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.
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.
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.
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.
[1] Conférence Interalliée des Mutilés. Paris, May, 1917.
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.
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.