Socia! Work in Out-Patient Clinics
Out-Patient Clinics for the treatment of mental disorders offer unique opportunities for constructive social work?constructive almost in a literal sense, for the main object of the worker is to establish the patient’s social life ?n such firm foundations that he can build upon and develop the more stable and enduring qualities in his character.
At present, the facilities for all who need such help and treatment are totally inadequate to meet the demand, but it is hoped that the Mental Treat- ment Bill will give an impetus to the establishment of new Clinics, and the further development of those already in existence. The three types of Out-Patient Clinics to be found in London and other cities are: ?
Clinics attached to General Hospitals.
Clinics connected with Mental Hospitals or Hospitals for Nervous Disorders, functional and organic.
Independent C
The General Hospital Clinic has many advantages over other types, as ^ell as some very obvious limitations. It is a great asset to have all the acilities offered by a large General Hospital for physical, bacteriological and other examinations and the genuinely early cases are more likely to be sent to a Citric of this type. But the large numbers usually attending, and the gener- ally depressing atmosphere of a Hospital Out-Patient Department, are adverse factors in the treatment of nervous patients.
The establishment of more Out-Patient Clinics, attached to, or connected with Mental Hospitals, would do much to break down the popular fear and dread of such Institutions and they would form a useful link between the Hospital and the outside world for those patients who have recovered and been discharged, but who yet feel the need of help and support in facing up to life’s responsibilities.
The independent Clinic is usually smaller than either of the other types and it is possible to create an atmosphere removed from all suggestion of ill- ness, which is tremendously helpful to the patients, but it is a costly method of providing out-patient treatment, and for many reasons is less likely to be adopted by Local Authorities or others when establishing new Clinics.
The appointment of specially trained social workers in Out-Patient Clinics for mental patients, is a comparatively new development, but it is becoming more and more evident that without their services, much of the time and effort expended by the psychiatrist on treatment, will be wasted. They form an indispensable link between the Clinic and the community and by their practical knowledge of social conditions, are able to help the patient to carry out the suggestions of the psychiatrist in matters of social re-adjust- ment.
The duties of a Clinic social worker vary slightly according to the type of Clinic she serves, but generally speaking, her activities fall under two head- ings: (i) investigation; (2) social treatment.
The investigation covers a wide field and calls for a high degree of tact and knowledge. The collection of family history and the early history of the patient requires knowledge in rejecting the irrelevant, and following up significant clues, as well as skill and tact in gaining the confidence of the patient and his relatives. A wide and varied experience of social conditions is also required if a true understanding of the patient’s environment is to be obtained and a constructive plan formulated for his future.
The first step in social treatment is to secure the sympathy and co-opera- tion of the patient’s relatives and friends. All too often, there is a complete lack of understanding on their part of his symptoms, and the unconscious motives for his words and actions, and the social worker can do much to establish the right atmosphere in his immediate home environment.
Where convalescent or other treatment away from home is advised, or when new work or additional recreational opportunities are essential, her help may well prove invaluable. For this more concrete side of her work, a close and friendly co-operation with other social agencies and public bodies is all- important, and the measure of success attainable in the social adjustment of the patient, will largely depend on the degree of understanding of his needs which the social worker is able to instil in the minds of others.
The cases which offer the best hope of success in social re-adjustment may be roughly classified as follows: ? (a) Adolescent girls or boys, who have shown great intellectual promise at school, but who do not fulfil that promise owing to erratic, unstable or irresponsible behaviour.
(b) Adolescent boys or girls of the intellectually dull type, who fail to hold their jobs and begin to show anti-social tendencies. (c) Young people between the ages of 20 and 25, of the shy, solitary type, who, by imperceptible degrees are becoming more and more secluded, and whose condition suggests a developing dementia praecox. (d) Adults who, under some prolonged strain, become physically and men- tally exhausted and apathetic. (e) Adults suffering from acute depression, or symptoms suggestive of a manic depressive state.
There can be little doubt that many of the adolescent cases are saved from a complete breakdown by treatment at this early stage. The environ- ment must be more sheltered than is necessary for the stable adolescent, and the patient must be led by slow but steady stages to the full responsibilities of adulthood. Very often the dull child breaks down through being placed in work beyond his capacity, and this can generally be rectified by the efforts of the social worker.
A good example of what can be done for the patient who appears to be in danger of withdrawing from the world of reality, is seen in the case of A. L., a girl of 24 who had been for some years in good domestic service but had left her situation because she felt she could not concentrate on her work, and only wished to be left alone. She had a good working class home and a very devoted mother, who waited on her hand and foot and allowed her to lie in bed or sit about doing nothing all day. The patient herself showed a desire to get well and responded to psycho-tiierapeutic treatment, attending the Out- Patient Clinic regularly week by week. During this time, the social worker visited the home constantly and gradually changed the mother’s outlook and Method of handling the patient, who was steadily drawn back into the active fire of the home. As soon as she was fit for it, she was sent to a small Home ln the country where she mixed with other girls and led an active, happy life. After a few weeks of this, she returned home and work was found for her.
She had one slight set-back, but except for that, steadily improved and was finally able to take her place again as a normal member of society. B- M., a married woman of 35, is a typical example of a patient, who must mevitably have been certified had it not been for the treatment available at the Out-Patient Clinic. She was the wife of a steady, good type of working ^Jan, had two young children and a home with a fair standard of comfort, ne had had a long strain, owing to the illness of one of the children and at e time of application to the Clinic, was in an exhausted condition, both mentally and physically. She was thin and looked ill and so apathetic had she become that her home and children were neglected and she herself was dirty and ill-kempt. The patient was ordered to bed and arrangements were made by the social worker to secure help in the home, and constant visits were paid to see that the psychiatrist’s instructions were faithfully carried out. She made an excellent recovery and there seemed every reason to expect the cure to be permanent.
As a picture of a manic-depressive, I would describe G. P., a girl of 23, who was first brought to the Clinic by a relative on account of depression and an abortive attempt at suicide. Immediate certification was advised and the patient sent to a Mental Hospital. Unfortunately, her relatives secured her discharge as soon as the period of depression was over, and they verv soon brought her back to the Clinic, complaining that she quarrelled with every- one and was in serious danger of losing her job as a clerk on account of her violent temper. It seemed probable that if she could be helped over the next few months she would make a complete recovery and the social worker inter- viewed the employers and secured their sympathy and help. Although she slowly improved, and eventually did recover, the vicissitudes in this case were many. The relatives lost patience and the worker had to find a Hostel for her?the employers bore with her for as long as they could, but finally had to give her notice. For two years the girl attended the Clinic and was helped through many a difficult time, but in the end her mental balance was restored and for the last five or six years she has carried on well and is once again on good terms with all her family.
It has not been possible to do more than indicate the general lines upon which social work in Out-Patient Clinics is carried out, but I have been at pains to show how great is the scope it offers for the successful re-adjustment of mental patients and how much can be done to prevent a total breakdown, even in those with marked psychotic tendencies. It should surely be an inspir- ation and an incentive to action, to know that by the establishment of Clinics of this kind, the burden of suffering which follows in the wake of insanity, may be lessened.
St. Clair Townsend.
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