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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 o f Male A d u l t P a t i e n t s With Rheumatic Heart D i s e a s e Admitted to Shaughnessy H o s p i t a l (1948 - 1951)  by BEN BYKTSS  T h e s i s Submitted i n P a r t i a l F u l f i l m e n t •of the Requirements f o r the Degree o f 'MASTER OF SOCIAL' WORK i n the S c h o o l o f S o c i a l Work  'Accepted as conforming to the standard r e q u i r e d f o r the degree of,Master of S o c i a l Work  School o f S o c i a l Work  19_52 'The U n i v e r s i t y o f - B r i t i s h  Columbia  (ii)  TABLE OF CONTENTS Chapter 1. I n t r o d u c t i o n Purpose of the study. The concept o f the p a t i e n t as-a-whole. Background o f s o c i a l work p r a c t i c e i n a m e d i c a l s e t t i n g . Emergence of the treatment team. Psychosomatic medicine. Research method used  page  1  Chapter 2. S o c i a l and P e r s o n a l I m p l i c a t i o n s Incidence o f s o c i a l pressures:" Case examples. P e r s o n a l i t y p a t t e r n s : Case examples - p a s s i v i t y , aggressiveness Chapter 3.  Case Work With Rheumatic Heart P a t i e n t s  L e v e l s o f case work treatment. The use o f e n v i r onmental m a n i p u l a t i o n . The use 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 Chapter 4.  18  38  Family I m p l i c a t i o n s  The e f f e c t on parents and s i b l i n g s : Case examplethe domineering mother. The e f f e c t on marriage p a r t n e r s : Case examples - s e x u a l i n c o m p a t i b i l i t y , immat u r i t y versus dependency. The e f f e c t on c h i l d r e n : Case examples - the " s e p a r a t i o n experience". Case work w i t h f a m i l i e s : Case example - the p a t i e n t ' s wife..59 Chapter 5.  C o n c l u s i o n s 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 p e r s o n a l problems and p h y s i c a l i l l n e s s * The r o l e of the s o c i a l worker i n a m e d i c a l s e t t i n g . Recommendations: S t a f f requirements. Resource r e quirements. The need f o r more r e s e a r c h . Adequate use o f r e c o r d i n g . P r e v e n t i o n  79  - Appendices A. M e d i c a l Aspects o f Rheumatic Heart Disease B. B i b l i o g r a p h y  96 101  (iv)  ABSTRACT The purpose of t h i s study has been to determine, (1) whether there i s a c o n n e c t i o n between a p a t i e n t ' s s o c i a l and p e r s o n a l background and h i s s u s c e p t i b i l i t y to rheumatic heart d i s e a s e , (E) whether emotion^producing c o n d i t i o n s a f f e c t the development and l a t e r r e c u r r e n c e s of t h i s d i s e a s e , (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 p e r s o n a l p r e s s u r e s and the course of a rheumatic h e a r t p a t i e n t ' s i l l n e s s , and (4) what the s o c i a l worker can c o n t r i b u t e towards a l l e v i a t i n g these emotion-produci n g c o n d i t i o n s a f f e c t i n g the p a t i e n t ' s i l l n e s s . Because o f 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 p o s s i b l e to determine the f i r s t o f these. A l l p a t i e n t s (25) with rheumatic h e a r t d i s e a s e who were r e f e r r e d f o r m e d i c a l s o c i a l s e r v i c e at Shaughnessy h o s p i t a l through a f o u r - y e a r p e r i o d (1947-1951), have been s e l e c t e d f o r t h i s study. An a n a l y s i s o f a l l a v a i l a b l e r e c o r d s of v a r i o u s branches d f the department of v e t e r a n s ' a f f a i r s i n t e r e s t e d i n the welfare o f these p a t i e n t s , has been made. M a t e r i a l s e l e c ted has been c o n f i n e d to three broad areas i n the p a t i e n t s ' l i v e s , (1) e a r l y p e r s o n a l i t y f o r m a t i o n , (2) s o c i a l and p e r s o n a l s t r e s s surrounding the onset, and (3) s o c i a l s e r v i c e s employed i n a l l e v i a t i n g emotional s t r e s s o f p a t i e n t s and t h e i r f a m i l i e s . The f i n d i n g s of t h i s study i n d i c a t e that an e v e r - i n c r e a s i n g c y c l e of s o c i a l problems a f f e c t the rheumatic h e a r t p a t i e n t , f o l l o w i n g the onset of h i s 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 s t r e s s , and these i n t u r n a f f e c t and are a f f e c t e d , by the e a r n i n g c a p a c i t y o f p h y s i c a l l y - l i m i t e d , c h r o n i c a l l y - d i s e a s e d p a t i e n t s . There are i n d i c a t i o n s o f pers o n a l i t y f a c t o r s r e a c t i n g upon the a b i l i t y of the p a t i e n t s to accept the l i m i t a t i o n s o f t h e i r i l l n e s s and the demands o f mature adulthood. Although t h i s study concerns i t s e l f only with war veterans, the m a j o r i t y of the f i n d i n g s are a p p l i c a b l e t o a l l p a t i e n t s a f f l i c t e d w i t h rheumatic h e a r t d i s e a s e . I n c l u d e d here are, (1) the need f o r adequate r e s o u r c e s , e.g. f i n a n c i a l grants, convalescent c e n t r e s , s u i t a b l e housing, l i g h t employment and r e t r a i n i n g programmes, (2) the need f o r more s o c i a l workers as w e l l as p r o f e s s i o n a l l y t r a i n e d s o c i a l workers to i n s u r e proper use o f a v a i l a b l e r e s o u r c e s , (3) the need f o r more r e s e a r c h not only w i t h a l l rheumatic h e a r t p a t i e n t s but w i t h a l l forms of c h r o n i c i l l n e s s , and (4) the need f o r p r e v e n t i v e measures e.g. through education, and e a r l y d i a g n o s i s and treatment of s o c i a l and p e r s o n a l problems. Problems r e s u l t i n g from i n c r e a s e d f i n a n c i a l grants g i v e n to v e t e r a n p a t i e n t s undergoing h o s p i t a l care, and l i m i t a t i o n s i n m e d i c a l s o c i a l s e r v i c e r e c o r d i n g under the department'of v e t e r a n s ' a f f a i r s , are two s p e c i f i c f i n d i n g s which are mainly a p p l i c a b l e to the v e t e r a n .  (v)  . ACKNOWLEDGMENTS G r a t e f u l acknowledgment to Mrs. C. M c A l l i s t e r ,  Director,  M e d i c a l S o c i a l S e r v i c e , Shaughnessy h o s p i t a l , i s made f o r her aid i n starting this project.  I wish to express deep a p p r e c i a -  t i o n to Miss G. R e i d and Mr. J . J.  Young, of the M e d i c a l S o c i a l  S e r v i c e s t a f f , Shaughnessy h o s p i t a l , f o r t h e i r through case d i s c u s s i o n s .  I am p a r t i c u l a r l y  contributions indebted t o Dr. L.  C. Marsh and Miss A. G. B l a c k , School o f S o c i a l Work, U n i v e r s i t y of B r i t i s h Columbia,  f o r the time and t h o u g h t f u l h e l p they have  g i v e n i n the f i n a l assembling o f the m a t e r i a l .  I am a l s o i n -  debted t o Dr. J . A. Traynor, f o r h i s h e l p f u l suggestions concerni n g the m e d i c a l a s p e c t s o f rheumatic, h e a r t .disease. I acknowledge the i n v a l u a b l e h e l p o f Miss L. McNee, M e d i c a l Records department,  Shaughnessy h o s p i t a l , f o r her i n t e r e s t and  a i d i n b r i n g i n g r e l a t e d r e a d i n g m a t e r i a l t o my a t t e n t i o n .  Also,  I wish to acknowledge the s e r v i c e s o f Miss T. White, as w e l l as M i s s L. McNee, M e d i c a l Records  department,  M i s s G. Jones and  Mrs. E . A. White o f the C l e r i c a l s t a f f o f M e d i c a l S o c i a l S e r v i c e , Shaughnessy h o s p i t a l , i n f a c i l i t a t i n g the process o f case  selec-  tion. F i n a l l y , I am completely indebted to my w i f e and s e c r e t a r y , Mrs. Fay R y k i s s , f o r h e r long and arduous months o f p a t i e n t  toil,  constant support, and s i n c e r e understanding - f o r without her, t h i s study c o u l d never have been  completed.  (vi)...  RHEUMATIC HEART DISEASE: THE MEANING- OF THIS ILLNESS TO PATIENTS AND THEIR FAMILIES Study o f Male A d u l t P a t i e n t s With Rheumatic Heart D i s e a Admitted to Shaughnessy H o s p i t a l (1948 - 1951)  CHAPTER 1 INTRODUCTION a For s e v e r a l c e n t u r i e s rheumatic f e v e r has but misunderstood d i s e a s e .  At f i r s t  i t was  only the j o i n t s of the body, but i t was e i g h t e e n t h and h e a r t was  observed.  not u n t i l the  late  Even a f t e r more advanced d i s c o v e r i e s were c o n s i d e r e d to be the  f e a t u r e o f rheumatic f e v e r and h e a r t involvement  "complication". its  thought to a f f e c t  e a r l y n i n e t e e n t h centiurles t h a t damage to the  made, f o r many years a r t h r i t i s was tial  been r e c o g n i z e d  essen-  merely a  I t i s ' o n l y r e c e n t l y t h a t c a r d i t i s has assumed  proper p l a c e as the most important  of the rheumatic  infec-  1  tions. One  recent study estimates  t h a t n i n e t y per cent o f the 2  f e c t i v e h e a r t s i n c h i l d r e n are'rheumatic a l s o estimated  i n nature.  de-  It is  that rheumatic h e a r t d i s e a s e i s the second  most p r e v a l e n t form o f h e a r t d i s e a s e i n a d u l t s , ( i . e . t h i r t y per c e n t ) .  About n i n e t y per cent o f the d i s e a s e occurs i n  p a t i e n t s before they reach f i f t y most p r e v a l e n t w i t h i n the f i r s t 3 cent of a l l RHD  patients  years o f age, f o u r decades.  and  deaths are  A t l e a s t 75  per  have one or more r e c u r r e n t bouts o f  d i s e a s e . I n an age where the young breadwinner f i n d s i t 1 W i l l i a m D. Stroud, D i a g n o s i s and Treatment o f C a r d i o v a s c u l a r Disease, V o l . 1, 3rd ed., pp. 70-71. 2 R. L. C e c i l , "Rheumatic Heart D i s e a s e " , Textbook o f Medic i n e , pp. 1185-1192. 3 For convenience, the a b b r e v i a t i o n RHD i s used as a s u b s t i t u t e f o r the term rheumatic h e a r t d i s e a s e .  (2)  difficult  enough to m a i n t a i n h i s economic e q u i l i b r i u m , the add-  ed burden of a c h r o n i c i l l n e s s , short l i f e  together w i t h the prospect o f  span, presents a s e r i o u s problem  t h e i r f a m i l i e s , and  for individuals,  society.  Although much r e s e a r c h on the m e d i c a l a s p e c t s of t h i s ease has  been done,  not been found.  1  still  the p e r f e c t treatment  dis-  programme has  As the m e d i c a l p r o f e s s i o n has gained i n c r e a s e d  r e c o g n i t i o n of the need to examine the " t o t a l " p a t i e n t , t h e r e has been a g r e a t e r awareness t h a t p h y s i c a l medicine complete  s o l u t i o n to t h i s p r e s s i n g problem.  i s not the  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 o f the  social  and emotional i n f l u e n c e s a f f e c t i n g the course of a p a t i e n t ' s illness.  I n t h i s r e s p e c t , some r e s e a r c h has been done on the  emotional f a c t o r s c o n t r i b u t i n g to c a u s a t i o n and care o f rheumatic  disease i n c h i l d r e n ,  yet very l i t t l e  written m a t e r i a l of a  s i m i l a r nature i s a v a i l a b l e on the male a d u l t RHD The  purpose  patient.  o f t h i s present study, i s to add something  the g r e a t e r understanding o f the s o c i a l and emotional of RHD  i n male a d u l t s .  T h i s study seeks to determine,  whether there i s a c o n n e c t i o n between an RHD  to  factors (1)  patient's social  and p e r s o n a l 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 o f the m e d i c a l a s p e c t s i n v o l v e d i n Rheumatic Heart Disease, r e f e r to Appendix A. 2 E l i z a b e t h R i c h a r d s o n 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 t h a t approximately 85 per cent of r h e u m a t i c a l l y d i s e a s e d c h i l d r e n show s i g n s o f emotional upsets.  (3)  whether emotion-prodticing l a t e r recurrences  c o n d i t i o n s a f f e c t the development  of t h i s disease,  (3) what the  t i o n s h i p i s between these s o c i a l and course o f an RHD  p a t i e n t ' s i l l n e s s , and  ker can c o n t r i b u t e  value  a b l e , f o r any  rela-  f a c t o r s and  the  (4) what the s o c i a l wor-  towards a l l e v i a t i n g these s t r e s s e s and  a f f e c t i n g the p a t i e n t ' s The  personal  specific  to the RHD  strains  illness. p a t i e n t of such a p r o j e c t i s unquestion-  r e s e a r c h which i s d i r e c t e d towards the  t i o n o f h i s i l l n e s s serves  t h i s purpose.  " f a m i l y " - h i s r e l a t i v e s , f r i e n d s and  To the  other  ameliora-  patient's  community members -  i n s i g h t i n t o the " t o t a l " r e a c t i o n s o f the p a t i e n t , should ate new  and  cre-  l i g h t on the p a r t they play i n encouraging or hampering  causation  and  treatment.  To the r e s t o f s o c i e t y , there  need f o r such a study, not only  from the  standpoint  is a  o f pure  en-  lightenment, but a l s o from the economic advantage which i s gained.  The  a i d which i s g i v e n the male a d u l t allows him  f u n c t i o n more-adequately as the  to  breadwinner o f h i s f a m i l y .  He  i s then b e t t e r able to become a c o n t r i b u t i n g member o f s o c i e t y r a t h e r than one  who  must c o n s t a n t l y  ers f o r the p h y s i c a l and his  remain dependent upon o t j i -  emotional w e l l - b e i n g  of himself  and  family. Unfortunately  the t o t a l acceptance or understanding o f  concomitant causes other i n general, i s due  than the p u r e l y  i s f a r from complete.  to the l a c k o f r e s e a r c h  Whereas vast  p h y s i c a l by the  P a r t of the  a l l o t t e d to the  public  blame f o r t h i s social  sciences.  sums of money have been spent to b r i n g the  field  of s c i e n t i f i c medicine to the p o s i t i o n i t i s today, p u b l i c apathy has  allowed i n v e s t i g a t i o n i n t o the s o c i a l aspects o f  (4)  d i s e a s e to l a g f a r behind.  I n Canada, as w e l l as i n o t h e r  c o u n t r i e s , the stigma connected w i t h mental incompetence g r e a t l y a f f e c t e d t h i s l a c k o f development. person who  can admit  Any  has  chronically-ill  to h i m s e l f that he i s unable to f a c e r e a l i -  ty and seeks escape from h i s s o c i a l and emotional problems t h r o u gh v a r i o u s p h y s i c a l m a n i f e s t a t i o n s , undergoes an extremely " p a i n f u l " mental p r o c e s s .  On the other hand, more s o c i a l  acceptance  i s gained by such a person when he has been pronounced m e d i c a l l y u n f i t through no f a u l t of h i s own.  F u r t h e r acceptance i s g i v e n  to h i s unfortunate encumbrance by the necessary a t t e n t i o n  doc-  t o r s , nurses, e t c . , p r o v i d e .  des-  The case of the RHD  c r i b e d i n Chapter 3, i s a good example of t h i s  patient  enigma.  1  The P a t i e n t - As - A Whole Before an assessment  o f the meaning of i l l n e s s to RHD  i e n t s and t h e i r f a m i l i e s can be made, some c l a r i f i c a t i o n  paton  what i s meant by the terms i l l n e s s and d i s e a s e , i s n e c e s s a r y . I l l n e s s has  been d e f i n e d by F l a n d e r s Dunbar, "as the d e v i a t i o n  from h e a l t h or from a s t a t e i n which a l l n a t u r a l a c t i v i t y f u n c t i o n s are performed discomfort".  and  f r e e l y and e f f i c i e n t l y without p a i n or  Disease, on the other hand, i s the "abnormal  s t a t e of the body r e s u l t i n g from harmful e f f e c t s of the proces2 ses, i n j u r i o u s substances or a c c i d e n t s " .  From these  defini-  t i o n s i t f o l l o w s that i l l n e s s i s the s u b j e c t i v e or a f f e c t i v e 1 See p. (  49  }.  2 F l a n d e r s Dunbar, Emotions and B o d i l y Changes, 1946, to 3rd e d i t i o n , p. SIX.  intro.  (5)  r e a c t i o n of the i n d i v i d u a l , whereas disease  i s the  observable r e a c t i o n .  pointed  As C. G. Robinson has  objective out,  ill-  ness, t h e r e f o r e , i s g r e a t e r than disease  because i t can e x i s t 1  with or without o b j e c t i v e r e c o g n i t i o n by  others.  Involved  here, i s an awareness of the t o t a l  environmental  and  h e r e d i t a r y f o r c e s which a f f e c t the i n d i v i d u a l w i t h RHD  any  other d i s e a s e .  T h i s m u l t i p l e approach to i l l n e s s i s what  i s meant by the term, the patient- - as - a whole. u a l meaning which h i s i l l n e s s holds f o r him, and  t r e a t e d i f the e f f e c t o f the disease  understood.  The way  he  p a t i e n t who  because he  The  continues  must be examined  i s to be  completely  Not  to work at strenuous employment  only i s i t necessary to  doctors, consider  the need f o r p h y s i c a l l y l i m i t i n g h i s a c t i v i t y here, but s i d e r a t i o n must a l s o be g i v e n to such c o m p l i c a t i n g t h i s p a t i e n t ' s i n n e r need to g a i n a p p r o v a l p h y s i c a l prowess, h i s i n a b i l i t y ous  kinds of work, the  has  created,  strenu-  immediate f i n a n c i a l debts which i l l n e s s  disease  are a f f e c t e d by him.  f a c t o r s , as  to f i n d or perform l e s s  As a f u r t h e r point .of c o n s i d e r a t i o n ,  i e t y , he i s not only  con-  through d i s p l a y s o f  the p h y s i c a l needs of h i s f a m i l y ,  i n g from a chronic  is  of p h y s i c a l s i g n s .  i s unable to accept the d i a g n o s i s of h i s  i s an example of t h i s .  individ-  f e e l s as a r e s u l t o f h i s d i s e a s e ,  more than a r e c o g n i t i o n or o b s e r v a t i o n The RHD  or  etc.  since a patient s u f f e r -  i s a member of a f a m i l y and  of  soc-  being a f f e c t e d by them but they i n t u r n Therefore,  i t i s reasonable to expect  1 George C. Robinson, The P a t i e n t As A Person, p.  3-4.  (6)  that they too w i l l need to be "understood" before r e a c t i o n - p a t t e r n surrounding the disease gerent a t t i t u d e o f the wife o f an RHD  the  i s known.  p a t i e n t who  total  The  belli-  ;is f o r c e d to  assume the p o s i t i o n as breadwinner of the f a m i l y , or o f f r i e n d s , employers, e t c . , who valescent  cannot understand the need f o r a l o n g con-  p e r i o d f o r an RHD  p a t i e n t who 'looks" p e r f e c t l y h e a l t h y ,  are more common i l l u s t r a t i o n s o f Background o f M e d i c a l The  this.  S o c i a l Work P r a c t i c e  r e c o g n i t i o n o f the need to evaluate  whole, i s one  the  patient-as-a  o f the basic elements o f s o c i a l work p r a c t i c e .  The  development o f t h i s more-complete approach, o f course  not  been c o n f i n e d  to the p r o f e s s i o n alone,  but has  resulted  from advances made i n the l a t e n i n e t e e n t h  and  early  century  The  profession  by s e v e r a l i s o l a t e d d i s c i p l i n e s .  s o c i a l work as i t i s r e c o g n i z e d  and  allied  s o c i a l sciences  ology,  e t c . , have been making.  understanding and by the  twentieth  p r a c t i c e d today, i s  which s o c i a l workers have i n c o r p o r a t e d  from the  has  of one  contributions  such as p s y c h i a t r y , anthropology,  soci-  As a r e s u l t , newer s k i l l s i n  t r e a t i n g human behaviour have been developed  s o c i a l worker, so that the emotional as w e l l as the  v i r o n m e n t a l problems of the  i n d i v i d u a l are  being g i v e n  en-  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 s p e c i a l i z e d branch o f the g e n e r a l  s o c i a l work f i e l d ,  con-  s i d e r a t i o n must be g i v e n to the developments which have a l s o occurred  i n the f i e l d of medicine.  p r a c t i t i o n e r gave way  As the r o l e o f the  general  to the demands f o r s p e c i a l i z a t i o n at  the  (7)  beginning of the t w e n t i e t h century, vast storehouses of m e d i c a l knowledge began to accumulate.  Y e t , d e s p i t e t h i s tremendous  advance towards m e d i c a l p e r f e c t i o n , the purpose had been designed, appeared  f o r which i t  to be the e l i m i n a t i o n o f d i s e a s e ,  r a t h e r than the a m e l i o r a t i o n o f the c o n d i t i o n o f the i n d i v i d u a l s u f f e r i n g from t h i s d i s e a s e .  I n r e c e n t y e a r s , many d o c t o r s  have begun to r e a l i z e that impersonal s c i e n t i f i c a n a l y s i s o f i s o l a t e d s e c t i o n s o f the human anatomy has not been s u f f i c i e n t . The g e n e r a l p r a c t i t i o n e r , without a l l the s p e c i a l i z e d knowledge of  today, at l e a s t knew h i s p a t i e n t as a member of a f a m i l y  a community.  and  There were times when h i s treatment of the "whole"  p a t i e n t , was more e f f e c t i v e than the medicine he had a t h i s d i s posal. As the awareness o f the need to base d i a g n o s i s and  treatment  on the p a t i e n t - a s - a whole began to take h o l d , the c o n t r i b u t i o n of  the g e n e r a l p r a c t i t i o n e r became more e v i d e n t .  r e t u r n to t h i s form o f m e d i c a l p r a c t i c e appeared  However, a impractical i n  view of the need f o r s p e c i a l i z a t i o n which i n c r e a s e d m e d i c a l knowledge demanded. s o c i a l workers who  I n s t e a d , there arose a growing demand f o r could h e l p the d o c t o r s understand and  the s o c i a l aspects o f the p a t i e n t ' s i l l n e s s . here at f i r s t , was  Most  treat  important  the follow-up s e r v i c e which s o c i a l workers  c o u l d do f o r a p a t i e n t whose doctor had p r e s c r i b e d s p e c i f i c  con-  v a l e s c e n t treatment measures i n a c c e s s i b l e to the p a t i e n t . The r o l e o f the s o c i a l worker i n a m e d i c a l s e t t i n g has t i n u e d to expand, s i n c e such a p o s i t i o n was  first  created i n  con* 1904  1 M. A. Dennis, " M e d i c a l S o c i a l Work", Canadian Welfare, p. 31.  18J  As  s o c i a l workers moved i n t o the m e d i c a l f i e l d ,  it  necessary to broaden t h e i r s k i l l s ,  t h a t "environmental m a n i p u l a t i o n " was p a t i e n t ' s problems.  f o r i t was  found  soon l e a r n e d  not the f i n a l  answer to a  By t h i s time, advances i n p s y c h i a t r i c  t h i n k i n g were opening up new "whole" p a t i e n t .  they too  The  channels f o r understanding the  i n c o r p o r a t i o n of psycho-social s k i l l s  necessary to t r e a t the emotional d i s t u r b a n c e s d i s p l a y e d by pati e n t s , added to the value o f the s o c i a l worker i n a setting.  R e c o g n i t i o n by the m e d i c a l p r o f e s s i o n o f the need f o r  t h i s l a t t e r f u n c t i o n to be performed unaccepted  hospital  by s o c i a l workers,  is still  to a g r e a t e x t e n t .  Emergence o f the Treatment  Team  Drawing from the g e n e r a l body of s o c i a l work knowledge, m e d i c a l s o c i a l workers^ therapy.  -  c o n t i n u a l l y r e v i s e d t h e i r methods o f  While development i n t h i s f i e l d had much to g a i n from  the advance of case work p r a c t i c e s i n r e l a t e d f i e l d s o f  social  work, i t became evident t h a t a d i f f e r e n c e i n approach would  be  necessary because of the type o f s e t t i n g i n which m e d i c a l soci a l work was  being performed.  The method o f h a n d l i n g emotional  problems o f p a t i e n t s w i t h i n the framework o f a h o s p i t a l and without the c o - o p e r a t i o n of d o c t o r s , nurses, etc.,  who  setting  dieticians,  came i n more frequent c o n t a c t w i t h the p a t i e n t ,  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  to r e c e i v e treatment, then due  1 S o c i a l workers who ting.  appearwas  c o n s i d e r a t i o n had to be g i v e n to  perform t h e i r s e r v i c e s i n a m e d i c a l  set-  (9)  the p a r t played  by each member of the h o s p i t a l s t a f f i n t e r e s t e d  i n the p a t i e n t ' s r e c o v e r y .  For example, one  used i n t h i s study i n d i c a t e d that an RHD becoming upset because he f e l t him"  and was  punishing  him  t i o n w i t h the nurses and t i e n t was  of the  records  p a t i e n t was  continually  the h o s p i t a l s t a f f was  "against  by t h e i r " r i g i d " demands.  Consulta-  attendants involved, revealed  that  c o n s t a n t l y m i s i n t e r p r e t i n g the requirements o f  t a l routine.  hospi-  Because the h o s p i t a l s t a f f , i n the performance o f  t h e i r d a i l y t a s k s , were not aware that the p a t i e n t d i d not derstand was  what was  expected o f him,  j u s t a c h r o n i c complainer.  they f e l t  that the  the p a t i e n t had  un-  patient  As a r e s u l t o f these s t a f f con-  s u l t a t i o n s , the members o f the treatment team understood  t i o n , to a v o i d  pa-  why  acted as he did, and were then i n a b e t t e r p o s i -  f u t u r e emotion-provoking i n c i d e n t s .  time, the s o c i a l worker was  At the same  a b l e to i n t e r p r e t to the  patient  the reason f o r the a c t i o n s o f the h o s p i t a l s t a f f , so t h a t he longer  became upset by t h e i r  I n many i n s t a n c e s  i t was  requests. easy to see where o v e r z e a l o u s wor-  kers would create resentment from nurses, d i e t i c i a n s , e t c . o f t e n there appeared to be much o v e r l a p p i n g As  no  Too  o f s e r v i c e s rendered.  the process of s p e c i a l i z a t i o n extended to each o f these pro-  f e s s i o n s , i t was  necessary f o r each of them to r e c o g n i z e  the  r e s u l t i n g narrowing o f s e r v i c e t h i s produced, i n much the same way  as the m e d i c a l p r o f e s s i o n had  nurses had cially, it  formerly  administered  done.  For example, whereas  e a r n e s t l y , although u n o f f i -  to the p a t i e n t ' s s o c i a l needs o u t s i d e  became d i f f i c u l t  to accept the  o f the h o s p i t a l ,  s o c i a l worker who  -taking over t h i s f i e l d o f endeavour.  .  was  now  Some nurses m i s t a k i n g l y •  (10)  felt if  t h e i r r o l e i n the h o s p i t a l might be taken over  such p r a c t i c e s were to c o n t i n u e .  T h i s problem o f  boundaries o f s e r v i c e , has extended  s e r v i c e , e t c . , and  setting  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 . o c c u p a t i o n a l and tetic  completely  physio-therapy,  die-  i s one which today, i s s t i l l not corn©  pletely resolved. S i n c e treatment o f the p a t i e n t i s c a r r i e d on i n a m e d i c a l s e t t i n g , i t was specialist  o n l y n a t u r a l t h a t the doctor as the l e a d i n g  in this field,  should be c a l l e d upon to d i r e c t  t h e r a p e u t i c e f f o r t s of the treatment  team.  been a c c e p t i n g , i f not demanding o f t h i s .  the  S o c i a l workers have Each member o f the  team has a job of removing symptoms, w h i l e i t i s the d o c t o r best determines be t r e a t e d .  what these symptoms are and how  who  they can best  Where there are emotional s t r a i n s i n evidence,  that member o f the team which i s s p e c i f i c a l l y t r a i n e d 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 m e d i c a l s o c i a l worker who'is i n a  l o g i c a l p o s i t i o n to i n t e r p r e t to the doctor as w e l l as to the other team members what p s y c h o l o g i c a l and  s o c i a l meaning the  p a t i e n t ' s i l l n e s s holds f o r him.  example o f t h i s  appears  i n the anxious, d i s a g r e e a b l e p a t i e n t - mentioned pre-  v i o u s l y , (p. 9), who was  A ready  seemed unaccepting o f treatment  because he  beset with f e a r s a r i s i n g out of h i s h o s p i t a l i z a t i o n ^ .  cause he was  unable  to express these f e a r s to the h o s p i t a l  s t a f f , h i s a n x i e t y mounted and h i s behaviour came worse.  The  Be-  s o c i a l worker was  f e a r s to team members i n such a way accept the p a t i e n t ' s behaviour,  on the wards  able to i n t e r p r e t  be-  these  t h a t they c o u l d not o n l y  but were b e t t e r a b l e to o f f e r '  (11)  support to him i n the a l l e v i a t i o n o f h i s f e a r s , r a t h e r than f u r t h e r a n t a g o n i z i n g him. Psychosomatic  Medicine  Mention has a l r e a d y been made o f the i n c o r p o r a t i o n of psyc h i a t r y and medicine i n t o s o c i a l work p r a c t i c e . c a l l y , the u t i l i z a t i o n o f what has been c a l l e d medicine, has been most u s e f u l .  Without  More s p e c i f i psychosomatic  engaging i n any o f the  c o n t r o v e r s y c e n t e r i n g around the use o f t h i s term, i s g i v e n to the g r e a t e r understanding which the  1  recognition  psychosomatic  approach has c r e a t e d i n terms o f c a u s a t i o n and treatment o f i l l n e s s and d i s e a s e . F l a n d e r s Dunbar suggests that there w i l l come a time when there w i l l no longer be any need to d i s t i n g u i s h between the terms psychosomatic being synonymous.  and medicine, f o r they w i l l be accepted as R e g a r d l e s s o f what terms are used, as l o n g  as they i n v o l v e the study o f the p a t i e n t as a p a r t o f a whole i n t e r r e a c t i n g system, who  both a f f e c t s and i s a f f e c t e d by h i s  r e l a t i o n s h i p s w i t h o t h e r s , and who  i s guided by  interlocking  i n t e l l e c t u a l and emotional responses to i n n e r and o u t e r s t r e s ses and s t r a i n s , then the w e l f a r e 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 i n c o r p o r a t e the advan-  tages which t h i s system has to o f f e r ,  but they do not f e e l  t h i s i s the l a s t answer i n r e s e a r c h .  Much more r e s e a r c h i s  1 F u r t h e r i n f o r m a t i o n on t h i s dilemma i s d i s c u s s e d i n two well-known books on the s u b j e c t by F l a n d e r s Dunbar, Psychosomatic D i a g n o s i s , and Emotions and B o d i l y Changes.  that  (12)  needed i n every aspect o f i l l n e s s .  The study o f the e f f e c t s ,  c r e a t e d by RHD, i s but one o f these s p e c i a l i z e d p r o j e c t s which must be i n v e s t i g a t e d and i n c o r p o r a t e d i n t o the e x i s t i n g knowledge t h a t i s now  possessed.  Research Method Used To assess the t r u e meaning o f i l l n e s s which RHD h o l d s f o r male a d u l t s , there are many q u e s t i o n s which need i n v e s t i g a t i o n . For example, what kind o f a person are the team members o f the h o s p i t a l s t a f f d e a l i n g with?  I s there a p a t t e r n surrounding the  immediate onset o f h i s i l l n e s s , which, when examined i n terms o f a p e r s o n a l i t y a d j u s t i n g to a l i f e through i l l n e s s and d i s e a s e ? tal  relationships?  s i t u a t i o n , r e v e a l s an "escape"  What a r e the p a t i e n t ' s environmen-  What do h i s p a r e n t s mean to him, h i s bro-  t h e r s and s i s t e r s , h i s r e l a t i v e s and f r i e n d s ? i l l n e s s mean to them? his  I s he married and, i f so, what e f f e c t has  i l l n e s s on h i s wife and c h i l d r e n ?  c u l t i e s , inadequate Keeping  What does h i s  Are there economic  diffi-  s e x u a l r e l a t i o n s h i p s , employment problems?  i n 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  w i t h RHD f a c e s , how has he accepted .these l i m i t a t i o n s ? r e a l i s t i c or does he deny the need f o r these  I s he  limitations?  To explore some o f these q u e s t i o n s , an a n a l y s i s has been made o f case r e c o r d s of male p a t i e n t s a t Shaughnessy  hospital  who were or a r e a f f l i c t e d with RHD and who were r e f e r r e d f o r medical s o c i a l s e r v i c e .  Over one hundred cases o f p a t i e n t s  known t o the h o s p i t a l s i n c e 1947 up to the present time  (1951),  have been cross-checked with medical s o c i a l s e r v i c e f i l e s and 25 o f these, r a n g i n g from ages 21 to 83,have o  been f i n a l l y  (1-3)  selected.  Because o f t h i s l i m i t a t i o n i n case s e l e c t i o n , no  d i s t i n c t i o n has been drawn between a c t i v e o r i n a c t i v e RHD patients.  A l s o , s i n c e the m a j o r i t y  1  of these p a t i e n t s i n a v e t -  eran's h o s p i t a l a r e a good deal o l d e r than the average person admitted to a g e n e r a l h o s p i t a l , i t has not been p o s s i b l e t o s e l e c t cases where RHD was the only d i s e a s e tient.  Generally  many other  a f f e c t i n g the pa-  speaking, i n c r e a s i n g age has brought w i t h i t  complications  f o r the RHD p a t i e n t .  I t i s not p o s s i b l e to a s s e s s the r e p r e s e n t a t i v e n e s s  of the  cases s e l e c t e d as a g a i n s t  the t o t a l number o f RHD p a t i e n t s  t r e a t e d a t the h o s p i t a l .  Because every p a t i e n t used i n t h i s  study has a t one time o r another been r e f e r r e d f o r s o c i a l  ser-  v i c e f o r some s o c i a l or emotional problem, i t does not necessarily  f o l l o w t h a t there were no problems a f f e c t i n g those pa-  t i e n t s who were not r e f e r r e d .  However, i t may be assumed t h a t  t h i s study i s d e a l i n g with a h i g h l y s e l e c t i v e group o f p a t i e n t s s i n c e 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 i n f o r m a t i o n the m e d i c a l r e c o r d s  available i n  o f p a t i e n t s who.were not r e f e r r e d , from  which comparisons can be made. In order  to o b t a i n s u f f i c i e n t  background m a t e r i a l f o r each  o f the p a t i e n t s s e l e c t e d , i t was necessary to u t i l i z e  records  of o t h e r - d i v i s i o n s o f the department o f veterans'  a f f a i r s , as  w e l l as other  Unfortunately,  s o c i a l agencies i n the community.  i n many o f the cases used, m e d i c a l s o c i a l s e r v i c e f i l e s were -^extremely l i m i t e d . . U s u a l l y a short contact w i t h the p a t i e n t  1 See Appendix A f o r d i f f e r e n t i a t i o n o f a c t i v e and i n a c t i v e RHD.  (14)  d i d n o t n e c e s s i t a t e a lengthy i n v e s t i g a t i o n .  The most v a l u a b l e  r e s o u r c e a v a i l a b l e , has been the D i s t r i c t O f f i c e f i l e ,  which  i n c o r p o r a t e s not only the m e d i c a l s o c i a l s e r v i c e r e p o r t s , but a l s o those o f s o c i a l s e r v i c e d i v i s i o n , v e t e r a n s ' w e l f a r e  offi-  c e r s , medical examiners, n u r s i n g s t a f f , o c c u p a t i o n a l t h e r a p i s t s , pensions advocates,  etc.  I n some o f the cases where c o n t a c t had  been or was being made by medical  s o c i a l workers who were  still  on s t a f f at the h o s p i t a l , a g f e a t d e a l o f h i g h l y - i m p o r t a n t a d d i t i o n a l m a t e r i a l was obtained through  c o n s u l t a t i o n s with them.  However, d e s p i t e these attempts to complement m i s s i n g m a t e r i a l from o t h e r r e s o u r c e s , on the whole there a r e many gaps which have not been overcome.  I n f o r m a t i o n i n v o l v i n g the emotional  r e a c t i o n s surrounding the development and p r o l o n g a t i o n of RHD, and e a r l y p e r s o n a l i t y f o r m a t i o n , have been the weakest areas of t h e r e s e a r c h . P r e s e n t a t i o n o f the m a t e r i a l o b t a i n e d , lends i t s e l f three d i v i s i o n s .  into  The f i r s t o f these cover the s o c i a l and per-  s o n a l f a c t o r s i n v o l v e d p r i o r t o , d u r i n g and f o l l o w i n g the development of, not only the o r i g i n a l , but a l s o r e c u r r e n t a t t a c k s of RHD.  I n c l u d e d here a r e the e a r l y environmental i n f l u e n c e s  surrounding the development o f h i s i l l n e s s ,  such as p a r e n t a l ,  s i b l i n g and community r e l a t i o n s h i p s , e d u c a t i o n a l attainment, c u l t u r a l p r e s s u r e s , kinds of employment, economic  stability  e t c . , as w e l l as the l a t e r s o c i a l p r e s s u r e s o f marriage,  chil-  dren and the a b i l i t y to m a i n t a i n the r o l e o f a breadwinner. Concurrent with these s o c i a l s t i m u l i i s the p e r s o n a l adaptat i o n of the i n d i v i d u a l p a t i e n t to these m u l t i p l e o u t e r s t r e s s e s and  strains.  The p a t i e n t ' s r e a c t i o n to h i s i l l n e s s and h i s  (15) d e s i r e and a b i l i t y to o b t a i n and f o l l o w medical a d v i c e , the e f f e c t of h o s p i t a l i z a t i o n , the mental o u t l o o k towards p h y s i c a l l i m i t a t i o n and employment demands, dency c o n f l i c t s i n terms o f e a r l y adjustments  growing  dependency-indepenand l a t e r m a r i t a l  c o m p a t i b i l i t y , make up the major p o i n t s o f c o n s i d e r a t i o n here. I n essence, this' f i r s t  d i v i s i o n attempts to present the p a t i e n t -  as-a whole and the p a r t i c u l a r meaning which h i s i l l n e s s h o l d s f o r him, as w e l l as the more g e n e r a l c h a r a c t e r i s t i c s which a l l RHD p a t i e n t s h o l d i n common. the The c o n t r i b u t i o n o f s o c i a l worker i n a m e d i c a l s e t t i n g i n a l l e v i a t i n g these s o c i a l and emotional p r e s s u r e s , i s i n c l u d e d i n the second area o f p r e s e n t a t i o n . M e d i c a l s o c i a l work i s essentially  s o c i a l case work p r a c t i c e d i n a m e d i c a l s e t t i n g .  Case work f o r the purpose o f t h i s study can be d e f i n e d as a process which uses p r o f e s s i o n a l s k i l l s o r techniques designed t o h e l p the i n d i v i d u a l , a l o n e . o r as part o f a f a m i l y , to r e s o l v e the c o n f l i c t s which r e s u l t from h i s environment inner tensions.  and/or  from  Because these c o n f l i c t s i n t e r f e r e w i t h the i n -  d i v i d u a l ' s a b i l i t y to make a s a t i s f a c t o r y s o c i a l adjustment, i t has been necessary f o r him to seek o u t s i d e h e l p o r to be d i r e c ted to i t by o t h e r s .  The p a r t i c u l a r use o f d i f f e r e n t i a l  thera-  p e u t i c 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 p a t i e n t presents i s t h e r e f o r e i n c l u d e d h e r e . Although the members of the RHD p a t i e n t ' s f a m i l y a r e cons t a n t l y a f f e c t i n g and being a f f e c t e d by the p a t i e n t , the part i c u l a r r e a c t i o n which these members have as a r e s u l t o f the presence o f i l l n e s s i n the f a m i l y , i s another area which l e n d s • i t s e l f to an i n d i v i d u a l p r e s e n t a t i o n . S i n c e the m a j o r i t y o f  (16)  the p a t i e n t s are or have been m a r r i e d , i t i s t o be expected that t h e i r wives w i l l Also  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 .  s e r i o u s l y i n v o l v e d , however, a r e parents and s i b l i n g s as  w e l l as the c h i l d r e n i n the home. the  The extended e f f o r t which  s o c i a l worker makes i n a l l e v i a t i n g the s t r e s s o f the f a m i l y  members, so they i n t u r n can b e t t e r a i d the p a t i e n t i n h i s r e covery, completes the f i n a l p a r t o f the p r e s e n t a t i o n . I n using only the case r e c o r d s  which have been r e f e r r e d to  medical s o c i a l s e r v i c e i t i s p a s s i b l e that a sampling o f rheumatic h e a r t  non-representative  p a t i e n t s was used.  I t i s felt,  however, that t h i s does not i n v a l i d a t e the r e s u l t s obtained, because the major d i f f e r e n c e between p a t i e n t s r e f e r r e d o r not r e f e r r e d , has been i n the i n d i v i d u a l judgement o f the doctor on the c a s e .  An attempt w i l l  be made to show t h a t a random sampling  of p a t i e n t s not r e f e r r e d f o r m e d i c a l s o c i a l s e r v i c e would appear to have s i m i l a r r e a c t i o n s t o t h e i r Because these a r e case r e c o r d s danger i n drawing c o n c l u s i o n s a d u l t s a f f l i c t e d w i t h RHD.  illness. o f v e t e r a n s o n l y , there  which do not apply  is a  to a l l male  Where war s e r v i c e has c o n t r i b u t e d 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 h o p e f u l l y only as added s t r e s s e s and s t r a i n s r a t h e r exclusive p r e c i p i t a t i n g factors.  than  I n other words, emphasis w i l l  be p l a c e d on the types o f emotion-producing s i t u a t i o n s which any  male a d u l t w i t h RHD may be expected t o r e a c t to i n a s i m i l a r  manner. F i n a l l y , s i n c e 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 ,  s t r e s s i s placed  upon the s o c i a l r a t h e r  than the  (17)  s t r i c t l y m e d i c a l a s p e c t s of the d i s e a s e and i t s meaning to the patient.  T h i s should not i n any way exclude, however, the com  p l i c a t i o n s which a r i s e out o f the emotional r e a c t i o n to the p h y s i c a l presence o f RHD.  CHAPTER 2 SOCIAL AND  PERSONAL IMPLICATIONS  The i n a b i l i t y of the RHD i n c r e a s i n g f i n a n c i a l burden, though i t i s perhaps cases examined.  p a t i e n t to cope w i t h h i s everi s perhaps the most  striking,  the most obvious c h a r a c t e r i s t i c o f the  I n every case r e f e r r e d to m e d i c a l s o c i a l  v i c e , the p a t i e n t was  ser-  e i t h e r overwhelmed by m e d i c a l expenses  and r e d u c t i o n of income, or was  i n r e c e i p t of some form o f  fin-  a n c i a l a s s i s t a n c e , e.g. pension or d i r e c t r e l i e f , which d i d not completely meet the requirements o f h i m s e l f or those dependent upon him. Although approximately one cases diagnosed as RHD it  q u a r t e r o f the t o t a l number o f  were, r e f e r r e d f o r m e d i c a l s o c i a l  service,  i s reasonable to expect t h a t the m a j o r i t y of those cases  which were not r e f e r r e d , a l s o had some f i n a n c i a l d i f f i c u l t y rounding t h e i r i l l n e s s .  T h i s c o n c l u s i o n i s based upon the  surfact  t h a t admittance to Shaughnessy h o s p i t a l i s mainly determined the f o l l o w i n g e l i g i b i l i t y requirements.  Where a v e t e r a n , (1) i s  i n r e c e i p t o f pension f o r a d i s a b i l i t y which prevents him earning an adequate a war  by  from  income, (2) i s unemployable and i s granted  v e t e r a n s ' allowance because he i s able to meet c e r t a i n  s e r v i c e requirements,  war-  (3) can pass a means t e s t , although he i s  not i n r e c e i p t of v e t e r a n s ' a i d , and  (4) i s over s i x t y years o f  age, i n f i n a n c i a l need, and t h e r e f o r e i s e l i g i b l e f o r permanent d o m i c i l i a r y c a r e , he can q u a l i f y f o r treatment. forms of e l i g i b i l i t y .more-acceptable  The  latter  e.g. war v e t e r a n s ' allowance, e t c . , are  s u b s t i t u t e s f o r d i r e c t r e l i e f or s o c i a l a s s i s - .  (19)  tance which m u n i c i p a l and is  p r o v i n c i a l governments p r o v i d e .  because the v e t e r a n l o o k s upon h i s p a r t i c u l a r type o f  b i l i t y as a " r i g h t " , r a t h e r than as an admittance  This eligi-  t h a t he  has  f a i l e d to adapt h i m s e l f to s o c i a l demands. Incidence o f S o c i a l P r e s s u r e s The RHD  p a t i e n t ' s f i n a n c i a l d i f f i c u l t i e s are mainly e x p l a i n -  ed by h i s i n c r e a s e d i n a b i l i t y  to compete on the labour market.  I n 88 per cent of the cases examined, p a t i e n t s were engaged i n some form of heavy p h y s i c a l labour p r i o r to the onset o f t h e i r illness. Only  two  As a r u l e , these p a t i e n t s had  little  education.  p a t i e n t s appeared to have any h i g h s c h o o l t r a i n i n g ,  none of these completing h i g h s c h o o l .  Many came from low i n -  come f a m i l i e s and were f o r c e d to leave s c h o o l a t an e a r l y i n order to h e l p support t h e i r f a m i l i e s . v a t i o n , the g e n e r a l p r a c t i c e was s k i l l e d heavy l a b o u r .  Regardless of moti-  to accept some form o f  un-  Of the case r e c o r d s which c o n t a i n e d  material, f o u r - f i f t h s followed t h i s pattern. cases r e v e a l some s t a b i l i t y  Although  cate frequent changes i n both nature and l o c a t i o n o f f e v e r and/or  indi-  this. rheumatic  h e a r t d i s e a s e , many continued to work i n heavy i n d u s t r y . fifty  Over  per cent of the case r e c o r d s i n d i c a t e an attempt to f i n d  more s u i t a b l e work, whereas only e i g h t per cent appear ful  such  three  i n employment, the m a j o r i t y  F o l l o w i n g the development o f rheumatic  age  i n achieving t h i s .  I t i s reasonable  to expect  d e c i s i o n to remain w i t h such employment, was  that t h e i r  largely  by t h e i r need to meet the demands o f f i n a n c i a l  success-  affected  responsibility.  Among the cases examined i n t h i s study, o n l y one p a t i e n t ,  (20)  a 2 8 - y e a r - e l d v e t e r a n , d i d not get m a r r i e d .  The r e s t of the  case r e c o r d s i n d i c a t e a continuous s e r i e s o f d i v o r c e , separat i o n and g e n e r a l upheaval i n m a r i t a l s i t u a t i o n s , which seem to go hand i n hand w i t h i n c r e a s e d s e v e r i t y of p h y s i c a l symptoms, i n a b i l i t y to m a i n t a i n employment, and added f i n a n c i a l  burdens.  Of the 19 cases c o n t a i n i n g such i n f o r m a t i o n , seventeen  reveal  i n d i c a t i o n s of unhappy marriages and nine show d i v o r c e or sepa r a t i o n o c c u r r i n g at l e a s t once. l e s , appeared  C h i l d r e n born to these coup-  to add to the d i f f i c u l t i e s .  Only 30 per cent o f  the cases had i n f o r m a t i o n about c h i l d r e n , but a l l o f these i n d i c a t e that the l a r g e r the; f a m i l y , the g r e a t e r the  financial  burden f o r the p a t i e n t . Where adequate  f i n a n c i a l means are l a c k i n g , i t i s to be  expected that inadequate t h i n g are to be found. complete  standards of food, housing and  A l t h o u g h only a few of the r e c o r d s were  enough to b r i n g out these i n s u f f i c i e n c i e s , these r e -  vealed the need f o r more adequate problems which was affected  clo-  encountered  housing as one o f the c h i e f  by the RHD  p a t i e n t and which  the adequacy o f h i s convalescence.  None of the case  r e c o r d s i n d i c a t e d housing c o n d i t i o n s which were s a t i s f a c t o r y , whereas a t l e a s t 52 per cent r e v e a l e d d e p l o r a b l e accommodations. For example, one p a t i e n t would r e t u r n to h i s c o l d , damp, badly d i l a p i d a t e d house-boat,  between h i s s u c c e s s i v e 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 d i f f e r e n c e s are important a s p e c t s f o r cons i d e r a t i o n when one  i s t r y i n g to understand the t o t a l  patient,  t h i s f a c t o r 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 d i f f e r e n c e s - e s p e c i a l l y  .where they apply to " m i n o r i t y " or " i n f e r i o r i t y " groups - may  .  (El)  enter the p i c t u r e i n s o f a r as e n f o r c e d s e g r e g a t i o n l e a d s to l e s s o p p o r t u n i t y f o r f i n a n c i a l g a i n , adequate housing, e t c . Case Examples o f S o c i a l P r e s s u r e s The  first  case i s t h a t , o f a 35-year-old RHD p a t i e n t , who  w i t h i n s i x years a f t e r a c q u i r i n g h i s f i r s t of  known acute a t t a c k  RHD, s u f f e r e d r a p i d p h y s i c a l d e t e r i o r a t i o n and e v e n t u a l l y  died. H i s e a r l y h i s t o r y r e v e a l s t h a t a f t e r f a i l i n g and r e p e a t i n g grades f i v e , s i x and seven, a t the age o f 15 he l e f t H i s employment r e c o r d i n d i c a t e s that he went from  school.  job to j o b ,  a l t e r n a t i n g between v a r i o u s occupations i n c l u d i n g horse ing,  shoe r e p a i r i n g , w a i t e r , b e l l hop, bar tender,  trad-  boilermaker's  h e l p e r , e t c . , so that by the time he j o i n e d the army 14 years l a t e r , he had developed  little  specialized s k i l l .  Two y e a r s  a f t e r he e n l i s t e d , he was discharged w i t h an aggravated matic h e a r t c o n d i t i o n , which was thought p r i o r to h i s s e r v i c e c a r e e r . to  rheu-  to have o r i g i n a t e d  He then attampted u n s u c c e s s f u l l y  engage i n v a r i o u s types of strenuous u n s k i l l e d  employment,  but on each o c c a s i o n , an e x a c e r b a t i o n o f h i s c o n d i t i o n r e s u l t e d . Four years l a t e r h i s d i s a b i l i t y was c o n s i d e r e d 100 per c e n t . The  p a t i e n t ' s m a r i t a l h i s t o r y i s e q u a l l y as u n f o r t u n a t e .  A f t e r l i v i n g i n common-law r e l a t i o n s h i p w i t h a married woman and then being i n v o l v e d i n her husband's subsequent s u i t f o r the d i v o r c e , p a t i e n t married her s h o r t l y a f t e r h i s d i s c h a r g e the army. iorated.  from  As expected, m a r i t a l r e l a t i o n s h i p s g r a d u a l l y d e t e r Two years a f t e r t h e i r marriage,  the p a t i e n t was r e -  ported as h a r b o u r i n g s u s p i c i o n s t h a t h i s wife was c a r r y i n g on  (22)  w i t h o t h e r men, and t h a t he was c h i l d i s h l y demanding o f h e r . She was noted as complaining o f d i f f i c u l t y ships.  No c h i l d r e n were born to them.  The  p a t i e n t ' s f i n a n c i a l inadequacy  acerbation of h i s condition. t h i s through ill.  i n sexual r e l a t i o n -  mounted w i t h each ex-  A t f i r s t h i s wife compensated f o r  p a r t i a l employment, but e v e n t u a l l y , she too became  Through s o c i a l a s s i s t a n c e from c i t y agencies and a s m a l l  pension from the department o f veterans* a f f a i r s , the p a t i e n t and h i s wife c a r r i e d on as best they c o u l d .  That t h i s was i n *  s u f f i c i e n t , i s e v i d e n t , f o r an i n v e s t i g a t o r ' s r e p o r t s t a t e d the p a t i e n t was l i v i n g i n a "crowded, damp and p o o r l y f u r n i s h e d t h i r d f l o o r apartment", d e s p i t e the recommendation o f h i s doct o r t h a t the p a t i e n t r e q u i r e d "housing on the ground f l o o r t h a t i s kept warm and dry; a l s o , t h a t he l i v e where no s t a i r s need climbing".  A year l a t e r , he d i e d .  Another example, i s the case o f a 42-year-old v e t e r a n , whose rheumatic  h e a r t c o n d i t i o n appears  to have o r i g i n a t e d d u r i n g h i s  e a r l y c h i l d h o o d at a time when he developed Although  an a t t a c k o f chorea.  s u f f e r i n g m i l d l y from v a r i o u s rheumatic  he appeared  aches and p a i n s ,  to be i n good h e a l t h u n t i l he e n l i s t e d i n the army  i n 1939. He was subsequently  d i s c h a r g e d w i t h a sore back and  an i n a c t i v e RHD c o n d i t i o n . The p a t i e n t l e f t two grades,  s c h o o l at the age o f 10 a f t e r  completing  but l a t e r taught h i m s e l f how t o read and w r i t e .  H i s work h i s t o r y i s very s p o r a d i c .  I n the 20 years p r i o r t o h i s  e n l i s t m e n t , i t i s noted t h a t he was engaged i n a t l e a s t d i f f e r e n t types o f heavy u n s k i l l e d labour e.g. farming,  five relief  .gangs, e t c . , but there i s no i n d i c a t i o n how many d i f f e r e n t  jobs  (23)  he h e l d or where he worked, except that he d i d not remain l o n g at  one type o f work.. Much i n s t a b i l i t y was a l s o noted i n h i s  post war employment - i n one seven-month p e r i o d he moved through five  jobs which were o b t a i n e d f o r him by r e h a b i l i t a t i o n  cers.  A l t h o u g h ^ i t i e n t was n o t bothered too much by h i s h e a r t  condition at f i r s t , his  offi-  a chronic a r t h r i t i c  condition resulting  from  back i n j u r y , paved the way f o r h i s l i m i t e d e a r n i n g c a p a c i t y  and subsequent  financial  difficulties.  P r i o r to h i s e n l i s t m e n t the p a t i e n t m a r r i e d a b l i n d woman. Little  i s known o f h i s r e l a t i o n s h i p w i t h her, except he was  away from home most o f the time.  She died s h o r t l y 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 o f the time.  The p a t i e n t r e m a r r i e d about  a year and a h a l f l a t e r , to a young woman t h i r t e e n years h i s junior.  D u r i n g the next e i g h t - y e a r p e r i o d , she was admitted t o  the mental h o s p i t a l f i v e times f o r a s c h i z o p h r e n i c d i s o r d e r . The p a t i e n t a l s o spent the major p o r t i o n o f these years i n hospital.  Two c h i l d r e n were born to them,and i t i s s i g n i f i c a n t ,  that as a r e s u l t o f the frequent h o s p i t a l i z a t i o n s o f the parents, the burden o f p r o v i d i n g and f i n a n c i n g f o s t e r home care became the r e s p o n s i b i l i t y of community a g e n c i e s .  As m e d i c a l  b i l l s mounted f o r both the p a t i e n t and h i s w i f e , they became completely dependent upon w e l f a r e a g e n c i e s . As a r e s u l t o f the p a t i e n t ' s ever-mounting  financial  diffi-  c u l t i e s and f u r t h e r i n a b i l i t y to accept employment, i t i s not s u r p r i s i n g t h a t i n v e s t i g a t o r s found the p a t i e n t ' s l i v i n g c o n d i t i o n s completely inadequate.  I n 1948, one i n v e s t i g a t o r p o i n t e d  out that the whole f a m i l y was l i v i n g i n a "two-room untidy  (24)  s u i t e " , that both the v e t e r a n and h i s wife were " i n poor h e a l t h and r e q u i r e d  b e t t e r food",  and that ''poor c l o t h i n g f o r the  whole f a m i l y " was much i n evidence.  A more recent  study made  by an i n t e r e s t e d community agency, i n d i c a t e d that they were " q u i t e d i s t r e s s e d by the d e p l o r a b l e veteran At  c o n d i t i o n s under which the  and h i s f a m i l y a r e l i v i n g " . the time t h i s study was made, the p a t i e n t had j u s t com-  p l e t e d another six-month h o s p i t a l i z a t i o n and was r e u n i t e d his family.  Considering  with  the l a t e s t i n v e s t i g a t o r ' s r e p o r t  a v a i l a b l e , i t wa.s to be expected that h i s r e t u r n to the h o s p i t a l w i t h i n a short time was i n e v i t a b l e .  L i v i n g c o n d i t i o n s were  c l a s s i f i e d as below-average, as the f a m i l y was l i v i n g i n a " d i l a p i d a t e d o l d b u i l d i n g , i n f e s t e d w i t h cockroaches". wife had r e c e n t l y r e t u r n e d  His  from the mental h o s p i t a l but i t was  d o u b t f u l how long she c o u l d c a r r y on.  The p a t i e n t ' s t o t a l i n -  come w i t h which he was expected to c r e a t e a more s u i t a b l e environment, was a minimum a s s i s t a n c e grant which i n c l u d e d the care o f h i s wife  but not h i s c h i l d r e n . ^  These two cases i l l u s t r a t e the e v e r - i n c r e a s i n g i n t e r a c t i o n of s o c i a l f a c t o r s a f f e c t i n g the RHD p a t i e n t , which u l t i m a t e l y i n f l u e n c e s h i s poor p r o g n o s i s f o r r e h a b i l i t a t i o n . s a i d that t h i s developing chronic  p a t t e r n i s c h a r a c t e r i s t i c o f other  i l l n e s s e s as w e l l as RHD.  the p o i n t ,  The w r i t e r does not d i s p u t e  but i n s t e a d , has attempted to show only  "factors do e x i s t .  I t can be  However, i n order  that  these  to understand the  1 War veterans' allowance does not i n c l u d e payments f o r c h i l dren o f veterans.  (25)  p a r t i c u l a r s i g n i f i c a n c e o f these s o c i a l f a c t o r s to the rheumat i c h e a r t patient, i t i s necessary s o n a l i t y p a t t e r n a f f e c t i n g and environment.  Although  to examine as w e l l , the  being a f f e c t e d  by t h i s  per-  social  i n r e a l i t y i t i s not always p o s s i b l e to  d i f f e r e n t i a t e between these i n n e r and outer p r e s s u r e s , t h i s i s being done because a more convenient d i v i s i o n o f m a t e r i a l i s thus obtained." Personality Patterns Probably ality  the most i n c l u s i v e study on the d e v e l o p i n g  s t r u c t u r e o f the p a t i e n t who  been done by F l a n d e r s Dunbar."'"  i s a f f l i c t e d w i t h RHD,has  I n the main, the r e s u l t s o f  t h i s present study do not c o n f l i c t w i t h her f i n d i n g s . as her case s e l e c t i o n c o n s i s t e d s o l e l y of RHD r e s e a r c h p r o j e c t has i n c l u d e d p a t i e n t s who p h y s i c a l c o m p l i c a t i o n s as w e l l .  Where-  patients,  this  s u f f e r from o t h e r  T h e r e f o r e , i t i s t o be expec-  ted t h a t some of the d i f f e r e n c e s i n f i n d i n g s can be to t h i s d i s c r e p a n c e .  person-  attributed  T h i s problem o f case s e l e c t i o n has a l 2  ready  been d e a l t w i t h  earlier.  Dunbar has shown t h a t the RHD adequate person who  p a t i e n t i s e s s e n t i a l l y an i n -  i s i n c o n f l i c t with a u t h o r i t y .  Because  t h i s type o f person has developed a sense o f Inadequacy, he f e e l s he i s unable to compete f a v o u r a b l y w i t h h i s s i b l i n g s f o r h i s parents a f f e c t i o n .  I n s t e a d , he i s l i k e l y  1 F l a n d e r s Dunbar, Psychosomatic 2 See pp.  (12-14) i n Chapter  1.  to i m i t a t e or  D i a g n o s i s , pp. 367 -  435.  (26)  c u r r y favour w i t h one or the o t h e r parent ;'  G e n e r a l l y speaking,  h i s parents are s t r i c t and, he p r e f e r s t h i s .  By e x p l o i t i n g h i s  1  abnormality and h i s a b i l i t y to s u f f e r , he d e r i v e s p l e a s u r e through  the esteem which he r e c e i v e s from being a b l e to take  punishment.  As he a c q u i r e s t h i s mode o f behaviour, he l e a r n s  to decrease g r e a t l y h i s tendency sentment.  to express a g g r e s s i o n or r e -  The o u t l e t f o r t h i s r e p r e s s e d h o s t i l i t y appears  a n o n - d i r e c t i v e urge to a c t i v i t y .  The  in  p a t i e n t then appears  deny the presence or make l i g h t of h i s i l l n e s s , as he s e l f - n e g l e c t f u l and o v e r e x e r t s h i m s e l f .  Where o v e r t  to  becomes expres-  s i o n of t h i s s e l f - p u n i s h i n g device i s blocked, the p a t i e n t may r e s o r t to day-dreams or i n f a n t i l e  phantasy.^"  U n f o r t u n a t e l y very few r e c o r d s used i n t h i s study, c o n t a i n ed s u f f i c i e n t  data from which an understanding o f e a r l y  a l and f a m i l y r e l a t i o n s h i p s c o u l d be o b t a i n e d . the l a t e r behaviour  Judging  personfrom  of the p a t i e n t s , as recorded i n the m e d i c a l  social 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 o f t h i s area of r e s e a r c h have been on a more s u b j e c t i v e l e v e l than would have p r e f e r r e d by the w r i t e r . I n any  event, c o n s i d e r i n g the i n t a n g i b l e q u a l i t y a t t a c h e d to  emotions and f e e l i n g s , the problem o f overcoming a s u b j e c t i v e a n a l y s i s of such m a t e r i a l i s a d i f f i c u l t  one.  Probably the most o u t s t a n d i n g f e a t u r e noted, was ked emotional dependence o f the RHD -figure  p a t i e n t upon some mother-  (e.g. mother, w i f e , s i s t e r , e t c . ) .  1 I b i d . , pp. 429 f f .  the mar-  C r y i n g s p e l l s were  (27)  frequent,  e s p e c i a l l y -when the p a t i e n t s  began t a l k i n g o f 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 t h e i r marriage r e l a t i o n s h i p s .  Ano-  ther o u t s t a n d i n g f e a t u r e , was the a p p r a i s a l which most wives gave o f t h e i r s i c k spouses.  Approximately 7E per cent i n d i c a -  ted t h e i r husbands were u s u a l l y very q u i e t ; a l s o , t h a t  they  were u s u a l l y poor c o n v e r s a t i o n a l i s t s i n company. Although f i f t y to curry favour,  per cent o f the cases i n d i c a t e d some attempt  i t i s s i g n i f i c a n t t h a t approximately another  35 per cent gave some evidence o f being unmanageable because of t h e i r aggressive  behaviour.  A t l e a s t three  defy treatment by i n d u l g i n g i n e x c e s s i v e bouts. tal  Some o f the i r r i t a b i l i t y  p a t i e n t s would  alcoholic drinking  was accentuated by the h o s p i -  s t a f f being unable to put up with the p e t t y f a u l t - f i n d i n g  of these p a t i e n t s .  T h i s marked evidence o f a g g r e s s i v e  i o u r , i s one o f the more s i g n i f i c a n t d e v i a t i o n s ings which F l a n d e r s  Dunbar produced.  behav-  from the f i n d -  However, the w r i t e r  feels  that t h i s i s not an i n d i c a t i o n o f a d i f f e r e n c e i n p e r s o n a l i t y profile,  but i n s t e a d , i s evidence, t h a t f o r some p a t i e n t s , the  mental mechanism o f c u r r y i n g favour breaks down to the p o i n t where a f u r t h e r r e t r e a t to an e a r l i e r l e v e l o f a g g r e s s i v e h a v i o u r takes The  place.  be-  1  rheumatic heart  p a t i e n t , then, would appear to be a  person who has not been able t o accept the a d u l t r o l e .  When  1 A m o r e - d e t a i l e d d e s c r i p t i o n o f the t h e o r e t i c a l i m p l i c a t i o n s t h a t are i n v o l v e d here, i s found i n Anna Freud, The Ego and Mechanisms o f Defense. A l s o , as an example o f t h i s see p. I 36 ).  (28)  pressures  become too great, he seems to r e g r e s s to an e a r l i e r  d e s i r e to e x p l o i t h i s i l l n e s s , so that he w i l l then be c a r e d for.  He i s u s u a l l y t i m i d and l a c k i n g i n s e l f - r e l i a n c e and  attempts t o please  i n h i s appeal f o r sympathy.  that he i s i n constant for him.  I t would appear  c o n f l i c t w i t h the u n s a t i s f i e d l o n g i n g  the s e c u r i t y which h i s unstable  childhood  never  provided  The long h o s p i t a l i z a t i o n and convalescence which f o l l o w s  recurrent attacks, possibly provides t h i s need to be cared  the s u b s t i t u t e source o f  f o r , so that the comfort gained by h i s  acquirement o f h i s d i s e a s e , would overshadow the s u f f e r i n g which i n e v i t a b l y f o l l o w s . Case I l l u s t r a t i o n s o f P e r s o n a l i t y (1) E s s e n t i a l l y P a s s i v e 44-year-old v e t e r a n  Patterns  - The f i r s t c a s e - i s that o f a  o f the f i r s t world war, "whose s o c i a l  tory i s q u i t e s i m i l a r to the previous  examples d e s c r i b e d .  hisThe  second e l d e s t son o f a f a m i l y o f s i x boys, p a t i e n t r e c a l l e d his  f a t h e r as being o v e r l y s t r i c t and at times unjust  punishment.  in his  H i s f a t h e r was the type who d i d not h e s i t a t e t o  use a whip, e s p e c i a l l y when he got drunk.  The p a t i e n t ' s  mother was the q u i e t type who sometimes defended the c h i l d r e n and  "expressed thanks t h a t they were a l l boys".  was apparently stature".  The p a t i e n t  a s t r o n g and husky c h i l d " i n s p i t e o f h i s  He p r e f e r r e d being c l o s e to home i n h i s e a r l y  small years,  however, when the f a m i l y came t o Canada when he was 21, they decided  t o r e t u r n to t h e i r n a t i v e land and he and one  remained i n Canada.  brother  He spent a b r i e f p e r i o d i n the B r i t i s h  navy a t the age o f 17, but soon developed h i s f i r s t  attack of  (29)  rheumatic While  f e v e r and was  d i s c h a r g e d with a pension f o r  RHD.  i n Canada, he engaged i n heavy bush and farm l a b o u r .  second a t t a c k of RHD, f i r s t one,  which o c c u r r e d seven y e a r s a f t e r  His  the  and which demanded f i v e months o f h o s p i t a l i z a t i o n ,  f o r c e d him to g i v e up t h i s strenuous work. S h o r t l y a f t e r h i s h o s p i t a l i z a t i o n , he m a r r i e d a g i r l n i n e years younger than h i m s e l f , (she was he f e l t  sorry f o r her.  s i m i l a r to h i s  16 at the t i m e ) , because  He remembers t h a t she had parents q u i t e  own.  The p a t i e n t was p h y s i c a l handicap.  employed almost c o n t i n u o u s l y i n s p i t e o f h i s F o l l o w i n g h i s second attack, he was  f i n d l e s s exhausting employment, but i t was left  helped to  not l o n g before he  t h i s to engage i n more strenuous p u r s u i t s .  His exercise  t o l e r a n c e g r a d u a l l y d i m i n i s h e d and so d i d h i s f i n a n c i a l ity.  stabil-  A f t e r moving from job to job, he f i n a l l y succumbed to  another a t t a c k of Again, a f t e r  RHD. spending the major p a r t of the f o l l o w i n g year  and a h a l f i n a h o s p i t a l , he subsequently d i e d . During t h i s p e r i o d of h o s p i t a l i z a t i o n , the case was red  to m e d i c a l s o c i a l s e r v i c e because the p a t i e n t was  over m a r i t a l d i f f i c u l t i e s . worker, the p a t i e n t was  On being i n t e r v i e w e d by a  shy and nervous, and i t was  patience t h a t a s o c i a l h i s t o r y was He was  finally elicited  l a t e r a b l e to express t h a t he u s u a l l y f e l t  women, although t h i s f e e l i n g had e a r l y adulthood.  refer-  upset female  with utmost from  him.  uneasy w i t h  somewhat d i m i n i s h e d d u r i n g h i s  H i s main a n x i e t y surrounded the f e a r that h i s  w i f e wanted a s e p a r a t i o n .  An i n t e r v i e w w i t h the  r e v e a l e d t h a t the p a t i e n t had developed  impotency  psychiatrist and  blamed  (30)  Ms  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 s a i d he had l o s t c o n f i d e n c e i n her.  ( I t i s i n t e r e s t i n g that she had p r e v i o u s l y accused him o f  the same t h i n g . )  Of s i g n i f i c a n c e , however,-is the  relationship  between the onset o f h i s impotency and the e x a c e r b a t i o n of h i s illness.  Attempts to i n t e r v i e w the w i f e , to get her s i d e o f the  picture,were c o n t i n u a l l y f r u s t r a t e d by the p a t i e n t , because he was  a f r a i d she would r e s e n t the f a c t t h a t he had d i s c u s s e d t h e i r  m a r i t a l problem w i t h o t h e r s . He maintained t h a t he d i s l i k e d crowds, d i d not dance, most comfortable with a few easy with women. haps he had  felt  f r i e n d s , read a l o t , and f e l t  I n r e f e r e n c e to h i s w i f e , he f e l t  un-  t h a t per-  been s e l f i s h , as he had wanted h e r - t o h i m s e l f and  had not r e a l i z e d she might want to enjoy the company of o t h e r s . 'Of the two  c h i l d r e n r e s u l t i n g from t h i s marriage,  t i e n t was  more a t t a c h e d to h i s daughter  mother was  c l o s e r to her son (age 7).  the  (age 15), and The  pa-  the  p a t i e n t expressed  the c o n f l i c t which t h i s c r e a t e d , by p o i n t i n g out t h a t h i s w i f e resented the a t t e n t i o n he gave to h i s daughter, his  and f e l t  w i f e would be c l o s e to him a g a i n i f the daughter  and l e f t home. he was  that  married  He had d i f f i c u l t y , however, i n d e c i d i n g whether  r e a l l y i n favour of h i s daughter  ever g e t t i n g m a r r i e d .  What type o f 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 h i s e a r l i e r l i f e  history  that "the p a t i e n t had never r e a l l y grown beyond the dependency stage.  H i s f e e l i n g o f i n f e r i o r i t y was  r e c o l l e c t i o n of h i s small s t a t u r e . w e l l expressed, although he was  first  expressed  by h i s  His fear of h i s father  was  not so bold i n d e s c r i b i n g h i s •  (31)  mother. tal  However, h i s f e a r o f women i n g e n e r a l , p l u s - h i s m a r i -  conflict,  seem t o i n d i c a t e much stronger f e e l i n g s towards  a mother-person. The  p a t i e n t married a g i r l much younger than h i m s e l f , so  that he c o u l d be assured  t h a t he would be i n c o n t r o l o f the  household j u s t as h i s f a t h e r was.  He was e s s e n t i a l l y depen-  1  dent upon the good graces o f h i s w i f e , and when he found  that  she was u n w i l l i n g to g r a t i f y h i s needs f o r l o v e and a f f e c t i o n , he turned to h i s daughter f o r t h i s s t i l l - u n s a t i s f i e d he sought as a c h i l d .  I t i s q u i t e probably  security  t h a t he r e s e n t e d  the attachment o f h i s wife t o h i s son, i n much the same way as he would compete w i t h h i s brothers and s i s t e r s f o r h i s mother's affection. The  p a t i e n t ' s f i r s t a t t a c k o f rheumatic f e v e r o c c u r r e d  a f t e r he had l e f t home f o r the f i r s t the d r i v e s o f adolescence  time.  A t a stage where  towards independence a r e s t r o n g e s t ,  the p a t i e n t chose the l i f e of a s a i l o r to achieve t h i s freedom.-. However, h i s u n d e r l y i n g dependency needs were re-awakened, and he was a b l e to s a l v e h i s conscience  by d e v e l o p i n g a p h y s i c a l  i l l n e s s which " f o r c e d " him t o give up h i s independence. a f t e r coming to Canada, he attempted to r e s o l v e t h i s and almost succeeded.  conflict  F i n a l l y , a f t e r d r i v i n g h i m s e l f , he end-  ed up i n the h o s p i t a l once a g a i n . married  Again,  Soon a f t e r h i s r e c o v e r y , he  and presumably he was a b l e to f i n d enough s a t i s f a c t i o n  1 Emulation o f a f e a r e d s u p e r i o r , e s p e c i a l l y i n phantasy, was a c h a r a c t e r i s t i c r e a c t i o n o f RHD p a t i e n t s noted by F l a n d e r s Dunbar, Psychosomatic D i a g n o s i s , pp. 367 - 435.  (32)  from h i s w i f e and was  thereby able to c a r r y on.  l a t e r , when h i s marriage was f e e l i n g s of inadequacy  Twelve y e a r s  s e v e r e l y threatened and  were re-aroused  early  by her r e j e c t i o n and h i s  subsequent impotency, the p a t i e n t succumbed to another a t t a c k . (2) E s s e n t i a l l y A g g r e s s i v e - Another case, t h a t o f a y e a r - o l d v e t e r a n who  developed RHD  26-  while i n the A i r Force, pre-  sents a more v i v i d p o r t r a y a l 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 f e e l i n g s o f dependence versus  indepen-  dence.  Only a very b r i e f account of h i s e a r l y h i s t o r y i s known,  however, the p a t t e r n i s w e l l 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 c o n d i t i o n and h i s emotional The  physical  instability.  p a t i e n t i s d e s c r i b e d as having an u n e v e n t f u l and  ently-happy  childhood.  appar-  The only i n f o r m a t i o n which seems to  throw some doubt on t h i s p e a c e f u l beginning, i s the f a c t t h a t one o f h i s s i s t e r s had a "nervous breakdown". Grade ten, he l e f t jobs - mainly  After  s c h o o l to engage b r i e f l y i n a v a r i e t y o f odd  farm labour and c o n s t r u c t i o n work.  years of age, he e n l i s t e d i n the A i r F o r c e . crew examinations,  At n i n e t e e n  Failing his air-  he became q u i t e upset by h i s demotion t o  g e n e r a l ground-crew d u t i e s , and he had h i s f i r s t  i t was  a t t a c k o f rheumatic  s h o r t l y afterwards, t h a t  fever.  He was  with a t h i r t y per cent pension, and although he was a g a i n s t engaging  i n heavy l a b o u r , h i s f i r s t  i n the s h i p y a r d s performing strenuous t a s k s . s u c c e s s i o n he was  completing  discharged warned  p o s t - s e r v i c e job F i v e years i n  h o s p i t a l i z e d f o r lengthy terms.  He r e c e i v e d  c o n s i d e r a b l e h e l p 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 o b t a i n i n g ployment that was  was  i n keeping w i t h h i s l i m i t e d c a p a c i t i e s ,  em-  but  (33)  he  u s u a l l y r e j e c t e d most of these.  place f r e q u e n t l y , and  He moved from p l a c e  although he had  years a f t e r h i s discharge  from the  examination r e p o r t r e v e a l e d  to  worked a t many jobs,  service, a routine  two  physical  t h i s comment.  The p a t i e n t i s a tense psychoneurotic i n d i v i d u a l . . . . H i s j o i n t pains are c o i n c i d e n t w i t h h i s d e s i r e to leave h i s employment, which he f i n d s u n s a t i s f a c t o r y . . . . The and  p a t i e n t married f o u r y e a r s a f t e r h i s s e r v i c e  four months l a t e r a c h i l d was  n i n g the marriage was d r i n k i n g and  a stormy one,  left  From the very  employment.,  expected, t h i s was  followed  by a very  b r i e f period  A month l a t e r , the case was  difficulties.  be-  On admittance, i t  noted t h a t " . . . h i s p a i n seemed out of p r o p o r t i o n  s e r v i c e because he was  infidelity,  him.  f o r e h i s next h o s p i t a l i z a t i o n o c c u r r e d .  ings".  begin-  and a f t e r a s e r i e s o f  gambling bouts, unstable  e t c . - h i s wife As  born.  discharge  to the  r e f e r r e d to m e d i c a l  d i s t u r b e d over employment and  I n t e r v i e w s w i t h the p a t i e n t r e v e a l e d  was  findsocial  marital that,  Numerous jobs h e l d by the p a t i e n t would appear, f o r the most p a r t , too heavy i n view o f h i s m e d i c a l c o n d i t i o n . .. .Some, he l o s t through h i s i l l n e s s but most, adm i t t e d l y , through heavy d r i n k i n g bouts. The p a t i e n t d e s c r i b e s h i m s e l f as impetuous....He gets depressed and d r i n k s to combat t h i s , . . . g o e s abs o l u t e l y crazy when drunk, then " b l a c k " out completely. F e e l s g u i l t y about t h i s . . . . T h e p a t i e n t seems immature and dependent....The p a t i e n t showed worker a l e t t e r he wrote to h i s wife but had not m a i l e d . I n i t he begs her to come out, so t h a t he can see her and the c h i l d . He p o i n t s out that he has c r i e d h i m s e l f to s l e e p . . . . He r e i t e r a t e s h i s determination to give up d r i n k i n g . . . but he admits t h a t whenever he r e c e i v e s a shock he "goes o f f the deep end". I t was u a t i o n was  f e l t a t t h i s time, t h a t the p a t i e n t ' s m a r i t a l extremely p r e c a r i o u s ,  and  that i t would be  sit-  increas-  (34)  i n g l y d i f f i c u l t f o r him restlessness.  to accept treatment, because of h i s  H o s p i t a l r e c o r d s i n d i c a t e d he would absent him-  s e l f from the ward each evening, and  would r e t u r n i n a drunken  state. I t was  f i v e months before he was  the h o s p i t a l . during  Four months l a t e r - having worked at two  t h i s i n t e r v a l , he had  also reunited  with h i s w i f e .  for  h i s f i n a n c i a l problems, and was  T h i s time he  i n g f a i r l y w e l l , u n t i l a year and  requested a i d  helped to o b t a i n work as  i n various h o s p i t a l s e t t i n g s .  a g a i n manifested RHD  jobs  j o i n e d A l c o h o l i c s Anonymous and  was  orderly  f i n a l l y d i s c h a r g e d from  He  seemed to be  adjust-  a h a l f l a t e r , when he  once  symptoms while working as an o r d e r l y  small-town h o s p i t a l , which allowed him  to r e t u r n f o r  an  in a  further  treatment. By  t h i s time the p a t t e r n o f dependency appeared more i n  evidence, as an examination d i d not b a s i s f o r h i s symptoms. dicated  patient's  He was  s e t t i n g played some p a r t i n h i s  d i s c h a r g e d a month and  l a t e r , a f t e r consistently defying ments o f the h o s p i t a l , and  the author.atative  per  t i o n o f a p e r s o n a l i t y make-up and The  It  increased  cent.  In t h i s case, as i n the o t h e r example used, the  dicated.  require-  immature behaviour.  a l s o noted, that h i s pensionable d i s a b i l i t y had  to f i f t y  a half  when l a s t heard o f , continued to  d i s p l a y impetuous, i r r e s p o n s i b l e and was  physical  A p s y c h i a t r i c a p p r a i s a l , however, i n -  "personality  present complaints".  reveal sufficient  interreac-  environmental s t r e s s , i s i n -  p a t i e n t developed h i s f i r s t a t t a c k o f i l l n e s s i n  .the A i r F o r c e , a t a time when h i s f e e l i n g o f inadequacy  had  (35)  p o s s i b l y been aroused.  By f a i l i n g to become a member o f the  a i r - c r e w , he became extremely d i s s a t i s f i e d w i t h the r o l e he then a sice d to p l a y .  The development  was  o f rheumatic f e v e r p r o v i d -  ed him w i t h an a c c e p t a b l e o u t l e t and he was a b l e t o escape from a frustrating situation.  Subsequently, h i s p a t t e r n o f i l l n e s s  became w e l l - e s t a b l i s h e d .  I n i t i a l l y he l e f t  the dependency  h i s home environment i n o r d e r to assume an independent  of  status.  H i s f i r s t means o f escape from u n s a t i s f y i n g employment, was t o j o i n the s e r v i c e .  F o l l o w i n g d i s c h a r g e , he c o n t i n u e d to show  ambivalent f e e l i n g s , as he c o n s i s t e n t l y opposed the a u t h o r i t y o f an employment s e t t i n g and s a t i s f i e d h i s dependency h i s a c q u i r e d escape i n t o  need  by  illness.  H i s marriage added a f u r t h e r burden to him.  He made impos-  s i b l e demands o f h i s w i f e , e s p e c i a l l y a f t e r the b i r t h o f the c h i l d , and when she f i n a l l y l e f t him, he was once a g a i n o v e r whelmed by i n c r e a s i n g f e e l i n g s o f inadequacy and  guilt.  The p a t i e n t d i s p l a y e d a t l e 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  illness,  the o t h e r was a l c o h o l .  The l a t t e r a l l o w e d him to  r e a l i z e h i s ambitions i n phantasy i f not i n f a c t .  Flanders  Dunbar p o i n t s out t h a t the t a k i n g o f s t i m u l a n t s such a s a l c o h o l i n l a r g e doses, i s one way h i s need to e x c e l l .  i n which an RHD  p a t i e n t could  satisfy  T h e r e f o r e , i f the p a t i e n t c o u l d not be a  success a t a n y t h i n g e l s e , at l e a s t he c o u l d e x c e l l as an a l c o holic.  1  The g u i l t and f u r t h e r d e p r e s s i o n which f o l l o w e d each  1 F l a n d e r s Dunbar, Psychosomatic D i a g n o s i s , pp. 367 - 435.  (36) d r i n k i n g bout only served  to remind him o f the added proof  of  h i s inadequacy. In c o n t r a s t to the type o f p a t i e n t who  tends to r e p r e s s  h o s t i l i t y , t h i s p a t i e n t expressed i t more openly,.  his  Although  he  sought the s e c u r i t y o f the h o s p i t a l s e t t i n g to cover up f o r h i s inadequacy, t h i s d i d not allow him H i s frequent  sufficient  compensation.  absences from the h o s p i t a l appeared to be a  ance a g a i n s t a u t h o r i t y , 'although i t i s noted that he drunk on these o c c a s i o n s . have sought the extra the g u i l t he  . The  may  s t i m u l a t i o n o f a l c o h o l as an escape from  s a t i s f a c t i o n from the a t t e n t i o n and  bably  became  w r i t e r f e e l s the p a t i e n t  f e l t , whereas the former p a t i e n t gained  a f f o r d e d him.  defi-  sufficient  sympathy, which h i s  However as i n d i c a t e d p r e v i o u s l y ,  1  illness  t h i s i s pro-  a l s o an i n d i c a t i o n that the l a t t e r p a t i e n t had  regressed  to: an e a r l i e r l e v e l o f behaviour a d a p t a t i o n .  Because o f  this,  h i s " p r i m i t i v e " d e s i r e s would be m o r e - r e a d i l y  expressed,  and  h i s 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 t o  a f f e c t i n g the course of. i l l n e s s of an RED have been presented.  As  male a d u l t  be patient,  suggested p r e v i o u s l y , i t i s p o s s i b l e  to produce members o f s o c i e t y who  undergo s i m i l a r s t r e s s e s  s t r a i n s , yet do not  The  formation  to the  such s o c i a l and  develop RHD.  importance o f t h i s i n -  s o c i a l worker l i e s i n the r e c o g n i t i o n that emotional problems do appear i n the RHD  -rand are i n f l u e n c i n g the p h y s i c a l a s p e c t s o f the d i s e a s e .  1 See  p.  (27),  and  patient The  (37)  special ber  of  brought  skill the out  -which, t h e  hospital in  the  s o c i a l worker  treatment  can contribute  team c o m b a t t i n g  f o l l o w i n g area  of  this  presentation.  as  a mem-  illness,  is  CHAPTER 5 . CASE WORK WITH RHEUMATIC HEART PATIENTS E s s e n t i a l l y the problem o f RHD i s a m e d i c a l one, and i t i s not the purpose o f t h i s study to minimize c i n e has to p l a y . concomitant  the r o l e which medi-  However, as has been suggested before, the  f a c t o r s which appear  to be a f f e c t i n g the course o f  the i l l n e s s , occur too f r e q u e n t l y to be c l a s s i f i e d as mere coincidence.  The s o c i a l and emotional c l i m a t e i n which the pa-  t i e n t l i v e s , i s o f 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 o f these problems a f f e c t i n g the illness,  that h i s s p e c i a l i z e d s k i l l s can best be put to use.  Because he i s concerned w i t h the patient-as-a-whole, h i s work on the p a t i e n t ' s b e h a l f w i l l extend beyond the boundaries o f 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-  t a c t w i t h the p a t i e n t ' s f a m i l y and community and attempts to u t i l i z e the s e r v i c e s which they as w e l l as the h o s p i t a l  staff  can render t o the p a t i e n t on a c o n t i n u i n g b a s i s . The w r i t e r has p o i n t e d o u t t h a t there i s a p a r i t c u l a r s e t of s o c i a l and emotional f a c t o r s which a f f e c t most RHD  patients.  The s o c i a l worker, needs such i n f o r m a t i o n i n order to guide h i s a p p l i c a t i o n o f case work s k i l l s towards a l l e v i a t i n g these p r e s sures.  However, a t no time should the s o c i a l worker attempt to  base h i s d i a g n o s i s and treatment on t h i s g e n e r a l i z a t i o n alone, f o r i n each person there are i n d i v i d u a l d i f f e r e n c e s which l a r g e l y determine illness.  the depth and d u r a t i o n o f emotional r e a c t i o n s to  Eor example, where i l l n e s s has become an escape mech-  anism f o r the p a t i e n t , treatment i n v o l v e s more than  just  (39)  breaking down t h i s defense. ed the compensation to  be exposed,  I n t h i s sense, i l l n e s s has  f o r a p a i n f u l mental c o n f l i c t .  the p a t i e n t must f i r s t  provid-  I f this i s  be helped to f i n d a more-  a c c e p t a b l e s o l u t i o n to h i s d i f f i c u l t i e s .  What i s i n v o l v e d i n  case work treatment, then, i s an "understanding" of these i n d i v i d u a l d i f f e r e n c e s and a g e a r i n g o f the case work process to the l e v e l o f adjustment which a p a r t i c u l a r p a t i e n t i s f u n c t i o n ing. LEVELS OF CASE WORK TREATMENT F l o r e n c e H o l l i s has o u t l i n e d f o u r l e v e l s a t which case work treatment can be used.^.  The f i r s t of these, environmental  m a n i p u l a t i o n , has been d e f i n e d as " a l l attempts to c o r r e c t , or improve  the s i t u a t i o n ( o f a p a t i e n t ) i n o r d e r to reduce  strain  and p r e s s u r e , and a l l m o d i f i c a t i o n s o f the l i v i n g experience 2 to  o f f e r o p p o r t u n i t i e s f o r growth o r change...."  For example,  t h i s process can i n v o l v e a changing or m a n i p u l a t i n g o f e n v i r o n mental p r e s s u r e s , such as p r o v i d i n g f i n a n c i a l a s s i s t a n c e ,  find-  ing  more-adequate l i v i n g q u a r t e r s , or even h e l p i n g r e l a t i v e s  to  be more understanding o f the meaning o f i l l n e s s to the pa-  tient.  S o c i a l workers are probably best fcnown f o r t h e i r work  i n the area of environmental a i d , f o r the very beginnings of s o c i a l work p r a c t i c e have been founded on the use o f t h i s 1 F l o r e n c e H o l l i s , "The Techniques of Case Work", J o u r n a l o f S o c i a l Case Work, June, 1949, pp. 235-44. p.  2 Gordon Hamilton, Theory and P r a c t i c e o f S o c i a l Case Work, 247.  (40)  h e l p f u l device.  Josselyn  1  being the l e a s t a r t i f i c i a l  speaks o f "environmental therapy" as approach,  and p o i n t s out t h a t some-  times t h i s i s the o n l y type o f treatment p o s s i b l e .  Environmen-  t a l m a n i p u l a t i o n must be p u r p o s i v e , i f i t i s to be c o n s t r u c t i v e . The  important t h i n g to remember, i s that the p a t i e n t must want  to  be helped and should be encouraged  of  the changing as p o s s i b l e .  t o p a r t i c i p a t e i n as much  The medical s o c i a l worker should  only perform such a c t i o n which the p a t i e n t i s unable to do f o r himself. The o t h e r three l e v e l s o f case work which H o l l i s d e s c r i b e s , ( p s y c h o l o g i c a l support, c l a r i f i c a t i o n and i n s i g h t ) i n v o l v e a more d i r e c t approach  to the p a t i e n t ' s i n n e r emotional  and d i f f e r as to the degree through these problems.  strife,  i n which he i s helped to work  An accurate d i a g n o s i s , based on a  c a r e f u l a n a l y s i s o f the p a t i e n t ' s problem, w i l l determine the type o f h e l p he can best use. P s y c h o l o g i c a l Support  i s a technique used to encourage the  p a t i e n t to t a l k about h i s problem.  D i s c u s s i o n i s f o c u s s e d up-  on h e l p i n g him to be aware o f and r e - e n f o r c i n g h i s i n n e r strengths, f i r s t  through guidance, r e l e a s e o f t e n s i o n , and  then through v a r i o u s forms o f reassurance designed to b o l s t e r his  self-confidence.  P s y c h o l o g i c a l support i s u s e f u l f o r  c a r r y i n g the b a s i c a l l y w e l l - a d j u s t e d person over a p e r i o d o f severe s t r e s s and s t r a i n caused .The approach  by p a i n f u l l i f e e x p e r i e n c e s .  i s a l s o h e l p f u l when working w i t h i n f a n t i l e and  1 Irene M. J o s s e l y n , "The Case Worker as a T h e r a p i s t " , J o u r n a l o f S o c i a l Case Work, November, 1948, pp. 351 - 355.  (41)  immature p a t i e n t s who  are i n need of guidance.  presses a sympathetic  understanding of p a t i e n t ' s f e e l i n g  accepts h i s behaviour.  The worker  ex-  and  i A s i n c e r e i n t e r e s t and d e s i r e to h e l p ,  a l o n g w i t h r e s p e c t f o r and a p p r o v a l o f a c t i o n taken when i t i s warranted,  a i d s i n b u i l d i n g up the p a t i e n t ' s c o n f i d e n c e .  a g a i n , the p a t i e n t ' s a b i l i t y to make h i s own important.  Here  decisions, i s a l l -  F i n a l l y , p s y c h o l o g i c a l support i s a technique  des-  igned to c r e a t e a p e r m i s s i v e r e l a t i o n s h i p , which i s intended to r e l i e v e a n x i e t y and f e e l i n g s of g u i l t . C l a r i f i c a t i o n i s a m o r e - i n t e n s i v e case work technique igned to h e l p the p a t i e n t understand h i m s e l f and the w i t h whom he i s a s s o c i a t i n g .  I t may  des-  people  be a matter o f h e l p i n g him  to l o o k a t the probable r e s u l t s o f a d e c i s i o n , or e v a l u a t e the o p i n i o n s of o t h e r s , or even to become aware o f h i s own and a t t i t u d e s i n a c o r r e c t p e r s p e c t i v e .  Ordinarily,  feelings clarifica-  t i o n i s given o n l y when a h i g h degree of p s y c h o l o g i c a l support i s used, unless the p a t i e n t i s r e l a t i v e l y h e a l t h y i n h i s pers o n a l i t y adjustment  or the problem  a f f e c t e d by p e r s o n a l i t y c o n f l i c t s . i e n c e s may  t r e a t e d i s one which i s unAlthough emotional  exper-  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 g i v e n to  c r e a t e an i n t e l l e c t u a l understanding o f c o n s c i o u s m a t e r i a l . Whereas C l a r i f i c a t i o n d e a l s w i t h f u l l y conscious m a t e r i a l the development of I n s i g h t i n v o l v e s a much deeper l e v e l of treatment.  T h i s device attempts  to reach f o r and  suppressed, r a t h e r than unconscious  b r i n g out,  f o r m u l a t i o n s , and i s  based upon an awareness of these e a r l i e r experiences o f the patient.  The medical m o c i a l worker does not attempt  to go  yond these l e v e l s of treatment, as the problem o f working  bewith-  (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 o f  e a r l y p e r s o n a l i t y formation, v i c e s of a q u a l i f i e d The not  i s a t a s k which c a l l s f o r the s e r -  psychiatrist.  s o c i a l worker i n working with the p a t i e n t , is' of  bound by any  p a r t i c u l a r type of case work treatment.  four l e v e l s are i n t e r c h a n g e a b l e , adjustment of the i n d i v i d u a l .  depending upon the  not  ure.  The  need  be a b l e to face what i s  being s a i d to them, and w i l l e i t h e r draw upon another o r e l s e break down completely  All  emotional  Even though p a t i e n t s may  p s y c h o l o g i c a l h e l p badly, they may  defences  course,  set o f  because o f this, expos-  s o c i a l worker c o n s c i o u s l y seeks to determine, through  accurate d i a g n o s i s , the degree o f h e l p which a p a t i e n t can at a given i n t e r v i e w . and  understood,  defences therapy.  and  As the p a t i e n t i s a b l e to f e e l  he w i l l  thereby  use  accepted  be able to g i v e up more and more o f h i s  p r o f i t from a more i n t e n s i v e l e v e l o f  Case work i s a g r a d u a l , s e n s i t i v e , p u r p o s e f u l ,  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  l e v e l of o p e r a t i o n and  b r i n g him to the h i g h e s t l e v e l o f ad-  justment o f which he  i s capable.  own  T h e r e f o r e , by " h e l p i n g the  c l i e n t to h e l p h i m s e l f " , 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 o f case work s e r v i c e s i s made. The m a j o r i t y o f the p a t i e n t s examined i n t h i s study, cated s t r o n g dependency f e e l i n g s .  Even under normal  stances, the extent to which the e s s e n t i a l l y - i m m a t u r e can p r o f i t by case work, i s l i m i t e d , f o r with RHD ;  indi-  circumperson  patients  there i s the added c o m p l i c a t i o n o f p h y s i c a l d e t e r i o r a t i o n to overcome.  I t i s not  s u r p r i s i n g , t h e r e f o r e , t h a t the most  (43)  important l e v e l o f case work h e l p which can be best u t i l i z e d the RHD  p a t i e n t , i s t h a t o f environmental m a n i p u l a t i o n .  by  Psy-  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 can be g i v e n mainly i n a i d i n g the acceptance  of a change i n the environment.  i n g of i n s i g h t to an RHD  p a t i e n t who  The  must remain dependent  cause of h i s p h y s i c a l handicap and who  has l i t t l e  givbe-  inner streng-  t h to use, i s of d o u b t f u l v a l u e , however. The w r i t e r has a l r e a d y p o i n t e d out how  damaging environmen-  1  t a l p r e s s u r e s can be to the RHD  patient.  The s o c i a l worker  must u t i l i z e those a v a i l a b l e r e s o u r c e s which e x i s t w i t h i n the h o s p i t a l and the community at l a r g e , i n order to ease pressures.  these  The a m e l i o r a t i o n o f these problems o f f i n a n c i a l  a i d , employment, housing, e t c . , i s p r i m a r i l y a s o c i a l , r a t h e r than a m e d i c a l r e s p o n s i b i l i t y .  I t i s not unusual, t h e r e f o r e ,  to expect, the community, o f which the p a t i e n t i s a member and i n which these s o c i a l problems e x i s t , to c r e a t e w e l f a r e s e r v i c e s which would combat t h i s s o c i a l dilemma.  I n the  unique  set-up of a v e t e r a n s ' h o s p i t a l , however, the bulk o f these necessary s e r v i c e s are a v a i l a b l e through the g e n e r o s i t y o f f e d e r a l l e g i s l a t i o n for veterans.  Pensions, and war  veterans'  allowances, plus v a r i o u s o t h e r funds such as the "Army Benevo l e n t /Fund", o f f e r p a r t i a l s o l u t i o n 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 s e l e c t e d job  placements.  .Convalescent homes, such as the George Durby H e a l t h and 1 See Chapter  2.  (44)  O c c u p a t i o n a l Centre,  (G.D.H. & 0.), provide an adequate s u b s t i -  tute f o r the inadequate  type o f housing and d i e t to which the  RHD p a t i e n t i s o f t e n f o r c e d to r e t u r n . more-adequate housing, The  can be arranged  Even h e l p i n f i n d i n g f o r the v e t e r a n .  s o c i a l worker r e c o g n i z e s the s p e c i a l r o l e which the  w e l f a r e o f f i c e r p l a y s i n making a v a i l a b l e these r e s o u r c e s , f o r he i s a l s o a v i t a l member o f the treatment  team.  However,  a v a i l a b i l i t y o f these r e s o u r c e s does hot n e c e s s a r i l y mean t h a t adequate use w i l l be made o f them. a c c e p t i n g environmental ker i s equiped  How.a p a t i e n t f e e l s about  a i d i s something which the s o c i a l wor-  to handle.  F o r example, i t has been p o i n t e d  out that the RHD p a t i e n t i s one who attempts to cover up h i s s t r o n g dependency needs by an e q u a l l y s t r o n g independent d r i v e . By a c c e p t i n g h e l p , he may be a d m i t t i n g f a i l u r e to become i n d e pendent.  I n order to keep up h i s defenses, he may then p r o j e c t  the cause o f h i s inadequacy on to h i s environment, and thereby become overdemanding o f h i s b a s i c r i g h t s as a c i t i z e n , d r as a war v e t e r a n .  The problem o f " 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 p l a y  i n t o the p a t i e n t ' s b a s i c dependency d r i v e s , so t h a t the s t r o n g er i s h i s need to keep up h i s defenses, h i s recovery.  the more d i f f i c u l t i s  As one p a t i e n t so a p t l y phrased  i t "Well, i t  1 I n p r o v i d i n g a system o f pensions, the government has not only developed a f a i r means o f compensating those handicapped, who, because o f war s e r v i c e , cannot compete on the labour market, but has a l s o c r e a t e d a dilemma. Many veterans have sought a s o l u t i o n from t h e i r p e r s o n a l inadequacies by c o n s c i o u s l y or u n c o n s c i o u s l y c l i n g i n g to o r i n c r e a s i n g p h y s i c a l handicaps, as an " a c c e p t a b l e " way o f s o l v i n g t h e i r f i n a n c i a l i n s e c u r i t y . . T h i s m a n i p u l a t i o n o f v e t e r a n l e g i s l a t u r e by the v e t e r a n , has become known as p e n s i o n i t i s w i t h i n the department of v e t e r a n s ' a f f a i r s .  (45)  sure i s n ' t my The Use One  f a u l t I'm  sick, i s i t ? "  of Environmental  Manipulation  of the s o c i a l -worker's s k i l l s  p a t i e n t to accept resources.  The  then, i s t h a t o f p r e p a r i n g  a  and make adequate use o f h i s environmental  y  f o l l o w i n g 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 who  i s unable to p r o f i t  by more i n t e n s i v e therapy, because o f  the deep-rooted emotional p a t t e r n o f h i s The  patient  illness.  case i s that o f a 5 7 - y e a r - o l d v e t e r a n who  to m e d i c a l s o c i a l s e r v i c e because he was  was  referred  d e s t i t u t e and  d i d not  have f r i e n d s o f f a m i l y w i t h i n the c i t y area who  could  him.  background  An  " i n v e s t i g a t i o x i ' of the p a t i e n t ' s s o c i a l  f i n a n c e s , e t c . , " was t i e n t was  requested.  A l s o , the doctor  care f o r  f e l t the  showing too much o p p o s i t i o n to placement under per-  manent d o m i c i l i a r y c a r e . p a t i e n t s , he  Following  the u s u a l p a t t e r n of  l e f t home at an e a r l y age  o f employment to another.  and moved from one  There i s an i n d i c a t i o n o f a  emotional dependency upon a m o t h e r - f i g u r e , o f an  an a l t o g e t h e r unhappy e x i s t e n c e . a c t i v i t y , was  halted temporarily  r e a l i z e d he  c o u l d no  H i s constant  RHD type  strong  incompatible  marriage r e s u l t i n g i n d e s e r t i o n , o f impetuous d e c i s i o n s  When he  pa-  and  d r i v e for  by repeated a t t a c k s o f  RHD.  longer compete on the labour mar-  ket, he turned' to r e l i g i o u s f a n a t i c i s m as a means o f s o l v i n g his  problems.  as he had The ing  He  would d r i v e h i m s e l f  unmercifully  i n phantasy  done i n r e a l i t y .  f i r s t i n t e r v i e w w i t h the p a t i e n t was  devoted to b u i l d -  up a h e l p f u l r e l a t i o n s h i p .  • i <•  P a t i e n t appeared f r i g h t e n e d and  hostile.  He  said,  (46)  "I have no p l a n s . What I want to know i s , what i s a l l t h i s going to- cost me....It c o s t s me f o r t y d o l l a r s every month I am i n h e r e . " Worker s a i d she would check, but that she thought treatment was not c o s t i n g him a n y t h i n g . . . , t h a t he had a pension and was on war v e t e r a n s ' allowance and was thereby enr t i t l e d to treatment... .He s a i d the doctor would be p u t t i n g him out o f the h o s p i t a l soon because he t a l k e d too much. Worker s a i d she was sure he would not be discharged u n t i l he was b e t t e r ; He seemed somewhat r e a s s u r e d . Here we  see the worker p i c k i n g up the p a t i e n t ' s ambivalent  dependency-independency c o n f l i c t . ing  He  i s at f i r s t  very demand-  and accusatory as he i n d i c a t e s h i s d e s i r e to get out of  hospital.  L a t e r , as he f e e l s the warm acceptance  the  o f the worker,  he i s a b l e to express h i s f e a r of being abandoned and the underl y i n g need f o r c a r e .  The worker f o l l o w s up by a s s u r i n g him,  ...there was n o t h i n g 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 t a l k e d t h i n g s over she might be a b l e to h e l p him i n d e c i d i n g what he wanted to do. The p a t i e n t s a i d he d i d n ' t want to decide i n a hurry. The worker s a i d t h a t 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 c o u l d stay w i t h t h a t s i s t e r . . . . H e s a i d e r n e s t l y , t h a t , t h a t 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 o f 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 l o o k a f t e r the f u r n a c e . He would l i k e t o go back there a f t e r he was d i s c h a r g e d , u n t i l he c o u l d stand on h i s own f e e t again....The worker asked i f he would l i k e us to w r i t e to h i s s i s t e r . . . . H e s a i d he would l i k e t h a t very much. The of  p a t i e n t had p r e v i o u s l y been t o l d by the d o c t o r i n charge  the case, t h a t he c o u l d be t r a n s f e r r e d to one o f the c o n v a l -  escent c e n t r e s f o r permanent r e s i d e n c e i f he  so d e s i r e d .  d i r e c t appeal to the p a t i e n t ' s dependency needs, met opposition.  w i t h much  The manner i n which the worker e x p l o r e s the  b i l i t y of another  r e s o u r c e i s worth n o t i n g .  p a t i e n t to b r i n g out h i s own  She  p l a n s , r a t h e r than  This  possi-  allows the 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 t o h e l p the p a t i e n t i n working out h i s problem a t h i s own pace.  P o s s i b l y she might have encouraged the p a t i e n t to  w r i t e h i s own l e t t e r , as t h i s would have c o n t r i b u t e d t o h i s f e e l i n g o f independence. mission ing  before  However, she a t l e a s t asks h i s per-  contacting his s i s t e r .  Too o f t e n , a well-mean-  person may f u r t h e r antagonize such a p a t i e n t , by doing  t h i n g s f o r 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 p l a n .  It  i s not uncommon to see a p a t i e n t o f t h i s type, whose independent d r i v e s a r e so g r e a t , o f f e r p a s s i v e r e s i s t a n c e to any plans which a r e thereby made f o r him. Since  the doctor  i s the head o f the treatment team, the  worker c o n f e r r e d w i t h him about the f e a s i b i l i t y o f the p a t i e n t ' s wishes.  Because o f the d o c t o r ' s  knowledge o f the extent  o f the'  p a t i e n t ' s p h y s i c a l handicap, he vetoed any p l a n whereby the pat i e n t would have to tend t o the furnace,  but f e l t the p a t i e n t  could care f o r h i m s e l f i n t h e home d u r i n g any absence o f h i s sister.  The p o s s i b i l i t y o f a nurse from the Volunteer  of Nurses v i s i t i n g him r e g u l a r l y , was a l s o  suggested.  A l e t t e r was then sent to the p a t i e n t ' s s i s t e r his  Order  explaining  d e s i r e t o be w i t h her and a l s o p o i n t i n g out the l i m i t a t i o n s  which the doctor had suggested.  The p a t i e n t responded r a p i d l y  to h o s p i t a l treatment f o l l o w i n g the i n i t i a l  i n t e r v i e w w i t h the  worker, whereas before, he d i d n o t appear to have any d e s i r e to get w e l l .  In a later  interview,  The worker s a i d we had w r i t t e n to h i s s i s t e r , and h i s face l i g h t e d up as he s a i d , "have you heard from h e r . . . t h a t ' 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 to Vancouver to p i c k him m a n i p u l a t i o n was  up.  performed  the p a t i e n t ' s s i s t e r came  Another phase o f  environmental  by the worker, as she a p p r a i s e d the  a b i l i t y o f the p a t i e n t ' s s i s t e r to meet h i s needs f o r care and a l s o helped her to understand  It is in  what these needs were.  t h i s i n t e r v i e w w i t h the p a t i e n t ' s s i s t e r , t h a t some  understand-  i n g of the p a t i e n t ' s m o t i v a t i o n to l i v e with her, a l s o  appears.  The worker makes t h i s comment. She appeared a competent and r e s p o n s i b l e person, able and w i l l i n g to make arrangements f o r her brother, and most anxious to have a chance to l o o k a f t e r him. She gave worker the impression t h a t 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 a t times. I t would seem t h a t the p a t i e n t has t r a n s f e r r e d h i s u n c o n s c i ous dependency f e e l i n g s f o r a mother-figure on to h i s s i s t e r , and i s a b l e to f i n d  satisfaction  f o r these needs here.  I n summary, the case presented, i s an example o f a p a t i e n t who  c o u l d not p r o f i t  culties.  by any  insight into his personality  diffi-  The worker i s a b l e to c o n t r i b u t e to a more-rapid  and  n a t u r a l r e c o v e r y o f the p a t i e n t by m a n i p u l a t i n g the environmenti . e . f i n d i n g a s u i t a b l e home f o r him,-yet a t the same time c o n s i d e r a t i o n i s g i v e n to the p a t i e n t , i n determining how need i s met.  An understanding of human behaviour and an  i t y t o meet t h i s i n d i v i d u a l at h i s own the keynote o f t h i s success.  full this  abil-  l e v e l of operation,  was  A p e r f u n c t o r y placement i n the  convalescent home, might e a s i l y have prolonged  the  illness  s t a t e , and proved more damaging to the p a t i e n t and more expens i v e t o the h o s p i t a l i n the l o n g run. found which was  However, a s o l u t i o n  s a t i s f a c t o r y to a l l concerned.  was  (49)  The Use  of P s y c h o l o g i c a l Support and  Although the w r i t e r has p a t i e n t s a f f e c t e d by RHD, ment i s u s u a l l y one  Clarification  suggested that f o r c h r o n i c a l l y  the m o r e - a p p l i c a b l e l e v e l o f t r e a t -  of environmental m a n i p u l a t i o n ,  a l s o f e e l s , t h a t w i t h c a r e f u l and  c l a r i f i c a t i o n can  w i t h RHD  patients.  For t h i s reason the  t i o n has  been i n c l u d e d  case was who  to show what can  had  a c c e s s to s k i l l e d  The  patient, a 52-year-old  had  two  c h i l d r e n , and  two-room s u i t e which was  be done under n e a r - i d e a l being conducted,  veteran,  He  was  s i t u a t e d on the t h i r d f l o o r , o f a The  doctor on the  case i n -  " i n an advanced s t a t e o f RHD" "unsuitable  for  with RHD  c a r r i e d on reasonably w e l l u n t i l  He  began to n o t i c e t h a t he was  strenuous work w i t h which he had  1 See  was  and  pp.  during  the  (42-43).  e a r l y war  eventually  while  f o r c e s , and  i n 1939,  and pa-  condition".  p a t i e n t developed rheumatic f e v e r i n 1919,  in'1922.  married  been l i v i n g i n a  i n g with the I m p e r i a l  when he  the  r e f e r r e d f o r case  home c o n d i t i o n s .  pointed'out that h i s present housing was i n view o f h i s  was  a l l four o f them had  d i c a t e d t h a t the p a t i e n t was  The  illustra-  supervision.  d i l a p i d a t e d h o t e l , i n a slum a r e a .  tient  f o l l o w i n g case  being c a r r i e d a c t i v e l y by a s o c i a l work student  work because o f h i s u n s u i t a b l e and  writer  be used advantageously  At the time t h i s study was  still  the  1  s k i l l f u l management, psycho-  l o g i c a l support and  conditions.  ill  discharged  unable to continue  been accustomed.  serv-  He  1935, the married  years, maintained economic  (50) stability. second  However, by 1944,  s h o r t l y a f t e r the b i r t h of h i s  c h i l d , and a t a time when f i n a n c i a l p r e s s u r e s began t o  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  n e c e s s i t y o f f i n d i n g adequate housing before the p a t i e n t c o u l d be d i s c h a r g e d ( i . e . environmental m a n i p u l a t i o n ) . one of the w e l f a r e o f f i c e r s was  e n l i s t e d , and a l t h o u g h s e v e r a l  arrangements were presented to the p a t i e n t , i t was to  The a i d o f  the worker t h a t i f r e h a b i l i t a t i o n was  soon obvious  to take p l a c e much  case work would have to be done, not o n l y w i t h the p a t i e n t , but with h i s w i f e as w e l l .  The  p a t i e n t and h i s f a m i l y were w e l l  known to v a r i o u s w e l f a r e a g e n c i e s i n the c i t y ,  and i t was  from  these r e s o u r c e s t h a t the worker l e a r n e d o f a more Important tor  i n the p a t i e n t ' s i l l n e s s - t h a t of a domineering  appeared  t o be r e j e c t i n g o f her husband.  T h i s was  wife,  facwho  verified in  subsequent c o n t a c t s w i t h the w i f e , although the p a t i e n t was able t o c r i t i c i z e her when'he f i r s t t i o n w i t h the worker.  Case work was  d i s c u s s e d h i s home s i t u a then d i r e c t e d a t p r o v i d i n g  emotional support to an i n d i v i d u a l who i n g s o f inadequacy",  not  had overwhelming  "feel-  which c e n t r e d around h i s . i n a b i l i t y to  m a i n t a i n h i s r o l e as head o f h i s household. the dominant f a c t o r here, i t was  S i n c e the wife  was  a l s o intended that a m o d i f i c a -  t i o n o f her a t t i t u d e s t o her husband and h i s i l l n e s s , would a l s o be attempted. , The  first  few  i n t e r v i e w s were focussed on e s t a b l i s h i n g a  good r e l a t i o n s h i p between the p a t i e n t and the worker, so t h a t the p a t i e n t would f e e l f r e e enough t o d i s c u s s h i s p e r s o n a l •difficulties.  Only a s u p e r f i c i a l r e l a t i o n s h i p r e s u l t e d ,  (51)  however^  I t was  noted a f t e r .3 weeks o f b r i e f but r e g u l a r con-  tacts that, The p a t i e n t i s now w i l l i n g enough to d i s c u s s h i s f a m i l y but u n w i l l i n g or unable to look a t h i s own position.in i t . He f e e l s he has b e e n r a t h e r hard done by, as f a r as v a r i o u s government agencies are concerned, and he does not f e e l t h a t t h e r e i s a chance of anything improving, as f a r as l i v i n g or economic c o n d i t i o n s a r e concerned. F o l l o w i n g a r e j e c t i o n by the p a t i e n t and h i s w i f e o f another housing p l a n a week l a t e r , a c o n s u l t a t i o n was members of the treatment and  s o c i a l worker).  team, (the doctor, w e l f a r e  I t was  not  been ready f o r  s e t t i n g f o r some time now.  damaging i n f l u e n c e of the p a t i e n t ' s w i f e was conference  officer,  f e l t t h a t the p a t i e n t was  showing any progress p h y s i c a l l y , although he had d i s c h a r g e to a convalescent  h e l d by  by the worker, and i t was  presented to the  decided t h a t u n t i l  time as the wife c o u l d be more c o - o p e r a t i v e and her husband, he should be t r a n s f e r r e d to the  The  such  accepting of  convalescent  ward ( C l a s s 6) where he would be g i v e n d o m i c i l i a r y c a r e . was  agreed  t h a t the s o c i a l worker would prepare  for this transfer,  ( i . e . environmental  It  the p a t i e n t  manipulation).  At f i r s t the p a t i e n t seemed q u i t e agreeable  to t h i s sug-  gestion. The p a t i e n t was seen d a i l y and C l a s s 6 ( d o m i c i l i a r y care) d i s c u s s e d . He appeared to accept t h i s q u i t e r e a d i l y and f i n a l l y s t a t e d . . . t h a t he and h i s wife probably would have separated anyway, due to what he regards as her mismanagement of any income and a l s o because he does not p a r t i c u l a r l y care f o r the type o f company t h a t she keeps....The p a t i e n t ' s w i f e appeared q u i t e pleased t h a t her husband had decided to s t a y . The  beginning o f the p a t i e n t ' s e x p r e s s i o n o f h o s t i l i t y  wards h i s w i f e appeared h e r e . . He was  still  unable  to see  to-  (52)  h i m s e l f as being r e s p o n s i b l e  f o r h i s predicament and  to p r o j e c t t h i s blame, although now person from which he has needs.  As  was  rejection.  evident  d i r e c t e d a t the  one  sought s a t i s f a c t i o n f o r h i s dependent  expected, he was  h i s wife's  i t was  continued  His  soon unable to face the r e a l i t y  of  "sour grapes" defense broke down, as  i n the r e c o r d o f the f o l l o w i n g two  weeks.  He (the p a t i e n t ) began to show concern about s i g n i n g an a p p l i c a t i o n f o r C l a s s 6. He s t a t e d he had been home f o r a day and that had been enough....(He was) seen almost d a i l y i n an e f f o r t to h e l p him a d j u s t to C l a s s 6 c a r e . He has been q u i t e upset... f e e l i n g that he had been f o r c e d i n t o i t and t h a t h i s wife was t r y i n g to get r i d o f him. He r e a l i z e s t h a t the h o t e l i s not a s u i t a b l e place f o r him but f e e l s h i s w i f e w i l l not do anything to get b e t t e r accommodation f o r the f a m i l y , unless he i s a b l e to "nag her"....An e f f o r t was made to get the p a t i e n t to see the p h y s i c a l i m p o s s i b i l i t y o f h i s going back to h i s previous l i v i n g quarters....(We) d i s c u s s e d v a r i o u s ways i n which he h i m s e l f c o u l d take the i n i t i a t i v e i n making arrangements f o r f u r t h e r accommodation, such as newspaper advertisements and p e r s o n a l c o n t a c t s with r e a l estate agents. I t i s b e l i e v e d the p a t i e n t was helped by these d i s c u s s i o n s . Two  weeks l a t e r .  The p a t i e n t was q u i t e c h e e r f u l - He s t a t e d t h a t he was doing quite w e l l now and f i n d s he i s a b l e to get around town a l o t more than he was at home....The pat i e n t now seems much happier i n the E x t e n s i o n , and i s being encouraged to =take the i n i t i a t i v e w i t h regard to h i s pension a p p l i c a t i o n and housing problem. _ In s p i t e o f e f f o r t s to work with the p a t i e n t ' s , w i f e , r e s i s t e d and  resented  any  she  i n t e r f e r e n c e i n t o her a f f a i r s .  She  f e l t compelled to continue i n t e r v i e w s w i t h the worker and a l though at one fell  time some progress was  noted, e v e n t u a l l y  back i n t o her o l d r e j e c t i n g p a t t e r n and  she  subtly defied  any attempts to f i n d a home which would be s u i t a b l e f o r her husband.  I t was  at l e a s t , she was  noted that from a f i n a n c i a l p o i n t o f view, b e t t e r o f f having her husband under h o s p i t a l  (53)  care. D u r i n g the f o l l o w i n g f o u r months, l i t t l e e i t h e r i n the p a t i e n t or h i s w i f e .  change was  S h o r t l y a f t e r , the  had  been unable to e s t a b l i s h a pension c l a i m f o r h i s  ty,  and h i s unrest  became n o t i c e a b l e once a g a i n .  r e d to the worker by the doctor, gone another h e a r t discharge.  a t t a c k , was  Case work was  l e v e l , but a t the  end  noted, patient  disabili-  He was  refer-  because the p a t i e n t had  under-  very  upset and was  a g a i n continued  requesting  on a more i n t e n s i v e  of four weeks, the: worker had  t h i s to  say.  The p a t i e n t has been extremely"unhappy r e c e n t l y and h i s r e l a t i o n s h i p w i t h h i s wife d u r i n g her v i s i t s have not been good, a c c o r d i n g to him. T h i s has been r e f l e c t e d i n h i s a t t i t u d e towards treatment. However, i t i s f e l t t h a t he would be able to l o o k on h i s present c o n d i t i o n 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 w e l f a r e o f his family. The  case worker o r i g i n a l l y assigned  seeing the p a t i e n t and h i s wife  to t h i s case had  s e v e r a l times a week.  As  numerous c o n s u l t a t i o n s w i t h team members were i n v o l v e d . l i t t l e wonder, t h a t as the c a s e l o a d  be  favourable  improved, and  well, It is  o f the worker became too  demanding o f h i s time, a r e a l l o c a t i o n o f h i s e f f o r t s was Since the p a t i e n t ' s a b i l i t y  been  made.  to respond to case work would not  u n t i l such time as the  f a m i l y s i t u a t i o n could  s i n c e the p a t i e n t ' s w i f e d i d not  show any  be  signs  o f changing her a t t i t u d e , the worker r i g h t f u l l y devoted more time to other  p a t i e n t s who  case work s e r v i c e s . v i c e agencies,  would b e n e f i t more-readily  from  T h i s i s a common problem i n s o c i a l  ser-  where the number o f cases which an i n d i v i d u a l  1 D u r i n g a p a t i e n t ' s h o s p i t a l i z a t i o n , u s u a l l y only ten d o l l a r s i s s u b t r a c t e d from h i s war veterans' allowance.  (54)  worker i s r e q u i r e d t o c a r r y , i s beyond the reasonable l i m i t i n which minimum s e r v i c e i s expected t o produce maximum r e s u l t s . One s o l u t i o n to t h i s problem, i s t o h i r e more t r a i n e d  staff.  Where t h i s i s not p o s s i b l e , the good case worker, c a r e f u l l y determines which o f the cases he i s c a r r y i n g , can make best use of h i s s e r v i c e s i n the s h o r t e s t p e r i o d o f time.  The s k i l l s o f  a p r o f e s s i o n a l l y t r a i n e d worker, enable him to m a i n t a i n g r e a t e r accuracy o f t h e f i n a l The  selection.  case was l a t e r t r a n s f e r r e d to a female  student worker,  who, because o f the advantage o f a t r a i n i n g s e t t i n g , c o u l d devote the time necessary to i n s u r e some measure o f success. Through a three-month p e r i o d o f h e r i n t e n s i v e case work e f f o r t , there has been a g r a d u a l a m e l i o r a t i o n o f the p a t i e n t ' s c o n d i tion.  The whole process o f e s t a b l i s h i n g and m a i n t a i n i n g a  secure r e l a t i o n s h i p w i t h the p a t i e n t and e s p e c i a l l y h i s w i f e , has  been a d i f f i c u l t one, as the w i f e has continued t o s t r i k e  out a g a i n s t her husband. A g a i n , the problem o f f i n d i n g a s u i t a b l e home where the p a t i e n t might e v e n t u a l l y r e t u r n , was the long-term p l a n .  Be-  f o r e t h i s could be achieved, the immediate problem o f supporti n g the p a t i e n t and h e l p i n g him accept the demands o f the conv a l e s c e n t h o s p i t a l s e t t i n g so t h a t he c o u l d respond ment, was i n t e n d e d .  to t r e a t -  As h i s f r u s t r a t i o n moymted, the p a t i e n t  became more o f a nuisance  to h o s p i t a l s t a f f and other p a t i e n t s .  H i s p e t t y 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 t o h i s i n c r e a s e d f e e l i n g o f i n adequacy and h e l p l e s s n e s s .  G r a d u a l l y , the suppressed  i t y which was being expressed through h i s behaviour,  hostilwas  (55)  c h a n n e l l e d by the worker as she encouraged him t o express h i s f e e l i n g s and f r u s t r a t i o n s .  A t f i r s t , he p r o j e c t e d h i s h o s t i l -  i t y onto the department o f v e t e r a n s ' a f f a i r s and other  govern-  ment o f f i c i a l s , then to h i s . w i f e , and finally.,' wa's a b l e to admit h i s own r e s p o n s i b i l i t y f o r h i s problems.  One o f the ear-  l i e r i n t e r v i e w s where the p a t i e n t was beginning to respond to the acceptance  o f the worker, p o i n t s out some o f h i s b a s i c  inner c o n f l i c t s .  *~  The p a t i e n t was i n a very depressed mood - p o s s i b l y as a r e s u l t o f h i s w i f e ' s l o n g v i s i t two days before ....He asked me a n x i o u s l y i f I thought h i s wife would f i n d a s u i t e f o r them t o l i v e i n . I s a i d I had no way of knowing and what d i d he t h i n k about the s i t u a t i o n . . Here, a l l the f r u s t r a t i o n s and h o s t i l i t i e s connected with h i s long stay i n the h o s p i t a l , caused the p a t i e n t to break down and weep h e l p l e s s l y . . . . D u r i n g h i s d i s c u s s i o n he wished f o r death, "to be out o f h i s misery".... I asked him what he f e l t h i s most p r e s s i n g problem was. He s a i d i t was e v e r y t h i n g combined, t h a t he c o u l d n ' t work, he hated being h e l p l e s s - he was j u s t "worried to death". He was r a t h e r incoherent much o f the time, and I f e l t t h a t p a s s i v e acceptance o f h i s statements, together with p e r i o d i c s u p p o r t i v e comments o f a c c e p t ance, was my o n l y r e c o u r s e . . . . A t one p o i n t he s a i d t h a t he wished h i s mother were here - she would h e l p him and wouldn't " l e t a l l t h i s happen" to him....On the s u b j e c t o f h i s f a m i l y , I t r i e d to draw the patient.jout to t a l k o f them. He had never done t h i s w i t h me and I sensed t h a t i t gave him some comfort t o do so. He t o l d me they had been a happy f a m i l y , s a y i n g t h a t he guessed t h a t was why none o f them had married e a r l y . . . . I s a i d "and you haven't been married long e i t h e r " . He r e p l i e d , "No, I waited a l o n g time" - pause, and then, " I o n l y married f o r a home anyway - and l o o k at me now"....As he t a l k e d o f h i s parents and c h i l d h o o d i n England, t h e p a t i e n t began t o be a l i t t l e l e s s tense, stopped c r y i n g and began to d i s c u s s h i s problems i n a more "matter o f f a c t " way. As  the worker was a l s o a b l e to h e l p the p a t i e n t ' s w i f e ex-  press her h o s t i l i t y , o n i z i n g her husband.  the w i f e was a b l e to r e f r a i n from  antag-  The worker's e f f o r t a t environmental  m a n i p u l a t i o n f o r the w e l f a r e o f t h e p a t i e n t a l s o  extended  (56)  toward a d j u s t i n g ances c o u l d  the h o s p i t a l s e t t i n g , so t h a t r e a l i s t i c  be avoided.  The p a t i e n t had become very  annoy-  attached  to the use o f a wheel c h a i r and when t h i s was taken away from him  by a new i n t e r n e on the ward, the p a t i e n t  became upset.  Although he used the wheel c h a i r s p a r i n g l y , t h i s sudden l o s s o f t h i s symbol o f s e c u r i t y , made him a f r a i d to venture from h i s bed without an impending f e a r that he would c o l l a p s e .  A l s o , he  i n t e r p r e t e d the removal o f the c h a i r as a f u r t h e r i n d i c a t i o n o f h i s r e j e c t i o n by the h o s p i t a l s t a f f .  A t a meeting o f the t r e a t -  ment team, the meaning o f the c h a i r t o the p a t i e n t was e x p l a i n ed by the worker, and i t was agreed to r e t u r n t h i s to t h e patient.  H i s response was immediate and q u i t e  favourable.  Because o f some minor d i f f i c u l t i e s on the ward, which were unavoidable i n terms o f p h y s i c a l s e t t i n g and h o s p i t a l t i o n s but were n e v e r t h e l e s s  regula-  a constant source o f i r r i t a t i o n to  the p a t i e n t , arrangements were made to have him t r a n s f e r r e d to a new ward.  Following  p a t i e n t became a d j u s t e d  a b r i e f period o f regression  u n t i l the  to the new s e t t i n g , h i s response to  treatment was remarkable.  D u r i n g t h i s time, the worker con-  s t a n t l y i n t e r p r e t e d the emotional needs o f the p a t i e n t t o the s t a f f members o f the new ward, and once a g a i n i n t e r v e n e d  on  behalf o f the p a t i e n t when t h e wheel c h a i r was a g a i n removed. More-recent i n t e r v i e w s  a t the time t h i s present study was  being made, i n d i c a t e the movement which has taken p l a c e over a two-month p e r i o d . The p a t i e n t was i n an amiable mood when v i s i t e d . He t o l d me t h a t he had been a l l o w e d to use a wheel c h a i r , and had been over t o the Red Cross Lodge w i t h h i s w i f e the day before....The p a t i e n t , who had been i n a h i g h l y nervous s t a t e when l a s t v i s i t e d , was calm, c h e e r f u l and c o n v e r s a t i o n a l  today.  I asked i f  (57)  he were using the wheel c h a i r much, and he smiled and s a i d i t was very s a t i s f a c t o r y , t h a t sometimes he wheeled h i m s e l f around and at o t h e r times he pushed i t . . . . T h e p a t i e n t smiled a t me and s a i d "you helped get i t f o r me d i d n ' t you?" I smiled back and s a i d that the doctor had been concerned about h i s w e l f a r e , and had a t f i r s t thought a c h a i r might be a hindrance r a t h e r than a h e l p 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 p a t i e n t was walking around the ward w i t h the a i d o f a cane when v i s i t e d , d i s p l a y i n g more energy than I have n o t i c e d h e r e t o f o r e . I...asked i f he were f e e l i n g as w e l l as he looked. He beamed at me and s a i d , " B e t t e r t h a n I l o o k and b e t t e r than I've been f o r some time"....I asked what he thought the reason was, and he s a i d , "Oh e v e r y t h i n g - but most of a l l because I am g e t t i n g my proper sleep s i n c e I moved t o the new ward...." He s a i d t h a t he f e l t b e t t e r and s t r o n g e r than he had f o r o v e r a y e a r . Then, he added that h i s doctor had come to see him the o t h e r day and had i n d i c a t e d amazement a t how much he had improved. I s a i d t h a t I guessed Dr...would be very p l e a s e d t o see him improving, and the p a t i e n t s a i d he thought Dr...was a good doctor, and they hadn't understood each o t h e r a t f i r s t . T h i s i s the f i r s t p o s i t i v e comment he has made to me about any member o f the h o s p i t a l s t a f f . Although  the worker had  been g i v i n g mainly p s y c h o l o g i c a l  support, c l a r i f i c a t i o n o f the d o c t o r ' s i n t e r e s t i n the p a t i e n t was  g i v e n and was  a c c e p t a b l e to him a t t h i s time.  the worker d i d not i n t e r p r e t the unconscious conflict,  Note t h a t  aspects o f  this  ( i . e . , c o n f l i c t w i t h a u t h o r i t y ) , but i n s t e a d worked  w i t h i n the c o n s c i o u s framework o f the p a t i e n t ' s thought  pro-  cesses. The worker's comments on the p a t i e n t ' s progress i s a good i n d i c a t i o n o f the movement which has taken p l a c e . R e l i e f of environmental pressures have caused this' p a t i e n t to f e e l t h a t the h o s p i t a l team i s work i n g f o r h i s w e l f a r e , w i t h a consequent improvement i n h i s r e l a t i o n s h i p w i t h h i s d o c t o r and the nursing s t a f f . I n addition,, h i s r e l a t i o n s h i p w i t h  (58)  the worker appears to be deeper than h e r e t o f o r e , and he has been a b l e to express more o f h i s h o s t i l i t y t o wards h i s w i f e and h i s a n x i e t y r e g a r d i n g h i s c h i l dren....! f e l t i n t h i s i n t e r v i e w , t h a t . t h e r e l a t i o n ship was developing to the p o i n t where the p a t i e n t c o u l d not o n l y express some o f h i s h o s t i l i t y towards h i s w i f e , but c o u l d accept h e l p i n g a i n i n g i n s i g h t i n t o h i s own behaviour. He seemed very r e c e p t i v e to comments concerning h i s a t t i t u d e towards the m a r i t a l situation. There i s s t i l l much case work to be done before the  pa-  t i e n t and h i s w i f e can ever come together i n t h e i r own home,, Because o f h i s d e t e r i o r a t e d p h y s i c a l c o n d i t i o n and the  diffi-  c u l t y o f f i n d i n g a s u i t a b l e home w i t h i n t h e i r f i n a n c i a l means, t h i s may  never  take p l a c e .  a member o f the treatment  The value o f the s o c i a l worker as team has been shown however, i n the  g r a d u a l p h y s i c a l improvement of the p a t i e n t , which went hand i n hand w i t h the a l l e v i a t i o n o f h i s emotional s t r e s s .  Their  is  case  little  doubt t h a t s k i l l f u l use has been made o f the  work techniques o f p s y c h o l o g i c a l support and  clarification,  i n b r i n g i n g about some b e n e f i c i a l environmental  changes f o r  the p a t i e n t . The m a t e r i a l of t h i s chapter i n d i c a t e s how ker, as a member o f the h o s p i t a l treatment his  p r o f e s s i o n a l case work s k i l l  the s o c i a l wor-  team, can  utilize  to a l l e v i a t e the s o c i a l  emotional problems of the p a t i e n t with RHD. and p r e c e d i n g chapters, r e f e r e n c e has  and  Throughout t h i s  been made to the  way  RHD  p a t i e n t s are a f f e c t e d by the members of t h e i r  families.  How  these p a t i e n t s i n t u r n 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 f u r t h e r s t r e s s e s and s t r a i n s , w i l l be d i s c u s s e d i n the f o l l o w i n g area o f p r e s e n t a tion.  CHAPTER 4 FAMILY IMPLICATIONS P r e v i o u s l y , i n d i s c u s s i n g adequate care f o r the RHD tient's illness, s o c i a l and  s t r e s s has  been placed on the treatment o f h i s  emotional problems.  Since  forms a v i t a l r o l e i n the c r e a t i o n and difficulties,  the p a t i e n t ' s f a m i l y prolongation  s o c i a l and  By  g a i n i n g some r e l i e f  emotional s t r e s s e s and  then b e t t e r a b l e to a i d the p a t i e n t i n h i s The  per-  of h i s  the s o c i a l worker must t r e a t the members o f  f a m i l y , as w e l l as the p a t i e n t . t h e i r own  pa-  this  from  s t r a i n s , they a r e recovery.  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 , although s e n s i -  t i v e to the need f o r case work s e r v i c e s to f a m i l i e s o f RHD t i e n t s , as a r u l e , has  a l i m i t e d r o l e to play i n the  ance o f these s e r v i c e s . welfare,  perform-  S p e c i a l i z e d agencies such as f a m i l y  children's a i d , public welfare,  s p e c i f i c a l l y created  pa-  e t c . , which have been  to a l l e v i a t e the s o c i a l and  emotional  problems e x i s t i n g w i t h i n t h a t broad area known as the  commun-  i t y , are b e t t e r equiped to meet the v a r y i n g needs o f family  mem-  1 bers.  In t h i s sense, the m e d i c a l  s o c i a l worker i s not o n l y a  member of the h o s p i t a l team, but i s a l s o p a r t o f the welfare  team w i t h i n the community.  J u s t as he  i s expected to  t r e a t the v a r y i n g a s p e c t s o f p h y s i c a l i l l n e s s , he aware o f the  1 The  i s also  s p e c i a l i z e d s k i l l s of p a r t i c u l a r welfare  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  social  agencies  emotional problems which  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 .  can  (60)  occur.  J u s t as a c o - o r d i n a t i o n o f the e f f o r t s o f the treatment  team i n the h o s p i t a l i s necessary, s i m i l a r c o - o r d i n a t i o n o f a l l the community w e l f a r e s e r v i c e s i s a l s o v i t a l .  The m e d i c a l so-  c i a l worker, then, can c a l l upon and i s c a l l e d upon by o t h e r s o c i a l agencies to a c t j o i n t l y i n promoting t i e n t s and t h e i r  the w e l f a r e o f pa-  families.  Although i t has been p o s s i b l e to formulate one g e n e r a l p e r sonal and s o c i a l p r o f i l e i n t o which most RHD p a t i e n t s f i t , i t has not been p o s s i b l e from the r e s u l t s o f t h i s study, t o d r a f t a s i m i l a r type o f p r o f i l e f o r members o f the p a t i e n t ' s f a m i l y . The reason f o r t h i s , i s f e l t to be due to the more-varied  indi-  v i d u a l d i f f e r e n c e s which a r e c h a r a c t e r i s t i c o f any f a m i l y constellation.  Very g e n e r a l areas o f s i m i l a r i t y w i l l  be p o i n t e d  out where p o s s i b l e , but as a r u l e , each f a m i l y member must be e v a l u a t e d on an i n d i v i d u a l b a s i s and treatment planned a c c o r dingly. The E f f e c t on Parents and S i b l i n g s At l e a s t one case r e v e a l s the c o m p l i c a t i n g e f f e c t which a dominating mother can have on her son's w e l f a r e . old cial  A  28-year-  s i n g l e v e t e r a n was r e f e r r e d by h i s d o c t o r to m e d i c a l sos e r v i c e f o r 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 i n d i c a t e d that the p a t i e n t ' s f a t h e r was dead, and t h a t although the p a t i e n t was the second o f f o u r s i b l i n g s , he was the sole f i n a n c i a l supporter o f h i s mother. c o n s i d e r a b l y about  t h i s , and complained  He w o r r i e d  that the o n l y f u t u r e  he saw f o r h i m s e l f , was the unhappy one o f having to m a i n t a i n her f o r the r e s t of h i s l i f e .  (61)  When f i r s t ingness  by t h e w o r k e r ,  the p a t i e n t  the p a t i e n t ' s mother r e f u s e d  will-  some s o l u t i o n ,  to a c c e p t h e l p , m a i n t a i n -  " t h e y would 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 " .  m o t h e r was  d e s c r i b e d by t h e w o r k e r a s  The p a t i e n t erratic  fluctuated  hostile  for him.  to oppose  r e v o l v e d around a request  that  RHD.  everyone  A t one t i m e ,  i t was  except her.  H e r demands  f o r an a d d i t i o n a l p e n s i o n f o r  d i s a b i l i t y which would provide f o r her as w e l l ,  fact  from  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 mother c r e a t e d  son's  suffered  between w i l l i n g n e s s to a c c e p t h e l p and  behaviour,  ed t h a t he was a b l e  The  being a "domineering un-  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  the  expressed  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  however, ing,  seen  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  not-  her  despite  assistance  elsewhere. P a r t of her income, a widow's the  department  eventually  of veterans'  affairs.  d y i n g from a heart  during his service  p e n s i o n , was b e i n g p a i d by  ailment, developed  i n the f i r s t w o r l d war,  for  this.  ity  between the n e u r o t i c  assumed h i s f a t h e r ' s  also developed.  pensioned  son!s  financially  illness. responsible  complained  The p a t i e n t h a d ' so effect,  She e n c o u r a g e d  d i r e c t l y affected  the  T h r o u g h h e r demands t h a t he a l o n e for her,  despite  o t h e r c h i l d r e n who m i g h t s h a r e attachment  father  t h a t he h a d , i n  r o l e w i t h the mother.  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  neurotic  neurasthenia  a n d was  symptoms o f w h i c h t h e  identified himself with his father,  three  although  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 -  and t h o s e w h i c h the p a t i e n t  of her  Her husband,  to her  the f a c t  that  this course  be  she h a d  this responsibility,  s o n became e v i d e n t .  Meanwhile,  her his  (62)  i l l n e s s and  h i s r e s u l t i n g pension, provided  a n c i a l s e c u r i t y to which she had Since  she  the  source of  fin-  long been accustomed.  c o n s i s t e n t l y d e f i e d a l l o f f e r s of case work and  p s y c h i a t r i c a i d , i t was  not  p o s s i b l e to help her son.  A psy-  c h i a t r i c r e p o r t on the p a t i e n t four months l a t e r , p o i n t e d that no  r e a l improvement had  H i s tense, r e s t l e s s and ;  taken p l a c e i n h i s RHD  emotional s t a t e was  tributing factor i n his i n a b i l i t y i t was As  to r e c o v e r .  s t a t e d t h a t " h i s mother was  long as she was  felt  out  condition.  to be the  con-  Specifically,  the d i s t u r b i n g i n f l u e n c e " .  unable to r e c o g n i z e  the d e t r i m e n t a l  effect  her demands were having on the p a t i e n t , the treatment team f e l t t h a t the c o n f l i c t -created his  by h i s dependency upon her  and  i n a b i l i t y to break away, would continue to a f f e c t the  l o n g a t i o n and  exacerbation  pro-  of h i s i l l n e s s .  T h i s case a l s o h i n t s at the e f f e c t 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 o f much  i l l - f e e l i n g , and  i t i s expected t h a t a great d e a l o f t h i s  aroused by the o v e r - a t t e n t i o n which the mother may to the p a t i e n t i n preference  have  was given  to her other c h i l d r e n .  Other cases d i d not r e v e a l so s t r i k i n g a r e l a t i o n s h i p between family members as t h i s one.  Since  the remainder of  s e l e c t e d cases were of o l d e r m a r r i e d veterans, appeared about parents and patient f e l t  towards them.  to t h e i r parents,  comment  s i b l i n g s except to express how The  f a c t t h a t RHD  u s u a l l y a f t e r the p a t i e n t s l e f t home, and returned  little  was  the  acquired  only i n r a r e  cases  accounts i n part f o r t h i s l a c k o f  information. Only one  the  other r e c o r d contained  sufficient  information  (63)  which would  b r i n g out s i b l i n g r e l a t i o n s h i p s , and t h i s has a l -  ready been d i s c u s s e d more f u l l y e l s e w h e r e . was  the s t r o n g e r bond which was  1  Of importance here,  formed between a p a t i e n t and h i s  s i s t e r as a r e s u l t o f h i s i l l n e s s .  Her d e s i r e "to mother" him,  was a c h i e v e d at a time when her brother was  finally  prepared t o  accept her h o s p i t a l i t y . The E f f e c t On Marriage P a r t n e r s Depending  upon the e x p e c t a t i o n s which wives o f RHD  seek i n t h e i r marriage, a v a r i e t y o f responses to t h e i r band's i l l n e s s can d e v e l o p . sentment  patients hus-  On the whole, f r u s t r a t i o n and r e -  appeared to be the more common responses i n at l e a s t  14 out of the twenty cases c o n t a i n i n g such i n f o r m a t i o n .  Al-  though data as to the cause o f t h e i r unhappiness, does not appear c o n s i s t e n t l y enough to i n d i c a t e s t a t i s t i c a l  comparisons,  i t was noted that many complained o f f i n a n c i a l inadequacy  and  the r e s u l t i n g p o v e r t y - s t r i c k e n c o n d i t i o n s w i t h which they were f o r c e d to contend.  Several s p e c i f i c a l l y  s t a t e d 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, e t c . , that s e x u a l r e l a t i o n s h i p s were poor and t h a t they no longer c o u l d continue to l i v e "as man as nurse and p a t i e n t " .  and w i f e , but r a t h e r  Although many complained about  envir-  onmental c o n d i t i o n s , a few o f them appeared q u i t e content t o care f o r t h e i r husband  - i n f a c t t h e i r marriage seemed to be  h e l d together by the changing s i t u a t i o n o f i l l n e s s .  1 See pp.  (45-48), i n Chapter 3.  (64)  Case Examples o f M a r i t a l  Difficulties  (!) Sexual I n c o m p a t i b i l i t y - One wife became i n c r e a s i n g l y concerned  about her 3 5 - y e a r - o l d husband's a t t i t u d e and s t a t e o f  mind, because o f h i s prolonged h o s p i t a l i z a t i o n s .  A t f i r s t she  gave the impression she was s i n c e r e l y i n t e r e s t e d i n h i s w e l f a r e , as she tended t o s p o i l and o v e r p r o t e c t him. Arrangements were made f o r her by the s o c i a l worker, to t a l k with the p a t i e n t ' s d o c t o r , and she was then g i v e n reassurance about her husband's condition.  When she r e t u r n e d a g a i n and a g a i n with  similar  f e a r s , some case work was g i v e n t o r e s o l v e her d i f f i c u l t i e s . She  began to complain  t h a t h e r husband was going c r a z y - t h a t  he accused h e r o f running around w i t h other men. course o f h e r treatment  During the  i t was r e v e a l e d t h a t she had l i v e d i n  common-law r e l a t i o n s h i p w i t h her husband, p r i o r to o b t a i n i n g a d i v o r c e from her f i r s t  husband.  She complained  o f poor s e x u a l  r e l a t i o n s h i p s and expressed c o n s i d e r a b l e f e e l i n g s o f g u i l t around  this.  I n t h i s sense, h e r a c c u s a t i o n s a g a i n s t her hus-  band, appeared She attempt  t o be p r o j e c t i o n s o f h e r own unconscious  responded  briefly  desires.  t o s u p p o r t i v e therapy, a l t h o u g h no  was made t o g i v e her i n s i g h t i n t o h e r b a s i c c o n f l i c t .  T h i s was s u f f i c i e n t t o make an improvement i n h e r husband's c o n d i t i o n and he was e v e n t u a l l y d i s c h a r g e d .  However, once a t  home, t h e i r m a r i t a l i n c o m p a t i b i l i t y upset the p a t i e n t , and i n a short time he r e t u r n e d t o the h o s p i t a l , where he d i e d . pected, t h e w i f e ' s g u i l t  f e e l i n g s mounted and she continued t o  r e t u r n t o the h o s p i t a l f o r h e l p with h e r problem. the deep-seated  As ex-  Because o f  appearance o f her emotional c o n f l i c t ,  were made t o r e f e r her f o r p s y c h i a t r i c treatment,  attempts  but t h i s was  (65)  c o n s i s t e n t l y r e f u s e d by her.  The worker summed up t h i s  diffi-  c u l t y with: No h e l p c o u l d be g i v e n her because o f her need "not to understand". (£) Immaturity  Versus Dependency - A second  that o f a young v e t e r a n who ture g i r l ,  example, i s  married an e q u a l l y young and imma-  s h o r t l y a f t e r he e n l i s t e d i n the s e r v i c e .  subsequently  posted overseas, developed  d i s c h a r g e d i n 194S,  - two  rheumatic  He  was  f e v e r and  years a f t e r h i s e n l i s t m e n t .  h o s p i t a l i z a t i o n s s i n c e then, were mainly a t t r i b u t e d  was  Repeated  to s e r i o u s  c o n f l i c t s with h i s w i f e . H i s was she craved.  a w i f e who  married f o r the romance and  Being even more dependent and  excitement  immature than her  husband, from the very beginning she r e f u s e d to accept her as a r e s p o n s i b l e w i f e .  While the p a t i e n t was  overseas,  she  s a t i s f i e d her needs through the a t t e n t i o n o t h e r s e r v i c e  men  role  gave her, and managed to d i s s a p a t e the savings which her husband sent her f o r safekeeping.  While the p a t i e n t was  d u r i n g the e a r l y years o f t h e i r marriage, two  hospitalized  she would abandon her  c h i l d r e n to go "bowling and dancing".  The p a t i e n t i n s i s t e d  at t h i s time t h a t he encouraged her to enjoy h e r s e l f , but i t was f e l t he was  r e a l l y unable  to oppose h e r .  F o l l o w i n g h i s t h i r d h o s p i t a l i z a t i o n i n January f a m i l y s i t u a t i o n completely erupted. f i v e c h i l d r e n to care f o r . 1948  1948,  By -this time, there were  However, i t was  not u n t i l November  and three h o s p i t a l i z a t i o n s l a t e r , t h a t the case was  red to m e d i c a l s o c i a l s e r v i c e ,  the  The p a t i e n t complained  w i f e ' s i r r e s p o n s i b i l i t y w i t h t h e i r f i n a n c e s , and  refer-  of h i s  suspected  she  (66)  was  running around w i t h o t h e r men.  C o n t a c t s w i t h her  through  the p u b l i c w e l f a r e agency i n her community, r e v e a l e d the extent of  her i r r e s p o n s i b i l i t y .  A t f i r s t , the s i t u a t i o n was  somewhat by the f e a r which the w i f e encountered s i o n of the p u b l i c w e l f a r e worker.  Two  at the  intru-  weeks l a t e r , the  t i e n t ' s w i f e l e f t him to l i v e w i t h another man, t h i s time t h a t she would d i v o r c e her husband.  pa-  and s t a t e d a t Her f a t h e r i n  the meantime, a r r i v e d from Saskatchewan and had dren with him.  eased  taken the  chil-  S h o r t l y a f t e r w a r d s , the p a t i e n t ' s w i f e changed  her mind and decided to r e t u r n to her parents' home i n Saskatchewan.  F o l l o w i n g a concentrated c o - o p e r a t i v e 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 p a t i e n t and his  w i f e were r e c o n c i l e d .  treatment  The  and a f t e r h e l p was  p a t i e n t responded  to h o s p i t a l  g i v e n i n e s t a b l i s h i n g a home f o r  them, he a l s o r e t u r n e d to Saskatchewan. No  sooner had r e c o n c i l i a t i o n taken p l a c e , when i t was  l e a r n e d t h a t the p a t i e n t r e t u r n e d ' t o the h o s p i t a l and was ing  a s e p a r a t i o n because o f h i s w i f e ' s continued  behaviour.  Again s o c i a l s e r v i c e brought  irresponsible  them t o g e t h e r , but  f o u r months l a t e r , the s i t u a t i o n became unbearable was  seek-  f o r him.  He  t r a n s f e r r e d back to Shaughnessy h o s p i t a l s h o r t l y  afterwards.  At the time t h i s study was  separated  made, the p a t i e n t was  from h i s w i f e , but continued to support h i s f a m i l y from an adequate pension f o r h i s 100 per cent d i s a b i l i t y . q u i t e happy with t h i s arrangement, s i n c e she was  She  appeared  l i v i n g with  her parents and they assumed the major share of care f o r the children. cial  Her husband's i l l n e s s has c r e a t e d f o r her the  s e c u r i t y which has been most important  to her.  finan-  I t has  (67)  a l s o meant f r u s t r a t i o n i n terms of her d e s i r e f o r romance and excitement,  however, i t i s reasonable  to expect she w i l l c o n t i n -  ue to seek s a t i s f a c t i o n f o r these needs from o t h e r  men.  The E f f e c t on C h i l d r e n The  c h i l d r e n whose parents are a f f l i c t e d w i t h c h r o n i c  nesses, are, u n f o r t u n a t e l y , the ones who run.  ill-  s u f f e r most i n the l o n g  I t i s from t h e i r e a r l y experiences i n the home that per-  s o n a l i t y p a t t e r n s emerge, and i t i s here t h a t a normal c h i l d develops a f e e l i n g of s e c u r i t y and w e l l - b e i n g .  S i n c e i t i s ex-  pected t h a t both parents must be reasonably w e l l - a d j u s t e d , phys i c a l l y , as w e l l as e m o t i o n a l l y , i f they are to c o n t r i b u t e to the w e l f a r e o f t h e i r c h i l d r e n , i t i s not u n n a t u r a l , t h e r e f o r e , to expect much t u r m o i l and i n s t a b i l i t y i n c h i l d r e n whose parents are so wrapped up i n t h e i r own  p e r s o n a l i t y c o n f l i c t s , t h a t they  can o f f e r l i t t l e to the dependent needs o f o t h e r s . The  d e t r i m e n t a l e f f e c t which a f a t h e r ' s absence c r e a t e s on  e i t h e r a son or daughter,  i s a s u b j e c t which has  been g i v e n a  great d e a l o f a t t e n t i o n by c h i l d p s y c h i a t r i s t s and o t h e r s i n terested i n child welfare.  1  S i n c e a f a t h e r with RHD  i s repeat-  edly e n t e r i n g h o s p i t a l f o r s e v e r a l months at a time, h i s peri o d i c absence from the home, c r e a t e s an unstable atmosphere for his children.  When he i s at home, h i s i l l n e s s u s u a l l y  mands the o v e r a t t e n t i o n of h i s w i f e .  Because o f h i s need f o r  r e s t and q u i e t , the c h i l d r e n a r e f o r c e d t o r e s t r i c t "natural exhuberence.  de-  their  A t the same time, i t i s not uncommon to  1 A more d e t a i l e d account o f t h i s i s g i v e n i n , E n g l i s h and Pearson, Emotional Problems of L i v i n g , pp. 91-97.  (68)  f i n d parents d i s p l a c i n g f r u s t r a t e d f e e l i n g s which i l l n e s s has c r e a t e d f o r both o f them, onto t h e i r c h i l d r e n a t t h e s l i g h t e s t provocation.  P h y s i c a l d e p r i v a t i o n , which u s u a l l y accompanies  reduced incomes o f RHD p a t i e n t s , a l s o a f f e c t s t h e i r Inadequate  children.  c l o t h i n g , d i e t and s h e l t e r , make them easy preys t o  i l l n e s s and d i s e a s e .  F i n a l l y , where f o s t e r home placements a r e  necessary, i n cases where both parents a r e unable to p r o v i d e care, i . e . through i l l n e s s o r m a r i t a l s t r i f e ,  the traumatic ex-  perience o f s e p a r a t i o n p r o v i d e s f o r t h e i r c h i l d r e n the climax f o r a t o t a l l y unfortunate beginning i n l i f e . R e c o g n i t i o n of these dangers  1  by government and p r i v a t e o r -  g a n i z a t i o n s , has l e d to t h e development o f v a s t c h i l d w e l f a r e programs to a l l e v i a t e these c o n d i t i o n s . ready  Some mention has a l -  been made o f the community r e s o u r c e s which the m e d i c a l 2  s o c i a l worker uses i n t h i s r e g a r d .  As a r u l e , d i r e c t c o n t a c t  w i t h these c h i l d r e n by the m e d i c a l s o c i a l worker i s avoided, and i n s t e a d , c o - o r d i n a t i o n o f the s e r v i c e s o f those a g e n c i e s best equiped and t r a i n e d to work with c h i l d r e n , i s attempted. Case Examples o f the E f f e c t on C h i l d r e n 3 The  f i r s t case, i s one t h a t has been d e s c r i b e d b e f o r e .  Here, both parents would r e g u l a r l y go i n t o h o s p i t a l , so t h a t f o s t e r home care f o r t h e i r 6-year-old c h i l d was needed. 1 Gordon Hamilton, Theory and P r a c t i c e o f S o c i a l Case .Work, pp. 281-83, p o i n t s out the problems encountered i n "The Sepa r a t i o n 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 c o n t a c t s with the c i t y s o c i a l s e r v i c e and the dren's a i d s o c i e t y (C.A.S.),  r e v e a l e d t h a t f i n a n c i a l a i d , as  w e l l as f o s t e r home care, had were a l s o concerned i l l n e s s on the  chil-  been g i v e n i n the p a s t .  C.A.S.  about the e f f e c t of the mother's mental  child.  .Where p o s s i b l e , c h i l d r e n are p l a c e d i n the care o f r e l a t i v e s i n preference to strange f o s t e r homes, as the  effect-of  s e p a r a t i o n i s not so great when a f a m i l i a r person i s p r e s e n t . Consequently,  C.A.S. arranged  t i e n t ' s mother-in-law.  to p l a c e the c h i l d with the  However, the p a t i e n t was  unable  pa-  to  accept t h i s p l a n , as he r e s e n t e d h i s mother-in-law f o r her many i n t e r f e r e n c e s i n t o h i s marriage. s o c i a l worker, the p a t i e n t was unreasonable  With the h e l p of the m e d i c a l  a b l e to g i v e up some o f the more-  conceptions o f h i s mother-in-law, i n view o f t h e  advantages her care c o u l d o f f e r h i s c h i l d . F o l l o w i n g the b i r t h o f a second c h i l d , the p a t i e n t again entered h o s p i t a l .  S h o r t l y a f t e r w a r d s , h i s w i f e began to show  s i g n s o f another mental breakdown. d i s c h a r g e as h i s wife was  admitted  The  p a t i e n t was  ready  for  to the mental h o s p i t a l ,  and,  i n a -state o f panic, he demanded t h a t C.A.S. p l a c e h i s c h i l d r e n immediately.  A day l a t e r , he changed h i s mind and decided to  care f o r the c h i l d r e n h i m s e l f .  A few days l a t e r , housekeeping  s e r v i c e s were o b t a i n e d through C.A.S., a f t e r the m e d i c a l worker encouraged him to u t i l i z e t h e i r When l a s t heard children.  social  services.  from;' both parents were at home w i t h  On the whole, the o l d e s t c h i l d has  of e i t h e r parent, and was  •  seen very  their little  showing i n s t a b i l i t y as a r e s u l t  .her unhappy experiences o f s e p a r a t i o n from them.  The  of  second  (70)  c h i l d has l i t t l e  to look forward t o , s i n c e i t was expected  both parents would s h o r t l y r e t u r n to the h o s p i t a l .  that  The p o s s i f  b i l i t y o f removing the c h i l d r e n to a permanent f o s t e r home, where more c o n s i s t e n t care c o u l d  be given, was being  considered.  Another case example which has a l s o been presented i n d i c a t e s s i m i l a r problems.  before,  1  Here f i v e c h i l d r e n were the v i c -  tims o f i n c o n s i s t e n t and immature parents - the f a t h e r e i t h e r being i n the army o r t h e ' h o s p i t a l most o f the time, and t h e mother abandoning them on s e v e r a l o c c a s i o n s .  I t i s not known  what was done f o r the c h i l d r e n except that c h i l d w e l f a r e c i e s have been i n v o l v e d , and presumably have provided stitute  agen-  some sub-  care.  I t i s d o u b t f u l how much can be done f o r c h i l d r e n who a r e a l ready so s e v e r e l y damaged e m o t i o n a l l y .  Two other  cases  indi-  cate the p o s s i b l e r e s u l t o f such n e g l e c t o f c h i l d r e n , as both of these r e v e a l d i f f i c u l t i e s w i t h j u v e n i l e c o u r t a u t h o r i t i e s . Case Work With F a m i l i e s One o f the few areas i n which the m e d i c a l 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 s e r v i c e s to a member  of a p a t i e n t ' s f a m i l y , i s i n h e l p i n g parents and marriage p a r t ners to understand how i l l n e s s a f f e c t s the mental o u t l o o k o f a p a t i e n t , and a l s o i n g a i n i n g some a s s i s t a n c e with t h e i r own d i f f i c u l t i e s which the p a t i e n t ' s i l l n e s s has c r e a t e d f o r them. The w r i t e r has suggested that as a r u l e , the p a r t i c u l a r communi 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  1 See pp. (65 - 67) .  s e r v i c e needed e.g. the  (71)  f a m i l y w e l f a r e bureau, would be c a l l e d upon to a i d the m e d i c a l s o c i a l worker w i t h t h i s l a t t e r t a s k . always p o s s i b l e .  I n r e a l i t y , t h i s i s not  Since t h i s study concerns i t s e l f w i t h the male  a d u l t RHD p a t i e n t , the wife o f a p a t i e n t may show a w i l l i n g n e s s to d i s c u s s her problems with the medical s o c i a l worker, under, the guise o f p r o v i d i n g i n f o r m a t i o n which w i l l h e l p the h o s p i t a l team to t r e a t her husband, but too o f t e n 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 f o r h e l p with s o c i a l and emotional problems imp l i e s a stigma, the wife may need much p r e p a r a t i o n by the medical  w o c i a l worker before she can f e e l f r e e to go elsewhere to  secure h e l p with her own problems. p. (64) i s a good example o f t h i s  The case r e f e r r e d t o on resistance.  An I l l u s t r a t i o n o f Case Work With a P a t i e n t ' s Wife The w r i t e r encountered  much d i f f i c u l t y i n p r e s e n t i n g a  f a i r example o f the k i n d o f case work which can and i s u s u a l l y g i v e n here.  I n some of the case r e c o r d s , i t i s apparent t h a t  c o n s i d e r a b l e case work had been g i v e n to p a t i e n t s ' wives and good r e s u l t s  achieved i n terms o f the p a t i e n t ' s h e a l t h .  How-  ever, i n only one case i s there s u f f i c i e n t r e c o r d i n g 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 a t the time t h i s study was made. ready  been presented i n Chapter  T h i s case has a l -  3, i n r e l a t i o n to the s o c i a l  work which can be o f f e r e d to p a t i e n t s w i t h  RHD.  1  Mention was made o f the d e t r i m e n t a l i n f l u e n c e t h i s p a t i e n t ' s  1 See pp. (49 - 58), i n Chapter  3.  (72)  w i f e had on h i s a b i l i t y and m o t i v a t i o n to get w e l l . v  worker on the case was  unable  The  to b r i n g about a n o t i c e a b l e change  i n her a t t i t u d e but subsequent c o n t a c t w i t h the second who  first  worker,  had more time to spend w i t h her, h e l p e d her to express much  o f her h o s t i l i t y which had p r e v i o u s l y been d i r e c t e d towards her husband.  A m o r e - d e t a i l e d p i c t u r e o f t h i s second  worker's  e f f o r t s i s , t h e r e f o r e , being presented at t h i s time. be noted t h a t although case work w i t h wives o f RHD  I t should  patients i s  on an environmental m a n i p u l a t i v e l e v e l i n r e l a t i o n to the t i e n t ' s treatment,  a l l f o u r l e v e l s may  b r i n g i n g about t h i s environmental  pa-  be used w i t h the wife i n  change.  I n an e a r l y i n t e r v i e w , where the worker i s a t t e m p t i n g to e s t a b l i s h a f r i e n d l y a c c e p t i n g r e l a t i o n s h i p w i t h the w i f e , couragement i s g i v e n to her which would allow her t o  en-  express  her f e e l i n g s about her husband's c o n d i t i o n . I asked, "how do you t h i n k 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 b e t t e r and he's l i k e l y to d i e at any time. I faced t h a t l o n g ago". I asked her i f she thought he should g i v e up the i d e a of ever l e a v i n g the h o s p i t a l and she s a i d very f o r c e f u l l y , "Well I haven't r e a l l y s a i d t h i s before, but I t h i n k he i s b e t t e r o f f s t a y i n g where he i s , and I t h i n k he knows i t most o f the time"....I s a i d i t was q u i t e a problem to have a husband who was unable, through no f a u l t of h i s own, to f u l f i l any o f the f u n c t i o n s 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 f o r f e e l i n g some resentment a t the way t h i n g s were, and she t o l d me she f g o t p r e t t y f e d up a t times". Although the worker does not agree with the w i f e ' s concept i o n o f her husband's i l l n e s s , w i f e ' s defence. that i t has  she does not c r i t i c i z e  I n s t e a d , she i n d i c a t e s t h a t she can  the understand  been d i f f i c u l t f o r the wife as w e l l as her husband.  •This h e l p s to c r e a t e a f e e l i n g o f acceptance  and g r a d u a l l y the  (73)  w i f e i s a b l e to b r i n g out h e r t r u e 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 f a c e the t r u t h . I s a i d , "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 f o r God's sake don't t e l l him". I s a i d t h a t i t was not our p o l i c y to repeat c o n v e r s a t i o n s w i t h the husband o r wife t o one another, and t h a t our c o n v e r s a t i o n would be respected as c o n f i d e n t i a l . At f i r s t  the w i f e i s t h r e a t e n e d  by the abruptness  o f her  d i s c l o s u r e ; but, once again, she i s g i v e n the necessary ance which would allow her t o d i s c u s s her f r u s t r a t i o n s  reassurfreely.  At t h i s p o i n t she begins t o r e v e a l her f e a r s i n f l u e n c e d by her past r e l a t i o n s h i p s with o t h e r s o c i a l workers. people who "pry i n t o other people's  She r e f e r s t o  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 p i c k e d up by the worker and an i n t e r p r e t a t i o n o f the r o l e o f s o c i a l work i s given t o the w i f e . I s a i d that while i t might appear t h a t way t o h e r , that p r y i n g i n t o other people's a f f a i r s had no place i n our work and t h a t our purpose was to g i v e people a chance to t a l k over any o f the t h i n g s t h a t might be bothering them - with the i d e a o f g i v i n g any h e l p we c o u l d . We d i d not want t o t e l l her what t o do; we a p p r e c i a t e d the f a c t that people are a b l e to make t h e i r own d e c i s i o n s , but t a l k i n g about them b e f o r e hand o f t e n makes the path to be f o l l o w e d c l e a r e r . The wife accepts t h i s , and then pours f o r t h her many f r u s t r a t i o n s a t having to assume the r o l e which i s normally by a husband, but which h i s i l l n e s s has changed.  carried  L i k e h e r hus-  band, who i s a l s o a dependent p e r s o n a l i t y , she i s unable t o assume any r e s p o n s i b i l i t y f o r her d i f f i c u l t i e s and p r o j e c t s the h o s t i l i t y which t h i s f r u s t r a t i o n c r e a t e s w i t h i n h e r , onto her husband and e v e r y t h i n g connected with him.  One by one, she  (74)  b r i n g s f o r t h much resentment towards the v a r i o u s  s t a f f members  t r e a t i n g her husband, and i n d i c a t e s t h a t she does not h e s i t a t e to make her h o s t i l i t y known to them.  Without attempting t o  i n t e r p r e t h e r behaviour t o her, the worker encourages the wife to b r i n g her f u t u r e complaints d i r e c t l y t o the worker. worker c h a n n e l l i n g the w i f e ' s  By the  h o s t i l i t y onto h e r s e l f , t h e hos-  p i t a l s t a f f i s thereby saved much n e e d l e s s argument w i t h a woman who i s a g g r e s s i v e The  and wishes to make t r o u b l e .  worker's a p p r a i s a l o f the w i f e , g i v e s a good i n d i c a t i o n  of her motivation. I f e l t two reasons f o r 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 i n g s around h e r r e j e c t i o n o f her husband and (2) an a t t e n t i o n - g e t t i n g device by which a dominant woman, r e s e n t i n g the f a c t t h a t she has no s t a t u s other than that o f f e r e d to a "veteran's" w i f e , (no s t a t u s i n being the wife o f a man you have r e j e c t e d ) , seeks t h i s s t a t u s 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 c l e a r that the wife has  i s l a t e r born out,  and i t becomes  i s j e a l o u s o f the a t t e n t i o n which everyone  been g i v i n g her husband i n the h o s p i t a l , w h i l e she has had  to c a r r y the l o a d o f m a i n t a i n i n g  a family  alone.  She s a i d he was a " s p o i l e d b r a t " and he expected her to s p o i l him the way h i s own mother had. I asked i f she had always thought t h i s was so, o r j u s t s i n c e he had been i n the h o s p i t a l . She s a i d , i n a tone o f d i s g u s t , that he had always been that way.... "I don't mind l o o k i n g a f t e r him, but I sure don't s p o i l him. She continued w i t h a long d i s s e r t a t i o n concerning h e r husband's need to get used t o h a v i n g a l l these people " w a i t i n g on him" and to g e t used t o the kind o f food he was going to get a t home. The worker then plans to o f f e r supportive wife,  case work t o the  so t h a t she can g a i n some measure o f s e l f - w o r t h .  By  making her a l s o f e e l important, i t i s expected that she w i l l  (75)  have l e 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 i n d i c a t e s how the worker i s a b l e t o handle  I asked Mrs...how she thought h e r husband was f e e l ing, and she s a i d r e l u c t a n t l y , " I f e e l that he i s much b e t t e r s i n c e he has been moved". I s a i d that I thought so too, and apparently the doctor b e l i e v e d t h i s to be true as w e l l . I thought Mrs...resented t h i s improvement, because she s a i d q u i c k l y , "Well i t won't l a s t I can t e l l you t h a t " . I - s m i l e d and s a i d , "You s a i d , t h a t so e m p h a t i c a l l y , that you must have some s t r o n g f e e l i n g about i t " . She paused, and then s a i d vehemently, "Well I don't want my husband, o r anyone e l s e , t h i n k i n g he can come home as soon as I get a house". A t t h i s p o i n t she g l a r e d a t me and looked very upset. I s a i d that t h i s was one o f the t h i n g s I had wanted to d i s c u s s w i t h her. I s a i d I r e a l i z e d that she was making a s e r i o u s e f f o r t to f i n d new l i v i n g accommodations, while a t the same time worrying about a l l the adjustments which would have to be made by each member o f the f a m i l y . I s a i d that I c o u l d understand t h a t her l i f e would be d i f f e r e n t w i t h her husband home, that they would have to get used to each o t h e r again....Mrs...looked r e l i e v e d , and s a i d she...had thought o f these t h i n g s , and i t bothered h e r . I s a i d t h a t 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 a t a time at home, with gradual, i n c r e a s e s o f time spent t h e r e , u n t i l they could see how t h i n g s were working o u t . She s a i d she was g l a d I thought t h i s way t o o , because she was a f r a i d the minute she got a house, everyone would t h i n k he should go r i g h t home. I s a i d t h a t t h e h o s p i t a l treatment team was concerned not only w i t h the p a t i e n t , but w i t h h i s adjustment a t home, and was t h e r e f o r e i n t e r e s t e d i n the whole f a m i l y . Following  the worker's supportive  understanding o f t h e w i f e ' s  c o n f l i c t and c l a r i f i c a t i o n o f the treatment team's i n t e r e s t i n her, as w e l l a s h e r husband, c l a r i f i c a t i o n i s extended t o an i n t e r p r e t a t i o n of the husband's f e e l i n g s about h i s lengthy talization. She s a i d , "Well he seems to have the crazy idea that he can move r i g h t home and e v e r y t h i n g w i l l be cosy". I s a i d that such an idea would seem " c r a z y " to those o f us who were a c t i v e , h e a l t h y , people and l i v i n g our normal l i v e s , but to a p a t i e n t who has spent about two years i n h o s p i t a l , i t was n a t u r a l to t h i n k he would be going home to the same s i t u a -  hospi-  (76)  t i o n he had l e f t . I p o i n t e d out that she c o u l d h e l p her husband by p l a n n i n g with him.... The w i f e ' s r e s i s t a n c e t o change i s accepted and understood by the worker and g r a d u a l l y other household  problems, such as  c o n t r o l over f i n a n c e s , care of the c h i l d r e n e t c . , are f a c e d . The worker encourages the p a t i e n t ' s w i f e t o d i s c u s s a l l these problems w i t h her husband, w h i l e he i s s t i l l i n t h e h o s p i t a l . It  should be mentioned, t h a t these areas o f c o n f l i c t were a l s o  d i s c u s s e d w i t h the p a t i e n t , and he was a l s o encouraged to t a l k with h i s w i f e .  I n t h i s way the g r e a t e r p a r t o f the t e n s i o n  between husband and w i f e , i s released-.:, i n the a c c e p t i n g atmosphere o f a w o r k e r - c l i e n t r e l a t i o n s h i p . I t i s i n connection w i t h t h i s problem o f home f i n d i n g , that the worker brings out one o f the basic p r i n c i p l e s o f case work - t h a t o f encouraging  the c l i e n t to make h i s own d e c i s i o n s .  As they r e t u r n from an i n s p e c t i o n o f a p r o s p e c t i v e apartment, the p a t i e n t ' s w i f e asks the worker to decide whether o r n o t she (the wife) should take t h i s  suite.  I e x p l a i n e d a g a i n that i t was not my f u n c t i o n adding t h a t I was sure she d i d n ' t want me. to make up h e r mind f o r her, although I hope she knew that I wanted to be o f h e l p i f I c o u l d . A t t h i s time a l l the f r u s t r a t i o n s o f e a r l y  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 b r i n g out t h i s h o s t i l i t y , c r i t i c i z i n g her, she h e l p s t h e w i f e to understand this  without  the cause o f  feeling. I s a i d , " t h i s s o r t o f t h i n g bothers you doesn't i t Mrs...because we've t a l k e d about i t b e f o r e , a l though you've/ never t o l d 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 h e r  (77)  c h i l d r e n . I s a i d you were perhaps a l i t t l e a f r a i d at the time and_ r e a c t e d by being angry? She paused and s a i d f i n a l l y that she guessed she had been " s o r t of scared". I s a i d that when we are f r i g h t ened, we o f t e n don't show t h a t we a r e , but hide our f e a r by g e t t i n g angry at someone - o f t e n 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, t h e r e has  been some  p o s i t i v e i n d i c a t i o n that the w i f e has changed s i n c e f i r s t by the worker.  On the whole, she has responded to the  of acceptance which the worker has  able to modify her demands upon him. before,  feeling  given, and together  the changing a t t i t u d e of the husband towards her,  seen  with  she has  been  As has been pointed  out  i t i s d o u b t f u l whether complete r e c o n c i l i a t i o n i n  1  t h e i r own  home, w i l l every  become a r e a l i t y .  The  patient's  p h y s i c a l c o n d i t i o n i s too s e r i o u s to ever allow t h i s f o r any l e n g t h of time, but at l e a s t the emotional  t e n s i o n which  merly e x i s t e d between husband and wife has  lessened  b l y , and the p a t i e n t has h o s p i t a l s t a f f , who  experienced  considera-  b e n e f i t from t h i s .  were formerly annoyed by a h o s t i l e  have a l s o r e c e i v e d b e n e f i t through the e f f o r t s of the worker on t h e i r The out  for-  The wife,  social  behalf.  purpose o f t h i s area o f p r e s e n t a t i o n has  been to p o i n t  the f a r - r e a c h i n g e f f e c t s which a p a t i e n t ' s i l l n e s s  produce on o t h e r s .  Because of the v a r y i n g i n n e r and  can  outer  needs which i n d i v i d u a l s i n a f a m i l y c o n s t e l l a t i o n seek to sat i s f y as they i n t e r a c t with one which i l l n e s s o f one  1 See  p.  another, and  the b a r r i e r s  of the members c r e a t e s i n the search f o r  (58) i n Chapter  3.  (78)  u l t i m a t e s a t i s f a c t i o n o f these b a s i c d e s i r e s , the r o l e o f soci a l workers i n the community  becomes c l e a r e r .  Ways i n which the  m e d i c a l 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 o f t h i s vast community ted.  team, have been sugges-  Too much emphasis cannot be g i v e n to the interdependent  r e l a t i o n s h i p which must e x i B t , n o t o n l y between members o f t h e h o s p i t a l team.but a l s o between the v a r i o u s community  agencies  i n t e r e s t e d i n the w e l l - b e i n g o f 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 o f these v a l u a b l e r e s o u r c e s are to achieve maximum  results.  The f o l l o w i n g s e c t i o n w i l l attempt to b r i n g t o g e t h e r  the c o n c l u s i o n s which t h i s study has to o f f e r i n making results  possible.  such  CHAPTER 5 CONCLUSIONS AND The and  RECOMMENDATIONS  purpose o f t h i s study has been to e x p l o r e the s o c i a l  emotional  backgrounds o f male a d u l t p a t i e n t s a f f e c t e d by  rheumatic heart d i s e a s e , i n order t o determine the f o l l o w i n g relationships: (1) The connection and  - i f any - between a p a t i e n t ' s s o c i a l  p e r s o n a l 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 r e l a t i o n s h i p between emotional course  (onset, convalescence,  d i s t u r b a n c e s and the  and l a t e r r e c u r r e n c e ) o f rheuma-  t i c heart disease. (3) The s p e c i f i c s o c i a l and emotional the p a t i e n t with rheumatic h e a r t  f a c t o r s which  affect  disease.  (4) The r o l e o f the s o c i a l worker - as a member o f t h e treatment al  team - i n a l l e v i a t i n g these  environmental  and person-  pressures. Two main f a c t o r s have i n f l u e n c e d the v a l i d i t y o f the f i n d -  i n g s , (1) the cases  selected for this  study, and (2) the  a v a i l a b l e s o c i a l and p e r s o n a l i n f o r m a t i o n c o n c e r n i n g the patients selected.  Because o n l y those p a t i e n t s which were r e -  f e r r e d for medical used, approximately  s o c i a l s e r v i c e a t Shaughnessy h o s p i t a l were t h r e e - q u a r t e r s o f a l l the RHD p a t i e n t s ad-  m i t t e d d u r i n g a f o u r - y e a r p e r i o d , (1947-1951), were  excluded.  M e d i c a l r e c o r d s a v a i l a b l e on each p a t i e n t , d i d not c o n t a i n sufficient  s o c i a l and p e r s o n a l i n f o r m a t i o n to make a more-  •complete study o f a l l RHD p a t i e n t s admitted  to the h o s p i t a l  (80)  possible.  Although m e d i c a l s o c i a l s e r v i c e r e c o r d s i n c l u d e d such  i n f o r m a t i o n , even these i n many i n s t a n c e s , d i d not possess ficient  m a t e r i a l from -which to draw v a l i d c o n c l u s i o n s .  supplementation 1 sources,  suf-  Despite  o f these r e c o r d s by m a t e r i a l o b t a i n e d from other  i t was s t i l l hot p o s s i b l e to o b t a i n enough i n f o r m a t i o n  about RHD p a t i e n t s - e s p e c i a l l y t h e i r e a r l y s o c i a l and p e r s o n a l histories. Although  only r e c o r d s o f veterans w i t h RHD have been exam-  i n e d , the f i n d i n g s o f t h i s study a r e , i n the main, a p p l i c a b l e to a l l p a t i e n t s a f f e c t e d by RHD.  The most o u t s t a n d i n g  not o n l y i n terms o f h o s p i t a l treatment,  finding,  but i n the broader a s -  pect of community r e s p o n s i b i l i t y , has been the r e l a t i o n s h i p between the i n c r e a s i n g economic d i f f i c u l t i e s which beset the RHD p a t i e n t and h i s e x t e n s i v e p h y s i c a l and p e r s o n a l i n a d e q u a c i e s . As a r u l e , the RHD p a t i e n t e n t e r i n g a veterans' h o s p i t a l , does not s u f f e r the added burden o f h o s p i t a l debt as does the average citizen. far  On the c o n t r a r y , t h e r e a r e times when the v e t e r a n i s  b e t t e r o f f f i n a n c i a l l y , e.g. i n c r e a s e d pension  r e h a b i l i t a t i o n programmes, e t c . expect  T h e r e f o r e , i t i s reasonable t o  t h a t economic d i f f i c u l t i e s  much g r e a t e r handicap  grants,  present as g r e a t , i f n o t a  to a l l RHD p a t i e n t s .  D e s p i t e the r e s o u r c e s w i t h i n the department o f v e t e r a n s ' affairs,  the RHD p a t i e n t s examined i n t h i s study have not been  able to make e f f e c t i v e use o f the environmental them.  a i d o f f e r e d to  P a r t o f the answer t o t h i s enigma l i e s i n the area o f  incomplete  o r inadequate  r e s o u r c e s , but what seems t o be o f  1 See pp. (13-14) i n Chapter  1.  (81)  equal importance, i s the p e r s o n a l i t y d e f e c t w i t h i n the RHD pat i e n t , that does not allow him t o make f u l l use o f t h i s a i d . Although  i n f o r m a t i o n surrounding  p e r s o n a l i t y f o r m a t i o n o f the  RHD p a t i e n t i s very sparse, there i s s u f f i c i e n t ilarity  evidence o f sim-  i n a l l the cases examined, t o i n d i c a t e there i s an i n -  t e r r e l a t i o n s h i p between p e r s o n a l a d a p t a b i l i t y , s o c i a l  pressure  and e v e n t u a l l y , p h y s i c a l d e t e r i o r a t i o n . I n a l l cases, i t was seen t h a t the RHD p a t i e n t ' s p r e p a r a t i o n for  adulthood  and the r e s p o n s i b i l i t i e s which'accompany  stage o f development, was mainly to  inadequate.  this  It i s difficult  say whether h i s e d u c a t i o n was l i m i t e d because o f s o l e l y  sonal or s o c i a l pressures.  per-  S i m i l a r i l y h i s choice o f a physi-  c a l l y - s t r e n u o u s v o c a t i o n would appear to be the r e s u l t o f a number o f i n t e r r e l a t e d f a c t o r s . that there has been l i t t l e ment o f s k i l l s .  I t i s s i g n i f i c a n t ^ however, ,  permanency o f employment or develop-  The e x e r c i s e o f manual labour i s the only com-  mon f a c t o r i n h i s choice o f employment. I t has been suggested  that the p e r s o n a l i t y o f the RHD.pa-  t i e n t has been founded upon i n s e c u r e r e l a t i o n s h i p s .  Somewhere  i n h i s development, he has " l e a r n e d " that i n o r d e r to g a i n a p p r o v a l , he must c o n s t a n t l y d r i v e h i m s e l f .  I n our c o m p e t i t i v e  society, where the p h y s i c a l l y - s u p e r i o r a t h l e t e i s g i v e n h i g h hon1  ours, i t i s not strange to equate acceptance by o t h e r s w i t h a show o f p h y s i c a l prowess.  I t has a l s o been suggested, t h a t des-  p i t e t h i s need t o e x e r t h i s independence, the RHD p a t i e n t has never r e a l l y r e s o l v e d h i s e a r l i e r dependency f e e l i n g s upon h i s parents and l a t e r upon parent  substitutes.  T h i s constant "un-  c o n s c i o u s " mental c o n f l i c t , t h e r e f o r e e x e r t s i t s e l f  "psychoso- .  (82)  m a t i c a l l y " upon h i s p h y s i c a l c o n d i t i o n , so t h a t by d r i v i n g hims e l f p h y s i c a l l y , he a c h i e v e s s a t i s f a c t i o n f o r both h i s dependency and independency needs.  He  gains a p p r o v a l f o r h i s martyr  r o l e as w e l l as dependent care which h i s r e s u l t i n g  illness  affords.  I n t h i s way, he i s able to r e s o l v e h i s c o n f l i c t  i t i s now  a c c e p t a b l e to h i s conscious  so t h a t  self.  T h i s p a t t e r n o f r e a c t i o n i s e v i d e n t i n a l l phases o f the patient's adult l i f e experiences.  RHD  Not o n l y i n h i s c h o i c e of and  a b i l i t y to m a i n t a i n s u i t a b l e employment i s t h i s n o t i c e a b l e , but, what i s e q u a l l y important, i n h i s m a r i t a l adjustments I t has  been shown how  many of the RHD  p a t i e n t s have attempted  seek a haven of dependent "emotional s e c u r i t y i n t h e i r but because t h e i r wives have not r o l e as was  as w e l l . to  marriage,  been able, to p l a y the mother-  expected o f them, more, r a t h e r than l e s s ,  p e r s o n a l and p h y s i c a l t u r m o i l has r e s u l t e d f o r these What i s then o b s e r v a b l e , i s a v i c i o u s , never-ending  social patients.  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 a t t a c k s of RHD.  As the RHD  p a t i e n t becomes f r u s t r a t e d  by h i s i n a b i l i t y t o ' m a i n t a i n a former comes more s u s c e p t i b l e to r e i n f e c t i o n .  l e v e l o f e x i s t e n c e , he By  becoming i l l ,  h i s en-  v i r o n m e n t a l problems i n c r e a s e , he becomes more f r u s t r a t e d , h i s a b i l i t y to respond  to treatment  i s impaired.  be-  and  I f and when he  does r e c o v e r , he r e t u r n s to an emotionally-charged atmosphere which has not improved d u r i n g h i s absence.  His physical condi-  t i o n i s f u r t h e r impaired, and the p a t t e r n r e p e a t s i t s e l f - perhaps u n t i l such time as death takes over. However, the problems which have surrounded npt stop here.  the i l l n e s s  The i n t e r r e l a t i o n s h i p of f a m i l y members and  do the  (83)  e f f e c t which the breadwinner, s u f f e r i n g from RHD, has had on them, remains.  I f . d i v o r c e o r s e p a r a t i o n has not ended the mar-  r i a g e long before not  t h i s , and c h i l d r e n born to t h i s union have  grown s u f f i c i e n t l y  to fend f o r themselves, the f a m i l y con-  t i n u e s to bear the brunt o f the e v e r - i n c r e a s i n g den which i l l n e s s has c r e a t e d .  financial  bur-  Because they have been f o r c e d  to l i v e under p o v e r t y - s t r i c k e n c o n d i t i o n s , the r o o t s f o r f u r ther s o c i a l and p h y s i c a l d i s o r g a n i z a t i o n have s t r u c k deep.  Be-  cause i l l n e s s has i n t e r f e r e d with the s a t i s f a c t i o n s normally sought i n marriage, p e r s o n a l  d i s i n t e g r a t i o n i n the wife has  reached a h i g h peak, but perhaps i t i s the c h i l d r e n of t h i s marriage that s u f f e r the most.  Since many c h i l d r e n have been  denied the b a s i c s e c u r i t y o f a happy normal home, t h e i r persona l i t i e s have a l r e a d y  been so s e v e r e l y damaged that they a r e  i l l - e q u i p e d t o face the mature demands o f l a t e r The  life.  r o l e o f the s o c i a l worker has been presented a s t h a t  member o f the h o s p i t a l treatment team, who i s s p e c i f i c a l l y t r a i n e d to cope w i t h these s o c i a l and emotional problems a f f e c t i n g p a t i e n t s with RHD, as w e l l as other Four types o f t h e r a p e u t i c pulation,  processess,  forms of i l l n e s s .  (1) environmental mani-  (2) p s y c h o l o g i c a l support, (3) c l a r i f i c a t i o n , and  (4) i n s i g h t have been i n t r o d u c e d  as basic forms o f d i f f e r e n -  l t i a l case work treatment.  Because o f the deep-seated nature of  the p e r s o n a l i t y c o n f l i c t of the RHD p a t i e n t and the permanent dependency s i t u a t i o n which accompanies the p h y s i c a l l i m i t a t i o n of a c h r o n i c  illness,  the w r i t e r has suggested t h a t the major  c o n t r i b u t i o n o f t h e s o c i a l worker, l i e s i n the a r e a onmental m a n i p u l a t i o n .  However, i n order  of envir-  to h e l p t h i s p a t i e n t  (84)  make t h e best use o f the r e s o u r c e s which a r e a v a i l a b l e , t h e v a l u e o f p s y c h o l o g i c a l s u p p o r t and c l a r i f i c a t i o n has been i n d i cated.  •  As p a r t o f the s o c i a l worker's  job of s o c i a l  amelioration,  h i s work w i t h the p a t i e n t ' s f a m i l y has a l s o been p r e s e h t e d . 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 ' w i v e s , f o r i t i s t h i s i n t i m a t e r e l a t i o n s h i p o f m a r r i a g e which has been so s e r i o u s l y damaged by i l l n e s s . Because the g r e a t e s t a r e a o f s o c i a l p r e s s u r e a f f e c t i n g t h e e m o t i o n a l w e l l - b e i n g o f the p a t i e n t and h i s f a m i l y stems from s o u r c e s w i t h i n the community, i t has been suggested t h a t t h e burden o f 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, t h e m e d i c a l s o c i a l worker has a l s o been p r e s e n t e d a s a member o f t h e community t r e a t m e n t team, as w e l l a s 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 t o p l a y w i t h  patients i n a hospital setting.  RHD  Specifically,this i s :  (1) To work t o g e t h e r w i t h o t h e r members o f t h e t r e a t m e n t team, to b r i n g about the b e s t p o s s i b l e t r e a t m e n t measures f o r the good o f the p a t i e n t . (2) To determine what e m o t i o n a l p r e s s u r e s a r e a f f e c t i n g the p a t i e n t ' s response t o m e d i c a l care - both from  "outside",  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 r e s o u r c e s which w i l l ameli o r a t e t h e c o n d i t i o n s c r e a t i n g t h e s e e m o t i o n a l p r e s s u r e s , so t h a t t h e p a t i e n t can b e t t e r respond t o m e d i c a l t r e a t m e n t . T h i s i n c l u d e s the use o f both e n v i r o n m e n t a l and p s y c h o l o g i c a l .aids.  (85)  (4) To work w i t h the community welfare team i n the mance o f t h e i r task to b r i n g about the  best  f o r the mental and  of the c i t i z e n s - w i t h i n  that  physical well-being  possible  perfor-  atmosphere  community.  Recommendations Treatment f o r RHD cause o f the i o d of RHD,  p a t i e n t s i s of long-term d u r a t i o n .  chronic nature and  the extended convalescent per-  adequate s o c i a l s e r v i c e to these p a t i e n t s must  on a continuous b a s i s . co-ordinated workers.  Be-  T h i s i n v o l v e s then, the  e f f o r t of both the m e d i c a l and  The  the p a t i e n t  former group i s r e q u i r e d  continuous  community  social  l a t t e r group's r e s -  p o n s i b i l i t y to provide adequate p r e p a r a t i o n  and  follow-up  v i c e s t o i n s u r e that h o s p i t a l treatment w i l l be and has  s u f f e r from RHD  and  s o c i a l treatment j u s t as any  ser-  been of  I f i t i s accepted that  who  and  to o f f e r treatment w h i l e  i s i n h o s p i t a l , but i t i s the  utmost b e n e f i t to the p a t i e n t .  be  people  have the r i g h t t o r e c e i v e p h y s i c a l , mental other member of s o c i e t y , then  the need f o r more-adequate s e r v i c e , i s s e l f - e v i d e n t . S t a f f Requirements As has  been pointed  workers who  are  out,  the g e n e r a l  1  social  c a r r y i n g a heavy case l o a d , i s to s e l e c t  g r e a t e s t number of p a t i e n t s who amount o f the worker's time. who  p r a c t i c e of  can  b e n e f i t from the  the  least  I t i s the c h r o n i c a l l y - i l l  patient  u s u a l l y must be s a c r i f i c e d when t h i s necessary procedure i s  c a r r i e d out.  1 See  pp.  There i s a need f o r more s o c i a l workers to cover  (53-54) i n Chapter  3.  (86)  t h i s gap i n t r e a t m e n t chronically-ill  services.  patients  mum t h a t  c a n be e x p e c t e d  services  by one  Again,  a t any one t i m e , to r e c e i v e  full  is  o f case work  time i n v o l v e d ,  there  i s a need  the  as w e l l as  two y e a r s o f  i s a great  dif-  "visits",  professional  s e l v e s " , but who h a s a l s o ,  The  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  possesses an innate c a p a c i t y  for "helping others  to help  t h r o u g h t r a i n i n g , added an  them-  objective  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 work i s  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  founded situation  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  c a l l s f o r added s k i l l ker's  best  l e n g t h y m e d i c a l s o c i a l work e x p e r i e n c e .  professional s o c i a l worker,  awareness to h i s  There  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  a n d t h e one who h a s h a d a t l e a s t  create.  for  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  between  training,  forty  probably the m a x i -  benefit  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 . ference  t h i r t y to  worker.  because o f the  sufficient  A case l o a d o f  and knowledge.  members  The m e d i c a l s o c i a l  f u n c t i o n i s to h e l p i n t e r p r e t to o t h e r  wor-  t e a m members,  the  meaning behind the p a t i e n t ' s  r e a c t i o n to i l l n e s s .  his  greater  s o c i a l s i t u a t i o n beyond t h e  tal  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 ,  cal  s o c i a l worker i s i n a n a t u r a l p o s i t i o n to perform t h i s l i a -  awareness o f the  s o n w o r k w i t h o t h e r members o f ordinarily  concerned w i t h the  the treatment  task  mate f o c u s i s  the medi-  not  s o c i a l and e m o t i o n a l a s p e c t s  f o r w h i c h t h e y h a v e been t r a i n e d . on the p a t i e n t - a s - a - w h o l e ,  not  specific  As always, just  the  of  hospi-  t e a m who a r e  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 cal  Because  of  medi-  the  ulti-  patient.  (87)  Resource Requirements Apart from the p h y s i c a l 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, e t c . , which permit the s o c i a l  worker t o c a r r y out h i s job without there a r e s p e c i f i c  unnecessary  s e r v i c e requirements  restrictions,  f o r t h e w e l f a r e o f RHD  p a t i e n t s which must supplement case work treatment.  I t has been  p o i n t e d out that a v e t e r a n s ' h o s p i t a l , such as the one where t h i s study has been made, has numerous v a l u a b l e r e s o u r c e s a t its disposal.  1  I n c o n s i d e r i n g the s o c i a l problems which a r e  most f r e q u e n t l y encountered  by RHD p a t i e n t s , the value o f f i n -  a n c i a l a i d f o r p a t i e n t s and t h e i r f a m i l i e s a t a time when hosp i t a l i z a t i o n i s c r e a t i n g t h e most s e r i o u s f i n a n c i a l burden, cannot be overlooked.  Too, the convalescent homes,(George Durby  H e a l t h and O c c u p a t i o n a l Centre, H y c r o f t ) , f i l l u s u a l convalescence  a need which the  i n overcrowded, damp, p o o r l y - c o n s t r u c t e d ,  c o l d homes o f RHD:patients,  does not p r o v i d e .  The p o s s i b l e  use o f n u r s i n g homes s p e c i f i c a l l y designed to meet the emotiona l as w e l l as p h y s i c a l needs o f the RHD p a t i e n t , r e q u i r e s f u r ther i n v e s t i g a t i o n .  Opportunity f o r r e t r a i n i n g through c o r r e s -  pondence courses e t c . , and a i d i n f i n d i n g employment which i s i n keeping w i t h the p h y s i c a l 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 o f a s h e l t e r e d workshop which i s  designed to b o l s t e r the confidence o f p h y s i c a l l y i n f e r i o r patients,  i s another area which needs f u r t h e r e x p l o r a t i o n .  R e t r a i n i n g a i d s serve t h e d u a l purpose o f not o n l y making Tt p o s s i b l e f o r the RHD p a t i e n t t o m a i n t a i n h i s r o l e a s  1 See pp. (43-44) i n Chapter 3.  (88)  breadwinner, but what i s e q u a l l y important,  p r o v i d e s him w i t h a  much-needed form o f d i v e r s i o n to c o u n t e r a c t h i s n a t u r a l tendency to brood over h i m s e l f d u r i n g the l o n g months o f h i s " r e s t f u l " , yet " r e s t l e s s " convalescence.  T h i s does not o b v i a t e the need  f o r other forms of o c c u p a t i o n a l therapy. group work w i t h RHD  The  p o s s i b l e use o f  p a t i e n t s , as a p a r t o f 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  U n f o r t u n a t e l y , these s e r v i c e s are not a v a i l a b l e f o r a l l c h r o n i c a l l y d i s a b l e d RHD  patients.  For those who  are not  eli-  g i b l e f o r maximum veteran b e n e f i t s , the e x i s t i n g s e r v i c e s o f the community have been used. ous gap  i n both r e s o u r c e s .  I n any  event,  there i s a  The p a t i e n t a f f e c t e d by RHD  serii s ex-  pected to f u n c t i o n w i t h i n the l i m i t a t i o n s o f the s o c i e t y i n which he l i v e s , as w e l l as w i t h i n h i s p h y s i c a l 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, e t c . , i s o n l y v a l u a b l e i n comparison to the a v a i l a b i l i t y o f these r e s o u r c e s w i t h i n the community. tically,  i t i s not always p o s s i b l e to f i n d s u i t a b l e  Realis-  employment  d e s c r i b e d as l i g h t work, e t c . , or low-cost, though adequate housing. For t h i s reason,  i t i s necessary  ards o f f i n a n c i a l a i d .  How  to re-examine our  much b e t t e r equiped,  stand-  emotionally  as w e l l as f i n a n c i a l l y , i s the one hundred per cent d i s a b l e d veteran who  r e c e i v e s s u f f i c i e n t income to meet the economic  1 C e l i a R. Moss d e s c r i b e s some i n t e r e s t i n g experiences on t h i s s u b j e c t o f group work i n a m e d i c a l s e t t i n g , i n her a r t i c l e , "Int e g r a t i n g Case Work and R e c r e a t i o n i n a M i l i t a r y H o s p i t a l " , J o u r n a l of S.C.W., Dec. 1946, pp. 307-313.  (89)  need o f h i m s e l f and h i s f a m i l y .  Consider  however, the p a t i e n t  who sees debts mounting up i n f r o n t o f him, with means a t h i s d i s p o s a l to counter-balance  them.  inadequate I s i t any wonder  that many a r e f o r c e d to abandon tke wise c o u n s e l l i n g o f d o c t o r s and r e t u r n t o p h y s i c a l l y strenuous employment which _is a v a i l a b l e , l o n g before i t i s s a f e f o r them to do any type o f work?  Is i t  any  physi-  wonder t h a t many delay m e d i c a l  c a l c o n d i t i o n becomes c r i t i c a l ? many c o n s c i o u s l y o r unconsciously  treatment u n t i l t h e i r  I s i t not a l s o p o s s i b l e t h a t seek to prolong t h e i r h o s p i -  t a l s t a y , because i t i s the o n l y 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 o f f i n a n c i a l debt? There i s a s t r o n g case f o r r e c o g n i z i n g the added burden which c h r o n i c i l l n e s s p l a c e s on the RHD p a t i e n t . the emotional  Since much o f  s t r a i n a f f e c t i n g the course o f 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  dis-  order, there i s a need f o r a more-adequate r e - a l l o c a t i o n o f w e l f a r e budgets which w i l l compensate f o r the RHD p a t i e n t s ' and t h e i r f a m i l i e s ' unequal s t r u g g l e f o r s u r v i v a l .  I t i s evident  t h a t the c o s t to s o c i e t y i s f a r g r e a t e r when a breadwinner i s undergoing h o s p i t a l treatment, than i f he can be maintained i n h i s own home.  A l s o , the value which h i s r e s u l t i n g  emotional  w e l l - b e i n g c r e a t e s i n terms o f t h e e f f e c t he has on h i s f a m i l y , cannot be overestimated.  An atmosphere f o r s t a b l e p e r s o n a l i t y  growth o f an RHD p a t i e n t ' s c h i l d r e n , p r o v i d e s g r e a t e r assurance that as these c h i l d r e n grow up, they w i l l be bet.ter-equiped t o cope with t h e demands, and c o n t r i b u t e to the needs, o f s o c i e t y . The Need f o r More Research More r e s e a r c h i s needed a l o n g s i m i l a r l i n e s o f t h i s  study  (90)  w i t h other groups of a d u l t male RHD  patients.  concerned i t s e l f mainly w i t h the veteran RHD  As t h i s  study  has  p a t i e n t s , there i s  a danger o f drawing c o n c l u s i o n s which are not a p p l i c a b l e to the general population.  A c o n t r o l group which i s more r e p r e s e n t a t i v e  of the young male a d u l t p o p u l a t i o n could be s e l e c t e d f o r a r e search p r o j e c t which would i n v o l v e the c o - o r d i n a t e d of s e v e r a l i n t e r e s t e d d i s c i p l i n e s .  activities  Since the a v a i l a b i l i t y  of.  background i n f o r m a t i o n , f e e l i n g s towards i l l n e s s e t c . , has l a c k i n g i n the r e c o r d s used f o r t h i s study,  been  i t i s f e l t that a  c o n t r o l l e d r e s e a r c h p r o j e c t c o u l d overcome t h i s d i f f i c u l t y , more-accurate s t a t i s t i c a l comparisons could  be made.  e f f e c t i v e measurements of the r e l a t i o n s h i p between and  and  Too,  more-  emotional  p h y s i c a l 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  R e l a t e d r e s e a r c h p r o j e c t s are a l s o needed. suggestion,  As a p o s s i b l e  there i s a need f o r a c l o s e r examination o f  the  p o s s i b i l i t i e s f o r g r e a t e r c o - o r d i n a t i o n of the e f f o r t s o f  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 ii.e.  disadvantages a f f e c t i n g the g r a n t i n g o f pensions  p e n s i o n i t i s ) , i s another area f o r f u r t h e r study.  Speci-  f i c r e s e a r c h p r o j e c t s on other- forms o f c h r o n i c i l l n e s s such as rheumatoid a r t h r i t i s , d i a b e t e s , e t c . , are a l s o needed. n e c t i o n with t h i s l a t t e r p r o j e c t , the formation o f a  I n con-  standard-  i z e d method of approach would prove i n v a l u a b l e i n terms of tistical  sta-  comparisons.  Adequate Use  of  Recording  S i n c e the major d i f f i c u l t y a f f e c t i n g the f i n d i n g s o f  this  (91)  study i n v o l v e s the u n a v a i l a b i l i t y o f complete m e d i c a l  social  s e r v i c e r e c o r d s of the p a t i e n t s s e l e c t e d , some change i n the f u ture p l a n o f r e c o r d i n g i s suggested. loads and ted  shortage  of m e d i c a l  at the time t h i s study was  In.view o f the l a r g e case  s o c i a l s e r v i c e s t a f f , which e x i s being conducted, r e c o g n i t i o n 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 r e c o r d i n g .  These recommendations  concerning  the more-adequate use of r e c o r d i n g , are being presented  i n terms  o f i d e a l "working c o n d i t i o n s which i n c l u d e the necessary  time f o r  such r e c o r d i n g . Because o f the unique use to which m e d i c a l r e c o r d s are .put, files. in  The  1  first  p r o v i s i o n should  social service  be made f o r two  kinds  of  would be s i m i l a r to the type of r e c o r d i n g  now  use - namely, a b r i e f r e p o r t on the s i g n i f i c a n t f a c t s s u r -  rounding  the s o c i a l and  the corresponding problems.  The  emotional  problems o f the p a t i e n t  case work treatment used to c o u n t e r a c t  second s e t of r e c o r d i n g should  and these  be a m o r e - d e t a i l -  ed account of the s i g n i f i c a n t f a c t o r s surrounding  the. p a t i e n t s 1  i l l n e s s , on an i n t e r v i e w by i n t e r v i e w b a s i s . Whereas the f i r s t file,  the second one  r e c o r d would be p l a c e d on the c e n t r a l would be r e t a i n e d f o r the e x c l u s i v e use  of  1 A l l departments o f D.V.A. are requested to f i l e i n d i v i d u a l r e p o r t s i n a common f i l e , so t h a t complete i n f o r m a t i o n o f a l l s e r v i c e s . r e n d e r e d 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 o f t h i s f o r m e d i c a l s o c i a l s e r v i c e , i s t h a t r e c o r d s must be w r i t t e n , not only f o r f u t u r e use by s o c i a l workers, but for other treatment team members who have l i t t l e i n t e r e s t i n det a i l e d r e p o r t s o f the process o f 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 s e r v i c e r e p o r t s u s u a l l y i n d i cate b r i e f l y , what has happened - not n e c e s s a r i l y how and why a change has taken p l a c e .  (92)  the m e d i c a l s o c i a l s e r v i c e s t a f f .  There i s value  i n this  set o f records not o n l y f o r f u t u r e r e s e a r c h purposes but f o r s u p e r v i s i o n and  t e a c h i n g o f case work s t a f f .  work used to r e l i e v e improved.  The  also  S k i l l s i n case  the p a t i e n t ' s problems, would thereby  Because of the  p r o v i s i o n should  latter  be  extra time i n v o l v e d f o r such r e c o r d i n g ,  be made f o r c l e r i c a l .staff to handle t h i s  use o f very f u l l  (process)  r e c o r d i n g i s , o f course, the  most v a l u a b l e method of o b t a i n i n g r e s e a r c h m a t e r i a l . i s very time-consuming, i t i s not thod f o r the average case l o a d . p a t i e n t are r a r e l y  me-  Changes i n the c h r o n i c a l l y - i l l of m a t e r i a l i s  r e c o r d i n g where the s p e c i f i c  p r o j e c t i s designed to b r i n g out  of case work treatment.  this  However, t h i s recommendation does not  o b v i a t e the use of process t i o n o f the r e s e a r c h  Since  suggested as a p r a c t i c a l  sudden, and much r e p e t i t i o n  unnecessarily recorded.  load.  functechniques  There i s room f o r much improvement i n  case work treatment w i t h the c h r o n i c a l l y - i l l patient.. Prevention The  best remedy f o r any  °? p r e v e n t i o n .  c h r o n i c i l l n e s s i s of course,  As with treatment, there are two  c o n s i d e r a t i o n (1) the r e s p o n s i b i l i t y prevention, RHD  and  of prevention  for  o f the community towards  (2) the r e s p o n s i b i l i t y  i s a social responsibility,  aspects  one  o f the  hospital.  t h e r e f o r e , the major  l i e s w i t h i n the community.  Since  "poverty"  role breeds  d i s e a s e " , more adequate s o c i a l measures are needed to remove e  t h i s source o f i n f e c t i o n .  Slum a r e a s , e t c . , need to  be  replaced  by l i v i n g c o n d i t i o n s more conducive to the p h y s i c a l w e l l - b e i n g of i t s i n h a b i t a n t s .  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  o f emotional f a c t o r s  to the development o f RHD, the importance cannot  o f mental  be o v e r l o o k e d i n any p r e v e n t i o n programme.  contributing pressures For t h i s  reason, adequate h e a l t h measures w i l l i n c l u d e both p h y s i c a l and mental h e a l t h education, e s p e c i a l l y d u r i n g e a r l y c h i l d h o o d years where the onset o f RHD i s so p r e v a l e n t .  The use of s o c i a l s e r -  v i c e s as a p a r t o f the programme, i s v i t a l . More s p e c i f i c a l l y , the h o s p i t a l ' s r o l e i n prevention, from a s o c i a l work p o i n t o f view, i s that o f e a r l y d i a g n o s i s and r e f e r r a l to m e d i c a l s o c i a l s e r v i c e as soon as i t i s apparent  that  there a r e s o c i a l and emotional problems a f f e c t i n g the course of the p a t i e n t ' s i l l n e s s .  On the b a s i s o f t h i s study, i t i s f e l t  t h a t there i s a s t r o n g p o s s i b i l i t y that many other RHD p a t i e n t s t r e a t e d i n t h i s and o t h e r h o s p i t a l s , have n o t been r e f e r r e d t o a m e d i c a l s o c i a l worker when such s e r v i c e might have been r e q u i r e d by the p a t i e n t .  For example, two r e c o r d s o f RHD p a t i e n t s  have been s e l e c t e d a t random from approximately t i e n t s who were never  seen by a m e d i c a l s o c i a l worker a t any  time w h i l e they were undergoing v e t e r a n h o s p i t a l The  first  s e v e n t y - f i v e pa-  treatment.  case i s that o f a 25-year-old v e t e r a n who s u f f e r -  ed w i t h RHD s i n c e h i s f i r s t a t t a c k of rheumatic  f e v e r i n 1942.  He d i e d s i x years l a t e r , a f t e r f o u r t e e n readmissions.  T h i s pa-  t i e n t presented the usual p a t t e r n o f s p o r a d i c , strenuous  employ-  ment, and although he r e c e i v e d some t r a i n i n g as a j e w e l l e r y r e pairman while undergoing h o s p i t a l treatment, he was never to support h i m s e l f a g a i n .  I n 1947 i t was noted t h a t he was  married, and that he was having d i f f i c u l t y dations.  able  f i n d i n g l i v i n g accomo-  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 a f t e r a c h i l d was are  born to h i s w i f e .  suggestions i n the r e c o r d o f f i n a n c i a l d i f f i c u l t i e s ,  There as w e l l  as p o s s i b l e f r i c t i o n w i t h h i s w i f e . The second case i s that o f a 63-year-old v e t e r a n who been c o n t i n u o u s l y i l l s i n c e World War averaged more than one admittance  1.  S i n c e 1919  has  per month to the h o s p i t a l .  i s known that h i s w i f e d e s e r t e d him i n 1947 c o n t i n u a l f i n a n c i a l problems.  he  has  and t h a t he has  It had  Although he has been informed o f  the l i m i t a t i o n s o f h i s c a r d i a c a i l m e n t , he c o n s t a n t l y denies t h i s and continues to work a t strenuous employment. f e l t that although t h i s p a t i e n t attempted i n e x p r e s s i o n " , he was immature. was  "independent  b a s i c a l l y e m o t i o n a l l y dependent and  quite  As an example o f h i s s e l f - d e s t r u c t i v e behaviour, i t  noted t h a t he once f e l l  on a farm, and  from a wagon while he was  f r a c t u r e d h i s l e f t arm.  moved h i s c a s t "because If  to very  I t was  working  A s h o r t time l a t e r he r e -  i t hampered h i s movements".  s o c i a l work s e r v i c e s are to be most e f f e c t i v e ,  referrals  must be made as e a r l y as p o s s i b l e by the doctor i n charge of treatment.  I n view of the f i n d i n g s of t h i s study, t h e r e would  a l s o appear to be a case f o r an automatic r e f e r r a l to m e d i c a l s o c i a l s e r v i c e of a l l RHD t i e n t s , who, because  patients.  S i n c e t h e r e are RHD  pa-  o f t h e i r q u i e t manner do not openly express  t h e i r emotional problems to h o s p i t a l s t a f f , i t i s important that they not be o v e r l o o k e d . his  difficulties,  psychosomatic  The p a t i e n t who  s u f f e r s much more mental  discomfort^ than the one who  f e e l i n g more r e a d i l y . t i o n , a comparison  cannot  s t r a i n and  express subsequent  can " r e l e a s e " h i s  As a f u t u r e r e s e a r c h p r o j e c t i n preven-  c o u l d be made between the p r o g r e s s o f  RHD  (95)  p a t i e n t s who were r e f e r r e d to m e d i c a l s o c i a l s e r v i c e on admiss i o n to h o s p i t a l , and those whose r e f e r r a l s were delayed u n t i l such time as t h e i r  s o c i a l and p e r s o n a l problems appeared t o the  h o s p i t a l s t a f f to be o f s u f f i c i e n t magnitude to warrant work s e r v i c e s .  social  APPENDIX A 1 MEDICAL ASPECTS OF RHEUMATIC HEART DISEASE Definition:  The v a r i o u s inflammatory changes i n the heart which  a r i s e i n rheumatic f e v e r , together with the v a l v u l a r deformit i e s and other disease. ual  s c a r s t h a t remain, c o n s t i t u t e rheumatic h e a r t  T h i s term i s now used to i n d i c a t e that the i n d i v i d -  has o r has had rheumatic f e v e r , even though i t has n o t  been c l i n i c a l l y Classification:  evident. Two c l a s s i f i c a t i o n s , a c t i v e and i n a c t i v e a r e  most commonly used w i t h RHD.  The former i s used to designate  that a. rheumatic i n f e c t i o n i s present s t r u c t u r e s o f the h e a r t . has  ceased but healed  i n one o r a l l o f the  The l a t t e r i n d i c a t e s t h e i n f e c t i o n  l e s i o n s remain.  These l e s i o n s a r e  u s u a l l y v a l v u l a r d e f o r m i t i e s r e s u l t i n g from a p r e v i o u s i n flammation. Another grouping minating  i n c l u d e s four c l a s s i f i c a t i o n s ,  (1) f u l -  - o c c u r r i n g d u r i n g the i n i t i a l a t t a c k o f rheumatic  f e v e r , (2) r e c u r r e n t a c t i v e - i n t e r v e n i n g i n t e r v a l s o f q u i escence, (3) c h r o n i c a c t i v e - inflammation p e r i o d s o f months o r years, and  p e r s i s t i n g over  (4) c h r o n i c i n a c t i v e -  where the disease e x i s t s f o r years without o f a rheumatic i n f e c t i o n , yet healed  s i g n s o r symptoms  s t r u c t u r a l l e s i o n s are  present.  1 E x t r a c t e d from R u s s e l L. C e c i l , "Rheumatic Heart Textbook of Medicine, pp. 1185 - 1192.  Disease,"  (97)  ETIOLOGY AND MORBID ANATOMY Although SO to 30 per cent do not show e x i s t e n c e o f rheu-  Cause:  matic f e v e r , i t i s b e l i e v e d that t h i s d i s e a s e i s the cause o f RHD. Development and Mode o f Onset:  Rheumatic f e v e r - An i n f e c t i o n  i n the form o f p o l y a r t h r i t i s , muscle and j o i n t p a i n s , 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 o f onset i n over 85  per cent o f rheumatic  f e v e r p a t i e n t s under t e n y e a r s o f age.  A f t e r age f o r t y , approximately 20 per cent of the p a t i e n t s are  so a f f e c t e d .  Rheumatic h e a r t d i s e a s e - approximately o n e - t h i r d o f the c h i l d r e n d e v e l o p i n g RHD g i v e evidence o f p o l y a r t h r i t i s another t h i r d have c a r d i t i s and chorea.  Young a d u l t s  first, usually  have p o l y a r t h r i t i s , whereas o l d e r people u s u a l l y have o n l y signs of v a l v u l a r Type o f I n f e c t i o n :  lesions. D u r i n g adolescence and e a r l y m a t u r i t y , c a r -  d i t i s i s seen more f r e q u e n t l y as a s i n g l e m a n i f e s t a t i o n . Symptomatology: of  Onset o f A c t i v e RHD - U s u a l l y an inflammation  the myocardium and v a l v e s - l e s s commonly o f the p e r i c a r -  dium.  Subsequent course - I n c h i l d r e n , the course o f i n f l a m -  mation may l a s t from s e v e r a l months t o s e v e r a l years - sometimes i t may never completely s u b s i d e . Disappearance  o f the c l i n i c a l  inflammatory process i s i n a c t i v e .  s i g n s does not mean that the F u r t h e r damage can r e s u l t  by i l l - a d v i s e d , premature p h y s i c a l a c t i v i t y .  Recurrent per-  iods o f a c t i v e RHD r e s u l t i n p r o g r e s s i v e damage to the h e a r t ,  (98)  h e a r t f a i l u r e , and death,  i f adequate r e s t and s i m i l a r meas-  ures a r e not e n f o r c e d . Onset o f I n a c t i v e RHD Not  a l l rheumatic f e v e r turns i n t o RHD o f a permanent n a t u r e .  Approximately  one-half o f rheumatic f e v e r p a t i e n t s from ages  twenty to f o u r t y do not get RHD.  Subsequent course - Symptom  f r e e unless c o m p l i c a t i o n s supervene (e.g. c o n g e s t i v e failure), twelve  i t i s p o s s i b l e t o remain symptom f r e e f o r t e n t o  y e a r s , then develop  congestive heart Complications  c a r d i a c i n s u f f i c i e n c y , f o l l o w e d by  failure.  - More commonly found  i n the i n a c t i v e group -  (1) Cardiac i n s u f f i c i e n c y - T h i s i s probably complication. of  heart  the most common  W i t h i n three o r f o u r years a f t e r the symptoms  c a r d i a c i n s u f f i c i e n c y , e.g. f a t i g u e and dyspnea,  appear, approximately  first  5 0 per cent o f the p a t i e n t s d i e i n  s p i t e o f treatment. (2) Heart  f a i l u r e - When the symptoms o f c a r d i a c  ciency are so e a s i l y induced  insuffi-  that the p a t i e n t becomes d i s -  t r e s s e d on s l i g h t e x e r t i o n o r even while a t r e s t , h e a r t f a i l u r e i s s a i d to e x i s t .  Heart  about two years a f t e r the f i r s t are i n evidence. at  f a i l u r e u s u a l l y appears signs o f cardiac i n s u f f i c i e n c y  About 80 per cent o f the RHD p a t i e n t s s u f f e r  l e a s t one a t t a c k o f h e a r t  failure.  (3) Embolism - The source o f emboli  i s u s u a l l y from a thrombus  i n one o f the a u r i c l e s o r a u r i c u l a r appendages. f a r c t i o n i s probably • RHD.  t h e most common embolic  Pulminary i n -  manifestation o f  (99)  (4) Arrhythmia i n g the RHD fifty ed.  - The most common i r r e g u l a r i t y of rhythm a f f e c t -  patient, i s auricular f i b r i l l a t i o n .  per cent o f the rheumatic Arrhythmia  Approximately  c a r d i a c p a t i e n t s are so  affect-  i s most commonly found i n the f o u r t h decade.  About 75 per cent d i e w i t h i n three years a f t e r the onset  of  t h i s complication. (5) B a c t e r i a l e n d o c a r d i t i s - Approximately o f the RHD  cent  p a t i e n t s d i e from t h i s - the m a j o r i t y from a sub-  acute type o f Incidence:  s i x to ten per  infection.  Sex - O r d i n a r i l y equal numbers o f males and  are a f f e c t e d by  females  RHD.  • Race - T h i s i s s t i l l an unknown f a c t o r , although i t i s common to f i n d h i g h e r i n c i d e n c e s among such r a c i a l groups as Negroes i n p a r t s o f U.S.A., where environmental these people  into infectious areas.  C l i m a t e - RHD  i s most commonly found  p a r t i c u l a r l y i n the northwestern British  p r e s s u r e s haye f o r c e d  i n the temperate zones,  areas o f U.S.A. and  the  Isles.  P r o g n o s i s - L i f e expectance i s s h o r t .  .About 50 per cent  live  nine y e a r s , 25 per cent l o n g e r than 17 y e a r s , and o n l y 10 cent longer than t h i r t y  years.  Treatment - Treatment of i n a c t i v e phase i s d i r e c t e d mainly wards c o m p l i c a t i o n s which may Convalescence  per  to-  arise.  - The r a t e o f recovery i s roughly p r o p o r t i o n a l to  the l e n g t h and  s e v e r i t y o f the i l l n e s s .  kept i n bed f o r two  The p a t i e n t i s u s u a l l y  or three weeks, u n t i l f r e e from f e v e r and •  (100)  other  s i g n s of i n f e c t i o n .  Following  t h i s , i s a p e r i o d where  the p a t i e n t i s allowed to s i t i n a c h a i r i n g r a d u a l l y i n g amounts, so that he  increas-  can s i t f o r f o u r o r f i v e hours a  without undue f a t i g u e or reawakening o f the i n f e c t i o n . he i s permitted  to walk at f i r s t only a few  climbing  permitted  tient.  i s not  steps.  day Then,  Stair  u n t i l w a l k i n g comes easy to the  pa-  Where p o s s i b l e , i t i s recommended that the p a t i e n t  moved to a southern c l i m a t e .  I n any  be  event, c o l d , damp e n v i r -  onments conducive to the c r e a t i o n o f r e - i n f e c t i o n , should  be  avoided. Recent experiments have been conducted w i t h c h i l d r e n are  s u s c e p t i b l e to s t r e p t o c o c c a l i n f e c t i o n s .  During the win-  t e r months, s m a l l doses of sulfanamides have been g i v e n them, and  t h i s treatment has  who  to  r e s u l t e d i n a lower i n c i d e n c e  r e - i n f e c t i o n than p a t i e n t s who  were not  of  given such treatment.  APPENDIX B BIBLIOGRAPHY General Reading C e c i l , L. R u s s e l , "Rheumatic Heart D i s e a s e " , Textbook o f M e d i c i n e , P h i l a d e l p h i a and London, W.B. Saunders Co., 1948, 3rd ed. Dunbar, F l a n d e r s , Emotions and B o d i l y Changes, N.Y., P r e s s , 1946. , Psychosomatic D i a g n o s i s , N.Y.,  Columbia  U.  Columbia U. P r e s s ,  1946. .  , Mind and Body: Psychosomatic Medicine, Random House, 1947.  N.Y.,  H i n s i e , L e l a n d , E., The Person i n the Body: An I n t r o d u c t i o n to Psychosomatic M e d i c i n e , N.Y., W.W. Norton & Co. I n c . , 1945. M e d i c a l Adenda: R e l a t e d E s s a y s on Medicine and the Changing Order, N.Y., The Commonwealth Fund, 1947. Richardson, Henry, B., P a t i e n t s Have F a m i l i e s , N.Y., wealth Fund, 1945.  The common-  Ronbinson, George, C , The P a t i e n t as a Person: A Study o f the S o c i a l Aspects o f I l l n e s s , N.Y., The commonwealth Fund, 1939. Stroud, W i l l i a m , D., D i a g n o s i s and Treatment o f C a r d i o v a s c u l a r Disease, P h i l a d e l p h i a , F. A. Davis Company, 1946, v o l . 1, 3rd ed. Upham, F r a n c i s , A Dynamic Approach to I l l n e s s , N.Y., S e r v i c e Assoc. of America, 1949.  N.Y.  Family  Weiss, Edward, Psychosomatic Medicine, P h i l a d e l p h i a & London, W.B. Saunders Co., 1943.  Selected A r t i c l e s  from the J o u r n a l of S o c i a l Case Work  Easby, Mary, "Rheumatic Jan. 1946.  Fever and Rheumatic  Heart D i s e a s e " ,  Eckka, Gordon, "Treatment o f Problems o f Dependency R e l a t e d to I l l n e s s " , Oct., 1942. De La F o n t a i n e , E l i s e , "Some I m p l i c a t i o n s o f Psychosomatic c i n e f o r Case Work", June, 1946.  Medi-  Fitzsimmons, Mgt., "Treatment of Problems o f Dependency R e l a t e d to Permanent P h y s i c a l Handicap", Jan., 1943.  (10E)  Haselkorn, F l o r e n c e and B e l l o k , Leopold, M.D., "A M u l t i p l e Serv i c e Approach to C a r d i a c P a t i e n t s " , J u l y , 1950. Hertzman, J e a n e t t e , "Case Work i n the Psychosomatic D e c , 1946.  Approach",  H o l l i s , F., "The Techniques of Case Work", June, 1949. J o s s e l y n , I r e n e , M., M.D., 1948.  "The Case Worker as T h e r a p i s t " , Nov.,  M a r g o l i s , H.M. M.D., "The Psychosomatic Approach D i a g n o s i s and Treatment", D e c , 1946. , "The Biodynamic  to M e d i c a l  P o i n t of View i n Medicine",  Jan., 1949. Moss, C e l i a , R., " I n t e g r a t i n g Case Work and R e c r e a t i o n i n a M i l i t a r y H o s p i t a l " , D e c , 1946. Rothstein, Mildred, C , ness", D e c , 1946.  "Individual Personality Factors i n I l l -  Ruesch, Jorgen, "V/hat Are the Known F a c t s About Medicine a t the P r e s e n t Time", Oct. 1947. S c h l e s s , B e s s i e ; " A c h i e v i n g Maximum Adjustment ness", D e c , 1946.  Psychosomatic i n Chronic  Ill-  Stamm, I s a b e l , "Understanding the T o t a l Person i n Treatment", Jan., 1946. Yocom, Susan, F o l k e s , "Case Work With the P h y s i c a l l y 111", Nov., 1939. Other S e l e c t e d A r t i c l e s Cohen, E t h e l , " S o c i a l Aspects ,of Rheumatic Heart D i s e a s e " , Wash., U.S. Dept. o f Labour, C h i l d r e n s Bureau, Read before the New England H e a l t h I n s t i t u t e , H a r t f o r t , Conn., A p r i l 16, 1940. Dennis, M. A . . , . "Medical S o c i a l Work"-, Canadian Welfare, Sept., 1945. Huse, B e t t y , "Rheumatic Fever i n C h i l d r e n " , The C h i l d , May 1943« J o s s e l y n , I r e n e , "Emotional I m p l i c a t i o n s o f Rheumatic Heart Disease i n C h i l d r e n " , American J o u r n a l o f O r t h o - p s y c h i a t r y , Jan., 1949. Senn, M i l t o n , J . E., M.D., "Emotional Aspects o f Convalescence", The C h i l d , Aug., 1945. Richardson, E l i z . ,  "A S o c i a l Worker Looks a t Psychosomatic  (103) Medicine", Canadian Welfare, Apr., 1946. R i c h a r d s o n , I l i z . , "An Adventure S o c i a l Worker, June, 1945.  i n M e d i c a l S o c i a l Work", The  S u t h e r l a n d , Helen, M., "General Case Work i n a M e d i c a l and Psyc h i a t r i c S e t t i n g " , B.C.'s W e l f a r e . J u l y , 1949. Yahraes, H e r b e r t , Rheumatic Fever Childhood's G r e a t e s t Enemy, American C o u n c i l on Rheumatic Fever o f the American Heart Assoc., I n c . , 1947.  

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