Training and Scope of Psychiatric Social Workers in Relation to Adults
- Author:
LEWIS, M.D., D.P.M.
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. ‘ Late Medical Superintendent, St. Bernard’s Hospital, Southall Brevity may be the soul of wit, but abbreviations, and especially medical abbreviations, are an abomination. Nevertheless, I am so appalled by the prospect of saying Psychiatric Social Worker approximately thirty times in the course of twenty minutes that I ask your permission to say ” P.S.W.” instead. I would also like to point out that if I refer throughout my remarks to P.S.W. as ” she “, and to a Psychiatrist as ” he “, this must not be taken to imply that I personally disapprove of male P.S.W.s or female Psychiatrists. That is in fact far from the case.
In the short time allotted I fear I can do little more than range over the field and attempt to provide opportunities for discussion. I propose to deal mainly with psychiatric social work as it affects the Mental Hospital and shall try so far as I can to provide food for thought on the basis of the modern declension of the irregular verb: I am stimulating, you are provocative, he is offensive. For my own part, I will endeavour not to lapse too frequently into the third person.
We should remember how young a branch of social science psychiatric social work is. It was not until 1912 that it began as such in the United States of America. The Mental Health Course of the London School of Economics was not started until 1929, and it was not until 1936 that that great body, the London County Council, appointed full-time workers in all their mental hospitals. Possibly even now there are some mental hospitals in the country with no P.S.W. at all, and I know for certain that there are a number with only untrained workers.
We can perhaps take stock by asking one or two questions which, so far as I am concerned, must, I confess, be regarded as entirely rhetorical. Have P.S.W.s proved their usefulness ? I have no doubt at all about this. Have they a function, or functions of their own, as distinct from other workers in the field ? Again I think there is no possible doubt. Will a time come when with saturation, if it ever happens, as regards psychiatrists, psychotherapists, nurses and the many other ancillary workers in the field, who impinge on the patient and his problems, the P.S.W. will become redundant ? This question was in fact posed to me sometime ago by an experienced P.S.W. who suggested that the answer might possibly be in the affirmative. For myself, I have no doubt that it must be in the negative.
In adult work there has been considerable variation of practice in different hospitals as to the use made of P.S.W.s, and I think it would be fair to state that neither the theory nor the practice has been so carefully worked o.ut, nor so tidily arranged as in work with children. Team work has not been developed in the same way, but this may have some compensatory advantages.
Main Duties of P.S.W.s 1. To act as intermediary between hospital and relatives and outside agencies. 2. To obtain social histories when required, or to fill in gaps in such histories if these have been obtained elsewhere. 3. To render reports on home environment of patients about to leave hospital. 4. To make arrangements for accommodation where no home exists. 5. To supervise patients on trial whether at home or elsewhere. 6. To help in after-care of patients who have been discharged or of Voluntary Patients who have departed. 7. To assist in follow-ups or special investigations. 8. To assist in dealing with property of certified and discharged patients in those cases where personal contact may be essential.
In respect of these duties I feel the P.S.W. should cast round in her mind to see if some * Summary of paper given at Meeting o f the Royal Medico-Psychological Association, on July 7th, 1948. Published by courtesy of the Editor of ” The Journal of Mental Science Iother person or social agency should do a particular job of work, or could do it better, and if not should get on with it herself. In relation to this problem one might perhaps refer to a phrase which Dr Golla used to be fond of using, ” the imponderabilia “, that is to say, that in this type of work, so often it may be a comparatively trival thing that is of the most fundamental importance at any given moment. As recent examples within my own experience, I would quote the disposal of a Labrador dog who arrived at the hospital in the same ambulance with its demented mistress, and another case in which a canary in a cage and a couple of cats had to be dealt with as a matter of urgency. Trivial and though perhaps absurd from a purely objective standpoint these matters may seem to be, nevertheless they were, in my view, at that time, of absolutely fundamental importance for this reason: that they did present at that time the most acute problem in the minds of the particular patients who were the owners of these animals, and it is this type of situation that calls for rapid decision on the part of the P.S.W. in the selection of her work.
Where there are a number of psychiatrists, and a number of P.S.W.s in a hospital, with varying experience, temperament and ability, it is obviously desirable that the work shall be co-ordinated and canalized into its proper channels by some one person, whether a Medical Superintendent, or as I should prefer it,
Clinical Director.
Relationship of P.S.W. and Medical Officer In the relationship between Psychiatrist and P.S.W. I think it is important that each should try continually to keep in mind the differences between their respective trainings and background, for by so doing they are more likely to be able to co-operate with mutual sympathy and understanding for the benefit of the patient. We should all try to be aware of our own shortcomings, whether arising from our training or our temperamental defects, for then we shall be more willing to take advantage of what our partners in the work can offer us. And perhaps most important of all we should bear in mind the differing angles from which we view what is, or should be, our mutual interest, the patient. It is, I think, true, though no doubt regrettable, that there is still a proportion of Mental Hospital Psychiatrists who have undergone no personal analysis and who have but a superficial and theoretical knowledge of psychotherapy or even the dynamic approach, and many also who have little knowledge of social science or social conditions.
Too few of us have entered or are entering psychiatry after a period of probation in general practice. It is moreover true that many of us tend to remain for too long limited in our view of the patient. We are too easily encouraged or discouraged as to his future by the outcome of the clinical interview. We do not always take the trouble to enquire into all aspects of the case, nor try to assess the patient as a whole?his attitude to his wife and family, to his job, to his foreman, to those under him, in his play, his attitude to religion, to politics, to the dogs, the pub and the club. It is in regard to these important, if seemingly trivial things, that we can learn, if we will, a great deal from other members of the staff, and especially from the P.S.W.
Psychiatrists should remember, and I fear that many of them forget, or perhaps do not realize that a P.S.W. may get a better rapport with the patient than a psychiatrist, especially in paranoid cases, for in these the doctor tends to be regarded with suspicion because of his custodial function, whereas the P.S.W. is more readily welcomed as a link with the outside world. I fear that some doctors, instead of realizing this fact and making use of it to exploit the situation to the advantage of the patient, resent the fact and so tend to indulge in injudicious resentment.
The P.S.W., for her part, must likewise remember that there are psychiatrists and psychiatrists : that all of us are not psychotherapeutically minded, and that biochemists, pathologists, physical therapists, enthusiasts in group therapy, social clubs, psychodrama, cultural activities, electro-encephalography or what will you, all have their place in the scheme of things, even if they may have their blind spots in relation to the particular problems of the patient which are absorbing most of her activities.
It is for these and other more obvious reasons?the doctor of a particular patient may be young and relatively inexperienced (and it is, alas, the young and relatively inexperienced who so often know all the answers), or the P.S.W. handling the case may be newly fledged and floundering and lost, sometimes almost submerged, in one of our too large hospitals?it is for these reasons, I would stress that the importance of direction of the social work of a hospital by one person cannot be overestimated.
All psychiatric social workers would agree that the work should be guided by a psychiatrist, but in the type of organization that we have today and are likely to have for some time to come, it may well be that if there is a clash of opinion between an experienced P.S.W. and a less experienced psychiatrist, the former may be more in the right of it : or perhaps it would be more diplomatic to suggest that the greater social knowledge and more mature judgment on social issues of the P.S.W. may offer a more fruitful future to the patient than the less balanced view of a junior psychiatrist. Psychiatrists should remember, and I fear that too often some of them forget, that their focus, by virtue of their training and the rather narrow bounds of their clinical room, is on the patient as a person to be cured or alleviated of his symptoms, whereas the P.S.W. has a different and perhaps in a number of ways a better and a wider focus, namely, on a social situation in which the patient is only a unit, albeit in some ways from the point of view of the hospital’s service, the most important unit.
The doctor has been trained, as I think, rather lamentably (and I hope this will before long be altered), to look upon his patient as a case, and the P.S.W. has been trained more wisely to look upon him as a member of the community, whilst not losing sight of him as a person in his own right.
It is for these reasons, then, that I advocate as strongly as I can that one senior psychiatrist? whether he be the Medical Superintendent or a Clinical Director?should be responsible for the direction of the social services of the hospital. He (or she) should know the patients, the doctors, the P.S.W.s. He should allot the work to psychiatric social workers on the basis of the patient’s needs?rather than on grounds of seniority, sex, administrative or geographical convenience (though all these may have to be taken into consideration)?and he should be available for consultation and guidance and maybe for explicit directions if that direful need should arise.
If it should be said that an Admirable Crichton, a person with exceptional qualities, is required, I agree, but then in my view, psychiatry, if it is to be well done, is a branch of medicine which calls for practitioners possessing exceptional qualities.
I can now only refer very briefly to a number of other aspects. In an active hospital there is almost always more work to be done than can physically be achieved, and it is only after proper exposition and discussion that a decision can be made on the priorities, and as to which aspect of a case, or which case altogether, should be dropped when all the work on hand cannot be given full attention.
The management at home of acute and chronic cases on trial, discharged, or departed, is always a ticklish job, and often calls for snap decisions. One has to consider the family as well as the patient, and in our experience at St. Bernard’s a temporary return of the patient to the hospital, even though he may not technically have relapsed to any real extent, has often eased the situation considerably, and also, in my judgment, though this can only be conjecture, prevented a severe relapse in a patient or a breakdown in a relative.
Another problem that one often meets, when patients are on trial while still showing residual symptoms, (and this applies especially to paranoid cases), is as to the right moment to break the link with the hospital by recommending the patient’s discharge. We have found, by experience, that it is often better to cut one’s losses by agreeing to this and to give the patient his chance to sink or swim on his own, rather than to insist on too high a standard of clinical recovery, when the patient is straining at the leash. In quite an appreciable number of cases we have noted a subsequent improvement, due doubtless to the patient’s relief at the removal of certification. Conversely, with depressives and with patients lacking self confidence, and perhaps especially with certain epileptics, I feel very strongly that the link with the hospital should be maintained, sometimes perhaps even in the face of pressure from official bodies.
It is with regard to such problems as these? where the P.S.W. under psychiatric guidance, does the spade work?that I think it so necessary to have a senior clinician of the right quality in charge of the department, to direct, advise and to make the final decision when the need arises.
So far as the relationship of P.S.W.s. to modern trends is concerned, especially group therapy, social therapy and cultural activities, these offer a field for discussion, but I can do no more than refer to recent advertisements of posts in which it has been suggested that a P.S.W., as such, should be responsible for the organization of the social activities of the hospital. I would enter a protest against this attitude. It may be that a P.S.W. with the right personality is exactly the right person for this type of work, but there are others who are not so suited, and quite definitely I would not regard it as a proper function in relation to the actual job of the P.S.W.
As far as training is concerned, is it long enough ? Is it comprehensive enough ? There are a variety of views. All I can say at present is that the time for learning, as with doctors so with psychiatric social workers, is really after graduation.
As regards mental health students in mental hospitals: our experience at St. Bernard’s over a period of, I think, some two years, has been entirely satisfactory. We have found them stimulating, and helpful, and on enquiries from various grades of staff I have had no adverse comments whatever. They have been welcomed and useful.
Finally, I would make a strong recommendation that in a large mental hospital it is essential to have an experienced P.S.W., and that certainly no newly-qualified student should be pitchforked into a mental hospital for her first job unless there is already another experienced worker there to advise and guide her. I would like to end by re-affirming my conviction that the best service will be rendered to the patients only by those hospitals, whose psychiatrists and P.S.W.s alike, realize to the full that each of them has an individual contribution to make. I think, too, that fuller understanding of their own individual psychologies by all members of the staff will engender a proper spirit of give and take. When that happy day arrives they will be truly fortified and able to work together in real co-operation, not only for the benefit of the patients whom they serve, but to their own fullest satisfaction.
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