MENTAL INVESTIGATION BY THE SOCIAL ASSISTANT
Ever since the days of Charcot, France has been the land of medical
psychology. France has never failed, as other countries have failed, to
take full account of the mental factors, the mental causes and results
in disease.
In America, on the other hand, the conspicuous disregard of medical
psychology by physicians has led to widespread and serious revolt on the
part of the public. Our physicians have too often treated the patient as
if he were a walking disease, a body without a mind. Medical psychology
has been neglected in our medical schools and in the practice of our
most successful clinicians. The result has been a revolt upon the part
of the laity, expressed in the popularity of the heretical healing cults
such as Christian Science and New Thought. These unscientific and
unchristian organizations illustrate an error opposite to that of the
physicians, but no greater in degree. Indeed, I think that our
physicians are more to be blamed than the leaders of these irrational
cults, because our physicians having received a scientific training
ought to be more thorough, more unprejudiced, more devoted to the truth,
and therefore less inclined to shut their eyes to a huge body of facts.
The physician often shuts his eyes to the existence of the mind as a
cause of disease. The Christian Scientist shuts his eyes to the
existence of the body as a cause of disease. Both are equally and
disastrously wrong. But the medical profession is on the whole more to
blame, because they ought to know better, whereas the heretical healing
cults have grown up among uneducated men who could not be expected to
avoid the sort of narrowness and prejudice from which liberal education
ought to free us.
The situation in America, then, is very different and on the whole worse
than in France. There, scientific men, educated physicians have taken
the leadership in the field of medical psychology. In America it has
been left for ignorant enthusiasts, devoid of any scientific training or
breadth of culture, to press upon our attention the neglected elements
of medical practice, and to lead a revolt against the medical
profession, an anti-scientific revolution which numbers its adherents by
millions. But in neither country has our established knowledge of the
mental elements of disease been properly incorporated into medical
practice, especially into the practice of dispensary physicians, and it
is here that the social worker forms an essential link in the chain of
effective action. Let me describe more completely what I mean by the
mental element in disease.
I refer not merely to the so-called nervous diseases, the neuroses and
psychoses, the myriad forms of nervousness without recognizable basis in
organic disease, but also to the mental complications and results of
serious organic diseases such as tuberculosis, arteriosclerosis, and
surgical injuries. The classical studies of Charcot, Pierre Janet, and
others have made clear to the whole world the existence of a body of
diseases in which the mental functions are obviously deranged while
still the patient is not insane in any legal sense, and does not show on
physical examination any evidence of gross organic disease.
Neurasthenia, psychasthenia, hysteria, are among the more common types
marked out by the studies of great psychologists and clinicians. Little
or nothing has been added by the studies of German, American, and
English physicians to our knowledge of these diseases. But throughout
the history and development of France's leadership in the study of these
diseases, one cannot help noticing that interest is concentrated largely
upon diagnosis; comparatively little attention is paid to treatment. The
great leaders have not been extensively followed. Their suggestions have
not been carried out on a large scale nor followed sufficiently into the
field of practical therapeutics.
Especially is this true in the field of _visceral neuroses_ or nervous
symptoms referred by the patient to one or another organ--the stomach,
the pelvic organs, the bowels--in which nevertheless no evidence of
disease can be found. In these diseases English, French, and American
physicians alike persist for the most part in humoring and soothing the
patient by the administration of remedies known to have no real
influence upon disease and designed chiefly to make the patient feel
that something is being done for him. This is superficial treatment. It
makes no attempt to attack the determining causes of the disease.
Whether or not there are any psychogenic diseases, whether or not purely
psychical events can be proved to produce the group of symptoms known as
neurasthenia, psychasthenia, or hysteria, or whether there are physical
causes contributing to produce the symptoms, this at any rate may be
said with confidence: that if we are to root out the patient's trouble,
if we are to bring about anything approaching a radical cure, we must
attack the mental symptoms directly and upon their own grounds, that is,
by mental means, chiefly by reëducation. _The mental element in these
diseases is at any rate the most vulnerable point of attack._ It is here
that we can most profitably exert therapeutic pressure.
Even in organic disease, such as tuberculosis or arteriosclerosis, it
may still be true that we can help the patient chiefly through
psychotherapy. There may be little that we can do for his arteries or
his lungs, and indeed the incurable destruction which has gone on in
these organs may not at the time that we are treating the patient be
producing any symptoms. All his symptoms just now may depend upon mental
states which we can quite easily influence and thereby cure him of all
that at present torments him, though we recognize that the organic
malady remains untouched, unimproved. Many a case of tuberculosis
suffers chiefly from his fears of the disease or from his
discouragement. If we can rid him of his constant dread that the disease
will advance or will injure others, if we can give him courage, the
natural healing power of his tissues may be all that is needed to bring
about the arrest of the disease. On the other hand, even an incipient
case of pulmonary tuberculosis may go steadily on from bad to worse,
because the patient is constantly fretting and worrying about his own
condition, or about the present sufferings of his family.
I remember a case of very early tuberculosis, but recently established
at the summit of one lung, but unfortunately occurring in a patient of
very active temperament, prone to fume and worry the instant that he was
taken away from his work. He was devoted to his family, but as soon as
he was aware of his trouble, he could think of them only as doomed to be
dragged down by the contagion of his own disease or by the poverty
resulting from his own inactivity. Unfortunately, no proper study was
made of this patient's malady. No account was taken of his character and
temperament. The condition of his lung occupied the whole field of the
physician's vision. The condition of that lung demanded for the patient
isolation and complete rest in a sanatorium. This was prescribed and
carried out. The patient remained in the sanatorium about two months,
fuming and worrying constantly. He then refused to stay any longer,
left the institution against the advice of his physician, returned to
his family, and died about two months later.
Now I think it is at least probable that had we studied the patient's
mind as carefully as we studied his lung in this case, his life might
have been saved. But the physician who made the diagnosis and prescribed
the treatment could spend but a few minutes upon the case, which formed
but one of many trooping past him in his consultation hour at the
dispensary. He had no time for the prolonged, detailed, wearisome
studies necessary to win this patient's confidence, to make him feel
that he was wholly understood, and bring him to the point when he would
let himself be reëducated upon the mental side and receive docilely the
advice given him. This work should have been carried out by the right
type of social worker. Such a visitor would no doubt have realized that
one must compromise to a certain extent with the difficulties of the
patient's temperament. One must adapt and modify the treatment suitable
for the average case because this particular patient differs from many
others in important respects.
In the first place, he must be made to understand the importance of a
correct mental attitude for the cure of his disease, must be taught that
his recovery depends to a considerable extent upon his own efforts at
self-control and self-education. Next he must be convinced that his
family will be adequately cared for during his absence from work.
Furthermore, the complete rest in bed which would probably be advisable
for him if one had only the condition of his lung to consider, should
probably in his case be modified owing to the fact that his mental state
makes it impossible for him to rest when he is confined to bed. In such
cases one has the outward appearances of repose but not the reality, one
clings to the form but misses the substance. What one has prescribed is
in reality _enforced impatience_, _enforced restlessness_, because one
has put the patient under a régime where no result can be expected
except impatient struggling against restraint. Such a patient should be
allowed a certain amount of work, carefully chosen and supervised, so as
not to exercise the larger muscles of the body and thus produce fever,
but sufficient to occupy an active mind and to make the patient forget
himself. To find such occupation is difficult, no doubt, but it is not
impossible. I have seen it done. In the case which I am now considering,
no such effort was made. The patient was excessively lonely and isolated
in the sanatorium to which he was sent. The doctor's visits were
occupied with physical examination and the reiteration of commands that
he should stop worrying and remain completely at rest.
Such treatment violated grossly one of the basal laws of medical
psychology, which recognizes that no one ever stops worrying because he
is told to do so. To give such a command is as irrational as to tell an
epileptic not to have convulsions or a choreic patient not to wriggle
his hands. Yet this sort of error is constantly committed by physicians
who have been well trained to understand the physical changes of
disease, but have never concerned themselves to recognize the simplest
and most obvious facts about the mental condition of the sick. As I have
already said, it is impossible for the dispensary doctor to become
acquainted with the details of the patient's malady, or to find out by
investigation and experiment how the patient's mind may be made to aid
his recovery rather than to impede it. This is the proper task for a
social worker, partly because she has more time, partly because she is a
woman, and is for that reason more fitted to get into close touch with
the patient's mind and to use skill and tact in managing him.
Such studies of the social worker are equally important in the case of
the functional neuroses; for example, in the cases where the patient's
troubles can be most effectively attacked by ridding him of his fears.
Fear plays a dominant role in the sufferings of many cases both of
organic and of functional disease. In a recent examination of six
hundred and sixty-two young men about to enter Harvard University, it
was found that "there were more boys who thought they had a serious
organic defect, usually of the heart, and were found entirely sound than
boys who thought they were well and had disease." They had been
threatened with heart disease by gymnasium instructors or ill-trained
physicians. They had in consequence restricted their physical activities
and been haunted by the fear that they might by some unusual exercise of
mind or body make themselves seriously ill or perhaps suddenly die. Such
fears were all the more disastrous in these young men for being only
half realized by themselves. It is exactly these shadowy apprehensions,
these dreads which dwell in the half light, never quite faced in full
consciousness, which torment and incapacitate us the most. Careful
physical examination showed that the young men just referred to were
free from all disease, and the clear and emphatic statement of this fact
rendered a prompt and important service.
But if such fears haunt the students about to enter Harvard College, who
are young men drawn from the better educated and more well-to-do
classes, we may be sure that fear plays even a larger part in producing
the sufferings of patients such as we examine and treat in a public
dispensary. For such patients are very apt to be influenced by
groundless rumors, panics, neighborhood gossip. They are prone to
believe medical lies which they read in newspapers and in the leaflets
and circulars sent to them by charlatans. Almost all their medical
education comes to them from such sources, and is made up of a mass of
systematic falsehoods designed to excite fear and to produce symptoms by
suggestion.
Now if it is true that even among educated and relatively
self-conscious classes the most troublesome and incapacitating fears are
those which are but dimly known to the patient himself, this is sure to
be still more frequently the case among dispensary patients. It is
especially difficult and especially important, therefore, that their
fears should be understood and brought to light through the
investigations of some one who has time, patience, and tact to devote to
the task. This cannot be the task of the physician who sees neurological
cases in the dispensary, any more than the psychological twists and
tangles of the tuberculous patient can be followed out by the specialist
in tuberculosis who examines the patient's lungs. It is the proper task
of the social worker. When she has brought the patient's fears to light,
when she understands the details of his malady, she can communicate
these facts to the physician. He then can exorcise the unclean spirits
with the full authority of his medical position.
Just here one sees a good example of the proper coöperation between the
physician and the social worker in the dispensary. Each brings to light
certain elements in the diagnosis. But in the end the physician must
unite all the knowledge accumulated either by himself or by his social
assistants, and thus must be enabled to act for the patient's benefit on
the basis of a body of information much larger than he could have
secured alone.
The social worker is also an essential aid to the physician in bringing
to light the mental torments and errors which result from difficult
personal relations within the family. These difficulties can only be
understood by one who visits the patient in his home, becomes intimate
and friendly with other members of his family, and understands,
therefore, the difficulties that may arise from friction, rivalry,
jealousy, and temperamental incompatibility within the home. In some
cases the patient's friends and companions in work or school must also
be understood. In other words, one must take account of the totality of
influences in the patient's environment, the physical influences of
nutrition, ventilation, clothing, but also the psychical influences
exerted upon him by his family and friends, by his own half-conscious
thoughts, by his worries, his remorse, his fears. Many a case of stomach
trouble cannot be cured by diet or remedies until one can find out what
it is that the patient is worrying about and can enable him to combat
and subdue his mental enemies. Innumerable vague pains which the doctor
cannot attribute to any organic disease, and for which the use of drugs
is only too likely to do harm, yield only when one can study and
influence the whole extent of the patient's mental, moral, and spiritual
life. Nothing can be excluded here. It is utterly unscientific to close
our eyes to any human interest no matter how little we may sympathize
with it personally. It is one of the facts of the case, and must be
understood and allowed for in our treatment.
More and more frequently in America the dispensary physician is
consulted about the physical and mental condition of children and
adolescents who are sent to him from courts. The judges, especially in
our juvenile courts, are coming to realize that their legal training,
their knowledge of the nature, the evidence, and the prescribed
punishments for proved offences, is only a small part of their equipment
if they are to deal with juvenile offenders in such a way as to promote
the public good. The legal profession is beginning to realize that the
physical, mental, and moral study of juvenile offenders is essential if
one is to do anything to prevent their offending again. If penology is
to be constructive and reformatory, if it is not merely to represent
revenge, repression, and intimidation, our judges must know something of
medicine and especially of medical psychology. In this field, as in the
field of the functional and visceral neuroses, France has furnished the
leaders, but apparently these leaders have been insufficiently followed.
The work of Binet in the psychological measurements of school-children's
intelligence seems to us in America to have been epoch-making. We
recognize its limitations, we recognize that in its details it cannot be
universally followed. But we have taken up the suggestions and the
method of Binet, and gratefully acknowledging our indebtedness to him we
have tried to carry these suggestions and methods much further, to apply
them to the needs of older children and to the examination of those who
cannot read and write. Binet's tests depended altogether too much upon
the use of books and upon linguistic facility. Yet with some
modifications they seem to us in America to be of the greatest value,
and in the remarkable book _The Individual Delinquent_ (Macmillan Co.)
by Dr. William Healy, of Boston, and in the books of his associates and
followers, the science of medicine and medical psychology are intimately
interwoven with the investigations and reports of the social worker.
In the first of the books to which I have just referred, Dr. Healy
presents in detail the cases of over three hundred children who were
sent to him as a physician and medical psychologist by the judge of the
Juvenile Court in Chicago, who requested Dr. Healy to aid him in his
legal treatment through a medical and psychological study of each case.
Dr. Healy with his corps of assistants and social workers studied in
each child the physical condition, especially the presence or absence of
defects of sight and hearing, and the mental condition carefully
measured by tests based upon those of Binet, but extended considerably
by Dr. Healy himself and by others. But he adds to the facts thus
ascertained a careful investigation of the child's social environment,
both physical and psychological; that is, of all the
influences--hereditary, domestic, economic, industrial, and
personal--which have contributed to lead the child into crime. The
influence of other boys and girls of the same age, of associates in work
or school, is investigated; also the good or bad example of parents,
the amount and quality of schooling, and the presence or absence of
religious instruction.
All these latter investigations are carried out for Dr. Healy by social
workers. Their results are then pooled with those obtained by him after
the physical and psychical examination of the child at the dispensary.
One sees, then, that Dr. Healy and the other Americans who have followed
him in this field, insist upon covering in every case four classes of
facts:
(1) The child's physical condition.
(2) The child's mental condition.
(3) His physical environment.
(4) His mental, moral, and spiritual environment.
All this investigation is necessary because it is now recognized that
crime may be committed because the child is an epileptic; because he is
feeble-minded; because he is strained and tortured by defects of sight
and hearing; by inability to keep up in school on account of these
defects; because he is abnormally susceptible, under the influence of
comrades, cinema shows, and sensational literature; because his
inheritance, his education, or his home training has been defective or
bad.
Since there is no reasonable doubt that physicians and judges will more
and more coöperate in the study of offences against the law, and will
more and more need the assistance of social workers to complete their
studies and to carry out the reforms which those studies suggest, it can
easily be appreciated that the social workers need to be familiar with
the methods and results of psychological examination in this field of
work.
_Mental diagnoses in social work_
The idea that social work necessarily concerns the poor is wholly wrong.
It concerns the sick; it concerns the tuberculous; some of the sick and
some of the tuberculous are poor. Others are not. The State provides
dispensaries for tuberculosis, and the people pay for them out of the
taxes. Hence all the people feel that they have the right to go there
and that they are not in any sense accepting charity in going there. But
social work is done in all these dispensaries. Thus the connection
between medical and social studies is tending to upset the old idea that
social work is necessarily concerned with poverty, and that economic
studies are the main part of it.
In America our leading ideas about social work (formerly called
charity), came originally from England and from the studies of English
economists. Hence to a considerable extent economic considerations have
governed the history and evolution of social work even up to the present
day. Economists and people interested especially in political economy
have studied, practised, and spoken and written upon these subjects, and
all who are governed by the traditions inherited from England are still
obsessed by the idea that money and money troubles are the gist of
social work.
Nobody should turn up his nose at economics. Anybody who is careless in
money matters is sure to come to grief. But in my medical-social work,
which has included a large number of cases where poverty existed, I have
almost never found the economic trouble to be the essential one.
Economics is everywhere present, everywhere subordinate. That is an
adaptation of a saying of the German philosopher Lotze: "Mechanism
everywhere present, everywhere subordinate." The idea applies also to
economics which has many qualities in common with mechanics. I shall
therefore lay especial stress in this book, not upon economic but mental
deficiencies, which in most cases seem to me more fundamental than
economic need or physical weakness.
A considerable portion of all social diagnoses should contain the word
_ignorance_. I wish to distinguish ignorance from moral fault. It is
true that somebody's sin, somebody's evil-doing is the fundamental thing
in the social diagnosis of many cases. I have never yet studied
carefully a case involving social work without finding some moral
weakness as an important element in the trouble. Moral elements always
enter into the study of a case of social work, but they are often not
the main element, often subordinate.
_Ignorance_, of course, is permanent. If we were not ignorant we should
never progress. Ignorance therefore does not necessarily mean culpable
ignorance, but still it may be the keynote to the trouble in which any
of us finds himself. Consider industrial ignorance, ignorance of where
best to turn one's forces. It would be impossible to say that any of us
is free from that. Are we perfectly sure that we have found the place
where the Lord intended us to work? This lack may not be such as to
bring us into trouble. It may not force us to seek social aid. Yet the
lack of a clear idea about where we ought to be working, how we can earn
the most money, do the most good, and be happiest--that is a deficiency
that none of us is free from.
_Industrial ignorance_ has been the ultimate diagnosis in some of the
cases that I have studied. The patient is an industrial misfit. He has
not found his niche. Perhaps there is no niche existing for him. Some
people seem to be made for another planet or another century. Evidently,
then, conception of an industrial misfit is wide, perhaps vague. Yet it
often dominates the economic situation. Your patient perhaps cannot earn
his living because he is working with only about one quarter of his
powers, and that the least useful quarter. That with which he is trying
to earn his living may be a mere superficiality. Half the women that I
know in industry are working with a wholly superficial part of
themselves, unconnected with any of their deepest interests. That is
less true of social workers than of any other body of women. They often
can put the best of themselves into their work. But many women in
industry, in business, hate it. They may be earning enough, but are
unhappy and unsatisfied, because the powers with which they were meant
to labor for the service of their kind are not being used at all.
_Medical ignorance_: A quarter, perhaps, of our task as social workers,
is medical instruction, the breaking-up of medical ignorance. Most
well-trained physicians of the present day do not believe that many
diseases can be cured by medicine or by surgery. We do not have great
confidence in chemical, physical, or electrical therapeutics. We believe
that when sick people are helped by a medical man or a social worker it
is because they have learned something of what we call _how to live_, a
large term which we usually limit to mean how to look after their
physical machine.
As I talk with supposedly educated people, I am amazed to see how little
people who have lived forty or fifty years in the same tenement of clay
have learned about that structure. I do not mean that everybody ought to
study physiology. I mean, for example, such a simple thing as _how to
rest_. One cannot rest just as somebody else rests. We have individual
finger-prints, no two alike, and individual hand-writing. So we
have--and should have found--our own way of working and of resting,
which is probably as individual as our finger-prints. But we follow each
other like sheep.
The instructions we give to a tuberculous patient are needed because of
his medical ignorance or that of others. I once received a wonderfully
touching letter from a middle-aged tuberculous lawyer who finally
learned the medical facts necessary to save his life through reading a
popular magazine. He was being treated for tuberculosis, about as badly
as a human being could be treated, but he did not know this. He had gone
to the best doctor in his vicinity. Through reading in a popular
magazine an account of a medical conference on the treatment of
tuberculosis he finally learned the truth and cured himself. Medical
ignorance in relation to diabetes, to stomach trouble, to venereal
disease, to heart disease, it may be one of our tasks to remove before
inculcating the régime needed in these troubles.
_Educational ignorance_, ignorance of proper institutions and methods to
give a man the power which he needs, is often exemplified in relation to
industrial training. One sees people in industry who could do a great
deal better work if they had better training. But they do not know where
to get it. In many cities there are scholarships and funds for people
who show ambition to be better trained. Educational ignorance, then, as
well as industrial and medical ignorance, may bring people into economic
trouble, even into physical trouble. Such people often turn up at a
dispensary asking the doctor merely to cure a headache or a
stomach-ache. Yet if the doctor is wise he will find this other trouble
hidden in the background.
Obviously ignorance as a cause of trouble is a historic, not a
catastrophic, cause. Ignorance does not happen suddenly. Its bad results
accumulate gradually.
_Shiftlessness_
Another mental element in social diagnosis I call _shiftlessness_, in a
particular sense that I want to define. Not shiftlessness in the sense
of a general moral accusation, but as a failure of
adjustment--maladjustment, due to shiftlessness in the sense of an
inability to shift when there is a need for it. Professor Edouard
Fuster[1] has spoken of social treatment as consisting almost entirely
of helping people towards a better self-adjustment to their actual or
attainable environment. People often make a failure of their lives
because they do not shift when the proper time arrives. There are also
people who shift too often, on the other hand. I shall speak of that
later.
The physical analogies of these mental faults are interesting, I think.
A person who has too great physical shiftlessness gets a bed-sore.
Healthy people when they have lain in a certain position in bed for a
time feel a discomfort and therefore instinctively turn over. We shift
ourselves now and then in our chairs as we sit, and thus we relieve
pressure which in turn would produce injury. But in chronic illness the
patient sometimes lies in one position so long that he wears out his
tissues till the raw flesh or even the bone is exposed. That is just as
true on the mental side of life, true of us all.
There is nothing I hate more than seeming to take a pharisaical attitude
in our social diagnoses. All of us probably have failed to shift when we
should. We might be more useful to-day if we had shifted more wisely.
Still, we are getting along somehow, and some other people come to us
for advice because they are even more shiftless than we. I never yet
made a social diagnosis in anybody that I could not make also in myself.
It is only a question of degree.
_Industrial shiftlessness_ is an obvious example. A person gets into the
wrong job and then does not get out of it. Most people choose their
professions by the most irrational process or lack of process that can
be conceived of. When a boy is ready to choose a profession, does he
look around him, study the alternatives, and select one? Not at all. He
does what the next man does, what his father did, what he happens to
have heard most about. This is true whether people are pressed for money
or not. They choose their job for no good reason; they are thrown into
work by something pretty near to "chance." But they are often saved from
the full consequence of their mindlessness because they shift. They
shift either within the job or into another job. I got into medicine
first on the laboratory side, began by writing a book on the blood and
doing an unconscionable amount of work in the laboratory. It was wrong.
I was not fitted for it, and luckily I knew enough to shift. Social
medicine was what I wanted. So many a man shifts within his profession.
That is why the wrong choice made at the start does not always get
people into serious trouble. But the chronically shiftless man remains
immobile. He does not know where else he might be besides the place
where he is. So he stays where he happens first to fall, gets bitter,
hard, poor, drunken, all because he is in the wrong niche.
One sees _racial shiftlessness_ when people cross the ocean and try to
take root in a new country. This racial non-adjustment has very tragic
results. We see it, for example, in the Armenians in America who have
come from a civilization two centuries back, and cannot jump these two
centuries. Hence comes the breaking-up of moral and industrial standards
because they have come suddenly into a civilization to which they cannot
adapt themselves.
A third kind of shiftlessness one might call _domestic shiftlessness_.
An English servant girl married an Italian fruit-dealer. She was taken
home into his Italian family in Boston and had to try to fit herself to
Italian customs. She and her husband got along excellently. But it was
very hard for her to understand the shifts which she must make in order
to adapt herself to his family. She was an old patient of mine, and
after her marriage she brought her physical troubles to me, quite
ignorant of the fact that she was worn out by family friction. My
efforts were devoted chiefly to teaching her Italian customs and
defending her husband's family to her. I did not know any too much
about it. I had myself to learn the subject which I was set to teach, as
one does so often in social work. I had to find out the meaning of many
queer Italian customs in order to interpret them to her. At first she
had no idea that when one crosses a racial line one must shift
considerably. But she has finally learned it, and she is happy now.
I have spoken of two social deficiencies--ignorance and shiftlessness. I
believe there are very few cases in the social worker's domain which
fail to show some sort of ignorance, some sort of shiftlessness, as an
element in the social diagnosis. Such diagnoses must usually be long.
They are complicated and cannot often be expressed in one word. The word
"feeble-minded" and the word "tramp" ("Wanderlust") are among the rare
examples of a brief social diagnosis which explains all the physical,
economical, moral misfortunes which one finds in a person. But generally
one cannot find such a phrase. So one makes a number of statements as
one makes a list of many diseased states in the different organs of the
human body. I do not regret this. The best medical diagnoses, those made
after death, contain from thirteen to seventeen items on the average.
One of my chief tasks during the last fifteen years has been to study
diagnoses made after death and compare them with those made in life. The
real diagnosis as it is revealed at autopsy contains on the average
thirteen to seventeen items. The diagnosis made during life contains
often but two or three items. This brevity is characteristic of the
very partial truth contained in our clinical diagnoses. Therefore I do
not altogether regret it when I see in a social diagnosis a long series
of items referring one after another to the main departments of human
life. When we are making our medical diagnoses we try to say what is
wrong with the heart, the arteries, the kidneys, the stomach, etc., in
each patient. So in making our social diagnoses we ought to go through
some such list as I have begun to give here. Is _ignorance_ a factor? If
so, where? Is _shiftlessness_ in this particular case a factor, and how?
There are certain organs of the human soul which one can go through and
check up. (Anything the matter here? Anything the matter there?) as one
goes through the bodily organs to make a medical diagnosis.
_Instability_
The shiftless person, in the sense in which I define the words, is the
person who does not move often enough, who rests too long on one
particular set of habits so that he allows the world to move away from
him while he is left high and dry. Or he allows himself to get fixed in
one little set of habits and becomes a person with one idea. That is
shiftlessness, the person who cannot accommodate or adapt himself.
The opposite of this is _instability_--the defect of the person who
shifts too often, who cannot stay in one field long enough. In the
physical field this applies to people with motor nervousness, people
who never can keep still. But we are more interested, of course, in the
psychical side of it. Any piece of work can be said to have three
phases, something like the phases that Sir Almoth Wright has emphasized
in his writings on immunity. We have first a stage of interest and
elation, then a slump, a depressed or negative phase, as Wright said, a
stage when things are not going smoothly or when organization seems
endlessly complicated. Then is the time when, if we are of an unstable
type, we throw up our work. The unstable person cannot believe that the
undertaking is going on and up to a third or positive phase, which in
the end will be on a higher level than the phase in which we started.
Normal people habitually expect these three phases in every human
undertaking. They foresee the negative phase before they get out of the
first one. Hence they are not astounded or bitter when the inevitable
slump comes in the second phase. But the unstable person breaks off at
that point and tries something else. It constitutes one of the most
serious blots in any one's record if we find that he has changed his
work four or five times already. "Why did you leave your first job?" we
ask, and, "Why did you leave the second one?" There is never a
satisfactory reason for so many changes. These people are rolling
stones; they gather no moss. They never accumulate skill, power, and
money as the result of having stuck long enough in one place.
We see mental instability also in temperament, in spirits. Many people
get into trouble because they do not realize their own "negative" and
"positive" phases. Most people, we say, have their ups and downs. But if
we take our ups and downs too seriously, then we may talk about suicide
as so many people do. It is in these emotionally unstable phases that
people give offence to others, quarrel with their families, lose their
jobs.
Instability is much less important in the adolescent stage. Many a
parent has been in despair over his adolescent children. "Nothing good
ever can come out of that boy. He is too unstable," the parent is apt to
say. Yet great good often does come out of such a boy, simply because he
grows older. Such a boy is generally between thirteen and nineteen.
Tremendous physical changes are going on, which are rather more than he
can manage. Hence he becomes for a time unreliable, capricious, moody.
There is almost no degree of mental instability and unsatisfactory
conduct which may not wholly disappear as we get past the adolescent
stage.
On the other hand, the older a person is the more serious the outlook in
a case of instability. A woman in the vicinity of sixty drifted into my
hands some years ago, after having been the round of doctors whose
diagnosis was essentially instability. Although I labored very long and
prayerfully with that individual, I cannot say that I produced any
considerable effect.
Remember always the possibility that such instability is due to drugs.
Among the most unstable people are the morphine-takers, and because that
has among other symptoms concealment and lying, it does not easily come
to light. In the evening the morphine-taker is full of prowess, is full
of hope, ready to make engagements for nine o'clock the next morning.
But he almost never turns up for that engagement the next morning. This
morning depression is common also in many other diseases, such as
neurasthenia and that rare disease, anemia. The anemic patient has a
hard time getting up in the morning, but it is the fault of his red
corpuscles and not of his character.
Another phase of instability is _abnormal suggestibility_, abnormal
openness to influence or "suggestion" in the psychological sense. I
cannot count the number of fond but foolish mothers who have said to me
about a child, "John is a good boy, only he is weak. He gets led astray
by his companions." Everybody is and ought to be somewhat suggestible,
normally suggestible. The man who is not suggestible is the person with
a monomania, who can see nothing but his own view, is stupidly attached
to one set of ideas and so cannot learn. But one can easily be too
suggestible. Over-suggestible people run after every craze, are
impressed with each new religion, or are tremendously excited with each
new friend and think of each new experience: "Ah! This is what I have
been looking for all my life. Nothing else matters." This is especially
common at the adolescent age, but it is a danger for all of us, men and
women of every age. We get carried away by popular crazes, by
influences, by suggestions, so that we cannot remember the good that
there was in our previous beliefs and interests. If so we are mentally
unstable in this respect.
We see in every dispensary many cases of abnormal physical
suggestibility, people who think that they have caught every disease
that they hear about. Among medical students and nurses in training
there are always some who become convinced that they have the disease
which they have just been studying in the hospital. In the social
assistant's work as a taker of histories she must remember that. Highly
suggestible people give curiously misleading histories because they
become obsessed with the idea that they have some terrible disease.
There are three examples of abnormal suggestibility which in my
experience recur with especial frequency: _heart disease_, _cancer_,
_insanity_. People are amazingly prone to fancy that they have heart
disease. If they have any symptoms in that part of the body where they
are taught to believe that the heart resides, or if they have heard
anybody talk of heart disease, or especially if anybody whom they know
has recently died of heart disease, there are many people likely first
to believe that they have heart trouble, and then to have actual
symptoms which they attribute to heart disease. They often say nothing
about this fear. That is just why it is so essential for social workers
to dig it out in the course of their history-taking. When people are
afraid of a thing they are especially apt to conceal that fear.
Insanity is feared, I think, even more often than heart disease. Every
doctor is consulted by people who are sure on most trifling evidence
that they are going insane. We hear people say, "Why my mind must be
failing, for I read down a page and when I get to the bottom I cannot
remember what I have read." Or, "I am losing all memory. I met a man
recently suddenly and I could not remember his name." These two normal
fatigue-products--failure of attention or failure of memory--often make
people think that they are going insane. A third result of fatigue which
often frightens people is the sense of unreality. Such people say, "I
seem to be numb. Things do not seem real to me. I talk to people and I
wonder if it is not all a dream. Am I not going crazy?" There have been
interesting essays written by French psychologists on the "Sense of the
_Déjà Vu_." For a few hours whatever we say or do seems a repetition; we
have said, done, heard all that before we fancy. It is a very
disquieting sense. But it is usually nothing but fatigue.
Cancer I suppose is the most dreaded of all diseases, but one of the
most unnecessarily feared. Patients may appear at the dispensary for
most trifling pains or stomach troubles, troubles that all of us would
disregard, and when we inquire why it is that they have come, sometimes
a long distance and at considerable expense, we find out that it is
because they have recently heard or read something about cancer, or
remembered that there is cancer in the family. We cannot be too careful
to tell people that cancer is not hereditary. People are apt to think it
hereditary, but this is one of the medical fallacies that we should all
of us do our part to eradicate from the public mind.
I will mention one or two other common groundless physical fears. We
should teach people that if they have a pain in the left side of the
chest the chances are about nine out of ten that the heart is perfectly
sound. If they have a pain, as they say, "across the kidneys," the
chances are ninety-nine out of one hundred that the kidneys are
perfectly healthy. The newspaper advertisements of charlatans do all
they can to make people think that a pain in the back must be kidney
trouble. We must fight such poisonous influences.
FOOTNOTE:
[1] Conférence Interalliée des Mutilés. Paris, May, 1917.