MENTAL INVESTIGATION BY THE SOCIAL ASSISTANT (_continued_)
_Fears and forgetfulness_
It is not merely because of a doctor's mental habit that I speak of life
in terms of diagnosis and treatment. For though those particular words
are medical, any part of life can be thus conveniently summed up. One
tries to find out the facts about some region of life in which one works
or plays, fights, loves, or worships (diagnosis), and then one tries to
do something about it (treatment). If one makes a friend one tries to
find out something about him and then to treat him accordingly. If one
comes to a new city one tries to diagnose its geography and to direct
one's self accordingly. If there is anything not included in that set of
phrases about the behavior of the human being towards the world, I do
not know it. Therefore it seems natural to sum up social work also in
terms of diagnosis and treatment.
I referred in the last chapter to social ignorance as a possible item in
a social diagnosis. I meant to recall those parts of a person's outfit
for dealing with life in which he is deficient because of _ignorance_,
industrial ignorance, or educational ignorance, or physical ignorance. I
went on to recall two other mental deficiencies or sources of
incapacity, _shiftlessness_ and _instability_.
In this chapter I want to exemplify _fears_ as sources of inefficiency
or deficiency, as causes of sickness, economic dependence, and
unhappiness. Christian Scientists define almost all human ills in terms
of fear. That is extreme. I know many people who do not seem to suffer
from any fears whatever. I sometimes wish they suffered from a few more.
I should not say at all that fears were the cause of all evil, or that
the fearless person was perfect. Still, fear is a very great factor in
social ills. I mentioned in the last chapter the three commonest
physical fears as met with in medical practice: fears about the heart,
about cancer, and about insanity. I sometimes feel that I will never let
a patient go from me without saying, "You have not got heart disease,
you have not got cancer, you are not going insane," even if he came to
me for a cut forger or an ingrowing toe-nail. No one but a physician can
appreciate how many people dread one of these three diseases.
But about physical fears as about other fears, the most important thing
to know is that they are disabling, crippling, in proportion as they are
not recognized, or only semi-conscious. I am one of those who believe
that one should not talk about unconscious consciousness, although
synonymous phrases are very popular among modern psychologists. But we
all of us know that a large part of our mental life is in a half light,
neither in full consciousness nor in oblivion. These half lights may be
quite harmless, but often they are especially mischievous. Our vague,
undefined experiences produce the fears which trouble us most. Fear of
the dark and fear of ghosts exemplify this rule, but it holds just as
well for fears about disease.
Partly because of this vagueness, people often do not tell the doctor
about their most serious fears. One has to go out of one's way to
reassure people about their fears, because they so often conceal them.
Of course there are exceptions to that. People come to a doctor often
for nothing else except fears. But that is not true of the majority of
patients nor of those suffering the most harmful and haunting fears. It
is for that reason that I am trying to give some idea of where to look
for facts that do not come spontaneously to you as patients tell their
stories. If the social assistant has not the medical knowledge or the
authority necessary to reassure the patient, she can bring him to
somebody who has. At the present time there is no piece of medical
service more clean-cut and satisfactory than the power to reassure a
person about an illness that he thinks he has, half-consciously fears he
has, and therefore tries to banish from his mind. To discover groundless
fears, then, fears of poverty, of ridicule, of marital unhappiness, and
to cure them by bringing them to light, is the task that I think every
social worker should consider as part of her job, in so far as she is
connected with medical work, as she must be always so far as I see.
It is astonishing how often people are relieved by knowing a truth
which we shrink from imparting. I recently examined at a Red Cross
Dispensary in Paris an old lady in face of whose troubles I was a little
daunted when I came to carrying out the principle of telling the truth
as I have long preached and tried to practise it. She had a chronic
asthma. She suffered a good deal from it both night and day, and I could
not see the slightest prospect that she would ever be any better,
because in people past middle life asthma is for all intents and
purposes an incurable disease. When I had finished examining this old
lady and faced my task of telling her the truth, I did not feel
comfortable about it at all. But I gave her the facts. The outcome was
striking. "Oh, yes," she said, "I rather thought that my asthma is
incurable. I did not expect that you could do anything to cure it. All I
wanted was to make sure that I had not got tuberculosis on top of it."
About this fear of tuberculosis she had said not a word to the
history-taker. It came to light quite unexpectedly. But when I assured
her that she had not got tuberculosis on top of her asthma, she seemed
quite contented and hobbled away very happily, puffing and blowing as
she went.
That illustrates the relief that comes to people from finding that a
deeper-concealed fear is groundless. Again and again I have pushed
myself up to the task of telling people what I knew they had to know,
and then found that instead of prostrating them I had relieved them of
torturing uncertainty.
I will relate an experience which shows how far this truth extends. An
elderly lady, whom I had known for nearly twenty-five years at the time
this incident happened, was in the habit each spring of coming from New
York, where she lived, to Boston, where she used to live, to make a
round of visits among her friends. While still on one of these visits
she telephoned me one day to come and see her. As I entered the house
where she was staying, I was met, as I have been met so many times, by a
member of the household, who, with finger on lip and every precaution
for silence, beckoned me into a side room and proceeded to tell me "what
nobody else must know." It was something like this: That my friend the
old lady had begun the first of her round of visits about a month before
this. On that first visit it had become pretty obvious to her friends
that she was mentally queer. She was not a millionaire, yet she was
spending and giving away an extraordinary amount of money. She was
ordinarily a person of quiet habits and not prone to hurry about, but
now she was making the dust fly all the time. She was ordinarily modest.
She had now become boastful. The first friend with whom she stayed
believed, as people usually do, that it would be dangerous to tell her
anything about her mental condition, yet found it impossible to keep her
in the house. Therefore the hostess made the excuse that she had a maid
leaving and could not really keep a visitor just now. Would my friend
mind moving on to the next visit? She moved on to Number Two; naturally
the same thing happened there. So the second hostess passed her along to
Number Three. She was with Number Four at the time when she called me.
All this was given me in the strictest secrecy in the little anteroom
close to the front door. My informant then tried to pledge me not to
tell the old lady the truth, fearing an outbreak of violence. But as I
had a good while ago sworn off all forms of lying, I refused to make any
such promise.
I went upstairs to see the patient. She poured out to me one of the most
pitiful stories I ever heard--the same story just given, but from her
own point of view. So far as she could see, her friends were all playing
her false in some way, or losing their affection for her. She knew that
it was not by accident that one friend after another had politely shown
her the door. Something was being concealed from her. What could it be?
She was really worn out, she said with worry and sorrow about it.
I told her at once the whole truth. I told her that she was insane. I
could also tell her truthfully that she would come out of it (as she
did), but that I must now take her away from this house, shut her up,
and take care of her. "Oh," she said, with immense relief in her voice,
"is that all? Is it nothing worse than that? Insanity is nothing
compared to losing all your friends." Insanity is one of the greatest of
human fears, but for this old lady, as for most of us, there is
something still worse--the fear that one has not a friend in the world.
Even to know that she was doomed to what most people would consider one
of the worst of fates was to her a relief; for there was a worse fear in
reserve, and that she now knew was groundless.
The _treatment of fears_, the only treatment that I know of, is that we
face them, look straight at them, as we turn a skittish horse's head
right towards the thing that he is going to shy at, so he can look at it
squarely. So we try to turn the person's mental gaze straight upon the
thing that he fears.
People frequently consult a doctor because they are afraid of fainting,
fainting in church or in the street, for example. In such cases I have
found it most effective to say, "Well, suppose you do--what harm will it
do?" From the answers to this question I find generally that the
patients have in the back of their minds, unconfessed, unrealized, the
_fear that if they faint_ and nothing adequate is done to cure them
_they will die_. They do not know that people who faint come to just as
well if they are let alone, and that all the fussing about that is usual
when people faint is useful merely to keep the bystanders busy and not
to revive the patient.
Make a person face "the worst" and you disarm its terrors.
"But suppose I get faint on the street?"
"Well, you probably will just sit down on the curbstone until you come
to."
That remark does not sound as if it would reassure a person even if
made with a laugh. But it does, because he is thereby freed of a fear of
something much worse, a fear that lurks in the background of his mind.
There is one other thing to be said about the treatment of fears. If a
person fears to do any particular act, such as going to church or into
the subway, if he fears to be alone in crossing a big square, if he
fears to get into a crowd (all these are common fears), the most
important thing is to _force him to do what he most fears_.
"Do the thing you are afraid of, or soon you will be afraid of something
else as well. And the more you do what you fear to do, the less you will
be afraid of it, because your act will bring you evidence of the truth.
Your act will prove to you that you can do the thing that you fear you
cannot. That fact will convince you a great deal more than all the
talking that your doctor or anybody else can do. You will get conviction
by reality, the best of all witnesses."
Among the poor, with whom we deal part of the time in social
work--though I insist that social work is concerned with the rich as
well--we have to face _economic fears_. In America and England economic
fears are a very real evil--fears of the work-house, fears of coming to
be dependent, of having no place of their own, are what poor people
often dread. Again, the clue for our usefulness is to find out what
people do not tell us of these economic fears, and then to see if we can
make them groundless.
In a certain number of people (I do not feel competent to say how large
a portion), life is rendered miserable by _the fear of being found out_.
I happened, as I have already said, to get driven some years ago into a
position where I thought it best to swear off medical lying. One of the
surprising parts of this experience was the sense of relief which I felt
when I knew that there was no longer anything in my medical work that I
was afraid of having any one find out. It was in benevolent, unselfish
medical lies that I had been dealing, according to the ordinary practice
of the medical profession. But as soon as I decided that I could abandon
these and need no longer fear that any patient might find out what was
being done to him, I had the sense of a weight taken off my shoulders.
_Forgetfulness_
There is a very eloquent passage in one of Mrs. Bernard Bosanquet's
books[2] about social work, in which she describes the psychology of the
poorer classes among whom she worked in London, and dwells especially on
their characteristic forgetfulness. They cannot learn because they
cannot remember. They cannot learn how to avoid mistakes in future
because they cannot remember past mistakes. One well-known difference
between a feeble-minded person and a person competent to manage the
affairs of life, is that the former forgets so extraordinarily, and
therefore cannot build up through remembrance of his past how to steer
better through the future. Of course we all of us have this disease in
varying degrees. We all forget, in the moral field as well as the
physical, things that we ought to remember. There are things that we
ought to forget. After we have started to jump a fence, we must not
remember the possibility of our failing. The time to remember that is
before we have begun to jump. Moreover, there is no particular benefit
in remembering our own past mistakes if they are such that we cannot do
anything about them, morally or any other way.
There are things, then, that we ought to forget, but allowing for these,
forgetfulness means forgetting the things which we ought to remember. In
alcoholism it is extraordinary how much the person forgets. One cannot
fail to be struck by the fact that the alcoholic gets into trouble again
and again because he cannot fully remember what happened before. In the
field of sex faults this truth is equally obvious. A man is unfaithful
to his wife because he allows himself to forget his wife--his memory of
her is for the moment blotted out. Nobody could violate his own
standards in this field if he could vividly remember them. Hence if we
are to help any one else to govern himself in matters of affection we
must help him to remember, help him _by planning devices that make it
nearly impossible to forget_.
Bad temper can ordinarily be explained by forgetfulness. We can hardly
lose our temper with a person if we remember the other sides of his
nature opposed to that with which we are just now about to quarrel.
Nobody consists wholly of irritating characteristics. We all possess
them; but we all possess something else besides. Hence if we can realize
some of our own moments of wrath, I think we must confess that for the
moment the person with whom we were enraged possessed for us but a
single characteristic. The rest were forgotten.
My account of these five common types of mental deficiency: ignorance,
shiftlessness, instability, fears, forgetfulness, is general and vague.
I mean to make it so. If my suggestions are of any use to the reader it
will be because he is able to make his own specific applications. I
want, however, to mention one example of a much more specific fault,
namely, _nagging_. In social work we often see families broken up or
seriously cracked by some one's nagging. It consists in reminding people
of their defects and shortcomings in season and out of season, until the
reminder finally gets upon their nerves. You are aware that your
husband, your wife, your child, has some very deleterious fault.
Admittedly he has it and it is constantly getting him into trouble. So
you want to be quite sure that it never gets him into trouble again;
and hence you keep reminding him of it again and again until you produce
an irritation that only aggravates the original fault.
Why do I take so trivial and specific a case as this? Because I can
remember several cases where I could not possibly leave out nagging when
I came to make my social diagnosis. It was one of the chief factors. One
cures this disease, in case one does help it at all, by making the
nagging person conscious of what it is that he is doing. The nagging
impulse is like an itch. _It recurs and scratching does not stop it._
The nagger does not know quite why he does it; he finds himself doing it
almost in his sleep. Hence we try to wake him up, to make him conscious,
if we can, of his foolishness, of the kind of harm he is doing, and of
the degree of incurability he is inducing in the person whom he is
trying to cure.
I will now sum up the last four chapters in a diagram which we have used
in Boston at the Massachusetts General Hospital to assist us in making
our social diagnoses. A social diagnosis can very seldom be made in one
word, such as _idiocy_ or _tramp_. It must include the patient's
physical state. It must summarize a person's physical, moral, and
economic needs. Our best social diagnoses, such as _idiocy_ or
_feeble-mindedness_, do not refer to the mind only. They refer to the
body just as much. Feeble-mindedness is a statement about the child's
body, his brain, his voracious appetite, the diseases to which he is
likely to succumb, his extraordinary susceptibility to cold, and his
poor chances of growing up. One says a great deal about the physical
side of a child as soon as one pronounces the word "feeble-minded." Also
one says a great deal about his financial future. One knows that the
feeble-minded child will never rise beyond a very low point in the
economic scale. One says also a great deal about his moral future. We
all know to what sexual dangers and temptations he is especially
exposed. And on the purely psychological side one can predict his entire
unteachability beyond a perfectly definite limit. All this is given in
the medical-social diagnosis, "feeble-mindedness."
This is an example, then, of an ideally complete and compact, though a
very sad, social diagnosis. It is almost the only good one we have
worked out as yet. The only other is "tramp." The tramp in a technical
sense is a person who has what the Germans call "Wanderlust." He is
unable to stay in one place. Perpetually or periodically he desires to
move and to keep moving. The tramp is a medical-social entity. He has
certain physical limitations, certain economic limitations, certain
moral deficiencies. But in America he is rather a rare being. One does
not see many typical tramps here.
Since few social (or medical-social) diagnoses can be stated in a single
word, one is usually forced to write down one's diagnosis in a great
many different items. As a guide I made four years ago a schedule for
our use at the Massachusetts General Hospital. Use--the only test for
that sort of thing--has shown this schedule to be of some value.
+ 1. Physical--+ a. Heredity.
| + b. Health.
+ I. The Individual --| + a. Mental deficiency.
| + 2. Mental --| b. Mental disease.
| | c. Temperament.
| + Character.
Diagnosis |
shall -| + a. Food. Clothes.
characterize| | Housing.
| | b. Industrial
| | conditions.
| + 1. Physical--| c. School conditions.
| | | d. Climate. Natural
| | | beauty or
+ II. His Environment-| + ugliness.
| + a. Family and
| | friends.
+ 2. Mental --| b. Education.
| Play.
+ c. Religion.
To make a social diagnosis we should make a summary statement about the
individual in his environment. That summary is to include his mental and
physical state, and the physical and mental characteristics of his
environment. (I here use the word "mental" to include everything that is
not physical; that is, to include the moral, the spiritual, every
influence that does not come under physics or chemistry.)
When the investigation of a patient is divided between doctor and social
worker, the doctor studies his physique; the social worker studies the
rest. I believe that there is nothing that we can want to know about
any human being, rich or poor, that is not suggested in that schedule.
Suppose, reader, that a friend of yours was engaged to be married.
Suppose you wanted to know something about the fiancé. You would
certainly want to know about his health and his heredity; then what sort
of a person he was, his mentality, whether he had any money--what are
the obvious physical facts about his environment. To what influences has
he been subjected, and what mental supports, such as education and
recreation, family, friends, and religion, can he count upon? You would
not want to know any more and you ought not to want to know any less.
So in summing up a social diagnosis I think it is convenient to use the
four main heads that I have put down here. I think these headings will
remind us of everything that we want to put down, and of everything that
we may have forgotten to look up. That is one function of such a
schedule--to remind us of the things which we have forgotten.
Made up in such a way as this, of course the social diagnosis will have
many items, and like medical diagnosis it will be subject to frequent
revisions. The doctor who never changes his diagnosis is the doctor who
never makes one, or who makes it so elastic that it means nothing. So
social workers should never fear to add to, to subtract from or to
modify their social diagnoses.
The best medical diagnoses--those made after death--often contain
fifteen or twenty items. Before death in a recent case we found
pneumonia. After death we found in addition: meningitis, heart-valve
disease, kidney trouble, gall-stones, healed tuberculosis, and ten minor
troubles in various parts of the body.
So a good social diagnosis will name many misfortunes of mind, body, and
estate, healed wounds of the spirit that have left their scar,
ossifications, degenerations, contagious crazes which the person has
caught, deformities which he has acquired.
FOOTNOTE:
[2] Bosanquet, Helen. _The Standard of Life and Other Studies._ (London,
Macmillan & Co., 1898.) _The Family._ (London, Macmillan & Co., 1906.)