The sociological or social service department of a hospital for mental diseases has functions related to (a) diagnosis, (6) treatment, (c) research, and (d) education. Every patient admitted requires consideration of his social condition as well as of his mental condition. In many cases a medical diagnosis can not be made without knowledge of the patient's social history. In some cases prolonged observation of the patient in the community is essential to a diagnosis.
1 The Training School of Psychiatric Social Work at Smith College: I. Educational Significance of the Course, by W. A. Neilson. II. A Lay Reaction to Psychiatry, by E. E. Southard. III. The Course in Social Psychiatry, by Edith R. Spaulding. IV. A Scientific Basis for Training Social Workers, by F. Stuart Chapin. V. An Emergency Course in a New Branch of Social Work, by Mary C. Jarrett. Mental Hygiene, Oct., 1918.
In order to obtain a full history it is usually necessary to go out into the community to make inquiries. Medical work is facilitated, and complete histories are insured, when this function is delegated to a worker trained in social investigation.
The history secured by the social worker from informants in the community to aid the physician in his diagnosis will contain essentially the same information that he might obtain himself if these informants should come to the hospital. The discussion of history taking in Chapter V (The Practice Of Psychiatry. History Taking - Methods Of Examination) will therefore guide the social worker in this connection,
In addition to the information required for medical diagnosis, certain sociological data are required by the social worker in order to understand the patients' social condition and to provide the best possible social care. To begin with, names and addresses of relatives, employers, neighbors, teachers, clergymen, friends must be noted exactly, so that these persons may be visited as sources of information. These addresses are also necessary because the social worker must discover what beneficial resources exist in the patient's environment and who among his relatives and acquaintances would be helpful in supplying the assistance that he needs for social adjustment. The character of his home and the neighborhood in which he lives must be gone into carefully both through inquiry and direct observation, in order to effect improvement in his surroundings if unsuitable conditions are found. It is important to have fairly complete knowledge of all members of the family group and other relatives who may be closely associated with the patient. The attitude of the family toward the patient is a matter of special concern.
The ratio between income and expenditures of the patient, or of the family group to which he belongs, and the relation between income and standard of living are matters of great practical importance in sociul care.
History from the patient through direct examination by the social worker is also essential, as data of sociological significance are required, which the physician either does not obtain at all or obtains without sufficient detail for the purpose of social work. The social worker will of course avoid duplication of work already covered by the medical examination. Among points of special concern to the social worker are: What are the patient's own plans for his future? Has he satisfactory living conditions in view? Has he a prospect of suitable employment? What financial resource has the patient? If employed, the question arises whether he is receiving suitable wages or might better his condition. The matter of financial assistance from the proper social agency must be taken up in needy cases. The patient's attitude toward his family is an important consideration in social treatment. It is desirable to know which members of his family have most influence with him. The character of the patient's friends and companions is to be learned partly from him and partly by inquiry from other sources. His attitude toward them and the extent to which they influence him should be inquired into.
The tastes and preferences of the patient in regard to employment, recreation, and occupation in leisure time must be learned to some extent by direct examination. Clues for further inquiry to secure history must be obtained with full names and addresses. The general social and educational background of informants who are to be seen or written to is of great importance. An inquiry is likely to be more fruitful if the investigator knows something of the character of the person approached. This is particularly true where the inquiry must be made by letter, and is of even more importance perhaps where the inquiry is made over the telephone. Finally in talking with the patient, the social worker establishes an intimacy which she must develop if she is to deal successfully with the intimate problems of his social life.
Another aid to diagnosis in connection with out-patient clinics is prolonged observation through the social service of doubtful cases in the community. Reports of the patient's behavior at home brought in by the social worker and notes on the way in which the patient responds to the efforts of the social worker to improve his social condition are often the means of reaching a correct diagnosis in a dubious case.
In treatment, the work of the social service is almost entirely with out-patients (both those who have been in hospital and those who have not), although some assistance is given in the treatment of patients in the hospital in such ways as setting in order difficulties at home, furnishing assurance that suitable conditions for discharge will be ready, and relieving the patient of other real anxieties. The responsibility to out-patients is two-fold: to secure to the patient continued medical treatment by following him up if he fails to come back to see the physicians as directed; and to see that he is socially adjusted in respect to home, friends, recreation, employment.
This second duty is the special function of social case work - to organize all factors existing within the individual and his environment to effect the best possible adaptation of that individual to society. In this process the welfare of the family group must also receive attention since it closely affects the welfare of the patient. The treatment of some patients, as Dr. Adolf Meyer has said, is treatment of the environment. Not infrequently the physician finds the difficulty to be entirely social and leaves the case in the hands of the social worker. In most cases medical treatment needs to be supplemented and reinforced by social care.
The recent development of out-patient clinics connected with state hospitals has created an important demand for social work. In several states each state hospital now conducts one or more clinics held either at the hospital or in a neighboring center of population.1 The services of social workers are indispensable in these clinics.
An important service of the social worker in a state hospital is in connection with the after-care of paroled patients. In New York "the average daily number of patients on parole from the 13 civil state hospitals during the year (1917) was 1504 compared with 1346 in 1916, 1280 in 1915, 1141 in 1914, and 978 in 1913." "The employment of field workers by the state hospitals and the establishment of additional clinics by the various institutions undoubtedly is responsible in a considerable measure for the increase in the number of patients on parole." l The reports point out the financial benefits of the parole system in saving maintenance and making room for new patients, thereby preventing overcrowding, as well as the more important advantage that the recovery of patients is often hastened, "when they can return to their own homes and familiar surroundings to complete the period of convalescence and at the same time continue under the watchful eye of the hospital. The hospital keeps in touch with these patients through its social workers who visit the homes before patients are paroled and who make periodical visits afterwards to see that conditions are satisfactory and that the patient is living in a manner calculated to prevent a recurrence of the disease, or, if a patient is not recovering satisfactorily, to see that he or she is returned to the hospital for proper treatment."
1 New York State Hospital Commission. Thirtieth Annual Report, 1917-1918.
In research, social investigation is required in many studies of mental disease that call for previous history and continued observation of cases in the community. Experimental medical work in neuro-syphilis is largely dependent upon social assistance in keeping patients faithful to treatment and in inducing other members of the family to be examined and, if necessary, treated. Certain psychiatric problems can not be studied successfully without social work, such as the care of the feeble-minded at home, the training of delinquents, the adjustment of the psychopathic employee. In studies of heredity, social investigation is essential. At the Eugenics Record Office, Cold Spring Harbor N. Y., a special course is given annually to train field workers for this purpose.
1 New York State Hospital Commission. Twenty-ninth Annual Report, 1916-1917.
In public education, social workers have an unusual opportunity to spread the facts and principles of mental hygiene through their varied and numerous contacts in the community. Interest that began in a social inquiry about a particular case, may lead a teacher, clergyman, or employer to better knowledge of the subject of mental disease and mental hygiene. The training of students in psychiatric social work is an important educational responsibility.