Training and Scope of the Psychiatric Social Worker in Relation to Adults II
The following contributions to a discussion at a meeting of the Royal Medico-PsycholSgical Assocpsychologicaly 1948, are published by kind permission of the Editor of the ” Journal of Mental Science An address :Author: Dr B. Lewis, given at the same meeting, was published in our last issue.?Ed. by :A ROBINA S. ADDIS
Regional Representative (Region 12), National Association for Mental Health It would be logical to begin with the scope of the psychiatric social worker, as training must be designed to fit her for her function, but if we are to discuss what is and what ought to be, it will be easier to start with a brief outline of training as it exists, and then to indicate by a description of the scope of the work, the principles and aims which should shape that training.
The concept of psychiatric social work was accepted from the United States and introduced into this country in 1929. The Mental Health Course was then founded at the London School of Economics, recently similar training has been started at Edinburgh and Manchester, and over 400 students in all have qualified.
The training is designed to fit a social worker who has specialized in mental health to function as a unit in a psychiatric team, either dealing with children or adults. Her position is usually clear in Child Guidance Clinics, which from the start were designed on a team-work pattern, though this is occasionally threatened by lack of staff, or because the members have not had a Child Guidance training. Many adult clinics have not this same definite pattern and, even where they employ a psychiatric social worker, do not fully exploit her role.
The lines on which the training is run indicate the function for which the psychiatric social worker is prepared. A candidate for the Mental Health course is expected to have a Social Science certificate (usually a two years’ university course of theory and practical work), or a degree followed by appropriate experience. Before starting her specialist course, it is preferred that the student should have an additional period of practical training such as family case work. At one time it was suggested that a period of five years’ relevant experience was advisable, and this still seems the ideal, as it would also mean that the student should be at least 25 years old when entering the Mental Health course, an age when a certain maturity should have been reached. The present minimum age is 22, but the average age on entry is 29 or 30.
The right personality is obviously all-important in this profession, and students are selected after individual interviews with the Tutor of the course, a psychiatrist and a psychiatric social worker, and recommendations are made by the particular college or university. During the training the personal development of the student in relation to her professional work, is the concern of her tutor and of her supervisor of case work. Qualifying depends on satisfactory case work as well as on passing the written examination. Theoretical courses occupy two days a week and cover individual development from childhood to maturity, adult and child psychiatry as well as social services and legislation. The rest of the week is given to supervised case work at a Child Guidance Clinic and at a psychiatric hospital. For most students the training involves personal adjustment in themselves, and reflections of every symptom and possibility of disorder may be found. We have to learn how to give help, yet economize our resources, how to tolerate anxiety and frustration in our work. Apart from anything else this takes time, so that the training period cannot well be cut down. The grave shortage of psychiatric social workers has led some to suggest that Health Visitors should be given a two weeks’ course to fit them for the work, or that transferred Relieving Officers could spare for training a day a week for a month or two to enable them to take over the function. We regard this as impossible, however excellent the quality of the candidate, for reasons which I hope will be clear by the end of the paper. The specialized nature of the training had been emphasized because the psychiatric social worker has a unique function, complementary to the psychiatrist’s but distinct. Her work is to help the patient and his family by every means available; her sphere includes prevention, adjustments in the individual and in his environment. Throughout she works in consultation with the doctor and in particular gives support to the patient and his family during treatment, and she also undertakes after-care.
Her material is the patient in his social setting, so that she is concerned with the effect of his illness on his environment as well as studying factors in the environment affecting his illness. Though mental health problems are her speciality, she needs a broad basis of social work knowledge to enable her to help the patient to make full use of opportunities for treatment, recreation and social contacts, suitable openings in employment, and of the social services (nowadays a highly complicated matter). Good co-operation with official bodies and social agencies is necessary for the smooth working of psychiatric social services, and any specialist who neglects this is undermining her own speciality.
The psychiatrist may claim that he, too, sees the patient against his background and that his diagnosis and treatment are based on a knowledge of factors in the environment. I would suggest that in the intricate interplay between internal and external forces which make up an individual’s experience, the psychiatrist is primarily concerned with the factors working from within outwards, though of course he will want to know all he can about the effect of exterior factors, and indeed cannot entirely divorce the internal from the external. The psychiatric social worker’s approach is in the opposite sense?from the outer factors, though again her focus is on their effect on the individual. Between the two partners in the team a complete picture should be built up of the patient.
It is sometimes suggested that if only the psychiatrist had time and could carry out all the interviews and home visiting himself, this would be an ideal state of affairs. Far be it from me to discourage any psychiatrist from the illuminating experience of home visiting, but to suggest that the psychiatric social worker should merely fetch and carry for him is to my mind a fundamental misunderstanding of her function.
Take, for instance, the collecting of a social history. In most cases the psychiatrist will require a full history of the illness, an account of the patient’s past experience and personality, and a description of the family and work situation. If he collects this himself it will be seen from his focus of interest which is from within the patient, radiating outwards. A young man is being treated for ” blackouts ” in which he wanders for several days and commits irresponsible acts. He tells the doctor of his sheltered life until war service, his dominating mother and elder sister, the social restrictions of the superior suburb where they live and the disgrace he felt when turned down for a commission in the Air Force. The sister also sees the doctor, gives details of her brother’s career and reveals the sacrifices which she has willingly made for the only boy. The doctor gets a picture of the way the patient has felt, the restriction and emotional demands made on him, and realizes that the family setting is something to which the patient has to adjust his personality, and treatment will be directed towards that end.
The psychiatric social worker gets the same story from the mother and sister but sees it from another angle. The mother, bored with a mediocre husband, has set all her frustrated ambitions on her son. She tries to buy a response from him by gifts and sheltering him from the consequences of his misdeeds. The patient’s sister, twelve years older, has adopted the same attitude and had willingly resigned her chance of training for a profession so that he might have every advantage of education. She shows a certain satisfaction that he steals from her as well as from the mother. The psychiatric social worker’s task then lies in trying to modify their attitude towards the patient, and in attempting to find constructive outlets for him in the environment. She has not merely listened to the family but has entered into the dynamics of the situation. Adjustments in their attitudes and in the environment will be her contribution to treatment.
This is the answer to the suggestion that any social worker can present the history and give a complete survey of the facts. The facts may be significant, but it is what the actors in the drama feel about them, and the action and reaction during the telling, which count for the psychiatric social worker, and this must be her own affair. Getting a picture of the problem and its origins, and building up the background, cannot be separated from her case-work which begins at her first contact. The psychiatric social worker, then, works through her relationship with the patient and with others in his environment. She is aware that asking for help involves the patient or his family in reactions of dependence or resentment which must be tackled. Some will make excessive demands for sympathy and advice and it is part of her skill not to allow them to infringe on the claims of others and yet give the sufferer confidence that his real need is understood. Mere rebuff will only increase his grievance against the world. This balance of restrained help is peculiarly the psychiatric social worker’s problem, since her work is not confined to clinic sessions, but she is free to give or withhold the favour of visits or to vary the length of interviews. Her judgment and integrity of purpose must be reinforced by professional skill.
Another patient who finds himself bound to ask for assistance will fight like a trapped animal against the helping hand. He accuses the psychiatric social worker of inaction, incapacity or even conspiracy. Provided he is still accessible to reason, she may have to face him with his attitude and bring him to see that he is repeating a situation, perhaps an early family one, which is connected with his present difficulties.
The psychiatric social worker knows that the removal of obstacles to a patient’s understanding himself, i.e. understanding his own powers and limitations, cannot be achieved on an intellectual level alone. A woman patient complained of sleeplessness and worry, makes heavy weather of her household duties, and bitterly contrasts her present family drudgery with her successful business career before marriage. In talking over possible adjustments of her routine, she showed resentment not merely at the change of a well-paid job for the housewife’s ” twentyfour-hour day ” as she calls it, but a resistance to the role of wife and mother. On linking up the present situation with her own life as a child, she released emotion and began to see things in proportion. She went through a period of making excessive demands on the psychiatric social worker and, when this was tackled, broke off her visits. Back she came again at the steadier level of working together with the psychiatric social worker, and used her gf>?d intelligence and fund of sense and sensibility to adjust to her position. Her husband made an approach to understanding which amazed and pleased her, and suddenly things began to fall into place. The striking feature was the release of energy which enabled her not only to cope with her household chores, but to carry out successfully a part-time job. She even started to write a book, but though this was not completed (perhaps a loss to psychology), her improved understanding of herself and increased use of her abilities, remained.
The patient’s knowledge of himself must be linked through association with emotion so that he understands for himself, in his own way, at his own time. The psychiatric social worker’s approach is from the conscious, though she should be sensitive to the implications of the unconscious. She is not a psychiatrist, but has her own function which can be expressed in many forms.
Where the psychiatrist is dealing directly with the patient’s mental illness or personality difficulties, the psychiatric social worker works out the implications in the patient’s social life and wins the co-operation in treatment, of his family and environment. A soldier invalided with anxiety state, after working for some time as an agricultural labourer, has a further breakdown. The young wife is aggrieved at having to make some sacrifices for him to obtain treatment as well as having to put up with his moroseness and self-absorption. When the psychiatrist suggests that the patient should return to the town life to which he was accustomed, she is bitterly resentful. It means giving up the tied cottage and her comfortable daily job. It needs all the confidence which has been established and much patient working out of her real difficulties, before she can co-operate in the environmental adjustments which would assist her husband’s recovery. She needs help in understanding him and learning the importance of her own part. Treatment would have been broken off and the plan have failed without the good relationship which the psychiatric social worker had built up with both patient and wife.
The aim of psychiatric treatment is to promote mental health so that the patient is able to develop his full personality as an individual and as a member of the community. In this aim the Psychiatric Social Worker feels she has her share in helping to make the adjustments, as well as assisting him to accept the claims of the community and winning acceptance in his environment of his special needs. This means that within his limitation he must be helped to satisfactory achievement. Congenial work is well known to be of therapeutic value, and in every case, whatever his disability, the psychiatric social worker will try to ensure that the patient has opportunity for using his powers to the full. She will consult with the D.R.O. whenever there is a question of finding suitable employment, and if necessary she will interview employers or seek out special jobs. When ordinary work is debarred she will try to find occupational therapy and, perhaps through the Red Cross or some other body, ask for handicrafts or other interests to be provided. Yet the adult’s needs will not be fully met, any more than the child’s, even with the ideal job, unless he also has the satisfaction of human relationships. However tenuously, in whatever terms, he must feel that he has a place in the world of men, that he belongs to someone, and that another has claims on him. Psychiatric social workers could testify again and again not only to the effect of the previous family life on the history of the illness, but on the all-important part these intimate relationships? or their lack?will play in his recovery. When a new case is referred with the statement that the patient is living alone in lodgings, our hearts sink at the impossibility of making good to him the background he requires.
It is a limitless task to help the patient to satisfactory achievement and good relationships, especially remembering that these must be effected within the limits of the patient’s powers. The whole efforts of the psychiatric team may be needed so that all curative resources may be used towards restoring a difficult balance, or creating self-confidence and independence in the patient. The P.S.W. therefore has her role in furthering this aim.
While confident in her own function she still relies on the psychiatrist for guidance. He gives the diagnosis, treatment and prognosis which will shape the course she follows. She has a creative part to play which makes constant demands on her own inner resources. Her work will be barren unless she gives emotional response, but she must maintain her professional role and avoid excessive identification with the patient or anyone else in his environment. Understanding of her own impulses and those of others will be necessary, but in itself is not sufficient. She must have worked out some code of values, some philosophy of life which will stand the tests of experience, as a background to the crises and problems with which she will be faced. Only an inner security of this kind can sustain her through the frustration of effort, and the need for patience and tolerance, and allow her to endure the strain of dealing with human material.
If she can feel associated in her work with a psychiatrist who is readily accessible with advice and encouragement and can help to clarify the issues and give due weight to the values involved, she will find immediate help in winning through to this philosophy?a philosophy most of us would find hard to put into words, but would have little hesitation in affirming to be essential to a psychiatric social worker.
If this paper achieves its aim it will give a description of the functions of the psychiatric social worker which indicates her need for knowledge of individual development and variety, for understanding of the family pattern and community forces, and for familiarity with all aspects of the social services. Knowledge of mental illness and defect, neurosis and maladjustment, possibilities of treatment and special care, has not been specifically mentioned, as it can be assumed as necessary.
All the psychiatric social worker’s work is on a case-work basis, i.e. she studies the individual reacting to his environment and matches his needs with the available resources. The widest variety of demands is made on her through the whole gamut of disturbance of mental health and mental disabilities, in rural cottages and town houses, amongst young and old, by the single who wish they were married, and the couples who wish they weren’t, calls coming in working hours and out of them. It follows that she needs technical knowledge, a clear concept of her aim and function, discrimination as to her material and methods, and above all a certain maturity of personality. If I be thought to describe a paragon I can only add that the nature of psychiatric work demands that the psychiatrist also should be a model of perfection.
Age alone and case-work experience will not necessarily bring the qualities required; much will depend on specific training. The highest standards in training by tutors, case-work supervision and lecturers are necessary. And in our work we have always looked for inspiration and guidance to the psychiatrist. We respectfully state that if full use is made of her, the psychiatric social worker can add to the effectiveness of psychiatric work for adults.
By W. J. T. KIMBER, M.R.C.S., L.R.C.P., D.P.M. Medical Superintendent, Hill End Hospital, St. Albans Dr.rKimber, referring to the shortage of psychiatric social workers for hospital work, said that this was due in part to the fact that they were being recruited now in many other fields. That was, he thought, a pity, because they were trained essentially to work with psychiatrists in a team.
The value of the psychiatric social worker to the psychiatrist, in helping him to carry out his work adequately, was very great indeed. She had to act as an interpreter in both directions. She must interpret to the relatives the psychiatric procedure of the doctor, the nurse and the other workers with whom she was brought into contact in dealing with the patient, so that the relatives could help instead of hindering the recovery of the patient, and she also had to interpret to the psychiatrist the relationships which the patient had with his relatives. The interpretation to the relatives was a matter requiring considerable discrimination, and the psychiatric social worker had to work in close agreement with the psychiatrist when she was functioning in this way.
The psychiatrist should realize the damage that he might do to the psychiatric social worker’s relationship with the patient’s family by being reticent about his procedure with the patient and, consciously or unconsciously, making himself appear too important as compared with the social worker, thus disturbing and belittling her position and influence with the patient’s relatives. The psychiatrist demanded complete loyalty from the psychiatric social worker and in his turn, if the work for the patient was to be fruitful, he must give fully and frankly all that the psychiatric social worker needed to maintain her relationship with the family.
If there was complete trust and loyalty between the psychiatrist and the psychiatric social worker, the result was a fruitful partnership of immense therapeutic power. He was sure that, given direction and support and granted freedom and scope for initiative, the social worker would realize herself as a valuable member of the/psychiatric team and would give that team a widened competence far beyond tha|’ of the individual psychiatrist.
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