Psychiatric Social Work
in
a
By MARGARET ASHDOWN Supervisor of Mental Health Course Students,
Mental and
ELSIE L. THOMAS, Social Worker, Runwell
Psychiatric A one
patient employing"
who had been in several mental
social worker!
psychiatric
a
How nice!
Hospital hospitals before
social worker exclaimed Now none of the other
on
transfer
introduction:
hospitals
"
to
A
had anyone
"
to arrange socials for us! Well, one can safely say that to provide entertainment is not one of the conscious aims of the psychiatric social worker,
but there remains
be, according
to
a
wide
whether
divergence of opinion as to what her happens to be a patient, a relative,
one
duties should a
psychiatrist
and indeed in the welter of innumerable and sometimes conflicting demands the psychiatric social worker has little time to evolve a conception of herself in the scheme of mental hospital treatment.
or a
member of the
public,
This, then, is a welcome opportunity to try to formulate a personal view function, but first it will be necessary to indicate in general terms her official duties. No particular hospital is intended, and although we have drawn chiefly on those procedures best known to us, it is believed that the general of her
34
MENTAL WELFARE
features of the work
are common to all mental hospitals employing psychiatric Naturally there are considerable modifications of details dependent on geographical factors, the individual traditions of the hospitals, the existence or otherwise of associated out-patient clinics, the demands of the psychiatrists and the varying possibilities of co-operation with other social workers in allied branches of mental welfare. As a case in point, there are still some boroughs where no Voluntary Associations for Mental Welfare exist, and this has been felt as a very real loss to psychiatric social workers
social workers-
in these districts. As
good an approach as any to the understanding of the duties of a psychiatric social worker is to consider her work in relation to a patient's Most mental hospitals now have outprogress through a mental hospital. patient clinics, usually held in general hospitals, at which the psychiatric social worker, if any, is required to attend. Here the degree of her participation will largely depend on whether the clinic is used primarily for diagnosis or whether regular out-patient treatment is also undertaken. In the latter case she may have an with the of co-operating psychiatrist in opportunity trying to effect adjustments in the social milieu or in encouraging a re-orientation of a patient's interests before any gross breakdown has occurred. This preventive aspect of her work is even more marked in those areas where children, in the unfortunate absence of accessible child guidance clinics, are also referred for consultation and advice. In the majority of cases a patient is first referred to a psychiatric social worker at the time of admission to the hospital, when a home visit is paid to obtain
history, which includes details of heredity, home conditions, developmental history, personality and symptoms of the illness. Indeed, in most hospitals, with the possible exception of those receiving patients from the London County Council observation wards which also employ psychiatric social
a
social
workers, the most urgent demand on the time of the worker is for these social histories for their value as an aid to diagnosis, prognosis and treatment. In point of fact, a newly appointed worker has often to be alert against this type of service to the exclusion of others, of no less importance the ultimate welfare of the patient if of less demonstrable value. This is
developing to
overlook the fact that social histories may reveal sources of difficulty in the environment on which treatment may be directed while the patient is in hospital. These first few weeks also seem the most favourable for establishing a sound contact between the patient and the worker, who has abundant not to
as a real link between the hospital and this world, although may sound rather a grandiloquent way of to the numerous messages between the patient and relatives with
opportunity
to demonstrate her role
the outside
referring
which she is entrusted !
35
MENTAL WELFARE The
social worker is usually required to visit and present the homes of all Certified and Temporary patients about to be unless these are already known to be satisfactory. Further, she
psychiatric on
reports
discharged, may supervise mend the
the
amount
When
care
of
a
patient discharged
of the
"
On Trial
"
and may
allowance which is
accompanying required, similar visiting is,
recom-
given
when
of course, done for Voluntary necessary. and Section 6b of Mental the Treatment Act may be used for them patients, as well as for other patients to enable grants to be made towards the cost of
clothes, tools, convalescence or admission to a hostel while seeking work. Hospitals, however, vary considerably in the use that they make of this clauseWhere boarding-out schemes are in operation the psychiatric social worker is often responsible for selecting suitable homes and -keeping in touch with the patients after placement. With reference
after-care, all workers seem to have a few discharged patients they keep in regular personal contact, usually because a mutual good relationship has been established; but about after-care in general there seems to be an interesting difference in policy. On the one hand, there to
with whom
those workers who themselves take the initiative in visiting patients they think will benefit by this; while others, sometimes through pressure of work but often deliberately, leave the initiative to the patient or are
whom his
it is necessary for the patient to know that service which the worker will be glad to render, and the mere knowof this seems to give a degree of security to some who are fearful of
family.
this is
ledge
In the latter
case
a
the future,
even
if
they
may
never
need to take
advantage
of the offer.
On the practical level much can be done in advising about training, employment, lodgings and social activities. The question of work calls for special comment, since sociological and psychological factors are here inextricably intertwined. Thus, while from one district in the Midlands a social worker reported that employment could be found for Anything that could push a wheel-barrow," in an area with a high incidence of unemployment social adjustment may consist in helping a discharged patient to accept the fact of his unemployability. This is not to suggest, of course, that such a situation is static, since it is largely dependent on such external factors as the general level of employment, developments in social legislation, changes in the social structure or even the possibility of revolution or war. The degree of responsibility assumed by the psychiatric social worker for direct work finding, varies considerably from hospital to hospital, and although previous employers may be seen with a view to reinstatement, it is often found that a recovered patient "
is his
best advertisement and may achieve better results without the intervention of a social worker. For the most part these practical services own
are not
such
as
provided direct,
but in
co-operation
with other social work
the Mental After-Care Association.
Personally,
we
agencies,
feel that this
MENTAL WELFARE
36
division of labour is greatly to be preferred, and that not only are such agencies better equipped for dealing with such specialised problems, but also that the particular contribution of the psychiatric social worker may be impaired by undue
pre-occupation
In those
with material wants.
hospitals where emphasis is laid on research the psychiatric social required to do the requisite social enquiries. Important as the present average of one worker to a mental hospital with
worker is often this is, with anything from to
one
thousand beds the most zealous enthusiast is unable appreciable extent in this way. Most workers, however,
to two
to any
co-operate with specific
investigations, such as the following up of general paralytics who have had malarial treatment, the routine visiting of patients discharged after insulin-shock therapy and so forth. help
roughly sums up the routine work of a psychiatric social worker in a mental hospital, and it is probably already clear that her appointment will increase rather than lessen the burden of the psychiatrist, for the approach from the social side, by emphasising the multiplicity of causation of the illness, will indicate the necessity of treatment from more than one angle, thus extending the scope of the hospital. Her work can only fairly be This
evaluated
as a new
service.
a psychiatric social worker was patient in a mental hospital, but a moment's thought will show that a social worker, simply because she is a social worker, has a dual aspect dependent on whether she is regarded from this internal or from an external standpoint such as the relative's- To develop this idea we might consider one of the duties that have already been mentioned, only this time from the external' standpoint. For example, we would say that the initial home visiting at the time of the patient's admission is not only of value for the clearer appreciation of a patient's mental condition, but also because of the opportunity it gives to the relative of expressing his difficulties arising out of the illness. Relatives may variously regard the patient's admission with relief, as an indication of their personal failure to cope with the situation, with guilt and anxiety lest the patient should be reproachful about his detention, with shame as to what the neighbours will think or with a burning resentment against the whole procedure of certification, which may have taken place without their approval. They came and snatched her away," said one man, and that phrase revealed the frustration felt by an unintelligent, unemployed man always up against authority in the shape of the Court of Referees, the Police and armies of social workers. With him, the fact that someone wrote to invite his co-operation and asked him to suggest a time convenient to himself for the interview was therapeutic, and it seems to us that the mere expression of these attitudes and grievances constitutes a
For purposes of
clarity
first considered in relation
the function of
to
the individual
'
"
MENTAL
WELFARE
37
of catharsis which is of real
sociological value. One woman wrote: after visit and felt comforted." This should certainly sleep your be justification for the visit equal to that of obtaining the social history. means
"
I
was
able to
This dual aspect of the function of a psychiatric social worker seems to us imply a dual responsibility. If the aim of the hospital and the community were always identical there would be no problem, but as it is there is someto
times discrepancy. For instance, some hospitals may count as success the placing of any patient in competitive work, but it may well be questioned, especially with unemployment at its present level, whether it is not socially preferable for unemployment to be borne by the less fit rather than by the able-bodied. The working out of the implications of this dual responsibility is a burden which the psychiatric social worker is only too anxious to share, and to avoid one-sided emphasis the fullest possible synthesis between the pychiatric and sociological aspects seems imperative. From this brief description of what is expected of the psychiatric social worker and what she herself aims at achieving, it will be clear that her work calls for special training, although here, as in every profession concerned with human material, it is personality and personal development which are of crucial importance. That the worker should have a practical knowledge of community resources, through which the discharged patient may be reinstated in society, needs no stressing. A wider basis of knowledge is demanded, however, if she is to appreciate the subtler interactions between the individual and his social group, such
as
will often have contributed
to
his illness and will almost
certainly have a bearing on his satisfactory reinstatement. This wider sociological knowledge, as well of family case-work involving experience in the use of the organised resources of society, is the foundation of all general social work worthy of the name and is laid in the Social Science courses of Problems of personality and of human London and other universities. relations are implicit in every kind of social work, but in psychiatric social work they are so inescapable that they call here for more specialised studyThe fundamental equipment of individuals, the development of personality from infancy onwards, the distortions which personality may undergo in the course of its development, the psychological reactions of one individual to another, especially in family relations, all these demand the closer consideration of the psychiatric social worker and must be covered by her specialised training. The problem of adjustment, moreover, between the individual's mental capacity and the demands which society makes upon him is an important aspect of all psychiatric social work and mental deficiency is frequently enough combined with mental disorder to make it desirable for the training of a psychiatric social worker in a mental hospital to include an introduction to the problems of mental deficiency and the community's provision for dealing with it.
38
MENTAL WELFARE
psychiatric social worker in a mental hospital knowledge of psychiatry is clearly essential, not only in order that she may co-operate intelligently with the psychiatrist, but also that she may see her way through the tangle of human relationships, shading imperceptibly from normal to For the
abnormal, within which her
own work lies. Much first hand contact with cases of mental disorder in mental hospitals, out-patient clinics and observation wards is needed before that more than external understanding of its various
manifestations is reached which is essential to her work. No psychiatric social lay claim to any expert knowledge of psychiatry, recognising
worker would
that its roots lie in lies, indeed, not in combination
a discipline other than her own. Her professional claim being an expert in any one thing, but in that particular of approaches or balance of factors which her title suggests.
The Mental Health Course of the London School of Economics and Political Science, at present the only recognised training course in psychiatric social work in Great Britain, is designed a mental hospital. The fact that it is
to meet
in
planned
the needs of the worker as a preparation for all
kinds of social work with adults and for work in child guidance clinics as well as to meet the case of general social workers who feel the need for the
psychiatric approach in in that it tends to keep
their
own
work,
the basis of the
year allows. The shortness of the entering shall have behind them a
may be
course as
course
regarded
as an
broad
the
as
advantage, period of one
makes it essential that students
general training in social work, and an its of sociological background, and for this reason the certificate understanding of a recognised University Department of Social Science is a requirement for admission only waived in special circumstances. The full period of the On its course is needed for the more psychiatric aspects of the training. theoretical side this is provided at the London School of Economics in close relation with the practical training in case work provided at the London Child Guidance Clinic, the Maudsley Hospital and observation wards, while a short introduction to mental deficiency is arranged by the Central Association for Mental Welfare, all these combining to build up the body of knowledge and experience which psychiatric social work in a mental hospital demands. importance of the personality of the psychiatric social worker in this field is recognised in the care with which candidates are selected for the course, not on the grounds that the qualities demanded for this kind of social work are in themselves higher than those demanded for any other, but that the damage caused by the worker whose unsolved personal problems or lack of sensitiveness in personal relations, intruding as they must into her work, is in the field of psychiatric social work more than usually far reaching Finally,
and serious.
the
in
a
By MARGARET ASHDOWN Supervisor of Mental Health Course Students,
Mental and
ELSIE L. THOMAS, Social Worker, Runwell
Psychiatric A one
patient employing"
who had been in several mental
social worker!
psychiatric
a
How nice!
Hospital hospitals before
social worker exclaimed Now none of the other
on
transfer
introduction:
hospitals
"
to
A
had anyone
"
to arrange socials for us! Well, one can safely say that to provide entertainment is not one of the conscious aims of the psychiatric social worker,
but there remains
be, according
to
a
wide
whether
divergence of opinion as to what her happens to be a patient, a relative,
one
duties should a
psychiatrist
and indeed in the welter of innumerable and sometimes conflicting demands the psychiatric social worker has little time to evolve a conception of herself in the scheme of mental hospital treatment.
or a
member of the
public,
This, then, is a welcome opportunity to try to formulate a personal view function, but first it will be necessary to indicate in general terms her official duties. No particular hospital is intended, and although we have drawn chiefly on those procedures best known to us, it is believed that the general of her
34
MENTAL WELFARE
features of the work
are common to all mental hospitals employing psychiatric Naturally there are considerable modifications of details dependent on geographical factors, the individual traditions of the hospitals, the existence or otherwise of associated out-patient clinics, the demands of the psychiatrists and the varying possibilities of co-operation with other social workers in allied branches of mental welfare. As a case in point, there are still some boroughs where no Voluntary Associations for Mental Welfare exist, and this has been felt as a very real loss to psychiatric social workers
social workers-
in these districts. As
good an approach as any to the understanding of the duties of a psychiatric social worker is to consider her work in relation to a patient's Most mental hospitals now have outprogress through a mental hospital. patient clinics, usually held in general hospitals, at which the psychiatric social worker, if any, is required to attend. Here the degree of her participation will largely depend on whether the clinic is used primarily for diagnosis or whether regular out-patient treatment is also undertaken. In the latter case she may have an with the of co-operating psychiatrist in opportunity trying to effect adjustments in the social milieu or in encouraging a re-orientation of a patient's interests before any gross breakdown has occurred. This preventive aspect of her work is even more marked in those areas where children, in the unfortunate absence of accessible child guidance clinics, are also referred for consultation and advice. In the majority of cases a patient is first referred to a psychiatric social worker at the time of admission to the hospital, when a home visit is paid to obtain
history, which includes details of heredity, home conditions, developmental history, personality and symptoms of the illness. Indeed, in most hospitals, with the possible exception of those receiving patients from the London County Council observation wards which also employ psychiatric social
a
social
workers, the most urgent demand on the time of the worker is for these social histories for their value as an aid to diagnosis, prognosis and treatment. In point of fact, a newly appointed worker has often to be alert against this type of service to the exclusion of others, of no less importance the ultimate welfare of the patient if of less demonstrable value. This is
developing to
overlook the fact that social histories may reveal sources of difficulty in the environment on which treatment may be directed while the patient is in hospital. These first few weeks also seem the most favourable for establishing a sound contact between the patient and the worker, who has abundant not to
as a real link between the hospital and this world, although may sound rather a grandiloquent way of to the numerous messages between the patient and relatives with
opportunity
to demonstrate her role
the outside
referring
which she is entrusted !
35
MENTAL WELFARE The
social worker is usually required to visit and present the homes of all Certified and Temporary patients about to be unless these are already known to be satisfactory. Further, she
psychiatric on
reports
discharged, may supervise mend the
the
amount
When
care
of
a
patient discharged
of the
"
On Trial
"
and may
allowance which is
accompanying required, similar visiting is,
recom-
given
when
of course, done for Voluntary necessary. and Section 6b of Mental the Treatment Act may be used for them patients, as well as for other patients to enable grants to be made towards the cost of
clothes, tools, convalescence or admission to a hostel while seeking work. Hospitals, however, vary considerably in the use that they make of this clauseWhere boarding-out schemes are in operation the psychiatric social worker is often responsible for selecting suitable homes and -keeping in touch with the patients after placement. With reference
after-care, all workers seem to have a few discharged patients they keep in regular personal contact, usually because a mutual good relationship has been established; but about after-care in general there seems to be an interesting difference in policy. On the one hand, there to
with whom
those workers who themselves take the initiative in visiting patients they think will benefit by this; while others, sometimes through pressure of work but often deliberately, leave the initiative to the patient or are
whom his
it is necessary for the patient to know that service which the worker will be glad to render, and the mere knowof this seems to give a degree of security to some who are fearful of
family.
this is
ledge
In the latter
case
a
the future,
even
if
they
may
never
need to take
advantage
of the offer.
On the practical level much can be done in advising about training, employment, lodgings and social activities. The question of work calls for special comment, since sociological and psychological factors are here inextricably intertwined. Thus, while from one district in the Midlands a social worker reported that employment could be found for Anything that could push a wheel-barrow," in an area with a high incidence of unemployment social adjustment may consist in helping a discharged patient to accept the fact of his unemployability. This is not to suggest, of course, that such a situation is static, since it is largely dependent on such external factors as the general level of employment, developments in social legislation, changes in the social structure or even the possibility of revolution or war. The degree of responsibility assumed by the psychiatric social worker for direct work finding, varies considerably from hospital to hospital, and although previous employers may be seen with a view to reinstatement, it is often found that a recovered patient "
is his
best advertisement and may achieve better results without the intervention of a social worker. For the most part these practical services own
are not
such
as
provided direct,
but in
co-operation
with other social work
the Mental After-Care Association.
Personally,
we
agencies,
feel that this
MENTAL WELFARE
36
division of labour is greatly to be preferred, and that not only are such agencies better equipped for dealing with such specialised problems, but also that the particular contribution of the psychiatric social worker may be impaired by undue
pre-occupation
In those
with material wants.
hospitals where emphasis is laid on research the psychiatric social required to do the requisite social enquiries. Important as the present average of one worker to a mental hospital with
worker is often this is, with anything from to
one
thousand beds the most zealous enthusiast is unable appreciable extent in this way. Most workers, however,
to two
to any
co-operate with specific
investigations, such as the following up of general paralytics who have had malarial treatment, the routine visiting of patients discharged after insulin-shock therapy and so forth. help
roughly sums up the routine work of a psychiatric social worker in a mental hospital, and it is probably already clear that her appointment will increase rather than lessen the burden of the psychiatrist, for the approach from the social side, by emphasising the multiplicity of causation of the illness, will indicate the necessity of treatment from more than one angle, thus extending the scope of the hospital. Her work can only fairly be This
evaluated
as a new
service.
a psychiatric social worker was patient in a mental hospital, but a moment's thought will show that a social worker, simply because she is a social worker, has a dual aspect dependent on whether she is regarded from this internal or from an external standpoint such as the relative's- To develop this idea we might consider one of the duties that have already been mentioned, only this time from the external' standpoint. For example, we would say that the initial home visiting at the time of the patient's admission is not only of value for the clearer appreciation of a patient's mental condition, but also because of the opportunity it gives to the relative of expressing his difficulties arising out of the illness. Relatives may variously regard the patient's admission with relief, as an indication of their personal failure to cope with the situation, with guilt and anxiety lest the patient should be reproachful about his detention, with shame as to what the neighbours will think or with a burning resentment against the whole procedure of certification, which may have taken place without their approval. They came and snatched her away," said one man, and that phrase revealed the frustration felt by an unintelligent, unemployed man always up against authority in the shape of the Court of Referees, the Police and armies of social workers. With him, the fact that someone wrote to invite his co-operation and asked him to suggest a time convenient to himself for the interview was therapeutic, and it seems to us that the mere expression of these attitudes and grievances constitutes a
For purposes of
clarity
first considered in relation
the function of
to
the individual
'
"
MENTAL
WELFARE
37
of catharsis which is of real
sociological value. One woman wrote: after visit and felt comforted." This should certainly sleep your be justification for the visit equal to that of obtaining the social history. means
"
I
was
able to
This dual aspect of the function of a psychiatric social worker seems to us imply a dual responsibility. If the aim of the hospital and the community were always identical there would be no problem, but as it is there is someto
times discrepancy. For instance, some hospitals may count as success the placing of any patient in competitive work, but it may well be questioned, especially with unemployment at its present level, whether it is not socially preferable for unemployment to be borne by the less fit rather than by the able-bodied. The working out of the implications of this dual responsibility is a burden which the psychiatric social worker is only too anxious to share, and to avoid one-sided emphasis the fullest possible synthesis between the pychiatric and sociological aspects seems imperative. From this brief description of what is expected of the psychiatric social worker and what she herself aims at achieving, it will be clear that her work calls for special training, although here, as in every profession concerned with human material, it is personality and personal development which are of crucial importance. That the worker should have a practical knowledge of community resources, through which the discharged patient may be reinstated in society, needs no stressing. A wider basis of knowledge is demanded, however, if she is to appreciate the subtler interactions between the individual and his social group, such
as
will often have contributed
to
his illness and will almost
certainly have a bearing on his satisfactory reinstatement. This wider sociological knowledge, as well of family case-work involving experience in the use of the organised resources of society, is the foundation of all general social work worthy of the name and is laid in the Social Science courses of Problems of personality and of human London and other universities. relations are implicit in every kind of social work, but in psychiatric social work they are so inescapable that they call here for more specialised studyThe fundamental equipment of individuals, the development of personality from infancy onwards, the distortions which personality may undergo in the course of its development, the psychological reactions of one individual to another, especially in family relations, all these demand the closer consideration of the psychiatric social worker and must be covered by her specialised training. The problem of adjustment, moreover, between the individual's mental capacity and the demands which society makes upon him is an important aspect of all psychiatric social work and mental deficiency is frequently enough combined with mental disorder to make it desirable for the training of a psychiatric social worker in a mental hospital to include an introduction to the problems of mental deficiency and the community's provision for dealing with it.
38
MENTAL WELFARE
psychiatric social worker in a mental hospital knowledge of psychiatry is clearly essential, not only in order that she may co-operate intelligently with the psychiatrist, but also that she may see her way through the tangle of human relationships, shading imperceptibly from normal to For the
abnormal, within which her
own work lies. Much first hand contact with cases of mental disorder in mental hospitals, out-patient clinics and observation wards is needed before that more than external understanding of its various
manifestations is reached which is essential to her work. No psychiatric social lay claim to any expert knowledge of psychiatry, recognising
worker would
that its roots lie in lies, indeed, not in combination
a discipline other than her own. Her professional claim being an expert in any one thing, but in that particular of approaches or balance of factors which her title suggests.
The Mental Health Course of the London School of Economics and Political Science, at present the only recognised training course in psychiatric social work in Great Britain, is designed a mental hospital. The fact that it is
to meet
in
planned
the needs of the worker as a preparation for all
kinds of social work with adults and for work in child guidance clinics as well as to meet the case of general social workers who feel the need for the
psychiatric approach in in that it tends to keep
their
own
work,
the basis of the
year allows. The shortness of the entering shall have behind them a
may be
course as
course
regarded
as an
broad
the
as
advantage, period of one
makes it essential that students
general training in social work, and an its of sociological background, and for this reason the certificate understanding of a recognised University Department of Social Science is a requirement for admission only waived in special circumstances. The full period of the On its course is needed for the more psychiatric aspects of the training. theoretical side this is provided at the London School of Economics in close relation with the practical training in case work provided at the London Child Guidance Clinic, the Maudsley Hospital and observation wards, while a short introduction to mental deficiency is arranged by the Central Association for Mental Welfare, all these combining to build up the body of knowledge and experience which psychiatric social work in a mental hospital demands. importance of the personality of the psychiatric social worker in this field is recognised in the care with which candidates are selected for the course, not on the grounds that the qualities demanded for this kind of social work are in themselves higher than those demanded for any other, but that the damage caused by the worker whose unsolved personal problems or lack of sensitiveness in personal relations, intruding as they must into her work, is in the field of psychiatric social work more than usually far reaching Finally,
and serious.
the
