h i s f i e l d , should be c a l l e d upon to d i r e c t the therapeutic e f f o r t s of the treatment team. S o c i a l workers have been accepting, i f not demanding of t h i s . Each member of the team has a job of removing symptoms, while i t i s the doctor who best determines what these symptoms are and how they can best be treated. Where there are emotional strains i n evidence, that member of the team which i s s p e c i f i c a l l y trained to remove them, namely, the s o c i a l worker, should be c a l l e d upon by the leader. Moreover, i t i s the medical s o c i a l worker who'is i n a l o g i c a l position to interpret to the doctor as well as to the other team members what psychological and s o c i a l meaning the patient's i l l n e s s holds for him. A ready example of t h i s appears i n the anxious, disagreeable patient- mentioned pre-viously, (p. 9), who seemed unaccepting of treatment because he was beset with fears a r i s i n g out of his hospitalization^. Be-cause he was unable to express these fears to the h o s p i t a l s t a f f , his anxiety mounted and his behaviour on the wards be-came worse. The s o c i a l worker was able to interpret these fears to team members i n such a way that they could not only accept the patient's behaviour, but were better able to offer ' (11) support to him i n the a l l e v i a t i o n of his fears, rather than further antagonizing him. Psychosomatic Medicine Mention has already been made of the incorporation of psy-chiatry and medicine into s o c i a l work practice. More s p e c i f i -c a l l y , the u t i l i z a t i o n of what has been c a l l e d psychosomatic medicine, has been most useful. Without engaging i n any of the controversy centering around the use of t h i s term, 1 recognition i s given to the greater understanding which the psychosomatic approach has created i n terms of causation and treatment of i l l n e s s and disease. Flanders Dunbar suggests that there w i l l come a time when there w i l l no longer be any need to di s t i n g u i s h between the terms psychosomatic and medicine, for they w i l l be accepted as being synonymous. Regardless of what terms are used, as long as they involve the study of the patient as a part of a whole int e r r e a c t i n g system, who both a f f e c t s and i s affected by h i s relationships with others, and who i s guided by i n t e r l o c k i n g i n t e l l e c t u a l and emotional responses to inner and outer stres-ses and s t r a i n s , then the welfare of t h i s i n d i v i d u a l i s best understood. S o c i a l workers attempt to incorporate the advan-tages which this system has to o f f e r , but they do not f e e l that t h i s i s the l a s t answer i n research. Much more research i s 1 Further information on t h i s dilemma i s discussed i n two well-known books on the subject by Flanders Dunbar, Psycho- somatic Diagnosis, and Emotions and Bodily Changes. (12) needed i n every aspect of i l l n e s s . The study of the ef f e c t s , created by RHD, i s but one of these specialized projects which must be investigated and incorporated into the e x i s t i n g know-ledge that i s now possessed. Research Method Used To assess the true meaning of i l l n e s s which RHD holds for male adults, there are many questions which need in v e s t i g a t i o n . For example, what kind of a person are the team members of the ho s p i t a l s t a f f dealing with? Is there a pattern surrounding the immediate onset of h i s i l l n e s s , which, when examined i n terms of a personality adjusting to a l i f e s i t u a t i o n , reveals an "escape" through i l l n e s s and disease? What are the patient's environmen-t a l relationships? What do his parents mean to him, his bro-thers and s i s t e r s , his r e l a t i v e s and friends? What does h i s i l l n e s s mean to them? Is he married and, i f so, what eff e c t has his i l l n e s s on his wife and children? Are there economic d i f f i -c u l t i e s , inadequate sexual relationships, employment problems? Keeping in mind the r e s t r i c t i n g elements which the i n d i v i d u a l with RHD faces, how has he accepted .these l i m i t a t i o n s ? Is he r e a l i s t i c or does he deny the need for these l i m i t a t i o n s ? To explore some of these questions, an analysis has been made of case records of male patients at Shaughnessy h o s p i t a l who were or are a f f l i c t e d with RHD and who were referred for medical s o c i a l service. Over one hundred cases of patients known to the ho s p i t a l since 1947 up to the present time (1951), have been cross-checked with medical s o c i a l service f i l e s and 25 of these, ranging from ages 21 to 83,have been f i n a l l y o (1-3) selected. Because of t h i s l i m i t a t i o n i n case selection, no d i s t i n c t i o n has been drawn between active or inactive RHD pa-t i e n t s . 1 Also, since the majority of these patients i n a vet-eran's h o s p i t a l are a good deal older than the average person admitted to a general h o s p i t a l , i t has not been possible to select cases where RHD was the only disease a f f e c t i n g the pa-t i e n t . Generally speaking, increasing age has brought with i t many other complications for the RHD patient. I t i s not possible to assess the representativeness of the cases selected as against the t o t a l number of RHD patients treated at the h o s p i t a l . Because every patient used i n t h i s study has at one time or another been referred for s o c i a l ser-vice f o r some s o c i a l or emotional problem, i t does not neces-s a r i l y follow that there were no problems a f f e c t i n g those pa-ti e n t s who were not referred. However, i t may be assumed that t h i s study i s dealing with a highly selective group of patients since there i s i n s u f f i c i e n t h i s t o r i c a l information available i n the medical records of patients who.were not referred, from which comparisons can be made. In order to obtain s u f f i c i e n t background material f o r each of the patients selected, i t was necessary to u t i l i z e records of other-divisions of the department of veterans' a f f a i r s , as well as other s o c i a l agencies i n the community. Unfortunately, i n many of the cases used, medical s o c i a l service f i l e s were -^extremely li m i t e d . . Usually a short contact with the patient 1 See Appendix A for d i f f e r e n t i a t i o n of active and inactive RHD. (14) did not necessitate a lengthy in v e s t i g a t i o n . The most valuable resource available, has been the D i s t r i c t Office f i l e , which incorporates not only the medical s o c i a l service reports, but also those of s o c i a l service d i v i s i o n , veterans' welfare o f f i -cers, medical examiners, nursing s t a f f , occupational therapists, pensions advocates, etc. In some of the cases where contact had been or was being made by medical s o c i a l workers who were s t i l l on s t a f f at the ho s p i t a l , a gfeat deal of highly-important addi-t i o n a l material was obtained through consultations with them. However, despite these attempts to complement missing material from other resources, on the whole there are many gaps which have not been overcome. Information involving the emotional reactions surrounding the development and prolongation of RHD, and early personality formation, have been the weakest areas of the research. Presentation of the material obtained, lends i t s e l f into three d i v i s i o n s . The f i r s t of these cover the s o c i a l and per-sonal factors involved prior to, during and following the dev-elopment of, not only the o r i g i n a l , but also recurrent attacks of RHD. Included here are the early environmental influences surrounding the development of his i l l n e s s , such as parental, s i b l i n g and community relationships, educational attainment, c u l t u r a l pressures, kinds of employment, economic s t a b i l i t y etc., as well as the l a t e r s o c i a l pressures of marriage, c h i l -dren and the a b i l i t y to maintain the role of a breadwinner. Concurrent with these s o c i a l s timuli i s the personal adapta-t i o n of the i n d i v i d u a l patient to these multiple outer stresses and s t r a i n s . The patient's reaction to his i l l n e s s and h i s (15) desire and a b i l i t y to obtain and follow medical advice, the eff e c t of h o s p i t a l i z a t i o n , the mental outlook towards growing physical l i m i t a t i o n and employment demands, dependency-indepen-dency c o n f l i c t s i n terms of early adjustments and l a t e r marital compatibility, make up the major points of consideration here. In essence, this' f i r s t d i v i s i o n attempts to present the patient-as-a whole and the pa r t i c u l a r meaning which his i l l n e s s holds for him, as well as the more general c h a r a c t e r i s t i c s which a l l RHD patients hold i n common. the The contribution of s o c i a l worker i n a medical setting i n a l l e v i a t i n g these s o c i a l and emotional pressures, i s included i n the second area of presentation. Medical s o c i a l work i s es s e n t i a l l y s o c i a l case work practiced i n a medical se t t i n g . Case work f o r the purpose of t h i s study can be defined as a pro-cess which uses professional s k i l l s or techniques designed to help the i n d i v i d u a l , alone.or as part of a family, to resolve the c o n f l i c t s which r e s u l t from h i s environment and/or from inner tensions. Because these c o n f l i c t s i n t e r f e r e with the i n -dividual's a b i l i t y to make a satisfactory s o c i a l adjustment, i t has been necessary for him to seek outside help or to be dir e c -ted to i t by others. The pa r t i c u l a r use of d i f f e r e n t i a l thera-peutic case work s k i l l s , i n meeting these i n d i v i d u a l problems which the patient presents i s therefore included here. Although the members of the RHD patient's family are con-stantly a f f e c t i n g and being affected by the patient, the par-t i c u l a r reaction which these members have as a re s u l t of the presence of i l l n e s s i n the family, i s another area which lends • i t s e l f to an in d i v i d u a l presentation. Since the majority of (16) the patients are or have been married, i t i s to be expected that t h e i r wives w i l l be most d i r e c t l y a f f e c t e d by the i l l n e s s . Also seriously involved, however, are parents and s i b l i n g s as well as the children i n the home. The extended e f f o r t which the s o c i a l worker makes i n a l l e v i a t i n g the stress of the family members, so they i n turn can better a i d the patient i n h i s re-covery, completes the f i n a l part of the presentation. In using only the case records which have been referred to medical s o c i a l service i t i s passible that a non-representative sampling of rheumatic heart patients was used. I t i s f e l t , however, that t h i s does not inv a l i d a t e the res u l t s obtained, be-cause the major difference between patients referred or not re-ferred, has been i n the i n d i v i d u a l judgement of the doctor on the case. An attempt w i l l be made to show that a random sampling of patients not referred for medical s o c i a l service would appear to have similar reactions to t h e i r i l l n e s s . Because these are case records of veterans only, there i s a danger i n drawing conclusions which do not apply to a l l male adults a f f l i c t e d with RHD. Where war service has contributed to the i n d i v i d u a l ' s f e e l i n g about h i s i l l n e s s , t h i s w i l l be noted, but hopefully only as added stresses and strains rather than exclusive p r e c i p i t a t i n g factors. In other words, emphasis w i l l be placed on the types of emotion-producing situations which any male adult with RHD may be expected to react to i n a similar manner. F i n a l l y , since t h i s i s a s o c i a l work approach to the meaning of i l l n e s s , stress i s placed upon the s o c i a l rather than the (17) s t r i c t l y medical aspects of the disease and i t s meaning to the patient. This should not i n any way exclude, however, the com p l i c a t i o n s which arise out of the emotional reaction to the physical presence of RHD. CHAPTER 2  SOCIAL AND PERSONAL IMPLICATIONS The i n a b i l i t y of the RHD patient to cope with his ever-increasing f i n a n c i a l burden, i s perhaps the most s t r i k i n g , though i t i s perhaps the most obvious c h a r a c t e r i s t i c of the cases examined. In every case referred to medical s o c i a l ser-vice, the patient was either overwhelmed by medical expenses and reduction of income, or was i n receipt of some form of f i n -a n c i a l assistance, e.g. pension or dir e c t r e l i e f , which did not completely meet the requirements of himself or those dependent upon him. Although approximately one quarter of the t o t a l number of cases diagnosed as RHD were, referred for medical s o c i a l service, i t i s reasonable to expect that the majority of those cases which were not referred, also had some f i n a n c i a l d i f f i c u l t y sur-rounding t h e i r i l l n e s s . This conclusion i s based upon the fact that admittance to Shaughnessy h o s p i t a l i s mainly determined by the following e l i g i b i l i t y requirements. Where a veteran, (1) i s i n receipt of pension for a d i s a b i l i t y which prevents him from earning an adequate income, (2) i s unemployable and i s granted a war veterans' allowance because he i s able to meet ce r t a i n war-service requirements, (3) can pass a means test, although he i s not i n receipt of veterans' aid, and (4) i s over sixt y years of age, i n f i n a n c i a l need, and therefore i s e l i g i b l e for permanent domiciliary care, he can qualify for treatment. The l a t t e r forms of e l i g i b i l i t y e.g. war veterans' allowance, etc., are .more-acceptable substitutes for d i r e c t r e l i e f or s o c i a l assis-. (19) tance which municipal and p r o v i n c i a l governments provide. This i s because the veteran looks upon h i s p a r t i c u l a r type of e l i g i -b i l i t y as a " r i g h t " , rather than as an admittance that he has f a i l e d to adapt himself to s o c i a l demands. Incidence of S o c i a l Pressures The RHD patient's f i n a n c i a l d i f f i c u l t i e s are mainly explain-ed by h i s increased i n a b i l i t y to compete on the labour market. In 88 per cent of the cases examined, patients were engaged i n some form of heavy physical labour p r i o r to the onset of t h e i r i l l n e s s . As a rule, these patients had l i t t l e education. Only two patients appeared to have any high school t r a i n i n g , none of these completing high school. Many came from low i n -come families and were forced to leave school at an early age i n order to help support t h e i r f a m i l i e s . Regardless of moti-vation, the general practice was to accept some form of un-s k i l l e d heavy labour. Of the case records which contained such material, f o u r - f i f t h s followed t h i s pattern. Although three cases reveal some s t a b i l i t y i n employment, the majority i n d i -cate frequent changes i n both nature and l o c a t i o n of t h i s . Following the development of rheumatic fever and/or rheumatic heart disease, many continued to work i n heavy industry. Over f i f t y per cent of the case records indicate an attempt to f i n d more suitable work, whereas only eight per cent appear success-f u l i n achieving t h i s . I t i s reasonable to expect that t h e i r decision to remain with such employment, was lar g e l y affected by t h e i r need to meet the demands of f i n a n c i a l r e s p o n s i b i l i t y . Among the cases examined i n t h i s study, only one patient, (20) a 28-year-eld veteran, did not get married. The rest of the case records indicate a continuous series of divorce, separa-t i o n and general upheaval i n marital situations, which seem to go hand i n hand with increased severity of physical symptoms, i n a b i l i t y to maintain employment, and added f i n a n c i a l burdens. Of the 19 cases containing such information, seventeen reveal indications of unhappy marriages and nine show divorce or sep-aration occurring at l e a s t once. Children born to these coup-l e s , appeared to add to the d i f f i c u l t i e s . Only 30 per cent of the cases had information about children, but a l l of these i n -dicate that the larger the; family, the greater the f i n a n c i a l burden for the patient. Where adequate f i n a n c i a l means are lacking, i t i s to be expected that inadequate standards of food, housing and c l o -thing are to be found. Although only a few of the records were complete enough to bring out these i n s u f f i c i e n c i e s , these re-vealed the need for more adequate housing as one of the chief problems which was encountered by the RHD patient and which affected the adequacy of h i s convalescence. None of the case records indicated housing conditions which were s a t i s f a c t o r y , whereas at l e a s t 52 per cent revealed deplorable accommodations. For example, one patient would return to his cold, damp, badly dilapidated house-boat, between his successive h o s p i t a l i z a t i o n s . Although c u l t u r a l differences are important aspects for con-sideration when one i s t r y i n g to understand the t o t a l patient, t h i s factor i s not apparent i n the examination of the selected cases. However, r a c i a l and r e l i g i o u s differences - especially .where they apply to "minority" or " i n f e r i o r i t y " groups - may . (El) enter the picture insofar as enforced segregation leads to les s opportunity for f i n a n c i a l gain, adequate housing, etc. Case Examples of So c i a l Pressures The f i r s t case i s that,of a 35-year-old RHD patient, who within six years a f t e r acquiring h i s f i r s t known acute attack of RHD, suffered rapid physical deterioration and eventually died. His early history reveals that aft e r f a i l i n g and repeating grades f i v e , six and seven, at the age of 15 he l e f t school. His employment record indicates that he went from job to job, alternating between various occupations including horse trad-ing, shoe repairing, waiter, b e l l hop, bar tender, boilermaker's helper, etc., so that by the time he joined the army 14 years l a t e r , he had developed l i t t l e s p e c i a l i z e d s k i l l . Two years after he enlisted, he was discharged with an aggravated rheu-matic heart condition, which was thought to have originated p r i o r to his service career. He then attampted unsuccessfully to engage i n various types of strenuous unskilled employment, but on each occasion, an exacerbation of h i s condition resulted. Four years l a t e r h is d i s a b i l i t y was considered 100 per cent. The patient's marital history i s equally as unfortunate. After l i v i n g i n common-law r e l a t i o n s h i p with a married woman and then being involved i n her husband's subsequent su i t for the divorce, patient married her shortly a f t e r h i s discharge from the army. As expected, marital relationships gradually deter-iorated. Two years a f t e r t h e i r marriage, the patient was re-ported as harbouring suspicions that his wife was carrying on (22) with other men, and that he was c h i l d i s h l y demanding of her. She was noted as complaining of d i f f i c u l t y i n sexual r e l a t i o n -ships. No children were born to them. The patient's f i n a n c i a l inadequacy mounted with each ex-acerbation of his condition. At f i r s t h i s wife compensated for th i s through p a r t i a l employment, but eventually, she too became i l l . Through s o c i a l assistance from c i t y agencies and a small pension from the department of veterans* a f f a i r s , the patient and h i s wife ca r r i e d on as best they could. That t h i s was i n * s u f f i c i e n t , i s evident, for an investigator's report stated the patient was l i v i n g i n a "crowded, damp and poorly furnished t h i r d f l o o r apartment", despite the recommendation of his doc-tor that the patient required "housing on the ground f l o o r that i s kept warm and dry; also, that he l i v e where no s t a i r s need climbing". A year l a t e r , he died. Another example, i s the case of a 42-year-old veteran, whose rheumatic heart condition appears to have originated during his early childhood at a time when he developed an attack of chorea. Although suffering mildly from various rheumatic aches and pains, he appeared to be i n good health u n t i l he enl i s t e d i n the army i n 1939. He was subsequently discharged with a sore back and an inactive RHD condition. The patient l e f t school at the age of 10 a f t e r completing two grades, but l a t e r taught himself how to read and write. His work history i s very sporadic. In the 20 years prior to his enlistment, i t i s noted that he was engaged i n at le a s t f i v e d i f f e r e n t types of heavy unskilled labour e.g. farming, r e l i e f .gangs, etc., but there i s no in d i c a t i o n how many di f f e r e n t jobs (23) he held or where he worked, except that he did not remain long at one type of work.. Much i n s t a b i l i t y was also noted i n h i s post war employment - i n one seven-month period he moved through f i v e jobs which were obtained f o r him by r e h a b i l i t a t i o n o f f i -cers. A l t h o u g h ^ i t i e n t was not bothered too much by h i s heart condition at f i r s t , a chronic a r t h r i t i c condition r e s u l t i n g from his back injury, paved the way for his li m i t e d earning capacity and subsequent f i n a n c i a l d i f f i c u l t i e s . P r i o r to his enlistment the patient married a blind woman. L i t t l e i s known of his r e l a t i o n s h i p with her, except he was away from home most of the time. She died shortly a f t e r he was discharged, and i t was then noted that they had been i n severe economic d i s t r e s s most of the time. The patient remarried about a year and a h a l f l a t e r , to a young woman th i r t e e n years h i s junior. During the next eight-year period, she was admitted to the mental h o s p i t a l f i v e times for a schizophrenic disorder. The patient also spent the major portion of these years i n hos-p i t a l . Two children were born to them,and i t i s s i g n i f i c a n t , that as a re s u l t of the frequent h o s p i t a l i z a t i o n s of the par-ents, the burden of providing and financing foster home care became the r e s p o n s i b i l i t y of community agencies. As medical b i l l s mounted for both the patient and his wife, they became completely dependent upon welfare agencies. As a re s u l t of the patient's ever-mounting f i n a n c i a l d i f f i -c u l t i e s and further i n a b i l i t y to accept employment, i t i s not surprising that investigators found the patient's l i v i n g condi-tions completely inadequate. In 1948, one investigator pointed out that the whole family was l i v i n g i n a "two-room untidy (24) suite", that both the veteran and h i s wife were " i n poor heal-th and required better food", and that ''poor clothing for the whole family" was much i n evidence. A more recent study made by an interested community agency, indicated that they were "quite distressed by the deplorable conditions under which the veteran and h i s family are l i v i n g " . At the time t h i s study was made, the patient had just com-pleted another six-month h o s p i t a l i z a t i o n and was reunited with hi s family. Considering the l a t e s t investigator's report ava i l a b l e , i t wa.s to be expected that his return to the hospi-t a l within a short time was ine v i t a b l e . L i v i n g conditions were c l a s s i f i e d as below-average, as the family was l i v i n g i n a "dilapidated old building, infested with cockroaches". His wife had recently returned from the mental h o s p i t a l but i t was doubtful how long she could carry on. The patient's t o t a l i n -come with which he was expected to create a more suitable en-vironment, was a minimum assistance grant which included the care of his wife but not h i s children.^ These two cases i l l u s t r a t e the ever-increasing i n t e r a c t i o n of s o c i a l factors a f f e c t i n g the RHD patient, which ultimately influences h i s poor prognosis for r e h a b i l i t a t i o n . I t can be said that t h i s developing pattern i s c h a r a c t e r i s t i c of other chronic i l l n e s s e s as well as RHD. The writer does not dispute the point, but instead, has attempted to show only that these "factors do e x i s t . However, i n order to understand the 1 War veterans' allowance does not include payments for c h i l -dren of veterans. (25) p a r t i c u l a r significance of these s o c i a l factors to the rheuma-t i c heart patient, i t i s necessary to examine as well, the per-sonality pattern a f f e c t i n g and being affected by t h i s s o c i a l environment. Although i n r e a l i t y i t i s not always possible to d i f f e r e n t i a t e between these inner and outer pressures, t h i s i s being done because a more convenient d i v i s i o n of material i s thus obtained." Personality Patterns Probably the most in c l u s i v e study on the developing person-a l i t y structure of the patient who i s a f f l i c t e d with RHD,has been done by Flanders Dunbar."'" In the main, the r e s u l t s of t h i s present study do not c o n f l i c t with her findings. Where-as her case selection consisted solely of RHD patients, t h i s research project has included patients who suffer from other physical complications as well. Therefore, i t i s to be expec-ted that some of the differences i n findings can be at t r i b u t e d to t h i s discrepance. This problem of case selection has a l -2 ready been dealt with e a r l i e r . Dunbar has shown that the RHD patient i s e s s e n t i a l l y an i n -adequate person who i s i n c o n f l i c t with authority. Because thi s type of person has developed a sense of Inadequacy, he f e e l s he i s unable to compete favourably with h i s s i b l i n g s for his parents a f f e c t i o n . Instead, he i s l i k e l y to imitate or 1 Flanders Dunbar, Psychosomatic Diagnosis, pp. 367 - 435. 2 See pp. (12-14) i n Chapter 1. (26) curry favour with one or the other parent1;' Generally speaking, hi s parents are s t r i c t and, he prefers t h i s . By e x p l o i t i n g h i s abnormality and his a b i l i t y to suffer, he derives pleasure through the esteem which he receives from being able to take punishment. As he acquires t h i s mode of behaviour, he learns to decrease greatly h i s tendency to express aggression or r e -sentment. The outlet for t h i s repressed h o s t i l i t y appears i n a non-directive urge to a c t i v i t y . The patient then appears to deny the presence or make l i g h t of h i s i l l n e s s , as he becomes s e l f - n e g l e c t f u l and overexerts himself. Where overt expres-sion of t h i s self-punishing device i s blocked, the patient may resort to day-dreams or i n f a n t i l e phantasy.^" Unfortunately very few records used i n t h i s study, contain-ed s u f f i c i e n t data from which an understanding of early person-a l and family relationships could be obtained. Judging from the l a t e r behaviour of the patients, as recorded i n the medical s o c i a l service f i l e s , some s i m i l a r i t i e s do occur, however, i n the main, the r e s u l t s of t h i s area of research have been on a more subjective l e v e l than would have preferred by the writer. In any event, considering the intangible quality attached to emotions and feelings, the problem of overcoming a subjective analysis of such material i s a d i f f i c u l t one. Probably the most outstanding feature noted, was the mar-ked emotional dependence of the RHD patient upon some mother--figure (e.g. mother, wife, s i s t e r , e t c . ) . Crying s p e l l s were 1 Ibid . , pp. 429 f f . (27) frequent, especially -when the patients began ta l k i n g of t h e i r f r u s t r a t i o n s r e s u l t i n g from their marriage r e l a t i o n s h i p s . Ano-ther outstanding feature, was the appraisal which most wives gave of their sick spouses. Approximately 7E per cent i n d i c a -ted t h e i r husbands were usually very quiet; also, that they were usually poor conversationalists i n company. Although f i f t y per cent of the cases indicated some attempt to curry favour, i t i s s i g n i f i c a n t that approximately another 35 per cent gave some evidence of being unmanageable because of t h e i r aggressive behaviour. At least three patients would defy treatment by indulging i n excessive a l c o h o l i c drinking bouts. Some of the i r r i t a b i l i t y was accentuated by the hospi-t a l s t a f f being unable to put up with the petty f a u l t - f i n d i n g of these patients. This marked evidence of aggressive behav-iour, i s one of the more s i g n i f i c a n t deviations from the f i n d -ings which Flanders Dunbar produced. However, the writer f e e l s that this i s not an i n d i c a t i o n of a difference i n personality p r o f i l e , but instead, i s evidence, that for some patients, the mental mechanism of currying favour breaks down to the point where a further retreat to an e a r l i e r l e v e l of aggressive be-haviour takes p l a c e . 1 The rheumatic heart patient, then, would appear to be a person who has not been able to accept the adult r o l e . When 1 A more-detailed description of the t h e o r e t i c a l implica-tions that are involved here, i s found i n Anna Freud, The Ego  and Mechanisms of Defense. Also, as an example of t h i s see p. I 36 ). (28) pressures become too great, he seems to regress to an e a r l i e r desire to exploit his i l l n e s s , so that he w i l l then be cared f o r . He i s usually timid and lacking i n s e l f - r e l i a n c e and attempts to please i n his appeal for sympathy. I t would appear that he i s i n constant c o n f l i c t with the uns a t i s f i e d longing for the security which his unstable childhood never provided him. The long h o s p i t a l i z a t i o n and convalescence which follows recurrent attacks, possibly provides the substitute source of th i s need to be cared f o r , so that the comfort gained by h i s acquirement of h i s disease, would overshadow the s u f f e r i n g which inevitably follows. Case I l l u s t r a t i o n s of Personality Patterns (1) E s s e n t i a l l y Passive - The f i r s t case-is that of a 44-year-old veteran of the f i r s t world war, "whose s o c i a l h i s -tory i s quite similar to the previous examples described. The second eldest son of a family of s ix boys, patient r e c a l l e d his father as being overly s t r i c t and at times unjust i n h i s punishment. His father was the type who did not hesitate to use a whip, especially when he got drunk. The patient's mother was the quiet type who sometimes defended the children and "expressed thanks that they were a l l boys". The patient was apparently a strong and husky c h i l d " i n spite of h i s small stature". He preferred being close to home i n h i s early years, however, when the family came to Canada when he was 21, they decided to return to t h e i r native land and he and one brother remained i n Canada. He spent a br i e f period i n the B r i t i s h navy at the age of 17, but soon developed his f i r s t attack of (29) rheumatic fever and was discharged with a pension for RHD. While i n Canada, he engaged i n heavy bush and farm labour. His second attack of RHD, which occurred seven years a f t e r the f i r s t one, and which demanded f i v e months of h o s p i t a l i z a t i o n , forced him to give up t h i s strenuous work. Shortly af t e r his h o s p i t a l i z a t i o n , he married a g i r l nine years younger than himself, (she was 16 at the time), because he f e l t sorry for her. He remembers that she had parents quite similar to his own. The patient was employed almost continuously i n spite o f his physical handicap. Following his second attack, he was helped to f i n d l e s s exhausting employment, but i t was not long before he l e f t t h i s to engage i n more strenuous pursuits. His exercise tolerance gradually diminished and so did h i s f i n a n c i a l s t a b i l -i t y . After moving from job to job, he f i n a l l y succumbed to another attack of RHD. Again, after spending the major part of the following year and a h a l f i n a h o s p i t a l , he subsequently died. During t h i s period of h o s p i t a l i z a t i o n , the case was r e f e r -red to medical s o c i a l service because the patient was upset over marital d i f f i c u l t i e s . On being interviewed by a female worker, the patient was shy and nervous, and i t was with utmost patience that a s o c i a l history was f i n a l l y e l i c i t e d from him. He was l a t e r able to express that he usually f e l t uneasy with women, although t h i s f e e l i n g had somewhat diminished during his early adulthood. His main anxiety surrounded the fear that h i s wife wanted a separation. An interview with the p s y c h i a t r i s t revealed that the patient had developed impotency and blamed (30) M s wife because she had spurned h i s sexual advances. He -accus-ed her of being u n f a i t h f u l and said he had l o s t confidence i n her. (It i s i n t e r e s t i n g that she had previously accused him of the same thing.) Of significance, however,-is the r e l a t i o n s h i p between the onset of h i s impotency and the exacerbation of h i s i l l n e s s . Attempts to interview the wife, to get her side of the picture,were continually frustrated by the patient, because he was a f r a i d she would resent the fact that he had discussed t h e i r marital problem with others. He maintained that he d i s l i k e d crowds, did not dance, f e l t most comfortable with a few friends, read a l o t , and f e l t un-easy with women. In reference to his wife, he f e l t that per-haps he had been s e l f i s h , as he had wanted her-to himself and had not r e a l i z e d she might want to enjoy the company of others. 'Of the two children r e s u l t i n g from t h i s marriage, the pa-ti e n t was more attached to his daughter (age 15), and the mother was closer to her son (age 7). The patient expressed the c o n f l i c t which t h i s created, by pointing out that his wife resented the attention he gave to h i s daughter, and f e l t that his wife would be close to him again i f the daughter married and l e f t home. He had d i f f i c u l t y , however, i n deciding whether he was r e a l l y i n favour of his daughter ever getting married. What type of a person i s t h i s and what does h i s i l l n e s s mean to him? I t can be assumed from his e a r l i e r l i f e h istory that "the patient had never r e a l l y grown beyond the dependency stage. His f e e l i n g of i n f e r i o r i t y was f i r s t expressed by h i s r e c o l l e c t i o n of h i s small stature. His fear of his father was well expressed, although he was not so bold i n describing h i s • (31) mother. However, his fear of women i n general, plus-his mari-t a l c o n f l i c t , seem to indicate much stronger feelings towards a mother-person. The patient married a g i r l much younger than himself, so that he could be assured that he would be i n control of the household just as h i s father was. 1 He was e s s e n t i a l l y depen-dent upon the good graces of his wife, and when he found that she was unwilling to gr a t i f y h i s needs for love and a f f e c t i o n , he turned to h i s daughter for t h i s s t i l l - u n s a t i s f i e d security he sought as a c h i l d . I t i s quite probably that he resented the attachment of his wife to his son, i n much the same way as he would compete with h i s brothers and s i s t e r s for h i s mother's a f f e c t i o n . The patient's f i r s t attack of rheumatic fever occurred a f t e r he had l e f t home for the f i r s t time. At a stage where the drives of adolescence towards independence are strongest, the patient chose the l i f e of a s a i l o r to achieve t h i s freedom.-. However, his underlying dependency needs were re-awakened, and he was able to salve his conscience by developing a physical i l l n e s s which "forced" him to give up his independence. Again, aft e r coming to Canada, he attempted to resolve t h i s c o n f l i c t and almost succeeded. F i n a l l y , a f t e r driving himself, he end-ed up i n the h o s p i t a l once again. Soon a f t e r h i s recovery, he married and presumably he was able to f i n d enough s a t i s f a c t i o n 1 Emulation of a feared superior, especially i n phantasy, was a c h a r a c t e r i s t i c reaction of RHD patients noted by Flanders Dunbar, Psychosomatic Diagnosis, pp. 367 - 435. (32) from h i s wife and was thereby able to carry on. Twelve years l a t e r , when his marriage was severely threatened and early feelings of inadequacy were re-aroused by her r e j e c t i o n and h i s subsequent impotency, the patient succumbed to another attack. (2) E s s e n t i a l l y Aggressive - Another case, that of a 26-year-old veteran who developed RHD while i n the A i r Force, pre-sents a more v i v i d portrayal of an e s s e n t i a l l y immature person i n constant c o n f l i c t over feelings of dependence versus indepen-dence. Only a very b r i e f account of h i s early history i s known, however, the pattern i s well set and one can expect continuous h o s p i t a l i z a t i o n s r e s u l t i n g from h i s already-weakened physical condition and his emotional i n s t a b i l i t y . The patient i s described as having an uneventful and appar-ently-happy childhood. The only information which seems to throw some doubt on t h i s peaceful beginning, i s the fact that one of h i s s i s t e r s had a "nervous breakdown". After completing Grade ten, he l e f t school to engage b r i e f l y i n a variety of odd jobs - mainly farm labour and construction work. At nineteen years of age, he e n l i s t e d i n the A i r Force. F a i l i n g his a i r -crew examinations, he became quite upset by h i s demotion to general ground-crew duties, and i t was shortly afterwards, that he had h i s f i r s t attack of rheumatic fever. He was discharged with a t h i r t y per cent pension, and although he was warned against engaging i n heavy labour, his f i r s t post-service job was i n the shipyards performing strenuous tasks. Five years i n succession he was hospitalized f o r lengthy terms. He received considerable help from r e h a b i l i t a t i o n o f f i c e r s i n obtaining em-ployment that was i n keeping with his l i m i t e d capacities, but (33) he usually rejected most of these. He moved from place to place frequently, and although he had worked at many jobs, two years a f t e r his discharge from the service, a routine physical examination report revealed t h i s comment. The patient i s a tense psychoneurotic i n d i v i d u a l . . . . His joint pains are coincident with h i s desire to leave his employment, which he finds unsatisfactory.... The patient married four years a f t e r h i s service discharge and four months l a t e r a c h i l d was born. From the very begin-ning the marriage was a stormy one, and a f t e r a series of drinking and gambling bouts, unstable employment., i n f i d e l i t y , etc. - h i s wife l e f t him. As expected, t h i s was followed by a very b r i e f period be-fore h i s next h o s p i t a l i z a t i o n occurred. On admittance, i t was noted that " ...his pain seemed out of proportion to the f i n d -ings". A month l a t e r , the case was referred to medical s o c i a l service because he was disturbed over employment and marital d i f f i c u l t i e s . Interviews with the patient revealed that, Numerous jobs held by the patient would appear, for the most part, too heavy i n view of his medical condi-t i o n . .. .Some, he l o s t through h i s i l l n e s s but most, ad-mittedly, through heavy drinking bouts. The patient describes himself as impetuous....He gets depressed and drinks to combat this,...goes ab-solutely crazy when drunk, then "black" out completely. Feels g u i l t y about this....The patient seems immature and dependent....The patient showed worker a l e t t e r he wrote to h i s wife but had not mailed. In i t he begs her to come out, so that he can see her and the c h i l d . He points out that he has cried himself to sleep.... He r e i t e r a t e s h i s determination to give up drinking... but he admits that whenever he receives a shock he "goes o f f the deep end". I t was f e l t at t h i s time, that the patient's marital s i t -uation was extremely precarious, and that i t would be increas-( 3 4 ) ingly d i f f i c u l t for him to accept treatment, because of h i s restlessness. Hospital records indicated he would absent him-s e l f from the ward each evening, and would return i n a drunken state. I t was f i v e months before he was f i n a l l y discharged from the h o s p i t a l . Four months l a t e r - having worked at two jobs during this interval, he had joined A l c o h o l i c s Anonymous and was also reunited with h i s wife. This time he requested aid for h i s f i n a n c i a l problems, and was helped to obtain work as an orderly i n various h o s p i t a l settings. He seemed to be adjust-ing f a i r l y well, u n t i l a year and a h a l f l a t e r , when he once again manifested RHD symptoms while working as an orderly i n a small-town h o s p i t a l , which allowed him to return for further treatment. By t h i s time the pattern of dependency appeared more i n evidence, as an examination did not reveal s u f f i c i e n t physical basis for h i s symptoms. A psychiatric appraisal, however, i n -dicated patient's "personality s e t t i n g played some part i n h i s present complaints". He was discharged a month and a h a l f l a t e r , a f t e r consistently defying the author.atative require-ments of the h o s p i t a l , and when l a s t heard of, continued to display impetuous, irresponsible and immature behaviour. I t was also noted, that h i s pensionable d i s a b i l i t y had increased to f i f t y per cent. In t h i s case, as i n the other example used, the interreac-t i o n of a personality make-up and environmental stress, i s i n -dicated. The patient developed h i s f i r s t attack of i l l n e s s i n .the A i r Force,at a time when h i s f e e l i n g of inadequacy had (35) possibly been aroused. By f a i l i n g to become a member of the air-crew, he became extremely d i s s a t i s f i e d with the role he was then a sice d to play. The development of rheumatic fever provid-ed him with an acceptable outlet and he was able to escape from a f r u s t r a t i n g s i t u a t i o n . Subsequently, h i s pattern of i l l n e s s became well-established. I n i t i a l l y he l e f t the dependency of his home environment i n order to assume an independent status. His f i r s t means of escape from unsatisfying employment, was to jo i n the service. Following discharge, he continued to show ambivalent f e e l i n g s , as he consistently opposed the authority of an employment setting and s a t i s f i e d his dependency need by his acquired escape into i l l n e s s . His marriage added a further burden to him. He made impos-si b l e demands of his wife, especially a f t e r the b i r t h of the c h i l d , and when she f i n a l l y l e f t him, he was once again over-whelmed by increasing feelings of inadequacy and g u i l t . The patient displayed at le a s t two escape mechanisms which he used to cover up h i s i n a b i l i t y to face r e a l i t y demands - one was i l l n e s s , the other was alcohol. The l a t t e r allowed him to r e a l i z e h i s ambitions i n phantasy i f not i n fact. Flanders Dunbar points out that the taking of stimulants such as alcohol i n large doses, i s one way i n which an RHD patient could s a t i s f y h i s need to e x c e l l . Therefore, i f the patient could not be a success at anything else, at least he could e x c e l l as an alco-h o l i c . 1 The g u i l t and further depression which followed each 1 Flanders Dunbar, Psychosomatic Diagnosis, pp. 367 - 435. (36) drinking bout only served to remind him of the added proof of his inadequacy. In contrast to the type of patient who tends to repress h i s h o s t i l i t y , t h i s patient expressed i t more openly,. Although he sought the security of the hospital setting to cover up f o r h i s inadequacy, th i s did not allow him s u f f i c i e n t compensation. His frequent absences from the h o s p i t a l appeared to be a d e f i -ance against authority, 'although i t i s noted that he became drunk on these occasions. . The writer f e e l s the patient may have sought the extra stimulation of alcohol as an escape from the g u i l t he f e l t , whereas the former patient gained s u f f i c i e n t s a t i s f a c t i o n from the attention and sympathy, which hi s i l l n e s s afforded him. However as indicated p r e v i o u s l y , 1 t h i s i s pro-bably also an i n d i c a t i o n that the l a t t e r patient had regressed to: an e a r l i e r l e v e l of behaviour adaptation. Because of t h i s , h i s "primitive" desires would be more-readily expressed, and his a b i l i t y to combat these urges m o r e - d i f f i c u l t to arouse. The s o c i a l and emotional problems which appear to be a f f e c t i n g the course of. i l l n e s s of an RED male adult patient, have been presented. As suggested previously, i t i s possible to produce members of society who undergo similar stresses and stra i n s , yet do not develop RHD. The importance of t h i s i n -formation to the s o c i a l worker l i e s i n the recognition that such s o c i a l and emotional problems do appear i n the RHD patient -rand are influencing the physical aspects of the disease. The 1 See p. (27), (37) s p e c i a l s k i l l -which, t h e s o c i a l w o r k e r c a n c o n t r i b u t e a s a mem-b e r o f t h e h o s p i t a l t r e a t m e n t t e a m c o m b a t t i n g t h i s i l l n e s s , i s b r o u g h t o u t i n t h e f o l l o w i n g a r e a o f p r e s e n t a t i o n . CHAPTER 5 . CASE WORK WITH RHEUMATIC HEART PATIENTS Es s e n t i a l l y the problem of RHD i s a medical one, and i t i s not the purpose of t h i s study to minimize the ro l e which medi-cine has to play. However, as has been suggested before, the concomitant factors which appear to be a f f e c t i n g the course of the i l l n e s s , occur too frequently to be c l a s s i f i e d as mere co-incidence. The s o c i a l and emotional climate i n which the pa-ti e n t l i v e s , i s of prime concern to the s o c i a l worker, and i t i s towards the a l l e v i a t i o n of these problems a f f e c t i n g the i l l n e s s , that his specialized s k i l l s can best be put to use. Because he i s concerned with the patient-as-a-whole, h i s work on the patient's behalf w i l l extend beyond the boundaries of the h o s p i t a l . The s o c i a l worker maintains that e s s e n t i a l con-tact with the patient's family and community and attempts to u t i l i z e the services which they as well as the ho s p i t a l s t a f f can render to the patient on a continuing basis. The writer has pointed out that there i s a p a r i t c u l a r set of s o c i a l and emotional factors which a f f e c t most RHD patients. The s o c i a l worker, needs such information i n order to guide h i s appl i c a t i o n of case work s k i l l s towards a l l e v i a t i n g these pres-sures. However, at no time should the s o c i a l worker attempt to base his diagnosis and treatment on t h i s generalization alone, for i n each person there are i n d i v i d u a l differences which large-l y determine the depth and duration of emotional reactions to i l l n e s s . Eor example, where i l l n e s s has become an escape mech-anism for the patient, treatment involves more than just (39) breaking down t h i s defense. In t h i s sense, i l l n e s s has provid-ed the compensation for a painf u l mental c o n f l i c t . I f t h i s i s to be exposed, the patient must f i r s t be helped to f i n d a more-acceptable solution to his d i f f i c u l t i e s . What i s involved i n case work treatment, then, i s an "understanding" of these i n -dividual differences and a gearing of the case work process to the l e v e l of adjustment which a p a r t i c u l a r patient i s function-ing. LEVELS OF CASE WORK TREATMENT Florence H o l l i s has outlined four l e v e l s at which case work treatment can be used.^. The f i r s t of these, environmental manipulation, has been defined as " a l l attempts to correct, or improve the s i t u a t i o n (of a patient) i n order to reduce s t r a i n and pressure, and a l l modifications o f the l i v i n g experience 2 to offer opportunities for growth or change...." For example, th i s process can involve a changing or manipulating of environ-mental pressures, such as providing f i n a n c i a l assistance, f i n d -ing more-adequate l i v i n g quarters, or even helping r e l a t i v e s to be more understanding of the meaning of i l l n e s s to the pa-t i e n t . S o c i a l workers are probably best fcnown for t h e i r work i n the area of environmental aid, for the very beginnings of s o c i a l work practice have been founded on the use of t h i s 1 Florence H o l l i s , "The Techniques of Case Work", Journal of  S o c i a l Case Work, June, 1949, pp. 235-44. 2 Gordon Hamilton, Theory and Practice of S o c i a l Case Work, p. 247. (40) 1 h e l p f u l device. Josselyn speaks of "environmental therapy" as being the least a r t i f i c i a l approach, and points out that some-times t h i s i s the only type of treatment possible. Environmen-t a l manipulation must be purposive, i f i t i s to be constructive. The important thing to remember, i s that the patient must want to be helped and should be encouraged to parti c i p a t e i n as much of the changing as possible. The medical s o c i a l worker should only perform such action which the patient i s unable to do for himself. The other three l e v e l s of case work which H o l l i s describes, (psychological support, c l a r i f i c a t i o n and insight) involve a more di r e c t approach to the patient's inner emotional s t r i f e , and d i f f e r as to the degree i n which he i s helped to work through these problems. An accurate diagnosis, based on a ca r e f u l analysis of the patient's problem, w i l l determine the type of help he can best use. Psychological Support i s a technique used to encourage the patient to ta l k about his problem. Discussion i s focussed up-on helping him to be aware of and re-enforcing h i s inner strengths, f i r s t through guidance, release of tension, and then through various forms of reassurance designed to bolster his self-confidence. Psychological support i s useful for carrying the b a s i c a l l y well-adjusted person over a period of severe stress and s t r a i n caused by painful l i f e experiences. .The approach i s also h e l p f u l when working with i n f a n t i l e and 1 Irene M. Josselyn, "The Case Worker as a Therapist", Journal of S o c i a l Case Work, November, 1948, pp. 351 - 355. (41) immature patients who are i n need of guidance. The worker ex-presses a sympathetic understanding of patient's f e e l i n g and accepts his behaviour. i A sincere int e r e s t and desire to help, along with respect for and approval of action taken when i t i s warranted, aids i n building up the patient's confidence. Here again, the patient's a b i l i t y to make his own decisions, i s a l l -important. F i n a l l y , psychological support i s a technique des-igned to create a permissive re l a t i o n s h i p , which i s intended to r e l i e v e anxiety and feelings of g u i l t . C l a r i f i c a t i o n i s a more-intensive case work technique des-igned to help the patient understand himself and the people with whom he i s associating. I t may be a matter of helping him to look at the probable r e s u l t s of a decision, or evaluate the opinions of others, or even to become aware of h i s own f e e l i n g s and attitudes i n a correct perspective. Ordi n a r i l y , c l a r i f i c a -t i o n i s given only when a high degree of psychological support i s used, unless the patient i s r e l a t i v e l y healthy i n h i s per-sonality adjustment or the problem treated i s one which i s un-affected by personality c o n f l i c t s . Although emotional exper-iences may be examined, c l a r i f i c a t i o n i s o r d i n a r i l y given to create an i n t e l l e c t u a l understanding of conscious material. Whereas C l a r i f i c a t i o n deals with f u l l y conscious material the development of Insight involves a much deeper l e v e l of treatment. This device attempts to reach for and bring out, suppressed, rather than unconscious formulations, and i s based upon an awareness of these e a r l i e r experiences of the patient. The medical mocial worker does not attempt to go be-yond these l e v e l s of treatment, as the problem of working with-(42) unconscious symbolism and other d i f f i c u l t i e s a r i s i n g out of early personality formation, i s a task which c a l l s for the ser-vices of a q u a l i f i e d p s y c h i a t r i s t . The s o c i a l worker i n working with the patient, is' of course, not bound by any p a r t i c u l a r type of case work treatment. A l l four le v e l s are interchangeable, depending upon the emotional adjustment of the i n d i v i d u a l . Even though patients may need psychological help badly, they may not be able to face what i s being said to them, and w i l l either draw upon another set of defences or else break down completely because of this, expos-ure. The s o c i a l worker consciously seeks to determine, through accurate diagnosis, the degree of help which a patient can use at a given interview. As the patient i s able to f e e l accepted and understood, he w i l l be able to give up more and more of h i s defences and thereby p r o f i t from a more intensive l e v e l of therapy. Case work i s a gradual, se n s i t i v e , purposeful, pro-cess which i s designed to meet a p a r t i c u l a r c l i e n t at h i s own l e v e l of operation and bring him to the highest l e v e l of ad-justment of which he i s capable. Therefore, by "helping the c l i e n t to help himself", at the i n d i v i d u a l pace which he alone can determine, the most e f f e c t i v e use of case work services i s made. The majority of the patients examined i n t h i s study, i n d i -cated strong dependency feel i n g s . Even under normal circum-stances, the extent to which the essentially-immature person can p r o f i t ;by case work, i s limited, for with RHD patients there i s the added complication of physical deterioration to overcome. I t i s not surprising, therefore, that the most (43) important l e v e l of case work help which can be best u t i l i z e d by the RHD patient, i s that of environmental manipulation. Psy-chological support and c l a r i f i c a t i o n can be given mainly i n aiding the acceptance of a change i n the environment. The giv-ing of insight to an RHD patient who must remain dependent be-cause of his physical handicap and who has l i t t l e inner streng-th to use, i s of doubtful value, however. The writer has already pointed out how damaging environmen-1 t a l pressures can be to the RHD patient. The s o c i a l worker must u t i l i z e those available resources which exist within the hos p i t a l and the community at large, i n order to ease these pressures. The amelioration of these problems of f i n a n c i a l aid, employment, housing, etc., i s primarily a s o c i a l , rather than a medical r e s p o n s i b i l i t y . I t i s not unusual, therefore, to expect, the community, of which the patient i s a member and i n which these s o c i a l problems exi s t , to create welfare ser-vices which would combat t h i s s o c i a l dilemma. In the unique set-up of a veterans' h o s p i t a l , however, the bulk of these necessary services are available through the generosity of fed-e r a l l e g i s l a t i o n for veterans. Pensions, and war veterans' allowances, plus various other funds such as the "Army Benev-olent /Fund", o f f e r p a r t i a l solution to t h i s economic problem. Employment d i f f i c u l t i e s f o r the handicapped, are handled through r e t r a i n i n g programmes and selected job placements. .Convalescent homes, such as the George Durby Health and 1 See Chapter 2. (44) Occupational Centre, (G.D.H. & 0.), provide an adequate su b s t i -tute for the inadequate type of housing and diet to which the RHD patient i s often forced to return. Even help i n f i n d i n g more-adequate housing, can be arranged for the veteran. The s o c i a l worker recognizes the sp e c i a l r o l e which the welfare o f f i c e r plays i n making avail a b l e these resources, for he i s also a v i t a l member of the treatment team. However, a v a i l a b i l i t y of these resources does hot necessarily mean that adequate use w i l l be made of them. How.a patient f e e l s about accepting environmental aid i s something which the s o c i a l wor-ker i s equiped to handle. For example, i t has been pointed out that the RHD patient i s one who attempts to cover up h i s strong dependency needs by an equally strong independent drive. By accepting help, he may be admitting f a i l u r e to become inde-pendent. In order to keep up h i s defenses, he may then project the cause of his inadequacy on to h i s environment, and thereby become overdemanding of his basic rig h t s as a c i t i z e n , dr as a war veteran. The problem of "p e n s i o n i t i s " i s one which i s very f a m i l i a r i n veteran's h o s p i t a l s . 1 I t i s much too easy to play into the patient's basic dependency drives, so that the strong-er i s h i s need to keep up h i s defenses, the more d i f f i c u l t i s his recovery. As one patient so aptly phrased i t "Well, i t 1 In providing a system of pensions, the government has not only developed a f a i r means of compensating those handicapped, who, because of war service, cannot compete on the labour mar-ket, but has also created a dilemma. Many veterans have sought a solution from t h e i r personal inadequacies by consci-ously or unconsciously c l i n g i n g to or increasing physical handicaps, as an "acceptable" way of solving t h e i r f i n a n c i a l i n s e c u r i t y . . This manipulation of veteran l e g i s l a t u r e by the veteran, has become known as pensionitis within the department of veterans' a f f a i r s . ( 4 5 ) sure i s n ' t my f a u l t I'm sick, i s i t ? " The Use of Environmental Manipulation One of the s o c i a l -worker's s k i l l s then, i s that of preparing a patient to accept and make adequate use of h i s environmental y resources. The following case i l l u s t r a t e s the case work proc-ess at an environmental-manipulation l e v e l , of a RHD patient who i s unable to p r o f i t by more intensive therapy, because of the deep-rooted emotional pattern of his i l l n e s s . The case i s that of a 5 7 - y e a r - o l d veteran who was referred to medical s o c i a l service because he was destitute and did not have friends of family within the c i t y area who could care for him. An "investigatioxi' of the patient's s o c i a l background finances, etc.," was requested. Also, the doctor f e l t the pa-t i e n t was showing too much opposition to placement under per-manent domiciliary care. Following the usual pattern of RHD patients, he l e f t home at an early age and moved from one type of employment to another. There i s an i n d i c a t i o n of a strong emotional dependency upon a mother-figure, of an incompatible marriage r e s u l t i n g i n desertion, of impetuous decisions and an altogether unhappy existence. His constant drive for a c t i v i t y , was halted temporarily by repeated attacks of RHD. When he r e a l i z e d he could no longer compete on the labour mar-ket, he turned' to r e l i g i o u s fanaticism as a means of solving his problems. He would drive himself unmercifully i n phantasy as he had done i n r e a l i t y . The f i r s t interview with the patient was devoted to build-ing up a h e l p f u l r e l a t i o n s h i p . • i <• Patient appeared frightened and h o s t i l e . He said, (46) "I have no plans. What I want to know i s , what i s a l l t h i s going to- cost me....It costs me f o r t y d o l l a r s every month I am i n here." Worker said she would check, but that she thought treatment was not costing him anything..., that he had a pension and was on war veterans' allowance and was thereby enr t i t l e d to treatment... .He said the doctor would be putting him out of the h o s p i t a l soon because he talked too much. Worker said she was sure he would not be discharged u n t i l he was better; He seemed somewhat reassured. Here we see the worker picking up the patient's ambivalent dependency-independency c o n f l i c t . He i s at f i r s t very demand-ing and accusatory as he indicates his desire to get out of the h o s p i t a l . Later, as he f e e l s the warm acceptance of the worker, he i s able to express h i s fear of being abandoned and the under-l y i n g need for care. The worker follows up by assuring him, ...there was nothing to worry.about. He was not '. .going;.to I be -discharged' fightj/away- but she! f e l t t h a t i f she came to see him and talked things over she might be able to help him i n deciding what he wanted to do. The patient said he didn't want to decide i n a hurry. The worker said that was not necessary, and remarked that she understood he came from Toronto and had a s i s t e r tiiere....She wondered whether he could stay with that sister....He said ernestly, that, that i s what he would l i k e to do....He stayed with h i s s i s t e r when he came out of Sunnybrook h o s p i t a l e a r l i e r t h i s year. A l l he would have to do i s look a f t e r the furnace. He would l i k e to go back there aft e r he was discharged, u n t i l he could stand on h i s own feet again....The worker asked i f he would l i k e us to write to h i s sister....He said he would l i k e that very much. The patient had previously been t o l d by the doctor i n charge of the case, that he could be transferred to one of the conval-escent centres for permanent residence i f he so desired. This dire c t appeal to the patient's dependency needs, met with much opposition. The manner i n which the worker explores the possi-b i l i t y of another resource i s worth noting. She allows the patient to bring out h i s own plans, rather than suggest (47) d i r e c t l y that he should l i v e with h i s s i s t e r . The worker then o f f e r s to help the patient i n working out his problem at h i s own pace. Possibly she might have encouraged the patient to write his own l e t t e r , as t h i s would have contributed to h i s fe e l i n g of independence. However, she at least asks h i s per-mission before contacting his s i s t e r . Too often, a well-mean-ing person may further antagonize such a patient, by doing things for him without h i s f u l l p a r t i c i p a t i o n i n the plan. I t i s not uncommon to see a patient of t h i s type, whose indepen-dent drives are so great, o f f e r passive resistance to any plans which are thereby made f o r him. Since the doctor i s the head of the treatment team, the worker conferred with him about the f e a s i b i l i t y of the patient's wishes. Because of the doctor's knowledge of the extent of the' patient's physical handicap, he vetoed any plan whereby the pa-ti e n t would have to tend to the furnace, but f e l t the patient could care for himself i n the home during any absence of h i s s i s t e r . The p o s s i b i l i t y of a nurse from the Volunteer Order of Nurses v i s i t i n g him regularly, was also suggested. A l e t t e r was then sent to the patient's s i s t e r explaining his desire to be with her and also pointing out the l i m i t a t i o n s which the doctor had suggested. The patient responded r a p i d l y to h o s p i t a l treatment following the i n i t i a l interview with the worker, whereas before, he did not appear to have any desire to get well. In a l a t e r interview, The worker said we had written to his s i s t e r , and his face lighted up as he said, "have you heard from her...that's what I would l i k e best - to go and stay with her". (48) Arrangements were f i n a l i z e d , and the patient's s i s t e r came to Vancouver to pick him up. Another phase of environmental manipulation was performed by the worker, as she appraised the a b i l i t y of the patient's s i s t e r to meet hi s needs f o r care and also helped her to understand what these needs were. I t i s i n t h i s interview with the patient's s i s t e r , that some understand-ing of the patient's motivation to l i v e with her, also appears. The worker makes thi s comment. She appeared a competent and responsible person, able and w i l l i n g to make arrangements for her brother, and most anxious to have a chance to look a f t e r him. She gave worker the impression that she would l i k e "to mother" her brother, but he i s very independent and d i f f i c u l t at times. I t would seem that the patient has transferred h i s unconsci-ous dependency feelings for a mother-figure on to h i s s i s t e r , and i s able to f i n d s a t i s f a c t i o n for these needs here. In summary, the case presented, i s an example of a patient who could not p r o f i t by any insight into his personality d i f f i -c u l t i e s . The worker i s able to contribute to a more-rapid and natural recovery of the patient by manipulating the environment-i . e . f i nding a suitable home for him,-yet at the same time f u l l consideration i s given to the patient, i n determining how t h i s need i s met. An understanding of human behaviour and an a b i l -i t y to meet t h i s i n d i v i d u a l at his own l e v e l of operation, was the keynote of t h i s success. A perfunctory placement i n the convalescent home, might easily have prolonged the i l l n e s s state, and proved more damaging to the patient and more expen-sive to the h o s p i t a l i n the long run. However, a solution was found which was sat i s f a c t o r y to a l l concerned. (49) The Use of Psychological Support and C l a r i f i c a t i o n Although the writer has suggested that for chronically i l l patients affected by RHD, the more-applicable l e v e l of t r e a t -ment i s usually one of environmental manipulation, 1 the writer also f e e l s , that with c a r e f u l and s k i l l f u l management, psycho-l o g i c a l support and c l a r i f i c a t i o n can be used advantageously with RHD patients. For t h i s reason the following case i l l u s t r a -t i o n has been included to show what can be done under near-ideal conditions. At the time t h i s study was being conducted, the case was s t i l l being carried a c t i v e l y by a s o c i a l work student who had access to s k i l l e d supervision. The patient, a 5 2-year-old veteran, was referred for case work because of h i s unsuitable home conditions. He was married and had two children, and a l l four of them had been l i v i n g i n a two-room suite which was situated on the t h i r d f l o o r , of a dilapidated hotel, i n a slum area. The doctor on the case i n -dicated that the patient was " i n an advanced state of RHD" and pointed'out that his present housing was "unsuitable for pa-t i e n t i n view of his condition". The patient developed rheumatic fever i n 1919, while serv-ing with the Imperial forces, and was eventually discharged with RHD in'1922. He carried on reasonably well u n t i l 1935, when he began to notice that he was unable to continue the strenuous work with which he had been accustomed. He married i n 1939, and during the early war years, maintained economic 1 See pp. (42-43). (50) s t a b i l i t y . However, by 1944, shortly a f t e r the b i r t h of h i s second c h i l d , and at a time when f i n a n c i a l pressures began to mount, he developed a series of recurrent attacks of RHD. The o r i g i n a l problem presented i n the r e f e r r a l , was the necessity of f i n d i n g adequate housing before the patient could be discharged ( i . e . environmental manipulation). The a i d of one of the welfare o f f i c e r s was e n l i s t e d , and although several arrangements were presented to the patient, i t was soon obvious to the worker that i f r e h a b i l i t a t i o n was to take place much case work would have to be done, not only with the patient, but with h i s wife as well. The patient and his family were well known to various welfare agencies i n the c i t y , and i t was from these resources that the worker learned of a more Important fac-tor i n the patient's i l l n e s s - that of a domineering wife, who appeared to be r e j e c t i n g of her husband. This was v e r i f i e d i n subsequent contacts with the wife, although the patient was not able to c r i t i c i z e her when'he f i r s t discussed h i s home s i t u a -t i o n with the worker. Case work was then directed at providing emotional support to an i n d i v i d u a l who had overwhelming " f e e l -ings of inadequacy", which centred around h i s . i n a b i l i t y to maintain his role as head of h i s household. Since the wife was the dominant factor here, i t was also intended that a modifica-t i o n of her attitudes to her husband and h i s i l l n e s s , would also be attempted. , The f i r s t few interviews were focussed on establishing a good relationship between the patient and the worker, so that the patient would f e e l free enough to discuss h i s personal • d i f f i c u l t i e s . Only a s u p e r f i c i a l relationship resulted, (51) however^ I t was noted a f t e r .3 weeks of b r i e f but regular con-tacts that, The patient i s now w i l l i n g enough to discuss h i s family but unwilling or unable to look at his own p o s i t i o n . i n i t . He f e e l s he has beenrather hard done by, as far as various government agencies are concerned, and he does not f e e l that there i s a chance of anything improving, as f a r as l i v i n g or economic conditions are concerned. Following a r e j e c t i o n by the patient and his wife of ano-ther housing plan a week l a t e r , a consultation was held by members of the treatment team, (the doctor, welfare o f f i c e r , and s o c i a l worker). I t was f e l t that the patient was not showing any progress physically, although he had been ready for discharge to a convalescent setting for some time now. The damaging influence of the patient's wife was presented to the conference by the worker, and i t was decided that u n t i l such time as the wife could be more co-operative and accepting of her husband, he should be transferred to the convalescent ward (Class 6) where he would be given domiciliary care. I t was agreed that the s o c i a l worker would prepare the patient for t h i s transfer, ( i . e . environmental manipulation). At f i r s t the patient seemed quite agreeable to t h i s sug-gestion. The patient was seen d a i l y and Class 6 (domicil-iary care) discussed. He appeared to accept t h i s quite r e a d i l y and f i n a l l y stated...that he and h i s wife probably would have separated anyway, due to what he regards as her mismanagement of any income and also because he does not p a r t i c u l a r l y care f o r the type of company that she keeps....The patient's wife appeared quite pleased that her husband had decided to stay. The beginning of the patient's expression of h o s t i l i t y to-wards hi s wife appeared here. . He was s t i l l unable to see (52) himself as being responsible for his predicament and continued to project t h i s blame, although now i t was directed at the one person from which he has sought s a t i s f a c t i o n f o r h i s dependent needs. As expected, he was soon unable to face the r e a l i t y of h i s wife's r e j e c t i o n . His "sour grapes" defense broke down, as was evident i n the record of the following two weeks. He (the patient) began to show concern about sign-ing an a p p l i c a t i o n f o r Class 6. He stated he had been home for a day and that had been enough....(He was) seen almost daily i n an e f f o r t to help him adjust to Class 6 care. He has been quite upset... f e e l i n g that he had been forced into i t and that h i s wife was t r y i n g to get r i d of him. He r e a l i z e s that the hotel i s not a suitable place for him but f e e l s h i s wife w i l l not do anything to get better accommodation fo r the family, unless he i s able to "nag her"....An e f f o r t was made to get the patient to see the physical i m p o s s i b i l i t y of h i s going back to his previous l i v i n g quarters....(We) discussed various ways i n which he himself could take the i n i t i a t i v e i n making arrangements for further accommodation, such as newspaper advertisements and personal contacts with r e a l estate agents. I t i s b e l -ieved the patient was helped by these discussions. Two weeks l a t e r . The patient was quite cheerful - He stated that he was doing quite well now and finds he i s able to get around town a l o t more than he was at home....The pa-t i e n t now seems much happier i n the Extension, and i s being encouraged to =take the i n i t i a t i v e with regard to his pension application and housing problem. _ In spite of e f f o r t s to work with the patient's, wife, she r e s i s t e d and resented any interference into her a f f a i r s . She f e l t compelled to continue interviews with the worker and a l -though at one time some progress was noted, eventually she f e l l back into her old r e j e c t i n g pattern and subtly defied any attempts to f i n d a home which would be suitable f o r her husband. I t was noted that from a f i n a n c i a l point of view, at l e a s t , she was better o f f having her husband under h o s p i t a l ( 5 3 ) care. During the following four months, l i t t l e change was noted, either i n the patient or h i s wife. Shortly a f t e r , the patient had been unable to e s t a b l i s h a pension claim for h i s d i s a b i l i -ty, and his unrest became noticeable once again. He was r e f e r -red to the worker by the doctor, because the patient had under-gone another heart attack, was very upset and was requesting discharge. Case work was again continued on a more intensive l e v e l , but at the end of four weeks, the: worker had t h i s to say. The patient has been extremely"unhappy recently and his r e l a t i o n s h i p with his wife during her v i s i t s have not been good, according to him. This has been r e f l e c t e d i n h i s attitude towards treatment. How-ever, i t i s f e l t that he would be able to look on his present condition and treatment was a more r e a l -i s t i c viewpoint, i f s a t i s f i e d about the welfare of his family. The case worker o r i g i n a l l y assigned to t h i s case had been seeing the patient and h i s wife several times a week. As well, numerous consultations with team members were involved. I t i s l i t t l e wonder, that as the caseload of the worker became too demanding of his time, a r e a l l o c a t i o n of h i s e f f o r t s was made. Since the patient's a b i l i t y to respond to case work would not be favourable u n t i l such time as the family s i t u a t i o n could be improved, and since the patient's wife did not show any signs of changing her attitude, the worker r i g h t f u l l y devoted more time to other patients who would benefit more-readily from case work services. This i s a common problem i n s o c i a l ser-vice agencies, where the number of cases which an i n d i v i d u a l 1 During a patient's h o s p i t a l i z a t i o n , usually only ten dol-l a r s i s subtracted from h i s war veterans' allowance. ( 5 4 ) worker i s required to carry, i s beyond the reasonable l i m i t i n which minimum service i s expected to produce maximum r e s u l t s . One solution to t h i s problem, i s to hire more trained s t a f f . Where this i s not possible, the good case worker, c a r e f u l l y de-termines which of the cases he i s carrying, can make best use of his services i n the shortest period of time. The s k i l l s of a professionally trained worker, enable him to maintain greater accuracy of the f i n a l s e l e c t i o n . The case was l a t e r transferred to a female student worker, who, because of the advantage of a t r a i n i n g setting, could de-vote the time necessary to insure some measure of success. Through a three-month period of her intensive case work e f f o r t , there has been a gradual amelioration of the patient's condi-t i o n . The whole process of es t a b l i s h i n g and maintaining a secure r e l a t i o n s h i p with the patient and especially h i s wife, has been a d i f f i c u l t one, as the wife has continued to s t r i k e out against her husband. Again, the problem of f i n d i n g a suitable home where the patient might eventually return, was the long-term plan. Be-fore t h i s could be achieved, the immediate problem of support-ing the patient and helping him accept the demands of the con-valescent h o s p i t a l setting so that he could respond to t r e a t -ment, was intended. As h i s f r u s t r a t i o n moymted, the patient became more of a nuisance to ho s p i t a l s t a f f and other patients. His petty f a u l t - f i n d i n g was accepted by the worker, as she i n -stead, gave emotional support to h i s increased f e e l i n g of i n -adequacy and helplessness. Gradually, the suppressed h o s t i l -i t y which was being expressed through his behaviour, was ( 5 5 ) channelled by the worker as she encouraged him to express h i s feelings and fr u s t r a t i o n s . At f i r s t , he projected his h o s t i l -i t y onto the department of veterans' a f f a i r s and other govern-ment o f f i c i a l s , then to his.wife, and finally.,' wa's able to ad-mit his own r e s p o n s i b i l i t y f or his problems. One of the ear-l i e r interviews where the patient was beginning to respond to the acceptance of the worker, points out some of his basic inner c o n f l i c t s . *~ The patient was i n a very depressed mood - possibly as a resu l t of h i s wife's long v i s i t two days before ....He asked me anxiously i f I thought his wife would fin d a suite for them to l i v e i n . I said I had no way of knowing and what did he think about the situation.. Here, a l l the fru s t r a t i o n s and h o s t i l i t i e s connected with his long stay i n the ho s p i t a l , caused the patient to break down and weep helplessly....During his discus-sion he wished f o r death, "to be out of h i s misery".... I asked him what he f e l t his most pressing problem was. He said i t was everything combined, that he couldn't work, he hated being helpless - he was just "worried to death". He was rather incoherent much of the time, and I f e l t that passive acceptance of his statements, together with periodic supportive comments of accept-ance, was my only recourse....At one point he said that he wished his mother were here - she would help him and wouldn't " l e t a l l t h i s happen" to him....On the subject of h i s family, I t r i e d to draw the patient.jout to t a l k of them. He had never done t h i s with me and I sensed that i t gave him some comfort to do so. He t o l d me they had been a happy family, saying that he guessed that was why none of them had married early....I said "and you haven't been married long either". He re p l i e d , "No, I waited a long time" - pause, and then, "I only married for a home anyway - and look at me now"....As he talked of hi s parents and childhood i n England, the patient began to be a l i t t l e less tense, stopped crying and began to discuss his problems i n a more "matter of fa c t " way. As the worker was also able to help the patient's wife ex-press her h o s t i l i t y , the wife was able to r e f r a i n from antag-onizing her husband. The worker's e f f o r t at environmental manipulation for the welfare of the patient also extended (56) toward adjusting the hospital setting, so that r e a l i s t i c annoy-ances could be avoided. The patient had become very attached to the use of a wheel chair and when this was taken away from him by a new interne on the ward, the patient became upset. Although he used the wheel chair sparingly, t h i s sudden loss of t h i s symbol of security, made him a f r a i d to venture from h i s bed without an impending fear that he would collapse. Also, he interpreted the removal of the chair as a further i n d i c a t i o n of his r e j e c t i o n by the h o s p i t a l s t a f f . At a meeting of the t r e a t -ment team, the meaning of the chair to the patient was explain-ed by the worker, and i t was agreed to return t h i s to the pa-t i e n t . His response was immediate and quite favourable. Because of some minor d i f f i c u l t i e s on the ward, which were unavoidable i n terms of physical s e t t i n g and ho s p i t a l regula-tions but were nevertheless a constant source of i r r i t a t i o n to the patient, arrangements were made to have him transferred to a new ward. Following a b r i e f period of regression u n t i l the patient became adjusted to the new setting, h i s response to treatment was remarkable. During t h i s time, the worker con-stantly interpreted the emotional needs of the patient to the s t a f f members of the new ward, and once again intervened on behalf of the patient when the wheel chair was again removed. More-recent interviews at the time t h i s present study was being made, indicate the movement which has taken place over a two-month period. The patient was i n an amiable mood when v i s i t e d . He t o l d me that he had been allowed to use a wheel chair, and had been over to the Red Cross Lodge with his wife the day before....The patient, who had been i n a highly nervous state when l a s t v i s i t e d , was calm, cheerful and conversational today. I asked i f ( 5 7 ) he were using the wheel chair much, and he smiled and said i t was very s a t i s f a c t o r y , that sometimes he wheeled himself around and at other times he pushed it....The patient smiled at me and said "you helped get i t for me didn't you?" I smiled back and said that the doctor had been concerned about his welfare, and had at f i r s t thought a chair might be a hindrance rather than a help to' him, but that we had agreed, that at present, i t would be h e l p f u l f o r him to have i t . A week l a t e r : The patient was walking around the ward with the aid of a cane when v i s i t e d , displaying more energy than I have noticed heretofore. I...asked i f he were f e e l i n g as well as he looked. He beamed at me and said, "Better than I look and better than I've been for some time"....I asked what he thought the reason was, and he said, "Oh everything - but most of a l l because I am getting my proper sleep since I moved to the new ward...." He said that he f e l t better and stronger than he had for over a year. Then, he added that h i s doctor had come to see him the other day and had indicated amazement at how much he had improved. I said that I guessed Dr...would be very pleased to see him improving, and the patient said he thought Dr...was a good doctor, and they hadn't understood each other at f i r s t . This i s the f i r s t positive comment he has made to me about any member of the h o s p i t a l s t a f f . Although the worker had been giving mainly psychological support, c l a r i f i c a t i o n of the doctor's inte r e s t i n the patient was given and was acceptable to him at t h i s time. Note that the worker did not interpret the unconscious aspects of t h i s c o n f l i c t , ( i . e . , c o n f l i c t with authority), but instead worked within the conscious framework of the patient's thought pro-cesses. The worker's comments on the patient's progress i s a good in d i c a t i o n of the movement which has taken place. R e l i e f of environmental pressures have caused this' patient to f e e l that the h o s p i t a l team i s wor-king for his welfare, with a consequent improve-ment i n h i s r e l a t i o n s h i p with his doctor and the nursing s t a f f . In addition,, his r e l a t i o n s h i p with (58 ) the worker appears to be deeper than heretofore, and he has been able to express more of h i s h o s t i l i t y to-wards his wife and his anxiety regarding his c h i l -dren....! f e l t i n t h i s interview, that.the r e l a t i o n -ship was developing to the point where the patient could not only express some of h i s h o s t i l i t y towards his wife, but could accept help i n gaining insight into h i s own behaviour. He seemed very receptive to comments concerning h i s attitude towards the m a r i t a l s i t u a t i o n . There i s s t i l l much case work to be done before the pa-t i e n t and his wife can ever come together i n t h e i r own home,, Because of h i s deteriorated physical condition and the d i f f i -culty of f i n d i n g a suitable home within t h e i r f i n a n c i a l means, th i s may never take place. The value of the s o c i a l worker as a member of the treatment team has been shown however, i n the gradual physical improvement of the patient, which went hand i n hand with the a l l e v i a t i o n of h i s emotional stress. Their i s l i t t l e doubt that s k i l l f u l use has been made of the case work techniques of psychological support and c l a r i f i c a t i o n , i n bringing about some b e n e f i c i a l environmental changes f o r the patient. The material of t h i s chapter indicates how the s o c i a l wor-ker, as a member of the h o s p i t a l treatment team, can u t i l i z e h i s professional case work s k i l l to a l l e v i a t e the s o c i a l and emotional problems of the patient with RHD. Throughout t h i s and preceding chapters, reference has been made to the way RHD patients are affected by the members of t h e i r f a m i l i e s . How these patients i n turn a f f e c t t h e i r f a m i l i e s , and how the s o c i a l worker operates to reduce these further stresses and st r a i n s , w i l l be discussed i n the following area of presenta-t i o n . CHAPTER 4  FAMILY IMPLICATIONS Previously, i n discussing adequate care f o r the RHD pa-t i e n t ' s i l l n e s s , stress has been placed on the treatment of his s o c i a l and emotional problems. Since the patient's family per-forms a v i t a l r o l e i n the creation and prolongation of h i s d i f f i c u l t i e s , the s o c i a l worker must treat the members of t h i s family, as well as the patient. By gaining some r e l i e f from t h e i r own s o c i a l and emotional stresses and s t r a i n s , they are then better able to a i d the patient i n his recovery. The s o c i a l worker i n a h o s p i t a l setting, although sensi-t i v e to the need for case work services to families of RHD pa-t i e n t s , as a rule, has a limited role to play i n the perform-ance of these services. Specialized agencies such as family welfare, children's a i d , public welfare, etc., which have been s p e c i f i c a l l y created to a l l e v i a t e the s o c i a l and emotional problems exi s t i n g within that broad area known as the commun-i t y , are better equiped to meet the varying needs of family mem-1 bers. In this sense, the medical s o c i a l worker i s not only a member of the h o s p i t a l team, but i s also part of the s o c i a l welfare team within the community. Just as he i s expected to treat the varying aspects of physical i l l n e s s , he i s also aware of the specialized s k i l l s of p a r t i c u l a r welfare agencies to a l l e v i a t e s p e c i f i c s o c i a l and emotional problems which can 1 The s o c i a l worker i n a hospital setting. (60) occur. Just as a co-ordination of the e f f o r t s of the treatment team i n the hospital i s necessary, si m i l a r co-ordination of a l l the community welfare services i s also v i t a l . The medical so-c i a l worker, then, can c a l l upon and i s c a l l e d upon by other s o c i a l agencies to act j o i n t l y i n promoting the welfare of pa-tie n t s and t h e i r f a m i l i e s . Although i t has been possible to formulate one general per-sonal and s o c i a l p r o f i l e into which most RHD patients f i t , i t has not been possible from the results of t h i s study, to draft a similar type of p r o f i l e for members of the patient's family. The reason for t h i s , i s f e l t to be due to the more-varied i n d i -vidual differences which are c h a r a c t e r i s t i c of any family con-s t e l l a t i o n . Very general areas of s i m i l a r i t y w i l l be pointed out where possible, but as a ru l e , each family member must be evaluated on an i n d i v i d u a l basis and treatment planned accor-dingly. The E f f e c t on Parents and Sibl i n g s At least one case reveals the complicating effect which a dominating mother can have on her son's welfare. A 28-year-old single veteran was referred by h i s doctor to medical so-c i a l service for a i d with h i s domestic and f i n a n c i a l problems. The r e f e r r a l indicated that the patient's father was dead, and that although the patient was the second of four s i b l i n g s , he was the sole f i n a n c i a l supporter of his mother. He worried considerably about t h i s , and complained that the only future he saw for himself, was the unhappy one of having to maintain her for the rest of his l i f e . (61) When f i r s t s e e n by t h e w o r k e r , t h e p a t i e n t e x p r e s s e d w i l l -i n g n e s s t o d i s c u s s h i s p r o b l e m and w o r k t o w a r d s some s o l u t i o n , h o w e v e r , t h e p a t i e n t ' s m o t h e r r e f u s e d to a c c e p t h e l p , m a i n t a i n -i n g , " t h e y w o u l d work o u t t h e i r p r o b l e m s o n t h e i r o w n " . The mother was d e s c r i b e d by t h e w o r k e r as b e i n g a " d o m i n e e r i n g u n -happy n e u r o t i c woman", who' i n c i d e n t a l l y , a l s o s u f f e r e d f r o m RHD. The p a t i e n t f l u c t u a t e d between w i l l i n g n e s s t o a c c e p t h e l p a n d e r r a t i c h o s t i l e b e h a v i o u r , d e p e n d i n g upon t h e f r u s t r a t i o n w h i c h h i s demanding m o t h e r c r e a t e d f o r h i m . A t one t i m e , i t was n o t -ed t h a t he was a b l e t o oppose e v e r y o n e e x c e p t h e r . H e r demands r e v o l v e d a r o u n d a r e q u e s t f o r a n a d d i t i o n a l p e n s i o n f o r h e r s o n ' s d i s a b i l i t y w h i c h w o u l d p r o v i d e f o r h e r a s w e l l , d e s p i t e t h e f a c t t h a t she was a l r e a d y r e c e i v i n g f i n a n c i a l a s s i s t a n c e e l s e w h e r e . P a r t o f h e r i n c o m e , a w i d o w ' s p e n s i o n , was b e i n g p a i d by t h e d e p a r t m e n t o f v e t e r a n s ' a f f a i r s . H e r h u s b a n d , a l t h o u g h e v e n t u a l l y d y i n g f r o m a h e a r t a i l m e n t , d e v e l o p e d n e u r a s t h e n i a d u r i n g h i s s e r v i c e i n t h e f i r s t w o r l d w a r , a n d was p e n s i o n e d f o r t h i s . The w o r k e r n o t e d t h a t t h e r e was a s t r i k i n g s i m i l a r -i t y between t h e n e u r o t i c symptoms o f w h i c h t h e f a t h e r c o m p l a i n e d and t h o s e w h i c h t h e p a t i e n t a l s o d e v e l o p e d . The p a t i e n t h a d ' so i d e n t i f i e d h i m s e l f w i t h h i s f a t h e r , t h a t he h a d , i n e f f e c t , assumed h i s f a t h e r ' s r o l e w i t h t h e m o t h e r . She e n c o u r a g e d t h i s u n h e a l t h y r e l a t i o n s h i p and t h e r e b y d i r e c t l y a f f e c t e d t h e c o u r s e o f h e r s o n ! s i l l n e s s . T h r o u g h h e r demands t h a t he a l o n e be f i n a n c i a l l y r e s p o n s i b l e f o r h e r , d e s p i t e t h e f a c t t h a t she h a d t h r e e o t h e r c h i l d r e n who m i g h t s h a r e t h i s r e s p o n s i b i l i t y , h e r n e u r o t i c a t t a c h m e n t t o h e r s o n became e v i d e n t . M e a n w h i l e , h i s ( 6 2 ) i l l n e s s and his r e s u l t i n g pension, provided the source of f i n -a n c i a l security to which she had long been accustomed. Since she consistently defied a l l o f f e r s of case work and psychiatric aid, i t was not possible to help her son. A psy-c h i a t r i c report on the patient four months l a t e r , pointed out that no r e a l improvement had taken place i n h i s RHD condition. His tense,; r e s t l e s s and emotional state was f e l t to be the con-t r i b u t i n g factor i n h i s i n a b i l i t y to recover. S p e c i f i c a l l y , i t was stated that "his mother was the disturbing influence". As long as she was unable to recognize the detrimental e f f e c t her demands were having on the patient, the treatment team f e l t that the c o n f l i c t -created by h i s dependency upon her and his i n a b i l i t y to break away, would continue to a f f e c t the pro-longation and exacerbation of h i s i l l n e s s . This case also hints at the effect which t h i s patient's i l l n e s s created on h i s s i b l i n g s . There i s evidence of much i l l - f e e l i n g , and i t i s expected that a great deal o f t h i s was aroused by the over-attention which the mother may have given to the patient i n preference to her other children. Other cases did not reveal so s t r i k i n g a r e l a t i o n s h i p be-tween family members as t h i s one. Since the remainder of the selected cases were of older married veterans, l i t t l e comment appeared about parents and s i b l i n g s except to express how the patient f e l t towards them. The fact that RHD was acquired usually a f t e r the patients l e f t home, and only i n rare cases returned to t h e i r parents, accounts i n part f o r t h i s lack of information. Only one other record contained s u f f i c i e n t information (63) which would bring out s i b l i n g relationships, and t h i s has a l -ready been discussed more f u l l y elsewhere. 1 Of importance here, was the stronger bond which was formed between a patient and h i s s i s t e r as a r e s u l t of h i s i l l n e s s . Her desire "to mother" him, was achieved at a time when her brother was f i n a l l y prepared to accept her h o s p i t a l i t y . The E f f e c t On Marriage Partners Depending upon the expectations which wives of RHD patients seek i n t h e i r marriage, a variety of responses to t h e i r hus-band's i l l n e s s can develop. On the whole, f r u s t r a t i o n and re-sentment appeared to be the more common responses i n at le a s t 14 out of the twenty cases containing such information. A l -though data as to the cause of th e i r unhappiness, does not appear consistently enough to indicate s t a t i s t i c a l comparisons, i t was noted that many complained of f i n a n c i a l inadequacy and the r e s u l t i n g poverty-stricken conditions with which they were forced to contend. Several s p e c i f i c a l l y stated they were t i r e d of having to assume r e s p o n s i b i l i t y f o r home management, c h i l -dren, etc., that sexual relationships were poor and that they no longer could continue to l i v e "as man and wife, but rather as nurse and patient". Although many complained about envir-onmental conditions, a few of them appeared quite content to care f o r t h e i r husband - i n fact t h e i r marriage seemed to be held together by the changing s i t u a t i o n of i l l n e s s . 1 See pp. (45-48), i n Chapter 3. (64) Case Examples of Ma r i t a l D i f f i c u l t i e s (!) Sexual Incompatibility - One wife became increasingly concerned about her 3 5-year-old husband's attitude and state of mind, because of h i s prolonged h o s p i t a l i z a t i o n s . At f i r s t she gave the impression she was sincerely interested i n h i s welfare, as she tended to s p o i l and overprotect him. Arrangements were made f o r her by the s o c i a l worker, to talk with the patient's doctor, and she was then given reassurance about her husband's condition. When she returned again and again with si m i l a r fears, some case work was given to resolve her d i f f i c u l t i e s . She began to complain that her husband was going crazy - that he accused her of running around with other men. During the course of her treatment i t was revealed that she had l i v e d i n common-law rel a t i o n s h i p with her husband, prior to obtaining a divorce from her f i r s t husband. She complained of poor sexual relationships and expressed considerable feelings of g u i l t around t h i s . In t h i s sense, her accusations against her hus-band, appeared to be projections of her own unconscious desires. She responded b r i e f l y to supportive therapy, although no attempt was made to give her insight into her basic c o n f l i c t . This was s u f f i c i e n t to make an improvement i n her husband's condition and he was eventually discharged. However, once at home, t h e i r marital incompatibility upset the patient, and i n a short time he returned to the h o s p i t a l , where he died. As ex-pected, the wife's g u i l t feelings mounted and she continued to return to the hos p i t a l for help with her problem. Because of the deep-seated appearance of her emotional c o n f l i c t , attempts were made to refe r her f o r psychiatric treatment, but t h i s was (65) consistently refused by her. The worker summed up t h i s d i f f i -c ulty with: No help could be given her because of her need "not to understand". (£) Immaturity Versus Dependency - A second example, i s that of a young veteran who married an equally young and imma-ture g i r l , shortly a f t e r he enlisted i n the service. He was subsequently posted overseas, developed rheumatic fever and was discharged i n 194S, - two years a f t e r his enlistment. Repeated ho s p i t a l i z a t i o n s since then, were mainly attributed to serious c o n f l i c t s with his wife. His was a wife who married for the romance and excitement she craved. Being even more dependent and immature than her husband, from the very beginning she refused to accept her role as a responsible wife. While the patient was overseas, she s a t i s f i e d her needs through the attention other service men gave her, and managed to dissapate the savings which her husband sent her for safekeeping. While the patient was h o s p i t a l i z e d during the early years of t h e i r marriage, she would abandon her two children to go "bowling and dancing". The patient i n s i s t e d at t h i s time that he encouraged her to enjoy her s e l f , but i t was f e l t he was r e a l l y unable to oppose her. Following his t h i r d h o s p i t a l i z a t i o n i n January 1948, the family s i t u a t i o n completely erupted. By -this time, there were fi v e children to care f o r . However, i t was not u n t i l November 1948 and three h o s p i t a l i z a t i o n s l a t e r , that the case was r e f e r -red to medical s o c i a l service, The patient complained of h i s wife's i r r e s p o n s i b i l i t y with th e i r finances, and suspected she (66) was running around with other men. Contacts with her through the public welfare agency i n her community, revealed the extent of her i r r e s p o n s i b i l i t y . At f i r s t , the s i t u a t i o n was eased somewhat by the fear which the wife encountered at the i n t r u -sion of the public welfare worker. Two weeks l a t e r , the pa-t i e n t ' s wife l e f t him to l i v e with another man, and stated at t h i s time that she would divorce her husband. Her father i n the meantime, arrived from Saskatchewan and had taken the c h i l -dren with him. Shortly afterwards, the patient's wife changed her mind and decided to return to her parents' home i n Saskat-chewan. Following a concentrated co-operative e f f o r t by case workers i n the h o s p i t a l and i n Saskatchewan, the patient and hi s wife were reconciled. The patient responded to h o s p i t a l treatment and aft e r help was given i n establishing a home f o r them, he also returned to Saskatchewan. No sooner had r e c o n c i l i a t i o n taken place, when i t was learned that the patient returned'to the h o s p i t a l and was seek-ing a separation because of h i s wife's continued irresponsible behaviour. Again s o c i a l service brought them together, but four months l a t e r , the s i t u a t i o n became unbearable f o r him. He was transferred back to Shaughnessy hos p i t a l shortly afterwards. At the time t h i s study was made, the patient was separated from his wife, but continued to support h i s family from an ade-quate pension for h i s 100 per cent d i s a b i l i t y . She appeared quite happy with t h i s arrangement, since she was l i v i n g with her parents and they assumed the major share of care for the children. Her husband's i l l n e s s has created for her the finan-c i a l security which has been most important to her. I t has (67) also meant f r u s t r a t i o n i n terms of her desire for romance and excitement, however, i t i s reasonable to expect she w i l l contin-ue to seek s a t i s f a c t i o n for these needs from other men. The Effect on Children The children whose parents are a f f l i c t e d with chronic i l l -nesses, are, unfortunately, the ones who suffer most i n the long run. I t i s from th e i r early experiences i n the home that per-sonality patterns emerge, and i t i s here that a normal c h i l d develops a f e e l i n g of security and well-being. Since i t i s ex-pected that both parents must be reasonably well-adjusted, phy-s i c a l l y , as well as emotionally, i f they are to contribute to the welfare of t h e i r children, i t i s not unnatural, therefore, to expect much turmoil and i n s t a b i l i t y i n children whose parents are so wrapped up i n th e i r own personality c o n f l i c t s , that they can o f f e r l i t t l e to the dependent needs of others. The detrimental ef f e c t which a father's absence creates on either a son or daughter, i s a subject which has been given a great deal of attention by c h i l d p s y c h i a t r i s t s and others i n -terested i n c h i l d welfare. 1 Since a father with RHD i s repeat-edly entering h o s p i t a l f o r several months at a time, h i s per-iodic absence from the home, creates an unstable atmosphere for his children. When he i s at home, his i l l n e s s usually de-mands the overattention of h i s wife. Because of his need for rest and quiet, the children are forced to r e s t r i c t t h e i r "natural exhuberence. At the same time, i t i s not uncommon to 1 A more detailed account of t h i s i s given i n , English and Pearson, Emotional Problems of Li v i n g , pp. 91-97. (68) f i n d parents displacing frustrated feelings which i l l n e s s has created for both of them, onto th e i r children at the s l i g h t e s t provocation. Physical deprivation, which usually accompanies reduced incomes of RHD patients, also a f f e c t s t h e i r children. Inadequate clothing, diet and shelter, make them easy preys to i l l n e s s and disease. F i n a l l y , where foster home placements are necessary, i n cases where both parents are unable to provide care, i . e . through i l l n e s s or marital s t r i f e , the traumatic ex-perience of separation provides f o r t h e i r children the climax for a t o t a l l y unfortunate beginning i n l i f e . 1 Recognition of these dangers by government and private or-ganizations, has led to the development of vast c h i l d welfare programs to a l l e v i a t e these conditions. Some mention has a l -ready been made of the community resources which the medical 2 s o c i a l worker uses i n this regard. As a rule, d i r e c t contact with these children by the medical s o c i a l worker i s avoided, and instead, co-ordination of the services of those agencies best equiped and trained to work with children, i s attempted. Case Examples of the Ef f e c t on Children 3 The f i r s t case, i s one that has been described before. Here, both parents would regularly go into h o s p i t a l , so that foster home care for t h e i r 6-year-old c h i l d was needed. 1 Gordon Hamilton, Theory and Practice of S o c i a l Case .Work, pp. 281-83, points out the problems encountered i n "The Sep-aration Experience". 2 See p. (43), i n Chapter 3. 3 See pp. (21-24), i n Chapter 2. (69) C o l l a t e r a l contacts with the c i t y s o c i a l service and the c h i l -dren's aid society (C.A.S.), revealed that f i n a n c i a l a i d , as well as foster home care, had been given i n the past. C.A.S. were also concerned about the e f f e c t of the mother's mental i l l n e s s on the c h i l d . .Where possible, children are placed i n the care o f r e l a -t i v e s i n preference to strange foster homes, as the e f f e c t - o f separation i s not so great when a f a m i l i a r person i s present. Consequently, C.A.S. arranged to place the c h i l d with the pa-t i e n t ' s mother-in-law. However, the patient was unable to accept t h i s plan, as he resented h i s mother-in-law f o r her many interferences into his marriage. With the help of the medical • s o c i a l worker, the patient was able to give up some of the more-unreasonable conceptions of his mother-in-law, i n view of the advantages her care could o f f e r his c h i l d . Following the b i r t h of a second c h i l d , the patient again entered h o s p i t a l . Shortly afterwards, h i s wife began to show signs of another mental breakdown. The patient was ready for discharge as his wife was admitted to the mental h o s p i t a l , and, i n a -state of panic, he demanded that C.A.S. place h i s children immediately. A day l a t e r , he changed his mind and decided to care for the children himself. A few days l a t e r , housekeeping services were obtained through C.A.S., afte r the medical s o c i a l worker encouraged him to u t i l i z e t h e i r services. When l a s t heard from;' both parents were at home with t h e i r children. On the whole, the oldest c h i l d has seen very l i t t l e of either parent, and was showing i n s t a b i l i t y as a r e s u l t of .her unhappy experiences of separation from them. The second (70) c h i l d has l i t t l e to look forward to, since i t was expected that both parents would shortly return to the h o s p i t a l . The possif b i l i t y of removing the children to a permanent foster home, where more consistent care could be given, was being considered. Another case example which has also been presented before, 1 indicates similar problems. Here f i v e children were the v i c -tims of inconsistent and immature parents - the father e i t h e r being i n the army or the'hospital most of the time, and the mother abandoning them on several occasions. I t i s not known what was done f o r the children except that c h i l d welfare agen-cies have been involved, and presumably have provided some sub-s t i t u t e care. I t i s doubtful how much can be done for children who are a l -ready so severely damaged emotionally. Two other cases i n d i -cate the possible r e s u l t of such neglect of children, as both of these reveal d i f f i c u l t i e s with juvenile court a u t h o r i t i e s . Case Work With Families One of the few areas i n which the medical s o c i a l worker can be c a l l e d upon to provide d i r e c t case work services to a member of a patient's family, i s i n helping parents and marriage part-ners to understand how i l l n e s s a f f e c t s the mental outlook of a patient, and also i n gaining some assistance with t h e i r own d i f f i c u l t i e s which the patient's i l l n e s s has created for them. The writer has suggested that as a rule, the p a r t i c u l a r commun-i t y agencies s p e c i a l i z i n g i n the s p e c i f i c service needed e.g. the 1 See pp. (65 - 67) . (71) family welfare bureau, would be c a l l e d upon to aid the medical s o c i a l worker with t h i s l a t t e r task. In r e a l i t y , t h i s i s not always possible. Since t h i s study concerns i t s e l f with the male adult RHD patient, the wife of a patient may show a willingness to discuss her problems with the medical s o c i a l worker, under, the guise of providing information which w i l l help the h o s p i t a l team to treat her husband, but too often she w i l l r e s i s t any r e f e r r a l to another agency. Because we are s t i l l l i v i n g i n an age when to ask for help with s o c i a l and emotional problems im-p l i e s a stigma, the wife may need much preparation by the medi-ca l wocial worker before she can f e e l free to go elsewhere to secure help with her own problems. The case referred to on p. (64) i s a good example of t h i s resistance. An I l l u s t r a t i o n of Case Work With a Patient's Wife The writer encountered much d i f f i c u l t y i n presenting a f a i r example of the kind of case work which can and i s usually given here. In some of the case records, i t i s apparent that considerable case work had been given to patients' wives and good re s u l t s achieved i n terms of the patient's health. How-ever, i n only one case i s there s u f f i c i e n t recording to i n d i -cate the case work process used, but t h i s case was s t i l l i n progress at the time t h i s study was made. This case has a l -ready been presented i n Chapter 3, i n r e l a t i o n to the s o c i a l work which can be offered to patients with RHD.1 Mention was made of the detrimental influence t h i s patient's 1 See pp. (49 - 58), i n Chapter 3. (72) wife had on his a b i l i t y and motivation to get well. The f i r s t v worker on the case was unable to bring about a noticeable change i n her attitude but subsequent contact with the second worker, who had more time to spend with her, helped her to express much of her h o s t i l i t y which had previously been directed towards her husband. A more-detailed picture of t h i s second worker's e f f o r t s i s , therefore, being presented at t h i s time. I t should be noted that although case work with wives of RHD patients i s on an environmental manipulative l e v e l i n r e l a t i o n to the pa-t i e n t ' s treatment, a l l four l e v e l s may be used with the wife i n bringing about t h i s environmental change. In an early interview, where the worker i s attempting to establish a f r i e n d l y accepting r e l a t i o n s h i p with the wife, en-couragement i s given to her which would allow her to express her feelings about her husband's condition. I asked, "how do you think your husband i s , Mrs...?" She r e p l i e d , a f t e r a pause, "Well, I know h e ' l l never be any better and he's l i k e l y to die at any time. I faced that long ago". I asked her i f she thought he should give up the idea of ever leaving the h o s p i t a l and she said very f o r c e f u l l y , "Well I haven't r e a l l y said t h i s before, but I think he i s better o f f staying where he i s , and I think he knows i t most of the time"....I said i t was quite a problem to have a hus-band who was unable, through no f a u l t of h i s own, to f u l f i l any of the functions of a husband. She r e p l i e d , "My G-odJ That's sure a true statement". I said that one c e r t a i n l y wouldn't blame a person for f e e l i n g some resentment at the way things were, and she t o l d me she fgot pretty fed up at times". Although the worker does not agree with the wife's concep-ti o n of her husband's i l l n e s s , she does not c r i t i c i z e the wife's defence. Instead, she indicates that she can understand that i t has been d i f f i c u l t for the wife as well as her husband. •This helps to create a f e e l i n g of acceptance and gradually the (73) wife i s able to bring out her true f e e l i n g s . 'Later, as the worker senses that the wife f e e l s more secure, the worker i s then able to help her face the truth. I said, "You r e a l l y don't want Mr...at home, do you", and she r e p l i e d , "No I don'.t, but for God's sake don't t e l l him". I said that i t was not our policy to repeat conversations with the husband or wife to one another, and that our conversation would be respected as c o n f i d e n t i a l . At f i r s t the wife i s threatened by the abruptness of her disclosure; but, once again, she i s given the necessary reassur-ance which would allow her to discuss her f r u s t r a t i o n s f r e e l y . At t h i s point she begins to reveal her fears influenced by her past relationships with other s o c i a l workers. She r e f e r s to people who "pry into other people's business", and although she does not mention the worker s p e c i f i c a l l y , t h i s i s picked up by the worker and an interpretation of the role of s o c i a l work i s given to the wife. I said that while i t might appear that way to her, that prying into other people's a f f a i r s had no place i n our work and that our purpose was to give people a chance to t a l k over any of the things that might be bothering them - with the idea of giving any help we could. We did not want to t e l l her what to do; we appreciated the fact that people are able to make th e i r own decisions, but t a l k i n g about them before-hand often makes the path to be followed cl e a r e r . The wife accepts t h i s , and then pours fort h her many fru s -trations at having to assume the role which i s normally c a r r i e d by a husband, but which h i s i l l n e s s has changed. Like her hus-band, who i s also a dependent personality, she i s unable to assume any r e s p o n s i b i l i t y for her d i f f i c u l t i e s and projects the h o s t i l i t y which th i s f r u s t r a t i o n creates within her, onto her husband and everything connected with him. One by one, she (74) brings f o r t h much resentment towards the various s t a f f members treating her husband, and indicates that she does not hesitate to make her h o s t i l i t y known to them. Without attempting to interpret her behaviour to her, the worker encourages the wife to bring her future complaints d i r e c t l y to the worker. By the worker channelling the wife's h o s t i l i t y onto her s e l f , the hos-p i t a l s t a f f i s thereby saved much needless argument with a woman who i s aggressive and wishes to make trouble. The worker's appraisal of the wife, gives a good i n d i c a t i o n of her motivation. I f e l t two reasons for t h i s h o s t i l i t y towards the s t a f f . (1) I t i s an attempt to assuage the g u i l t f e e l -ings around her r e j e c t i o n of her husband and (2) an attention - getting device by which a dominant woman, resenting the fact that she has no status other than that offered to a "veteran's" wife, (no status i n being the wife of a man you have rejected), seeks t h i s status i n a n e g a t i v i s t i c way be t r y i n g to dominate i n the h o s p i t a l s i t u a t i o n . This early diagnosis i s lat e r born out, and i t becomes clear that the wife i s jealous of the attention which everyone has been giving her husband i n the ho s p i t a l , while she has had to carry the load of maintaining a family alone. She said he was a "spoiled brat" and he expected her to s p o i l him the way his own mother had. I asked i f she had always thought t h i s was so, or just since he had been i n the h o s p i t a l . She said, i n a tone of disgust, that he had always been that way.... "I don't mind looking a f t e r him, but I sure don't s p o i l him. She continued with a long d i s s e r t a t i o n concerning her husband's need to get used to having a l l these people "waiting on him" and to get used to the kind of food he was going to get at home. The worker then plans to offer supportive case work to the wife, so that she can gain some measure of self-worth. By making her also f e e l important, i t i s expected that she w i l l ( 7 5 ) have le s s need to r e j e c t her husband. A l a t e r interview points out t h i s problem and indicates how the worker i s able to handle I asked Mrs...how she thought her husband was f e e l -ing, and she said r e l u c t a n t l y , "I f e e l that he i s much better since he has been moved". I said that I thought so too, and apparently the doctor believed t h i s to be true as well. I thought Mrs...resented t h i s improve-ment, because she said quickly, "Well i t won't l a s t I can t e l l you that". I-smiled and said, "You said,that so emphatically, that you must have some strong f e e l i n g about i t " . She paused, and then said vehemently, "Well I don't want my husband, or anyone else, thinking he can come home as soon as I get a house". At t h i s point she glared at me and looked very upset. I said that t h i s was one of the things I had wanted to discuss with her. I said I r e a l i z e d that she was making a serious e f f o r t to f i n d new l i v i n g accommodations, while at the same time worrying about a l l the adjustments which would have to be made by each member of the family. I said that I could understand that her l i f e would be d i f f e r e n t with her husband home, that they would have to get used to each other again....Mrs...looked r e l i e v e d , and said she...had thought of these things, and i t bothered her. I said that I hoped that when she found a house, Mr... would take the t r a n s i t i o n i n stages - f i r s t a weekend at a time at home, with gradual, increases of time spent there, u n t i l they could see how things were working out. She said she was glad I thought t h i s way too, because she was a f r a i d the minute she got a house, everyone would think he should go r i g h t home. I said that the hos p i t a l treatment team was concerned not only with the patient, but with his adjustment at home, and was there-fore interested i n the whole family. Following the worker's supportive understanding of the wife's c o n f l i c t and c l a r i f i c a t i o n of the treatment team's i n t e r e s t i n her, as well as her husband, c l a r i f i c a t i o n i s extended to an i n -terpretation of the husband's feelings about his lengthy hospi-t a l i z a t i o n . She said, "Well he seems to have the crazy idea that he can move r i g h t home and everything w i l l be cosy". I said that such an idea would seem "crazy" to those of us who were active, healthy, people and l i v i n g our normal l i v e s , but to a patient who has spent about two years i n h o s p i t a l , i t was natural to think he would be going home to the same si t u a -( 7 6 ) t i o n he had l e f t . I pointed out that she could help her husband by planning with him.... The wife's resistance to change i s accepted and understood by the worker and gradually other household problems, such as control over finances, care of the children etc., are faced. The worker encourages the patient's wife to discuss a l l these problems with her husband, while he i s s t i l l i n the h o s p i t a l . I t should be mentioned, that these areas of c o n f l i c t were also discussed with the patient, and he was also encouraged to t a l k with his wife. In this way the greater part of the tension between husband and wife, i s released-.:, i n the accepting atmos-phere of a worker-client r e l a t i o n s h i p . I t i s i n connection with t h i s problem of home finding, that the worker brings out one of the basic p r i n c i p l e s of case work - that of encouraging the c l i e n t to make his own decisions. As they return from an inspection of a prospective apartment, the patient's wife asks the worker to decide whether or not she (the wife) should take t h i s suite. I explained again that i t was not my function adding that I was sure she didn't want me. to make up her mind fo r her, although I hope she knew that I wanted to be of help i f I could. At t h i s time a l l the frustrations of early experiences with s o c i a l workers and s o c i a l agencies i s expressed, and as the worker encourages her to bring out t h i s h o s t i l i t y , without c r i t i c i z i n g her, she helps the wife to understand the cause of t h i s f e e l i n g . I said, " t h i s sort of thing bothers you doesn't i t Mrs...because we've talked about i t before, a l -though you've/ never told me why you d i s l i k e s o c i a l workers". She paused, and t o l d me how she had hated the woman who had "butted i n " about her (77) children. I said you were perhaps a l i t t l e a f r a i d at the time and_ reacted by being angry? She paused and said f i n a l l y that she guessed she had been "sort of scared". I said that when we are f r i g h t -ened, we often don't show that we are, but hide our fear by getting angry at someone - often a d i f f e r e n t person than the one who had made us a f r a i d . Although progress has been very slow, there has been some positive i n d i c a t i o n that the wife has changed since f i r s t seen by the worker. On the whole, she has responded to the f e e l i n g of acceptance which the worker has given, and together with the changing attitude of the husband towards her, she has been able to modify her demands upon him. As has been pointed out before, 1 i t i s doubtful whether complete r e c o n c i l i a t i o n i n t h e i r own home, w i l l every become a r e a l i t y . The patient's physical condition i s too serious to ever allow t h i s for any length of time, but at least the emotional tension which f o r -merly existed between husband and wife has lessened considera-bly, and the patient has experienced benefit from t h i s . The h o s p i t a l s t a f f , who were formerly annoyed by a h o s t i l e wife, have also received benefit through the e f f o r t s of the s o c i a l worker on their behalf. The purpose of t h i s area of presentation has been to point out the far-reaching e f f e c t s which a patient's i l l n e s s can produce on others. Because of the varying inner and outer needs which in d i v i d u a l s i n a family c o n s t e l l a t i o n seek to sa-t i s f y as they i n t e r a c t with one another, and the barriers which i l l n e s s of one of the members creates i n the search for 1 See p. (58) i n Chapter 3. (78) ultimate s a t i s f a c t i o n of these basic desires, the r o l e of soc-i a l workers i n the community becomes clearer. Ways i n which the medical s o c i a l worker seeks to combat these r e s u l t i n g d i f f i c u l -t i e s , as a member of thi s vast community team, have been sugges-ted. Too much emphasis cannot be given to the interdependent re l a t i o n s h i p which must exiBt, not only between members of the ho s p i t a l team.but also between the various community agencies interested i n the well-being of i t s c i t i z e n s , i f the i n d i v i d -ual e f f o r t s of these valuable resources are to achieve maximum r e s u l t s . The following section w i l l attempt to bring together the conclusions which t h i s study has to o f f e r i n making such r e s u l t s possible. CHAPTER 5 CONCLUSIONS AND RECOMMENDATIONS The purpose of t h i s study has been to explore the s o c i a l and emotional backgrounds of male adult patients affected by rheumatic heart disease, i n order to determine the following relat i o n s h i p s : (1) The connection - i f any - between a patient's s o c i a l and personal background and h i s s u s c e p t i b i l i t y to rheumatic heart disease. (2) The re l a t i o n s h i p between emotional disturbances and the course (onset, convalescence, and l a t e r recurrence) of rheuma-t i c heart disease. (3) The s p e c i f i c s o c i a l and emotional factors which a f f e c t the patient with rheumatic heart disease. (4) The role of the s o c i a l worker - as a member of the treatment team - i n a l l e v i a t i n g these environmental and person-a l pressures. Two main f a c t o r s have influenced the v a l i d i t y of the f i n d -ings, (1) the cases selected for this study, and (2) the available s o c i a l and personal information concerning the pa-tie n t s selected. Because only those patients which were re-ferred for medical s o c i a l service at Shaughnessy h o s p i t a l were used, approximately three-quarters of a l l the RHD patients ad-mitted during a four-year period, (1947-1951), were excluded. Medical records available on each patient, did not contain s u f f i c i e n t s o c i a l and personal information to make a more-•complete study of a l l RHD patients admitted to the ho s p i t a l (80) possible. Although medical s o c i a l service records included such information, even these i n many instances, did not possess suf-f i c i e n t material from -which to draw v a l i d conclusions. Despite supplementation of these records by material obtained from other 1 sources, i t was s t i l l hot possible to obtain enough information about RHD patients - especially their early s o c i a l and personal h i s t o r i e s . Although only records of veterans with RHD have been exam-ined, the findings of t h i s study are, i n the main, applicable to a l l patients affected by RHD. The most outstanding finding, not only i n terms of hos p i t a l treatment, but i n the broader as-pect of community r e s p o n s i b i l i t y , has been the re l a t i o n s h i p be-tween the increasing economic d i f f i c u l t i e s which beset the RHD patient and h i s extensive physical and personal inadequacies. As a rule, the RHD patient entering a veterans' hospital, does not suffer the added burden of h o s p i t a l debt as does the average c i t i z e n . On the contrary, there are times when the veteran i s far better o f f f i n a n c i a l l y , e.g. increased pension grants, r e h a b i l i t a t i o n programmes, etc. Therefore, i t i s reasonable to expect that economic d i f f i c u l t i e s present as great, i f not a much greater handicap to a l l RHD patients. Despite the resources within the department of veterans' a f f a i r s , the RHD patients examined i n t h i s study have not been able to make e f f e c t i v e use of the environmental aid offered to them. Part of the answer to t h i s enigma l i e s i n the area of incomplete or inadequate resources, but what seems to be of 1 See pp. (13-14) i n Chapter 1. (81) equal importance, i s the personality defect within the RHD pa-t i e n t , that does not allow him to make f u l l use of t h i s a i d . Although information surrounding personality formation of the RHD patient i s very sparse, there i s s u f f i c i e n t evidence of sim-i l a r i t y i n a l l the cases examined, to indicate there i s an i n -t e r r e l a t i o n s h i p between personal adaptability, s o c i a l pressure and eventually, physical deterioration. In a l l cases, i t was seen that the RHD patient's preparation for adulthood and the r e s p o n s i b i l i t i e s which'accompany t h i s stage of development, was mainly inadequate. I t i s d i f f i c u l t to say whether h i s education was limited because of sol e l y per-sonal or s o c i a l pressures. S i m i l a r i l y h i s choice of a physi-cally-strenuous vocation would appear to be the r e s u l t of a number of in t e r r e l a t e d factors. I t i s significant^ however, , that there has been l i t t l e permanency of employment or develop-ment of s k i l l s . The exercise of manual labour i s the only com-mon factor i n his choice of employment. It has been suggested that the personality of the RHD.pa-ti e n t has been founded upon insecure r e l a t i o n s h i p s . Somewhere i n his development, he has "learned" that i n order to gain approval, he must constantly drive himself. In our competitive society, where1 the physically-superior athlete i s given high hon-ours, i t i s not strange to equate acceptance by others with a show of physical prowess. I t has also been suggested, that des-pite t h i s need to exert h i s independence, the RHD patient has never r e a l l y resolved h i s e a r l i e r dependency feelings upon h i s parents and l a t e r upon parent substitutes. This constant "un-conscious" mental c o n f l i c t , therefore exerts i t s e l f "psychoso- . (82) matically" upon his physical condition, so that by d r i v i n g him-s e l f physically, he achieves s a t i s f a c t i o n for both h i s depen-dency and independency needs. He gains approval for h i s martyr role as well as dependent care which h i s r e s u l t i n g i l l n e s s affords. In t h i s way, he i s able to resolve h i s c o n f l i c t so that i t i s now acceptable to his conscious s e l f . This pattern of reaction i s evident i n a l l phases of the RHD patient's adult l i f e experiences. Not only i n h i s choice of and a b i l i t y to maintain suitable employment i s t h i s noticeable, but, what i s equally important, i n h i s m a r i t a l adjustments as w e l l . I t has been shown how many of the RHD patients have attempted to seek a haven of dependent "emotional security i n t h e i r marriage, but because their wives have not been able, to play the mother-role as was expected of them, more, rather than l e s s , s o c i a l personal and physical turmoil has resulted f o r these patients. What i s then observable, i s a vicious, never-ending cycle of s o c i a l and emotional problems which appear to p r e c i p i t a t e r e -peated attacks of RHD. As the RHD patient becomes frus t r a t e d by h i s i n a b i l i t y to'maintain a former l e v e l of existence, he be-comes more susceptible to r e i n f e c t i o n . By becoming i l l , h i s en-vironmental problems increase, he becomes more frustrated, and h i s a b i l i t y to respond to treatment i s impaired. I f and when he does recover, he returns to an emotionally-charged atmosphere which has not improved during his absence. His physical condi-t i o n i s further impaired, and the pattern repeats i t s e l f - per-haps u n t i l such time as death takes over. However, the problems which have surrounded the i l l n e s s do npt stop here. The i n t e r r e l a t i o n s h i p of family members and the (83) e f f e c t which the breadwinner, suffering from RHD, has had on them, remains. If. divorce or separation has not ended the mar-riage long before t h i s , and children born to t h i s union have not grown s u f f i c i e n t l y to fend for themselves, the family con-tinues to bear the brunt of the ever-increasing f i n a n c i a l bur-den which i l l n e s s has created. Because they have been forced to l i v e under poverty-stricken conditions, the roots for f u r -ther s o c i a l and physical disorganization have struck deep. Be-cause i l l n e s s has interfered with the s a t i s f a c t i o n s normally sought i n marriage, personal d i s i n t e g r a t i o n i n the wife has reached a high peak, but perhaps i t i s the children of t h i s marriage that suffer the most. Since many children have been denied the basic security of a happy normal home, t h e i r person-a l i t i e s have already been so severely damaged that they are il l - e q u i p e d to face the mature demands of l a t e r l i f e . The role of the s o c i a l worker has been presented as that member of the ho s p i t a l treatment team, who i s s p e c i f i c a l l y trained to cope with these s o c i a l and emotional problems a f f e c -ti n g patients with RHD, as well as other forms of i l l n e s s . Four types of therapeutic processess, (1) environmental mani-pulation, (2) psychological support, (3) c l a r i f i c a t i o n , and (4) insight have been introduced as basic forms of d i f f e r e n -l t i a l case work treatment. Because of the deep-seated nature of the personality c o n f l i c t of the RHD patient and the permanent dependency s i t u a t i o n which accompanies the physical l i m i t a t i o n of a chronic i l l n e s s , the writer has suggested that the major contribution of the s o c i a l worker, l i e s i n the area of envir-onmental manipulation. However, i n order to help t h i s patient (84) make the best use of the resources which are a v a i l a b l e , the value of p s y c h o l o g i c a l support and c l a r i f i c a t i o n has been i n d i -cated. • As part of the s o c i a l worker's job of s o c i a l a m e l i o r a t i o n , h i s work wi t h the p a t i e n t ' s f a m i l y has a l s o been presehted. Most common, i s the i n t e r p r e t i v e work which must be done w i t h the p a t i e n t s ' wives, f o r i t i s t h i s intimate r e l a t i o n s h i p of marriage which has been so s e r i o u s l y damaged by i l l n e s s . Because the greatest area of s o c i a l pressure a f f e c t i n g the emotional w e l l - b e i n g of the p a t i e n t and h i s f a m i l y stems from sources w i t h i n the community, i t has been suggested that the burden of r e s p o n s i b i l i t y i s l a r g e l y a community one. I n the broader sense, the medical s o c i a l worker has also been presen-ted as a member of the community treatment team, as w e l l as the h o s p i t a l s t a f f . The s o c i a l worker, t h e r e f o r e , has a r o l e to play w i t h RHD p a t i e n t s i n a h o s p i t a l s e t t i n g . S p e c i f i c a l l y , t h i s i s : (1) To work together w i t h other members of the treatment team, to b r i n g about the best p o s s i b l e treatment measures f o r the good o f the p a t i e n t . (2) To determine what emotional pressures are a f f e c t i n g the p a t i e n t ' s response to medical care - both from " o u t s i d e " , and w i t h i n the h o s p i t a l . (3) To u t i l i z e a l l the a v a i l a b l e resources which w i l l amel-i o r a t e the c o n d i t i o n s c r e a t i n g these emotional pressures, so that the p a t i e n t can b e t t e r respond to medical treatment. This i n c l u d e s the use of both environmental and p s y c h o l o g i c a l .aids. (85) (4) To work with the community welfare team i n the perfor-mance of their task to bring about the best possible atmosphere for the mental and physical well-being of the citizens- within that community. Recommendations Treatment for RHD patients i s of long-term duration. Be-cause of the chronic nature and the extended convalescent per-iod of RHD, adequate s o c i a l service to these patients must be on a continuous basis. This involves then, the continuous and co-ordinated e f f o r t of both the medical and community s o c i a l workers. The former group i s required to o f f e r treatment while the patient i s i n h o s p i t a l , but i t i s the l a t t e r group's res-p o n s i b i l i t y to provide adequate preparation and follow-up ser-vices to insure that h o s p i t a l treatment w i l l be and has been of utmost benefit to the patient. I f i t i s accepted that people who suffer from RHD have the r i g h t to receive physical, mental and s o c i a l treatment just as any other member of society, then the need for more-adequate service, i s self-evident. Staff Requirements As has been pointed out, 1 the general practice of s o c i a l workers who are carrying a heavy case load, i s to select the greatest number of patients who can benefit from the least amount of the worker's time. I t i s the c h r o n i c a l l y - i l l patient who usually must be s a c r i f i c e d when t h i s necessary procedure i s carried out. There i s a need for more s o c i a l workers to cover 1 See pp. (53-54) i n Chapter 3. (86) t h i s gap i n t r e a t m e n t s e r v i c e s . A c a s e l o a d o f t h i r t y t o f o r t y c h r o n i c a l l y - i l l p a t i e n t s a t any one t i m e , i s p r o b a b l y t h e m a x i -mum t h a t c a n be e x p e c t e d t o r e c e i v e f u l l b e n e f i t o f c a s e work s e r v i c e s by one w o r k e r . A g a i n , because o f t h e t i m e i n v o l v e d , t h e r e i s a n e e d f o r s u f f i c i e n t h i g h l y - s k i l l e d s o c i a l w o r k e r s who c a n make t h e b e s t use o f t h e t i m e a l l o t t e d t o e a c h p a t i e n t . There i s a g r e a t d i f -f e r e n c e between t h e u n t r a i n e d s o c i a l w o r k e r who m e r e l y " v i s i t s " , a n d t h e one who has h a d a t l e a s t two y e a r s o f p r o f e s s i o n a l t r a i n i n g , as w e l l as l e n g t h y m e d i c a l s o c i a l w o r k e x p e r i e n c e . The p r o f e s s i o n a l s o c i a l w o r k e r , i s t h e t y p e o f p e r s o n who, n o t o n l y p o s s e s s e s a n i n n a t e c a p a c i t y f o r " h e l p i n g o t h e r s t o h e l p t h e m -s e l v e s " , but who h a s a l s o , t h r o u g h t r a i n i n g , added a n o b j e c t i v e a w a r e n e s s to h i s u n d e r s t a n d i n g o f human b e h a v i o u r . The p l e a f o r e x p e r i e n c e i n m e d i c a l s o c i a l w o r k i s f o u n d e d upon t h e c o m p l e x i t i e s w h i c h s o c i a l w o r k i n a m e d i c a l s i t u a t i o n c r e a t e . The a b i l i t y t o w o r k w i t h o t h e r t r e a t m e n t - t e a m members c a l l s f o r a d d e d s k i l l and k n o w l e d g e . The m e d i c a l s o c i a l w o r -k e r ' s f u n c t i o n i s t o h e l p i n t e r p r e t t o o t h e r team members, t h e m e a n i n g b e h i n d t h e p a t i e n t ' s r e a c t i o n t o i l l n e s s . B e c a u s e o f h i s g r e a t e r a w a r e n e s s o f t h e s o c i a l s i t u a t i o n beyond t h e h o s p i -t a l s e t t i n g and h i s u n d e r s t a n d i n g o f human b e h a v i o u r , t h e m e d i -c a l s o c i a l w o r k e r i s i n a n a t u r a l p o s i t i o n t o p e r f o r m t h i s l i a -s o n work w i t h o t h e r members o f the t r e a t m e n t team who a r e n o t o r d i n a r i l y c o n c e r n e d w i t h t h e s o c i a l and e m o t i o n a l a s p e c t s o f i l l n e s s , b u t a r e more d i r e c t l y i n t e r e s t e d i n t h e s p e c i f i c m e d i -c a l t a s k f o r w h i c h t h e y h a v e been t r a i n e d . A s a l w a y s , t h e u l t i -mate f o c u s i s o n t h e p a t i e n t - a s - a - w h o l e , n o t j u s t t h e p a t i e n t . (87) Resource Requirements Apart from the physical equipment, such as adequate o f f i c e space, c l e r i c a l s t a f f , telephones, etc., which permit the s o c i a l worker to carry out his job without unnecessary r e s t r i c t i o n s , there are s p e c i f i c service requirements for the welfare of RHD patients which must supplement case work treatment. I t has been pointed out that a veterans' h o s p i t a l , such as the one where t h i s study has been made, has numerous valuable resources at i t s d i s p o s a l . 1 In considering the s o c i a l problems which are most frequently encountered by RHD patients, the value of f i n -a n c i a l aid for patients and their families at a time when hos-p i t a l i z a t i o n i s creating the most serious f i n a n c i a l burden, can-not be overlooked. Too, the convalescent homes,(George Durby Health and Occupational Centre, Hycroft), f i l l a need which the usual convalescence i n overcrowded, damp, poorly-constructed, cold homes of RHD:patients, does not provide. The possible use of nursing homes s p e c i f i c a l l y designed to meet the emotion-a l as well as physical needs of the RHD patient, requires f u r -ther i n v e s t i g a t i o n . Opportunity for r e t r a i n i n g through corres-pondence courses etc., and aid i n fi n d i n g employment which i s i n keeping with the physical l i m i t a t i o n s , i s and should be, also a v a i l a b l e . Temporary use of a sheltered workshop which i s designed to bolster the confidence of physically i n f e r i o r pa-ti e n t s , i s another area which needs further exploration. Retraining aids serve the dual purpose of not only making Tt possible for the RHD patient to maintain his r o l e as 1 See pp. (43-44) i n Chapter 3. (88) breadwinner, but what i s equally important, provides him with a much-needed form of diversion to counteract h i s natural tendency to brood over himself during the long months of h i s " r e s t f u l " , yet " r e s t l e s s " convalescence. This does not obviate the need for other forms of occupational therapy. The possible use of group work with RHD patients, as a part of treatment, i s another area which s t i l l needs much more e x p l o r a t i o n . 1 Unfortunately, these services are not available for a l l chronically disabled RHD patients. For those who are not e l i -g ible for maximum veteran benefits, the existing services of the community have been used. In any event, there i s a s e r i -ous gap i n both resources. The patient affected by RHD i s ex-pected to function within the l i m i t a t i o n s of the society i n which he l i v e s , as well as within his physical limitations» The use made of r e t r a i n i n g programmes, employment services, f i n a n c i a l support, etc., i s only valuable i n comparison to the a v a i l a b i l i t y of these resources within the community. R e a l i s -t i c a l l y , i t i s not always possible to f i n d suitable employment described as l i g h t work, etc., or low-cost, though adequate housing. For t h i s reason, i t i s necessary to re-examine our stand-ards of f i n a n c i a l a i d . How much better equiped, emotionally as well as f i n a n c i a l l y , i s the one hundred per cent disabled veteran who receives s u f f i c i e n t income to meet the economic 1 C e l i a R. Moss describes some in t e r e s t i n g experiences on t h i s subject of group work i n a medical s e t t i n g , i n her a r t i c l e , "In-tegrating Case Work and Recreation i n a M i l i t a r y Hospital", Journal of S.C.W., Dec. 1946, pp. 307-313. (89) need of himself and his family. Consider however, the patient who sees debts mounting up i n front of him, with inadequate means at his disposal to counter-balance them. Is i t any wonder that many are forced to abandon tke wise counselling of doctors and return to physically strenuous employment which _is available, long before i t i s safe for them to do any type of work? Is i t any wonder that many delay medical treatment u n t i l t h e i r physi-c a l condition becomes c r i t i c a l ? Is i t not also possible that many consciously or unconsciously seek to prolong t h e i r hospi-t a l stay, because i t i s the only s o l u t i o n they can v i s u a l i z e to an ever-widening c i r c l e of f i n a n c i a l debt? There i s a strong case for recognizing the added burden which chronic i l l n e s s places on the RHD patient. Since much of the emotional s t r a i n a f f e c t i n g the course of h i s i l l n e s s sur-rounds h i s f i n a n c i a l inadequacy and i t s r e s u l t i n g s o c i a l d i s -order, there i s a need for a more-adequate r e - a l l o c a t i o n of welfare budgets which w i l l compensate for the RHD patients' and the i r f a m i l i e s ' unequal struggle for s u r v i v a l . I t i s evident that the cost to society i s fa r greater when a breadwinner i s undergoing h o s p i t a l treatment, than i f he can be maintained i n his own home. Also, the value which h i s r e s u l t i n g emotional well-being creates i n terms of the eff e c t he has on h i s family, cannot be overestimated. An atmosphere for stable personality growth of an RHD patient's children, provides greater assurance that as these children grow up, they w i l l be bet.ter-equiped to cope with the demands, and contribute to the needs, of society. The Need for More Research More research i s needed along similar l i n e s of thi s study (90) with other groups of adult male RHD patients. As t h i s study has concerned i t s e l f mainly with the veteran RHD patients, there i s a danger of drawing conclusions which are not applicable to the general population. A control group which i s more representative of the young male adult population could be selected for a re-search project which would involve the co-ordinated a c t i v i t i e s of several interested d i s c i p l i n e s . Since the a v a i l a b i l i t y of. background information, feelings towards i l l n e s s etc., has been lacking i n the records used for t h i s study, i t i s f e l t that a controlled research project could overcome t h i s d i f f i c u l t y , and more-accurate s t a t i s t i c a l comparisons could be made. Too, more-ef f e c t i v e measurements of the r e l a t i o n s h i p between emotional and physical responses should r e s u l t , by the comparisons which each d i s c i p l i n e can make, as s p e c i f i c treatment measures are introduced. t Related research projects are also needed. As a possible suggestion, there i s a need for a closer examination of the p o s s i b i l i t i e s for greater co-ordination of the e f f o r t s of the treatment team, both i n and out of the h o s p i t a l s e t t i n g . The advantages and disadvantages a f f e c t i n g the granting of pensions i i . e . p e n s i o n i t i s ) , i s another area for further study. Speci-f i c research projects on other- forms of chronic i l l n e s s such as rheumatoid a r t h r i t i s , diabetes, etc., are also needed. In con-nection with t h i s l a t t e r project, the formation of a standard-ized method of approach would prove invaluable i n terms of sta-t i s t i c a l comparisons. Adequate Use of Recording Since the major d i f f i c u l t y a f f e c t i n g the findings o f t h i s (91) study involves the u n a v a i l a b i l i t y of complete medical s o c i a l service records of the patients selected, some change i n the f u -ture plan of recording i s suggested. In.view of the large case loads and shortage of medical s o c i a l service s t a f f , which exis-ted at the time t h i s study was being conducted, recognition i s given to the l i m i t e d time which the s o c i a l workers have been able to devote to recording. These recommendations concerning the more-adequate use of recording, are being presented i n terms of i d e a l "working conditions which include the necessary time for such recording. Because of the unique use to which medical s o c i a l service records are .put, 1 provision should be made for two kinds of f i l e s . The f i r s t would be similar to the type of recording now i n use - namely, a brief report on the s i g n i f i c a n t f a cts sur-rounding the s o c i a l and emotional problems of the patient and the corresponding case work treatment used to counteract these problems. The second set of recording should be a more-detail-ed account of the s i g n i f i c a n t factors surrounding the. p a t i e n t 1 s i l l n e s s , on an interview by interview basis. Whereas the f i r s t record would be placed on the central f i l e , the second one would be retained for the exclusive use of 1 A l l departments of D.V.A. are requested to f i l e i n d i v i d u a l reports i n a common f i l e , so that complete information o f a l l services.rendered to the veteran i s r e a d i l y a v a i l a b l e . The d i s -advantage of t h i s for medical s o c i a l service, i s that records must be written, not only for future use by s o c i a l workers, but for other treatment team members who have l i t t l e i nterest i n de-t a i l e d reports of the process of s o c i a l work as such, l o r t h i s reason, as a r u l e , medical s o c i a l service reports usually i n d i -cate b r i e f l y , what has happened - not necessarily how and why a change has taken place. (92) the medical s o c i a l service s t a f f . There i s value i n t h i s l a t t e r set of records not only for future research purposes but also for supervision and teaching of case work s t a f f . S k i l l s i n case work used to r e l i e v e the patient's problems, would thereby be improved. Because of the extra time involved f o r such recording, provision should be made for c l e r i c a l .staff to handle t h i s load. The use of very f u l l (process) recording i s , of course, the most valuable method of obtaining research material. Since t h i s i s very time-consuming, i t i s not suggested as a p r a c t i c a l me-thod for the average case load. Changes i n the c h r o n i c a l l y - i l l patient are r a r e l y sudden, and much r e p e t i t i o n of material i s unnecessarily recorded. However, t h i s recommendation does not obviate the use of process recording where the s p e c i f i c func-t i o n of the research project i s designed to bring out techniques of case work treatment. There i s room for much improvement i n case work treatment with the c h r o n i c a l l y - i l l patient.. Prevention The best remedy for any chronic i l l n e s s i s of course, one °? prevention. As with treatment, there are two aspects for consideration (1) the r e s p o n s i b i l i t y of the community towards prevention, and (2) the r e s p o n s i b i l i t y of the h o s p i t a l . RHD i s a s o c i a l r e s p o n s i b i l i t y , therefore, the major role of prevention l i e s within the community. Since "poverty" breeds disease", more adequate s o c i a l measures are needed to eremove thi s source of i n f e c t i o n . Slum areas,etc., need to be replaced by l i v i n g conditions more conducive to the physical well-being of i t s inhabitants. Although t h i s study does not attempt to (93) v e r i f y t h e o r e t i c a l assumptions of emotional factors contributing to the development of RHD, the importance of mental pressures cannot be overlooked i n any prevention programme. For t h i s reason, adequate health measures w i l l include both physical and mental health education, especially during early childhood years where the onset of RHD i s so prevalent. The use of s o c i a l ser-vices as a part of the programme, i s v i t a l . More s p e c i f i c a l l y , the hospital's role i n prevention, from a s o c i a l work point of view, i s that of early diagnosis and re-f e r r a l to medical s o c i a l service as soon as i t i s apparent that there are s o c i a l and emotional problems a f f e c t i n g the course of the patient's i l l n e s s . On the basis of t h i s study, i t i s f e l t that there i s a strong p o s s i b i l i t y that many other RHD patients treated i n t h i s and other hospitals, have not been r e f e r r e d to a medical s o c i a l worker when such service might have been re-quired by the patient. For example, two records of RHD patients have been selected at random from approximately seventy-five pa-ti e n t s who were never seen by a medical s o c i a l worker at any time while they were undergoing veteran h o s p i t a l treatment. The f i r s t case i s that of a 25-year-old veteran who s u f f e r -ed with RHD since his f i r s t attack of rheumatic fever i n 1942. He died six years l a t e r , a f t e r fourteen readmissions. This pa-ti e n t presented the usual pattern of sporadic, strenuous employ-ment, and although he received some t r a i n i n g as a jewellery r e-pairman while undergoing h o s p i t a l treatment, he was never able to support himself again. In 1947 i t was noted that he was married, and that he was having d i f f i c u l t y f i n ding l i v i n g accomo-dations. A few months l a t e r , i t was noted that he entered (94) h o s p i t a l immediately aft e r a c h i l d was born to h i s wife. There are suggestions i n the record of f i n a n c i a l d i f f i c u l t i e s , as well as possible f r i c t i o n with h i s wife. The second case i s that of a 63-year-old veteran who has been continuously i l l since World War 1. Since 1919 he has averaged more than one admittance per month to the h o s p i t a l . I t i s known that h i s wife deserted him i n 1947 and that he has had continual f i n a n c i a l problems. Although he has been informed of the l i m i t a t i o n s of his cardiac ailment, he constantly denies t h i s and continues to work at strenuous employment. I t was f e l t that although t h i s patient attempted to very "independent i n expression", he was b a s i c a l l y emotionally dependent and quite immature. As an example of his se l f - d e s t r u c t i v e behaviour, i t was noted that he once f e l l from a wagon while he was working on a farm, and fractured h i s l e f t arm. A short time l a t e r he re-moved his cast "because i t hampered his movements". I f s o c i a l work services are to be most e f f e c t i v e , r e f e r r a l s must be made as early as possible by the doctor i n charge of treatment. In view of the findings of t h i s study, there would also appear to be a case for an automatic r e f e r r a l to medical s o c i a l service of a l l RHD patients. Since there are RHD pa-tients, who, because of t h e i r quiet manner do not openly express the i r emotional problems to ho s p i t a l s t a f f , i t i s important that they not be overlooked. The patient who cannot express his d i f f i c u l t i e s , suffers much more mental s t r a i n and subsequent psychosomatic discomfort^ than the one who can "release" h i s f e e l i n g more r e a d i l y . As a future research project i n preven-tio n , a comparison could be made between the progress of RHD ( 9 5 ) patients who were referred to medical s o c i a l service on admis-sion to hospital, and those whose r e f e r r a l s were delayed u n t i l such time as their s o c i a l and personal problems appeared to the ho s p i t a l s t a f f to be of s u f f i c i e n t magnitude to warrant s o c i a l work services. APPENDIX A 1 MEDICAL ASPECTS OF RHEUMATIC HEART DISEASE  De f i n i t i o n : The various inflammatory changes i n the heart which arise i n rheumatic fever, together with the valvular deformi-t i e s and other scars that remain, constitute rheumatic heart  disease. This term i s now used to indicate that the i n d i v i d -ual has or has had rheumatic fever, even though i t has not been c l i n i c a l l y evident. C l a s s i f i c a t i o n : Two c l a s s i f i c a t i o n s , active and inactive are most commonly used with RHD. The former i s used to designate that a. rheumatic i n f e c t i o n i s present i n one or a l l of the structures of the heart. The l a t t e r indicates the i n f e c t i o n has ceased but healed lesions remain. These lesions are usually valvular deformities r e s u l t i n g from a previous i n -flammation. Another grouping includes four c l a s s i f i c a t i o n s , (1) f u l -minating - occurring during the i n i t i a l attack of rheumatic fever, (2) recurrent active - intervening i n t e r v a l s of qui-escence, (3) chronic active - inflammation p e r s i s t i n g over periods of months or years, and (4) chronic inactive -where the disease exists for years without signs or symptoms of a rheumatic infection, yet healed s t r u c t u r a l lesions are present. 1 Extracted from Russel L. C e c i l , "Rheumatic Heart Disease," Textbook of Medicine, pp. 1185 - 1192. (97) ETIOLOGY AND MORBID ANATOMY Cause: Although SO to 30 per cent do not show existence of rheu-matic fever, i t i s believed that t h i s disease i s the cause of RHD. Development and Mode of Onset: Rheumatic fever - An i n f e c t i o n i n the form of p o l y a r t h r i t i s , muscle and joint pains, chorea and c a r d i t i s , i s the c h a r a c t e r i s t i c mode of onset i n over 85 per cent of rheumatic fever patients under ten years of age. After age forty, approximately 20 per cent of the patients are so affected. Rheumatic heart disease - approximately one-third of the children developing RHD give evidence of p o l y a r t h r i t i s f i r s t , another t h i r d have c a r d i t i s and chorea. Young adults usually have p o l y a r t h r i t i s , whereas older people usually have only signs of valvular lesions. Type of Infection: During adolescence and early maturity, car-d i t i s i s seen more frequently as a single manifestation. Symptomatology: Onset of Active RHD - Usually an inflammation of the myocardium and valves - less commonly of the pericar-dium. Subsequent course - In children, the course of inflam-mation may l a s t from several months to several years - some-times i t may never completely subside. Disappearance of the c l i n i c a l signs does not mean that the inflammatory process i s i n a c t i v e . Further damage can result by i l l - a d v i s e d , premature physical a c t i v i t y . Recurrent per-iods of active RHD r e s u l t i n progressive damage to the heart, (98 ) heart f a i l u r e , and death, i f adequate rest and sim i l a r meas-ures are not enforced. Onset of Inactive RHD Not a l l rheumatic fever turns into RHD of a permanent nature. Approximately one-half of rheumatic fever patients from ages twenty to fourty do not get RHD. Subsequent course - Symptom free unless complications supervene (e.g. congestive heart f a i l u r e ) , i t i s possible to remain symptom free for ten to twelve years, then develop cardiac i n s u f f i c i e n c y , followed by congestive heart f a i l u r e . Complications - More commonly found i n the inactive group -(1) Cardiac i n s u f f i c i e n c y - This i s probably the most common complication. Within three or four years a f t e r the symptoms of cardiac i n s u f f i c i e n c y , e.g. fatigue and dyspnea, f i r s t appear, approximately 5 0 per cent of the patients die i n spite of treatment. (2) Heart f a i l u r e - When the symptoms of cardiac i n s u f f i -ciency are so easily induced that the patient becomes d i s -tressed on s l i g h t exertion or even while at rest, heart f a i l u r e i s said to ex i s t . Heart f a i l u r e usually appears about two years af t e r the f i r s t signs of cardiac i n s u f f i c i e n c y are i n evidence. About 80 per cent of the RHD patients suffer at least one attack of heart f a i l u r e . (3) Embolism - The source of emboli i s usually from a thrombus i n one of the a u r i c l e s or auricular appendages. Pulminary i n -f a r c t i o n i s probably the most common embolic manifestation of • RHD. (99) (4) Arrhythmia - The most common i r r e g u l a r i t y of rhythm a f f e c t -ing the RHD patient, i s auricular f i b r i l l a t i o n . Approximately f i f t y per cent of the rheumatic cardiac patients are so a f f e c t -ed. Arrhythmia i s most commonly found i n the fourth decade. About 75 per cent die within three years aft e r the onset of t h i s complication. (5) B a c t e r i a l endocarditis - Approximately six to ten per cent of the RHD patients die from t h i s - the majority from a sub-acute type of i n f e c t i o n . Incidence: Sex - Ordinarily equal numbers of males and females are affected by RHD. • Race - This i s s t i l l an unknown factor, although i t i s common to f i n d higher incidences among such r a c i a l groups as Negroes i n parts of U.S.A., where environmental pressures haye forced these people into infectious areas. Climate - RHD i s most commonly found i n the temperate zones, p a r t i c u l a r l y i n the northwestern areas of U.S.A. and the B r i t i s h I s l e s . Prognosis - L i f e expectance i s short. .About 50 per cent l i v e nine years, 25 per cent longer than 17 years, and only 10 per cent longer than t h i r t y years. Treatment - Treatment of inactive phase i s directed mainly to-wards complications which may a r i s e . Convalescence - The rate of recovery i s roughly proportional to the length and severity of the i l l n e s s . The patient i s usually kept i n bed for two or three weeks, u n t i l free from fever and • (100) other signs of i n f e c t i o n . Following t h i s , i s a period where the patient i s allowed to s i t i n a chair i n gradually increas-ing amounts, so that he can s i t f o r four or f i v e hours a day without undue fatigue or reawakening of the i n f e c t i o n . Then, he i s permitted to walk at f i r s t only a few steps. S t a i r climbing i s not permitted u n t i l walking comes easy to the pa-t i e n t . Where possible, i t i s recommended that the patient be moved to a southern climate. In any event, cold, damp envir-onments conducive to the creation of re-infection, should be avoided. Recent experiments have been conducted with childr e n who are susceptible to streptococcal i n f e c t i o n s . During the win-ter months, small doses of sulfanamides have been given to them, and t h i s treatment has resulted i n a lower incidence of r e - i n f e c t i o n than patients who were not given such treatment. APPENDIX B  BIBLIOGRAPHY General Reading C e c i l , L. Russel, "Rheumatic Heart Disease", Textbook of Medicine, Philadelphia and London, W.B. Saunders Co., 1948, 3rd ed. Dunbar, Flanders, Emotions and Bodily Changes, N.Y., Columbia U. Press, 1946. , Psychosomatic Diagnosis, N.Y., Columbia U. Press, 1946. . , Mind and Body: Psychosomatic Medicine, N.Y., Random House, 1947. Hinsie, Leland, E., The Person i n the Body: An Introduction to  Psychosomatic Medicine, N.Y., W.W. Norton & Co. Inc., 1945. Medical Adenda: Related Essays on Medicine and the Changing  Order, N.Y., The Commonwealth Fund, 1947. Richardson, Henry, B., Patients Have Families, N.Y., The common-wealth Fund, 1945. Ronbinson, George, C , The Patient as a Person: A Study of the S o c i a l Aspects of I l l n e s s , N.Y., The commonwealth Fund, 1939. Stroud, William, D., Diagnosis and Treatment of Cardiovascular  Disease, Philadelphia, F. A. Davis Company, 1946, v o l . 1, 3rd ed. Upham, Francis, A Dynamic Approach to I l l n e s s , N.Y., N.Y. Family Service Assoc. of America, 1949. Weiss, Edward, Psychosomatic Medicine, Philadelphia & London, W.B. Saunders Co., 1943. Selected A r t i c l e s from the Journal of S o c i a l Case Work Easby, Mary, "Rheumatic Fever and Rheumatic Heart Disease", Jan. 1946. Eckka, Gordon, "Treatment of Problems of Dependency Related to I l l n e s s " , Oct., 1942. De La Fontaine, E l i s e , "Some Implications of Psychosomatic Medi-cine for Case Work", June, 1946. Fitzsimmons, Mgt., "Treatment of Problems of Dependency Related to Permanent Physical Handicap", Jan., 1943. (10E) Haselkorn, Florence and Bellok, Leopold, M.D., "A Multiple Ser-vice Approach to Cardiac Patients", July, 1950. Hertzman, Jeanette, "Case Work i n the Psychosomatic Approach", Dec, 1946. H o l l i s , F., "The Techniques of Case Work", June, 1949. Josselyn, Irene, M., M.D., "The Case Worker as Therapist", Nov., 1948. Margolis, H.M. M.D., "The Psychosomatic Approach to Medical Diagnosis and Treatment", D e c , 1946. , "The Biodynamic Point of View i n Medicine", Jan., 1949. Moss, C e l i a , R., "Integrating Case Work and Recreation i n a M i l i t a r y Hospital", D e c , 1946. Rothstein, Mildred, C , "Individual Personality Factors i n I l l -ness", Dec, 1946. Ruesch, Jorgen, "V/hat Are the Known Facts About Psychosomatic Medicine at the Present Time", Oct. 1947. Schless, Bessie; "Achieving Maximum Adjustment i n Chronic I l l -ness", Dec, 1946. Stamm, Isabel, "Understanding the Total Person i n Treatment", Jan., 1946. Yocom, Susan, Folkes, "Case Work With the Ph y s i c a l l y 111", Nov., 1939. Other Selected A r t i c l e s Cohen, Ethel, " S o c i a l Aspects ,of Rheumatic Heart Disease", Wash., U.S. Dept. of Labour, Childrens Bureau, Read before the New England Health I n s t i t u t e , Hartfort, Conn., A p r i l 16, 1940. Dennis, M. A . . , . "Medical S o c i a l Work"-, Canadian Welfare, Sept., 1945. Huse, Betty, "Rheumatic Fever i n Children", The Child, May 1943« Josselyn, Irene, "Emotional Implications of Rheumatic Heart Disease i n Children", American Journal of Ortho-psychiatry, Jan., 1949. Senn, Milton, J. E., M.D., "Emotional Aspects of Convalescence", The Chi l d , Aug., 1945. Richardson, E l i z . , "A S o c i a l Worker Looks at Psychosomatic (103) Medicine", Canadian Welfare, Apr., 1946. Richardson, I l i z . , "An Adventure i n Medical S o c i a l Work", The  So c i a l Worker, June, 1945. Sutherland, Helen, M., "General Case Work i n a Medical and Psy-c h i a t r i c Setting", B.C.'s Welfare. July, 1949. Yahraes, Herbert, Rheumatic Fever Childhood's Greatest Enemy, American Council on Rheumatic Fever of the American Heart Assoc., Inc., 1947. 

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