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Case-work treatment possibilities for alcoholic patients : a classification study of patients admitted… McKay, Anna Isabelle 1951

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CASE-WORK TREATMENT: POSSIBILITIES PGR ALCOHOLIC PATIENTS: A Classif ication Study of Patients Admitted to the: Psychiatric Ward. Vancouver General Hospital during one year, (1950). &m& ISABELLE McEAY Thesis Submitted in Par t i a l Fulfilment of the Requirements for the Degree of MASTER OP SOCIAL WORK in the Department of Social Work 1951 The University of B r i t i s h Columbia ABSTRACT This study is from a soc ia l work view-point and examines the nature and elass i f ication of the cases of alcoholism admitted to the Psych-i a t r i c Ward of a General Hospital., I t gives: par-t icular emphasis: to underlying personality factors and their relation to cause and cure. The case material was gleaned from records compiled by members of the medical staff and de-lineates three categories of alcoholics , namely, (a) those who can be helped by case»work treatment, fb) those who cannot be helped by case-work because of deep-seated problems,but whose families can be helped, and (c), those who cannot be helped by either direct or indirect means. The findings of this study indicate the need for case-work services (a) in screening alco-holic patients who probably cannot benefit from treatment, (b) in deterajjlng the best treatment pro-cedure for those who can be treated, (c) in working with other professional personnel in an: integrated team approach ta treatment, (d) i n helping the patient with rehabil i tat ion from the hospital , and (e), in preventive work in the community. This thesis i s dedicated to Eleanor J . Bradley, Case-work Supervisor, Vancouver General Hospital, for her untiring efforts to improve professional standards in socia l work. TABLE: OF CONTENTS Chapter 1. Treatment F a c i l i t i e s f o r A l c o h o l i c P a t i e n t s The S e t t i n g . Treatment f a c i l i t i e s i n the Psych-i a t r i c Ward. The need f o r a team approach i n treatment. The r o l e of the s o c i a l worker i n treatment:. The purpose* of the study. S e l e c t i o n of Cases. Chapter 2. A l c o h o l i c P a t i e n t s Who Can U t i l i z e Case- Work Treatment Problems w i t h which a l c o h o l i c s r e q u i r e case-work help: - m a r i t a l d i f f i c u l t i e s , , p s y c h o l o g i c a l problems, attempted s u i c i d e * beginning of the a l c o h o l i c * p a t t e r n , i n t e r p r e t a t i o n of other mental c o n d i t i o n s . Chapter 5. Case-Work With F a m i l i e s of A l c o h o l i c s Who  Cannot Be: Treated. I n t e r p r e t a t i o n of a l c o h o l i s m and p e r s o n a l i t y problems to the f a m i l y . The need f o r case-work wi t h fam-i l i e s of psychopathic a l c o h o l i c s , and i n complex f a m i l y s i t u a t i o n s i Helping the f a m i l y understand the need f a r more i n t e n s i v e treatment,or permanent committal to another i n s t i t u t i o n . Chapter 4 . A l c o h o l i c s Who Cannot U t i l i z e Case-work  Treatment The psychopathic p e r s o n a l i t y . Chronic a d d i c t i o n . The r o l e of the s o c i a l worker i n d i a g n o s t i c areas. Chapter 5. P a l l i a t i v e s and Preventatives Summary of cases s t u d i e s . P o s s i b i l i t i e s of case-work treatment i n Ward *R" i n d i a g n o s i s , on the treatment team arid i n e f f e c t i n g r e h a b i l i t a t i o n . Comparative use o f s o c i a l workers i n s i m i l a r s e t t i n g s . The r o l e of s o c i a l work i n prevention. CASE-WORK TREATMENT: POSSIBILITIES FOR ALCOHOLIC PATIENTS s A. Classification Study of Patients Admitted to the Psychiatric Ward, Vancouver General Hospital during one year, (1950). CHAPTER I Setting The Psychiatric Ward, (commonly referred to as Ward •R") i n the Vancouver General Hospital is comprised of thirty beds and is regarded as giving a specialized treatment service. Alcoholic patients admitted here are hospitalized for compara-t ively longer periods than alcoholics admitted to other wards which means that more time can be spent studying: the total prob-2 lem. There is a variety; of reasons why patients are admitted to this ward, but the common factor in a l l cases i s the presence of some symptom of mental disorder. These mental aberrations can be manifested in d e l u s i o n s » . hallucinations, and being but of touch with rea l i ty . The patient may be admitted by his doctor, family, friends or the police for Observation or treatment of some rea l or suspected disturbance. Admissions come from the J a i l or from other wards of the hospital or after an attempted suicide is reported to the, police department. There is no screen-ing process for admission to this ward. Because of this , there is no accurate way of t e l l ing whether or not the patient wants 1. Vancouver General Hospital has capacity for 1200 patients requiring hospitalization for acute conditions. 2. Average hospitalization period for the alcoholic patient in Ward *Rf in 1950 was 4& days. In comparison, the alco-holic patient admitted to the Emergency Ward,.was hospitalized for one day and then discharged home or to another ward for some condition other than alcoholism. * ^ 2 treatment or i f he will" be able to u t i l i ze any treatment he does receive. Treatment ff&cllities Treatment on Ward "RM consists primarily of shock ther-apy, which Is administered only to cases: with an acute disorder. More serious cases, or patients requiring long term orr custodial care are discharged to the Provincial Mental Hospital at Esson-dale where there are f a c i l i t i e s for; intensive treatment• There i s l i t t l e i f any psycho-therapy carried on by the neuro-psychia-t r i s t s on the ward, pr incipal ly because of time limitations im-posed by large numbers of patients on the ward and by their p r i -vate practices. Need for a Team Approach in Treatment There is a minimum of referral made to the psychiatric social worker on the ward for case-work treatment of the patient's emotional, environmental and economic problems which may be creat-ing or aggravating the maladjustment. While the influence of emotional problems upon both mental and physical conditions i s given verbal recognition, i t does not appear to be ut i l i zed in treatment given on the ward at the present time. Treatment, to be successful, should consider the relationship between mind and body and the subsequent interaction of any maladjustment in one area upon the other. This approach treats the patient as a whole rather than aa a part of the whole. Use of this approach nec-essitates use of other specialized professional personnel in the total treatment process. Use of the team is becoming basic in 3 medicine and psychiatry. Realization of the need for soc ia l , psychological, and physical examination prior to formulating a diagnosis is being made by the medical profession. An example of this has been found in treatment of venereal diseases. A few p e n i c i l l i n injections w i l l cure syphilis but w i l l hot pre-vent the patient from becoming reinfected. Nor does p e n i c i l l i n remove the emotional, and social components; of the disease. I t has been proven in the Vancouver treatment centre for venereal diseases that consideration of the emotional and social problems of the patient together with p e n i c i l l i n treatment, has effected a more complete cure. It has reduced recividism and has helped the patient with the personality problems which made him Beek an escape through promiscuous behaviour* Similarly with alcohol-ism? there is need for treatment in a l l areas If the cause creat-ing the pathological need to- escape by excessive drinking is to be alleviated and possibly removed. The presence of a social worker on the treatment team to help the patient with hia social and emotional d i f f i cu l t i e s is becoming recognized as essential . Social Worker in Ward "R* The position of social worker in Ward "R" was created in 1946, for the purpose of helping patients with problems re-. ' \:. 4 lated to their condition, treatment and rehabi1itation. This 3. The treatment team on Ward "R" i s comprised of psychiatrist , doctor, nurse, social worker and occupational therapist. 4. This worker also gives services to the Psychiatry CliniP. in the Outpatients Department, to the Neurology Ward and c l i n i c . More adequate services could.be given i f provision could be^made for divis ion of these services so that there i s a worker on each ward and at; each e l i n i c . 4 job was original ly intended to be a specialized treatment role but s tat i s t ics from the ward show that i t has become more of a routine, fact-finding, short-contact situation; Referrals from the doctors on the ward consist almost entirely of requests for sooial histories and routine work entailed In contacting other institutions or agencies; for pertinent information about the patient, or for placement in nursing or boarding homes. There has been no pattern established for the referrals which the medical staff makes to the social worker. This haa resulted In a haphazard service as each doctor has a different method of re-f e r r a l . Such a situation can be attributed to several factors, the chief: of which would appear to be lack of interpretation given by the social service department to medical staff about what i s entailed in the practice of socia l case-work in a med-i c a l and psychiatric setting^. Recent changes within the department: are improving professional standards and also increasing the interpretation of case^work to> the doctors and other professional staff . Stat-i s t i c a l reports for this br ief period indicate the value of such •i interpretation. With this growing realization of the need for additional case work services for patients admitted to Ward WRM, pressure is being brought to bear upon the hospital administra-tion and the Br i t i sh Columbia Hospital Insurance Commission for additional personnel so that,case-work services, once requested for a l l patients, w i l l be adequate and able to meet the needs of a l l . It is against this background that this study is. pre-seated. Social Work Treatment Processes It may be asked why social case-work is necessary in treatment and how this process can help those with personality problems make a more satisfactory adjustment. Case-work is carried on through the medium of the case-work interview, with the worker assuming a warm, interested, yet objective role,^ The purpose of this interview is to help the worker explore the pa-tie nt*s personality pattern to determine the area of his indiv-idual needs, his a b i l i t y fo r coping with problems and the manner In which he could use case-work treatment for effecting a more healthy adjustment to l i f e * By giving the patient understanding, warmth and acceptance, the worker Is able to help the patient to see himself more clearly in relation to his specific problem and then in relation to his total l i f e . This does not mean that 5 the worker imposes her ideas; upon the patient. The rights of the individual to; selfr-determination are upheld* He is encour-aged with^case-worker's help, to think for himself, and to make decisions for himself. He is helped by a reevaluation of his ideas and feelings, to find a new way of l i v i n g that w i l l be more satisfactory to him. By use of diagnostic s k i l l s , the worker is able to shape the case-^work givem to- meet the needs of the indiv-idual patient, to determine who can u t i l i ze case-work treatment, and who, because of deep-seated personality disturbances, are 5. For purposes of c l a r i ty throughout this paper, "he* w i l l re-fer to the patient, and *shen to the case-worker, unless otherwise specified by context of the histories . unable to profit, from use of case-work as a method of treatment. The case-worker's sk i l l s in treatment l i e in an under-standing of behaviour dyhamles, aa ab i l i ty to help the patient verbalize his feelings and ideas, and an awareness of defenses (devices) used by the patient to cover up or hide his true feel-ings* Treatment s k i l l s cara be u t i l i zed only after a thorough exploration is made of the patient's background and development; an assessment of the total situation should be made by the work-er In conjunction with other members of the treateaent team as a, whole. The treatment tools which are used, as a means of achiev-ing change in the person's outlook include environmental counsell 6 ing, psychological support, and insight therapy. Use of counsell-ing cannot be included, in work with anyone showing personality problems, such as alcoholism, as i t s use i s dependent upon the patient having a; strong; ego and the a b i l i t y to make decisions for himself. Environmen ta l Treatment Environmental treatment should be used when the patient is not able to effect a change in environmental factors himself. Examples of this process would be interviewing relatives to re-^ duce their pressure upon the wife of a psychotic patient or in helping an alcoholic patient obtain employment as a part of re-habi l i ta t ion. In these situations, the worker attempts to modify 6. No attempt in made to effect a change in the patient's basic personality pattern, as this is the areas of deep psycho-analytic therapy, not social case-work. 7 or manipulate certain environmental factors which are creating or aggravating patient's problems and over which he has no con-t r o l * Relaxation of strain In the environment has been found to reduce strain upon the patient, so that he no longer has the same need to escape from unbearable r e a l i t y by means of alcohol, or any of the other escape mechanisms such as drug addiction, suicide, or psychogenic i l lnes s , that i s i l lness without any organic basis. When environmental pressures are removed or mod-if ied^ the patient is often more able to accept treatment focuss-ed on his emotional problems. Psychological Supportive Therapy Both psychological support and Insight therapy treat the emotional problems of patients, but are employed with diff^ erent types of patients, depending-upon their capacity for self-7 help and for achieving emotional growth. Both use different means in working with patients, helping them to work through their emotional problems, to effect a healthier, more normal adjustment. Psychological support is givent to patients who lack suff icient strengths for insight therapy, and who are primarily dependent people with weak ego formations* In giving support to the patient, worker assumes a good-parent role in that she i s permissive and warm, allowing the patient to talk freely about his problems without berating; or be l i t t l ing him. This type of 7 . In this situation the use of "insight^, by social workers has a special connotation and refers specif ical ly to the thera-peutic process in which the patients re-l ive past l i f e exper-iences. This process of re- l iv ing past experiences is called ahreaction. 8 treatment is focussed upon relieving anxiety and gui l t within the patient and in promoting confidence in his ab i l i ty to handle his problem* This helps the patient to function on a more real-i s t i c , more comfortable l e v e l . This does not change him basic-a l l y but gives him psychological support- by his borrowing of strength from the worker. Such an approach Is often referred to as ego-building therapy. The emphasis throughout the process, is on reinforcing: the patient's a b i l i t y to deal with l i f e and i t s problems through guidance,, release of inner tension and re-assurance. There i s no attempt made to develop the patient's understanding of himself unless he reaches the point where his ego has been reinforced suff iciently to permit, him to cope with understanding of his behaviour and reactions. Those with an alcoholic problem have been found to have a personality problem. Use of psychological supportive treatment is usually the best way of treating alcoholics while in hospita l . Any attempt to give treatment ftn a deeper, more intensive level would be too threatening, as the ir limited egos could not cope with such material . While supportive therapy is being given the alcoholic patient in hospital , a change in the environment should be made i f there are any pressures in the home or employment, situations which seem to be creating or aggra-vating the patient's need to escape* The patient's permission is always obtained in working with environmental problems so that, he w i l l fee able to enter in on formulation of treatment and in planning for his future• It Is usually d i f f i cu l t to work 9 with the patient's family as experience has shown families to have problems of their own which must be worked with before any attempt is madef to? help them understand the patient • s con-ditiono It has been found in c l in ic s treating; emotionally dis-turbed patients that use of environmental and supportive ther-apy might be a l l that Is required to remove the cause of the disturbance. Similarly with alcoholic patients, i f the factors causing the need to escape are removed or reduced, there appears no further need for the alcoholic to escape• In such situations, a follow-up programme or referral to; Alcoholics Anonymous is sufficient to keep the patient free of his compulsion to drink. Insight Therapy - In cases where the ego is strong: or has been bu i l t up by environmental and supportive treatment, case-work can be directed to giving the patient some understanding of his behav-iour. This treatment is called insight therapy* It Is only used with those who have the capacity to change thema&lves* Insight; Involves a re l iv ing of current and past emotions in a therapeutic atmosphere so that some of the affect may be dis-charged in order to bring: i r ra t iona l i t i e s so clearly to the sur-face that they w i l l be recognized, at f i r s t in the safety of the treatment relationship and later in real l i f e * This helps the patient become aware of unconscious factors creating his current behaviour; With this form of treatment, the elements of the unconscious are not as deeply explored as ihpycho-analysis , which i s on a much deeper, Intensive l eve l * The growth 10 of the patient in this insight situation i s , to a large extent, dependent upon the phenomena of transference, in which the work-er i s unconsciously identif ied with someone in the patient*s l i f e * usually a- parent or re la t ive . The transference may be positive or negative but usually changes during the emotional growth of the patient in treatment. The worker in this situation is accepting and permits the patient to express his feelings, both positive and negative^and gives him help in understand-ing the basis for them. It is advisable for psychiatric con-sultation to be available for a worker using insight because of the unconscious elements involved. While environmental and supportive treatment are tools used by a l l workers, special training and s k i l l s are required by workers using insight. Hot many of the alcoholics within the confines of this study would be able to use insight therapy without con-siderable work f i r s t being done on the environmental and support-ive levels However, i f the ego could be bui l t to the point where the patient could effect a change within himself, i t might be possible to- give insight. For purposes of this study however, the emphasis on treatment for alcoholics w i l l be in the main, directed at using environmental and supportive ther-apies. With these professional techniques for helping people to work through their emotional and environmental problems, the social worker in the medical setting i s in a key position to work closely with others on the treatment team and to help the - 11 patient u t i l i z e a l l professional and community resources for his treatment and rehabi1ita t i on• Purpose of Study It is the purpose of this study to? discuss how case-work can be ut i l ized, in treatment of a lco lhol ics . Tlie writer recognizes that, not; a l l alcoholic a are able to use this form of treatment, by reason of the deep-seated, nasi.ture of their problems. However, case-work could be ut i l i zed by both pat-ients and families i f a referral of these patients was made by the medical staff to the social worker on the ward. I t was found in reviewing the medical records of these forty-six a l -" " i . . . . . . coholie patients admitted to Ward MRW in 1950 for observation and possibly treatment, that SO percent disclosed problems in marital* economic or emotional'area a, which could, have been and should have been treated by the sooial worker. However, nc re ferra l was made for this help. By this fai lure to use a l l members of the treatment team in treatment, a valuable opportunity was lost in helping these patients work through their d i f f i c u l t i e s . I f problems of the nature to be presented In the following chapters had been worked with, i t Is l i k e l y that these patients would have obtained benefit from hospital-izat ion* If they had received some measure of help either on the Ward or by referral to another agency, their neurotic need 8. Undoubtedly other patients had problems in social and psych-ological areas, but these were either not disclosed, not recorded on the medical record, or were so deeply repressed ita the unconscious area of the mind, that they would have been ex-pressed only by means of deep, analytic therapy.' 12 for alcohol could hare been minimized, possibly removed. Selection of Cases The cases presented in this study were chosen as they represent problems occurring in one form or another in a l l admissions to the Psychiatric Ward. The nature of these problems and the patients' ab i l i ty for helping themselves to> overcome these problems indicate the degree to which the i n -dividual condition can be treated. There are some patients who can be helped to overcome their need to drink excessively i f treatment Is directed to helping them with their immediate problems - either Environmental or psychological in nature. There are other patients who can be worked with by indirect means only, that i s , by the worker modifying environmental pressures upon the patient. Many of the patients in this cat-egory cannot be treated because of deep-seated personality problems} others might be treated i f external or internal, pressures are reduced; For patients who have problems of a psychopathic or progressive type and who are without family t i e s , treatment, oh a case-work level is neither feasible nor pract ica l . However, the case-worker's services could be u t i l -ized in a diagnostic; area with these patients. Cases from each category w i l l be discussed with emphasis on how socia l case-work could be instrumental in helping the patient. CHAPTER' II Treatment Procedure f o r Those Who Can be Treated In t h i s study, a l c o h o l i c p a t i e n t s who can be helped by case-work treatment are those who express problems i n mari^ t a l , economic or emotional areas and who d e s i r e h e l p . Such help i s d i r e c t e d a t changing; or working w i t h environmental c o n d i t i o n s and a t g i v i n g the p a t i e n t p s y c h o l o g i c a l support* In many cases treatment i s not confined to the p a t i e n t , but i s c a r r i e d on simultaneously w i t h h i s f a m i l y . Treatment of the t o t a l s i t u a t i o n has been found to be the most e f f e c t i v e , most p r a c t i c a l way of coping w i t h the problem of a l c o h o l i s m . ' M a r i t a l and P s y c h o l o g i c a l Problems John A., a married man of 46 years, was admitted to Ward "R" w i t h t o x i c d e l i r i u m r e s u l t i n g from a l c o h o l i s m ; He had c i r r h o s i s of the l i v e r and n u t r i t i o n a l anemia* Por the f i r s t few days of h o s p i t a l i z a t i o n , he had paranaddal h a l l u c i n a t i o n s . He thought that a man w i t h a gun pointed a t him was coming through the window t o *get him". He i s s t a t e d to d r i n k h a l f a b o t t l e of whiskey every n i g h t while a t work and s e v e r a l glasses of beer. The p a t i e n t works i n a l o c a l n i g h t club as orchestra l e a d e r . The p s y c h i a t r i s t reported that the "basic cause of the trouble was p s y c h o l o g i c a l , w i t h domestic i n f e l i c i t y as a major problem. He i s recoverable i f he w i l l stop a l c o h o l a b s o l u t e l y . 1.4 It might be- a good Idea- f o r him to go away for a time, as conditions at home do not favour recovery." During h o s p i t a l i z a t i o n , he often repeat-ed that he could not relax as he had so much to do. He missed his children and wanted to return hOm to them. After 35 days h o s p i t a l -i z a t i o n , he was discharged as cured, that I s , the physical problems which had been treated on the Ward had been cured. Nothing had been done about his personality or alcohol prob-lems. The nature of this patient's problems would seem to indicate that r e f e r r a l should be made to the case-worker on the Ward i f the t o t a l treatment process was to have any value f o r the patient. During these 3 5 days h o s p i t a l i z a t i o n , some psych-i a t r i c help should have been directed towards these psychologic-a l problems so that patient could have received some help with his basic problem. Without such help, i t would seem that he could not gain anything concrete from this period on Ward "Rw, that the reasons f o r his being there were not treated or a l l e v -iated, that his problems s t i l l remain and w i l l continue to be expressed by resorting to alcohol or any other escape mechanism. If a r e f e r r a l had been made to the case-worker on the Ward* at the beginning of patient's h o s p i t a l i z a t i o n , information obtained from the s o c i a l history would have brought up the matter of complicated marital, relationships and the patient's problems in adjustment to l i f e . More accurate information concerning his alcoholism would have been forthcoming, so that the t o t a l picture of his problem i n this area would have been presented. T r e a t a b i l -15 i t y could have been determined by a team approach:, that i s , by the s o c i a l worker and doctor discussing Apatlent*s i n d i v i d u a l problems and determining the area which required the focus of treatment. The process of obtaining the so c i a l history could have been therapeutic f o r both patient and his wife, i f used by the soc i a l worker with t h i s aim i n mindi The wife could have ex-pressed her possible g u i l t and concern about her husband's a l c o -holism and- also about the marital problems. In this way, she could have expressed the anxiety and feelings which seem to be within her i n a si t u a t i o n such as t h i s . Case-work directed a t helping her with these problems and in t e r p r e t i n g her husband's problems could be Instrumental in r e l i e v i n g some of the s t r a i n upon p a t i e n t in his home and also prepare the way for his return home. In a case l i k e t h i s , i t Is mandatory that environmental pressures be released so that^patient does not return home to the same problems as o r i g i n a l l y caused him t c e f f e c t an escape by resorting to alcohol. In this connection, i t i s interesting to note that spouses of alcoholics require considerable work both to help them with t h e i r own personality problems and also to understand their spouses condition. It has been found that wives of alco-h o l i c s are often dominating and l i t e r a l l y nag t h e i r husbands into f i n d i n g an escape. Their continued berating attitude to thei r husbands, a f t e r drunken bouts creates a vieious c i r c l e and the continued need to escape. Or, i t may be that the wife 16 -might have a deep-seated need to mother the al c o h o l i c and keep him i n a dependent position, enabling her to be the dominant figure i n the household. Some case-work help should have been given to thi s patient while he was hospitalized to have him express his f e e l -ings about his condition, and the marital s i t u a t i o n . His over-concern about his children, his unrest, his d i s s a t i s f a c t i o n appear symptomatic of underlying problems. These deep-seated problems, with s k i l l e d use of case—work techniques could have been brought to the fore and the patient could have been helped to work through his f e e l i n g s , that is to rearrange his ideas so that they would be more acceptable to the conscious portion of his mind and not create the inner tension which in turn give3 r i s e to the anxiety and alcoholism. Treatment, to be successful, must consider the e f f e c t of the mind upon the bbdyj and must be directed to both areas. I f symptoms only are treated, then the problem w i l l reappear i n a short time or w i l l f i n d --a* new media of expression. I t i a essential to treat the cause i f the roots of the in f e c t i o n are to be removed. Upon discharge from t h i s Ward, r e f e r r a l should have been made to the Family Welfare Bureau f o r marital counselling 9 to continue this modification of the environment. Also i t i s possible that t h i s p a t ient could have been helped by contact 9 * S o c i a l work ethics require that r e f e r r a l s of patients from one agency to another be made Only with the patient's consent being obtained f i r s t . 17 with Alcoholics Anonymous. Referraltto this organization should have been made, so that a member could have v i s i ted the patient before his discharge and discussed the A.A. approach to alco-holism. There should be some form of case-work follow-up from the ward during the post-hospitalizatlon period, as i t is here when the greatest strain Is imposed upon the patient. The need far an escape from rea l i ty arises again as the patient i s con-fronted with a new and threatening situation after the depend-ency of a long period of hospital izat ion. For treatment to be successful and the problem of alcoholism to be dealt with ad-equately, referral to the case worker is necessary in cases involving obvious problems as were indicated in this situation. Treatment with Complex Psychological Problems Other cases present more complex problems than those involved In the case of John A. This next case, for example, shows a patient with deep-seated problems^who might have prof-i t ted from case-work treatment. Mary B . , age 34 years, was admitted to: Ward "R" by police for observation after she allegedly threatened her hus-band with a knife following an alcoholic bout. She l a ter denied this charge, saying that her husband had threatened her with a gun, that she was using the knife in aelf-defense only. The patient, when sober, stated that she never drank heavily unt i l she was married but that she has been drinking considerably in recent months to forget the misery of her mar-riage and her husband's brutal i ty. She has been depressed late ly and has increased her - l a drinking because of this . Her husband'beats' her she "claimed and showed bruises to'substan-tiate her claims. She gets palpitations from fear of 'him and is afraid that she has a heart cbhditioh, C r a i s was later found t.©» hare no-organic- basis) . Both patient and her husband drink heavily. His drinking is reported to have increased dur-ing the last six months since he has been un-employed. The patient states that she useia a l -cohol to take away her problems. She. believes that. "a whiskey sour drives a l l pain away." Physical examination revealed thatpat ient needed a ga l l bladder operation, that she has a functional heart condition and residual low-er extremity atrophy resulting from polio at. the age of 2 years. She has been obese since the b ir th of her chi ld six years ago. Treatment consisted of three insul in shocks to reduce depression and sodium amytal. The psychiatrist called for consultation stated that the patient "showed no insight, has poor judgment but that there is no definite psychoses present." After five days hospital ization, she was discharged to a boarding home to rest for the g a l l bladder operation. Mary B. seemed to be asking for help in marital and psychological aKeas* but help was not forthcoming. Prom the medical history, i t appears that the psychogenic heart condi-tion is the result of personality problems related to d i f f i cu l t -ies experienced in early emotional growth and aggravated by patient's husband * s cruelty. Problems with a psychogenic or-igin can be treated by case-work with a re lat ively high degree of success, usually to the point where the problem is understood by the patient, and the symptoms disappear because pent-up emo-tions, fear, anxiety and hos t i l i ty are released through verbal-• 19 -izatlon father than through symptom formation. There appear to be several reasons why this patient has resorted to alcohol as a means by which she can escape from rea l i ty d i f f i c u l t i e s . However, the primary reason appears to result from the marital s i tuation. In giving case-work help, the patient should be helped to discuss her feelings in this area and to work through the d i f f i cu l t l ea which she i s experiencing. It i s interesting that she made no reference to wanting a spar-atlop from her husband. This could mean that she s t i l l retain-ed enough affection for him that, with help, the problem could be worked through; or that this patient had erected & mental block about obtaining release, from this marriage as: i t might be answering some deep-seated need to suffer and to be punished. The patient's; obesity since the bir th of her chi ld s ix years ago would indicate that there is some emotional prob-lem* possibly on the unconscious l e v e l , in connection with the birth of her ch i ld * It haa been found in other studies being made at the Vancouver General Hospital that obesity is a result of poor emotional adjustment. This condition, In conjunction with patientss alcoholism would indicate that she: requires con-siderable Intensive help in disuseing her emotional problems. From the history* i t appears that she has had health problems since early childhood, that by the nature of these problems her emotional attitudes and. her emotional growth have been re-tarded and possibly distorted. To be helped with these problems treatment should be directed at cuase, rather than at symptoms 20 only, Her i l lness * her obesity,, her alcoholIsm, can a l l be re-garded as an escape from rea l i ty and the d i f f i cu l t i e s encounter-ed in r e a l i t y . Treatment with case-work would be directed; at modifying environmental pressures, giving- ego-building: support and helping the patient to effect a more normal, and healthy adjustment to l i f e . Placement of patient by her doctor in a nursing home to relax prior to; her operation was good procedure as environ-mental pressures upon her were relaxed somewhati However, a long range point of view would have included case-work services to both patient and husband during this period of separation. Some practical consideration should have been made about the chi ld and whether or not placement in a foster home during this period, would be necessary* If there were ho relatives or friends able to look after her* a referral should have been made to the Children!s Aid Society for temporary placement* It i s l i k e l y that help in this area would have lessened the mother's gui l t at leaving her ch i ld . It has been found that parents who un-consciously re ject their children, have strong: gu i l t feelings at leaving them for even brief periods as they are inclined to over-protect rejected children, to compensate for their f ee l -ings of rejection which they are afraid might come to the fore. Considerable help should be directed to working with the husband in this case. However, the r e a l i t y of the lack of time for intensive work with his problems could not be over-looked? this work could not be accomplished on the Ward. 21 -It would seem that, the worker should discuss the poss ib i l i ty of this couple obtaining further help with their marital prob-lems. An intefpretatioh aod Family Welfare Bureau work should have been given, and with their consent, a re ferra l made to? this agency for help with the marital and personality problems. In this way, this couple could have recelved^help requested by the wife and which l a needed so badly. Attempted Suicide Uorah C. would appear to be in need of direct case-work treatment and probably able to prof i t from i t . She was admitted by her landlady because of attempted suicide during an alcoholic bout. Stat is t ics revealed that she had met and married her husband when both were in Br i ta in during the war. She is 33 years old, and a practising Roman Catholic. Patient was a trained- physiotherapiat but had not renewed her pro-fessional a f f i l i a t ions when she came to Canada. She served in the English army for three years and w a a ° s e r g e a n t . Her hus-band was a sergeant in the R . C . A . F . When she and her husband came to Canada* they went to the Okanagan where he wofked on a farm. He stayed here for two years, and was committed to Essondale Mental Hospital because of depression. She stated that she was feeling: de-pressed and had "turned oh the gas" after drinking* She i s lonely and has made few friends since being in Vancouver for two years.. She expressed a wish to die as "there is nothing le f t to l ive fo r " . She gave her occupation as kitchen help in the Vancouver General Hospital . She l ives 22 In a single room"in a large rooming; house near the hospita l . Her work i s " t i r i n g and she Is never able to go; out at night*so that she has had no oppbr-tunity to; make friends.. Psyehlatric examination found her in good health. She was discharged after five days hospital ization. In this ease, there would appear to be considerable scope for the use of case-work in helping the patient to make a better, more adequate adjustment. The only way by which she could achieve this would be through help directed f i r s t a t her immediate problem - probably her wish to die;. Considerable work would have to be done to have her express her feelings in this matter. Case-work would then be directed a t an interpretation of her husband's condition, as this seems to be the basis for her depression and loneliness. Her feelings about his condition should be explored, and she should be helped to express them rather than repress them. She should be helped to get r id of any gui l t she has in connection with his condition and given warm acceptance and understanding so that she does not fee l too threatened, by the release of any threatening unconscious material. It is possible that some insight might be used to help^patlent; rearrange her feelings and ideas, but this would only be possible i f her ego was found to be strong. Considerable environmental help is required. This should be arranged between worker and patient, with patient assuming added responsibil i ty as she improved In mental outlook. Al change in job would appear indicated, i f a more suitable one 23 -could fee found. The services of the Rotary Vocational Counsell-r ?,1*G. A ing Bureau could be interposed and a referral made for a test of vocational aptitude. It is possible that her complaints of being: t ired are emotional in or ig in , but; with the help of the ease-worker and vocational counsellor, she would receive help i n this area* There should also be a referral made, with her consent of course* to the parish priest who; could help patient become interested in church groups and also be able to help her with the religious gui l t she probably is experiencing; with the attempted suicide. I f the patient prefers non-religious com-munity act ivi ty , , then a referral to* one of the many g i r l s and women's clubs would be better. These referrals to clubs and possibly Alcoholics Anonymous would help her to extend her in t -erests and give her a, healthy outlet for her pent-up energy. A discussion of this situation with the Social Ser-vice Department at Essondale Mental Hospital seems indicated so that mere, Inf prmatlon could he obtained, about the nature of the husband's condition. Also information should be e l i c i t ed from this agency to see i f there is any connection between / ^ e . patientts condition and that of her. husband. Some arrangement should be made for follow-up services from Essondale to keep patient informed about her husband'a condition and progress, and also to help her further with her feelings in this area. By the nature of this patient's problems, and the lack of help she received, i t would appear that her problems s t i l l exis t , that she continues to use alcohol as a means of escape. Any benefit that she received from treatment during hospitaliza-tion would seem to be n i l , except for the: rest which she re-ceived, the interest of the nurses: and the companionship of the ether patients, which she enjoyed so much, on the sunporch. With this patient, as with other patients who have problems which could be helped i f they so desired, treatment should be aimed at cause aa weIX as symptoms. Case-work as a: Tool in Prevention of Alcoholism In working with alcoholio patients considerable pre-' ventive work is required with those who? are in the process of forming an alcoholic pattern. Such work should, be focussed on replacing their need for alcohol with some other form of ac t iv i ty in a group situation, preferably a th le t i c , or a r t i s -t i c . It Is also important that those who are in the early stages of alcoholism be; helped to work through their problems so that they w i l l not merely substitute their alcoholism with another form of escape, such as addiction to drugs, sleeping; p i l l s , or, in the ultimate, suicide. In the cases used in this study, a comparatively high percentage of patients showed drug addiction as well as alcoholism; many had attempted sui-cide during an alcoholic bout. Characteristic in the majority of cases in the early stages of alcoholism was the need for help expressed by these patients in marital , employment and emotional areas. As this help was not forthcoming, these pat-ients received another frustration, from which their only means of escape would be to resort to alcohol (and possibly later , • 25 as the oondition progressed* to drugs or to attempt suicide. Early; Stages of Alcoholism The following; case i l lustrates the heed for a pre-ventive approach in case-work treatment of patients who> are in the early stages of alcohol addiction. Pete S., a 24 year old male, single and: a miner by occupation, was brought to Ward WR* by police following a street; brawl i n which he had injured his hose* Restraints were necessary because of patient's combative att itude. When sober, he told the doctor that he and his friends were in town for the week-end to celebrate? that they always "go oh bats", that this i s their favourite recrea-t ion , Whein patient?s physical Injury was treated, and he was sobered up, he was dis-charged. He was hospitalised for 1& days. Caserwork treatment in this case would of course be limited because of the short-term of h o s p i t a l i z a t i o n » However, in cases of this nature, when the pattern of alcoholism is be-ginning to be established* some br ief but intensive service should be made available to: the patient. This could best be accomplished by the social worker taking a socia l history for the psychiatrist or doctor. If this situation was u t i l i zed to the maximum, the history-taking could be therapeutic. Any personality problems brought up by the patient could be dis-cussed and some understanding could be given to the patient about the need for further help. Referrals could be made to the Family Welfare Bureau for help with any personality probl-lems, or to Alcoholics Anonymous. The group ac t iv i ty offered by and the satisfaction through helping other alcoholics • 2 6 <R cam be therapeutic for even those in the i n i t i a l stages of the disease* The most practical way of dealing with the total prob-lem Off alcoholism with the large group of potential alcoholics found in basic induatrles would be to. institute a preventive programme so that patients like this youth could be helped to) redirect their energies into healthful, constructive outlets 10 rather than dissipating i t in drunken behaviour. Introduc-tion of some organized group acti v i t i e s into industrial areas, especially logging and mining camps, would help reduce the in-cidence of alcoholism by giving the workers something concrete to do. Many of the patients in this study told their doctors that they drank * t 0 pass away the time*. These are the people who could use group activity i f there was a strong leader who could help them to. assume, gradually, more responsibility for group projects. In this way, the potential alcoholic could be helped to effect a more healthy type of adjustment. Those with problems requiring case-work help could be referred by the group leader to a local social agency. Case-work in Conjunction with Other Treatment The case of Emma J. points out the need for case-work services being given to a l l patients admitted to Ward •R*, re-10. One half of the male patients in this study was comprised of single men from basic seasonal industries who drifted to the c i t y in winter. 27 gardless of diagnosis. This would ensure maximum treatment being given the patient and would improve his a b i l i t y to u t i l -ize a l l treatment f a c i l i t i e s . In the long: run, this would mean that treatment: standards in the Ward would be improved in a l l areas. A. re ferra l to; the case-worker at admission would also be helpful in formulating the diagnosis and the patient's ab-i l i t y to u t i l i z e treatment. Emma J . i s a middle aged woman who was admitted for involutional melancholia plus acute alcoholism. She was des-cribed on admission as "tense, anxious and down in the dumps". She had been a nurse but since her marriage ten years previous had not worked. She stated that her marriage was happy. Her relationship with her husband whenever he v i s i ted seemed to confirm th i s . Patient said that she could not help herself, she was "so blue*. Medical history showed that patient had her right breast removed 5 years ago; a vag-inal f i s t u l a removed 3 years ago. She re-peated her desire to have had children and wished that she had married before the date she did. Her depression seemed to stem from her frustration in this area. She drank "to forget". She was hospitalized for 14 days and re-ceived 4 shock treatments to relieve pres-sure. When discharged, she said that she "can think straight now". In this s ituation, case-work help should have been u t i l i zed to help patient work through her feelings about the menopause. This would have helped her, in conjunction with the 28 «• shock therapy, to get r i d of pent-up anxiety, tension and fears about her health. It would have given reassurance and support and enabled her to work through her feelings about middle age. Shock treatment does relieve symptoms of depression, but i t does not remove or help the patient with the problems basic to the depression. Interpretation of shock treatment, what i t would mean to her and how i t would help her should have been given by the case-worker to- prepare the patient for this treatment. In this respect, the worker i s able to help the doctor ensure the suc-cess; of the treatment. If a- patient i s not informed about what i s entailed in this type of treatment, fear and anxiety and lack of cooperation prevent ultimate success of the treatment process. Foliow-up interviews with the case-worker have been proven one of the most successful means of sustaining the gains accrued by shock treatment. During this follow-up period, the patient is helped to meet any crises which arise and is: given considerable • support by the worker u n t i l he i s able to cope in a more real-i s t i c , adequate manner with problems which might ar ise . Once thisi patient received help to resolve her prob-lems about menopause i t would be probable that her heed to drink would disappear. There would be nothing from which to escape. Some discussion of this would seem necessary to help the patient talk about her problems In this area, to relieve any g u i l t and to receive help to function without the need for resorting to alcohol whenever frustrations were presented. 29 -Some help should also be given the husband in this s i t -uation to understand the nature of his wife 's health problems, so that there w i l l be a minimum of environmental strain upon her. Prom the type of relationship apparent here, the husband would appear to? be a; strength which should be u t i l i zed in the tota l treatment of this patient* Referral to Alcoholics Anonymous would seem invalu-able here. Contact with this organization would give the >pat-ient a creative experience and might help her to redirect her unconscious mother instincts to; helping other alcoholics , once she herself is able to abstain. While case-work of this nature i s not class i f ied as intensive, i t is; important in helping the individual patient to realize maximum benefits from the total treatment process. In treating alcoholic patients, wtet whole*rather than a part of-the whole must be treated, otherwise, the cause remains intact and symptoms reappear. Summary: For a l l patients to; benefit from hospitalization on Ward MR", i t appears necessary that a team approach be u t i l i zed from the time of admission. This would ensure a l l facets of the patient's problems, - soc ia l , medical and emo-tional being examined, with subsequent treatment focussed on areas which are judged treatable* Such an approach would prove most effective, as patients who have problems which can be helped would have access to- the case-worker. CHAPTER III Case-work with Families when Patients Cannot be Treated Hb experienced person would suggest that a l l alcohol-ics are treatable. But a careful screening system should be in i t ia ted so that time and services of the treatment team can be u t i l i zed to the maximum. With the alcoholic cases admitted to Ward WRw, such a screening process would reveal that there are several reasons why not a l l alcoholic patients can pro f i t from treatment f a c i l i t i e s available at the present time. This 11 includes the presence of psychopathology, of progressive ment-a l disorders such as senile dementia, or the nature of the treatment f a c i l i t i e s available. In many instances where the patients are not able to respond to treatment, some case-work services can be directed to the i r families. This work usually takes the form of. work-ing with the family to reduce pressures on the patient thereby reducing his need to drink as an escape from an unfavourable environment. In time, when environmental pressures are reduced, a patient of this nature may become accessible to treatment, that i s , be able to accept case-work services and profit from them. If the patient's disturbance is too deep-seated to be treated by means of psycho-therapy or shock-therapy, then the 11. Psychopathology w i l l be discussed in Chapter IV, 31 case-worker directs work with families to an interpretation of other treatment centres, such as the Provincial Mental Hospit-a l at Essdndale and helps- the family to work through their fears and gu i l t about committing the patient to such an i n s t i -tution • To determine treatabi l i ty of a patient, the members of the treatment team- should make a thorough study of soc ia l , physical , psychiatric and psychological areas in order to assess the patient's ego strengths, his a b i l i t y to accept, u t i -l i ze and prof i t from case-work treatment, and in order to see in which area most remedial work is required,. Obtaining a social history upon admission would appear to be one of the necessities in the treatment process; A. social history serves several purposes. The information obtained from the patient helps determine his capacity for treatment? the information ob-tained from the family gives a complete picture of the tota l scene and reveals i f the family has any strengths which can be worked with in treating the patient. When a patient is found unable to prof i t from treat-ment, work is directed to his family i f they have been found through the soc ia l history to have suff icient strengths for u t i l i z i n g case-work treatment to help patient with his prob-lems. Work with families consists of interpreting jvpatient • s oondition, his limitations because of this condition and is d i r -ected to helping them work through their feelings aboutpatient's condition and enlist ing their cooperation in the treatment plain; 32 In this way, any pressures which the family were consciously or unconsciously placing on patient are lessened, and possibly eliminated. It has been found in other cases worked with in medical and psychiatric settings that when families are worked with in this manner that, the patient often becomes aible t c accept and u t i l i z e case-work services i f there is ho psycho-pathology present. As in work with a l l patients who have emo-t ional problems and possibly psychiatric d i f f i c u l t i e s , i t l a basic that the family's cooperation be obtained, otherwise the treatment plan w i l l be l iable to f a i l ; With alcoholics this is part icularly true, as help must be given to the family to under-stand that alcohol far the patient' is s t r i c t ly prohibited; The family must be eJbiLped to help the patient l ive within the l imi t -ations imposed by his condition. In thes cases of alcoholicsr diagnosed has having: a psycho-pathic personality; considerable supportive work must be done with the patient's family. As psychopathic personalities are at present considered incurable because of the deep-seated nat-ure cf the discrder, i t is inexpedient to; attempt treatment when the time and energy involved could be used to treat those who would be able to prof i t from treatment. Here again, a complete social history and thorough investigation of^patient by a l l members of the treatment team would serve as a means of determining who is able to use the treatment f a c i l i t i e s of social worker and psychiatrist . 33 In some cases, case-work services have to be direct-ed to helping the patient's family accept the heed for place-ment in Institutions other than Ward "H* or nursing homes. With the 46 patients who were admitted to this Ward in 1950, 6 were discharged to Provincial Mental Hospital at Issondale for further treatment or for incarceration for the remainder of their l i ve s . In cases of this nature, a referral should be made by the doctor to the social worker to have interpretation of the patient's need for inst i tut ional iz ing given to the fam-i l y In order to work through any gui l t or fear they may have. Often, families require considerable case-work to help them understand the: need for further treatment. This work is usu-a l l y intensive in nature as the family quite often feels guilty about their contribution to the patient's condition; They have to> be helped in situations of this type to work through their feelings and to understand that placement i s the best procedure for both patient and family. An interpretation about treatment f a c i l i t i e s should also be given to a l lay any fears the family may have about treatment. In a l l these situations, services given the families of patients f ac i l i t a te the giving of services by other members of the treatment team. The case-worker helps integrate these services and helps the patient accept the tota l treatment plan. Helping the Family of a Psychopathic Alcoholic . Minnie E , , a 42 year old woman was admitted to Ward ttR* by her husband following an unscucessful attempt aat suicide. 34 The husband stated that his wife drinks to, the point of uncon-sciousness. On this particular occassion she had been drink-ing prior to dinner and had passed out while l ighting the gas stove. He appeared anxious to help her and was concerned about her condition. The patient gave a long history to the doctor of marital conf l i c t ; She stat-ed that she would leave her husband.that that she had nowhere to go. They f ight ' constantly especially when she is drunk. Pstlent has been brooding for years about the violent death of her daughter and drinks to forget this*(Nothing further was stated In the record about this . ) Patient spends most of her time "beering, clubbing and gambling.M Her husband's occupation was l i s ted as carpenter. They l ive in a common-law relationship. Patient was hospitalized for one day and discharged when sober. Diagnosis on discharge showed that she had a psycho-pathic personality plus alcoholism. From the information given to the doctor and record-ed oh the patient's medical record, i t would seem that a referr-a l to the social work department would be necessary to discuss the situation with the husband of this patient. His. expression of concern indicates that he wished to obtain some help. At the time of admission, a discussion of the problem with the case-worker would have served to relieve his concern and the un-conscious gu i l t which is expressed in this concern. A dis-cussion with the worker would have helped him to express his feelings about his commonrlaw relationship and also about his wife's attempted suicide. His ego-strength and a b i l i t y to use case work help would also have been determined during this 35 i n i t i a l interview. Brief follow-up v i s i t s to help with pat-ient 's re-adjustment and her husband's understanding of her con-dit lon, should have been Instigated, In this' (and a l l other cases) as i t is usually following discharge from the dependency of the hospital that the need for alcohol both to escape the past and to give comfort is. at a maximum. It: is d i f f i cu l t to know what c r i t e r i a the doctor used for designating this patient as a psychopathic: personality as reasons for the diagnosis were not on the chart and do not appear too evident from the medical history. Despite the pre-sent incurabi l i ty of this condition, i t i s possible that a v i s i t from the ease-worker during her hospitalization would have help-ed her to express her feelings about the attempt, at suicide and possibly relieve some fear and guil t about i t * Her chronic alcoholism and the attempt at suicide show that there are some unconscious reasons for this heed to escape from rea l i ty . How-ever, from the psyc hopathology of this ease, i t would seem fut i le to embark on any intensive form of case^work or psychiat-r i c treatment* Some supportive elements of a brief contact could prove more helpful than detrimental. Because of the marital s ituation, a referra l to the Family Welfare Bureau could be discussed with the patient and her husband. Here, they would receive help in working through their marital problems. A referral of the patient to a consult-ing psychiatrist to confirm the diagnosis of psychopathology would be in order to determine the depth of the condition or i f 36 any treatment, medical or psychological, could be inst i tuted. While the psychopathology of this patient would indicate a poor prognosis, referral to Alcoholics Anonymous could be made as i t might be possible that the therapeutic effect of this group's ac t iv i ty might make some impression on the patient, and give a respite from the chronic condition her alcoholism. Case-work in a Complex Family Situation Tom J . , 42 years old, and a doctor by profession, was admitted to Ward "R" with cerebral edema-, paranoidal halluc-inations and alcoholism. He was stated to have a considerable history of alcoholism and has been in and out of nursing homes in the d i s t r i c t in the last few years, never staying long enough to complete the prescribed treatment. His hyper-activity caused him to be placed in restraint . He cooperated with nurses when sober and, according to the nurses'• report, "acted l ike a l i t t l e boy who knows he has been bad". I t was learned from the history ob-tained by the interne that patient started drinking heavily during the war while over-seas as he learned that his wife was having; an a f f a i r with another man. He subsequent-l y divorced her and retained custody of their daughter, now ten years o ld . She is a "quiet mouse"5, the patient said. She l ives with patient in her maternal grandmother's home. This patient was admitted twice to Ward "R" during the course of 1950. The f i r s t time he was hospitalized for 9 days; the second time for 3 days. At the time of his f i r s t admission, he was engaged to a woman his own age. SHe however, did not wish to get married for "some time" as she did. not desire the responsibility of the chi ld . 3 7 At the time of his second admission, he was married to this woman and i t was she who admitted him to the ward as he was delusional # She expressed concern and anxiety about his condi-t ion . This patient was given several interviews by the psychiatrist during his f i r s t admission. The summary of this contact is as follows: "Patient is reticent and secretive about se l f , mak-ing rapport d i f f i c u l t . His attitude, i s superf ic ia l . He states that he won't drink again. He does not seem to want help and makes no effort to cooperate. He does not seem to be a patient to 12 recommend for antabuse because of this . It would appear that he is using alcohol as a means of escaping from real i ty and his problems." The psychiatrist's remarks indicate that this patient cannot be helped at present because he i s not able to accept help. The intensity of the problems presented would almost suggest the presence of some elements of psychopathology. How-ever as this diagnosis was not made by the psychiatrist , i t must be assumed for purposes of this study that this patient had erected a mental block and was not ready for treatment at this point. As in other cases of this nature, i t would be riecess-ary to obtain a social history to learn more facts aboutApatient'S alcoholism and the specific causes to which his alcoholism-could be attributed. His a b i l i t y to function adequately in the 1 2 . Antabuse is a drug given alcoholics to reduce and possibly eliminate their craving for alcohol . It 's presence sets up a toxic reaction in the patient's body whenever alcohol i s taken. It i s essential that patients cooperate fu l ly in this treatment as the toxic reaction can be dangerous. Antabuse is one of many conditioned reflex treatments. 38 professional f i e l d , his sense of responsibil i ty; in to to-, his ego-strength, would have to be determined before any treatment plan could be embared upon. In this case, with the intensity of the problems, i t would be best to have a psychiatric con-sultant; called in for examination to determine any evidence of psychopathology. While the husband i s hot able to profit from case-work services at this time, considerable work would appear to be necessary with his wife. From her anxiety/ i t appears that she wishes help with her husband's problem and might be recep-tive to help given. As in other cases of this nature, help would consist of^interpretation of alcoholism, and of how she could best help her husband. It would also entail having her work through her feelings about her marriage and about her husband's condition. The fact that she married him when she was aware of his alcoholism i s s ignif icant. It could mean that she i s answering some deep-seated unconscious need to be a^  mother person, to protect him, and nurse him back to sobriety, which would tend to give her a dominant role in the family. Or i t could mean that she married him for economic security, tenuous as i t appears. Any case-work with her would have to take these poss ib i l i t ie s into consideration. It would be essential to have her cooperation in the treatment plan as any attempt to change the situation might be threatening to her unconscious motives and result in fai lure because of that; It would also be in the best interests of the treatment plan i f the worker had the wife talk about her feelings toward 39 her ten year old step-daughter. If this woman was s t i l l re-r jectihg her* i t i s possible that some other arrangement for the chi ld should be made at least unt i l her father's condi-tion could be helped or a l leviated. A referral of this s i t -uation to; the Children's Aid Sooiety should be made i f any evidence^ of neglect - physical or emotional, was found; It might be necessary that some professional interpretation of her father's condition, preferably by media of play therapy, be given the chi ld to help her understand the situation sbsshe won't develop further anxiety or gui l t about i t . Children of alcoholic parent(s) need considerable help in achieving emo-t ional maturity as their parents have usually been unable to; give them adequate attention or affection during the early periods; The background history of this child almost indicates the presence of emotional problems. Her parent's divorce in her early childhood, the loss of her mother while s t i l l young, placement with her maternal grandmother, possible ambivalent feelings towards either or both parents, her father's remarr-iage and her step-mother's d i s l ike of children, a l l add up to the fact.that this child should have some help in understanding herself and her family before she develops further symptoms of the problems which she seems at the present time to be suppress-ing. With engendering a sense of responsibil ity within the wife of patient, i t is possible that indirect help could be 40 given him through her. In this way, environmental pressures would be reduced and the patient's ego-strength might be bu i l t to the point where he would be able to accept psychiat-r i c and/or case-work help. This would be a slow process, but with s k i l f u l work i t could be managed as i t has been in cases dealing with various types of mental disturbance. While there might be need for marital counselling at a later date, a referr-a l at that time could be made to the Family Welfare Bureau. Interpretation to Family of Permanent Committal Sarah G . , a 65 year old woman, was admitted to. Ward "R" by her son and pol ice . She was actively hallucinating and drunk. Her son, an automobile salesman by occupation, gave the following history to the doctor with considerable show of emotion. This patient is reported to have start-ed drinking 20 years ago. After bouts, she would become.demented, angry, resentful. The problem became so acute, that her husband d i -vorced her 10 years ago. He later remarried. Unt i l 1946 aha stayed off-and-on with her son, who l ives in a near-by c i t y . Her drinking became so bad that she was admitted to Bsson-dale for a 4 month period at this time. How«-ever, her son states that nothing was done about her alcoholism, that only her "temper was treated!! She was discharged to her son. He furnished an apartment for her as he preferred that she did not l ive with him. She went on Social Assistance at this time, and l ived i n a different community than her son. Sometime during the last year, she became acquainted with a man of her age* He apparently wanted to marry her but she could not make up her mind. He said he would give her a while to think i t over but was not heard from since. - 41 .SIie\b^came''depfe8se(SE over th i s "and west on a long; binge* She became Violent, and uncontrollable. The landlord, contacted her son and he flew here. During her 4 days' hospitalization she hallucinated actively and appeared to get worse father; than better. Her answers contradicted themselves. She showed a d u l l in te l l ec t . Her son f e l t gui l ty about her condi-t ion and fe l t that she might hot have be-come so bad i f he had shown more interest In her. After considerable doubt and delay he signed her committal, form for Essondale, where she was duly admitted. Her diagnosis was senile dementia.. Although this woman's condition was too far advanced for her to. u t i l i z e any case-work help, her son should have been re-ferred to the social worker for help i n working out his feelr ings of gui l t about placing his mother in the mental hospital . His gui l t and ambivalence about the placement impeded her re-moval from Ward WR" for a. few days. Use of the socia l worker in the i n i t i a l stage of this case would have fac i l i t a ted her discharge to* the ether inst i tut ion and would have made her bed available to another patient. The worker would also have help-ed the son with his feelings so that he could have accepted the placement as, necessary, and realize!that his gui l t was understand-able but not r e a l i s t i c , that the problem was deep-seated and had started during patient's early childhood, but was precipi-tated by matters over which he had no control . Summary It is important to give relatives an adequate inter-42 * pretation of the patient's condition, of the treatment f a c i l -i t i e s so that they wi l l cooperate during the treatment pro-cess and rehabil i tat ion period i f there i s one. However, i t is highly unlikely that there would be a rehabil i tat ion per-iod in a ease of senile dementia-. For re lat ive ' s peace of mind, i t i s essential that they be relieved of feelings of gui l t so that they w i l l not experience a mental disturbance in later years, resulting from accumulation of g u i l t . Case-work help with relatives when placement in mental institutions is being considered, and especially when there are feelings of gu i l t , should be mandatory as a preventive aspect in the to ta l mental hygiene programme. From these examples c i ted, and a careful study of similar cases admitted, to Ward M R n , i t appears that some case-work services to families of patients who cannot be treated is indicated* This service would usually be supportive in nature and consist of given|Interpretation of the patient's condition, of the type of treatment the patient would require and of f a c i l i t i e s in the community for such treatment. Work of this nature with families i s important to reduce any gui l t they might have about the patient's psychological and. alco-ho l i c conditions and to obtain their cooperation in helping: the patient to accept further treatment, such as i s given at the Provincial Mental Hospital at Essondale. It is necessary that families be helped to know community resources so tha.t 45 the family problems being expressed In the patient by his alcoholism and maladjustment can be modified or removed be-fore such problems emerge in similar or other forms in other members of the family. Considerable work, preventive and therapeutic, can be done with families in this respect even though the patient is considered not able to prof i t from case-work treatment per se. CHAPTER IV Patients who Cannot Ut i l i ze Case-work Treatment, Direct ly or Indirectly.. Case-work cannot help in the treatment of deeply-disturbed alcoholic patients when their families are also disturbed or when the patient has los t contact with them. The presence of psychopsthology or of progressive mental dis-order (such as senile dementia) rules a patient untreatable as far as. use of case-work services is concerned. Nor i s i t possible to, treat a patient, with any degree of success when he does not desire treatment. In this connection, i t i s interesting, to note that a basic step in the Alcoholics Anon-ymous programme is that the patient must earnestly wish help and seek i t himself. However, there is a place for the social worker in helping the team to* evaluate the condition and to arrive at the diagnosis. This consists of interviewing the patient, his family, and others who could give information about his behaviour, background and social adjustment. Definition of Psycbbpathology/ The question might be asked why those diagnosed as having psychopathic personalities cannot be treated. Were a simple, standard, definit ion of what constitutes psychopaethol-ogy agreed to among psychiatrists and doctors, the issues in this problem would be less acute. However* there is no such agreement* Confusion surrounds this condition and i t s treat-ment. Psychopathology is considered a medical paradox. The patient is judged sane by standards of psychiatry, aware of a l l the facts which we ourselves recognize and free from de-lusions but conducts himself in a way quite as absurd as any-' : 13 thing found among the psychotic." For general purposes, a psychopath can be described as a person who appears normal up to a point but whose social behaviour and character are deviant. This type of personality has been found to be ir*» responsible, unreliable, insincere; to have poor judgment, an inab i l i ty to learn from experience, a pathologic ego-centr ic ! ty and inab i l i ty to form mature relationships with people. He has no anxiety over his antisocial behaviour and is unable to carry out any effective l i f e plan. There i s , however, an absence of delusions and other signs of i r ra t ion-a l thinking, an absence of "nervousness * or psychoneurotic manifestations* An early name for psychopath and now dis-carded, was, "moral insani ty . * Lack of Treatment F a c i l i t i e s Because of this lack of psychotic characteristics, a psychopath cannot be kept in a treatment centre, such as the Provincial Mental Hospital as he is not regarded as 13. Clecklev. Hervev. The Mask of Sanity. St. Louis, The C.V. Mosby Company, 1950, p. 395. 4& legal ly insane. He can admit himself for "treatment", but because of this and his non-psychotic condition, can leave at any. time* Because he lacks anxiety about his condition, and does not feel guilty about his antisocial behaviour, he has no true desire to get better* This is the antithesis of the neurotic personality whose anxiety and confl ict create m desire to get better* Not being able to form meaningful relationships, i t i s impossible to; conduct case-work or psych-ia t r i c therapy with a psychopathic personality. Nor are there any treatment centres where this type of patient can be help-ed or kept under supervision to prevent continuation of irres-14 ponsible ac t iv i t i e s . Relationship of Psychopathology and Alcoholism The combination of alcoholism and psychopathology is common, in fact i t is often thought to be inseparable* But this does not mean that alcoholism is a causative factor of" psychopathology (or vice versa) as many seem to believe* Dr. Cleckley states in this respect that Alcohol w i l l not bring out any impulse that is not already in a personality, nor i s i t l i k e l y to casfe behaviour into* patterns for which there i s not already significant 14. In 1947, a Canadian law. was passed respecting "habitual criminals" . This law provides for indermlhatet prison . sentence for those who have been convicted three times for the same indictment., the sentence of which must be five years or more. 47 sub-surface predilect ion. The alcohol" merely facIIItates expfession by narcot-iz ing inhibitory processes.1-5 The psychopath's emotional make-up being what i t i s , he re-quires l i t t l e alcohol to make him act In hia characteristic irresponsible way. It has been found that psychopaths a t t r ib-ute their problems to drinking, but that i s usually another indication of their need to project blame on a- source other than themselves. Role of Case-worker in Work with Psychopathic Personalities The case-worker's role in treating alcoholic pat-ients who are also; psychopathic, is therefore l imited. How-ever, before the diagnosis of psyc hopavtho 1 ogy i s made, the psychiatric case-worker should obtain background information from the patient*s family, friends and physician in order to give a complete picture of the patient*s social and psycho-logica l problems and his behaviour pattern to, ethers on the treatment team. This process i s not followed in Ward"R*. This team approach seems necessary to ensure accurate diag-noses of the total problem and eliminate the poss ib i l i ty of psychopathology becoming a "catch-all t t for alcoholic patients. C l i n i c a l evidence does not point to any success In treatment of psychopathqlogy by changing the environment or modifying the family's attitude towards the patient. These measures prove fut i le aa the drives in the psychopath are 15. Cleckley, op. c i t . . p.362;, 3 0 strong that as soon as he Leaves a protected environment he usually returns to his pattern of i rregular i ty and incon-sistency. However,! as pointed out In the previous chapter, case-work with families of such patients i s invaluable i f they are able to u t i l i s e i t . With patients whose families are also disturbed, such work Is f u t i l e . Case-Study The case of Clara M.. shows how alcoholism and psycho-- » pathology compliment each other and also, why case-work and psychiatric treatment, is not feasible with the present limited knowledge of this condition. This patient, a 36 year old graduate nurse shows a long aeries of irresponsible behaviour jand an inab i l i ty to prof i t from past experiences. She showed no anxiety at her unsuccessful attempt at suicide (by an over-dose of sleeping p i l l s ) and shrugged i t off by saying that she had often thought of doing i t before. Her manner about her problems was casual and she showed no concern or remorse. Towards the end of hospitalisation, she thought that she had made this attempt at suicide to attract some attention, which she thought true of a l l her deviant behaviour. She inte l lect-ualized freely about her abnormal reactions but this was found to be on a superficial level and she displayed no interest in changing her ideas or practices. During her ten days hospital-izat ion, she showed no signs of wishing treatment and was stated to be "sarcastic:, hyperactive and belligerant" whenever 49 the psychiatrist or interne spoke with her. The history recorded by the interne: shows patient* s distorted sense of values and '" ~" deviant behaviour dating back to pre-school days. She was described as " incorr ig ible" by her teachers and considered a "strenuous person to l ive wi th , * (Patient volunteered this information and seemed proud of her record). Pollowing graduation as a nurse, she married and put her husband through medical school. He obtained a divorce from her because of her "constant affairs and irresponsible behaviour". He received cus-tody of their only c h i l d , now 7 years: o ld . Her behaviour became worse after t h i s , ahd-she: was more promiscuous and began drinking heavily. Her work pattern, never too stable, became steadily worse. She "never made a. success of anything and never tr ied t o . " At this time she began taking barbituatea and heavy doses of sleeping p i l l s . She jo in-ed Alcoholics Anonymous for a few weeks but soon quit as she- "could not l ive without l iquor * . By the nature of the patient's behaviour and symptom-atology, a. diagnosis of psychopathology was made. Her a t t i -tude was described as being "far from pleasant". Her inab i l i ty ta form any relationship with the psychiatrist and interne and her lack of desire to get better made i t impossible to em-bark on any treatment plan. Hbr was i t possible to work with her family thereby giving the patient an indirect form of treatment. The patient's family background was r i g i d * Her parents, both over 70 now, have: never permitted the word "alcohol" to be spoken in their presence, despite the fact patient, a maternal aunt and patient?s brother are alcoholics of long standing. She has poor relationships with a l l members of the family and i « jealous of them a l l . 50 The: patient v i s i t s her home frequently although she has hot l ived there for some time how:; "These v i s i t s are characterized hy cohstant fighting with her parents; over her: "Immoral, irresolute ways". This , patient considers, is "great sport1* and takes a vicious delight In "stirring; up trouble" wherever she goes. When the diagnosis of psychopathology was made and the patient had recovered from the effects of the excess dose of sleeping p i l l s and alcoholism, she was discharged to her parents* home. She was hospitalized for a tota l of ten days. Although this patient is regarded as being hot able to prof i t from treatmentj i t does not mean that there Is no place for the caseworker in the total s ituation; Case-work help in determining, the social and psychological problems in cooperation with other members of the treatment team would appear necessary to arrive a t a complete diagnosis in each area* Such work is not technically regarded as treatment as treatment is aimed at rel ieving the psychological problems and helping the patient to effect a more adequate form of l i v i n g . It might have been possible for the worker to dis * cuss the patient's discharge with her family, although in view of their r i g id i ty and patient's condit ion, i t i s highly possible that she w i l l not stay home long but w i l l l i k e l y return to her old ways. Chronic Addict Another type of alcoholic patient who could not prof-i t from treatment is the chronic addict who has no family t ie s . This patient is usually regarded as the •drunken bum" found on the "skid-row**, although he can be found in any strata; of society. While there may be elements of psycho-pathology in their emotional structure, such patients are not technically regarded as psychopathic personalities because they present delusional behaviour and temporary psychotic features, resulting from a toxic reaction to a lcohol . Such delusions, are not. thought to. occur in the true psychopath. These patients* addiction to alcohol over a period of years has dulled their senses. They do not, express any desire to get better, may have limited intelligence and l i t t l e i f any ego-strengtba with which the worker or psychiatrist may work to effect, rehabi 11 tat ion. Case-work with Chronic, Addicts Case-work on a treatment l eve l with these patients in this category appears impossible. As the patient's type of personality i s not usually known upon admission (unless he is a rec iv id i s t ) there is a need for assessment of social and psychological factors to determine his t reatabi l i ty . How-ever, the patients admitted to Ward "R* axe not automatically referred to the case-worker by the doctor for a social hist-ory. As a result , several days, often elapse before the doctor, psychiatrist or interne are able to obtain diagnostic informa-t ion from the patient. If such a procedure of referral were 52. the rule rather than the exception, the social, worker could determine the depth of the patient*a problems and. act oh a diagnostic l e v e l . She could point out urgent situations to the doctors and help them in working with the more agitated patients. In conjunction with the psychiai.trist, the worker could discuss the patient's problems in soc ia l , environmental, emotional and physical areas and decide upon the focus (or foci) of treatment which the diagnostic; facts indicate. In cases showing; a chronic addiction pattern, the presence of temp-orary psychotic features and the patient's lack of interest in treatment, case-work would be on a routine fact-finding l eve l , but would nevertheless be important in formulating; the diagnosis. The case-worker could discuss the patient's prob-lems and his pending discharge with any agency with which the patient was in contact, making joint plans, with the help of the patient, once he became rat ional . Case-Study Annie W., a: 57 year old Indian woman, was brought in by the police after being picked up on the "skid-row" where she had been drinking canned, heat with a group of Indians and whites. She was vomitting considerably upon admission and was hallucinating actively^ - speaking to some friends who were supposedly on the c e i l i n g . She was found, to have a 17 year history of alcoholism, l i t t l e i f any understanding of her con-dit ion and no desire to effect a change. Her l i f e centred in the "skid-row* area. Her condition was too far gone for any treatment to effect a change. 53 Ori adsri.ssion she was placed in~re-straint as she was paranoidal arid v iolent . Further "exaiiination wheni sober revealed: tEat; sfie was' quiet , "withdrawn' ani d u l l in intel l igence. She gave a long; history of Instabil ity and promiscuous: behaviour; She has been married but her husband deserted after the bj^th of a second i l legit imate chi ld 12 years ago. She had 3 other chi ld-ren by her husband• She is unable to work because of poor health arid has been in re?> ceipt of Social Assistance in the amount of #35.00 per month for several years. Her poor health is attfibuted to venereal i n -fection she contracted during her youth. The attending'psychiatrist stated that, her "chronic state of alcoholism is unlikely to be modified by treatment". In this ease a referral was made to the social work-on Ward "R" to arrange for placement on discharge. Contact was made with the City Social Service office which was admin-istering the Social Assistance but there was no information about family or resources which could be u t i l i z e d in arrang-ing placement for this, patient; The patient decided to v i s i t a friend in Steveston, a neighboring town, to recuperate after hospital izatlon. Arrangements were made by the socia l worker oh the Ward to f ac i l i t a te patient receiving her Assistance cheque upon discharge as she would be moving outside the jur-isdict ion of the Municipal Welfare off ice; This case should have been referred to the case* worker upon admission for a diagnostic history in socia l and psychological areas. If this had been done, the worker would have been aware of this patient's need for placement oh dis-54 charge and could have helped her make the necessary arrange-ments. This would not have prolonged her stay i n hospital which was what happened when she announced that she had no place to go when the doctor told her that she could be d i s -charged. It was at thi s point that the case was referred to the s o c i a l worker. While i t i a recognized that case-work treatment i s not p r a c t i c a l f or psychopathic p e r s o n a l i t i e s or chronic addicts, the need for the s o c i a l worker i n diagnostic areas and arranging placement i s e s s e n t i a l . CHAPTER V Summary of Cases-The alcoholic patients admitted to the Psychiatric Ward represent only a small portion of the tota l number of alcoholics in Vancouver. However, the patients in this study appear to present problems regarded as common to alcoholics , with many stating; problems in marital , emotional, family and f inancial areas. These patients were drawn from a l l strata: of society. A l l were admitted to this Ward for observation and possibly treatment of some suspected or rea l mental dis-order. Alcoholism was l i s t ed as secondary to the i r mental 16 aberrations. The cases presented in this study indicate that there are three categories: of alcoholic patients; namely, Ca) those who can be helped by case-work treatment, (b) those who cannot be helped direct ly because of deep-seated prob-lems but whose families can be helped, and (c) those who cannot be helped by either direct or indirect means because of the present lack of resources. These cases point out the need for case-work services in screening out alcoholic pat-ients who probably cannot benefit from treatment, in deter-mining the best treatment procedure for those who can be 16. Alcoholism only is not sufficient reason for admission to either a General Hospital or to a Psychiatric Ward; i t is usually treated in private nursing homes. treated^ in working with other professions in an integrated team approach to treatment* in helping the patient with rehab-i l i t a t i o n from the hospital and in preventive work In the com-munity. For thia procedure to be adopted there would have to be a re-evaluation of the role of the case-worker on the Ward. Diagnostic Role of the Social Worker For services of this Ward to be u t i l i zed to the max-imum* there i s a need for alcoholic patients being admitted to .s- " ' ' • 1 7 be carefully screened. Such a screening process would ensure that treatment f a c i l i t i e s were being used profitably and by those who could prof i t from them. Patients diagnosed as psychopathic or as having; a severe mental disorder could be discharged or referred to other institutions:. To be effective, this screening process would have to take place before patients were admitted to the Ward, or at least during the f i r s t few days of hospital ization. In this way, some of the over-crowding and waiting; l i s t s would be eliminated, as would the tendency for patients to remain in the Ward when they are no longer in need of observation or treatment for a mental condi-t ion . Given the opportunity, the social worker could play an important role in the screening process. In conjunction with the psychiatrist and doctor, she would assess the pat-ient 's condition and h i s ab i l i ty to prof i t from treatment. 17. These suggestions could apply to a l l patients being ad-mitted to this Ward, not only to the alcoholic patients. 57 The screening process would depend oh obtaining a- social history* that i s , information from the patients * doctor, fam-i l y and possibly from the patient himself, concerning his condition and any related problems- In this discussion, the social worker would be in a good position to make referrals elsewhere i f the nature of these problems did not merit ad-mission or treatment in the psychiatric ward. During the process of taking the social history the worker could gain knowledge about the patient * s behaviour pattern, his past adjustment, and whether or not help could be given to his: fam-i l y to help them understand his condition and possibly to re-duce environmental pressures on the patient. When the inter-viewing is done by i sk i l led person, obtaining the social hist-ory can be & therapeutic process for both the patient and his family. Problems could be dealt with as they arise in the interview* Such information would be invaluable in determin-ing diagnosis, the type of treatment which would best meet the patient's needs, and In assessing his a b i l i t y to profit from his current experience, from medical treatment and from help directed at hie family. The Social Worker's Position on the Treatment Team Because she. possesses the professional techniques for treating social and psychological problems which are- creat-ing or aggravating maladjustment in the patient, the psych-i a t r i c case-worker should have an important position on the treatment team. Case^work treatment should be available to a l l patients admitted to this; Ward* The best way for patients 58 to learn of this treatment would be from individual interpret-ation by the case-worker. Such interpretation would help the patient to understand what is involved in treatment of his condition, and how the worker can help him with problems he may be experiencing in any social or psychological areas* In these ways, the social worker can help Integrate the work of a l l members of the treatment team, and help the patient to make the maximum use of a l l treatment f a c i l i t i e s . Rehabili tation from the Ward. Helping the hospitalized patient to make an adequate plan for rehabil i tat ion upon discharge is essential in pre-venting further breakdown. For the a lcohol ic or in fact, any disturbed patient, the patient's change from the dependency of the hospital to the pressures and tensions of the outside world, i s often sufficient to create a need to escape from unpleasant r e a l i t y . As a result, many alcoholic patients dis-charged from the psychiatric ward are returned to hospital , (not necessarily to- this. Ward), with functional disorders or for injuries received during an a lcoholic bout. Some are placed in j a i l on drunken or vagrancy charges. Helping the patient to make his own plans for rehabil i tat ion i s one way of helping him to work through any problems he may have about his discharge. In this way, case-work can be therapeutic. In many situations, the patient has further need for help with problems which do not necessitate a. follow-up from the Ward. As the social worker is aware of the patient's problems 59 and also aware of community resources, she i s in a position to put the patient in touch with the agency most suited to helping him. The case-»worker, with the patient's permission, then contacts the agency/ or organization most suited to help-ing him, explains the nature of the patient's condition, and discusses her contact with the patient and asks that this: agency "*e help the patient further. The agencies to; whom a l -coholic patients can be referred are varied. In this study, referrals to the following professionally-staffed agencies were discusses^ The Family Welfare Bureau for marital and family counselling; the Childrens Aid Society for temporary placement of children and for help with disturbed chi ldren; the Rotary Vocational Counselling Service for intelligence testing and vocational guidance; City Social Service Depart-ment for f inancial assistance. Referrals to Alcoholics Anon-ymous,"-' Society of ex-alcoholics who help alcoholics to ab-stain^are made in the same way as referrals to agencies for professional help. In some cases, an intensive follow-up service from the Ward i s necessary to prevent further breakdown. In these ways, the case-worker i s able to work on both treatment and preventive levels . However, fbllow-up can be done most effectively If the worker has had contact with the patient from the time of his admission to the ward. The use of more intensive case-work services to a l l patients on this Ward indicates the need for additional professional social work staff or for a reduction of the rout-ine work and removal of the Neurology Wards and Cl in ic from the work of the present psychiatric case-worker. By working only in the Psychiatric Ward the worker would have more time to de-vote to the necessary interpretation of her job t» other pro-fessional groups in the hospital . This would improve their understanding of what Is entailed in social work in a medical setting and would be a. basic step towards the goal of having; a l l patients with psychiatric problems referred to the social worker upon admission. Also, with more time at her disposal, the worker could conduct some research pmjects concerning case-work services on the Ward, which is another way of improving the standards of services given to the patient. Comparative Use of the Case-Worker in Other Institutions At this point the question could be very well asked i f the social worker's services are being used in a: s imilar manner in other psychiatric settings. At the Montreal Neuro-logica l Hospital, a social worker is in charge of screening patients for admission. Psychiatric consultation services are available to her i f there is any question concerning a patient. Only those who appear able to prof i t from hospitalization in this ins t i tut ion are admitted. This plan is meeting with success and is proving that a l l services can be ut i l i zed in a more pract ical * eff icient way, and that treatment standards can be improved i f such a screening process is instituted in 61 psychiatric settings. Use of the social worker In screening alcoholic patients and in determining diagnosis and treatment is becom-ing an integral part: of procedure in c l in ic s dealing only with the problems of alcoholism. The Yale C l i n i c , which started in 1944, has served as a model for s imilar c l in ic s in the United States. This C l in ic u t i l i ze s the social worker in treatment which consists of work with patients:, families and interested friends. The basis of this C l i n i c ' s approach is a detailed study of the individual . Emphasis Is placed on helping the patient with those emotional problems which are d irect ly or indirect ly conducive to drinking, and on removing any of the various pressures which create the need within the patient to drink to excess. Another service this c l i n i c is giving to; the f ight against alcoholism is in arousing public interest in the pre-ventive aspects of alcoholism!. Its emphasis on this l eve l i s that treatment of the total personality is the most pract-i c a l , economical approach to the problem. This interpreta-tion is increasingly serving as an incentive to other commun-i t ie s to establish treatment centres, and to cope more ade-quately with the fight against alcoholism. As a result of this public relations programme, treatment centres are developing in a l l parts of the United States. Typical of such centres i s the Information and Re-habil i tat ion Centre for Alcoholism at the University of Buff-62 alo Chronic Disease Research Institute. The purpose of this Centre is to help and treat people whose excess use of alco-hol interferes adversely with their daily lives; : to demon-strate the public health services which are essential for case-finding;, treatment, and control of alcoholism in the patient and in the community; and to cooperate with the pub-l i c and voluntary rehabilitation services in the care and treatment of alcoholics:. The Centre's objective is; reached through the application of knowledge and s k i l l of internal medicine, psychology, soc ia l work and psychiatry working to-18 gether as a team uni t . This Centre has instituted a screening process for patients so that the c l i n i c staff can be u t i l i zed to the max*. Imum. The screening process"consists of a. study of social and environmental factors Influencing the patient*s condi-t ion, a physical examination, and a psychological test as to, mental status* When this is completed, there i s a staff conference on the findings of the tota l examination to deter-mine whether or not the patient's background and condition is such that he w i l l be able to benefit from treatment. Each case i s treated individually so that a l l needs can be met wherever possible. The purpose is not only to soien out those who; probably cannot benefit, but, to decide on the best possible treatment for those who. can benefit from treatment. The lat ter also i s only possible i f the case i s conferred on. 18. Palkey, Bruce, Chief Information Centre a t University of Buffalo, le t ter to writer, May 5> 1951. 63 Plans for a Treatment. Centre in Vancouver To date, there has been no c l i n i c established in Canada for the exclusive purpose of treating alcoholic pat-ients* However, plans have been under way for some time in Vancouver for formation of an Alco l i c Foundation for the treatment of alcoholics who could profit from treatment. Est-ablishing such a c l i n i c entails many problems, such as obtain-ing adequate space, experienced staff, and adequate f inancial support. This Foundation is intended to be a. nonfprofit org-anisation of private citizens who are interested in the treat" merit of a lcohol ics . Financial support at f i r s t w i l l be drawn from the members of the Foundation* but i t i s thought that government funds might be obtained once the C l in ic begins op-erating. In addition, i t is intended, that fees w i l l be col lect-ed from those patients who are able to pay. Procedure on the l ines of the Yale Plan w i l l be used for diagnosis and treatment. It Is also interided that there should be u t i l i z a t ion of socia l workers in screening, diagnosis.* treatment, and rehabi l i tat ion. This proposed Foundation is being endorsed by the Community Chest and Council of Greater Vancouver in accordance with recommendations made by this group following a study during this last winter of the problem of alcoholism in this community. Suggestions for Treatment on Ward "R* The service offered a l l patients in the Psychiatric - 64 Ward at the Vancouver General Hospital could be improved i f there was a re-evaluation of the treatment approach and air introduction of the team method as outlined in the cases pre-sented in this study and as u t i l i zed at the Montreal Neurolog-i ca l Hospital and the Yale and Buffalo C l i n i c s . Preventive: Role of the Social Worker As well as recognizing the need for improved treat-ment f a c i l i t i e s to cope with the problem of alcoholism, there must be a preventive programme adopted in the community. Such a programme. to> be successful, must deal with cause rather than with symptoms alone. Mental hygiene, counselling and treatment f a c i l i t i e s should be improved in a l l areas; and for a l l age groups; but the main improvements in these areas should be directed at helping children so that emotional problems, which later contribute to the"formation of alcoholism, can be deaith with in their early, formative stages. Parents should be helped to; understand the process of emotional growth in their children, and access to professional help with family problms should be facilita-ted. Existing; treatment f a c i l i t i e s such as Child Guidance Cl in ics and Family and Childrens Ag-encies should be enlarged and improved in both personnel and professional standards so that adequate help w i l l be available for those who require I t . Treatment for behaviour, problems» which are usually symptomatic of d i f f i cu l t i e s in adjustment, should be introduced in the schools so that such problems can be worked through before they become deep-seated. 65 The introduction of a course called ^Effective L iv ing * Into high schools in B.C. i s a step in the r ight d i r -ection. This course is designed to prepare students to cope with the problems which they w i l l encounter in l i f e * It also embraces a. course on education about the excessive use of a l -cohol. The education authorities in the province recognize: that such a course w i l l not prevent problems from occuring but feel that i t w i l l help students to understand the nature of the social responsibi l i t ies which w i l l confront them as they mature. In connection with this course, some treatment personnel, preferably a psychiatric social worker, should be introduced into a l l schools so that any emotional maladjust-ment can be coped with before developing Into a serious soc ia l problem* While introduction of these additional services might be considered as expensive, i t appears necessary that some preventive measures be introduced so that the total losses 19 suffered by society because of alcoholism can be reduced. The goal towards the prevention of alcoholism would appear to be best effected by u t i l i za t ion of an integrated professional team approach In attacking the underlying: person-a l i t y factors and their relation to cause and cure. 19. John Beaufort in "Alcoholism - Do You Know the Answer?" states that, the economic loss chargeable to alcoholism rums close to a b i l l i o n dollars per year in the United States. The expenses estimated for 1950 include: #432,000,000 « potential wage loss 188,000,000 - crime 81,000,000 - hospital and medical care 89,000,000 - accidents 25,000,000 - maintenance of drunken persons in local j a i l s . 66 BIBLIOGRAPHY BOOKS 1. Alcoholics; Anonymous, New York, Works Publishing: Inc. , 1939. 2. Alcohol. Science and Society, New Haven Conn., Quarterly Journal of Studies on Alcohol, 1945. 3. Brown, Junius FV and Karl A . Menninger, Psychordynamios of Abnormal Behaviour-, New York, McGraw«-Hill, 1940. 4* Carrol , Robert 3 . , What- Price Alcohol?. New York, MacMillan Co. , 1941. 5. Cleckley, Hervey, The Mask of Sanity. St, Louis, Mosby Co., 1950. 6. English, O.S. arid G.H.J.Pearson, Emotional Problems of Living, New York, W.W.Norton Co, , 1945. 7. Haggard, Howard W., and E.M. Jel l inek, Alcohol Explored, New York, Doubleday, Doran and Co.* 1942. 8. Harvey, Alan B . , 1949 Supplement to. Tremeear's Annotated Criminal Code of CAnada. Toronto. Carswell. 1950, pp. 95 «* 105• 9. H o l l i s , Florence, Women in Marital Confl ict , New York, Family Service Association of America, 1949. 10. Karpman, Benjamin, The Alcoholic Woman, New York, Linacre, 1950. 6? -11. Lowrey, lawson G . , Psychiatry for Social"Workers, New York, Columbia University Press, 1950. 12. McCarthy^ Raymond G . , and Edgar I I . Douglass. Alcohol and Social Responsibility.New York, Thomas Cromwell and Yale Plan C l i n i c , 1949. 13. Menninger, Kar l , Man. Against Himself. New York, Harcourt Brace and Co. , 1939. 14. Menninger* Wm... Psychiatry in a Troubled World, New York, MacMillan Co . , 15. Sapirstein, M.R.* Emotional Security. New York, Crown Publishers, 1948. 16. Strecker, Edward A . , and Francis T. Chambers, J r . . Alco-hol t One Man's Meat. New York, The MacMillan Co.,1941. ARTICLES and PAMPHLETS 1. Beaufort, John, Alcoholism - Do You Know The Answer?. Vancouver* B .C . * Vancouver Committee for Education on Alcoholism, 1951. 2. B e l l , R.G. "Alcoholism - What is the Answer?" Health. Toronto* Health League of Canada, May-June, 1949. pp. 13, 32-4. "Could you Become an Alcoholic?" Health, Toronto Health League of Canada, Jan.-Feb.1949, pp.1, 26. "How you Become an Alcoholic? Health. Toronto, Health League of Canada, March-April,1949,ppl9,22-23. 3 . ^ B e l l , R . G . , "Alcoholism*, Health. Toronto, Health League of Canada, Jam.-Feb.* May-June* 1949. - 68 4. Block, Marvin "AV, "The> Community Concept/*'av. New Approach, to Alcoholism", Partners:, - The Magazine of. Labor  and Management, New York, March, 1950* 5. Block, Marvin A , , The Problem of Alcoholism!, New York, Western New York Committee for Education on Alco-holism, 1950, 6, Is Alcoholism Everyone Is Problem? New York, The West-ern New York Committee for Education on Alcoholism* 1951. 7, Davies, John £ . - , "To-day's Treatment of Alcoholism** Hygeia, 1947, pp.266. 8, Medicine Looks at Alcoholics Anonymous, New York, Works Publishing; Inc.* 1950, 9. Moore, M e r r i l l , Alcoholism* A Public Health Problem* New York, Association of Life insurance Medical Directors of America* Oct, 1940, 10. Studies in Alcoholism-. A. Report on the Work of the C. Dudley Saul C l i n i c . 1946-49, Philadelphia* Board of Trustees, 1949. 11* Thimann, Joseph, "Alcoholics and Their Treatment", Hygeia, Chicago, American Medical Association, Oct. 1943, pp.729-30. THESES 1* Cheriton, Lorna, Treatment and Rehabilitation of Attempted Suicide Patients, (Vancouver General Hospital,1948)• 2. Wyness* Enid . A: Social Approach to the Venereal Disease Problem, (Vancouver, Provincia 1 Government V . D . C l i n i c , Department of Health and Welfare, 1948). LETTERS 1. Falkey, D. Bruce, Chief, Information and Rehabilitation Centre for Alcoholism, University of Buffalo* let ter to the writer^ tr,>is<-

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