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Social Work and Social Agencies: Contribution to Medical Practice
Social Work and Social Agencies: Contribution to Medical Practice GERALDINE Y. ZOUSMER, ACSW*
EVOLUTION OF SOCIAL WORK Social work was initially conceived as an organized method of alleviating the distress of the poor. Medical social work was begun under the leadership of physicians and laymen who believed that adequate medical care included attention to the social needs of patients. It was first established in the Massachusetts General Hospital, Boston, in 1905, and since then there has been a steady increase in the number of social service departments in all types of hospitals - teaching hospitals affiliated with schools of medicine, voluntary institutions, and governmental hospitals, including Army, Navy, and veterans' hospitals. Whereas, prior to World War I, social work had existed as a social and economic aid given to people, for the purpose of relieving poverty, by the time the war was over and prosperity had come to the nation, a new consideration entered into the thinking. Leaders in the field recognized that the personality of the client was somehow an important element in the giving and receiving of help. There began a change of emphasis from the purely environmental to the psychological aspects of problems. An important factor which influenced this change was the establishment of the Home Service Divisions of the American Red Cross during the war. In this setting people representating a crosssection of the population indicated that they had problems, and that these problems could not be solved by financial assistance alone. So we began helping people "above the poverty line" and psychiatric social work was born. Before the war a few social workers had been employed in mental hospitals to help psychiatrists secure information about the social aspects of patients' lives and to arrange for the care of patients after discharge. The war greatly increased the need for such workers, for shell shock and other symptoms were recognized as neurotic ailments; under the stress of war conditions much more responsibility for direct
*Assistant Director of Social Service in Psychiatry, The Mount Sinai Hospital, New York, N.Y. Medical Clinics of North America- Vo!. 51, No. 6, November, 1967
1485
1486
GERALDINE
Y.
ZOUSMER
work with patients was given to social workers than had previously been the case. By 1920, psychiatric social work was a well-established specialty of the social work profession. After the demise of the wartime Red Cross program, the numbers of family welfare agencies increased, with much of the new point of view incorporated into their programs. The name of the American Association of Societies for Organizing Charity was changed in 1919 to the American Association for Organizing Family Social Work (and later to the Family Welfare Association of America) indicating that family welfare had replaced charity and that service rather than financial relief was the agencies' focus. By the 1920's it had become a point of pride that perhaps half the people who applied for help and were accepted did not need financial assistance. With the Depression in the 1930's, family agencies discovered that they could not cope alone with all of the economic aspects of client need, which then had to be taken up by the newly emerging public assistance agencies. A parallel development was the federal social insurance program which included Old Age and Survivors Insurance, Unemployment Insurance, and Workmen's Compensation. Being relieved, in the main, of their money-giving responsibilities, the family agencies were freer to relate themselves to the attitudinal, emotional needs of people in trouble. These developments then forced social workers to look for a better understanding of clients' motivations, for neither personality nor environmental pressures provided adequate explanation of the differences in response that were found when the caseworkers' services were offered. The acceptance of Freud's teaching and its influence on psychiatry had a profound effect on the evolution of social work as we know it today. Caseworkers learned that each individual's behavior is the result of a lifelong series of events, both outside and inside an organism, that is continually choosing among them, reacting to them, and being shaped in the process. Among the events, those which represent interpersonal relationships are of great importance, particularly the relationships in which the individual is first involved, usually in his own family. It follows, therefore, that an individual's mode of behavior is not something deliberately chosen, the result of a conscious decision to act in a given way, but is rather a response to needs that have a long history and that are inextricably bound up with his whole existence. In other words, behavior is meaningful. Whether a man behaves in a socially acceptable or unacceptable manner, there is a reason for his behaving as he does; and, moreover, the way he behaves has value to him, since it represents his solution of a possible conflict between his desire and the demands of the outside world. The work of family welfare agencies was modified only slowly by this new point of view. Family caseworkers were absorbed in refining the techniques of investigation and analysis of problems that had earlier engaged their attention. The development of the implications of the psychological theories for casework was carried on largely in
SOCIAL WORK AND SOCIAL AGENCIES: THEIR CONTRIBUTION TO PRACTICE
1487
child guidance clinics. In both clinics and family agencies, however, the first effect of the psychiatric discoveries was that of increasing the number of facts social workers thought they had to secure in order to understand adequately the problems and needs of their clients. This search demanded not only more knowledge and skill than the majority of caseworkers had at that period but also more time than could be allotted to the average case. Family agencies, therefore, began to add psychiatric social workers to their staffs to supplement family workers in difficult cases, and to consider the possibility of limiting their intake to families whose problems were not too much complicated by emotional maladjustment. Another effect of the new knowledge was to force family caseworkers to relinquish what had been one of their main tenets: that the family is the unit of their work. When the importance of psychological factors was recognized, a subtle shift occurred in family work in which individuals rather than families came to be regarded as clients. Casework or counseling in interpersonal relationships and social functioning continued through the 1950's, which ushered in the Civil Rights Movement. This was to stimulate a growing awareness that an understanding of and working with individual personality strengths and weaknesses, on a one-to-one basis, was not sufficient. The development of the social sciences and role theory, greater interest in cultural differences, and the effects of poverty, began to bring the social work professional increasingly to look for other methods, other techniques for helping people. Throughout the years, casework, with its use of a one-to-one relationship with the authority, was the prime method in social work, while group work and community organization took a back seat in importance. Today, there is a rebirth of interest in the family, and in the group method, as we rediscover a source of help to family members as a unit, as well as to unrelated people through peer relationships. There is also a new and important emphasis on community organization or social action in which semiprofessional workers and nonprofessional people out of the indigenous leadership of a community can participate in making constructive social change.
CURRENT AGENCIES, SERVICES, AND TRAINING A. variety of public and voluntary agencies carry programs to meet different needs. There are, for example, public assistance programs, family and child welfare services, social services for the mentally ill, physically disabled, aged, and those related to the courts, delinquency, probation, parole. Personal difficulties, marital problems, requests for adoptions all have their places. Agencies can serve individuals or family units; some are concerned chiefly with larger groups, as in the poverty area. The agencies' approaches may be reflected in three basic methods of social work practice - casework, group work, and community organization. Caseworkers may counsel a couple who have marital problems, arrange for financial help or homemaker service, give voca-
1488
GERALDINE
Y.
ZOUSMER
tional guidance, arrange for foster or institutional care as well as health services. Group workers may be found in community centers and increasingly in the hospitals and clinics where they work with people of all ages in the process of helping each other through group activities and discussions. Community organizers may work with the neighborhood to help it arrive at the social change it wants. The training for professional social work includes as a basic requirement two years in an accredited school of social work beyond the college degree. Study includes such things as psychoanalytic theory, normal and abnormal behavior, individual family dynamics, medical disease entities, group interaction, sociocultural factors in society, interviewing techniques, administration, and research, as well as the various aspects of practice. Included in the latter are "internships" in local social agencies, clinics, and hospitals under intensive supervision. After graduation a social worker should be ready to function in most settings since training is for the most part generic; however, for the purposes of discussion here, the principal areas of social work function in most communities will be looked at separately. The following are direct services to people in need but an equally important and increasingly used area of competence in this field is that of education and consultation with other professional and nonprofessional people in the community, such as physicians, clergy, teachers, and recreational personnel. Social work teaching in medical schools is recognized as an important part of the curriculum by many forward looking universities and hospitals. Family services (Family Service Association of America) are generally rendered through voluntary agencies, such as the Community Service Society, Jewish Family Service, and Catholic Charities in New York, but increasingly through the public assistance agency as well. Counseling to strengthen family life, to improve marital adjustment, and to help individuals with their problems in interpersonal relationships, work, school, and social adjustment are their chief functions. Individual casework and family or group counseling methods are generally used. Child welfare services (Child Welfare League of America) are carried on in both government and voluntary agencies and institutions. These agencies deal with the problems of dependent, neglected or troubled children and the institutions care for the mentally retarded and disturbed. Caseworkers may find foster or adoptive parents, place children and counsel both parents and children in foster homes and in adoption. The school social worker has an important function in most communities. Medical social work is practiced in government hospitals and clinics (Veterans Administration) and most voluntary hospitals, clinics, and rehabilitation centers. Caseworkers and group workers work directly with patients and their families to help them meet problems accompanying or affecting illness, recovery, and rehabilitation, as part of the medical team. They participate in community health planning.
SOCIAL WORK AND SOCIAL AGENCIES: THEIR CONTRIBUTION TO PRACTICE
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Psychiatric social work is also practiced in most government and voluntary psychiatric clinics and hospitals in the United States, its workers being part of the clinical team which includes the psychiatrist, nurse, and psychologist. Caseworkers and group workers help patients and their families understand and accept the nature of the illness and assist patients in using the treatment available to them in the community. They counsel people individually or in groups. Psychiatric social workers participate in community mental health programs. Corrective work with both adults and children most often is related to governmental institutions, such as courts, training schools, and prisons. Social workers here may counsel youthful delinquents and/or their parents, and are concerned with prevention or possible future adjustment in the community. Voluntary agencies doing prevention or parole work also employ caseworkers and group workers.
SOCIAL WORK AND SOCIAL HEALTH People seek or are encouraged to take help with their social health because there has been a breakdown in their interpersonal adjustment. This may be acute and temporary or chronic and life-long. It may be directly and primarily the problem of a woman who comes because she "can't keep friends" or "indirectly" the problem of a woman who seeks help with placement of a sick spouse. In any case there are generally three sources for such breakdown, and with most people considerable overlapping. The first and perhaps most easily recognized is where the reality situation in a person's life exerts such pressure as to be unmanageable without aid. The second is where the individual's infantile needs and wishes get in the way of his gaining satisfactions in his adult life, and the third source is in poor ego or superego functioning. Environmental life pressures include such things as economic deprivation which may mean poor job opportunities, inadequate housing and neighborhood facilities, and the inability to purchase many of the comforts which others enjoy. It also means illness of oneself or a family member, and death. Added to these are all those situations which arouse disturbing feelings of tension, anxiety, anger, inadequacy or guilt. When a person's discomfort is largely in the environment, the social worker can sometimes alter things directly. Where there is financial need, public assistance can provide money for food, clothing and shelter. Medical care can be obtained during illness, adoptive or foster care can be found for dependent children, housing can be located, and different kinds of educational facilities brought in for training and placement. While workable facilities can be introduced to the needy person, this is frequently not enough. The individual generally needs to be helped to accept and use these facilities so that environmental manipulation most often is part of a larger psychological service, generally over a period of time, involving both client and resource. The social worker works with the fears, distortions, motivations, and resistances that lie within or just without a person's awareness.
1490
GERALDINE
Y.
ZOUSMER
Infantile needs which persist in adult life may lead to excessive hostility or dependence, fear of separation from meaningful people, and problems in the expression of sexual and aggressive drives. Sometimes these needs can be met in social situations; however, for the most part, this does not happen. Such a person then is left with a sense of frustration and behaves in a manner that brings antagonism and disallows satisfactions he might otherwise have in his family and social relationships. Poor functioning of the ego and superego can aggravate the environmental pressures felt by the individual and it is in reducing some of these self-created pressures that the social worker can be helpful. In these situations, the person responds in an exaggerated way to a distortion of reality. Here, too, gratification is lost, guilt can be aroused, inadequacy felt, leading to less satisfying functioning at work, play, or in interpersonal relationships. The casework process generally includes social study, diagnosis, treatment planning, and treatment procedures. Every treatment step is a goal-directed procedure, and brings into action various dynamics to bring about its intended effect. Hollis cites and discusses the case of a widow who is afraid of an operation partly because she is too sick to work out plans for the care of her children during her absence from home, partly because she is going to a strange doctor and is uncertain about the outcome of the operation, and partly because unconsciously she fears punishment for her hostile attitudes toward her mother, who had a similar illness and became a permanent cripple following an operation which the patient erroneously assumes was similar to the one she is about to undergo. * Many different dynamics can be employed to reduce this woman's anxiety and make it possible for her to take the treatment she needs with some comfort. Illness can have a strong impact on an individual's social relationships, employment status, recreational outlets, and family relationships. The ability of a patient to cope emotionally with his illness or physical limitations is enhanced or blocked by the attitude and actions of the family. Motivation toward health and rehabilitation can be quickened or hindered by meaningful people in the patient's environment. As the role of the patient in the family sometimes changes during illness, important changes of role and responsibility do occur in other family members, which then may lead to negative feelings toward the patient. The most obvious examples of this which comes to mind is the bedridden husband and father who can no longer work, forcing the wife to assume the breadwinner role in the family. The family equilibrium is upset, often with tension and resentment ensuing. It is in such family situations resulting from the pressure of illness that referral to a social agency can prove quite helpful. There are countless problems in which intervention by a social
"Hollis, Florence: Casework: A Psychosocial Therapy. New York, Random House, 1964, p.50.
SOCIAL WORK AND SOCIAL AGENCIES: THEIR CONTRIBUTION TO PRACTICE
1491
worker can be useful to the patient, to the family and to the doctor. For example: 1. A husband or wife who expresses some problem which is causing difficulty in the marriage and seems insoluble without aid. 2. A parent who needs guidance in how to handle a sick child-is overprotective or undercaring. 3. An offspring of a geriatric patient who wants to decide whether to place an aged parent away from home. 4. Parents who must separate from a mentally ill or retarded child. 5. An adolescent who is having an undue amount of friction at home. 6. A young adult who is having social or vocational problems. 7. An unmarried mother. 8. A person who cannot accept recommended medical treatment, or a family who will not allow it. 9. An individual who will not accept rehabilitative care.
Sometimes it is not clear where a situation had best be referred. In any community the local social agency could offer the doctor expert discussion and advice out of its understanding and knowledge of the psychosocial components of illness. The social service department of any hospital can also be called on to advise the doctor as to the most appropriate available resource to meet the case need. Consultation and collaboration witIi the physician on medical-social problems which emerge in his practice are part of the function of the social worker. Social Service Department The Mount Sinai Hospital 100th Street and Fifth Avenue New York, N.Y. 10029
EVOLUTION OF SOCIAL WORK Social work was initially conceived as an organized method of alleviating the distress of the poor. Medical social work was begun under the leadership of physicians and laymen who believed that adequate medical care included attention to the social needs of patients. It was first established in the Massachusetts General Hospital, Boston, in 1905, and since then there has been a steady increase in the number of social service departments in all types of hospitals - teaching hospitals affiliated with schools of medicine, voluntary institutions, and governmental hospitals, including Army, Navy, and veterans' hospitals. Whereas, prior to World War I, social work had existed as a social and economic aid given to people, for the purpose of relieving poverty, by the time the war was over and prosperity had come to the nation, a new consideration entered into the thinking. Leaders in the field recognized that the personality of the client was somehow an important element in the giving and receiving of help. There began a change of emphasis from the purely environmental to the psychological aspects of problems. An important factor which influenced this change was the establishment of the Home Service Divisions of the American Red Cross during the war. In this setting people representating a crosssection of the population indicated that they had problems, and that these problems could not be solved by financial assistance alone. So we began helping people "above the poverty line" and psychiatric social work was born. Before the war a few social workers had been employed in mental hospitals to help psychiatrists secure information about the social aspects of patients' lives and to arrange for the care of patients after discharge. The war greatly increased the need for such workers, for shell shock and other symptoms were recognized as neurotic ailments; under the stress of war conditions much more responsibility for direct
*Assistant Director of Social Service in Psychiatry, The Mount Sinai Hospital, New York, N.Y. Medical Clinics of North America- Vo!. 51, No. 6, November, 1967
1485
1486
GERALDINE
Y.
ZOUSMER
work with patients was given to social workers than had previously been the case. By 1920, psychiatric social work was a well-established specialty of the social work profession. After the demise of the wartime Red Cross program, the numbers of family welfare agencies increased, with much of the new point of view incorporated into their programs. The name of the American Association of Societies for Organizing Charity was changed in 1919 to the American Association for Organizing Family Social Work (and later to the Family Welfare Association of America) indicating that family welfare had replaced charity and that service rather than financial relief was the agencies' focus. By the 1920's it had become a point of pride that perhaps half the people who applied for help and were accepted did not need financial assistance. With the Depression in the 1930's, family agencies discovered that they could not cope alone with all of the economic aspects of client need, which then had to be taken up by the newly emerging public assistance agencies. A parallel development was the federal social insurance program which included Old Age and Survivors Insurance, Unemployment Insurance, and Workmen's Compensation. Being relieved, in the main, of their money-giving responsibilities, the family agencies were freer to relate themselves to the attitudinal, emotional needs of people in trouble. These developments then forced social workers to look for a better understanding of clients' motivations, for neither personality nor environmental pressures provided adequate explanation of the differences in response that were found when the caseworkers' services were offered. The acceptance of Freud's teaching and its influence on psychiatry had a profound effect on the evolution of social work as we know it today. Caseworkers learned that each individual's behavior is the result of a lifelong series of events, both outside and inside an organism, that is continually choosing among them, reacting to them, and being shaped in the process. Among the events, those which represent interpersonal relationships are of great importance, particularly the relationships in which the individual is first involved, usually in his own family. It follows, therefore, that an individual's mode of behavior is not something deliberately chosen, the result of a conscious decision to act in a given way, but is rather a response to needs that have a long history and that are inextricably bound up with his whole existence. In other words, behavior is meaningful. Whether a man behaves in a socially acceptable or unacceptable manner, there is a reason for his behaving as he does; and, moreover, the way he behaves has value to him, since it represents his solution of a possible conflict between his desire and the demands of the outside world. The work of family welfare agencies was modified only slowly by this new point of view. Family caseworkers were absorbed in refining the techniques of investigation and analysis of problems that had earlier engaged their attention. The development of the implications of the psychological theories for casework was carried on largely in
SOCIAL WORK AND SOCIAL AGENCIES: THEIR CONTRIBUTION TO PRACTICE
1487
child guidance clinics. In both clinics and family agencies, however, the first effect of the psychiatric discoveries was that of increasing the number of facts social workers thought they had to secure in order to understand adequately the problems and needs of their clients. This search demanded not only more knowledge and skill than the majority of caseworkers had at that period but also more time than could be allotted to the average case. Family agencies, therefore, began to add psychiatric social workers to their staffs to supplement family workers in difficult cases, and to consider the possibility of limiting their intake to families whose problems were not too much complicated by emotional maladjustment. Another effect of the new knowledge was to force family caseworkers to relinquish what had been one of their main tenets: that the family is the unit of their work. When the importance of psychological factors was recognized, a subtle shift occurred in family work in which individuals rather than families came to be regarded as clients. Casework or counseling in interpersonal relationships and social functioning continued through the 1950's, which ushered in the Civil Rights Movement. This was to stimulate a growing awareness that an understanding of and working with individual personality strengths and weaknesses, on a one-to-one basis, was not sufficient. The development of the social sciences and role theory, greater interest in cultural differences, and the effects of poverty, began to bring the social work professional increasingly to look for other methods, other techniques for helping people. Throughout the years, casework, with its use of a one-to-one relationship with the authority, was the prime method in social work, while group work and community organization took a back seat in importance. Today, there is a rebirth of interest in the family, and in the group method, as we rediscover a source of help to family members as a unit, as well as to unrelated people through peer relationships. There is also a new and important emphasis on community organization or social action in which semiprofessional workers and nonprofessional people out of the indigenous leadership of a community can participate in making constructive social change.
CURRENT AGENCIES, SERVICES, AND TRAINING A. variety of public and voluntary agencies carry programs to meet different needs. There are, for example, public assistance programs, family and child welfare services, social services for the mentally ill, physically disabled, aged, and those related to the courts, delinquency, probation, parole. Personal difficulties, marital problems, requests for adoptions all have their places. Agencies can serve individuals or family units; some are concerned chiefly with larger groups, as in the poverty area. The agencies' approaches may be reflected in three basic methods of social work practice - casework, group work, and community organization. Caseworkers may counsel a couple who have marital problems, arrange for financial help or homemaker service, give voca-
1488
GERALDINE
Y.
ZOUSMER
tional guidance, arrange for foster or institutional care as well as health services. Group workers may be found in community centers and increasingly in the hospitals and clinics where they work with people of all ages in the process of helping each other through group activities and discussions. Community organizers may work with the neighborhood to help it arrive at the social change it wants. The training for professional social work includes as a basic requirement two years in an accredited school of social work beyond the college degree. Study includes such things as psychoanalytic theory, normal and abnormal behavior, individual family dynamics, medical disease entities, group interaction, sociocultural factors in society, interviewing techniques, administration, and research, as well as the various aspects of practice. Included in the latter are "internships" in local social agencies, clinics, and hospitals under intensive supervision. After graduation a social worker should be ready to function in most settings since training is for the most part generic; however, for the purposes of discussion here, the principal areas of social work function in most communities will be looked at separately. The following are direct services to people in need but an equally important and increasingly used area of competence in this field is that of education and consultation with other professional and nonprofessional people in the community, such as physicians, clergy, teachers, and recreational personnel. Social work teaching in medical schools is recognized as an important part of the curriculum by many forward looking universities and hospitals. Family services (Family Service Association of America) are generally rendered through voluntary agencies, such as the Community Service Society, Jewish Family Service, and Catholic Charities in New York, but increasingly through the public assistance agency as well. Counseling to strengthen family life, to improve marital adjustment, and to help individuals with their problems in interpersonal relationships, work, school, and social adjustment are their chief functions. Individual casework and family or group counseling methods are generally used. Child welfare services (Child Welfare League of America) are carried on in both government and voluntary agencies and institutions. These agencies deal with the problems of dependent, neglected or troubled children and the institutions care for the mentally retarded and disturbed. Caseworkers may find foster or adoptive parents, place children and counsel both parents and children in foster homes and in adoption. The school social worker has an important function in most communities. Medical social work is practiced in government hospitals and clinics (Veterans Administration) and most voluntary hospitals, clinics, and rehabilitation centers. Caseworkers and group workers work directly with patients and their families to help them meet problems accompanying or affecting illness, recovery, and rehabilitation, as part of the medical team. They participate in community health planning.
SOCIAL WORK AND SOCIAL AGENCIES: THEIR CONTRIBUTION TO PRACTICE
1489
Psychiatric social work is also practiced in most government and voluntary psychiatric clinics and hospitals in the United States, its workers being part of the clinical team which includes the psychiatrist, nurse, and psychologist. Caseworkers and group workers help patients and their families understand and accept the nature of the illness and assist patients in using the treatment available to them in the community. They counsel people individually or in groups. Psychiatric social workers participate in community mental health programs. Corrective work with both adults and children most often is related to governmental institutions, such as courts, training schools, and prisons. Social workers here may counsel youthful delinquents and/or their parents, and are concerned with prevention or possible future adjustment in the community. Voluntary agencies doing prevention or parole work also employ caseworkers and group workers.
SOCIAL WORK AND SOCIAL HEALTH People seek or are encouraged to take help with their social health because there has been a breakdown in their interpersonal adjustment. This may be acute and temporary or chronic and life-long. It may be directly and primarily the problem of a woman who comes because she "can't keep friends" or "indirectly" the problem of a woman who seeks help with placement of a sick spouse. In any case there are generally three sources for such breakdown, and with most people considerable overlapping. The first and perhaps most easily recognized is where the reality situation in a person's life exerts such pressure as to be unmanageable without aid. The second is where the individual's infantile needs and wishes get in the way of his gaining satisfactions in his adult life, and the third source is in poor ego or superego functioning. Environmental life pressures include such things as economic deprivation which may mean poor job opportunities, inadequate housing and neighborhood facilities, and the inability to purchase many of the comforts which others enjoy. It also means illness of oneself or a family member, and death. Added to these are all those situations which arouse disturbing feelings of tension, anxiety, anger, inadequacy or guilt. When a person's discomfort is largely in the environment, the social worker can sometimes alter things directly. Where there is financial need, public assistance can provide money for food, clothing and shelter. Medical care can be obtained during illness, adoptive or foster care can be found for dependent children, housing can be located, and different kinds of educational facilities brought in for training and placement. While workable facilities can be introduced to the needy person, this is frequently not enough. The individual generally needs to be helped to accept and use these facilities so that environmental manipulation most often is part of a larger psychological service, generally over a period of time, involving both client and resource. The social worker works with the fears, distortions, motivations, and resistances that lie within or just without a person's awareness.
1490
GERALDINE
Y.
ZOUSMER
Infantile needs which persist in adult life may lead to excessive hostility or dependence, fear of separation from meaningful people, and problems in the expression of sexual and aggressive drives. Sometimes these needs can be met in social situations; however, for the most part, this does not happen. Such a person then is left with a sense of frustration and behaves in a manner that brings antagonism and disallows satisfactions he might otherwise have in his family and social relationships. Poor functioning of the ego and superego can aggravate the environmental pressures felt by the individual and it is in reducing some of these self-created pressures that the social worker can be helpful. In these situations, the person responds in an exaggerated way to a distortion of reality. Here, too, gratification is lost, guilt can be aroused, inadequacy felt, leading to less satisfying functioning at work, play, or in interpersonal relationships. The casework process generally includes social study, diagnosis, treatment planning, and treatment procedures. Every treatment step is a goal-directed procedure, and brings into action various dynamics to bring about its intended effect. Hollis cites and discusses the case of a widow who is afraid of an operation partly because she is too sick to work out plans for the care of her children during her absence from home, partly because she is going to a strange doctor and is uncertain about the outcome of the operation, and partly because unconsciously she fears punishment for her hostile attitudes toward her mother, who had a similar illness and became a permanent cripple following an operation which the patient erroneously assumes was similar to the one she is about to undergo. * Many different dynamics can be employed to reduce this woman's anxiety and make it possible for her to take the treatment she needs with some comfort. Illness can have a strong impact on an individual's social relationships, employment status, recreational outlets, and family relationships. The ability of a patient to cope emotionally with his illness or physical limitations is enhanced or blocked by the attitude and actions of the family. Motivation toward health and rehabilitation can be quickened or hindered by meaningful people in the patient's environment. As the role of the patient in the family sometimes changes during illness, important changes of role and responsibility do occur in other family members, which then may lead to negative feelings toward the patient. The most obvious examples of this which comes to mind is the bedridden husband and father who can no longer work, forcing the wife to assume the breadwinner role in the family. The family equilibrium is upset, often with tension and resentment ensuing. It is in such family situations resulting from the pressure of illness that referral to a social agency can prove quite helpful. There are countless problems in which intervention by a social
"Hollis, Florence: Casework: A Psychosocial Therapy. New York, Random House, 1964, p.50.
SOCIAL WORK AND SOCIAL AGENCIES: THEIR CONTRIBUTION TO PRACTICE
1491
worker can be useful to the patient, to the family and to the doctor. For example: 1. A husband or wife who expresses some problem which is causing difficulty in the marriage and seems insoluble without aid. 2. A parent who needs guidance in how to handle a sick child-is overprotective or undercaring. 3. An offspring of a geriatric patient who wants to decide whether to place an aged parent away from home. 4. Parents who must separate from a mentally ill or retarded child. 5. An adolescent who is having an undue amount of friction at home. 6. A young adult who is having social or vocational problems. 7. An unmarried mother. 8. A person who cannot accept recommended medical treatment, or a family who will not allow it. 9. An individual who will not accept rehabilitative care.
Sometimes it is not clear where a situation had best be referred. In any community the local social agency could offer the doctor expert discussion and advice out of its understanding and knowledge of the psychosocial components of illness. The social service department of any hospital can also be called on to advise the doctor as to the most appropriate available resource to meet the case need. Consultation and collaboration witIi the physician on medical-social problems which emerge in his practice are part of the function of the social worker. Social Service Department The Mount Sinai Hospital 100th Street and Fifth Avenue New York, N.Y. 10029