Social Case Work: An Outline for Teaching. With Annotated Case Records and Sample Course Syllabi 9780231890687

Table of contents :
Foreword
Contents
Part I. Introductory
1. Pedagogical Problems of Social Case Work
2. Practice, Principles, and the Curriculum
Part II. Case Record Annotated for Teaching
3. The Case Record of Edward Stone
4. The Case Record of Eleanor Meyer
5. The Case Record of Richard Heath
6. The Case Record of John and Helen Theocrates
7. The Case Record of the Grieg Family
Part III. Twp Courses in Social Case Work
8. A Course on Content of Social Case Work
9. The Course in Interviewing
Appendix. The Syllabus and Its Construction
Index

Citation preview

SOCIAL CASE W O R K

SOCIAL CASE

WORK

AN O U T L I N E FOR T E A C H I N G With Annotated Case Records and (ßatnple (course Syllabi

BY A C O M M I T T E E THE

NEW

YORK

SCHOOL EDITED

OF

OF

SOCIAL

WORK

BY

MARY A N T O I N E T T E

CANNON

AND

PHILIP

KLEIN

PUBLISHED

FOR

T H E NEW YORK S C H O O L OF SOCIAL WORK BY

COLUMBIA

UNIVERSITY

NEW YORK

· 1933

PRESS

MEMBERS RESPONSIBLE

MARGARET

OF

FOR T H E

T H E

COMMITTEE

PREPARATION

F. B Y I N G T O N · M A R Y A N T O I N E T T E

GORDON HAMILTON · SARAH HELEN

OF

PAYSON K E M P T O N

· PHILIP

THIS

CANNON

IVINS

KLEIN • PORTER

W A L T E R W. P E T T I T · GEORGIA G. R A L P H ETHEL

TAYLOR

· HENRY

COPYRIGHT

COLUMBIA

W.

PUBLISHED

THURSTON

1 9 3 3

UNIVERSITY I 9 3

PRESS

3

P R I N T E D IN T H E U N I T E D STATES O F A M E R I C A COMMONWEALTH

PRESS, W O R C E S T E R ,

BOOK

MASSACHUSETTS

R. LEE

FOREWORD T h e question of the curriculum and of teaching method in education for social work has received increasing attention in the professional schools during recent years. This book presents some products of a study of social case work and instruction in that subject which has been in process in The N e w Y o r k School of Social W o r k since 1928. In this School the content of individual courses has always been left to the instructor, but the scope of the curriculum and the integration of the courses have been the concern of the entire faculty. T h e curriculum as a whole is designed to cover the subject matter of social work. This study, however, is confined to one group of classroom courses, namely, the courses in social case work. It was the outgrowth of an attempt to relate the School's newly organized Research Department to the constant need of the faculty for teaching material. It was made by a committee of the faculty, including instructors in social case work, instructors in community organization, and the Director of the Research Department of the School as chairman. The results of the study, tangible and intangible, have been useful enough to the School to make it worth while to note them down in comprehensive form. They may thus serve f o r purposes of reference and as a statement of points of departure for further study of this and other subjects in the curriculum. The first result of the study was a change in the organization of the School's courses in social case work together with the introduction of a more generic point of view as to their interrelationship. Concurrently with this change in organization progressively accurate thinking developed on the part of the instructors as to the nature of the classroom teaching and the presentation of their subject. A third result is a master list of items of curricular content for social case work which has been named " T h e Syllabus." Finally, out of this study has

vi

FOREWORD

developed, on the part of the g r o u p concerned in it, a wish to contribute an explicit f o r m u l a t i o n of the teaching problem of this one area, social case w o r k , to the exploration of pedagogical problems of social w o r k , as a whole. T h e Syllabus which appears as an a p p e n d i x to this book serves m u c h the same purpose f o r the m a i n content o f the text that the b a c k d r o p serves f o r the characters and action on the stage. In itself it does nothing, b u t b y its mere existence in the b a c k g r o u n d it gives a certain perspective and setting to the action of the principals. T h e following chapters, the c o m mittee believes, will have more meaning if they are read with the Syllabus in m i n d than if they stand f o r t h alone. T h e main content of this v o l u m e consists of five case records annotated for use in teaching social case w o r k , the outlines of t w o social case work courses, and some description of the use of record material in the classroom. T h e case records are here presented under disguise which has been approved b y the agencies s u p p l y i n g them. T h e y represent different specific f o r m s of social case work and they illustrate also its generic aspects. T h e teaching notes which a c c o m p a n y the records illustrate the process of preparing the material in the record f o r classroom discussion. These notes are in m a n y cases suggestive of starting points only. A good class discussion is likely to develop leads into the significance of the case record which are m o r e f r u i t f u l than any the instructor has noted in advance. T h e case record material considered with the outlines of courses and the discussion in C h a p t e r II indicates fairly well how, in the instruction of the School, the total subject m a t ter of social case w o r k as outlined under the five divisions of the Syllabus is analyzed and blended in the c u r r i c u l u m and in the actual classroom teaching. T h e decision to publish some of the results of our s t u d y of social case work and the teaching of this subject was influenced b y several considerations. T h e preparation of the Syllabus, like the organization of a course or the editing of a case record f o r instruction, was in a sense an experience in f o r m u l a t i n g the

FOREWORD

V Ίΐ

subject matter of social case work. Once formulated the results of all three of these experiences have been of service within the School to others than those who participated in them. It is reasonably clear that professional literature grows by the process of accumulating in print the record of study, speculation, and experience, much of it highly tentative and even controversial in character. Every thesis, discovery, or achievement recorded so that it is available for criticism, stimulation, or use by others is an addition to the resources of the whole profession. Other schools have already made available some of their experience in the organization of instruction in social work, to the advantage of every other group in the field. This book has been prepared for the purpose of adding to the published material available to social workers for reference or other use. Its subject matter has no claim to universal validity since it has been shaped by the faculty of one school. It is, however, authentic as an expression of one school's experience and thinking in one area of social work and in the area of professional education in that field. The following committee members have contributed case record and course material for the text of the book: Mary Antoinette Cannon, Gordon Hamilton, Sarah Ivins, Helen Payson Kempton, Porter R. Lee, Georgia G. Ralph, and H e n r y W . Thurston. The other members of the committee have shared in the achievement of the Syllabus and in all other results of the study. These members are: Margaret F. Byington, Philip Klein, Walter W . Pettit, and Ethel Taylor. Miss Cannon and Mr. Klein have been responsible for the editing of the book. PORTER R .

LEE

C O N T E N T S F O R E W O R D

P A R T

I. I.

BY

PORTER

R.

LEE

Ν

I N T R O D U C T O R Y PEDAGOGICAL P R O B L E M S OF SOCIAL

CASE

WORK II.

PRACTICE,

Ι PRINCIPLES,

AND

THE

CUR-

RICULUM

P A R T

II.

CASE

R E C O R D S

20

A N N O T A T E D

FOR

T E A C H I N G III.

T H E C A S E RECORD OF EDWARD STONE

.

49

IV.

T H E C A S E RECORD OF E L E A N O R

MEYER

.

132

T H E C A S E RECORD OF R I C H A R D H E A T H

.

230

V. VI.

T H E C A S E RECORD OF J O H N

AND

HELEN

THEOCRATES VII.

P A R T

III.

347

T H E C A S E RECORD OF T H E GRIEG F A M I L Y

T W O

COURSES

IN

SOCIAL

424

CASE

W O R K VIII.

A C O U R S E ON C O N T E N T OF SOCIAL C A S E WORK

IX.

A COURSE IN I N T E R V I E W I N G

525 .

.

.

.

558

.

581

A P P E N D I X T H E S Y L L A B U S A N D ITS CONSTRUCTION

I N D E X

627

PART I INTRODUCTORY

CHAPTER I

PEDAGOGICAL PROBLEMS OF SOCIAL CASE W O R K HISTORICAL

PERSPECTIVE

Curricula of schools of social work vary greatly in scope. Theoretically they cover the whole field of social work; actually they provide instruction in as much of the subject matter of the field as practicable. Practicability is determined by m a n y factors: the financial resources of the school, the availability of teachers, the experience and special interests of teachers, the types of field work which are locally available and the faculty's conception of what social workers ought to know. The special interests of teachers may, indeed, go so far as to influence a school to emphasize preparation for some preferred area of the field of social w o r k ; or they may lead in other cases to "schools of t h o u g h t " promoted by different schools. These differing curricula have at least this in c o m m o n : they all include social case work among the subjects offered. Social case work was one of the earliest f o r m s of social work and probably the first to develop c o m m o n l y accepted methods and standards. It offered the schools f r o m the beginning, and has continued to offer, a more specific content of purpose, methods, and recognized principles than other fields of social work. In its various divisions also, such as family social work, child welfare, probation, medical social work, and psychiatric social work, it continues to use a greater proportion of the personnel of social work than any other part of the field. Its dominating place in the curriculum of most schools is, therefore, not surprising, although other subjects are beginning to achieve comparable status. Despite the long period during which social case work has had the leading position in the curricula of our professional

2

PEDAGOGICAL

PROBLEMS

schools, there is as yet no sure basis of uniformity among the schools in regard to the teaching of it and no dependable channel open to all the schools through which teaching material can be secured. The efforts recently initiated by the American Association of Schools of Professional Social Work to determine the present scope and content of the teaching of social case work are an important step towards the correction of this condition. Complete u n i f o r m i t y among the schools is probably no more desirable than it is achievable. Nevertheless all the schools are conscious of a need for common understanding of the subject matter, common access to teaching material, and access also to the established teaching practices, as well as to the pedagogical experimentation, of other schools. Progress in this direction would contribute to desirable uniformity in our concepts of social case work, and to richer teaching material and would give constructive significance to the variations of teaching practice which are inevitable in different localities and under the influence of different theories of social case work. This unsettled state of our teaching of social case work is not due entirely to lack of common understanding on the part of the schools. It is due quite as m u c h to the unsettled state of social case work itself. The dominant influence upon any form of professional education must be the requirements of the best current practice within its field. Professional education for social work started under the auspices of social work itself. Its development has been influenced by many other factors, such as educational tradition, social science, and social philosophy. But the dominant influence has been the character of contemporary practice of social work. It is obvious that professional education can be no more scientific, no broader in scope, no more definite in its procedure, and no richer in substance than is contemporary practice. If this statement seems to make social case work responsible for unsatisfactory standards of teaching in the schools we should add to it that the schools are not discharging their own

PEDAGOGICAL

PROBLEMS

3

responsibility unless their teaching fully meets the standards of the best current practice. A t this point we arrive at the c r u x of the major difficulty faced by the schools. The best current practice of social case work has never been adequately analyzed and to an even lesser extent has it been formulated. There may, indeed, be no agreement on a "best practice," but rather the possibility of best practices as they may be f o r m u lated on the basis of diverse theories held with respect to the nature of social case work. It is evident that if social case work and professional education are to meet the changing and increasingly exacting demands upon them during the immediate f u t u r e , they must make more systematic and more scientific study of the problems which they face. T h e task of this more systematic study will become clearer upon a consideration of the development during the present century of social case work itself and of our training programs. A t the close of the nineteenth century social case work was practiced only in the field of family rehabilitation and in some parts of the developing field of child welfare. Its leading emphases were upon investigation as a necessary preliminary to treatment, and upon treatment which was conceived as a combination of personal advice and control of environment. The purpose of social case work was, as now, to put its clients into a position which would enable them to achieve the fullest possible measure of self help. Social workers were constantly seeking better methods of achieving this purpose. During the t h i r t y - t w o years which have followed, the development of social case work has been so rapid that any scientific intrenchment of the new positions gained has been difficult and at times almost impossible. It might be said that at times social case work has accumulated experience of profound significance more rapidly than such experience could be inventoried and appraised. Some of the trends in this piling up of new opportunities, new discoveries, and new responsibilities throw light upon the task of scientific study and interpretation which social case work is beginning to undertake in earnest.

4

PEDAGOGICAL

PROBLEMS

Of these accumulating experiences some are in the nature of events, and others represent new ideas. Conspicuous among the former are the World War, the creation of the new Red Cross program for war service and subsequent peace time program, the succession of disasters and the establishment of a disaster relief routine. N o t least among these events is one whose importance cannot yet be evaluated, namely the economic depression which set in in 1929, and which may lead to far-reaching changes in the nature, auspices, and personnel of social work. One important new influence upon the development of social case work came with its lateral extension to a place within the practice of other professional fields. This occurred first when it was incorporated into the program of hospitals as medical and psychiatric social work, followed rapidly by its application to the programs of courts as probation, and to the work of visiting teaching in the schools. T h e result of this lateral extension was to bring social case work into contact with other professional activities and to give it for the first time a close professional association with some forms of scientific knowledge in practical use with which up to that time it had not been familiar professionally. All these new relationships stimulated within social case work the effort to improve the standards of its own achievement and the desire also to make its professional contribution sufficiently adaptable to be of real service outside of agencies wholly engaged in social case work. The period following the war was marked by a more rapid pace in all these developments. It brought further, through the organization and development of national agencies, a rapid extension of basic social-case-work programs to new communities. The period from 1920 to 1 9 2 9 was one of rapidly increasing resources available for social work of which agencies were quick to take advantage. It meant the organization of many new agencies and a concentrated effort to improve the quality of social case practice. Here again, during the past ten years, wc find within the field of social case

PEDAGOGICAL

PROBLEMS

5

w o r k itself pressure towards a steadily maintained purpose to raise its standards, to penetrate more deeply into the u n d e r s t a n d i n g of its problems and to add to its technical a n d scientific e q u i p m e n t . A m o n g the c h a n g i n g ideas that social case work has had to a b s o r b and integrate d u r i n g these years a conspicuous one is the e n l a r g i n g connotation of the social study. T h e effects of b o t h environmental and personal factors in the lives of clients h a v e been more clearly appreciated and more intensively e x plored. T h e extended use of the case method in social research has had a meaning for social case practice. T h e n there are the relatively more external developments, such as changes in the c o n c e p t and actual content of the standard

of living,

in w a g e

scales and real wages, in the proportion of g a i n f u l l y employed in the population, especially a m o n g women, and the g r o w t h o f the recreation m o v e m e n t . P r o b a b l y the most p r o f o u n d influence upon the character of social case work during the past fifteen years has been exercised b y mental hygiene. Social case work has always c o n ceived of its major objective in terms of human personality. Its professional equipment f o r dealing with h u m a n personality has been largely derived empirically. T h e subject m a t t e r of mental hygiene, as it has been made available to social case w o r k , has both reinforced m a n y of its own conceptions a n d added to them a g r o w i n g b o d y of new knowledge and methods which is beginning t o revolutionize its practice. T h i s developm e n t is still in process. We are still trying to find the f o r m u l a of assimilation which will give us the most serviceable blend of mental hygiene and the other elements of social case w o r k . A considerable part o f the present unsettled condition of social case work is due to the effort to bring about this assimilation. Social case work has little professional literature. B u s y p r a c titioners do not easily develop habits of study, and a good practitioner is not necessarily proficient in research. These considerations must be added to the pace of development d u r ing the past thirty-five years to explain the absence o f a n y

6

PEDAGOGICAL

PROBLEMS

adequate record of that development. It must be admitted that in other professions, whose development has been as rapid, a vastly more substantial body of professional literature has resulted. Social work, however, entered the twentieth century neither with adequate foundation material, such as is represented by physiology, chemistry, and biology for medicine, and by psychology and pedagogy in education, nor with accepted, or even controversial, fundamental theories such as those in economics, law, or political science, f r o m which details and procedure might be elaborated. In spite of this handicap the area of common understanding among social workers has steadily widened and deepened. The stability and precision which are most dependably established through research and the treatise have been in some measure achieved by social workers through their close contact with each other. Discoveries, changes in methods and objectives, and the interpretation of experience generally, have been shared by social workers in conferences, through a wide development of the committee device, and through periodicals. Fragmentary writings in brief papers, and direct personal contact have been substitutes for an adequate professional literature and not, as they eventually should be in professional work, an indispensable supplement to it. This process has served to keep social workers abreast of their own immediate professional need but it has undoubtedly limited their growth. In other professions when one wishes to consult the authorities one goes to a library. In social work one goes to another social worker. In the long run this leads to a c o n f u sion between the authority and the oracle which is perilous to scientific work. Moreover, such a condition makes the whole subject matter of social work much less accessible than it should be to those outside the field of social work practice, who need to maintain relationships with it. The present economic emergency has brought all social work into touch with a wider range of interests in American life than ever. It has been subjected to critical scrutiny in

PEDAGOGICAL

PROBLEMS

7

some quarters; it has been welcomed as a collaborator in others. It faces a period of reduced resources. It has apparently no reason to expect anything b u t widespread confidence in its service. It seems clear, however, that to meet its own need to plan for the immediate f u t u r e and to make its meaning and content clear, otherwise than by word of mouth, to those who wish to maintain relationships with it, the record of its achievement and its self-study must be expanded and made more readily available. T h e rapid changes in social case work have been reflected in equally rapid changes in the curricula of the schools, and with the dearth of any body of formulated knowledge growing out. of the practice of social case work, have given the curricula a highly tentative and experimental character. PROBLEMS OF C U R R I C U L U M B U I L D I N G

The three major problems in the organization of professional instruction are: the determination of the character and scope of the subject matter of the field; the selection of material f r o m this subject matter, and its organization into courses comprising the curriculum; and the development of the teaching methods which will contribute most effectively to the development in students of proficiency as practitioners. Study of the Field as Basis for Curriculum

Building

In the absence of either definition or analysis of the field which might serve as a chart, the greatest asset of the professional school in planning its curriculum has been the practical experience of its faculty. W i t h some exceptions faculties have been composed of men and women who have had successful experience as social workers. Their total experience has included a fairly comprehensive range of the different forms of social work. In so f a r as authentic conceptions of the field and its problems are more accessible at the present time through the personal knowledge of social workers than through pro-

8

PEDAGOGICAL

PROBLEMS

fessional literature, a school whose faculty has had widely diversified experience in practical social work has one of the best available resources for working at the first problem of curriculum building: determination of the character and scope of the subject matter of the field. There are limits to the qualifications of a full-time faculty, even though composed of experienced social workers, for the task of determining the needs of the professional field and accurately appraising its development. This is especially true of those who teach social case work. W i t h o u t ample opportunities for practice, their interpretation may lack a certain element of verisimilitude which is derived only f r o m current practical experience. T o some extent this may be compensated for by the close contact which teachers maintain with the field in carrying on special studies, in regular case conferences, and in committee work. T h e schools have encouraged service of this kind, both as part of their contribution to social work and as a means of keeping their faculties in vital touch with the field. There are, however, several important channels through which the knowledge of the full-time faculty may be supplemented in their study of the requirements of the field. School faculties have always included part-time teachers. In most instances these part-time teachers have been workers in leading positions in social work who have carried no responsibility at the school except for their own courses; b u t they have often been invaluable in bringing to discussion of the curriculum, current first-hand knowledge which the full-time instructors have not had. All the early courses in social case work were given by part-time instructors. Another asset in the effort to achieve accurate understanding of the scope and need of the field has been the close relationship of the schools to field-work agencies. In no part of the program of professional education for social work has progress in recent years been more marked than in the educa-

PEDAGOGICAL

PROBLEMS

9

tional quality of field work. T h e attitude of agencies towards the training of social workers has changed f r o m that of extending a courtesy to the schools in providing field work to one of full collaboration in an educational enterprise with a real assumption by the agencies of educational responsibility. This has been achieved b y continuous cooperative efforts between faculty and agency staff to develop constantly higher standards of field training. T h e significant result of this development for our present discussion has been the opportunity to feed into faculty discussion of curriculum development the conceptions of trends and current standards of which the agency staff m a y be more dynamically aware than a full-time faculty can be. A more opportunistic avenue to contact with the field is available through conference with organizations and leaders who are concerned with the problems of definition and personnel. Many of the national organizations maintain departments or committees responsible for the study of training and personnel. 2 The interest of national organizations is naturally in the more specific type of social work, fostered by the national organization, rather than in the whole of social work. B u t the whole of social work is built up of specific fields, their specific problems, their inter-relationships, and their common technology, science, and objectives. C o n t a c t with national or1

*The integration of opportunities

f o r p r a c t i c e w i t h the o t h e r f e a t u r e s of a p r o f e s -

s i o n a l e d u c a t i o n is p r o b a b l y seen at i t s b e s t in m e d i c a l e d u c a t i o n . T h e of

medical

tionship

schools u p o n hospitals

between

organization.

In

administrative

the a

two,

few

and

frequently

scattered

responsibility

for

a n d c l i n i c s h a s led to

instances social

an

schools

agencies,

to close

organized of

but

merger

sociaj in

dependence

administrative work

general

rela-

within

have

schools

of

social

work have secured opportunities for p r a c t i c e b y students t h r o u g h cooperation t h e r e g u l a r a g e n c i e s in t h e 'Several

of

them

in

some instances

their

with

field.

have created

s c h o o l s of s o c i a l w o r k

one

assumed

committees

to

have frequently

been

representatives

have

study

their

represented taken

a

future

programs.

The

on such c o m m i t t e e s ,

leading

part.

Some

instances are the f u t u r e p r o g r a m c o m m i t t e e s o f the F a m i l y W e l f a r e Association America, Workers.

the

Joint

Vocational

Service,

and

the

American

Association

of

and

notable of

Social

10

PEDAGOGICAL

PROBLEMS

ganizations thus leads t o a p r o d u c t i v e q u a r r y o f knowledge p e r t i n e n t to c u r r i c u l u m building. C o n f e r e n c e with specially selected leaders has the same value, as t h e schools have repeatedly discovered.

Construction

of the

Curriculum

T h e second problem o f c u r r i c u l u m building, the organization o f s u b j e c t m a t t e r i n t o courses, was, in the early years o f professional education, relatively simple. As has already been stated the courses were given b y w o r k e r s in the field who added teaching in the school to their regular professional w o r k . W i t h b u t little professional literature t o draw upon and n o precedents, orthodox or otherwise, t o determine w h a t

the

scope and c o n t e n t o f such courses should be, they naturally were descriptive in character. T h e y were attempts to set f o r t h in orderly fashion w h a t social w o r k was t r y i n g to do, and w i t h w h a t kinds o f agencies it was t r y i n g to do it. W i t h the expansion o f s u b j e c t m a t t e r , however, there have come t o be fairly wide areas within social case w o r k which are c o m m o n to almost all instruction in the s u b j e c t . T h e early p a r t - t i m e teachers had little to guide t h e m e x c e p t their own experience. T h i s had been gained t o so high a degree by the trial and error method t h a t the courses tended t o be didactic presentation, to the student, o f what social workers had learned t o be t h e best way o f dealing with persons in distress. T h e o r e t i c a l l y a c u r r i c u l u m should be based upon an analysis o f the whole field o f social w o r k . It should not be overweighted with instruction in any one s u b j e c t or field, and it should app r o x i m a t e comprehensiveness w i t h respect to the field as a whole. T h e trend in c u r r i c u l u m development has been in this direction. A c t u a l l y , however, as has been said, the courses in a n y one c u r r i c u l u m have tended t o develop around the interests and qualifications o f the teachers. T h e r e is no c o m p r e h e n sive c h a r t o f the field. T h e t w o - y e a r c u r r i c u l u m in schools o f social w o r k is about t w e n t y years old. W i t h i n t h a t t i m e the development o f relevant s u b j e c t m a t t e r has increased so rapid-

PEDAGOGICAL

PROBLEMS

II

ly that curricula of three or even four years could be organized with confidence that the longer period could be profitably used in training. T h e maximum period remains fixed at two years, and is not likely, for professional training as such, to be extended in the near future. This makes necessary a selection of subject matter with the same necessity f o r comprehensiveness in mind. Subjects are added to the curriculum because of a demonstrated need f o r them. Recent illustrations are the courses in mental hygiene and in public welfare, both of which have become indispensable to the social case worker. It is nevertheless true that every curriculum grows to some extent by a fission-like process. T h e teacher who starts with a single course in family rehabilitation is likely to find, as he accumulates material and analyzes it, and follows through the developments of the field, that he soon has enough material to provide adequately for two courses, or that, with or without adequate teaching material, the need of social workers for more extended treatment of one of the topics within his original course is so pressing that material should be developed and instruction should be offered in it. Thus we find the original subjects of family rehabilitation and child welfare followed by courses in interviewing, in recording, in diagnosis, in the delinquent child, in the defective child, etc. Another highly significant stage in the growth of courses in social case work was marked by the appearance of the concept of generic social case work. U p to about 1 9 1 5 the teaching of social case work had been in courses on family rehabilitation, child welfare, hospital social service, etc. The common elements in all forms of social case work had not been stressed. Indeed these common elements, when they were perceived by the field, did not assume in practice anything like the importance that was attached to the specific forms of social case work. The beginnings of instruction in generic social case work were directed towards the presentation of methods common to all forms. This began to u n i f y instruction and it also

12

PEDAGOGICAL

PROBLEMS

disclosed a more substantial body o f technical material t h a n we had t h o u g h t existed. T h e recognition o f the generic c h a r acter o f the specific f o r m s o f social case w o r k had been p r o ceeding in the field, b u t it is p r o b a b l y fair t o say t h a t the first practical use o f this distinction between the generic and the specific was made in the professional schools. Perhaps the most p o t e n t f a c t o r in l i f t i n g the methods c o m m o n to all fields o f social case w o r k o u t o f their specialized setting has been the influence o f mental hygiene. T h e psychological factors emphasized b y m e n t a l hygiene b o t h in etiology and in t r e a t m e n t have provided the largest c o m m o n denominator, or generic area, f o r all social case w o r k . These three factors: the absence o f a comprehensive c h a r t o f social case w o r k , the t e n d e n c y o f c u r r i c u l u m subjects t o m u l tiply by subdivision, and the conception o f social case w o r k as both generic and specific have c o n t i n u e d to c o m p l i c a t e the problem o f the selection o f subjects f o r courses in t h e b u i l d ing o f the c u r r i c u l u m . N o roster o f courses could adequately indicate the scope o f a c u r r i c u l u m . M a n y vital topics, not themselves indicated b y the title o f the course, are, n e v e r t h e less, included within the courses as labeled. In the absence o f a c h a r t , or more particularly o f the t h o r o u g h - g o i n g s t u d y f r o m which a c h a r t would emerge, it is always difficult t o k n o w whether a given c u r r i c u l u m is reasonably w e l l - b a l a n c e d , or whether it is unduly weighted w i t h t h e whimsicalities o f i n structors or the c u r r e n t tangential interests t o w h i c h every y o u t h f u l organism is prone. I t is in m e e t i n g this difficulty t h a t some benefit is hoped f o r f r o m o u r Syllabus. Problems

of Teaching

Method

T h e development o f t e a c h i n g m e t h o d is t h e t h i r d m a j o r problem in the organization o f professional e d u c a t i o n . T h e teaching methods of the professional school m u s t be influenced b y the f a c t t h a t its f u n c t i o n is to prepare students t o practice. Professional practitioners are tested by the wisdom, the range o f knowledge, and the technical proficiency w h i c h t h e y use

PEDAGOGICAL

PROBLEMS

13

in meeting distinctive problems. Professional education in contrast with general education is not only learning; it is also learning to use what one has learned. For the purpose of "learning to use" the most important part of the curriculum of the school of social work is the field work. The present volume does not include a discussion of field work, but we shall discuss its bearing upon some of the problems of class teaching. The School's conception of field work and methods of field training have been presented elsewhere/ While field work must be the chief reliance of the professional school for the development of the student's proficiency in practice, a distinct contribution to such development can be made in courses. Success here is largely dependent upon teaching method. Professional education includes both a grasp of new concepts, new facts and new knowledge and also the development of the capacity to use them. Good teaching can achieve both in the same experience, although some educational experiences may yield more of one than the other. One of the problems of a school, whose curriculum combines science, philosophy, and technology, is presented by the student whose intellectual capacity to grasp facts and concepts is greater than his practical ability to recognize them outside of the classroom or the library. T h e greatest limitation of didactic instruction is that it merely informs students without developing their capacity to use the information or to find their way in the practical situations f r o m which the information is derived. The contrast between the learner and the doer is traditional. Nowhere is failure to rccognize it more serious than in a professional school. It was a happy inspiration which led to the introduction of the case method to the teaching of social case work. It has not supplanted the lecture in professional schools and probably will not, b u t it has proved its value f o r those situations in which the development of capacity, simultaneously with the imparting of information, is essential. The case method of 'Lee j n d K e n w o r t h y , Menial

Hygiene

and Social Work,

N e w Y o r k , 1928.

14

PEDAGOGICAL

PROBLEMS

class instruction, a f t e r its initiation in l a w and adoption in medicine, came into education f o r social w o r k about 1 9 1 0 . It has been the school's most p r o d u c t i v e teaching device and, w i t h field w o r k , its greatest s a f e g u a r d against t h e o v e r - p r o d u c tion of the learner t y p e of student. T h e r e are definite limitations to the use o f the case m e t h o d of teaching. It is rarely possible in a course conducted b y this m e t h o d to present the o r d e r l y d e v e l o p m e n t of a subject w h i c h is relatively simple in the lecture s y s t e m . A student's insight into general principles or a total s u b j e c t is likely to be episodic and f r a g m e n t a r y w h e n the case m e t h o d is used unless, in the hands of a s k i l l f u l i n s t r u c t o r , these episodic and f r a g m e n t a r y bits are integrated. It is also true that the case record seems to present to a class a total situation, something w h i c h n o case record c a n do. It is n o more than a record of a situation w i t h all the d y n a m i c elements of personality and its f u n c t i o n in the relationship of w o r k e r and client omitted. T h e s e d y n a m i c elements, w h i c h can be apprehended o n l y in the f a c e to f a c e contacts of social case w o r k , are f r e q u e n t l y of more c o m p e l l i n g influence in det e r m i n i n g the course of a professional relationship t h a n a n y of the data w h i c h the paper record m a y contain. T h e most i m p o r t a n t leads a teacher has are the reactions of the students to the data u n d e r discussion. A teacher's f a i t h in the case m e t h o d m a y lead him to interpret these reactions as t y p i c a l of the student's total reactions to the client or the organization. T h i s interpretation is likely to be f a l l a c i o u s , h o w e v e r , as a student's class reactions are reactions to case w o r k situations w i t h the d y n a m i c psychological f a c t o r s w h i c h operate in f a c e to f a c e relationships omitted. T h i s is in no sense an i n d i c t m e n t of the case method, b u t it is a limitation w h i c h p u t s a p r e m i u m upon the skill of the instructor. T h e o u t s t a n d i n g value of the case m e t h o d is its peculiar a d a p t a b i l i t y to the pedagogical task o f developing the c a p a c i t y of students. T h e greater part of the social case w o r k e r ' s time is spent in i n t e r v i e w i n g and c o n f e r e n c e . A good deal o f it is

PEDAGOGICAL

PROBLEMS

15

devoted to the sorting out and interpretation of the data secured in interviews and conferences and to the planning of next steps and ultimate objectives. This process requires logical thought, the ability to reason, and as applied to social case work, the ability to reason one's way through the specific data which are characteristic of social case work. Experience has demonstrated that by the use of appropriate teaching methods proficiency in interviewing and conference can, to some extent, be developed in courses although practical experience in the field is a much more fruitful and realistic medium for the purpose. For the development of the capacity to reason one's way through the data of social case work, class discussion can be made the most productive experience possible. The material for discussion may come from the practical experience of the student, with or without the presentation of a written record; it may come from the experience of the teacher, again either with or without the record; and it may come from the experience of a third person, in which case the record is usually the medium for presenting the situation. All three sources are commonly used in any social case work course. Each has its advantages. There is no substitute for one's own experience; the test of education is the student's use of what he learns, and he truly learns only that of which he has need. Every student should have opportunity to bring into the class some of the problems which actually confront him in the field and require his practical action. T o only one student at a time, however, can the problem thus presented have the full weight of immediate interest. T o the rest, the discussion may become a helpful experience in proportion as they enter into it, add their own illustration, and make clear their own thought and attitude. The disadvantage of the student's case as class material is that until the student has been at work in the field for some appreciable length of time, he is likely to have to depend upon fragmentary knowledge of any situation, and to lack the confidence to set forth even what he knows, or his questionings.

l6

PEDAGOGICAL

PROBLEMS

T o supply subject matter to start the discussion, therefore, as well as to bridge gaps in student experience and insure a full enough variety of illustration of the area of social case work, the case record is almost universally used, and its discussion may be made an educational experience as may that of the case presented by a student. The closer the case used comes to the actual experience of the teacher, the better. It is not always possible for the teacher to draw from his own current practice. Therefore, to maintain currency, important in a fast-developing art, the practitioner in the field is called upon to supply material. Perfect records do not exist, to be sure, but the teacher of social case work is always looking for them. A good teaching record must be typical of the problems, the purposes, and the current procedures of social case work and it must be so constructed as to disclose what these are. The teacher must be not only a teacher; he must be a social case worker if he is to select records with discrimination; and he must have the knack of editing, for few case records carry their pedagogical significance on the surface. Reference has already been made to the significance which in recent years has come to be attached to the generic aspects of social case work. Organized social case work is always specific. It is family case work, placing out of children, probation, etc. Its generic aspects are in practice always hidden by their specific adaptations to the requirements of the different fields. But these generic factors are coming to be recognized as the foundation of all sound practice. They comprise the body of content, method, purpose, and knowledge which are essentially the same for all forms of social case work. A case must necessarily represent the adaptation of generic social case work to the requirements of a specific field. It therefore offers an ideal opportunity in class discussion for breaking down specific case material into its generic substance. This is the process of selecting general principles from particular instances which, in Chapter II, is discussed as inherent in the scientific study of

PEDAGOGICAL

PROBLEMS

17

social case work. There are other ways of deriving generic implications from specific incidents but the use of case records for this purpose in class discussion puts a high degree of reality and precision into the process. T h e case method of teaching tests to the utmost the skill of the teacher. Ability to handle discussion is essential and skill in leading discussion means more than facility in carrying on conversation, or in provoking either questions or answers to questions. Discussion is essentially the process of assimilating the product of the simultaneous thought and experience of several persons in arriving at a clarification of a problem which to some members of the group at least has been obscure. When any one person in the group takes control of the discussion by formulating and assuming acceptance of his own reasoning and conclusion, it ceases to be group discussion and for the others it loses the value of contributing to intellectual growth, although it may of course add to their store of knowledge. The case method of teaching is most productive when the teacher has the gift of keeping all the members of the class active participants in the pursuit of all relevant significance in the case record. Here, as in other activities, it is frequently more congenial to do the work oneself than to keep others at the task of pursuing the result. One of the great problems of education for social work is to develop in its students flexibility in the use of their professional equipment. The community setting of social work in America ranges from the highly developed urban community, with great diversity in its organized social resources, to the simpler rural section where facilities for social work are relatively few. There can be no question about the wisdom of basing a program of instruction upon the best and most scientific subject matter that the practice of social work has achieved and social science can contribute. The best possible professional equipment is none too good for the heavy responsibility for human welfare which the social worker carries. The professional school, however, must keep constantly in

l8

PEDAGOGICAL

PROBLEMS

mind that in many communities no such standard of social work is achievable at the present time. Moreover it is fundamental in the philosophy of social work that it is not the collective voice of experts imposing their conceptions of social welfare upon the community, but a type of service through which the community more completely achieves its own purposes. Good social work will, therefore, begin with community conditions as they are and will progress towards better standards of social welfare just as rapidly as the public sentiment of the community progresses in the same direction. In so far as social workers can and should provide leadership in this type of community progress such leadership is safer and in the end more productive of real progress if the social worker has a grasp of the best that social work is able to achieve. Such a grasp of the best standards, methods, and goals will insure both a more substantial ultimate achievement and a more effective immediate program however simple the immediate program has to be. Since field work is essential to professional education, the majority of the schools must be located in the larger cities which offer the widest range of facilities. The danger is that students trained in a city setting, which affords ample facilities for fine-grained social case work—clinics, institutions, legal facilities, special classes—will find themselves at sea when they try to work in a less well-organized community where none of these is available. In many sections of the country the social worker is almost the only agency actually engaged in the promotion of social welfare. I f a school does not graduate social workers who are equipped with the best that a highly developed setting can give them and also with the flexibility in professional temperament which will enable them to adapt their practice to the requirements of any community, however primitive in its standards, it has failed in one of the fundamental objectives of professional education. This flexibility is not easy to achieve. It results in part from a knowledge of this diversity of community settings in which

PEDAGOGICAL

PROBLEMS

social work is done, such as may be derived, for example, f r o m a course in community organization. It is to a much greater degree the product of classroom experience in which the e f f o r t is made to. work out problems taken f r o m different types of communities and different levels of social case work. For this purpose the case method of teaching is invaluable. A case problem may be presented in class for discussion of the possibilities of study, planning, and solution under the actual conditions surrounding it as the case record discloses them. It is then possible to discuss what would be sound procedure with such a problem if the conditions were different: fewer comm u n i t y resources, a more or a less apathetic public, etc. N o part of professional education presents a greater test of the instructor than this task of developing in the student flexibility in the use of professional equipment. It is almost wholly dependent upon teaching method, rather than upon subject matter. Assuming instructors alive to its importance, discussion, case discussion particularly, is the most effective medium for it.

C H A P T E R II

P R A C T I C E , PRINCIPLES, A N D T H E

CURRICULUM

CLASSIFICATION A N D U N D E R S T A N D I N G

In the teaching of a practical art such as social case work it is inevitable that the attempt should be made to derive a theory f r o m the practice. The human mind has to analyze and classify, dangerous as the adventure may be. W e want a system of concepts back of our practice for the uses we can make of them, namely: definition of field of interest, relation of the art to certain sciences, invention of hypotheses as to cause and effect which may aid in understanding individual problems, learning by our own experience, preservation and transmission of knowledge, and the making of a communicable technique or way of thinking. Without these no professional activity is possible. Let us recognize as fully as possible the danger that lies in the use of theory in social case work. As we have said, its use presupposes classification. In applying this process to any experience we are likely to mistake the form for the substance. But in case work, social or other, there is this special reason for being wary of classification, that the very essence of case work is to act, not by label, but according to the meaning of the whole particular case, each case being different f r o m all others. This t r u t h has been explicitly as well as implicitly the basis for the establishment of social case work as an organized activity, and has been used and abused enough to be established firmly in the language of social work. "Every case is different" is the refuge of the unthinking, who use it without realizing how it is true. Yet this has not saved us f r o m exposure to danger f r o m confusion of classification with understanding. For example, we have borrowed the term "diagnosis," which could

PRACTICE

AND

PRINCIPLES

21

hardly fail to be misleading. The diagnostic process as used in medicine results, perhaps, in understanding a case of sickness but it results also in the giving of a label, "the diagnosis," which is a classification. When we try in "social diagnosis" to use the medical diagnostic process we, too, arrive at a classification, more or less elaborate, and wonder why it is for us so useless in solving of the problem. R E L A T I O N OF S T U D Y TO T R E A T M E N T

In medicine "the diagnosis" often suggests a more or less definite treatment. In social work "the diagnosis" as classification does not indicate treatment. Even medicine is less able than the layman often thinks, to cure the sick by specific treatment, and social work has no specific treatment for isolated causes of social ills. Therefore, any case analysis which ends in the identification of factors or groups of factors in the case and in a classification of the case by such factors leads into a blind alley so far as treatment of the case is concerned. Most of the books and treatises which mark the progress of thinking, in attempting to bring order and method into social case work, stop short of connecting study and treatment. The Kingdom of Evils/ for example, and Mrs. Ada Elliot Sheffield's paper on "The 'Situation' as the Unit of Family Case Study,"' are almost wholly given to the elaboration of classification schemes. Social Diagnosisgave us material for teaching in the classroom a method of studying social cases, but it did not follow that we could teach a method of treatment in the same way. Treatment was learned in field work, in highly practical fashion, in dealing with cases one by one. Classroom discussion was like a staff conference. A Changing Psychology in Social Case Work* 1930, marked " D r . Ε. E. S o u t h a r d a n d M a r y C. J a r r e t t , The ' A d a E. Sheffield, in Social

Forces,

Kingdom

of Erils,

N e w Y o r k , 192 2.

Vol. I X , J u n e , 1931. " T h e ' S i t u a t i o n ' as t h e U n i t

of F a m i l y C a s e S t u d y . " ' M a r y E. R i c h m o n d , Social

Diagnosis,

' V i r g i n i a P. R o b i n s o n , Λ Changing N . C . , 1930.

New York, Psychology

1917.

in Social

Case

Work,

Chapel

Hill,

22

PRACTICE

AND

PRINCIPLES

the reaction f r o m the tendency to classify problems, and receded altogether f r o m classification as a method in social case work, emphasizing more clearly than any previous statement the necessity to understand each case separately, and t o interpret each item in that case in the light of the meaning of the case problem as a whole, in order to be able to enter into the process of solution. There had been plenty of practical treatment heretofore b u t hardly any theory which explained why there should be skill in treatment. This gave us for the first time a theory of treatment which, however adequate or inadequate it might be to explain all practical treatment, related it immediately to the process of study. The fundamental thought processes, analysis and classification, enable the author to use scientific material (in this case largely f r o m psychiatry) in the development of concepts. Because, however, of a consciousness of the value of the emotional and of the perceptual in experience, she finds a way of presenting the idea of a practice in which the very act of understanding the problem contains a dynamic which is therapeutic. This therapy the author calls "relationship." In advocating as she does a deliberately particular, almost a perceptual method, Miss Robinson in A Changing Psychology in Social Case Work is under the necessity faced by Bergson and other mystic philosophers, namely, that of giving rational expression to the unbroken, unrelated whole in experience. We need not trace this difficulty too far back into the complexities of the thought process. T h e important t r u t h for the teacher is that it is possible to include in theory some principles of idea of study-and-treatment, without abandoning the idea of individuality of "case." A practice is then conceivable in which awareness of the particular is reinforced, not overwhelmed, by familiarity with scientific concept or general idea. We have implied that the theory of treatment as "relationship" does not cover all parts of social case treatment. W e shall have something to say as to the part of practice which is not

PRACTICE

AND

PRINCIPLES

23

explained by this principle of direct relationship. All practice, however, is subject to the principle of t r e a t m e n t of the caseas-a-whole. T H E INDIVIDUAL C A S E AND G E N E R A L

PROBLEMS

I n teaching social case w o r k we m u s t m a k e a distinction between the s t u d y of the individual p r o b l e m and the s t u d y o f generalized problems. T h e individual case is the concrete illustration of the general or abstract p r o b l e m , as f o r example, Disease, Ignorance, P o v e r t y , Vice, C r i m e . T o say of any case that it is a case of crime is not thereby to have understood the m e a n i n g of that case as a whole, nor to k n o w what help or t r e a t m e n t to give. Y e t to k n o w something of crime as a general p r o b l e m is to have something to use in the u n d e r s t a n d i n g of the case which presents the clinical p i c t u r e of crime. Analysis and classification of case problems serve a purpose of research in the field o f social case w o r k . F o r the treatment of the individual case they serve b u t indirectly as they f u r n i s h the means whereby the worker arrives at an u n d e r s t a n d i n g or attribution of meaning which w o u l d never come with a single unrelated experience. If the student is to learn not to m a k e w r o n g use of classification

in practice he m u s t be t a u g h t in such a w a y as t o

avoid over-emphasis upon general knowledge. Preparation f o r social case work m u s t be such as to foster that freedom, flexibility, and receptivity which are of the very essence of the professional attitude. Sensitiveness to the new f o r m of experience and a habit o f questioning as to its particular m e a n i n g will always produce some degree of u n d e r s t a n d i n g , for it will drive the worker to seek the new k n o w l e d g e he needs. O n the other hand he can never acquire, in advance, enough k n o w l edge to enable him to interpret all f u t u r e experiences. It is a m a r k of professional service that it requires perpetual acquisition of knowledge. All that is known o f h u m a n life and h u m a n relationships 'Classification used by D r . S o u t h a r d and Miss J a r r e t t in The

Kingdom

of

Evils.

24

PRACTICE

AND

PRINCIPLES

constitutes the potential background of social work. The particular area appropriate to its practice is determined by the method of practice itself. The fundamental outlines of method are relatively comprehensible and must be completely covered in a social case work curriculum. In other words, any course in social case work is primarily a course in method. As method cannot be discussed without reference to the problems in which it is used, certain subject matter also must come into the course. This originates from individual case problems. The case material used can be presented with reference to general social problems such as dependency, delinquency, etc., and with reference to the social and biological sciences which offer explanations of certain elements in it. It can also be treated as a series of exercises in method of study, and in the grasping of the meaning of an individual case. In presenting and discussing case material, recognition of the case as a whole is always necessary, for upon it depends the student's acquisition of the sense of the particular, his ability to use the particular case to increase general knowledge, and his habit of being at the same time guided in case treatment, not by any one recognized factor, but by the combination of factors into a total which is something more than the sum of its parts. This does not mean that every known fact in the case must be rehearsed each time the case is discussed, but that the case must always be understood in a form or configuration of its own. Discussion of case problems cannot take the place of meeting them at first hand in practice. But when a student has actually encountered a difficulty, discussion can help him to find forms and meanings in it, and to realize his own total emotional reaction to it. Similarly, the presentation by word alone of a new situation may not only give opportunity for intellectual exercise, but also evoke a response corresponding to that which the situation itself would have stimulated. As the part he will play as social worker in these situations will depend largely upon his emotional reaction, his development

PRACTICE

AND

PRINCIPLES

25

of an unbiassed, stable attitude is i m p o r t a n t as p a r t of his professional preparation. T h o r o u g h exploration of this part of education is aside f r o m our main p u r p o s e here, b u t we recognize as one of the values in the presentation of the case as a whole ( c o n f i g u r a t i o n ) the influence such presentation m a y have in tempering the emotional reaction. Rejection, f o r e x a m p l e , or s y m p a t h y , aroused in regard to a single element of setting, behavior, or experience in the case, is likely t o be modified as the case is sensed as a c o m p l e x o f m a n y elements of setting, behavior, and experience. W i t h g r o w t h o f interest in the meaning of the whole, prejudices against the classes in which the case belongs subside and the m o r e u s e f u l professional attitude emerges. This is not the only w a y of dealing with inadequacies of attitude, b u t it seems to play a part, and possibly f o r m s a point of contact between intellectual and emotional activities. U S E OF T H E

SYLLABUS

T h e selection of content of social case w o r k presented in this book is based upon the assumption t h a t social case work is a process in which the client, worker, a n d c o m m u n i t y have each a part to play. T h e social case worker is to participate with the client in the improvement of a situation, possibly in a change of outlook for f u t u r e experience, in which the client's relationship to other people is important. In order to be o f use the social worker must be able to establish an appropriate relationship with the client, and this relationship in itself o f t e n constitutes treatment, resulting directly in release or increase of power in the client. B u t usually there is a g r o u p or situational purpose in view, and again in order to be o f use the social case worker m u s t be able to b r i n g k n o w l e d g e a n d a sort of leverage through which c o m m u n a l power m a y be b r o u g h t to bear. We have recognized this as indirect t r e a t m e n t o f the client. W h a t equipment does the social case worker need in order to enter into the social case process, both in direct relationship

2 6

PRACTICE

AND

PRINCIPLES

with the client and in transmission of power through organization of environment? For direct relationship he needs a professional attitude and a habit of understanding a personality or case as a whole. All that he has assimilated of knowledge of human life will help him. For dealing with the environmental situation he will need besides this a point of view as to community and member, knowledge of social patterns and institutions, and knowledge of a possible range of concrete facts which are to be the materials of environmental change. The knowledge actually used will differ in different fields. N o course and no professional experience covers all possible areas of knowledge. Some common area, however, if covered in the thinking of all social case workers, would give us a locus for our exploration and a foundation of generic practice upon which special bodies of knowledge and skill could be built. It was in an attempt to be more clear as to the ground to be covered in any adequate presentation of generic social case work, and as to the principles which should guide the selection of problem material for social work courses, that a group of teachers of the N e w York School of Social W o r k in 1928 embarked upon the joint inquiry which produced the "Syllabus" herewith presented in the Appendix. A n y social case history is a synthesis of elements of facts, interpretation, and treatment combined in a whole unit or "particular configuration" representing a situation as viewed f r o m a professional standpoint. The content of this Syllabus has resulted f r o m a process of breaking down such situational units into more or less elementary ideas, each represented by a term. The social case worker is a part of the situation in which the client and his surroundings are under study and treatment. The terms, therefore, represent the purpose, tools, and method of the worker as well as the status and behavior of the client and his associated groups, and the setting in which the action takes place. In the Syllabus these terms have been distributed among

PRACTICE

AND

PRINCIPLES

27

five categories or divisions that seem helpful both for breaking down the particular case situation and for organizing the elements of knowledge by which he arrives at a better understanding of the case. T h e y are: A.

Area of Social Case W o r k (AREA).

B.

Technical Methods o f Social Case W o r k (METHODS).

C.

Social Resources for the Practice of Social Case W o r k

D.

Philosophical Questions or Values Involved in Social

E.

Formulated Knowledge in Social W o r k and Kindred

(RESOURCES) .

CaseWork

(PHILOSOPHY).

Fields ( K N O W L E D G E ) . T h e first o f these divisions, AREA, includes terms denoting ideas o f deviation from an assumed norm of social life and social behavior which creates a situation appropriate for the social worker's method o f study and treatment. It has been difficult to come upon any satisfying scheme for subdivision of this subject matter. T h e sub-headings used, Factors

and Behavior

Responses,

Contributory

suggest that the first set o f

terms indicates causes, the second, effects. As a matter of fact, cause and effect cannot be thus separated: every deviation is potentially both cause and effect, and quite often the interaction among factors is o f reciprocal character, so that the situation presents the phenomenon o f the vicious circle. O f ten, too, the coexistence of conditions is explicable, not directly by causal relationship between them, but by some c o m mon origin in a third element. Thus poverty may make for' sickness and sickness for poverty, while both poverty and sickness may arise from poor physical constitution, or from some environmental deficiency, such as poor industrial c o n ditions. Nevertheless it has seemed that on the whole such terms as begging,

desertion,

neglect,

nonsupport,

sexual

irregularity

could be grouped together as social behavior attributable to individuals, leaving to the category of " C o n t r i b u t o r y F a c t o r s " all the more impersonal terms indicating process o f nature and of society gone wrong, such as disease,

feeble-mindedness,

28

PRACTICE

malnutrition, ployment,

early

cultural

AND

death;

PRINCIPLES

industrial

maladjustment,

lag, loss of bread-winner.

unem-

T h u s we differ-

entiate roughly between factors of environment and of hereditary constitution on the one hand, and on the other the individual's response to these factors, conscious or unconscious. These contributory factors and behavior responses occur in combination with each other and with " n o r m a l " and c o m pensatory elements in each and every case known to social w o r k . The social case worker sees the total case as a configuration,

particular

having a unity and a meaning of its own, and

a combination of parts never f u l l y duplicated. There is a recurrence, however, not only of single factors and responses, but also of certain combinations. Recognition of these enables us to classify cases in groups, in each of which the cases will have a degree of similarity inversely proportional to the size of the group. Thus we may classify many cases by the single f a c t o r widowhood, widowhood, widow

fewer by

the combination

still fewer by the larger combination

with children.

configurations.

dependent dependent

We have called these combinations type

Like the single terms, they give us a means

of relating particular case to general concept, and thereby of communicating our thought. T h e y may f o r m the basis f o r categorical schemes of relief, etc., though not of individual case treatment. E v e r y case may be thought of as a particular configuration and also as belonging to a type configuration. T h e arrangement of terms under the Syllabus section AREA is as follows: I. Deviations

from

of social a. Contributory b. Behavior

garded a. Type

a

breakdown

factors. responses.

II. Configurations sponses,

normal that may indicate

self-maintenance:

of

and other

contributory

factors,

circumstances

constituting

as: configuration.

b. Particular

configuration.

behavior case,

rere-

PRACTICE

AND

PRINCIPLES

The terms of the division of T E C H N I C A L classified under three main sub-heads:

METHODS

29

were

I. Social case work processes—the use in this area of the scientific problem-solving and treatment methods common to all professions; study, diagnosis, etc. II. Teclmique—bearing on the worker's task, as carried on in the field, and emphasizing procedures in which skill may be developed by practice and emulation, making for greater efficiency and "sureness of touch." III. Administrative function—denoting those phases of social case work which grow out of its dependence upon an agency or organization representing the community of which the social case worker is at the same time employe and interpreter. Relations within the agency, between agencies, and between the agency and the community, in so far as these may be perceived and translated into administrative procedure, are important factors in the actual practice of social case work. is the title given to the group of terms expressing the organized community forces which make goods and service available for the person who needs them. This group is subdivided into: SOCIAL RESOURCES

I. Organized practice—referring to social work itself as practiced in the several fields, under both public and private auspices, with both paid and volunteer personnel, and II. Facilities available for social case work—including individuals bound to the client by common interest, and institutions provided by the community. Such resources are essential to social case practice. The heading of the next section, P H I L O S O P H I C A L Q U E S indicates a body of thought which by the very nature of social practice is assumed to underlie it, but which has been relatively little formulated. The content of this section is classified as follows: TIONS,

30

PRACTICE

AND

PRINCIPLES

I. General questions of human life and human II. The social worker's

relations.

philosophy.

Part one is intended to cover terms indicating group values and the values for the individual in his relation to the group. Part two is intended to cover the special ethics of the relationship between worker and client, and worker and community. The School group in making the Syllabus gave some thought to the question of the sense in which the matter classified in this section could be called philosophical. It did not seem to be metaphysical matter, nor was it of the nature of epistemology, nor yet did it coincide exactly with the field of ethics. It did seem, however, to be significant to social work as indicating social values. Social values may be thought of as qualities attributed to forces as they favor or hinder ( ι ) the survival of the group, and ( 2 ) the fullness of individual and group life and development. Ideas as to social value seem to emerge in our consciousness whenever we confront a conflict in possible objectives, or in the interests of two or more persons or groups. In society as a whole there are many sub-groups. Some of these over-lap, and for this reason certain conflicts of interest arise and choices have to be made by the individual who belongs to the overlapping groups. The importance of individuality as such creates another element of difference and possible conflict. There may be an essential harmony between individual values and the widest social value but often it seems to the individual that sacrifice of his interest is demanded by the group. The question of values as determining choice comes into the practice of social work because the social worker is constantly confronted with a question of changing worse situations to better and has to determine objectives and decide upon methods in accordance with some general principle as to what is good for person and for group. The brief outline of philosophical questions in the Syllabus gives but little indication of the subject matter covered in the

PRACTICE discussions

which

AND

PRINCIPLES

preceded the

final

summary.

3

1

Practically

e v e r y t e r m in t h e S y l l a b u s indicates either d i r e c t l y or i n d i r e c t l y sonne p o s s i b l e q u e s t i o n o f values, a n d m a n y o f t h e t e r m s as t h e y c a m e u p in o t h e r c o n n e c t i o n s were discussed f r o m this p o i n t of v i e w . W r i t t e n s t a t e m e n t s were p r e p a r e d s e t t i n g f o r t h c o n c e p t s o f v a l u e associated w i t h v a r i o u s c h o s e n t e r m s . A s m a l l n u m b e r o f these s t a t e m e n t s is i n c l u d e d in A p p e n d i x , D i v i s i o n D . A s i n g l e e x a m p l e q u o t e d here m a y serve t o illustrate this a p p r o a c h and method of thinking. Kinship Ties: In social case work the value we place upon kinship is likely to be a f a c t o r in determining action whenever the capacity of a family or individual for self-maintenance has broken or is breaking down, provided that the individual or family has living relatives. A special case is that of the child placed away from his own home. Homeless individuals, and dependent families estranged from their kin are other common instances. There seem to be two main questions as to kinship. First, does the tie of blood relationship carry with it responsibility for financial support; if so, of what other relationships does it take precedence, e.g., employment, lodge membership, church connection, friendship, neighborhood? If kinship obligation does take precedence of other obligations, other things being equal, does it do so even when the attitude of the relatives toward each other has been indifferent or antagonistic, whereas other associations have been congenial and mutually beneficial? The law recognizes an obligation upon parents and children, grandparents and grandchildren, brothers and sisters, to support or help each other, according to comparative abilities. H o w is this justified, if at all? Second, is there, apart from financial responsibility, a peculiar value in the associations of kindred for which there is no social equivalent or substitute? If so, what is its nature and origin? We often see persons exhibit strong emotional response toward relatives hitherto unknown. Foster children when they are grown up sometimes seek their own relatives. Is this evidence of an instinctive recognition of biological similarities, or is it the result of public opinion, itself founded in common experiences of family life over

32

PRACTICE

AND

PRINCIPLES

long periods of time? W h a t is the basis of our o w n attitude t o w a r d the special values of kinship? People differ in their feeling as to the importance of

kinship.

Should the effort of social work be to foster or decrease the feeling of special value? Is the preservation of the f a m i l y group in its extended sense an object of social case w o r k , or is its object the development of personality, and does kinship rank according to its merit as a f a c t o r in social environment, just as other relationships do? W h e n antagonism exists between relatives, as it o f t e n does, is there a reason f o r trying to overcome it? W h a t is the reason? It m a y be because we feel an essential value in the f a m i l y group as such, or it may be because of injurious conflict produced in one or more individual personalities. In the latter case, indifference might be as good a solution as affection, probably better than sense of d u t y . In either case, can we say that members of a f a m i l y o u g h t to love one another? What would such a proposition mean in psychological terms? T h e possibility of arriving at a happy and constructive f a m i l y relationship through conflict is one to be borne in mind. H o w can this be brought about? Probably the psychological basis of the social value of kinship is in the natural potentialities of f a m i l y life f o r a f f o r d i n g that personal security which is one of the first essentials to the development of the socially normal individual. T h e danger of the f a m i l y situation is in the possibility of too much protection and too easy satisfaction w i t h in the narrow group. T o realize the f u l l value of the f a m i l y relationship, the members of the f a m i l y must free themselves f r o m any sense of property in each other and must recognize the freedom of each as an individual. Parents must be willing to release children and children willing to transform immature into mature relationships. When this recognition of individuality is lacking, may relatives be repudiated by a rebel individual? Are there other ways of adjusting to overkinship? T h e section headed KNOWLEDGE occupies space in the S y l l a bus disproportionate to the place g i v e n it in actual teaching o f w h a t w e have said was primarily a " m e t h o d " course, w i t h problem matter chosen f r o m the appropriate " a r e a . " T h i s is necessarily so, f o r a claim must be staked here f o r all the scientific material to w h i c h the social case w o r k e r needs to have

PRACTICE

AND

PRINCIPLES

33

access in order to be able to meet any conceivable demand f o r his particular b r a n d of service. All other professions are theref o r e represented in this division, besides the social and biological sciences and the whole field o f social work itself as source of knowledge. E a c h term of the Syllabus represents not only a possible element in a particular configuration, b u t also a subject or general idea which m a y be used in social case work. These s u b j e c t s are of the nature of categories which would serve f o r the classification and indexing of case material. T h e list here presented is not exhaustive; p r o b a b l y there is no such thing as an exhaustive list of categories for a living professional activity. N o outline, such as this, can do more than present the t h o u g h t of a person or g r o u p in view of a certain purpose a n d u p t o a point of time. T h e Syllabus is capable of elaboration a c c o r d i n g to the material to be indexed. In such terms, m o r e over, appropriately selected, g r o u p e d , and set in order, the subject matter of the various units of the social case w o r k course m a y be indicated. GENERAL

PROPOSITIONS IN SOCIAL C A S E

WORK

T h e Syllabus items m a y also be made the terms of general propositions. This does not mean that scientific laws can be f o r m u l a t e d for the solution of social case problems. It means that the area in which they arise can be described, concepts of method can be clarified, and even, we believe, the assumptions as to values, purposes, and professional relationships which tacitly a c c o m p a n y all practice can be stated so that their validity can at least be argued. For present use we m a y define "general proposition" as a statement of a relationship which has been recognized, in our experience as social case workers, o f t e n enough to have become f o r us an assumption which influences our j u d g m e n t s and decisions in the area wherein it is appropriate. T h e statement m a y represent a " f a c t " or a " f i c t i o n , " but in any case it " w o r k s . " W e can guide our action by it.

PRACTICE

34

AND

PRINCIPLES

General propositions vary m u c h as to the soundness of the observation upon which they are based and the extent of their applicability. Some are the outcome of deliberate s t u d y , some merely represent c o m m o n knowledge, some express an accepted interpretation, or an idea current a m o n g practitioners. Some are, or m a y become, controversial; some have almost passed into proverbs. N o a t t e m p t will be made here t o select according to any test of reliability. E a c h proposition set down p u r p o r t s to be expressed or implied in some part of social case practicc, and to show a possible meaning of some part of the c u r r i c u l u m material covered in the Syllabus. Its purpose here, however, is to illustrate the way in which at any time statements m a y be made in terms of social case w o r k , as they are m a d e , f o r example, in discussing cases and general subject matter in a course. In discussion a general statement rarely stands alone b u t usually is part of a network of t h o u g h t developing some complex subject. T h e r e f o r e these propositions are g r o u p e d in series. F r o m a m o n g an indefinite number of propositions that m i g h t have been f o r m u l a t e d here, these are selected because they have been suggested by the course and case material which constitute the main part of this book. SERIES I.

PURPOSE AND N A T U R E OF PRACTICE

A m o n g the most important of the propositions derived f r o m our t h i n k i n g about social case material are those which f o r m the rational basis for the concept of social case w o r k which we have accepted. T h e y express its purpose and the nature of its practice. These are suggested by the sections of the Syllabus on Philosophy and Method, 1 ' and are illustrated in all cases contained in this volume. i.

T h e c o m m u n i t y assumes responsibility f o r the meeting

of certain basic individual needs of its members. Some needs (e.g. elementary education, u r b a n sanitat i o n ) are provided f o r by the c o m m u n i t y under ordinary circumstances. Responsibility for other needs, such "See A p p . S y l l a b u s Β and C .

PRACTICE

AND

PRINCIPLES

35

as economic maintenance, care of health, and conformity of conduct is assumed only when individual and f a m i l y effort fail to meet them. Both public and private resources are used in meeting these needs. 2. Social work agencies represent the community's responsibility for provision for its members when they fail to provide f o r their own basic individual requirements. Social work is mainly supported by public and private organizations for the purpose of putting this responsibility into effect. We have practically no private practice in social work (i.e., service to an individual who pays a f e e ) . This is not to say that private practice of social case work is inherently impossible. The technique is essentially appropriate to the solution of certain personal difficulties, and service could be privately bought, as in law, medicine, and education—and it occasionally is so bought. But, as in law, medicine, and education, (λ) often the very condition demanding the service precludes ability to pay for it, and even the recognition of its desirability, (b) in so f a r as it is required by the standard of the group, it must then be provided by the group, (c) even in private practice the group interest will limit action in the interest of the individual whenever the two are contrary. Moreover, social case work is always concerned with relationships between person and person or person and group, and this conditions practice, making it less simple in focus upon individual interests than other professions in private individual practice may be. 3. As between public and private organization there is no clear division of social work function. Both seem needed in present circumstances of public opinion, etc. ( 1 9 3 2 ) , though the emphasis upon each in social work thought seems to be shifting. The public agency, from being assigned the residual burden of social failures, is coming to be thought of in the

36

PRACTICE

AND

PRINCIPLES

primary role as representing the whole community's organ for self-help. (See Theocrates.y 4. Responsibility exists for the social worker because his community assumes it and delegates it to him, but this does not mean that he individually is responsible for the economy, health, or behavior of other individuals. His delegated responsibility is limited to that which the group can assume for the member; beyond that he may respond, as individual, according to the will of the client as another individual, and as the client finds use for his technical service. j . The objective of the community is constructive interaction of adequately functioning individual members. This can be achieved only by a method of treatment of individuals which preserves and increases their individuality and power of self-maintenance and social contribution. 6. The principle of participation is essential to any method of treatment effective in developing individuality and power of self-maintenance and social contribution. Both client and social worker enter into the operation actively. Restraint and coercion, while effective for the accomplishment of some social purposes, are useless for the purpose of developing individuality. 7. Practice of this method, in which participation is f u n damental, has developed a certain technique of human relationship which constitutes the expertness of the social case worker. T h e community must recognize this expertness as essential to social case work, since its purposes cannot be accomplished otherwise. 8. As expert, the social case worker has a basis for an individual relationship with the client which may carry beyond the responsibility delegated by the community. That is, the social case worker has reason to help because he has a means of helping, just as is true of other professions. Supporting communities and institutions must recognize this reason for ' P a r e n t h e t i c a l notes of this nature r e f e r to the case records contained in chapters I I I to V I I — S t o n e , M e y e r , H e a t h , Theocrates, G r i e g .

PRACTICE

AND

PRINCIPLES

37

service arising out of the expertness itself in relation to the appropriate situation or problem. 9. As representative of an agency and therefore delegate of the community, the social case worker is not confined to his relationship to any one individual but must to some extent execute the standards of the community as they apply to all members. For example, members are not to be allowed to die, to kill, to spread contagion, etc.; minors are not to be injured, defectives are to be cared for, etc., and the social case worker is one of the agents by which this common will is carried out. 10. As the social case worker is at first hand concerned with the working of the systems, etc., of society, he is concerned also with the nature of those systems, and may reflexly act to improve them at their source in public thought. T o sum up, there is a double purpose of social case work, namely the purpose of integrating the member with the group (society) and the purpose of skilful service to the individual to free him from limitations. There is a delegated responsibility for maintenance, health, and some degree of conformity, but none residing in the worker as a person. Beyond the responsibility delegated, the worker should proceed only as his skill may be accepted. SERIES II.

C L I E N T , SITUATION, AND PROBLEM

(Syllabus, Section A ) 1. The client-position may be single or multiple; that is, in any case either a single person or a group of persons (usually a family) may be in the position of client of the social agency and of the social case worker. 2. When the client-position is held by a group of persons, each one has an individual relationship to the worker, and for each one the rest of the group is in environmental relationship. 3. The degree of client participation varies with the per-

38

PRACTICE

AND

PRINCIPLES

sonal capacity of the client. In case of children, persons of subnormal or abnormal mind, sick and incapacitated persons, etc., often the major responsibility and participation in problem solving are carried by some other member of the clientgroup. 4. Even when the client cannot assume responsibility f o r himself, he can often participate to some extent, and his participation should be fostered to the greatest possible extent. j . The client's power as a person is, at one and the same time, extended and curtailed by the immediate group of which he is a member. 6. Moreover this personal power is still further extended and curtailed by the larger society of which he is a member. The community's resources are his to use; to use them he must conform to certain group standards and regulation. 7. A situation in which person and environment are out of adjustment offers a problem for social case work. 8. The lack of adjustment between person and environment may be due to factors of personal inadequacy (physical and psychic), to factors of environmental inadequacy (material and social), and to combinations of factors of both kinds. SERIES III.

METHOD OF PRACTICE, G E N E R I C

AND

SPECIFIC

(Syllabus, Section B ) i. The technical procedure in social case work may be planning, organization of experience, giving of opportunity through change of environment, giving information, etc., or it may be the development of a single liberating relationship, that between worker and client, or it may be a combination of these. With all these procedures the desirable social case work result is possible only as worker and client participate. (Theocrates.) 1. Social case procedure may take as immediate objective a change in the client as person, or a change in the social situation. (Theocrates.)

PRACTICE

AND

PRINCIPLES

39

3. Social case procedure may take as objective the removal of present dissatisfaction. It may also take as objective the prevention of future ills, physical, psychological, economic, and other. Immediate procedure is often determined by the objective of prevention of some ill foreseen as probable result of existing causes. (Γhi'ocrates.) 4. Social case procedure may be instituted by the initiative of the client, or by interference. 5. Study and treatment, as in all other professions, are f u n damental methods in social case work. 6. Study may precede treatment, and planning may enter as a step in the procedure. 7. Study and treatment may proceed at one and the same time, the same procedure constituting both. 8. There are two technical processes by which social case work obtains its immediate responses; they are the interview and the conference. The interview is an interchange of expression between two persons, the conference among three or more. (These terms are not universally used with these meanings but their usage in social work seems clear only if we define them for our purposes). 9. The best relief is adequate relief. Adequacy may be measured by the existing measurable need, physiological, psychic, and economic, and also by estimated future welfare. In other words, relief may become an investment, justified by the probable returns in future personal and social satisfactions. (Theocrates.) 10. The term diagnosis has been used to name the process of achieving a formulation of the meaning of the case as a whole. This process may be expressed as interpretation, as explanation, or as understanding, any one of which words seems preferable, because the term diagnosis has also been used to name a class into which the case falls by reason of some factor or group of factors in it. For the latter use the term classification, or the term class (according to context) would seem clearer.

40

PRACTICE

11.

AND

PRINCIPLES

Method of study varies according to the purpose of

the understanding sought. Evidence f r o m various sources is used for the planning and executing of a change in situation. Personal self-revelation of the client is used for interpretation of his reactions and for his self-help. 12.

In the interview a step towards the accomplishment of

the social case w o r k purpose is the accrediting of the personality of each b y the other party to the interview. (See Course in interviewing, Chapter I X . ) 13.

If in the interview decisions and choices are to be

made, the client should make his o w n decision or choice by self-conviction, first, because only in this w a y does he enter actively into the social case procedure, and second, because in this w a y he exercises his capacity for self-direction and thereb y furthers the main purpose of the relationship. (Course in interviewing.) SERIES I V .

FACILITIES

(Syllabus, Section C ) 1.

Resources used vary, especially as to frequency of use,

with the special field and the professional alliance of social case w o r k ; the general interrelationship and principles of use are the same for all. (Illustrated in all cases here included.) 2.

T h e practice of any agency is conditioned b y its sup-

porting c o m m u n i t y group. 3.

Institutions may be used to control environment of dis-

abled persons whose usual home cannot be made to offer the conditions required for recovery or compensatory ment. (See 4.

adjust-

Stone.)

Facilities differ in different communities according to

wealth, tradition, degree of organization, and other conditions besides need. (Theocrates; Stone; Heath; 5.

admission policies. (See 6.

Grieg.)

Children's institutions differ in theory of care and in Heath.)

Collaboration between institutions makes for effective

treatment of their common patients.

(Stone.)

P R A C T I C E

A N D

P R I N C I P L E S

4

1

7. Public and private agencies may combine to meet a citizen's needs. (Stone.) 8. Agencies do best to economize jointly and not one at the expense of another, since the same community supports them all. SERIES

V.

VALUES

(Syllabus, Section D ) i . Personality (Quoted from statement by Porter R . 8 Lee ). Social case work deals with individual human beings. It accepts as axiomatic that this includes dealing with the personalities of human beings. Personality is conceived as the combined functioning of the physical, intellectual, and emotional parts of the human organism. For the social worker the conception of personality includes a conception of potential self-control with respect to the interests and relationships of the individual. From one point of view the human personality is the highest product of evolution. From another point of view it is a divine implantation. From another point of view it is the seat of all which distinguishes significantly the human species f r o m other species. From another point of view it is the emanation of certain physical processes largely chemical in their nature. Social case work seems to have been motivated by the point of view that handicapped and undeveloped individuals share the eifort of the race to achieve satisfaction and are entitled, therefore, to a reasonably fair opportunity to participate in this general effort. If this is so, then, to the social case worker, personality has a high value in itself. The obligation of the social case worker with respect to the personality of his client would seem to be, first, to conceive of the client as having a dignity, a status, and a right to the "This statement and others referred to in succeeding pages relate to extracts f r o m "thumb-nail sketches" described elsewhere. See App. pp. 613 to 626.

42

PRACTICE

AND

PRINCIPLES

control of his own affairs different in no particular f r o m the dignity, status, and right to self-maintenance of any other human being. When there is a conflict over the right of a personality to develop at the expense of others, the social worker may have to decide where his influence in the matter shall be thrown, and his decision must be guided not only by his respect for personality as such but by his consideration of factors which may not be apparent to those directly concerned. 2. The Family (Quoted f r o m statement by Gordon Hamilton). In some theories of the state the duty of woman is clearly laid down as childbearing for the purposes of the state, and children are state assets. Another theory is that the family is a f o r m of mutual aid and an institution primarily suited for personal development. In social case work the family is not treated as a whole or a solid, but it becomes for the social case worker a complex group of differing and interacting individuals, the welfare of one of whom inevitably affects the family group and is affected by the family group. 3. Community (From a statement by Walter W . Pettit). Community may be defined as a geographical unit or it may be defined as a unit in terms of common interest. Community is a relationship into which we are born, which is essential to existence, and which can be severed only through death. Community is the source of social controls. It is more intense and more fundamental than any association, even the greatest association, the state. This concept of community is of value to the social case worker in that an appreciation of the strength or weakness of these bonds of common interest is necessary in studying attitudes and behavior. 4. Confidential Relationship between Client and Worker (Quoted from a statement by M. Antoinette C a n n o n ) . A confidential relationship between two persons signifies on

PRACTICE

AND

PRINCIPLES

43

the o n e hand a willingness to give i n f o r m a t i o n in regard to i n t i m a t e personal affairs and on the other hand an obligation to u s « such i n f o r m a t i o n only in the interest of the person conc e r n e d , and not to pass it on to a third person. Social work is in this respect like the professions of law, medicine, and the priesthood or ministry. Its practice requires k n o w l e d g e of the client's personal history and situation such as w o u l d not be shared except f o r some trouble in which he finds

himself. Such knowledge m u s t be used for both indi-

vidual and social welfare. H o w exactly do the two coincide? Sometimes the client's interest itself seems to d e m a n d the s h a r i n g of i n f o r m a t i o n about the client with a third person, whether the client desires it or not. C o n c e p t s of individual values and of professional responsibility differ, and j u d g m e n t is o f t e n difficult in the concrete instance. O n e concept is that ultimately the social and the individual good m u s t be one, since the h u m a n individual is essentially a social being. O n the other h a n d , the individual's a u t o n o m y m a y be considered essential to his individuality and the individual is o f t e n short-sighted as to his own f u t u r e , and more so as to his oneness with society. I f the social worker sees or thinks he sees a good beyond that recognized b y the individual, m a y he t r y to influence the individual? M a y he act f o r the individual? It is a point of justice and kindness not to take a d v a n t a g e of the m i s f o r t u n e of a person whose need of a certain service puts him within one's power to harm. T h e r e m a y be a conflict of interests of individual clients, and the confidential relationship between worker and client may, therefore, be rendered impossible. There m a y be a conflict between the interest of the individual and that of the g r o u p , and in some instances that o f the g r o u p m a y so outweigh that o f the individual as to m a k e the confidential relationship impossible if the two c a n n o t

be

reconciled. Y e t because observance of the confidential relationship is

PRACTICE

44

AND

PRINCIPLES

necessary to the existence of professional service, the law recognizes the right of the physician, lawyer, and clergyman to withhold information professionally obtained, even when such information is needed or would be useful in other connections, f o r the sake of other persons, as f o r example, in the detection of crime. SERIES

VI.

KNOWLEDGE

FROM

SCIENCES

(Syllabus, Section E ) A.

Sociology 1.

T h e culture of a people (racc or nation) influences the

behavior of individual members, and to k n o w the culture helps the worker to understand the reactions of the member of the cultural group. (See 2.

Theocratcs.)

Personality is expressed in the role the person plays in

the group, and any one person may v a r y in his personality manifestation according to the group in which he appears. (See Theocratcs 3.

and Stone.)

Status in the group, i.e., recognition by the group of a

role and a set of relationships of the individual, plays a part in the expression of personality. (See B.

Stone.)

Economics 1.

Relief funds come f r o m the community through taxes

and through voluntary gifts. 2.

Insurance is a method of using statistical knowledge of

group liabilities in order to build up f u n d s to meet individual needs. 3.

Relief is given most economically (i.e. with best results

in proportion to expenditure) when the needs of person or f a m i l y are measured according to standards of physiology, and food, shelter, etc., are provided in accordance with this measured need. 4.

Relief policies of a social agency should be made and

administered, not only in view of individual needs, but also in

PRACTICE

AND

PRINCIPLES

45

view of the industrial conditions which help to create individual inadequacy. Otherwise an agency may help perpetuate a cause of the difficulty it strives to eliminate. C.

Psychology

ι. Intelligence can be tested and rated according to an established norm for chronological age. 2. Mental phenomena correlate in certain ways with the nervous mechanism of the body. 3. The simple response apparatus with which man is endowed at birth is much elaborated and complicated during life by the conditioning of reflexes. 4. Conscious response of the person seems to be to a situation perceived as a whole. SERIES

VII.

KNOWLEDGE

FROM

OTHER

PROFESSIONS

(Syllabus, Section E) A.

Medicine

1. The name of the client's disease is of little use to the social case worker but the physician's explanation of the client's condition is of use. The physician may be table to tell: (a) in what functions the client is disabled; (b) how much he is disabled; (c) in what stage his disease now is; (d) whether or not he is likely to recover; (c) what treatment and conditions of life will be most favorable to recovery; (/) whether he is a danger to other people. He may be able to answer other questions as to detail of requirements, etc. 2. There are but few specific drugs known to medicine. Most medical treatment is a collaboration with the healing power of the organism itself. 3. The patient's participation is important in treatment of most (some would say all) diseases, and especially important in the chronic diseases. 4. The patient's constitution, temperament, and emo-

46

PRACTICE

AND

PRINCIPLES

tional attitude are factors in his resistence to and recovery f r o m disease. 5.

Disease is not an entity but a reaction.

6.

Medical study has certain routines and patterns which

it follows as to history-taking, physical examination, precise instrumental measurement, chemical analysis, etc. I t also f o l lows a clue or hypothesis in the mind of the diagnostician according to which the possible tests are varied and chosen to exclude or to substantiate the tentative explanation. 7.

Medical prognosis is an estimate based upon statistics

and qualified by knowledge of the individual case. It usually requires testing under k n o w n circumstances before it can be depended upon as a forecast. (See 8.

Stone.)

Physical condition and emotional attitude react upon

each other and their inter-reaction must be understood in order to understand the person's sickness and his behavior. (See Stone.) 9.

Health may be improved and f u t u r e health conserved

b y maintenance of good nutrition, health habits, peace of mind, etc., to which social case work may contribute.

(See

Theocrates.) B.

Psychiatry 1.

Behavior is purposive.

2.

Parental attitude is the earliest social influence which

acts upon the child. (See 3.

Meyer.)

Security in home and f a m i l y life f a v o r stability, inse-

curity makes f o r instability in the child. (See 4.

Heath.)

N o r m a l life history of a human being is a progress from

infantile dependency to adult independence. 5.

Neurotic individuals have not made a mature f o r m of

adjustment to reality. 6.

" L i f e patterns repeat themselves, each day's experience

being colored by the feeling-tones of the days and years which have preceded." 9 " P o r t e r R. Lee and M a r i o n K e n w o r t h y , Mental The Commonwealth

Hygiene

and Social

F u n d , Division of P u b l i c a t i o n s , N e w Y o r k ,

Work, 1929.

page 90,

PRACTICE

AND

PRINCIPLES

47

7. Anti-social attitudes can often be traced to childhood rebellion against parental authority. C.

Law

1. The purpose of law is order in social life. 2. Civil law regulates individual rights as between persons and is concerned with reparation. 3. Criminal law regulates the state's control over the individual and is concerned with punishment of wrong-doing. 4. Common law is the inherited body of judicial decisions as to socially acceptable relationships, both civil and criminal (in Anglo-Saxon Jurisprudence). j . Statute law consists of regulations enacted by legislatures and recorded. 6. Legal evidence is subject to more exact limitation than is the whole range of evidence as admitted by the layman. 7. Legal evidence of neglect is required to change natural guardianship of a child. (Heath.) Summary and

conclusion

This chapter is an attempt to show meanings in a classified list such as the Syllabus, and uses to be made of its terms and groups of terms. It discusses first the difficulties inherent in teaching social case work, due to the indirect relationship between theory and practice. Some reasons are given for the belief that classroom discussion can contribute to practice, though but indirectly. The reasoning here is based upon the assumption of a practical effectiveness of ability to particularize and ability to generalize in dealing with real situations, and also of a practical value of emotional balance on the part of the practitioner. Such thought processes and such balance can, it is claimed, be fostered in the classroom. The Syllabus which accompanies this book is then explained as an attempt on the part of one teaching group to organize

48

PRACTICE

AND

PRINCIPLES

material f r o m which the content of classroom teaching may be derived. T h e material of the Syllabus had its origin in case experience and may reappear, in various configurations, in illustrations used in the classroom. It reappears also in the f o r m of general ideas and propositions which enter classroom discussion both inductively and deductively as concrete p r o b lems are discussed. A n u m b e r of series of "general propositions" is added, suggested for the most part b y the cases and courses herein described, but given enough order and

connection

within each series to suggest the actual course of possible lines of t h o u g h t . T h i s g r o u p of teachers has wanted to c o m m i t itself, chiefly for its own sake, in order to establish a point of departure for f u t u r e t h i n k i n g . In order to do so it is necessary to s e e m — perhaps t o be—sententious. In either case the effect u p o n the reader will be the same, and that no matter how o f t e n or in what m a n n e r the dogmatic attitude is disclaimed. Y e t this is a risk the teacher must take. Perhaps the ultimate stand of the teacher has never been better stated than b y Socrates in his last conversation, as recorded in " P h a e d o . " It is said that " S o c r a t e s paused awhile, and seemed to be absorbed in reflection. A t length he said: Y o u are raising a tremendous question, Cebes, involving the whole nature of generation and

corruption,

about which, if you like, I will give you m y own experience; and if a n y t h i n g which I say is likely to avail toward the solution of your difficulty you m a y m a k e use of i t . " In some such spirit this teaching exercise was performed.

PART II CASE R E C O R D S A N N O T A T E D F O R T E A C H I N G

C H A P T E R III

T H E CASE RECORD OF E D W A R D STONE A MEDICAL SOCIAL CASE TEACHING

OBJECTIVES

The case of Edward Stone has been used in a general social case work course to illustrate the medical elements in a medical social problem. It seems useful to include such material in the basic course for two reasons. First, all social cases contain an element of physical health, either as asset or as liability, and the concepts used in understanding this physical element in relation to mental and environmental components of the problem are the same in all fields of social case work. These concepts can well be presented in connection with a case in which the physical factor is large and distinct, and has been focused upon in study and treatment, both medical and social. The second reason for including such a case in this course is that it shows characteristic procedures in a special field of social case work, and makes clear the relations between that special field and other fields of social work. Cases in which there is a complex problem of ill health and social inadequacy have to be dealt with, not by social work alone, but by social work plus medicine. The two services must understand each other sufficiently to act together to meet the total difficulty at the same time that each performs its own special task by use of its own technique. Knowledge of the purpose and nature of medical procedures in study and treatment of sickness is therefore an essential part of the equipment of the social case worker, and the use of such knowledge is necessary to study and treatment of the medical social situation. This case offers material for discussion of medical examination, diagnosis, prognosis, and treatment, and so may lay a

50

EDWARDSTONE

f o u n d a t i o n for the knowledge o f this subject needed by the social worker. Besides this knowledge o f the method o f an allied profession, the social case worker should have certain concepts o f health and disease, f u n d a m e n t a l to the lay person's cooperation w i t h the medical profession and t o practice and teaching o f hygiene. W h a t is disease? W e speak o f a person's having " a disease," and o f a disease as something f o r a c o m m u n i t y t o c o m b a t , as if disease were an e n t i t y . T h e social w o r k e r o f t e n asks the doctor to name the disease, or state the " d i a g n o s i s " o f the sick client, and takes the medical classification as somet h i n g with which to solve the puzzle of personal adequacy in a social situation. Such a case as this illustrates a more useful c o n c e p t o f a person's condition o f health, n a m e l y t h a t o f an individual reaction to certain disturbing stimuli, w i t h its indications as to t r e a t m e n t and o u t c o m e . 1 T h e subject m a t t e r in this case which sets f o r t h the medical social situation is indexed under Division A , AREA. T h a t which indicates the procedures o f medical and other social workers in study and t r e a t m e n t is indexed under Division B , METHOD. M u c h o f the value o f the case is in the material above referred t o which describes medical procedure and physical c o n d i t i o n , and this is indexed under Division E , KNOWLEDGE. T h e r e are also parts o f the subject m a t t e r which fall u n d e r Division C , RESOURCES, t h o u g h the case would not be chosen f o r the special purpose o f presenting organization o f c o m m u n i t y

re-

sources. Finally, there is a problem of responsibility, as will be shown later, w h i c h m a y be classified under Division D , PHILOSOPHY. T h e case was chosen f o r teaching on a c c o u n t o f its c o n t e n t under KNOWLEDGE and AREA chiefly, and it is plain t h a t these t w o parts o f the c o n t e n t relate closely t o METHOD, so that the three parts are unified in teaching. Indeed all five kinds o f subject m a t t e r are closely integrated in the case. T h e record used is the unit history o f a hospital. I t includes "William A. White, M.D., The Baltimore, 1926.

Meaning

of

Disease,

Williams & Wilkins

Co.,

EDWARDSTONE

51

m e d i c a l history, both ward and out-patient, medical social w o r k e r ' s history and notes, and correspondence with other m e d i c a l and social agencies. T h e record f o r m itself m a y be o f f e r e d as an e x a m p l e of the c a r r y i n g o u t of certain policies of recording, and the advantages and disadvantages of these policies m a y be discussed. C O N T E N T OF T H E R E C O R D A N D ITS T R E A T M E N T IN TEACHING

T h e hospital's problem in this case is first presented to the s t u d e n t . E d w a r d Stone appears at an out-patient clinic c o m p l a i n i n g of

headache, dizziness, partial

blindness,

loss of

m e m o r y , and irritability, all d a t i n g f r o m a head injury received in an industrial accident one and a half years ago. Since the accident he has been unable to work at all. It is apparent that here is a personal and economic failure, but that is not the hospital's first concern. T h e medical question is, w h a t is the n a t u r e of the m a n ' s injury, where is it located, and is it remediable by any k n o w n means? T h e medical procedure indicated in the record is the usual one with a new patient. T h e first step is the special examination indicated b y the complaint. T h i s examination is an X - r a y of the head. N e x t his record is obtained f r o m the hospital which cared f o r him at the time of his injury one and one-half years ago. W h e n this and the X - r a y report are available a " g e n e r a l w o r k u p " begins, following a definite order or pattern which includes f a m i l y history, personal history, description of present illness, etc., and a detailed physical examination. H e is then referred to a special d e p a r t m e n t where a " v i s u a l

field"

examination is made. Routine laboratory examinations are also made. In all this there is a combination of two methods which, for lack of accepted terms, have been here called " c l u e " and " p a t t e r n . " There is enough use of " p a t t e r n " to insure k n o w l edge along all essential lines. Besides this, the signs and s y m p toms revealed in the complaint and in the results of e x a m i n a -

52

EDWARDSTONE

tions are f o l l o w e d up b y means of the p a r t i c u l a r s t u d y w h i c h they indicate. S u c h f o l l o w i n g of " c l u e " m a y suggest a h y p o thetical e x p l a n a t i o n of the trouble the testing of w h i c h m a y result in a diagnosis. If it does not, resort must be had again to the " p a t t e r n " or a r b i t r a r y routine until m o r e " c l u e s " are t u r n e d up. T h i s is a method c o m m o n to m a n y f o r m s of s t u d y , a m o n g them social w o r k . T h e l a y m a n ' s use of the expert m a y be discussed here as a general question w i t h particular application to medicine. T h e lay p u b l i c m a y c o n s t r u c t i v e l y learn to e x a c t of the profession a certain a m o u n t of adherence to p a t t e r n , or standard p r o cedure. T h e c l u c - f o l l o w i n g , h o w e v e r , is a m a t t e r f o r the e x pert. H o w f a r can standardization g o , and h o w f a r trust in e x p e r t j u d g m e n t , to g i v e the best results? T o illustrate shall w e , as a lay p u b l i c , d e m a n d a W a s s e r m a n test as p a r t of the routine of a medical institution, or shall w e leave it to the physician to use it w h e n indicated? If it is routine, more health k n o w l e d g e becomes available and m a n y f a i l u r e s of diagnosis due to negligence or f a u l t y j u d g m e n t w i l l be avoided. O n the other h a n d , the cost and the waste m o t i o n m u s t be c o u n t e d and the value also of c u l t i v a t i n g the responsibility of the diagnostician. It is impossible to m a k e the p a t t e r n exhaustive

for every

patient e x a m i n e d .

The

forming

and

testing of hypotheses is the e c o n o m y of e f f o r t that enables m u c h to be accomplished. W h e r e shall the line be d r a w n , or w h a t c o m b i n a t i o n be made? T h i s case is an e x a m p l e of one practical a n s w e r to the question. The

examination

in

this

case

leads

to

an

hypothesis

( a r a c h n o i d cysts, 1 . 1 9 . 2 7 ) and the suggestion of a special p r o cedure, spinal p n e u m o g r a m , w h i c h m a y c o n f i r m the guess as to the n a t u r e of the lesion, a n d w h i c h , m o r e o v e r , " s o m e t i m e s is good t h e r a p y . " T h e a r g u m e n t f o r the p r o c e d u r e is noted w i t h the statement of t e n t a t i v e diagnosis. T h i s r e c o m m e n d a t i o n is carried o u t as soon as possible, w i t h c o n f i r m a t i o n of the tentative diagnosis and i m m e d i a t e relief of s u f f e r i n g . T h e question of prognosis then arises. T o w h a t

EDWARD

STONE

53

extent may c o m f o r t be expected to last, to what extent may w o r k i n g capacity be restored, and under what circumstances? Medically, the outlook is favorable. A t this point the conditions under which the patient lives become important to the doctor. A n examination into the whole medical-social situation is required. As we have noted, this case plainly presents social difficulties connected with the physical, and a social agency has been interested in it f r o m the time of the injury to E d w a r d Stone. (See " S u m m a r y of Case f r o m Family Bureau as of 1 . 5 . 2 7 , " p. 7 $ ) . T h e facts as to his f a m i l y and income and the f a m i l y problem are briefly stated in a summary of information given over the telephone by the Family Bureau at the time of the patient's coming to the

hospital. This

information

is supplemented

by

facts

obtained in the medical social worker's "admission i n t e r v i e w . " T h e history thus gathered shows him to live in dark, crowded quarters with a w i f e and seven children. H e is receiving compensation, his w i f e earns the rent. T w o daughters are old enough to work but one is a cripple and has been over-indulged. Mr. Stone's abnormal sensitiveness demands peace and quiet, even after the operation which has relieved his headache. I n stead of this he has noise, confusion, and anxiety. H e has been unable to control his irritation and therefore has stimulated his children to behavior more and more irritating.

Both

parents and the older children have realized what was happening but all have been unable to change the reaction under existing circumstances. T h e social inquiry is inadequate at this time, in view of the very apparent close connection between the patient's physical health and his living conditions. T h e medical social worker does not come to any conclusion as to what this connection means or what changes may be desirable. N o plan is made even f o r continued social observation or f o r collaboration between f a m i l y agency and hospital. This incompleteness is due chiefly to the favorable prognosis made by the physician, but the medical social worker, as the event showed, was wrong in tak-

5 4

EDWARD

STONE

ing this hopeful prognosis as final, and disregarding the social element in the progress of the case. The meaning of prognosis is here discussed with the students. Prognosis is not prophecy nor the scientist an oracle. The prognosis is the best estimate as to future developments that can be made by knowledge (a) of the way in which similar conditions have developed in thousands of actual cases, and (b) of all the circumstances affecting this particular case. Prognosis will always require to be checked up by observation and often will have to be altered as further knowledge is acquired. Moreover a prognosis that would hold good in given conditions may often appear to be contradicted in the event, because conditions may change, unknown to the doctor or social worker. The parts played by the medical social worker, the non-medical social worker, and the doctor in observing the patient's progress can be shown here in relation to each other. The social worker is in a sense in loco patieniis to the doctor, but with a greater knowledge and more impersonal attitude (theoretically) than the patient has. Just what that knowledge should be the student may well consider for himself, but such concepts as these, of prognosis and diagnosis and of disease and health, which we are expressing and illustrating here, must, we believe, enter into it. The teacher will no doubt raise in his own mind the question of the value of teaching from "the negative," or the instance of failure, as here from the worker's inadequate examination and diagnosis. Were there no positive to contrast with the negative and thus give real content to the idea, it might be poor teaching to pay much attention to the fault in practice. In this case, however, the study, begun and dropped at this point, is later concluded and made the basis of a plan of action, so that the earlier incomplete procedure can be used to clarify the positive idea. This use of the double form, "this is the procedure, this is not the procedure" seems to emphasize the concept to the student. Even though no medical-social diagnosis is arrived at in

EDWARDSTONE

5 5

this first period of treatment of the case, the correspondence between the medical social worker and the Family Bureau begins to illustrate the interpretation of particular medical case necessary to the medical-social study. N o t only is technical information given as to the nature of the man's injury, etc., but the medical treatment is described and the outlook stated in terms of probable working ability at definite jobs. T h e w o r k i n g out of this particularized description of Mr. Stone's physical-mental condition is carried much farther in the later stages of the case and can be used as good illustration of the kind of information the social worker requires from the expert in another field. Medically the case is kept under routine observation and the doctor's notes on his condition are entered in the record at periods of one week, one month, and three months after the operation. These show that the improvement at first experienced continued for three months. The Family Bureau is interested as before and, in a report of 3 . 1 2 . 2 7 , says that they expect to move the family to better quarters "when Mr. Stone and J e n n y find w o r k . " There is, however, no thorough understanding between the Family Bureau and the medical social worker of a social program related to Mr. Stone's health; this is true in spite of the several reports exchanged. The permanence of the patient's improvement is taken for granted and treated as a causal factor which will change the whole situation, instead of a reciprocal factor, affected by, as well as affecting, other factors in the total situation. Some discussion may well take place here as to the nature of such factors as they occur in social complexes. O f t e n a difficulty can be understood or diagnosed only as the relation between its elements is seen as interaction. When the factors in question are partly physical and partly social the statement of interrelationship constitutes a medical-social explanation. Such explanation often needs to be made by social workers outside of hospitals and must always be part of the procedure of the hospital or medical social worker. The doctor must be party

56

EDWARDSTONE

to it, since the understanding of the physical factor must be authentic. Four months after Edward Stone's operation he comes to the doctor with a new complaint, "pain in back," for which he is given treatment. This condition appears to have been considered relatively insignificant and is not referred to again. However, three months after this, 9.19..27 (seven months after the operation), he comes in again with a complaint which seems to be related to his old injury, a tendency to fall. The falling continues and grows worse and, 1 1 . 1 7 . 2 7 , he is readmitted to the hospital ward and a second insufflation of air is done, again with good effect. N o w follows an interval of six months, from late N o v e m ber, 1 9 2 7 to late May, 1928, when the patient is not seen at the hospital, and nothing is done by the hospital to follow his progress. Then comes a statement from the Family Bureau that he "is becoming increasingly irritable and disagreeable at home." They wonder if he should be in an institution. It is necessary, in order to understand this lapse of observation, to know something of the turnover of personnel in the agencies. In this and other parts of what may be called the framework of the case it is necessary for the teacher to have knowledge beyond what is given in the record itself. This knowledge would need to cover the structure and functioning of the agencies taking part in treatment, the facilities offered by the community in which the action takes place, and any significant events or circumstances in the patient's life which for any reason are not included in the agency's record. Probably most records can be better used in teaching if they are supplemented by such collateral knowledge. We should not expect to find the framework in the social worker's record of the individual case. It happens that soon after Mr. Stone's second operation the surgeon who performed it and whose specialty it was left the city permanently. His patients had to be transferred to other

EDWARDSTONE

57

d o c t o r s . A specialist in n e u r o - s u r g e r y f r o m another hospital held a special clinic f o r these patients at the U n i v e r s i t y H o s pital once a m o n t h . (See letter 1 4 , 6 . 1 1 . 2 8 ) . A l s o the medical social w o r k e r w h o had first k n o w n M r . Stone l e f t the hospital a n d her case load w a s taken o v e r b y another w o r k e r . T h e r e w a s at a b o u t the same time a c h a n g e in w o r k e r s on the case at t h e F a m i l y B u r e a u . A lesson is to be learned here as to t r a n s f e r of cases f r o m w o r k e r to w o r k e r . A l l these s h i f t s in service help to b r i n g it about that f r o m N o v e m b e r to M a y v i r t u a l l y n o t h i n g is k n o w n of M r . Stone. In t h a t i n t e r v a l , discouraged b y f a i l u r e to i m p r o v e , b y his i n a b i l i t y to w o r k , and b y the d e p a r t u r e of the great doctor, he relapses into his old state of misery and irritability, and indeed becomes w o r s e t h a n b e f o r e . E v e n w h e n the F a m i l y B u r e a u and medical social w o r k e r m a k e a n e w a t t e m p t to get h i m again u n d e r medical care he fails to keep his a p p o i n t m e n t a n d thus delays his r e e x a m i n a t i o n in the special clinic b y a month. I n this m o n t h , h o w e v e r , a more determined a t t e m p t than b e f o r e is instituted b y social w o r k e r s in and outside the hospital to come to an u n d e r s t a n d i n g of the whole situation. F o r the first time it seems to be recognized t h a t it is a c o m p l e x of medical and social, and that it m u s t be a t t a c k e d f r o m t w o points, as medical t r e a t m e n t alone is not the k e y . T h e doctor's less f a v o r a b l e prognosis corroborates the f a m i l y w o r k e r ' s o b servation that M r . Stone is g r o w i n g worse instead of better. T h e letter of J u n e 1 , 1 9 2 8 f r o m the F a m i l y B u r e a u is w o r t h s t u d y as the first e x a m p l e in the record of f a c t s not o n l y ' k n o w n and cited b u t used and set in relation to the problem in such a w a y as to lead t o w a r d s a medical-social diagnosis, a medical-social

prognosis

or

f o r e c a s t , and

a

medical-social

treatment plan. T h i s letter is f o l l o w e d b y a c o n t i n u a t i o n of the reasoning process b y the medical social w o r k e r w i t h suggestions and questions as to immediate procedure based u p o n the doctor's opinion.

58

EDWARDSTONE

The medical examinations continue over several months more. In October, 1928, the medical social worker's own observation and conference with the patient and his w i f e is added to that of the Family Bureau. The combination of study and service here is of interest to the student. In November, 1928, the combined studies result in conferences, first between medical social worker and doctor, then between medical social worker and Family Bureau, in which a decision is reached as to treatment to be tried. Mr. Stone is to be removed from his family for a time and observed under controlled conditions " t o see whether under good conditions and understanding supervision he is able to adjust himself to f a r m work or other occupation" ( 1 1 . 5 . 2 8 ) . The facilities available for such an experiment constitute again a point of interest for the student and discussion may take place as to the differences in localities, the essentials and various ways of securing them. In this case a convalescent home offers just the cooperation needed. The correspondence between the medical social worker and the superintendent of the home is a good illustration of combined procedure in study, treatment, observation of progress, and planning based upon experiment, both participants having the same understanding of the case and the same objectives. The Family Bureau at the same time is participating on the same terms by seeing that the family is cared f o r and observing how they get on without the father. The case so f a r as we know it is inconclusive. Mr. Stone reacts well to the quiet country environment and is able to work and maintain himself. He is not able to work, or even to be well, at home with his family. They are not happy when with him in the country. He is not contented to remain permanently away from them. Is it wise to use for teaching a case which ends in a question? Certainly it would not be advisable to use only, or chiefly, such cases, for the outcome of the case should be some test of the social worker's method, and the student must learn to evaluate

EDWARDSTONE

59

it. B u t some cases, indeed many, do actually show after long effort no definite " r e s u l t " or ending of problem, and it is part of the professional attitude to be able to bear this truth. Moreover much thinking may be done on the unsolved problems of such cases, and much may be learned f r o m the attempt to understand the issues. T h e question of procedure at the point where this record is cut short is partly a question of social values. Something must be sacrificed, either the patient's health, comfort, and ability to w o r k , or his family relationships. It is for the patient and his f a m i l y , not for doctor or social worker, to make the choice. Supplementary information is now ( 1 9 3 ι ) available to show that the patient chose to return to his family, and to show the continued attempts at medical care and social adjustment made in view of his course of action. A compromise was made which allowed him to be away from home during the hot weather, his hardest season. In the discussion of this case by the students the subject of responsibility always is brought up, usually by the students, but if not by them, then by the instructor. H o w far is a man in Mr. Stone's condition responsible for his actions? He throws dishes at his wife, he turns his daughters out of the house. H e is not responsible, we may say, because his brain is injured. His daughter, on the other hand, who runs away with an exconvict and contracts gonorrhea, may be considered responsible for her unwise behavior. Y e t is not this responsibility a matter of degree and not an "either-or" proposition? Can we truly say that there are two classes of people, one responsible, the other not responsible for their conduct? What is this idea of responsibility, and of what practical use is it to the social worker, or, indeed, to anybody? Is it not true that Mr. Stone can in some measure control his behavior, at least by entering into plans that will change the conditions to which he reacts, and is it not useful to give him, as we say, some responsibility? Is not the daughter, though "normal," reacting essentially as her father does in ways which

6 0

EDWARD

STONE

c a n be predicted if the conditions are k n o w n , and must she n o t control her course o f action, if at all, in the same way in which he m a y control his, namely by p l a n n i n g in advance t o avoid certain stimuli and to seek others. F o r her, t o o , t h e social w o r k e r m a y constructively use the idea o f responsibility, b u t as a stimulus, not as a justification for c o n d e m n a t i o n . W e m a y sum up the main points in the t e a c h i n g o f the case o f E d w a r d Stone as follows: T h e record o f E d w a r d Stone is useful m a i n l y t o illustrate t h e medical elements in a medical social p r o b l e m ,

medical

methods o f study, diagnosis, and t r e a t m e n t , and t h e parts played b y medical and social work in an a t t e m p t t o understand and remedy a total situation. T h e social methods to be emphasized in teaching this case are: ( a ) the securing o f particular data f r o m the expert source, in c o n t r a d i s t i n c t i o n t o t h e securing o f a general statement or classification o n l y , and ( b ) the altering o f environmental conditions in a c c o r d a n c e w i t h medical and social observation. I n the course o f the s t u d y of the case, the o c c u r r e n c e o f a lapse of joint action and the subseq u e n t steps taken to regain the lost a d v a n t a g e give opportun i t y to note the results o f differing procedures. T h e medical social problem is one o f physical injury and social irritations i n t e r - r e a c t i n g to f o r m an intolerable family and personal situation. O n e f a c t o r to be f o u n d and deal: with is t h a t o f the resources within the group and available to it t o meet the needs created by the patient's disability. T h e understanding o f these i n t e r a c t i n g f a c t o r s and their total sum gives us the " m e d i c a l social e x p l a n a t i o n " or " p a r ticular c o n f i g u r a t i o n " o f this case. T h e r e is specific knowledge to be got t h r o u g h this case as t o ways in which brain i n j u r y m a y affect behavior, possibilities o f surgical t r e a t m e n t , etc., b u t this is o f m i n o r importance and the student must be t a u g h t that no generalizations on these points can be made f r o m this, or a n y one case. Indeed, t h e main point o f knowledge and good social m e t h o d to be made f r o m this case is t h a t the useful e x c h a n g e between experts is o f

EDWARDSTONE

6 I

the particular configuration, and not of the type alone. It is the particular explanation which the social worker must seek, f r o m whatever source, and it is, likewise, the particular explanation which the social worker will most usefully give, to whatever collaborator. The medical procedure illustrated is that of study, diagnosis, prognosis, and treatment, and the meaning of these methods to the patient and to his group can be made clear. Questions can be discussed as to the use of experts by lay people, what should be expected, what demanded, and in what should guidance and initiative be left to the expert. For example the scope and order of medical examination, as recorded, introduces discussion of the uses of routine and the extent to which medical examination may be expected to cover points not particularly indicated in the case. The relative exactness of laboratory processes and use of intruments may be noted, as well as the difficulty of interpretation, requiring expertness. The social worker must know that he cannot himself make use of laboratory findings, X-ray, etc., but must get the doctor's explanation of their meaning in the particular case before they become findings for social work. Medical prognosis is a matter of estimate and must always be checked by observation of actual progress of the patient under k n o w n conditions. In connection with organization and collaboration, the integration of the work of two social agencies and a convalescent home as seen in correspondence and interviews is of interest. The case illustrates the purposes and available services, medical and social, of the hospital and its relationships to the family agency and the convalescent home. The usefulness to an urban community of a rural convalescent home where complete environmental change may be had, is demonstrated here. The superintendent's point of view and participation in social treatment is especially interesting. Workmen's compensation plays an important part in the

62

EDWARD

STONE

case, both in giving support to the victim of an industrial accident and to his family, and in securing for him medical and social care. The difficulty of getting continuous adequate care in a seemingly hopeless case is apparent. Some questions as to social values appear in this case. The greatest difficulty in evaluation of objectives arises in this case after the patient has been for a year separated f r o m his family with happy results for both, except for the fact that he wants to live with his wife and to see his children, whereas his wife fears pregnancy and cannot content herself in the country. He tries returning to the city home. His old trouble recurs. It is perhaps the patient's conflict and not one into which the social worker may enter except as an onlooker. It appears that something must be sacrificed by someone in this family. The purpose of the hospital constitutes another general question in the case, though one which may be answered partly in terms of expediency. Whether the hospital shall see a patient through a long period of expensive convalescence, necessitated by family circumstances, may depend upon the economics of division of labor between agencies. The interest, however, of the hospital in the patient as a social as well as a physical being, and its purpose to restore him to social life, seems somewhat a matter of philosophy. Finally the question of responsibility may suitably be discussed f r o m the illustrations offered in this case. Questions of general usage in teaching arise, chief of which are the use of negative instances or instances of failure, and the use of the inconclusive case. Arguments have been given for the inclusion of some such material in the teaching of social case work to foster mental hardihood and thoughtfulness. C A S E OF EDWARD S T O N E

Particular

configuration

as of

6.1.28

An American mechanic has a wife and seven children between the ages of sixteen and one. H e has sustained a head

EDWARD

STONE

63

injury in connection with his work, the result of which has completely disabled him for a period of three years, and will partially disable him permanently. He has defective vision and hearing as a result of this injury, is subject to spells of dizziness and to severe headache, and has suffered loss of memory and increased nervous sensibility which has altered his temperament. He was formerly of cheerful, even disposition; he is now irritable and impatient. The economic insufficiency due to his loss of wages is partly made up for by workmen's compensation. The extra strain upon the wife has injured her health and made her, too, relatively nervous and irritable. The oldest child is a cripple. The second child, a girl, is headstrong and rebels against the irritability and authority of the father; and the younger children are all suffering more or less from the instability and strained personal relationships within the family. This family situation in turn reacts upon the man and hinders his improvement. As a recipient of compensation from the state, this man came to the attention of the After-Care Bureau, a social agency, which saw that his physical suffering and disability called for attempt at relief by medicine. The aid of social work was required first to secure effective medical service because the ordinary sources were not adequate to this peculiar case, and second to supplement the medical service because (a) the physical defect was incurable, ( b ) there was a considerable psychic element in the patient's reaction, and ( c ) the family friction resulting from his condition, besides being in itself bad, reacted unfavorably upon his health. Type

configuration

Incapacitating illness. Domestic discord. Economic insufficiency (compensated).

64

EDWARD

Name: Edward Stone Address: 20 Downing St.

ADMISSION

STONE

Age: 42 Married Occupation: Auto machinist Nativity: U.S.A.

DISCHARGE DIAGNOSIS

Date

Wd.

2.7.27

XII

OPERATIONS

RESULT

Date 2.16.27

Cyst of Pia Arachnoid

Unimproved Cranial Pneumography

6.15.27

OPD

11.16.27

XII

Acute Periostitis of 11th and 12th ribs 11.16.27

Meningeal Headache

Improved Cranial Pneumography

UNIVERSITY

HOSPITAL

Name: Stone, Edward Age: 43 Address: 20 Downing Street Married Birthplace: U.S.A. Date: January 30th, 1927 (pt. first seen Jan. 5th, 1927) Surgical Diagnostic

Extract from Record of City Hospital. Admitted: 6.4.25. Discharged: 6.28.25. Diagnosis: Fractured skull. Patient brought in by fellow worker for Garage. Has laceration of scalp, fractured nose, and bleeding from right ear and nostril. No one seems to know how injuries were received other than that a cab had fallen on him.

EDWARD

STONE

65

Physical examination: A d u l t , male, white, about 40 years of age, semicomatose condition but can be aroused. Oriented and rational on questioning. There is profuse bleeding f r o m the right ear and a large irregular laceration of the scalp over right occipital region, pupils are unequal, left greater than right. They react to light only slightly. Marked swelling and ecchymosis of l e f t eye with sub-conjunctival hemorrhage. Ears and nose: hemorrhage of right ear. Mouth: tongue covered with blood. [Syllabus reference:

KNOWLEDGE,

Medical method, s t u d y . ]

T E A C H I N G N O T E : In case of emergency, examination is first and mainly of clue type with minimum of routine. It is focussed on apparent injury, in this case. 6 . 4 . 2 5 — X - R a y s — T h e Roentgen examination of the skull in the lateral and anterior regions fails to show any evidence of a fracture. T E A C H I N G N O T E : Special examinations may be made at once. 6 . 6 . 2 5 — T h e Roentgen examination of the skull shows a f r a c ture through the right temporo-parietal region. Urine examination: 6.6.25. A m b e r , acid, negative. T E A C H I N G N O T E : Certain examinations, however, are made routinely to avoid errors of treatment, and to establish facts as to general physical condition which may affect reaction to the disturbing element. 6.5.25—Patient brightly alert, has sharp pain in right occipital region, radiating to forehead. This is increased on movement of the head. R i g h t temporal hemianopsia. Sees only half of examiner's head when straight f o r w a r d . T h e outer or temporal side is not visible. Complete sixth-nerve paralysis on right. N o other extreme nerve paralysis. Drooping left corner of mouth. [Syllabus reference: K N O W L E D G E , General medical concepts, signs and symptoms.] 6.6.25—Spinal puncture, bloody fluid practically with

no

pressure. Manometer reading four mm. only. 6.6.25—-Eyes: left, contusion of l e f t upper and lower lid.

66

EDWARD

STONE

Ecchymosis l e f t h a l f , bulbar c o n j u n c t i v a , l e f t p u p i l

larger

than r i g h t , responds t o l i g h t sluggishly. T e m p o r a l field l e f t eye c o n t r a c t e d 10.50; nasal field 30; inferior field 2 5 ; superior field 30; r i g h t eye central vision, perception o f light at a distance o f a b o u t 2 m m . , color perception at same distance. R i g h t eye: l i g h t perception 3 m m . nasal field; r i g h t ( t e m p o r a l ? )

field

no perception at all. F u n d u s e x a m i n a t i o n , l e f t eye negative, right eye negative. 6.11.2 5 — R i g h t

eye

fields,

right

temporal

field,

complete

hemianopsia. L e f t - e y e hemianopsia t o w i t h i n 5 degrees. 6.11.2 5 — S c a l p w o u n d clean, sutures removed. General c o n dition i m p r o v e d , eyesight i m p r o v e d . 6 . 1 6 . 2 5 — D i f f u s e headache still present w i t h greatest intensity in r i g h t occipital region. L e f t pupil 5 centimeters, and r i g h t pupil 5 centimeters. Pupils react to c o n v e r g e n c e and react to consensual, r i g h t to l e f t and l e f t to right. R e a c t to light slightly. B a b i n s k i present on r i g h t side, abdominal reflexes are active, l e f t s l i g h t l y less than right. Cremasteric is less on right, but both active. R i g h t rectus paresis still present. [ S y l l a b u s r e f e r e n c e : KNOWLEDGE, Medical m e t h o d , s t u d y . ] T E A C H I N G N O T E : Special examinations are made as case develops. Progress of disease or effect of injury is noted in this way, and also reaction, degree of recovery, complicating conditions, etc. 6 . 2 1 . 2 5 — O n the nasal side o f right eye there is a defect, arteries u n u s u a l l y contracted, distinct pallor on nasal side o f f u n d u s o f r i g h t side, possibly due to some obstruction

of

vessels w h i c h a c c o u n t s f o r temporal field o f disturbance. T h e r e m a y be an occlusion o f one o f the smaller vessels. ( E n d of e x t r a c t f r o m C i t y Hospital R e c o r d ) .

T E A C H I N G N O T E : This record of earlier history of the case, in another institution, is made use of in study by the University Hospital.

T E A C H I N G N O T E : Study of case, as of 1927, begins by ordering of special examination, namely, X-ray.

EDWARD

STONE

67

1 . 5 . 2 7 — T h e patient is to return to surgical diagnostic f o r a complete history and w o r k - u p , then he will be seen in neurological out-patient. X - r a y s of the skull have been ordered; visual field examination, etc., will be done a f t e r his general work-up. Diagnosis, unclassified. 1 . 5 . 2 7 — R e p o r t of X - r a y examination:

( A detailed technical

report of the skull as shown in X - r a y picture. A b o u t ten typew r i t t e n lines.) 1 . 1 1 . 2 7 — S u r g i c a l diagnostic: T . 9 8 . 6 , W . 2 0 2 . cc. headache and dizziness 1 J/ί years. [Syllabus reference:

KNOWLEDGE,

General medical concepts,

signs and s y m p t o m s . ] T E A C H I N G NOTE: General routine inquiry by the hospital into history and present conditions follows. Note subjects and order of inquiry. F a m i l y history: Mother died aged 67, heart disease. Father died 65, asthma. O n e brother and one sister living and well, one sister died in i n f a n c y . N o cancer, tuberculosis, diabetes, neurosis, or hereditary diseases. Personal history: Born U.S., in this city all of life. O c c u p a tion, machinist; Habits regular; Eats, T . I . D . ; Smokes average amount. Coffee 1 ; Tea 1 ; Alcohol o; D r u g s o. Marital history: Married 1 6 y 2 years, 7 children living, w i f e has had one stillborn and two miscarriages, occurred between full-term

pregnancies.

Weight,

best

202.

Average

192.

Present 202. Past history: Health always good until 1 l/z years ago. Infectious diseases: patient had scarlet, pneumonia, as child. Operations 2. C l e f t palate at 4 years. Bullet removed f r o m left arm when patient was 14 years old. Injuries: P . I . H e a d : negative before P . I . E y e s : negative before P.I.Ears: O . M . C . C . left before P . I . N o s e : negative. T h r o a t : negative. G . I . :

negative.

G . U . : negative. N e u r o muscular negative before P.I. Present illness: Onset J u n e 4, 1 9 2 5 , 1 Υ2 years ago. Trouble dates clearly f r o m an accident. Patient was cranking an auto-

68

EDWARDSTONE

mobile, another auto came f r o m behind and he had head caught between the t w o autos. H e does not remember just how he was injured as he was taken to the C i t y Hospital unconscious following the injury. A t C i t y Hospital he was treated f o r a fractured skull, right temporo-parietal region, fractured nose and ribs, and a dislocated jaw. For findings following accident, see report C i t y Hospital (p. 6 4 ) . Present condition: H e a d : Patient has very severe headache of frontal region, continuous. Patient cannot sleep with his head on the back or the right side, because it starts a bad ache in this region. Eyes: Since accident his eyesight has been very poor, he can hardly see anything f r o m the right eye, the left eye also has visual impairment, not so bad as right. Ears: Patient has lost all hearing f r o m right ear since accident. T h e hearing f r o m the left ear is about the same as before accident. Nose: Obstruction in breathing through l e f t nostril since accident. Has lost sense of smell completely. Mouth: Tongue no paralysis. Sense of taste completely lost. Neck:

O.K.

T h o r a x : Still has ache on right side of chest. Abdomen:

Negative.

Spine: Patient cannot bend f o r w a r d or w o r k when he has to bend f o r w a r d , because he has a very sharp pain in the pit of the back which travels down to the sacrum. Extremities:

N o paralyses of arms or legs.

Sensory: The right cheek and the right lateral region of thigh feel numb. Psyche: Memory: Poor f o r names of people and things. Patient does not have trouble understanding conversation. Patient says that he has difficulty expressing himself in speech, because he cannot remember ideas that he wishes to express, not because he cannot move tongue Ο. K . N o hallucination of

EDWARDSTONE

69

sight or hearing. Sleeps poorly. Wakes at slightest noise; patient's emotional reactions have changed since injury, whereas before injury he was talkative, bright and cheerful, now he is melancholy a good portion of the time and does not care to talk, but sits around and does not show interest in conversation. He has less emotional control since accident. N o w he gets angry much easier. He worries over small things that ordinarily never annoyed him. [Syllabus reference: KNOWLEDGE, Behavior, nervous integration. AREA, Deviations f r o m normal, contributory f a c tors, disease.] Physical examination: (Report of complete physical examination under headings General, Head, Eyes, Nose, Ears, Mouth, N e c k , Thorax, Abdomen, Genitalia, Rectal, Spine, Extremities, Reflexes. Summary as follows: "Patient shows definite evidence of intracranial injury f r o m accident which is probably irreparable." There are orders for complete urinalysis, Wasserman, and neurological examination.) T E A C H I N G N O T E : Note subjects and order of physical examinations. The medical study proceeds by use of routine order, and routine laboratory tests. 1 . 1 2 . 2 7 — R e p o r t from Neuro-surgery: ( A detailed examination is reported in full, with diagram, and summarized as follows: "There has followed the accident, bitemporal hemianopsia, failure of convergence, and irregularity of pupils. Deafness in right ear of middle ear type, headache in right side and dizziness.") 1 . 1 2 . 2 7 — ( R e p o r t of urinalysis is essentially negative. Report of Wasserman, both antigens negative. Report of X - r a y , films of the optic foramen show them to be equal and apparently normal. There is no evidence of bone destruction.) T E A C H I N G NOTE: The medical study must interpret the meaning of laboratory results. 1 . 1 9 . 2 7 — N e u r o - s u r g e r y : A spinal pneumogram might show arachnoid cysts on right frontal region and this procedure

70

EDWARDSTONE

sometimes is good therapy. H e should be fitted for glasses first and then return. Refer to Ophthalmological Hospital

for

glasses. [Syllabus reference:

Medical method, diag-

KNOWLEDGE,

nosis, plan, medical problem, disease.] T E A C H I N G N O T E : This note of 1.19.27, suggests a tentative diagnosis and recommends a procedure which may confirm the diagnosis and, at the same time, relieve the conditions. Treatment and study or testing are often one and the same. The arguments from both standpoints go into the thinking and often into the record. 1.24.27

Letter 1 OPHTHALMOLOGICAL

HOSPITAL

January 24, 1927 Dr. Clark Supt. O . P. D . New York City R e : E d w a r d Stone OPD

Dr. York

Dear D o c t o r : T h e above named patient was registered in our E y e Clinic on January 22nd, 1927. H e has a primary descending O p t i c A t r o p h y . Vision, Perception of light only. Prognosis: T h e doctor states there will be no probability of vision being improved. V e r y truly yours, E. COGSWELL, ETHEL

Supt.

RIVERS

Director Social Service.

1.26.27—Spinal pneumogram may be made later for his headache, if it is severe enough. Diagnosis: Partial amblyopia, subarachnoid cyst, subsequent to trauma. T o come in for spinal pneumogram. [Syllabus reference:

KNOWLEDGE,

Medical method, diag-

nosis.] T E A C H I N G N O T E : Medical diagnosis finally takes the form of a classification term which is more or less definite. This term does not take the place of description of the particular case.

EDWARDSTONE

71

2 . 2 . 2 7 — P a t i e n t m a y be admitted tomorrow if there is a bed. 2 . 7 . 2 7 — P a t i e n t admitted to surgical ward. Nurse's Notes: 2 . 7 . 2 7 — C o m f o r t a b l e since admission, quiet day without complaints. 2 . 8 . 2 7 — A p p a r e n t l y slept all night, no headache this morning, quiet, comfortable day. 2 . 9 . 2 7 — Q u i e t all night, sleeping, good day, no complaints. 2 . 1 0 . 2 7 — S l e p t well, excellent day. 2 . 1 1 . 2 7 — I n t o operation. Recovery quiet. N o pain. Slight nausea on return to ward. Later, headache relieved by medication. C o m f o r t a b l e this evening. [Syllabus reference: KNOWLEDGE, Medical method, treatment, nursing.] TEACHING NOTE: These notes are of interest as showing something of the patient's experience day by day, under observation in the hospital. He seems to suffer less than previous complaints would indicate. This is often true. There are several possible explanations. The objective observer does not exaggerate past pain; the patient may exaggerate. The quiet of the ward may give relief from pain and restlessness. 2 . 1 1 . 2 7 — O p e r a t i o n : Spinal pneumogram. ( T h e operation is described in detail. A lumbar puncture is made, spinal fluid is withdrawn in small amounts and replaced with like amounts of air until a total amount of 50 c.c. of air has been introduced.) [Syllabus reference: KNOWLEDGE, Medical method, treatment.] Cerebral pneumogram. (Description of the X - r a y picture of skull after injection of air: " T h e bubbles are so numerous and small as to suggest that there is a good deal of atrophy of the brain in this portion and that the normal outline gyri is not present, there is no evidence of a large cyst and there is no area over this lobe where the arachnoid space does not fill. Conclusion, atrophy of cerebral cortex or increased complex of the subarachnoid channel of the right frontal lobe f r o m some other cause.")

72

EDWARDSTONE

[Syllabus reference: K N O W L E D G E , Medical method, study.] 2.12.27—(Report of X - r a y examination of the skull made on this day: "There is now a small collection of air about the size of a nickel in the right frontal region and a few small bubbles around it apparently on the surface of the brain. Diagnosis arachnoid cyst.") [Syllabus reference: K N O W L E D G E , Medical method, diagnosis.] 2 . 1 2 . 2 7 — N u r s e ' s note: Slept soundly all night, pulse good quality and remained about 72. Quiet, uncomplaining day. 2.12.27—Doctor's note: Patient had a bad headache ("Pressure feeling") after pneumograph of spine, lasted 1 hours. Following this the headache disappeared except in the back of head and when he moved head. Feels much better this morning. 2 . 1 3 . 2 7 — N u r s e ' s note: Slept well all night, up and about, good day. 2 . 1 3 . 2 7 — D o c t o r ' s note: The effect of the spinal pneumograph in overcoming the patient's symptoms has been quite remarkable. Yesterday and today the headache, his chief symptom, has completely disappeared and he says he "feels like a new m a n . " This afternoon he got up for a walk and felt a little weak on his feet, but otherwise felt excellent. [Syllabus reference: K N O W L E D G E , General medical concept, disease, a reaction, not an entity.] 2.16.27—Patient discharged from hospital. T E A C H I N G NOTE: Compare use of pattern with use of clue, and classification with particularization of case. 2.16.27—Discharge note (Medical). The first admission of a 42 year old American machinist who entered f o r a craniopneumogram. Family and personal history negative. Had a cleft palate repaired in childhood, and a bullet removed from left arm at age of 14. Otherwise previous health good until P.I. This began with a head injury sustained 1 l/i years ago for which he was

EDWARD

STONE

73

t r e a t e d at C i t y H o s p i t a l . A t t h a t time X - r a y showed a f r a c t u r e in t h e r i g h t t e m p o r o p a r i e t a l region, and he was said to h a v e η r i g h t t e m p o r a l hemianopsia. A f t e r discharge he suffered f r o m a l m o s t c o n t i n u o u s severe r i g h t f r o n t a l headache, n o t a b l y on b e n d i n g b a c k his head, together w i t h pain in the l u m b a r region o n e f f o r t . F u r t h e r m o r e , his vision steadily decreased, m o s t m a r k e d l y on r i g h t , his r i g h t ear w a s almost t o t a l l y d e a f , he n o t i c e d f a i l i n g m e m o r y , and he had an i m p e d i m e n t to respiration in the l e f t nostril. P h y s i c a l e x a m i n a t i o n showed a rather obese m a n , not l o o k i n g ill. H e a d n e g a t i v e e x c e p t f o r m a r k e d t e m p o r a l d i m i n u t i o n of b o t h visual fields, O M C C on l e f t , and r u p t u r e d m e m b r a n u m t y m p a n i w i t h a b u n d a n t g r a n u l a t i o n s on r i g h t . L u n g s , heart, and

abdomen

negative.

R e f l e x e s present.

Urine:

negative.

W a s s e r m a n : n e g a t i v e . X - r a y of skull showed w h a t was a p p a r e n t l y a small arachnoid c y s t in r i g h t f r o n t a l region. A d m i t t e d 2 . 7 . 2 7 f o r cranial p n e u m o g r a m , in the hope of r e l i e v i n g his headache. T h i s w a s p e r f o r m e d on 2 . 1 1 . 2 7 ,

ant

^

in a d a y o r t w o , patient began to experience r e m a r k a b l e relief f r o m his headache w h i c h b y 2 . 1 3 . 2 7 had completely disappeared. Pain did not r e t u r n . Plates of the skull, taken a f t e r the air injection, indicated an a t r o p h y of the cerebral c o n v o l u t i o n s in the r i g h t f r o n t a l region. C y s t of pia a r a c h n o i d , cranial p n e u m o g r a p h y . D i a g n o s i s : C y s t of pia arachnoid. Deliberate a t t e m p t to relieve meningeal headache b y air injection has m e t w i t h astonishing success. Prognosis good. SOCIAL HISTORY:

ADMISSION

INTERVIEW

2 . 9 . 2 7 — F o l l o w i n g history obtained f r o m w i f e w h e n patient w a s a d m i t t e d to hospital. Interested agencies: Society f o r H a n d i c a p p e d C h i l d r e n : Mrs. F

(through

interest in Louise, w h o has been u n d e r their supervision since she had i n f a n t i l e paralysis 5^2 years a g o ) . F a m i l y B u r e a u : G i v e s 1 q u a r t Β grade milk daily f o r b a b y . Previous hospital: C i t y , and O p h t h a l m o l o g i c a l f o r eyes.

EDWARD

74

STONE

Patient was born with c l e f t palate which was operated upon in Lutheran Hospital when he was f o u r years old. [Syllabus reference:

RESOURCES,

Organized practice, social

case work organization, social case work facilities, economic, medical.] Family: W i f e — J a n e , age 34. P a t i e n t — E d w a r d Stone, age 42. Children—Louise, age 1 6 , crippled; J e n n y , age 1 5 , goes to Continuation School, P. S. » 0 1 , East Main Street. Has her w o r k i n g papers and school is trying to place her. T o m , age i } , P. S. S02; Alice, age 8; Charlotte, 3; Rose, 2 ; James, age 3 months, born October 25, 1926. Housing: Patient lives in basement, 20 D o w n i n g St. W i f e is janitor. Patient, w i f e , and 7 children sleep in three dark, damp rooms, very crowded. N o rent, and they receive $5.00 a month to pay f o r light and gas. [Syllabus reference:

AREA,

Deviations f r o m normal, con-

tributing factor, inadequate housing.] Income: Compensation, receives $20.00 a week

through

Garage where patient was employed as a mechanic when accident occurred. Accident: Another car backing into him when he was repairing a car. H e suffered f r o m fracture of skull. Present condition thought to have some relation to accident. H e was a night-foreman receiving $ 3 7 . 5 0 and was due f o r a raise. 2.16.27—-Discharge note: (Social.) D r . P. says patient will be able to do work as watchman or porter. Family Bureau notified. Worker will see patient February 2 3 , in f o l l o w - u p clinic. If patient is unable to get work himself he will consult us. Prognosis: Status: Inquired into. [Syllabus reference:

METHOD,

Social case w o r k procedure,

social study, expert.] T E A C H I N G N O T E : loint inquiry by family social case work and medical social case work.

EDWARD

STONE

75

S U M M A R Y OF CASE F R O M F A M I L Y B U R E A U AS OF

I.5.27

E d w a r d Stone was referred to the Family Bureau by the A f t e r - C a r e Department of the Workmen's Compensation Bureau in December, 1925. He had been injured at work J u n e , 1 9 2 5 . H e was a taxi driver and mechanic. He was repairing an automobile when a jack slipped and the car came down on his head. H e was cared f o r in City Hospital and later by Compensation Bureau doctors. He has never recovered from the injury sufficiently to be able to work, suffers almost constant headache, has defects of speech, eyesight, and hearing, and is extremely irritable. [Syllabus reference: AREA, Particular configuration. METHOD, Social case work procedures, definition of problem, administrative function, inter-agency practice.] T h e family consists of: E d w a r d Stone (patient), 43, German, Roman Catholic; Mrs. Stone, 40, Irish, Roman Catholic; and seven children born between 1 9 1 1 and 1926. Mr. Stone was awarded $20.00 a week compensation. This was insufficient so the Family Bureau gave an allowance until J e n n y was able to work. Until Mr. Stone's accident the family had been harmonious and independent. Mr. Stone made a fair, steady wage and Mrs. Stone was a capable housewife and good mother, with unusually even, cheerful disposition. Since the injury Mr. Stone has become so difficult to live with that the wife and children begin to show the effect of strain and friction. Mrs. Stone understands that Mr. Stone's irritability is the result of his physical condition, but is unable to protect the children from suffering its bad effect, and she herself is becoming depressed and does not seem physically well. It is necessary, from the standpoint of the Family Bureau, to know whether Mr. Stone can be relieved of his complaints and enabled to work; if so, at what kind of work; and also, whether his sensitiveness can be reduced to the point where he can endure the strain

7 6

EDWARDSTONE

incident to living in a large f a m i l y in close quarters, and therefore can conduct himself normally in relation to his w i f e and children. (History and inquiry to this effect by telephone to S S D , University Hospital, f r o m Family Bureau.) [Syllabus reference: METHOD, U n i t R e c o r d . ] SOCIAL HISTORY

TEACHING NOTE: Compare "social history" with Family Bureau report 12.10.28. Personal: Patient's parents were born in G e r m a n y , but emigrated to U . S . A . and died here. His father was a cigar-maker, but patient did not care to follow that line of w o r k . Father was a citizen of U . S . A . Education: Patient left school at age of 1 4 years,

finishing

grammar school. H e then had to go to w o r k and was apprenticed to a mechanic f o r three years, getting a thorough k n o w l edge of general mechanics, including steam-pipe

fitting.

He

did not go to Trade School. W o r k history: Patient has always been a mechanic and earned very good wages. W i f e says he has always been a good, conscientious worker. When accident ocurred he was in line f o r advancement. Since accident patient has attempted several things, but his headaches, and eyes have always gone back on him. H e tried assembling radio parts, and all went well until he was given the finer parts which proved to be too great a strain on his eyes. H e then went to work at the A u r o r a Borealis Electric Fixture C o m p a n y , but here, too, he was given

finer

work, and he had to give up that. T h e sanitary conditions there were also very poor, and even had the w o r k proved satisfactory he probably would have left. [Syllabus reference: METHOD, Social case-work procedure, social study.] 2 . 1 0 . 2 7 — C l e a r e d through Social Service Exchange. to following agencies: Family Bureau (active).

Known

E D W A R D

7 7

STONE

Children's Division, Western Hospital, 2 . 1 5 . 2 2 . Maternity Hospital and Dispensary, 6.16.22. Society f o r Handicapped Children, 6 . 1 4 . 2 3 - 1 1 . 2 . 2 3 . Catholic Aid, 2 . 1 8 . 2 5 . A f t e r - C a r e , 12.5.25. Sheltered Shop and Employment Bureau, Employment, 8.28.26. 2 . 1 5 . 2 7 — F a m i l y Bureau telephoned asking if it would be necessary to have patient referred to Institute for the Blind, for rehabilitation, on account of patient's sight impairment. Consulted D r . Land and D r . Y o r k who say that patient's sight has improved since treatment here, may still improve a little, and will not get worse. They see no need for patient to spend time learning new work. He will be able to take any job such as a watchman, rough porter, or elevator operator, in fact, anything that does not require close vision. Notified Family Bureau of doctors' recommendations and sent them a written report of our findings. [Syllabus reference: RESOURCES, METHOD, prognosis, plan.] T E A C H I N G NOTE. The social forecast depends upon the medical, and the social plan depends upon both. In this instance the vocational advice of the doctors was poor. The medical social worker should have brought more facts into consideration and should have been more suspicious at this point. The advice as to vision and retraining may have been correct, but "watchman or rough porter work" is almost always an uncritical suggestion and calls for analysis and check-up. Letter 2 UNIVERSITY HOSPITAL February 17,

1927

Miss R o o s e v e l t Family Bureau R e : Stone, E d w a r d D e a r Miss R o o s e v e l t : W e are sending y o u the f o l l o w i n g report on E d w a r d Stone as per y o u r request b y telephone a f e w days ago. Patient

was

admitted on F e b r u a r y

7th,

1927,

and

discharged

7 8

E D W A R D S T O N E

February 1 6 , 1 9 2 7 . Diagnosis: cyst of Pia Arachnoid. Patient was admitted f o r treatment (pneumogram) to break up adhesions which were causing him intense headaches. A f t e r treatment, his headaches completely disappeared within three days and did not return: vision also improved after treatment. Doctor's recommendation: Patient, on account of vision impairment, will not be able to resume his work as a mechanic, but he will be able to take any kind of work which does not require close vision or use of eyes to any great extent. Jobs such as a watchman, possibly rough porter work, or anything else in that line he is able to get. If he is unable to find employment we will be glad to have him talk the matter over with us and refer him to one of the handicapped bureaus. I believe he is known to the Sheltered Shop and Employment Bureau, and if they arc still interested perhaps they may have something to offer him. Patient has a follow-up date for February 23rd and by that time, if all goes well, he will be able to start work. We will see him here on that date. D o you know how long he will be getting compensation? We understand he is getting $20. a week at the present time. We would appreciate a short report from you. Sincerely yours, ELIZABETH

BUCKMINSTER

Director Social Service Department T E A C H I N G N O T E . A well-meaning but inadequate letter. It is easy to mistake quotation of expert for interpretation. 2 . 2 3 . 2 7 — D r . Y o r k saw patient in clinic and says he is ready for light work. Phoned Family Bureau regarding same. 2 . 2 4 . 2 7 — M i s s Roosevelt f r o m Family Bureau phoned asking if we would send her a slip for Bureau for Handicapped as patient had no w o r k of proper type in sight. Sent her the handicapped slip filled in for Mrs. Malloy of the Bureau f o r Handicapped. Status, taken up. Patient has been k n o w n to Sheltered Shop and E m p l o y m e n t Bureau, and will only go to other bureau if they cannot place him.

EDWARD

STONE

79

T E A C H I N G N O T E : A handicap in a potential worker is supposedly recognized and thought appropriate for treatment by a special employment agency. F i n d i n g s : A n American man of 42 years, living with w i f e . Seven children. H e a v i l y built. Injured by taxicab's bumping into him while at work in a garage in J u n e , 1 9 2 5 . H e has been receiving $20. a week compensation. 1. Patient is suffering f r o m severe headaches and partial loss of vision due to growth of adhesions in brain membrane, relieved b y treatment. Vision impaired. 2.

C l e f t palate operation when a child.

3. Reaction modes: even tempered and amiable before accident. I n j u r y caused intense headache which changed patient's attitude toward f a m i l y , etc., making him irritable. Extremely g r a t e f u l f o r relief of headaches. Melancholy at times, lacked interest in surroundings. Daughter, age 16 years, crippled, infantile paralysis. K n o w n actively to Family Bureau and Society f o r Handicapped Children. Must change type of employment owing to vision impairment. T E A C H I N G N O T E : The selection of facts considered to have significance, positive or negative, in explaining the problem is a step toward formulation of the full explanation, i.e., the diagnosis. Is this list of "findings" adequate? Diagnosis, Tentative: Disability, Physical: Partial, Permanent. Disability, Intellectual: Memory-loss. Occupational limitation: (a) D e f e c t of eyesight; ( b ) Speech impairment. General inefficiency: Lethargy. Radical change of employment necessary. [Syllabus reference:

AREA,

T y p e configuration.]

T E A C H I N G N O T E : In spite of form and attempt at classification, the social worker fails here to extract full significance, otherwise there would be further study and observation. To classify tends to stop work on individual case and divert to study by statistics and generalization.

8θ

EDWARDSTONE

T o diagnose leads to prognostication and treatment. Note that medical follow-up here was better than social.

2.23.2 7—Neuro-surgery: T E A C H I N G N O T E : The medical study continues after treatment has begun.

Doctor's entry: Completely cured of headache, children say: " W h a t ' s the matter—daddy has no headache!" T h e salient features of the headache were right eye and forehead pain continuous, like a pressure behind eye, then there came sharp and stabbing pains about every five minutes or when stooping. T h e stab spread to opposite and lasted only a f e w seconds. A t night he lay on his face and rested hand on left eye. H e couldn't sleep at all he says. H i s w i f e says he slept a f e w minutes, then woke up excited, the least thing disturbing him. A f t e r rising f o r J/2 to 1 hour he was free f r o m pain; stooping to put on shoes " w a s m y d o w n f a l l . " His w i f e put on his shoes. In heavy weather he was very bad, and he had nausea and occasionally vomited. E v e r y morning when headache started the nausea began and lasted several hours. This dizziness came suddenly when he was walking and passed off in five or ten minutes. H e stopped and held on to things f o r that time, then went on. H e always staggered to the l e f t , never right. This left staggering was f r o m very beginning, this is gone also, and he says his eyesight is clearer. H e can do f u l l w o r k now, not fine work to begin with. T E A C H I N G N O T E : What use is made of this minute description of symptoms? What, in general, is the meaning of any symptom?

Letter 3 SHELTERED SHOP AND E M P L O Y M E N T

BUREAU

March i , 1 9 2 7 University Hospital City Dear Sir: Mr. Edward Stone has applied here for work. We would be grateful if you would give us as much information as possible about his

EDWARD

STONE

8 I

physical condition, in order that we may place him in suitable employment. H e states that he received treatment in your hospital in Ward 1 2 , on February 1 2 , 1927. Yours sincerely, K . R . MARKS

Employment Secretary. Letter 4 UNIVERSITY

HOSPITAL

March 2, 1927 Miss K . R . Marks, Employment Secretary Sheltered Shop and Employment Bureau City Re: Stone, Edward Dear Miss Marks: Y o u r letter regarding above patient just received. Patient was admitted on February 7th, 1 9 2 7 , and discharged February 16th, 1927. Diagnosis: Cyst of Pia Arachnoid. Patient was admitted for treatment (pneumogram) to break up adhesions which were causing him intense headaches. A f t e r treatment, his headaches completely disappeared within three days and did not return; vision also improved after treatment. Doctor's recommendation: Patient, on account of vision impairment, will not be able to resume his work as a mechanic, but he will be able to take any kind of work which does not require close vision or use of eyes to any great extent. Jobs, such as a watchman, possibly rough porter work, or anything else in that line he is able to get. We are informed through the Social Service Exchange that patient was known to your Employment Department in 1926 and we feel sure that you will be able to place him at some satisfactory work. Thanking you very much, Sincerely yours, ELIZABETH BUCKMINSTER

Director Social Service Department [ S y l l a b u s r e f e r e n c e : RESOURCES.] T E A C H I N G N O T E : Over sanguine letter based upon imperfect medical social prognosis.

82

E D W A R D

S T O N E

Letter j FAMILY

BUREAU

March 1 2 , 1927 Miss B u c k m i n s t e r Social Service D e p a r t m e n t U n i v e r s i t y Hospital City M y dear Miss B u c k m i n s t e r : W e are sending a short a c c o u n t of M r . E d w a r d Stone, 2 0 D o w n ing Street, w h i c h y o u asked f o r . M r . Stone was a mechanic, and while employed w i t h the G a r a g e , was in an accident, 6 . 4 . 2 5 , and rcccivcd a severe head i n j u r y , w h i c h resulted in headaches, bleeding at the ears, and impaired eyesight, m a k i n g him incapable of w o r k i n g f o r any length of time. H e was granted $ 2 0 . a week compensation, and was examined by the f o l l o w i n g : 6. 4 . 2 5 — C i t y Hospital, D r . X i . 6.26—Dr.

Y

4. 6 . 2 6 — D r . Ζ 4· γ.ι6—Dr.

A

6.23.26—Dr. Β D

Garage. Bureau.

. . , Neurological Clinic,

Dr. C 1 0 . 6.16—Dr.

. D r . of

of W o r k m e n ' s Compensation

Hospital.

, Sanatorium. , 90 Bridge St.

His condition was not really improved u n t i l he was cared f o r by D r . Y o r k of y o u r hospital. A t present, his eye-sight is m u c h better and he has no more headaches. T h e Sheltered Shop and E m p l o y m e n t Bureau is t r y i n g to find w o r k f o r him. His f a m i l y consists of his w i f e , the janitress of the tenement in w h i c h they live, receiving $ 5 . a month and f r e e rent, and seven children, Louise, age 1 6 ; J e n n y , 1 5 ; Alice, 8; C h a r l o t t e , 3 ; Rose, 2, and James, f o u r months. J e n n y is n o w attending c o n t i n u a t i o n school. T h e i r basement apartment is d a m p and dark, and as soon as M r . Stone and J e n n y find jobs, we hope to m o v e them to better quarters. M r . Stone is v e r y g r a t e f u l f o r w h a t the U n i v e r s i t y H o s p i t a l has done f o r him and is greatly encouraged over his i m p r o v e d condition. Sincerely yours, CATHERINE

PERKINS

S e c r e t a r y , F a m i l y Bureau

E D W A R D

S T O N E

8 3

T E A C H I N G N O T E : T h e succession of medical practitioners spoken of in this letter results only in discouragement. Study, nowhere conclusive or leading to constructive plan for medical-social treatment, leaves it for a social agency to find more effective expert facilities, medical and social.

3 . 2 1 . 2 7 — O n e month after operation: Doctor's note: Patient has no more headaches, is able to sleep in any position, has no more dizziness. He feels his eyesight is a little bit better. He sees double on close vision, sticking pains have disappeared. T o rough test he still has roughly bitemporal hemianopsia. T E A C H I N G N O T E : Medical study continues after diagnosis, treatment, and prognosis.

3.28.29—Social worker's note: Mr. and Mrs. Stone to hospital, Mr. S. now working as a watchman, is to have a compensation hearing early in May and wanted hospital report to take with him. Was told to have Compensation Board write hospital requesting information wanted. T E A C H I N G N O T E : Medical testimony is required for decision and procedure of Compensation Board. Note form and content of report given.

5 . 4 . 2 7 — ( R e p o r t from hospital to Workmen's Compensation Bureau.) Letter 6 UNIVERSITY

HOSPITAL

May 4, 1 9 2 7 Prepared at request of Miss Prince, Investigator, Bureau of W o r k men's C o m p e n s a t i o n , C i t y : Name:

Stone, E d w a r d .

Address: Admitted: Discharged:

City. February 7th,

1927.

February 16th,

1927.

Diagnosis:

C y s t of Pia A r a c h n o i d .

Operation:

Cranial Pneumography.

Final note: The

first

admission of a 4 2 - y e a r - o l d

entered f o r a craniopneumogram.

American

machinist

who

84

E D W A R D

S T O N E

Family and personal histories negative. Had a c l e f t palate repaired in childhood and a bullet removed from left arm at age of 14. Otherwise previous health good until present illness. This began with a head injury sustained 1 Yi years ago for which he was treated at City Hospital. A t that time X-ray showed a fracture in the right temporoparietal region and he was said to have a right temporal hemianopsia. A f t e r discharge he suffered from almost constant severe right-frontal headache, notably on bending back his head, together with pain in the lumbar region on effort. Furthermore his vision steadily decreased, most markedly on right, his right ear was almost totally deaf, he noticed failing memory and he had an impediment to respiration in the left nostril. Physical examination showed a rather obese man not looking ill. Head negative except for marked temporal diminution of both visual fields, and ruptured membrana tympani with abundant granulations on right. Lungs, heart, and abdomen negative. Some tenderness, on bending, over sacrum. Reflexes present. Urine: negative. Wasserman: negative. X-ray of skull showed what apparently was a small arachnoid cyst in right frontal region. Admitted for cranial pneumogram in the hope of relieving this headache. This was performed February n t h and in a day or two patient began to experience remarkable relief from his headache which, by February 13 th, had completely disappeared. It did not return. Plates of the skull taken after the air injection indicated an atrophy of the cerebral convolutions on the right-frontal region. A A R O N RHODES

(Superintendent) [Syllabus reference: RESOURCES.] 5 . 1 6 . 2 7 — T h r e e months after operation: Doctor's note: N o dizziness. Occasional weakness of the right 7th nerve, undoubtedly due to returning function of this nerve. N o headaches. H e is doing heavy porter work, states that he sometimes cannot see to read, able to read for short time but cannot see well enough to put screw in wall, therefore, not trying to do any more mechanical work. Says he cannot see slot in screw although he can see screw. States he has difficulty in opening eye.

EDWARD

STONE

85

T E A C H I N G N O T E : Routine return visits at stated lengthening intervals check up study and prognosis and insure further study and treatment as needed. Letter 7 UNIVERSITY HOSPITAL

May 1 7 , 1927 Edward Stone City Dear Sir: We are sending you, enclosed, the letter Dr. York wrote referring you to Specialist Eye Hospital. Yours very truly, C. Q. JENKS

Surgical Follow-up Worker [Syllabus

reference:

RESOURCES,

KNOWLEDGE,

Medical

method.] Letter 8 UNIVERSITY HOSPITAL

May 1 7 , 1927 Superintendent Specialist Eye Hospital City Dear Sir: We are referring patient, Mr. Edward Stone, to you, in whom we have been greatly interested. He has a Bitemporal Hemianopsia, which is complete for right eye, but incomplete for the left eye. This followed a fracture of the skull, which undoubtedly injured the optic chiasm. We have been able to relieve his headaches, but he is unable to return to his work as expert mechanic because of difficulty in close vision. He states that he can see quite well at a distance. He seems to have central vision intact, at least on the left. Is it not possible to provide him with glasses which will make close work possible? We would appreciate your interest in this case. Yours very truly, T . YORK, M . D .

8 6

E D W A R D S T O N E

( L e t t e r sent to M r . E d w a r d Stone to present to Specialist E y e Hospital

St., C i t y . )

5 . 2 4 . 2 7 — T e l e p h o n e call f r o m Miss S i m m o n s , E y e H o s p i t a l , saying patient is in clinic, says he c a n n o t p a y f o r glasses. S h e asks f o r s u m m a r y . S u m m a r y sent ( L e t t e r

9).

Letter 9 UNIVERSITY

HOSPITAL

M a y 24, 1 9 2 7 Miss Simmons Social Service D e p a r t m e n t Specialist E y e Hospital City R e : Stone, E d w a r d M y dear Miss Simmons: In response to y o u r telephone request, we are sending the f o l l o w i n g information concerning E d w a r d Stone. H e was a patient here f r o m February 7, 1 9 2 7 , to F e b r u a r y

16,

1 9 2 7 , and since that time has been under treatment in the O u t patient D e p a r t m e n t . In 1 9 2 $ he had a f r a c t u r e d skull, the result of an accident

at

the

Garage,

Street

and

A v e n u e , where he was employed as an auto mechanic. A diagnosis of A r a c h n o i d C y s t was made and a Cranial P n e u m o g r a m was perf o r m e d here. F o l l o w i n g this, the patient experienced

considerable

relief. M r . Stone is married and has seven children whose names and ages are as f o l l o w s : W i f e — J a n e , 34 years. C h i l d r e n — L o u i s e , 16 years ( c r i p p l e ) . J e n n y , 15 years. T o m , 13 years. A l i c e , 8 years. C h a r l o t t e , 3 years. Rose, 2 years. James, about 6 months. T h e f a m i l y occupies a basement apartment of three rooms w h i c h are damp and dark. H o w e v e r , they get their rent f r e e and $ 5 . 0 0 a month is payment f o r Mrs. Stone's services as janitress of the building.

EDWARD

STONE

87

Prior t o the accident, Mr. Stone was employed as an auto mechanic and worked as night foreman, earning f r o m $ 3 7 . to $ 5 0 . a week. H e was in line f o r promotion. Since the accident, he has been unable to resume his old job because of the damage to his eyesight. H e was awarded $ 2 0 . a week compensation, but we do not k n o w whether or not he is still receiving it. When he was at the clinic May 1 6 t h , he stated that he had recently secured a job doing heavy porter w o r k . T h e f a m i l y is under the supervision of the Family Bureau. M r . Stone was treated as a free patient in this hospital as he had no financial resources available at the time and no immediate prospect of resuming his w o r k . Unless there has been a definite change in the f a m i l y circumstances, it does seem impossible f o r him to meet any additional expenditures at this time. Sincerely yours, ELIZABETH

BUCKMINSTER,

Director of Social Service [ S y l l a b u s reference: METHOD, R e c o r d i n g , correspondence.] 6.15.27—Neuro-surgery:

Doctor's

note:

No

dizziness

headache. Glasses m a k e reading possible. Pain in back

nor now.

( T h e r e is a short discussion here of the meaning of the pain in the b a c k . ) Diagnosis:

Periostitis of

11th

and

12th

ribs,

treatment,

strapping. T E A C H I N G N O T E : Lapse of three m o n t h s in observation, both medical and medical-social, not unreasonable in view of good progress to 6.15.27. In that time, however, patient begins to lose ground. 9 . 1 9 . 2 7 — D o c t o r ' s note: Patient states that he had three a t tacks, w h e n his r i g h t leg g a v e w a y . H e is able to hear things and understand but cannot answer, the hearing is all r i g h t . O n c e he remained d o w n ten minutes. T h e f a l l i n g is preceded b y " f u n n y " feeling of weakness, has no headaches and is w o r k ing. T h e r e has been no dizziness. ι o . 5 . 2 7 — N o f u r t h e r attacks of right-side weakness. H e notices weakness of right leg, he has to t h r o w most of w e i g h t on l e f t foot. N o trouble w i t h right arm. A s the result o f straining in l i f t i n g there is no disturbance.

88

EDWARDSTONE

If he bends over quickly to right or l e f t , thus swinging his head, he has a curious sensation—he seems to hear a rush of water "like the foot of a w a t e r f a l l . " Then he grasps something knowing that he will hit the floor in a moment. H e can stoop f o r w a r d with no symptoms and can l i f t ash-can easily. In carrying things, right leg sometimes gives out but usually 0 . K . In walking J/2 mile he has that unsteady feeling, after this begins he is unsteady as long as he keeps walking. I f he strikes on heels hard it is more apt to come on than if he slides along. This unsteadiness is like what he had before operation, 1.e. the dizziness, no headaches. (Report of eye examination and reflexes.) Diagnosis: Jacksonian epilepsy. T E A C H I N G N O T E : This classification has no particular social significance, nor is it verified medically. 1 0 . 2 6 . 2 7 — H i s falls, when he cannot speak, are like the dizzy spells but more so. H e has not more of them because he stops when he hears the waterfall, he made the movement which brought on this noise (here in clinic), and face grew red and he stopped, saying he heard it. I can hear no bruit either before or after this sound and dizziness. While dizzy there is no change in eye-signs. H e still has quick jerk to l e f t on gaze left. Recommendation: A d m i t and do spinal air insufflation. 10.26.27—Social worker's note: Patient ready to come in on first vacancy. 1 1 . 2 . 2 7 — S o c i a l worker's note: Patient arranged w i t h admission office to telephone 1 0 . 3 0 . 2 7 and come in then if bed available. H e did not telephone. Letter to patient concerning this. 1 1 . 7 . 2 7 — A d m i t t i n g office: Patient now ready, no bed. Will wait f o r telegram. 1 1 . 1 7 . 2 7 — R e a d m i s s i o n note: Interval history. T E A C H I N G N O T E : Interval history is of interest as making record of the patient continuous. The second admission of an American automobile mechanic who sustained a fractured skull about i Y z years ago while

EDWARD w o r k i n g on a

STONE

89

taxi. T a k e n to C i t y Hospital bleeding

f r o m nose and right ear, with right-occipital scalp wound, and f r a c t u r e of skull in right temporo-parietal region, revealed b y X-ray. Following accident he began having right-frontal headaches, continuous like pressure over eye, with sharp, stabbing pains every five minutes or when stooping. W i f e put on his shoes. H e had to sleep with hand resting on l e f t eye. Headaches worse in bad weather. When walking on street o f t e n became dizzy and staggered, always toward left side. His other c o m plaints were o f : diminished vision (could not do fine w o r k ) ; deafness in right ear; obstruction l e f t anterior nares and loss of smell and taste; sharp pain in lumbar region on bending f o r w a r d ; poor memory f o r names and ideas; melancholia and irritability.

He

went

to several prominent

neurologists

and

neurological clinics but got no relief. N e a r l y a year ago D r . Y o r k saw him in Out-patient Department, and in addition to

his

symptoms

found

optic

atrophy

with

bitemporal

hemianopsia, right-middle ear deafness, amaurosis (left pupil larger) and failure of convergence of pupils. Ten months ago he was admitted f o r subarachnoid insufflation of air, and a small subarachnoid cyst was f o u n d in rightfrontal region with some convolutional atrophy. T w o or three days a f t e r injection of 50 cc. of air his headache disappeared and dizziness improved, as did vision after a time. A b o u t two to three months ago began having " d i z z y attacks" again. O n bending over quickly to either side he would hear a sound like the rush of a waterfall, then grasp something knowing he would soon fall. T h e right leg sometimes gives out, and feels numb. H e comes in f o r another air injection to relieve these attacks if possible. 1 1 . 1 7 . 2 7 — P a t i e n t admitted to ward. ( A complete physical examination is made immediately a f t e r patient's admission to the ward. It follows the same f o r m as the previous physical e x amination. T h e most noteworthy finding is in regard to the ears. The report is a "slight greenish purulent discharge f r o m left-exterior auditory meatus, left drum obscured by greenish

90

EDWARDSTONE

pus and granulations?—gives impression of b u l g i n g . R i g h t drum

has a vascular 'membrane'

over malleus,

Shrapnell

membrane"). ι i . i 7 . 2 7 — L u m b a r puncture was done . . .

I t h i n k about

1 0 0 cc. of fluid was replaced b y air in 5 cc. amounts. Patient had pain during operation but w i t h very little headache f o l lowing. 1 1 . 1 7 . 2 7 — ( R e p o r t of X - r a y examination of the skull f o l l o w ing the injection of air into the l u m b a r canal.) 1 1 . 2 1 . 2 7 — ( S e c o n d X - r a y examination of the s k u l l . ) 1 1 . 2 1 . 2 7 — D o c t o r ' s note: Since the encephalography on N o vember 1 7 , there has been no dizziness. F o r m e r l y when he m o v e d f r o m side to side q u i c k l y he was v e r y dizzy. N o w these movements though continued over a considerable period of time cause no discomfort. H e is v e r y m u c h encouraged over his improvement and optimistic as to the f u t u r e . ( R e p o r t of examination of eyes and reflexes.) T h e patient's teeth are in miserable condition. Because of his deafness of the middle ear t y p e and p r o b a b l y due to a catarrhal otitis media secondary to his c l e f t palate he should be treated f o r this also. H e apparently has been greatly relieved b y the second encephalography procedure. 1 1 . 2 4 . 2 7 — D i s c h a r g e note ( m e d i c a l ) : Second admission of an A m e r i c a n automobile mechanic, whose skull was f r a c t u r e d 2 V2 years ago. A s sequelae he had r i g h t - f r o n t a l headache, dizziness and staggering, particularly when head m o v e d f r o m side to side, bitemporal hemianopsia, right-ear deafness, loss of smell and taste and some psychic disturbances. T w o to three months ago dizziness returned and he came in f o r another air injection to relieve that. Physical examination: A w . d. and n. man 2 in no distress. L e f t pupil is larger than right, l e f t t y m p a n i c membrane o b scured b y pus and granulations, deaf in right ear. His teeth were f o u l and palate c l e f t posteriorly, beat reflexes normal. *A well-developed and nourished man.

E D W A R D

Course:

S T O N E

9

1

A i r w a s injected and spinal fluid removed b y l u m -

bar p u n c t u r e . T h e second day post-operation he had a c o u g h w h i c h produced headache, but a f t e r that he was s y m p t o m f r e e a n d optimistic, feeling his dizziness w a s cured as it did not recur w h e n head was m o v e d f r o m side to side, the t h i n g that had been most effective in p r o d u c i n g dizziness before. (Urinalysis report). Meningeal adhesions. Cerebral pneumography. ( T h e a t t e n d i n g physician adds:

" H e says his head feels

smaller.") T E A C H I N G N O T E : A n interval of about one month elapses between this operation and the following letter which indicates renewed attack o n the problem by the Family Bureau, an attack which, h o w ever, comes to naught. Letter 1 0 FAMILY

BUREAU

December 29, 1 9 2 7 Dr. York University Hospital City My dear D r . Y o r k : W e are interested in the f a m i l y of E d w . and J a n e Stone, now living at 20 D o w n i n g St. W e know that E d w a r d Stone was in your hospital, February 7, 1 9 2 7 , to February 1 6 , 1 9 2 7 , and that his condition was greatly improved by treatment he received f r o m you at that time. We understand f r o m his w i f e that he is still under your care. Would you be good enough to send us a report of his present condition and what, if any, treatment he is receiving. W h a t should we look forward to as f u t u r e developments of his condition? Sincerely yours, LUCY

QUEED

Asst. District Secretary

92

E D W A R D

S T O N E

Letter 1 1 UNIVERSITY

HOSPITAL

January 9, 1928 Family Bureau City Attention of Miss Queed Dear Miss Queed: We shall answer your communication regarding Edward Stone, as soon as we are able to get an opinion relative to his present and future status from the surgeon attending him. Very truly yours, University Hospital B. CLARK,

M.D.

(Superintendent O . P . D . )

Letter ι ζ UNIVERSITY

HOSPITAL

January 18, 1928 Family Bureau City Attention of Miss Queed Dear Miss Queed: Edward Stone had meningeal adhesions following a fracture of the skull. He has some difficulty in vision which will probably not improve. The headaches of which he complained have been relatively better. He still has some dizziness which was very much improved for a while and had returned. I feel that he is capable of earning his living if proper work can be secured for him. We shall like to see him from time to time. If his dizziness should become worse it might be advisable to perform an operation. Very truly yours, University Hospital B. CLARK,

M.D.

Superintendent

O.P.D.

T E A C H I N G N O T E : This 1.18.28 report from records is true as of a date six weeks ago, but is inadequate at this time and does not further social treatment. Note the discontinuity of social observation and treatment in both agencies. H o w can it be accounted for? Can it be avoided? If so, at what cost and with what profit?

E D W A R D

93

S T O N E

Between the preceding letter and the following telephone call nearly six months elapses. Note result of lapse in collaborate study and treatment. In this lapse of six months the difficulty develops to a point demanding better study. More thorough history, leading to a formulation of the medical-social problem, with statement of some apparent factors given by family agency to medical-social worker, starts both workers on a better focussed attention to case. There is a change of worker on the case in the hospital, the original worker having departed in the interval. In a sense, the social work on the case may be said to begin at this point. The surgeon who operated upon Mr. Stone has now left the city and a transfer must be made to another doctor. Stone, E d w a r d

Social Service

j . 2 9 . 2 8 — M i s s Q u e e d , F a m i l y Bureau, telephoned: T h e y are h a v i n g a v e r y difficult time w i t h patient, w h o is becoming i n creasingly irritable and disagreeable at home. F a m i l y B u r e a u wonders if he should be in an institution and asks if he can be seen again in clinic here, in order to have a medical opinion and advice. W i l l send detailed i n f o r m a t i o n o f present situation. A p p o i n t m e n t t o see D r . R o l f of Hospital f o r N e r v e Diseases g i v e n patient f o r June n t h . D r . R o l f is c o m i n g here to see a g r o u p o f D r . Y o r k ' s cases. E. SYDENHAM 6 . 1 . 2 8 — S e e letter 13 f r o m F a m i l y Bureau. Letter 13 FAMILY

BUREAU

June 1, 1928 Miss Evelyn Sydenham University Hospital City Re:

Stone, Edward, "

Mrs. Jane Louise Jenny Tom Alice Charlotte Rose James

born 1883 "

1892 1911 1912 1915 1918 1923 1924 1926

94

EDWARD

STONE

My dear Miss Sydenham: A t your suggestion, I am writing to you about the family of E d ward Stone, one of your patients, who, I believe, has not been known to you for some time. As so many new developments have occurred this winter, we are very anxious to get your advice about the next step. As Mr. S's health and consequent behavior seem to be the underlying cause of many of the family's difficulties, we do not like to take any drastic action without the hospital's full knowledge of the social history and their permission. [Syllabus reference: AREA, Particular configuration, deviation, contributory factor, financial strain.] As you probably know, since Mr. Stone's accident in 1 9 2 5 , he has been receiving the Workmen's Compensation of $20. a week. For a time we supplemented this amount until he started earning a little money on the side. Louise also tried to work but this was very irregular. Last summer because of staff changes and pressure of work, the case was inactive and was taken up again in December of this year. A t that time the family income was only $20. a week and they were very much behind in clothes, bedding and other necessities. Mrs. Stone was janitress receiving free rent. During this winter we have helped to a considerable extent in irregular amounts, but at the present time we are starting a weekly allowance of $8.00 a week, as the family have had to move into a five-room apartment costing $30. a month, because Mrs. Stone is not well enough to do janitor work. A t the present time Jenny is working earning $ 1 2 . a week. The family's budget is $40. a week which is covered by this arrangement. When we went in to see the family in December, we found that Jenny was in City Hospital with a diagnosis of gonorrheal vaginitis and a 2 plus Wasserman. She is a very headstrong, impulsive girl, and had gotten into difficulties with a man who had served two sentences in States Prison. Jenny's unadjustment seems to lie in the fact that she cannot get on with her father. He has shown himself to be most unreasonable in dealing with her, and abnormally irritable. We have spent considerable time trying to make the relationship between them better, in trying to show Jenny that her father's behavior can be excused on the grounds of his ill health, and in turn, trying to get Mr. Stone to understand Jenny's needs. Of course, when she came out of the hospital, it was very difficult to get her work because of the unusual unemployment situation. Although Jenny was extremely

E D W A R D S T O N E

95

anxious to w o r k , it was impossible to get any work at all f o r a girl under 1 7 . She and Mr. Stone had continual arguments, and he finally threatened to throw her out of the house if she did not get a job. N o t h i n g we could say w o u l d prevent these arguments. T E A C H I N G N O T E : W h y was this so, when reason was so contrary to such behavior? W a s it due to Mr. S's disease? Cause and responsibility may be discussed here. Louise had I n f a n t i l e Paralysis when she was 5 years old and since then has been considered the f r a i l one in the f a m i l y and has been over indulged. Mr. Stone in the past has been very f o n d of her, but this winter he took a v e r y hard attitude about Louise and threw her out of the house. She is now living with Mrs. Stone's sister, Mrs. R . It is only possible f o r Louise to do the lightest kind of work and of course it is v e r y difficult to get anything to suit her. T E A C H I N G N O T E : W h y was Louise's reaction different from Jenny's? Again, what factors decide the outcome? [ S y l l a b u s reference: AREA, Deviations f r o m normal.

Be-

havior responses.] A l t h o u g h T o m is 1 5 , he is only in j B at school and probably has some glandular trouble f o r which he is attending clinic at Jackson Hospital. T o m is the one in the f a m i l y who is the go-between between Mr. Stone and the sisters. Alicc, Charlotte and Rose present no particular problems. James the baby is in such a nervous condition that he had the beginning of chorea f o r which we had to send him up to the I n f a n t H o m e as there was no w a y of giving him rest and good care at home. T E A C H I N G N O T E : Is there any connection between Mr. S's condition and this child's chorea? Mrs. Stone shows great initiative, good management and always presented in the past a most smiling, happy disposition in the f a c e of great odds. This winter her physical condition has not been good, but as yet Jackson Hospital has given us no diagnosis. T h e y merely said she should be free f r o m the janitor work and have more rest. Lately the home conditions and Mr. Stone's behavior, seem to have worked on her so that we feel she is on the point of a breakdown. She weeps quite frequently when she talks to us whereas before she was always laughing and gay. She says that Mr. Stone's irritabili-

9 6

EDWARD

STONE

ty is becoming worse and worse. He demands to be the center of attention all the time and if the children do not wait on him immediately, he scolds them and drives them out of the house. She has tried every form of persuasion to try to make him see the error of his ways, but all to no avail. She says if she did not have the younger children, she would separate from him and take a position. I talked to Dr. York this March and he told me he thought Mr. Stone could take some light work, suggesting porter work or elevator running. Mr. Stone tried elevator running but could not see the numbers on the floors, so had to give that up. H e cannot do porter work because, when his attacks of dizziness come on, he is absolutely useless. T E A C H I N G N O T E : An illustration of social work observation as check on expert's prognosis and advice. The doctor himself might have got this information, but, as a matter of fact, did not and often cannot because of remoteness, other work for more acute troubles, etc. (Dr. York had by this time left the city and Mr. Stone was probably too discouraged to return to the hospital of his own initiative.) Several times this winter he has fallen downstairs. A t one time he was out in the street and as he did not see a car coming, he was nearly run over and finally had to jump on the hood of the car to avoid being crushed. The insurance company has been urging Mr. Stone to settle for a lump sum so that he could start a business. Neither Mrs. Stone nor ourselves feel that this would be at all wise in view of the improbability of Mr. Stone's being able to run it. New symptoms that he shows according to Mrs. Stone are fits of trembling. Apparently he will have a week or two of feeling pretty well, and then a week of continuous headaches, dizziness, and trembling. In March Dr. York told me that if his symptoms did not clear up he would operate on him in the fall, in Montreal. This does not seem very practical to us as we understand the hospital in Montreal will not take a non-resident patient free of charge, and of course, our relief funds would not permit our paying for medical care when free care is available. Mr. Stone himself says that heat affects him to a great extent, and last summer, he could not sleep in the house and often slept on benches in the park. He himself asked if we could send him away for the summer. It would seem to us that if Mr. Stone were away from the home,

E D W A R D S T O N E

9 7

the problem of J e n n y , Louise, and Mrs. Stone would clear up, and also J a m e s ' chorea. T h e y are certainly a most interesting f a m i l y and we feel that each one tries to do the best he can. I have talked to M r . Stone about the various members of the f a m i l y endlessly, and he a l w a y s sees what w e are trying to do and, I feel, tries himself to do the best he can and keep his temper. It must be his physical condition w h i c h makes him unable to control his outbursts. H o w e v e r , sending him away f o r the summer w o u l d only be a temporary measure and the matter of his care would have to come up f o r a decision in the f a l l again. W e would like t o k n o w a little more, if possible, of whether Mr. Stone's disease is getting progressively worse and, if so, w h a t we should do about his care. D o you consider that he will eventually have to be placed in a hospital f o r chronic cases? If such a decision can be made at this time, would you consider it wise to send him away f o r the summer and if so, where? [ S y l l a b u s reference: METHOD, Social c a s e - w o r k procedure, diagnosis, plan, treatment objectives, assets and liabilities.] Miss Roosevelt and I would very much appreciate having a conference with you a f t e r you have talked with the surgeon. T h a n k i n g you f o r your cooperation, I am, V e r y sincerely yours, LUCY

QUEED

Asst. Secretary, Family Bureau Stone

Social Service

6 . 1 1 . 2 8 — P a t i e n t did not come to clinic. D r . R o l f w e n t o v e r chart. Said it quite likely that patient is getting progressively worse and that operative procedure m i g h t be indicated in a f e w months' time. In the meantime, patient m i g h t be somew h a t quieted b y taking luminal. If he really seems to require institutional care suggests that he be taken to M u n i c i p a l H o s pital, and the matter settled b y the doctors there. H o w e v e r , f r o m information given him so f a r D r . R o l f does not believe patient could be c o m m i t t e d to hospital f o r mental diseases though it m a y come to that. L e t t e r to F a m i l y Bureau g i v i n g above information. [Syllabus reference: KNOWLEDGE, Medical method, ning.]

plan-

98

EDWARD

STONE

T E A C H I N G N O T E : A d i f f e r e n t o u t l o o k in the case f r o m a n e w expert. T i m e and observation also h e l p to account for change by g i v i n g m o r e basis f o r prognostication. Letter UNIVERSITY

14 HOSPITAL

June 1 1 ,

1928

T E A C H I N G N O T E : W i t h the f o l l o w i n g letter the m e d i c a l social w o r k e r begins to participate in p l a n n i n g . F r o m the point of v i e w of the f a m i l y agency the hospital social service is a "social resource." W h a t is to be expected of i t ? Miss L u c y Queed Family Bureau City Re:

Stone, E d w a r d

My dear Miss Queed: W e are v e r y sorry indeed to tell y o u that E d w a r d Stone did not keep his clinic appointment here this morning. It is especially u n f o r t u n a t e as the clinic, a special one conducted f o r D r .

York's

patients by an attending physician f r o m Hospital f o r N e r v e Disease, will not be held again until J u l y 9th. D r . R o l f did go over the c h a r t , and said he thought it quite possible that M r . Stone is g e t t i n g progressively worse and that in a f e w m o n t h s operative procedure m i g h t be indicated. H e suggested that the patient take l u m i n a l regularly as this w o u l d tend to take the edge off his nervousness and make him a little easier to deal w i t h . I f , h o w e v e r , you and the f a m i l y feel it quite impossible to take care of M r . Stone at home, D r . R o l f t h o u g h t it would undoubtedly be wise to r e f e r him to the clinic at Municipal Hospital and let the doctors there settle the question of institutional care. F r o m y o u r last letter, it does not seem as though the patient had made any definite threats of physical violence against the members of his f a m i l y but rather that he is v e r y irritable and disagreeable and is succeeding in breaking d o w n their spirit and their morale. T h e latter reasons of course, w o u l d not hold in court as a reason f o r c o m m i t t i n g the patient to an institution f o r mental diseases. D r . R o l f will see M r . Stone, on J u l y 9th, and will then send a report of his condition to D r . Y o r k . D o you feel satisfied t o let things go on as they are at present until that date, or do you feel something else should be done immediately?

EDWARD

99

STONE

W e appreciate very much your very complete report on this case and assure you of our interest and willingness to cooperate in any way possible. Sincerely yours, ELIZABETH

BUCKMINSTER

Director Social Service [Letter by E. Sydenham.] [Syllabus

reference:

METHOD, Administrative

function,

adaptation of technique to specialty, RESOURCES, Organized practice, hospital social service.] T E A C H I N G N O T E : Medical social worker carries forward thinking on case, using medical opinion. Letter ι j FAMILY

BUREAU

June i 2 , 1928 Miss Sydenham University Hospital City R e : Stone, Edward My dear Miss Sydenham: 1 am very sorry to hear that Mr. Stone did not keep his appointment. I will certainly remind him to go for the next one. A l l things considered it would seem best to delay making any plans until he sees Dr. R o l f . Thank you very much f o r your letter. Sincerely yours, LUCY

QUEED

Asst. District Secretary 8 . 2 8 . 2 8 — I n response to a recent inquiry from Family Bureau, worker called up Mr. Miller of Family Bureau, giving him the findings of the last two clinic examinations. H e says that instead of getting gradually better, patient's condition is becoming progressively worse, his left leg has become so paralyzed he can hardly walk and one hand and arm are growing

100

EDWARD

STONE

weaker. H e is unable to sleep, in spite of taking his luminal regularly. Appointment made for him to see D r . Rolf at the September ioth clinic. 9 . 1 0 . 2 8 , 9 . 1 3 . 2 8 , 9 . 1 8 . 2 8 Letters 16, 1 7 , and 1 8 . Letter 16 UNIVERSITY

HOSPITAL

September 10, 1928 Foot Hospital City Gentlemen: We are referring the bearer, Edward Stone, to you for examination and treatment for his left heel. Patient complains of inability to walk on his left heel, he must step on the ball of his foot. This has been present for the past few months. Any weight or pressure on the left heel causes pain, at times swells considerably. Thanking you for your cooperation in the care of the patient. Yours very truly, University Hospital B. CLARK,

M.D.

Superintendent O.P.D. Letter 1 7 UNIVERSITY

HOSPITAL

September 13, 1928 Foot Hospital City Re: Stone, Edward Gentlemen: Referring further to the patient, Edward Stone, whom we referred to you under date of September 10th, for treatment of his left heel, the following information might prove of value to you. The above patient was admitted here on February 16, 1927, and the diagnosis of Cyst of Pia Arachnoid was made, with an operation of Cranial Pneumography. On June 1 5 , 1 9 2 7 , there was a diagnosis

EDWARD

STONE

ΙΟΙ

of A c u t e Periostitis of i i t h and 1 2 t h ribs. On November 24, 1 9 2 7 , a diagnosis of Meningeal Headache was made with Cranial Pneumography operation. Very truly yours, University Hospital Clinic B. CLARK,

M.D.

Superintendent O.P.D.

Letter 1 8 FAMILY

BUREAU

September 18, 1928 Miss E v e l y n Sydenham University Hospital City Re:

Stone, Edward

My dear Miss Sydenham: Before I left on m y vacation, Miss Buckminster and I had some correspondence about having a conference to discuss Mr. Stone's f u t u r e . As Miss Roosevelt and I are both back in the office, I am wondering if we could come up to see you in the near future. We would like very much to have Miss Buckminster present at the conference if she could give the time to it. Perhaps you would be good enough to ask her. Our treatment of the family is being made very difficult by the effects of Mr. Stone's illness. We are particularly anxious to know just what we can expect from him. Sincerely yours, LUCY

QUEED

Asst. District Secretary 10.25.28—Summary

of present situation: See report f r o m

Family Bureau (Letter 9 . 1 8 ) . Miss Queed sent a subsequent verbal report, October 1 9 t h , that patient is becoming difficult at home, that his w i f e c o m plained he was throwing china about and that she and the children had to leave the house because of his behavior. Miss Roosevelt feels that the situation is acute and that patient is

102

EDWARDSTONE

a definite obstacle in the home and to her w o r k w i t h the f a m i l y . H o m e visit made b y social w o r k e r t o d a y . T E A C H I N G N O T E : The medical social worker's interview and observation supplement those of Family Bureau and make more direct report to Doctor possible. I n t e r v i e w w i t h patient w h o is alone in the a p a r t m e n t . P a tient says his condition seems on the whole a b o u t the same; he complains of pain and stiffness e x t e n d i n g f r o m his n e c k d o w n his back w h i c h prevents his rising f r o m a r e c u m b e n t position w i t h o u t several minutes e f f o r t , he has d i f f i c u l t y also in calling as his " v o i c e will not c o m e . " T h e pain in his heel has been relieved b y hot soaks and keeping off his f e e t as p r e scribed b y the F o o t H o s p i t a l . H e complains that if he becomes " e x c i t e d " he has a feeling of heaviness and pressure in the back of his head g i v i n g h i m a sensation of being t h r o w n f o r w a r d ; at such times he has dizziness, b u t his f o r m e r severe headaches have not returned. H e says if people leave him alone he is all r i g h t , b u t trouble w i t h his d a u g h t e r r e c e n t l y has u p set him. She is o u t of w o r k and lies in bed till 9 A. M. instead of l o o k i n g f o r a j o b ; the tenant below has c o m p l a i n e d a b o u t noise made b y the children, and patient became i n v o l v e d in a heated a r g u m e n t . P a t i e n t a c k n o w l e d g e s that he has become u n u s u a l l y upset, says he is ashamed of his lack of c o n t r o l , a n d that he " i s p u t t i n g u p a fight" b u t that w h e n t h i n g s h a p p e n to upset him he does not care w h a t happens, a n d that a f t e r w a r d s he regrets his actions. H e does not blame his w i f e or children, and says that F a m i l y B u r e a u h a v e helped him v e r y m u c h . H e says " t h i n g s have quieted d o w n " and he has decided to " p u t on his hat and g o f o r a w a l k " w h e n he begins to get upset. H e believes because he c a n n o t w o r k people t h i n k he is a b u m .

E.S.

1 0 . 2 7 . 2 8 — C a r e of patient: Social w o r k e r reports to F a m i l y Bureau that D r . R o l f will not be at the clinic until u / f

and

that his advice w o u l d h a v e to be asked b e f o r e a n y radical steps could be t h o u g h t of f o r institutional care. Miss R o o s e v e l t believes patient is psychotic and says she believes situation is too

EDWARD

STONE

IO3

acute to wait until N o v e m b e r 5th. She then asks if patient could be sent to Convalescent H o m e in meantime. Social w o r k e r says no advice can be given regarding patient's care w i t h o u t D r . R o l f ' s approval. From social worker's observation the case does not seem, on the surface, to warrant institutional care.

E.S.

1 1 . 1 . 2 8 — C a r e of patient: Conference with patient's w i f e . Feels that patient is trying hard to control himself, but that he is becoming increasingly irritable and difficult, is easily e x cited and becomes uncontrolled and violent. She and the children are afraid of him in these states. W i f e recognizes that this is due to patient's condition and seems to bear him no malice. She is f e a r f u l of becoming pregnant, but more f e a r f u l that he will do an injury to her or the children. She wants him to go a w a y and says he wishes this himself. It would seem that patient and his w i f e are really f o n d of one another, but that his condition and resulting incapacity is creating an extremely difficult situation f o r both patient and his f a m i l y .

E.S.

1 1 . j . 2 8 — P l a n s f o r patient: Conference with D r . R o l f . Patient

not

suitable case

f o r commitment,

not

considered

psychotic, will probably keep along on same level f o r an indefinite period, and it is the expectation that his irritability will decrease as time goes on. D r . Rolf does not expect this man to lose ground. H e will not be able to do work involving stooping or climbing. D r . Rolf believes it would be better f o r him to do work outside this city, perhaps on a f a r m .

E.S.

[Syllabus reference: METHOD, Social case-work procedure, plan, argument.] T E A C H I N G N O T E : More careful consideration of disability than hitherto. Use by doctor of social work report. Report

from

Compensation

Bureau:

(Miss

Enright)

Patient was awarded compensation at $20. weekly f o r 3 3 - 1 / } weeks, covering period of February 9 to September 28, 1 9 2 8 , amounting to $ 6 6 3 . 3 3 . Case is now pending new hearing to be held latter part of November, 1 9 2 8 . N o payments to be made

1 0 4

E D W A R D S T O N E

in meantime. In the event of patient's death the case would be closed and taken up as a Death case, and further payments would depend upon proof that cause of death was due to accident. Patient's number 0007 A f t e r - C a r e Department. C o n f e r ence with Family Bureau. Decision: Social worker to make effort to have patient placed on Riverview Farm f o r a stated period (perhaps 8 - 1 0 weeks), as an experiment to see whether, under good conditions and understanding supervision, he will be able to adjust himself to f a r m work or other occupation. If this prove satisfactory, an effort will be made to place patient permanently in some such position as helper on a country estate. The possibilities for such a placement to be looked up by hospital social worker and Family Bureau worker in the interim. Family Bureau will be willing to undertake one-half the expense of an experiment at Riverview. [Syllabus reference: METHOD, Social case-work procedure, Argument, case decision.] T E A C H I N G N O T E : It is unfortunate for teaching that the substance of the conference is not recorded. However, the recording of the decision arrived at is of main value for general purposes and also for teaching. Note that it is made jointly by the two agencies which will collaborate in carrying it out. Letter UNIVERSITY

19 HOSPITAL

November 14, 1928 Mrs. Strong Riverview C o r n w a l l , Conn. Re:

Stone, E d w a r d

M y dear Mrs. Strong: W o u l d you be willing to help us with an experiment which we are anxious to make? We would like to send to you f o r a period of ten weeks a 43 year old man, E d w a r d Stone, who has been under the

E D W A R D

S T O N E

1 0 5

care of this hospital since F e b r u a r y , 1 9 2 7 . H e w a s operated upon in the U n i v e r s i t y Hospital because of

a head i n j u r y sustained in an

accident in a garage, and has since been under the care of our brain surgeon. T h e man has reached the point where the doctor feels that he can give a f a i r prognosis of w h a t to expect. H e is in no sense a p s y c h o t i c patient but is easily irritated or worried and his enforced idleness has been v e r y hard f o r him to bear. T h e doctor feels that he should be in the c o u n t r y a w a y f r o m the disturbance of c i t y life and the worries of his f a m i l y , and our wish is to t r y him out f o r a period in the c o u n t r y w i t h someone w h o will give him patient and understanding care, and if he does well, to make an effort to place him later, possibly on an estate, to help w i t h light w o r k . M r . Stone feels considerably improved since his operation in that his headaches have almost entirely disappeared; b u t his injury has l e f t him w i t h a permanent handicap w h i c h is best described b y a sense of heaviness in the back of the head and dizziness, w h i c h is brought

on b y

undue excitement,

such

as altercations

with

his

neighbors, or b y the disobedience of his children, or other irritations w h i c h are bound to o c c u r in f a m i l y life; bending d o w n also brings on this sensation and makes him lurch f o r w a r d . A p a r t f r o m this he seems in a fairly good physical condition; he is a w e l l - b u i l t man and the doctor says is able to do w o r k w h i c h does not entail stooping or climbing, and which

will

not give him any feeling of hurry or

strain. T h e doctor feels that the prolonged idleness and the continual small irritations may have a considerably

deterring effect on the

man's improvement. M r . Stone has the record of a steady mechanic, making good wages prior to his accident. H e has a w i f e and seven children, all living at home, the oldest 1 7 , the youngest 2 years. T h e y seem a devoted f a m i l y , and M r . Stone's injury has been a real c a l a m i t y in their home. H i s w i f e tries hard to be patient and keep the f a m i l y together, and w i t h the help of the F a m i l y Bureau and the $ 2 0 . a week compensation which he has been receiving, she has managed so f a r to make ends meet. W e are greatly interested in this case and anxious to give the man a fair chance under good conditions. T h i s hospital is willing t o pay the board at R i v e r v i e w F a r m at $ 1 0 . a week f o r ten weeks if y o u will take him. W e do not believe he will be a difficult patient; he is most anxious to w o r k and w a n t s to try w o r k i n g in the c o u n t r y . W e be-

I 06

EDWARD

STONE

lieve you will find him willing to help in any way about the grounds, and we hope he may prove really useful to you. Would you let us know about this at your earliest convenience? Sincerely yours, University Hospital Social Service EVELYN

SYDENHAM

Surgical Division [Syllabus reference: RESOURCES, Convalescent H o m e . ] T E A C H I N G N O T E : Letter to Supt. of Convalescent Home is good example of cooperative technique. Letter 20 RIVERVIEW

November 17, 1928 Miss Sydenham University Hospital City My dear Miss Sydenham: We shall be glad to take Mr. Edward Stone at hope that he can find some real benefit here. We morning train on either Tuesday or Friday. Our wall ο ί ο ι . Mr. Stone should come prepared for high arctics or rubber boots are important. Sincerely ANN

once on trial, and would suggest the telephone is Corncold weather, and yours,

FULLER

(for Mrs. Strong) T E A C H I N G N O T E : Response to letter 19 shows effectiveness of letter and willing attitude of Supt. of Convalescent Home. The medical social worker had counted upon this attitude.

EDWARD

STONE

Letter 2 i UNIVERSITY

HOSPITAL

November 22, 1928 Mrs. Strong Riverview Cornwall, Conn. Re: Stone, Edward Dear Mrs. Strong: Thank you so much for your letter of November 17th and for your willingness to take Mr. Edward Stone under your care. He is looking forward very much to his visit with you and we shall see that he goes supplied with either high arctics or rubber boots as you suggest. The plan outlined in our letter holds good and this hospital will be responsible f o r paying his board at the rate of $ 1 0 . a week for 10 weeks. Mr. Stone will go to you on Friday, November the 23 rd, on the morning train which arrives at Cornwall about noon. It will be of very great interest to us to hear from you how Mr. Stone fits into you household and what progress he seems to make. Would it be asking too much from you to send us a short report after he has been with you a week or two to let us know how he seems to be doing. We shall very greatly appreciate hearing from you, and shall be glad to see that you receive the check f o r his board regularly on receipt of your bill. Will you accept our very warm thanks for your willingness to take this patient. We hope very much that you will feel that it has been worth your while. We, ourselves, feel very satisfied with the plan. Sincerely yours, University Hospital Social Service EVELYN

SYDENHAM

Surgical Division T E A C H I N G N O T E : Letters carry on cooperative treatment plan. The sharing of cost on basis of its relation to patient's health and family maintenance is a reasonable procedure. Stone

Social Service

1 1 . 2 3 . 2 8 — C a r e of patient: Sent to Riverview Farm today. E.S.

See Correspondence to date: N o v . 1 4 , 1 7 , 22.

Ιθ8 Arrangements:

EDWARD

STONE

T h i s hospital u n d e r t a k i n g

entire

expense

of patient's care f o r ten weeks at $ 1 0 . at R i v e r v i e w . Patient's attitude:

Seems m u c h encouraged over prospect

of g o i n g on a f a r m , anxious to show w h a t he c a n do to help. S a y s he is ashamed to stay idle at home as his people t h i n k he is a b u m . Letter 2 2 UNIVERSITY

HOSPITAL

December 2, 1 9 2 8 Mrs. Strong Riverview C o r n w a l l , Conn. Re:

Stone, E d w a r d

My dear Mrs. Strong: W o u l d it be possible f o r you to send us a short report of how M r . Stone seems to be adjusting himself in your group of patients on the f a r m . H e has been with you now ten days and although we realize that it is too early to gauge much progress it w o u l d be of v e r y great interest to us to have even a short preliminary report f r o m you. H e was very anxious to have an opportunity of being in the country and seemed so delighted that you agreed to take him, that we felt that he would do his best to be a helpful person about the f a r m . W e realize that you are pretty busy but shall v e r y greatly appreciate hearing f r o m you at your earliest convenience. Sincerely yours, University Hospital Social Service EVELYN

SYDENHAM

Surgical Division T E A C H I N G N O T E : Follow-up and continued cooperative action by medical social worker. 12.7.28—Patient's 12.3.28.

progress:

See

report

from

Riverview

E D W A R D

S T O N E

I O 9

Letter 23 RIVERVIEW

December 3, 1928 My dear Miss Sydenham: W e take pleasure in reporting regarding Mr. Edward Stone, that he seems to be doing remarkably well, and is himself delighted with his own improvement. From the very first he has slept well, which he says is unusual for him. We have left it entirely to him to find and choose his own occupation and he is now cheerfully busy at odd jobs most of the time, showing a most willing spirit and decided capability. He is ready to turn his hand to anything, and is quick to see what is most needed. H e seems to be thoroughly enjoying himself, and shows no sign of too high tension. He is really a great help to us. W e appreciate your generosity in the matter of his maintenance while here, and will send a memo, of his expenses fortnightly, for your convenience. Sincerely yours, ANN

FULLER

[Syllabus reference: METHOD, Social case-work procedure, placement

(adult).]

T E A C H I N G N O T E : Complete change of environment is accomplished for a period by placing the patient on this farm. Observation of his health and behavior during this period is a necessary part of the study as basis for continued treatment. Letter 24 UNIVERSITY

HOSPITAL

December 3, 1928 Miss Lucy Queed Family Bureau City Re: Stone, Edward My dear Miss Queed: I have taken up with Miss Buckminster, (Director of S.S. D e p t . ) , the question of payment for Mr. Stone's care at Riverview Farm, and the decision is that this hospital will assume entire financial responsibility for his board for a period of ten weeks. This we hope will enable you to do all that is possible for his family during this experiment. We are planning to keep in close touch with Mrs. Strong

I I ο

EDWARD

STONE

concerning his progress and shall be glad to f o r w a r d you a copy of her reports. A f t e r a month has lapsed it would seem to us wise to take stock and if Mr. Stone seems to be making good adjustment, and conditions in general seem to warrant a more permanent placement in the country, it would then seem wise to begin inquiries concerning this; we hope very m u c h that you will be able to help us with that part of the program. Sincerely yours, University Hospital Social Service EVELYN

SYDENHAM

Surgical Division T E A C H I N G N O T E : Method: Hospital's payment of board, Family Bureau's support of family shows combination in responsibility for medical and social relief. Planning for future treatment goes forward during experimental treatment, with weighing of alternative plans in view of available resources. Letter 25 UNIVERSITY

HOSPITAL

December 5, 1 9 2 8 Dear Mr. Stone: I have meant to write you long before this, but have been pretty busy. I wanted to tell you how glad I was that Mrs. Strong was able to take you on her f a r m . Yesterday I had a very nice letter f r o m Miss F u l l e r saying that they were finding you a great help. I felt sure you would make good there and that you would feel better away f r o m the c i t y . Y o u m a y have ups and downs f r o m time to time, like most of us, but if on the whole you feel better and are able to do some work steadily it will mean a great deal to you and y o u r f a m i l y I am sure. I would like to hear f r o m you some time how you are feeling, so that I can tell the Doctor. A n d I w a n t you to feel free to write me at any time f o r I shall be v e r y glad to know how things are going with you. W i t h good wishes Y o u r sincere f r i e n d , (Signed)

EVELYN

SYDENHAM

[ S y l l a b u s reference: METHOD, Social c a s e - w o r k procedure, treatment relationship.]

EDWARD

I I I

STONE

L e t t e r 26 UNIVERSITY

HOSPITAL

December 5, 1928 Miss Ann Fuller Riverview Cornwall, Conn. M y dear Miss Fuller: Y o u r report of December 2nd about Edward Stone, which reached us yesterday, is most encouraging and we are more than glad that Mr. Stone is proving a help to you and that he seems so happy. It will be of the greatest interest to us to see whether this experiment, under good conditions, should prove that permanent placement on a f a r m is the thing for him. Thanking you again so much for helping us with this problem. We shall look forward to hearing from you of his further progress. Sincerely yours, University Hospital Social Service EVELYN

SYDENHAM

Surgical Division 1 2 . 7 . 2 8 — S e e report f r o m patient. Letter 27 RIVERVIEW

December 7, 1928 Dear Friend Miss Sydenham: I was very glad to hear from you, and I was going to write to you but I was afraid I would be a little too forward. But I shure was glad to hear from you. Miss Sydenham I owe you a million thanks for what you have done for me and also for my family. I am feeling fine, am on the go all day, doing repairs of all kinds around the house and keeping plenty of chopped wood in the house; and keep the outside of the house clean, also wash and dry dishes. I never thought that I would ever come back to health as I am at present. I am stopping as much as possible avoid looking up over my head as I get a staggering spell when I forget myself. Mrs. Strong is a wonderful lady and we get along splendid. I have a beautiful room with all the comforts

1 1 2

EDWARD

STONE

that any one could ever wish for. I still have severe pains in the back and top of my head, but I don't give it a thought here. The lower part of my back is very weak, but that will all go away in time. The air is wonderful here, we had zero this morning but I was out at 7 o'clock and not cold at all. In f a c t , I feel better in cold weather than I do in warm weather. Miss Sydenham I wrote a letter to Miss Roosevelt yesterday and in the letter I sent my best wishes to you, and a hour later I received your letter. Tell Dr. Rolf I am very thankful to him for letting me come out here, and he will see a new man in place of the wreck I was when I left the city. Well, Miss Sydenham, I will close with my best wishes to you and Dr. R o l f . Also wishing you both a Merry Christmas and a Happy N e w Year. Also please wish Miss Jenks the same. Hoping to hear from you again, I remain, Sincerely, EDWARD STONE

[Syllabus

reference:

METHOD,

Treatment

relationship.

KNOWLEDGE, Disease, a reaction, not an e n t i t y . ] T E A C H I N G N O T E : Watching the progress of disease under treatment gives further understanding of the reaction of the person to the injury. Letter 28 RIVERVIEW

Dear Friend Miss Sydenham: A m feeling fine, wishing you a Merry Christmas and a Happy New Year. Sincere friend, EDWARD STONE

1 2 . 1 0 . 2 8 — ( F a m i l y Bureau has conference with Western H o s pital. Report

filed.)

S u m m a r y made by Family Bureau visitor for Western H o s pital, Social Service Department, and Family Bureau, meeting. 1 2 . 1 0 . 2 8 — T h e third conference between the staffs of Western Hospital, Social Service Department, and the Family Bureau, was held December 10th, 1 9 2 8 . T h e family for discussion was the Stone family, known to the Family Bureau for three years, and referred b y the Family

EDWARD

STONE

1^3

B u r e a u to Western Hospital. T h e f a m i l y was referred to the F a m i l y Bureau b y the A f t e r - C a r e Department of the W o r k men's Compensation Bureau. T h e f a m i l y consists of Mr. and Mrs. Stone, he G e r m a n , and she Irish, w h o are both R o m a n Catholic and w h o have lived in this city all their lives, and seven children: Louise, born 1 9 1 1 ; J e n n y , 1 9 1 2 ; T o m ,

1913;

Alice, 1 9 1 8 ; Charlotte, 1 9 2 3 ; Rose, 1 9 2 4 , and James, 1 9 2 6 . Mr. S. was a taxi driver and mechanic and earned good money. T h e f a m i l y got on well until M r . S's accident in J u n e , 1 9 2 5 , when a jack slipped and the automobile he was repairing came d o w n on his head. H e was cared f o r b y Compensation doctors f o r some time. T h e n , Mrs. G . , of the A f t e r - C a r e Department of the Compensation Bureau, was not satisfied w i t h the care the Compensation doctors were g i v i n g him, and the Family Bureau took him to D r . Y . , the eminent brain surgeon, attached at that time to University Hospital. D e f e c t s of speech, eyesight and hearing were prevented f r o m increasing b y the brain operation, but his speech is bad even now. H e is somewhat deaf and lame, and not too alert, physically. Compensation of $ 2 0 a week until his death was awarded. This was insufficient f o r the large f a m i l y so the F a m i l y Bureau started an allowance which was continued until J e n n y was able to w o r k . D u r i n g Family Bureau's earlier contact the above services were performed and other health defects of the whole f a m i l y were attended to, school adjustments made, etc. In the winter of 1928 the case became active again. J e n n y had had immoral relations w i t h a y o u n g man w h o was later sent to the Tombs. She was in the Continental Hospital with a G C vaginitis and probable 2 plus Wasserman, this last doubtf u l , as it was difficult to get reports. T h e social situation had become difficult because M r . S's condition and irritability were causing personality difficulties in the children. Louise had infantile paralysis at five years. She is in f a i r condition now but has always been overindulged so that she considers herself frail. J e n n y is a vigorous girl with m a n y positive assets in spite of her apparent wildness. It was she w h o

I ι 4

EDWARD

STONE

clashed particularly with her father as he disapproved of the way young people managed their lives nowadays. Tom was found to be retarded in a psychological examination. A t L i f e Camp he was said to be 31 pounds overweight. With the family he does not get on very well and is always the butt of their jokes. Alice gets on fairly well in the family and at school but was 21 pounds overweight. James has always been a difficult problem as he is a frail child. During the summer of 1 9 2 8 , Mr. S., while really loving his family fundamentally, became so irritable that he was positively a menace. A f t e r reexamination at University Hospital it was decided to send him to Riverview to see if he would improve in the open air and where he could perform certain light duties on the f a r m . A f t e r being tested out he is to be placed on a large estate if possible to do the same kind of things that he has learned to do there. T h e Family Bureau problem for the future of the family is to maintain and encourage the family as best it can with Mr. S. a part of the family life but not in the home. In the Spring of 1928 the Family Bureau referred the case to Western Hospital. Four workers know different members of the family. Miss C. reported that James, Charlotte, and Rose were examined in the Children's Clinic. Charlotte and Rose were essentially negative. James had pneumonia and a cardiac condition und was admitted to the hospital. A f t e r he went home he reported to the cardiac clinic for further care. There were rales over his chest. H e was a feeding case. H e was given convalescent care at Infant's Home f o r five weeks. Later, he was readmitted due to his cardiac condition, and was then followed in the cardiac clinic. Miss C . also said that Mrs. S. had a pain in her chest and was diagnosed a tuberculosis suspect. She had periodic examinations with negative results but the hospital felt that she was to be watched. She was transferred to the cardiac clinic and was found to have a heart defect, but she never returned. T o m was given complete dental attention during the summer.

EDWARDSTONE

115

A l i c e was f o u n d t o be o v e r w e i g h t and was transferred t o the e n d o c r i n e clinic. Miss B. reported her c o n t a c t w i t h the f a m i l y : James rep o r t s r e g u l a r l y to the cardiac clinic. A s he w a s b r o u g h t in r a t h e r a d i r t y state to the clinic Miss B. paid a h o m e visit a n d f o u n d the h o m e clean. She g a v e b a t h i n g instructions. She, w i t h the F a m i l y B u r e a u , is m u c h impressed w i t h Mrs. S's c h e e r f u l disposition. Miss H . reported that J e n n y had been t o the neurological clinic. She has a m i n o r chorea f o r w h i c h a b r o m i d e was prescribed. It w a s r e c o m m e n d e d that she g o to Β

f o r a rest

of six weeks, b u t she o n l y stayed ten d a y s as she wished to be at h o m e f o r the holidays. H e r G C vaginitis cleared u p at an earlier date w h i l e she was in the C o n t i n e n t a l H o s p i t a l b u t the question o f a syphilitic c o n d i t i o n is not settled. S u m m a t i o n o f health p r o b l e m s b y Miss B : Mrs. S. possible cardiac disease and possible tuberculosis. Louise, old paralysis w i t h a s o m e w h a t neurasthenic attitude. J e n n y , f o r m e r chorea, former G C

vaginitis and possible lues. H e r physician is t o

k n o w the f u l l social history. T o m , o v e r w e i g h t a n d m e n t a l l y retarded. A l i c e , o v e r w e i g h t . C h a r l o t t e a n d Rose, negative once b u t t o be f o l l o w e d . James, cardiac, susceptible t o colds and p n e u m o n i a , chorea. It was explained that w h i l e f o u r people m i g h t be w o r k i n g on the situation at the hospital, Miss B. w o u l d be responsible f o r the w h o l e f a m i l y and w o u l d correlate the w o r k o f the different clinics. If J e n n y becomes an e q u a l l y i m p o r t a n t case w i t h James, her w o r k e r w i l l m a k e a separate case b u t will also report t o Miss B. E a c h patient has a clinic record, b u t there is o n l y one social service record unless t w o members o f the f a m i l y become m a j o r cases. Unless there is a social history the health w o r k f o r the various m e m b e r s o f a family is not p u t together. T E A C H I N G N O T E : This summary of the Family Bureau's conference with another hospital social service department adds to Mr. Stone's record information concerning the health and social behavior of the other members of the family. 12.27.28—Letters out.

I I 6

EDWARD

STONE

Letter 29 UNIVERSITY

HOSPITAL

December 27, 1928 Miss Queed Family Bureau City My dear Miss Queed: We should very much appreciate having a brief report from you of the present conditions in the family of Edward Stone. It is now slightly more than a month since he went to Riverview and we have written to Mrs. Strong asking for a report of his progress. In showing this to the doctor, we would like to have, at the same time, a report of the home situation, so that we can have some idea of whether the plan we have jointly worked out is proving a good one. May we hear from you at your earliest convenience? Sincerely yours, University Hospital Social Service EVELYN

SYDENHAM

Surgical Division Letter 3 0 UNIVERSITY

HOSPITAL

December 27, 1928 Mrs. Strong Riverview Cornwall, Conn. Re: Stone, Edward My dear Mrs. Strong: May we trouble you again for a further report of Edward Stone's progress? Now that he has been with you for a little over a month we should like very much to look forward and be prepared with some plan when his time with you has expired. A good deal depends upon his continued progress, and your first report was most encouraging. Mr. Stone, himself, also wrote us a letter full of interest in his life on the farm and we felt that he was sincerely trying to be of help to you, and was happy and contented. We should be most interested to have any suggestions you, your-

EDWARDSTONE

I 17

self, would like to make, as we need your help in planning for the future. We hope that, now that you know him better, you will feel free to tell us frankly what you believe is the best way to help him, the kind of work which seems possible for him, and the things which have seemed to benefit him. Will you write us at your earliest convenience so that we may show your report to the doctor? Thanking you again most sincerely for the help you are giving us with this patient, Sincerely yours, University Hospital Social Service EVELYN

SYDENHAM

Surgical Division 1 2 . 2 8 . 2 8 — S e e report f r o m F . B . Letter 31 FAMILY

BUREAU

December 28, 1928 Miss Sydenham University Hospital City Dear Miss Sydenham: The home situation in the Stone family is working out remarkably well. The tension seems to have relaxed, and, according to Mrs. Stone, they are getting on very well. James, you will recall, had chorea and this is clearing up quite rapidly. Louise has not been able to go to work because she has been ill with the grippe, but she is going down to the Girls' League next week looking for work. Western Hospital has not yet made any recommendations about Jenny's working. A t the present time we are giving them an allowance of $ 1 8 . a week which, with the $20. a week from the Workmen's Compensation, gives them an income sufficient to cover their needs adequately. Mrs. Stone is taking more interest in the health of the various members of the family. This week she has gone herself for a physical examination at Western Hospital which is a real achievement as we have been urging this ever since last winter but she always insisted

I I 8

EDWARD

STONE

that she was too busy to go. James is under treatment in the cardiac clinic there. A l i c e and T o m are having their teeth attended to at Western Hospital. Mrs. Stone frequently speaks of her husband and of the enthusiastic letters which the f a m i l y receive regularly f r o m him. It is v e r y sure that he has a definite place in their affections as they all seem to write him f r e q u e n t l y . Mrs. Stone telephoned him on long distance on Christmas D a y . We had a letter f r o m Mr. Stone saying that he had never f e l t so well in his life and was so pleased that he could do some work around the place. Apparently, he is not worrying about the f a m i l y and is not suspicious of what the girls may be up to as he was last year. We feel very pleased with the way the plan is w o r k i n g out and I hope that you will agree with us. Let me take this opportunity to tell you how much we appreciate the hospital's meeting the bill f o r Mr. Stone. Sincerely yours, LUCY

QUEED

Assitant D i s t r i c t Secretary 12.30.28—Patient's

progress:

See

report

from

Riverview,

12.30.28. Letter 3 2 RIVERVIEW

December 30, 1928 University Hospital City My dear Miss Sydenham: We are glad to say that Mr. Stone continues to do well and seems very happy. He is willing to turn his hand to a n y t h i n g — w o o d - c u t ting, dishwashing, mopping and cleaning, and general tinkering and repairing. H e is clean, thorough, quick, ingenious, and skilful. H e is w a t c h f u l f o r anything in which he can be useful, keeps himself busy to excellent advantage most of the time, and if he has any leisure time, is c a r e f u l to tell us where he can be f o u n d if wanted. A t the same time he shows little or no evidence of nervous tension and makes no complaint of any unfavorable symptoms. H e is quiet and refined in his ways, kind-hearted, and a general favorite. O u r

E D W A R D S T O N E

1 1 9

conditions here, with plenty to do but nobody to drive him, seem to suit him e x a c t l y . O u r location is too remote to be favorable f o r finding e m p l o y ment f o r anyone, but we shall be glad to recommend him when occasion arises. I will send a memo of his board in a day or two. Sincerely yours, ANN

FULLER

(For Mrs. Strong.) 1 . 2 . 2 9 — P a t i e n t ' s progress: See report f r o m patient. 1 . 2 . 2 9 . Letter 33 RIVERVIEW

J a n u a r y 2, 1 9 2 9 Dear Friend Miss Sydenham: I received your letter, also the present and wish to thank you v e r y much f o r same. I am still holding my own, am feeling good again, had a cold but kept on the go and worked it off. Miss Sydenham please ask D r . R o l f if I could wear a wide belt f o r the lower part of m y spine is v e r y weak, when I bend down I have a hard time coming up again. I have lost about 1 0 lbs., but my muscles have turned t o iron. My w i f e w o n ' t k n o w her hubby when she sees me again. I hope you enjoyed the holidays, as I had a w o n d e r f u l time here. We have snow and hail here now, with a snow storm just starting again. I am out in the open most of the time. I don't mind the cold. We have 1 0 above as I am writing this letter. T h e cold in N e w Y o r k seemed to give me more discomfort. W e had zero here and I was out most of the day c u t t i n g wood and bringing it into the house. I keep the house supplied w i t h wood, wash the dishes 3 times a day and sweep, and do any repairs necessary. Also clean the snow away f r o m around the house. I never thought I would come back as good as I did, I surprised myself. But I have you to thank Miss Sydenham f o r y o u r great interest that you gave me and my f a m i l y . I will close now hoping this letter finds you in the best of health. I remain your sincere friend w i t h many thanks. M R . EDWARD

STONE

Will be v e r y pleased to hear f r o m you. It is snowing very hard now. 1 . 2 . 1 9 — L e t t e r out.

12 0

EDWARD

STONE

Letter 3 4 UNIVERSITY

HOSPITAL

January 2, 1 9 2 9 Miss Queed Family Bureau City Re:

Stone, Edward

My dear Miss Queed: Thank you very much f o r the encouraging report of Mr. Stone's family. It does seem as though things were looking much brighter for them and f o r him also, since his placement at Riverview. Y o u will be interested to have a copy of Mrs. Strong's report of December 30th, which we enclose. Dr. Rolf is due in his clinic on January 9th, and we are anxious to show him the reports to date. If he agrees with us that the plan seems to be working well, it would seem to be time to make inquiries toward a more permanent arrangement f o r him, as he has now been at Riverview about half the time we planned for. W i l l you be willing to help us with this? We thought that possibly through your board, or through the board of this hospital, we might hear of some estate on which he might be placed to advantage and do useful work within his limitations. Sincerely yours, University Hospital Social Service EVELYN

SYDENHAM

Surgical Division 1 . 2 . 2 9 — P l a n for patient: D r . R o l f feels placement on f a r m is proving satisfactory, believes separation f r o m home, in relations and occupation under congenial conditions, are responsible for patient's improvement. H e suggests that patient might wear a broad leather belt to support lower region of back to be secured after patient returns to N e w Y o r k . D r . Rolf

believes further

placement in c o u n t r y

after time at

R i v e r v i e w is expired w o u l d be worthwhile. N O T E : Separation from home is satisfactory from medical standpoint. Is it so from social standpoint? T E A C H I N G

EDWARD

12 1

STONE

Letter 35 FAMILY

BUREAU

January 4, 1929 Miss Sydenham University Hospital City My dear Miss Sydenham: We are delighted to have Mrs. Strong's very encouraging report about Mr. Stone. Our district committee meets next Wednesday morning, January 10th, and we will take up the question of his future employment at that time. If the committee is not helpful it might be possible to find a place through one of the members of our Central Council. Sincerely yours, LUCY

QUEED

Assistant District Secretary Letter 36 RIVERVIEW

January 9, 1929 My dear Miss Sydenham: I have been having a good talk with Mr. Stone and am so deeply interested in him. I find, which I didn't know before, that he is bent on staying on the farm! I am equally glad to think of his staying— he is so more than acceptable and helpful but I am giving a good deal of thought to the practical consideration. I find that he has a very reasonable attitude. He would not expect us to change our policy and put him on a salary sufficient to support his large family, but he thinks that perhaps he could still draw compensation from the state and work out the rest. Do you think this a possible thing or would his being in Connecticut prevent this? Then too, there is the big subject of housing as it would be unsuitable to place a group of little children in the main house even if we had room. One of our houses (which we depend upon as soon as spring opens) is available at the moment, but in the spring we would be facing the question of building a cottage. You know what an expense this is—and yet I have such a conviction that Mr. Stone is

12 2

EDWARD

STONE

right about his coming that I feel as if a way ought to be made for him. The kind of life here is ideal for him for he has plenty of incentive, in meeting our needs, and plenty of elasticity in doing what he can, and not being required to do more than is good for him. It would do your heart good to see his splendid return to health and good spirits. Another question that faces us would be the education of the children—the combination of the Catholic and Protestant factors, etc. If, however, the expense matter can somehow be handled I believe these other matters could be, as the school problem is already partly solved here by a primary department on the farm, and cooperation with our own boys' unit and that of the public school ι '/i miles away. I promised Mr. Stone to open the subject with you and it is really very much in my heart. Sincerely yours, MARY

STRONG

T E A C H I N G N O T E : The superintendent of the convalescent home and the patient take part in planning for his future. Letter 3 7 UNIVERSITY

HOSPITAL

January 10, 1929 Mr. Edward Stone Riverview Cornwall, Conn. My dear Mr. Stone: I was delighted to have your letter and the good news of your improvement. Dr. Rolf was in his clinic on Monday, and I showed him both of your reports, which he felt were very encouraging. He says you have done well, and he thinks that the life on the farm is just the thing for you. He has asked me to tell you that he believes a strong, wide leather belt would be a good support for the lower part of your back, and he suggests that when you return, we should try to get something of this kind for you, but it would be difficult to do this without having you here to get the proper fitting. Miss Queed tells me that things are going well at your home, and I am very glad about this. Your wife will certainly be delighted

EDWARD

STONE

I 23

w i t h your improvement when she sees you again. Miss Queed and I are both making inquiries to see whether we can find a position f o r y o u on some country f a r m or estate, so that when youc time at R i v e r v i e w is up, you might be ready to take regular employment. D r . R o l f feels that your improvement shows y o u r capability in takin g a regular job, and I am sure you will feel encouraged about this. I should like very m u c h to hear f r o m y o u whether you have been t h i n k i n g over some f u t u r e plan, and if you have any suggestions to m a k e I should be glad to help you in any w a y that I can. Of course, yo>u would w a n t to come to see your f a m i l y before undertaking any definite position, but I believe that you will make good in some work, s u c h as you have at R i v e r v i e w , and it certainly would be a satisfaction, would it not, to be able to earn your w a y once more. I will write you again before long, and let y o u know what I am able to find out. In the meantime, I shall be very glad to hear f r o m y o u , yourself, what you think about such a plan. Y o u r sincere friend, University Hospital Social Service EVELYN

SYDENHAM

Surgical Division [ S y l l a b u s r e f e r e n c e : METHOD, P l a n . ] L e t t e r 38 UNIVERSITY

HOSPITAL

January 16,

1929

Mrs. Strong Riverview C o r n w a l l , Conn. M y dear Mrs. Strong: I am so sorry f o r this delay in answering your letter which reached me on J a n u a r y 1 2 t h , and which is most interesting. It crossed a letter which I sent to M r . Stone, asking him to let me know whether he felt he would like to take a position on a f a r m after his time with you expired. We do very much appreciate the help you are trying to give us in planning his f u r t h e r care and employment; he has done so well with you that we feel, in many ways, it would be an excellent thing if he might remain on as a regular worker. T h e plan of moving his

124

EDWARD

STONE

family would, as you know, bring up many points for consideration, and we do not feel, at the moment, that it is possible to give any definite opinion, as we must first talk the matter over with his w i f e and with the Family Bureau who have been helping her. We should like to get in touch with you when we have done this. It is most gratifying that you should wish to have him remain at the farm, and we feel that his improvement and happiness there has been, in a great measure, due to your consideration and helpfulness. Sincerely yours, University Hospital Social Service EVELYN

SYDENHAM

Surgical Division Letter 39 RIVERVIEW

January 19, 1 9 2 9 Dear Friend Miss Sydenham: I received your welcome letter and was very happy to hear from you, and also Dr. Rolf. What Dr. Rolf thought about my condition made me feel very happy, and I feel that I will be able to hold down some kind of a job after all. Dear Friend Miss Sydenham, Mrs. Strong was speaking to me about staying out here and also having my family out also. Mrs. Strong said she does not know how she can part with me here, as I am just the man she always wanted around the house. Mrs. Strong said she would write to you about it. So when my time is up here I will stop in to talk matters over. I just got up today from bed. I had a bad cold but am O.K. again. Most of the people here were sick and some still are in bed with colds. I think I will have to have a belt for my back when I come in to the city, as it bothers me very much, even when I walk or sit down. Miss Sydenham please excuse my writing as I have a hard time to see after the first few lines, I keep putting on and taking off the glasses so I can see the lines. I can't do such close work at all, as my sight blurs up right away, and I don't see nothing but black streaks. Everything is going good with me here, I hope you are in good health and also Dr. Rolf. I will close hoping to hear from you soon. I remain Your sincere friend, EDWARD

STONE

E D W A R D

S T O N E

I

2 5

Letter 40 RIVERVIEW

January 3 1 ,

1929

M y dear Miss S y d e n h a m : M r s . S t r o n g has sprained her right wrist and therefore has asked rne to write f o r her in regard to M r . Stone w h o will be the bearer of this letter. Since he has apparently improved so m u c h , and since he h i m s e l f wishes to r e t u r n , w e would be v e r y glad indeed to have him c o m e back, if it w o u l d be h e l p f u l , f o r the rest of the w i n t e r and s p r i n g , on the basis of w o r k i n g out his o w n board. W e are particularly interested in M r . Stone, and in his f u t u r e and w a n t to cooperate as f a r as we possibly can f o r the benefit of the whole family. V e r y sincerely y o u r s , ANN

FULLER

( f o r Mrs. S t r o n g )

Letter 4 1 FAMILY

BUREAU

F e b r u a r y 2, 1 9 2 9 Miss Sydenham U n i v e r s i t y Hospital City M y dear Miss S y d e n h a m : I a m enclosing a copy of a letter M r . Stone w r o t e his w i f e . T h e last part I believe is quite indicative of his feelings. Mrs. Stone was v e r y m u c h distressed over the whole thing and said that she cried all m o r n i n g on the day it came because she feels he does not appreciate w h a t the f a m i l y does f o r him. I had warned her before about w r i t i n g him as f r e q u e n t l y as possible and expressing affection, etc., w h i c h she insists that she does. J e n n y is quite weak a f t e r her recent illness in C o n t i n e n t a l H o s p i tal w h i c h did not help her nervous condition any as you can imagine. She told her mother that if her f a t h e r came home he would " t h r o w her out the w i n d o w " f o r not w o r k i n g . T h e other children h a v e also been ill and apparently there is a good deal of f r i c t i o n as a result. I talked over with Mrs. Stone the possibility of her husband s t a y ing on up there and she thinks it would be a splendid idea. She w o u l d like him to come d o w n to see the children f o r a short time b u t feels

I 2 6

EDWARD

STONE

that it would be better to wait until Jenny is working. I told her that I agreed and consequently wrote Mr. Stone that we would be glad to pay his carfare down and back to Riverview but that the children were all ill at the present time and it would be better to wait until they were in good health again. Sincerely yours, LUCY

QUEED

Assistant District Secretary (Enclosed is an affectionate letter from M r . Stone to his wife, telling of an attack of influenza, and dwelling upon the good care he has had at the farm. H e refers to his associates there as "the best friends I have in the world," and this seems to be the cause of her disturbance. The letter ends " G o d bless my kiddies. D a d . " ) T E A C H I N G N O T E : The next difficulties to be encountered are foreshadowed in the above letter. Letter 4 2 UNIVERSITY

HOSPITAL

February 4, 1929 Foot Hospital City Re:

Stone, Edward

Gentlemen: The above patient has been treated in this hospital. We are referring him to you as our doctor says that he is in need of a properly fitting belt for the sacroiliac condition on his right side. Thanking you, we are, Very truly yours, University Clinic B. CLARK,

2.4.29—Plan

M.D.

for patient: See report of reexamination on

chart. Patient seems to be in excellent spirits, rather excited over being at home, full of enthusiasm over the life on the farm. The fact that he has made good in his own estimation and in the estimation of others seems foremost in his mind. H e is very grateful for what has been done for him. H e wants to live

EDWARDSTONE

127

permanently on the farm with his family, is convinced that the country agrees with him, and says he feels the city disturbing since his return. He wants to return without delay to the farm and have his wife accompany him so that she may meet Mrs. Strong and talk over the plan. H e is anxious to secure a belt for support for his back, but is obviously disappointed over any delay in returning to Riverview. Patient's expression and bearing seem changed for the better, and now more alert and purposeful; he is thinner, but seems more muscular and less flabby. H e says he feels a different person. (Conference with Patient's W i f e in O . P . D . ) W i f e is obviously pleased over patient's improvement. Is swayed by her wish to remain in the city and her fear that, if she insists upon this, patient will think she does not want to live with him. She thinks it best to return with patient to Riverview and talk matters over with Mrs. Strong; her plan would be to allow the two eldest girls to go to her sister, and to go with the younger children to the farm. She says that children are "wild to g o . " She says that patient is showing signs of irritability since his return home. TEACHING N O T E : Difficulty is developing as to future arrangement which will suit both patient and family. D r . Rolf's advice: T h a t patient remain away from his family at least until Spring, returning to the farm on Mrs. Strong's arrangements that he work for his board. T h a t the question of his family joining him be postponed for the present in view of previous friction between himself and his wife and children. Advice to patient: Dr.'s advice explained on basis of trying the experiment for a longer period; question of family friction left out. W i f e to go with patient for visit to farm if they wish this. Patient to return to farm as soon as belt is secured. Patient to go with letter to Foot Hospital and notify social worker of expense of belt prescribed. Above report given to Family Bureau. See letter to Mrs. Strong explaining Dr.'s advice. E. S.

1 2 8

E D W A R D

S T O N E

Letter 43 UNIVERSITY

HOSPITAL

February 6, 1 9 2 9 Mrs. S t r o n g Riverview Cornwall, Conn. Re:

Stone, E d w a r d

Dear Mrs. S t r o n g : I was indeed v e r y m u c h surprised to see the marked i m p r o v e m e n t in M r . Stone when he came yesterday to the hospital, and y o u w o u l d be gratified if y o u had heard the doctor's report of his condition. T h e r e is no doubt about it, t h a t y o u have done wonders w i t h h i m , and the doctor considers that his progress is due to being in the c o u n t r y under good conditions, and away f r o m the disturbances in his home, also to his being helped to feel that he is a u s e f u l person. M r . Stone is whole hearted in his gratitude to you, and enthusiastic about his w o r k on the f a r m , and is asking to return as soon as possible. H e is anxious f o r his w i f e to make the trip w i t h him, so that she m a y have an o p p o r t u n i t y of t a l k i n g w i t h you about his f u r t h e r plans. H e does seem v e r y anxious to move up to the f a r m w i t h his w i f e and children, and it m a y be that this can be worked out w i t h y o u r help at a later date. T h e doctor feels, however, that in as m u c h as part of the d i f f i c u l t y lay in the f r i c t i o n between M r . Stone and his w i f e and children, and as this has begun again to bother him, even since his r e t u r n to t o w n , it would be better not to make any definite plans yet f o r this. T h e doctor's recommendations are that M r . Stone return to y o u w i t h o u t his f a m i l y , and w o r k , as y o u h a v e been kind enough to suggest, f o r his board, and that the plan of m o v i n g his f a m i l y be b r o u g h t up f o r consideration at a later date, perhaps in the spring. W e are glad to have this chance of securing a proper back support f o r M r . Stone while he is in t o w n . T h e doctor believes that a strong belt will relieve the pain in the lower region of his b a c k , of w h i c h he has been c o m p l a i n i n g . It m a y take a f e w days to have this belt made, but w e are a t t e n d i n g to this n o w , and will let you k n o w w h e n he is ready to r e t u r n to C o r n w a l l . W e f e e l w e have in no measure expressed to you how f u l l y w e appreciate w h a t y o u have done f o r this patient. He seems to us a

EDWARD

1 2 9

STONE

d i f f e r e n t person. His whole expression and bearing is happier, and f u l l of l i f e and purpose. W e are deeply t h a n k f u l to you f o r y o u r help. W e have submitted your bill to our accounting department, and y o u w i l l receive reimbursement directly f r o m that office. If there should be any undue delay in this, I hope you will let us k n o w . Sincerely yours, U n i v e r s i t y Hospital Social Service EVELYN

SYDENHAM

Surgical Division [ S y l l a b u s reference: METHOD, P l a n . ] Letter 4 4 RIVERVIEW

February 9, 1 9 2 9 Dear Miss Sydenham: M y sister asks me to send her special thanks f o r y o u r very kind letter of the 6th. We too are rejoicing over Mr. Stone's improvement, but cannot feel that it is due to any effort on our part. W e have written him that we shall be glad to have his w i f e visit us w h e n he returns, as we feel that mutual acquaintance is necessary before any f u r t h e r plans can be worked out. A p p r e c i a t i n g the kindness of your cooperation and hoping that it m a y sometime be possible f o r you to visit the f a r m yourself as our guest. Sincerely yours, ANN

FULLER

( f o r Mrs. S t r o n g ) Feb. 1 9 2 9 :

Compensation D e p a r t m e n t in hospital reports that

patient's residence will not interfere w i t h p a y m e n t s of c o m pensation. So long as he is granted an a w a r d , this should be continued w i t h modifications depending u p o n his ability to w o r k and graded according to his present c a p a c i t y and his previous earnings. 2 . 1 3 . 2 9 — P a t i e n t ' s condition at home: F a m i l y B u r e a u R e p o r t . Miss Roosevelt states that since patient's return the quarreling and friction w i t h i n the home has been " w o r s e than e v e r . "

ι 30

EDWARD STONE

T h a t patient is v e r y suspicious of his w i f e and she is in c o n stant fear of bringing on one of his attacks. Patient has been threatening his f a m i l y and is excited and upset. W i f e wishes to come to hospital and see social w o r k e r but fears to do so and will wait until patient has returned to R i v e r v i e w . Social worker explains delay in h a v i n g patient return to f a r m is due to time required in m a k i n g belt. T E A C H I N G N O T E : Difficulty as to family adjustment and patient's health continues. Report

from

Foot

H o s p i t a l : Mrs.

U.

[social

worker]:

Patient reported on F e b r u a r y 8th, w h e n X - r a y s were taken w h i c h showed some arthritis of lower spine, belt prescribed on F e b r u a r y 1 3 t h , w h i c h will not be ready until F e b r u a r y 2 0 t h . Social w o r k e r explains patient's leave of absence f r o m R i v e r view, and advisability of his return at earliest possible date. Mrs. U . States that belt is being made free of charge f o r patient. Letter 45 UNIVERSITY

HOSPITAL

February 2 3 , 1 9 2 9 Miss L u c y Queed Family Bureau City Re:

Stone, E d w a r d

Dear Miss Queed: Will you excuse our delay in sending you a copy of the report we received f r o m R i v e r v i e w in the case of E d w a r d Stone? W e are enclosing also a copy of our letter to Mrs. Strong f o r y o u r i n f o r m a tion. We hope there will be as little f u r t h e r delay as possible in having Mr. Stone return to the f a r m , where it would seem that he is much happier and better adjusted than in the city and at home. We received Mrs. Strong's bill f o r Mr. Stone's care, in which she included the expense of transportation. I remember that you were willing to undertake this, and we shall be glad to receive your reim-

E D W A R D

S T O N E

I 3

1

bursement for $6.00, which covers the trip from Riverview to the city, at your earliest convenience. Very sincerely yours, University Hospital Social Service EVELYN

SYDENHAM

Surgical Division 3 . 9 . 2 9 — C a r e of p a t i e n t : ( R e p o r t f r o m Family Bureau.) P a t i e n t r e t u r n e d t o Riverview, March ist. Belt secured. 3 . 2 2 . 2 9 — C a r e of p a t i e n t : See letter f r o m patient a f t e r ret u r n to Riverview, complaining of dimness of eyesight f o r t w o weeks, white mist over l e f t eye and right eye closing, bleeding f r o m l e f t ear. H e says t h a t belt gives great relief to his b a c k . H e seems very h a p p y over r e t u r n t o f a r m . 4 . 1 . 2 9 — C a r e of p a t i e n t : Patient's letter explaining condition s h o w n to D r . Rolf. Social worker acknowledged letter t r y i n g n o t t o alarm patient over his condition, advising h i m to report his c o n d i t i o n again t o social w o r k e r in week's time. D r . Rolf says it is difficult to account f o r patient's s y m p t o m s w i t h o u t seeing him, advises social worker to await f u r t h e r development w i t h o u t in a n y way alarming patient. E. S. [Syllabus reference: METHOD, Administrative f u n c t i o n , interagency practice, adaptation of technique to specialty.] T E A C H I N G N O T E : 1930. Mrs. Stone's visit to the farm was not satsifactory as far as plans for the future were concerned. She could not content herself there long and neither could the older children. Mr. Stone returned home in the summer of 1929 and his old troubles returned. A plan of more intensive medical treatment was made, with use of the hospital and the convalescent home at intervals. The problem of individual and family adjustment is in part that of marital relationship. Mr. S. is not contented permanendy separated from his wife. She fears pregnancy and, at the same time, fears to arouse his anger.

C H A P T E R IV

T H E CASE R E C O R D OF E L E A N O R MEYER TEACHING

OBJECTIVES

In a general case-work course for beginners, a mental hygiene record may be included in the material for discussion. In the N e w York School of Social Work it is usual for students to carry their first field assignment in case work simultaneously with their introductory course in case work, and with the first course in mental hygiene. 1 A record which concentrates on behavior problems offers opportunity for pointed discussion of the practical usefulness of mental hygiene theory and method, as well as for the conscious correlation of case work with psychiatry. A n y clinic record may be used in a variety of ways in class, the objectives of the particular course determining the presentation of material. Emphasis on psychiatric technique, on the interplay between psychiatry and social work, and on the analysis of processes, has been selected for discussion in the course for which this case record has been prepared. b o u r s e 61, New York School of Social W o r k . The following definitions arc those used by Dr. Marion Kenworthy. C f . Psychoanalytic Concepts in Mental Hygiene, The Family Nov. 1926. Posi/iic:

Describing feelings of satisfaction, with respect to experience, whether

on ego or libido level, or both. Negjliir:

The reverse of posi/iic,

the two representing opposite poles of feel-

ing value. Destruc/iie:

Experiences which have a feeling value of satisfaction or dissatis-

faction which tend to interfere with the growth and development towards a mature and well-integrated personality adjustment. Constructiie:

Experiences, either satisfying or unsatisfying, which tend to inte-

grate the personality and lead to mature adjustment. Ego:

This term is conceived in its simple definition as an impulse to grow, to

live, and to maximate one's own personality, which may be reflected in objective external relationships, or in some ways as an internal value. Libido:

The impulse to love and be loved, which reflects itself in atfcctional rela-

tionships—love for self, love for family, love for mate, and so on.

E L E A N O R

M E Y E R

1 3 3

T h e present record* was prepared for use towards the latter p a r t of a course, after the student group has had experience in the field and sufficient psychiatric theory to make them eager to discuss it. 3 The annotations suggest points of emphasis a r o u n d which the discussion will play, rather than points to w h i c h the discussion will be limited, as the group will lead the w a y into m a n y by-paths. The instructor may be called upon to summarize the discussion now and then, in order to clarify a n d point up the broader mental hygiene implications under study. T h e preliminary mental hygiene course, " T h e N a t u r e and Varieties of H u m a n Behavior" in the N e w Y o r k School curriculum emphasizes the following basic concepts: Each human being is the product of his life experience to date. H e responds with behavior which is purposive and satisfying for him. Such behavior m a y be constructive, or it may be destructive in that it impedes or slows up his social adjustment. The unconscious motivations for his conduct will be f o u n d in the emotional value for him of each experience, and its subsequent relation to each new experience. Each new factor upsets or modifies the established pattern and so creates a need for some shift in values as well as a change in conduct. The response m a y be a substitution of behavior which is acceptable, satisfying, and so basically constructive, or it may be a compensation only, and lacking in permanent constructive values. In the preparation of this record the above concepts have been used. Other schools of psychiatry would of course suggest other interpretations of the case record material. [Syllabus reference: KNOWLEDGE, Psychiatry.] 2

The Syllabus has facilitated the distinguishing, in both theory and practice of

teaching, between

the

items selected

and

those rejected

and omitted

for

the

pedagogic use of this case in the classroom. The annotations concentrate upon the use of "psychiatric-social" content and technique, that is divisions " B " and

"E"

of the Syllabus, with relatively slight reference to the other divisions such as those designated AREA and RESOURCES. AS such material overlaps constantly it is not possible to label it as belonging solely to any one heading or grouping of the Syllabus. The instructor has not, in this instance, used the case previously in classroom.

ELEANOR

134

MEYER

T h e concepts summarized in the foregoing paragraph s u g gest the necessity for as complete an understanding as possible of all that has gone before the event that creates the crisis f o r the family or individual. It means a search for cause and effect relations, for the motivation of behavior, for the patterns that have been so deeply instilled through practice or environmental familiarity that they appear in situations which are emotionally unlike those in which they had their origin. T h e importance of feeling tones has become recognized in present day case w o r k ; therefore the client's attitudes and reactions are the focal points in treatment, his environment secondary and pertinent only to the extent that it is directly related to his behavior disability. In this approach we find the basis for the developing relation between the technique of psychiatry and the technique of social case w o r k . W e must k n o w how the client feels about his life. T h e successful establishment of rapport with psychiatrist and social worker is the first and essential step towards this understanding. W h e n this has been accomplished the client is ready to participate in treatment. [Syllabus reference: KNOWLEDGE, Psychiatry, i . problem; 2. psychiatric method; s t u d y . ] T h e clinic set-up of psychiatrist, psychologist, and social worker prepares the background from which doctor and social worker will function. T h e social study b y the social worker, and the examinations by psychiatrist and psychologist give us a broad understanding of the problems as well as the opportunity for diagnostic assistance. Treatment, which must start at the point where the patient, 1 or referring agent, sees the need for help, will be directed and influenced accordingly. T h r o u g h this service the psychiatrist and social worker will be enabled to proceed w i t h d o u b t f u l points of health and intellectual capacity cleared up and positive values established. 4This

term

will

henceforth

be used

in v i e w

of

the

fact

that, although

Eleanor

M e y e r represents a case in social w o r k a n d is t h e r e f o r e a " c l i e n t , " in the g e n e r a l l y a c c e p t e d use o f t h a t t e r m , t r e a t m e n t in a c l i n i c u n d e r the g u i d a n c e of a p h y s i c i a n a u t o m a t i c a l l y changes her status to that of a " p a t i e n t . "

ELEANOR

MEYER

135

Child-guidance clinics concern themselves with behavior and with the factors behind behavior which t h w a r t self-development, interfere with constructive social relationships, and with a d j u s t m e n t on a m a t u r e emotional level. The psychiatrist and psychiatric social worker work together. The division of responsibility is determined by the needs of the case, the clinic set-up, the technical equipment of the worker, and the social experience and point of view of the doctor. The psychiatrist sees the patient removed f r o m the daily difficulties and irritations which block treatment. T h e social worker is in touch w i t h these very factors in environment, either t h r o u g h home calls, in which psychiatric treatment is carried on, or t h r o u g h cooperative relationships with teachers and others who may be i m p o r t a n t , either as emotional determinants or as resources in treatment. Together they have an enriched picture of the emotional life of the patient. W i t h these general concepts in mind, the clinic case of Eleanor Meyer was prepared f o r class study. A record f r o m a clinic allows concentration on behavior without the digressions of financial worries, foster parents, etc., that usually appear in cases of other agencies. The Meyers Eleanor Meyer is a ten year old child, adopted when t w o weeks old and brought u p to believe that Mr. Meyer and his first wife were her o w n parents. T h e case opens when the second Mrs. Meyer, a Jewish woman of thirty-six, is unable to control Eleanor or to agree with Mr. Meyer, a Jewish man of forty, about disciplinary measures. T h e family is in danger of permanent disruption. Eleanor gives the picture of the selfloving child, whose early environment created patterns that demand and accept, b u t do not give. H e r foster mother's death, with its resulting separation f r o m her foster father, destroyed the libidinal environment and threw her entirely within herself for love and approval. T h e objective, critical, and sharing atmosphere of a boarding school at which she

136

ELEANOR

MEYER

stayed could not be either a substitute or a compensation f o r a home where she had been the love object. T h e injection of Eleanor and her emotional needs into the lives o f Mr. Meyer and his newly married second w i f e was a threat to their relationship a n d to p e r m a n e n t f a m i l y u n i t y . A n y threat m a y re-create u n h a p p y early experiences. Insecurity, rejections, tensions, loss of perspective, m a y follow. T h e reversion to early or infantile behavior patterns is natural under such circumstances as o f f e r i n g the security of the f a miliar. T h e emotional life of M r . and Mrs. Meyer, upset b y the injection of Eleanor's problems, in t u r n contributes to the f u r t h e r disruption of Eleanor's behavior in a vicious circle of cause and effect. T h e problem which the clinic m e t was, therefore, three-fold, as Mr. Meyer, Mrs. Meyer, and Eleanor were emotionally involved. Their h a p p y a d j u s t m e n t and ability to handle day b y day feelings and events would alone create f a m i l y u n i t y . T h e clinic thus had three new patients f o r t r e a t m e n t instead of one. T h e pedagogical points u p o n which, and a r o u n d which, the class discussion will be m a d e in this use o f a child guidance clinic record have already been suggested. T h e amalgamation of psychiatry and social work is perhaps the f o u n d a t i o n stone of child-guidance work. T h i s record, which shows the constant sharing of psychiatric t r e a t m e n t b y doctor and social worker, illustrates the use of the psychiatrist as a social resource. T h e concentration of the problems of this case in the emotional needs of the f a m i l y limits the use of active treatm e n t resources to the clinic personnel; f o r instance, the school and the R a b b i are kept in t o u c h with developments, but do not play active parts in t r e a t m e n t in accordance with the clinic plan. T h e f o r m u l a t e d knowledge of p s y c h i a t r y , with its resulting techniques, is clearly shown t h r o u g h the m e t h o d of recording in the clinic. T h e main objectives then f o r the use o f this case record are to increase the students' practical k n o w l e d g e of certain f u n -

ELEANOR

MEYER

137

d a m e n t a l psychiatric concepts, to let them become familiar w i t h psychiatric and " p s y c h i a t r i c - s o c i a l " technique, and to f o l l o w and analyze the progress of treatment. A teaching note s u g g e s t i n g ways of h a n d l i n g the above follows each e n t r y t h a t the class will be asked t o discuss. T h e material of this record is presented in t w o parts, an artificial b u t useful device f o r emphasizing the part which social history and e x a m i n a t i o n s play in planning treatment. P a r t I carries us t h r o u g h the social study and examinations b y specialists, a logical place to stop f o r interpretation, diagnosis, and p l a n n i n g of treatment. A written assignment m a y be given a t that point to prepare f o r the initial conference which opens P a r t II. T h e mechanics o f the recording of this case include entries o f weighing and e v a l u a t i n g , and so offer the students a natural approach to a t h o u g h t f u l and analytic method of w o r k . T h e students will need copies of the record for study. A s t r e a t m e n t progresses the students will be interested in the success and failure o f the methods under study. It is f r e q u e n t l y easier to evaluate a record than to participate in t r e a t m e n t ; a class is free o f all responsibility, is rem o v e d f r o m the personal relationships of clinic and home, and can i d e n t i f y with any person involved in the case, or with the public. A recognition of the inherent difficulties in personal contacts, as well as the d a n g e r of the extreme detachment of the classroom, can help to m a k e the role of critic pedagogically profitable. N o psychiatrist and no social worker knows how to measure his participation in the lives of others. A s a catalytic agent he is necessary; perhaps that is sufficient when we understand all that it connotes. In this case we have the added f a c t o r of student or less expert and less experienced assistance. Both doctor and worker were s t u d e n t s , ' w o r k i n g under supervision. T h e class, as the record is discussed, is aware of high professional standards, a considerable b a c k g r o u n d of the f o r m u lated k n o w l e d g e of p s y c h i a t r y , familiarity with psychiatric and social techniques, and an excellent w o r k i n g partnership. " T h e d o c t o r , a p s y c h i a t r i s t , b u t i n e x p e r i e n c e d iri c h i l d - g u i d a n c e w o r k ; t h e s t u d e n t a social case w o r k e r , b u t w i t h l i m i t e d social p s y c h i a t r i c

background.

i

3

8

ELEANOR

MEYER

In the use of the record for a beginning case-work group, no attempt will be made to evaluate the psychiatry and social work, except as we are aware of pertinent leads which are not followed u p and of the superficial level of much of the t r e a t ment. The case shows limited progress in four months of clinic contact—the class will undoubtedly question the reasons f o r this. Perhaps experienced clinicians would have helped these people to a more rapid adjustment, perhaps their problems were sufficiently deep seated to need psychoanalytic treatment, perhaps the father was the key person in the situation. A t this point, the students may question and prepare the way f o r the discussion of tHe equipment of the social worker, which will close the class study of Eleanor. TEACHING NOTE: It may be desirable to give the student group an opportunity to ask general questions about behavior problems and to express personal points of view about mental hygiene and its methods, before discussing a record. Such a discussion can be introduced by a description of any mental hygiene clinic—its function, treatment, procedure, type of recording, and its personnel—and followed by a discussion of such questions as: What is a behavior problem? (A deviation from the normal that may indicate a breakdown of social self-maintenance.") What precipitates clinic treatment? (The act of recognizing7 the individual, or family, as constituting a situation suitable for case-work treatment and appropriate to a case-work agency and the existence of organized practice"; the availability of psychiatric social work.) What practical and emotional factors operate in the division of treatment responsibility between psychiatrist and social worker? (The social worker's philosophy: a. values in his professional life b. in relation to his clients.9) Through this establishment of common understanding, students can concentrate upon the specific problems of the Meyer family. "See App. Syllabus, D i v . A.

'Ibid., Dil. Β.

'ibid., Div. C.

'Ibid., Div. D.

ELEANOR P A R T I.

Registration

139

MEYER

SOCIAL STUDY

Data Date & Place

Name: Meyer,

Eleanor

Statement

of Birth: 4.5.18, Louisville, Ky. Address: 45 West 4th Street Phone: Spring-2963 Referred by: Mother Phone: Interview: X Telephone: X Mail: Has consent of responsible relative been obtained: Yes Parents' source of knowledge of Clinic: Dr. Gold far b School: 66 Grade: 5A Teacher: Mrs. Healey Religion: Jewish Living with: Parents Adoptive Father: Frank Meyer Occupation: Salesman Mother: Ottillie Franck (first) (maiden) Marital Status of Father and Mother: Married Couple Siblings (names and ages): Eleanor 10-8 problem

of

Sex: Female

Child lies and is considered very difficult to manage. She fails to obey, particularly when they are indulgent with her. She puts off doing what she is told to do. Stepmother says she is the one source of unhappiness between her husband and herself. He thinks she is too hard with the child. Referral

data

Mrs. Meyer, a rather genial looking woman, came into the office after telephoning for an appointment. She had been referred to Dr. Goldfarb by one of her friends, and Dr. Goldfarb referred her to Clinic because he is to be out of town. He assured her that anybody she would get at the Clinic would be as good as he, and told her that her husband's financial reverses at this time would not prevent him from taking the case if he were to be in town.

14°

ELEANOR

MEYER

Eleanor was adopted, in Louisville, w h e n she was t w o weeks old b y M r . M e y e r and his first w i f e . T h e present Mrs. M e y e r is her h u s b a n d ' s second w i f e . T h e y took Eleanor w i t h t h e m f r o m school, three w e e k s a f t e r their marriage, t w o years ago. E l e a n o r was a w a r b a b y . H e r m o t h e r was G e n t i l e , and her f a t h e r w a s said to be Jewish, b u t Mrs. M e y e r believes that this w a s claimed in order to g e t M r . M e y e r to a d o p t her, as she does n o t look Jewish. M r . M e y e r and his first w i f e sent out cards o f a n n o u n c e m e n t o f her b i r t h , and wished all friends and relations to t h i n k she b e l o n g e d to t h e m . T h e y had not been able t o have a child o f their o w n . Mrs. M e y e r explains her c h a r a c t e r i z a t i o n o f Eleanor's c h i l d h o o d as a v e r y spoiled one, b y describing her h u s b a n d as a v e r y mild m a n , w h o has n e v e r been k n o w n to say one u n k i n d w o r d , and his first w i f e as a " s a i n t . " T h e y b o t h idolized this child. W h e n the first Mrs. M e y e r died, Eleanor was a b o u t 6 or 7 and was placed in the D e Forrest School at S u n n y s i d e , C o n n . T h e present Mrs. M e y e r began g o i n g to see her a b o u t six m o n t h s a f t e r her p l a c e m e n t at this school. T h e teachers alw a y s described Eleanor as a v e r y hard child to m a n a g e , and said t h e y had lots o f t r o u b l e w i t h her. Mrs. M e y e r n o t i c e d t h a t t h e y never seemed to give her a n y a f f e c t i o n . She u n d e r stands n o w t h a t w h e n Eleanor gets a n y e x t r a show o f affection she exploits it, and b e y o n d Eleanor

welcomed

her

as

c o n t r o l . Mrs. M e y e r says t h a t "mother,"

and

has

called

her

" m o t h e r " since t h e y took her h o m e f r o m the school, t h o u g h b e f o r e that she had called her " A u n t H e l e n . " A t first she w a s inclined to be depressed and u n h a p p y , b u t c h a n g e d this dem e a n o r to one of loveliness and a p p a r e n t happiness a f t e r a mastoid operation. Mrs. M e y e r resolved, b e f o r e she m a r r i e d M r . M e y e r , that she w o u l d n o t be the " s t o r y b o o k " k i n d o f stepmother. H e r m e t h o d s o f p u n i s h m e n t , in the order t h e y w e r e t a k e n u p , have been: reasoning w i t h her u n t i l t h a t n o l o n g e r w o r k e d ; scolding her; then w h i p p i n g her; n o w r e a l i z i n g t h a t w h i p p i n g s d o no g o o d , she w i t h h o l d s kissing her at n i g h t or in the m o r n i n g , and refuses t o speak t o her for a d a y

ELEANOR

MEYER

Μ

1

or two. She tries to get her husband to cooperate with her in these last two methods, but finds that if she doesn't give Eleanor her goodnight or goodmorning kiss, her husband will. T h e situation, she now thinks, is desperate, because the girl gets affection f r o m her father, and discipline and sternness f r o m her stepmother. Mrs. Meyer has threatened to leave her husband several times on account of his mildness with Eleanor, and at one time had her t r u n k packed. These measures were mere threats which she did not want to carry out. Mrs. Meyer had difficulty in recalling recent lies that Eleanor has told. The one big one was when she claimed to have been skipped in school, and later Mrs. Meyer found she was in the same grade. This the youngster explained, and Mrs. Meyer understood, was result of taking the child seriously when she told them, just for f u n , that she had been skipped. Their response was so immediate and she was so feted and praised for it, that Eleanor said she couldn't bear to tell them differently Her mother takes her severely to task for her conduct grade of C which kept her academic grades down to B. A couple of weeks ago, she had trouble about tickets which she was expected to buy for a school performance. H e r mother refused to believe her tale of having lost part of the money for this, until later, when it developed the child had told the truth, and only part of her story had been untrue. O n this occasion the mother and father both refused to speak to her. They found a note on the table at the end of a day and a half, in which Eleanor wrote "goodbye"—they would never see her again—she was going over to see the Rabbi. They f o u n d , on calling the Rabbi, that she had seen him. He told them she had promised never to tell another lie, and he had sent her home. There was a later incident in which she lost her Sundayschool book, and after being prodded and scolded about it, by her mother, for about four weeks, she was threatened with a whipping unless she got another one. She promptly brought one which she claimed the Rabbi had given her. They f o u n d

Μ

2

ELEANOR

MEYER

on investigation, that the Rabbi had refused her one, and she had wheedled this out of the sexton. Mrs. Meyer lauded the child's brightness, remarkable memory, and musical talents, and acknowledged that she knows she has made many mistakes with Eleanor, but doesn't know what they are. She wants some help that will relieve her, as she feels "all tense"—and she wishes to do the right thing. When she heard of the treatment procedures of the Clinic and the approach, she was greatly relieved that own mothers were numbered among Clinic parents, as well as stepmothers, and said her friends made her think she had trouble because she was a stepmother. She had told Eleanor and Mr. Meyer that everything else had been done—that the Rabbi could do nothing else with her—and now she would have examinations of her by experts. She promised to undo this impression if possible, by telling the youngster of the number of children who come to the Clinic, where people are trained to understand boys and girls and want to be friends with them. The youngster has been deathly afraid of physicians since her mastoid experience. Mrs. Meyer agreed to show her husband the Bulletin of Information of the Clinic, and to tell him of her visit, changed ideas, etc., about it, and to suggest that he come down to see us, and decide for himself whether to refer Eleanor. 12.28.28—Mr. Meyer came into Clinic when supervisor was out, and left message that he would call for an appointment. Several attempts were made to reach him by telephone before Mrs. Meyer replied and reported that he had been very busy, and was still hoping to get in, but requested that we would accept the case without waiting for him, that he was favorably impressed with her description of Clinic and with the Bulletin. The family would like study to begin as soon as possible. Eleanor is interested herself now, since her mother went over it with her on a different basis. Mrs. Meyer asked that the worker call, either in the evening or early morning before 8:00 A.M., for appointment when she wants to see either of them.

ELEANOR

MEYER

143

1.3.29—Mr. Meyer telephoned that he could not get in to the Clinic, b u t that he would be glad if Clinic would proceed with the case. TEACHING NOTE: The discussion method will be used in class, the students having had the opportunity to become familiar with the record prior to its use by the group. In the first session, therefore, they are ready to answer and ask questions, to suggest procedures, and to give their opinions. In introducing the Meyer family through Part I of the Record, the class may be asked to state the questions that have arisen as they read the case, the points about which they are uncertain, and the value and use of such a heading as Referral Data: Several points of emphasis, which the instructor has selected as leads into the problem, will either be brought out by the students or injected by the instructor through the class contributions. The three following points are illustrated by a few selections from the record: 1. A picture of the emotional level of the current situation. "Mrs. Meyer resolved before she married Mr. Meyer that she would not be the story book kind of stepmother." " . . . the girl gets her affection from her father and discipline and sternness from her mother." " . . . recent lies that Eleanor has told." "She has told Eleanor and Mr. Meyer that everything else has been done . . . now she should have examinations by experts." 2. Treatment has to begin at the point where the client recognizes his problem. "The situation she now thinks is desperate." "Mrs. Meyer has threatened to leave her husband." "On this occasion the father and mother both refused to speak to her." 3. Leads to follow in gathering the formal social history. "They both idolized this child" "His first wife was a saint" "She tries to get her husband to cooperate" "One time had her trunk all packed" "He was favorably impressed with her description of the Clinic and with the Bulletin." "Mr. Meyer telephoned that he could not get in to the Clinic."

1

44

ELEANOR SOCIAL

Identifying

MEYER

EXAMINATION

data

Eleanor Meyer is a girl of ten years and eight months, was born in Louisville, K e n t u c k y , on 4.5.18. She is a well built, fair-haired child, w i t h a bright manner. H e r school grade is j A . Eleanor's father was killed in the W a r before she was born, and her mother died in childbirth. A t t w o weeks she was adopted by Mr. Meyer and she does not k n o w that he is not her real father. T h r e e years ago, the first Mrs. Meyer died, and a year later he married again. T h e home is a comfortable one, although small. T h e f a m i l y consists of Mr. and Mrs. Meyer and Eleanor. T h e parents' attitude at the time history was taken made it seem wise to delay the question of v e r i f y i n g birth date, until a better rapport is established. Mrs. Meyer

(second w i f e of Mr. Meyer, and k n o w n as

patient's stepmother)

consulted D r . G o l d f a r b w h o advised

the Clinic, and she obtained her husband's somewhat grudging consent. T r e a t m e n t was at first held over the child as a threat, and, although the adoptive stepmother has since tried to destroy this first impression b y explaining that the Clinic wants to help both mother and daughter, it is d o u b t f u l how far this has been successful. A f t e r Mrs. Meyer had gone over the ground w i t h Eleanor, patient returned f r o m an interview with Rabbi Finkelstein, saying that she was not going to the Clinic, and that the R a b b i disapproved of it, and did not think that it would be good f o r her. Mrs. Meyer's method of dealing w i t h this attitude was ( b y her o w n a c c o u n t ) first to make Eleanor w i t h d r a w her statement about the R a b b i , and then to assure her that all arrangements were made, and that she would do as she was told. T h e adoptive stepmother explained the value of the w o r k of the Clinic, and thinks that Eleanor is no longer antagonistic.

ELEANOR Siources of information

MEYER

and worker's

145

contacts

M r s . M e y e r : J a n u a r y i i t h at the home. J a n u a r y 1 5 t h , and 1 j t h , at the C l i n i c . M r . M e y e r : J a n u a r y 10th and 18th at C l i n i c . M r . M e y e r was v e r y ready t o discuss patient and a d o p t i v e stepmother, b u t rep e a t e d several times t h a t he did not consider there was a n y p r o b l e m o f character. H e was v e r y evasive w h e n a n y a t t e m p t w a s made t o b r i n g the conversation a r o u n d t o his o w n u p bringing. M r s . H e a l e y , Class teacher, P.S.66: J a n u a r y 7 t h . She hesitated at first about g i v i n g i n f o r m a t i o n , b u t u n b e n t and then said t h a t she had an o n l y child w h o showed m a n y o f the same c h a r acteristics as the patient, that c o n s e q u e n t l y she f e l t v e r y s y m p a t h e t i c t o w a r d s Eleanor. Mrs. H e a l e y did n o t g i v e the i m pression of b e i n g v e r y observant. D r . A . S. Finkelstein: J a n u a r y 7 t h at his office. A y o u n g rabbi w h o has had patient in his S u n d a y school f o r three months. H e prides himself on his success w i t h p r o b l e m children, and f r a n k l y regretted that Eleanor had not been l e f t to him. H e g a v e i n f o r m a t i o n readily, h o w e v e r , and expressed his desire to cooperate. H e has seen the a d o p t i v e stepmother t w o or three times, and the adoptive f a t h e r oncc o n l y , and has little k n o w l edge of t h e m . H e said that he was not successful w i t h parents, a n d therefore never a t t e m p t e d to w o r k w i t h t h e m . H e had n o s y m p a t h y w i t h m o d e r n parents. T E A C H I N G N O T E : It may be well to discuss policies of child-placing agencies in regard to adoption; for instance, should a child be told that he is an adopted child, is it desirable that the family have the child prior to adoption in order to determine the unity of the new family group, etc.? The emotional values behind these two policies is obvious, but may be discussed in relation to their increased significance in a stepmother situation such as is found in the Meyer case. In this entry students may also note the importance attached to the establishment of relationship: "Delay the question of verifying birth date until a better rapport is established."

14^

ELEANOR

MEYER

"Treatment was first held over the child as a threat, and, although the adoptive stepmother has since tried to destroy this Erst impression . . . "

Problems

revealed

Mrs. Meyer complains that patient lies, is disobedient, defiant and beyond control. T o this should perhaps be added dawdling, and for a time, masturbation. Lying.—According to the adoptive father, patient lies to excuse herself. She says the first thing that comes into her head without any thought for the consequences. T h e lies are o f t e n stupid. In addition to the examples already given, Mrs. Meyer gave a description of how, some time back, patient came home saying she had been chosen to take the part of "KNOWLEDGE" in a school play. Later she said she would need a dress, and gave her adoptive stepmother the necessary description. Mrs. Meyer made the dress and Eleanor took it with her to school and after the play brought it back. It was not until later that, accidentally, the adoptive stepmother learned that patient had not taken part in the play, and she admitted that although chosen in the first place, the part had been taken away f r o m her for misconduct. Recently the stepmother has also detected cheating in school work. It is not unusual for the children to correct their own books, and Mrs. Meyer found that she marked a problem right which was clearly wrong, and gave herself full marks. She also got a boy to tell her the answers to two questions which Mrs. Meyer knew she could not have answered correctly unassisted. The adoptive stepmother wrote to the class teacher about this, asking that Eleanor should not be trusted to do her own corrections. Mrs. Meyer has also threatened to go to the principal and ask him to announce to the school that patient lies. She says that she realizes that this is a very terrible threat to use even though she has no intention of putting it into action. From Mrs. Meyer's accounts of these more serious lies, one was left with the impression that the careless, boastful, or ex-

ELEANOR

MEYER

147

c u s i n g lie gets beyond her control owing to fear of humiliat i o n , and possibly punishment. Mrs. Meyer has punished by refusing to talk to her, and by whipping, without result. Recently, she asked Eleanor why she lied, and patient said that she found lies easier. Mr. Meyer could not say whether patient lied as a small child. He admits he would not have noticed it, but said that he looks at it all " w i c h the eyes of a child" and that lying is natural to children. Disobedience.—Over matters both large and small, but chiefly concerned with tidiness. Since the first day that Eleanor was b r o u g h t back f r o m boarding school, Mrs. Meyer has had one long struggle to make Eleanor orderly in her conduct, and with her belongings. Getting up promptly, dressing quickly, changing her clothes, putting her clothes in their right place, both in the morning and at other times of the day, behaving nicely at the table, not prolonging bath indefinitely, etc. The impression made on worker was that the adoptive stepmother is continually nagging, and she herself says that where she had hoped to rule by love, she finds she is more and more ruling by fear. Mrs. Meyer describes herself as firm and emphatic. At first her methods were less stern, but Eleanor is said (by both adoptive parents) to take advantage of any kindness. She is sometimes defiant, doing deliberately what she has been repeatedly forbidden to do. Temper.—Beyond the defiance referred to, which Mrs. Meyer deals with sternly, there have been no signs of temper at home. Friends with whom she has stayed for week-ends, however, complain of her temper. Recently she kicked a small boy on the knee and then locked herself in the bathroom. Both adoptive parents say that f r o m accounts given, she appears to break loose the moment she leaves her adoptive stepmother and refuses to do anything she is told. Dawdling or daydreaming.—Mrs. Meyer mentions this in connection with dressing in the morning. She says that Eleanor will take fifteen minutes to put on her stockings if left alone. Mr. Meyer says that sometimes she does not hear when she is

ι 48

ELEANOR

MEYER

spoken to, even though not doing anything at the time (this he thinks only partly due to deafness), and when dusting she will go over one spot again and again, while gazing out of the window. Beyond control.—By this Mrs. Meyer means that punishment appears to make no lasting impression. Five minutes afterwards the episode is forgotten. Whipping is the only punishment that has any permanent effect, and that only for about two weeks. Her adoptive father says that patient has no feeling of responsibility, that her memory is very good when she is interested, but that she never remembers Mrs. Meyer's instructions. Masturbation.—One other problem was mentioned in the course of interviews. For a short time Eleanor masturbated when lying down. A friend drew attention to this, and Mrs. Meyer questioned patient who said that it was due to irritation. Mrs. Meyer does not feel that she overemphasized this. She explained quietly that if patient washed and dried herself well, there would be no irritation, and she gave her some ointment. At the same time, she told Eleanor that masturbating was harmful both mentally and physically. There does not appear to have been any repetition of this. The adoptive stepmother often goes in to her at night, and has never found her hands near her genitals.

Family

problems

Mr. and Mrs. Meyer disagree completely in their attitude towards Eleanor, and their relations are becoming strained in consequence. Mr. Meyer refuses to scold Eleanor and continues to treat her as though nothing has happened even when his wife is not speaking to the child. For two days before Eleanor was brought up for psychological examination, Mr. and Mrs. Meyer were not speaking and meals were entirely silent. Mr. Meyer is in the habit of kissing his wife morning and night and this he omitted to do.

ELEANOR

MEYER

M 9

T E A C H I N G N O T E : As the problems, from Mrs. Meyer's point of view, are clearly presented in Part I of the Record, the class will be asked to consider their emotional value for each member of the family. T h i s discussion will of necessity be a limited one, as the history material revealed up to this time is meager. Such a discussion will have value in preparing the class for: 1. T h e kind of information which the psychiatrist and social case worker look for in the social history and topics around which it may be secured, e.g., Why does "patient have to lie to excuse herself?" Why is it that " M r . Meyer could not say whether patient lied as a smaU child?" Why is Mrs. Meyer "more and more ruling by fear, etc.?" 2. Problems which should be handled at least superficially because they represent the reason for referral and the point at which the individual patients may be reached and contact established. 3. T h e suggested depths of the problems which superficially seem to be limited to the behavior of a child, but which represent the emotional results of the life experience of three individuals; for instance "Mrs. Meyer has also threatened to go to the principal and ask him to announce to the school that patient lies." "Since the first day Eleanor was brought back from boarding school, Mrs. Meyer has had one long struggle to make Eleanor, etc." "Mr. and Mrs. Meyer disagree completely in their attitude towards Eleanor, etc." The social history outline will probably not need elaboration, as this type of outline has become familiar to all new workers and students.'" The special examinations are also familiar but may be discussed in detail when they appear chronologically in the record. Tbc family Parental

and its

evolution

Background.—Of

patient's

real

parents

nothing

could be learned. T h e adoptive father either would not, or could not give information. Adoptive

parental

background.—Paternal

g r a n d p a r e n t s were

Austrian Jews o f good standing. A c c o r d i n g t o the adoptive father, there was little o f the traditional A u s t r i a n sternness in 10

Thi

but

vilue

of

associated

social with

ques:ionid at this

history, treatment

point.

dissociated for

the

from

treatment,

psychiatrist

and

as

the

social

patient worker,

sees

it,

may

be

15°

ELEANOR

MEYER

the home, although he says that obedience was e x p e c t e d a n d obtained. T h e g r a n d f a t h e r more particularly, he described as exceptionally sweet tempered, and Mr. Meyer says that w h e n speaking of his father, he is always very m u c h m o v e d , that he was v e r y attached to him. T h e r e were three boys, all b o r n in the States. T h e adoptive father is the youngest. T h e second one died y o u n g . T h e eldest son is married, b u t has no children. Mrs. Meyer says that he is always quarreling w i t h his w i f e , but gets on quite well w i t h patient's adoptive f a t h e r , a l t h o u g h they do not see a great deal o f each other. H e has retired and lives in Canada. H e is v e r y close w i t h his m o n e y and does not e x p e c t his w i f e to keep a maid. Adoptive

step-maternal

background.—Grandmother

Russian, and g r a n d f a t h e r t h o u g h t to be G e r m a n b y

was birth.

T h e i r children were born in the States. M o t h e r describes her home as a v e r y c o m f o r t a b l e one. T h e r e were seven children and they all had a great respect f o r their f a t h e r , a l t h o u g h he was not stern. T h i s she attributes to the respect w h i c h her mother showed him. T h e g r a n d m o t h e r was v e r y stern, and meticulous. Mrs. M e y e r says that w h e n y o u n g , she f e l t that her mother was overparticular. N o w , she has c h a n g e d her point of view, however, and thinks that her methods were justified. ( M r . Meyer, w h o did not k n o w his w i f e ' s m o t h e r , says that she n a g g e d ) . She has modeled herself on her m o t h e r , and considers that they are as m u c h alike as any t w o people can be. Questioned as to how the other children reacted to g r a n d m o t h e r ' s training, Mrs. Meyer said that they paid less attention to it, and have not perpetuated the pattern. A f t e r g r a n d m o t h e r ' s death, Mrs. Meyer w e n t to live w i t h an elder married sister, w h o m she describes as an easy g o i n g careless housekeeper, w h o gladly l e f t the care of the home and child t o her. Mrs. Meyer is in constant correspondence w i t h her f a m i l y , b u t they do not live near. T h e youngest b o y (r 3 years y o u n g e r than patient's adoptive stepmother, the next y o u n g e s t c h i l d ) died of pneumonia w h e n nine. T h e others (all married) are in good positions, and in good health.

ELEANOR

MEYER

I5

T

T h e r e are no immediate relations with whom patient is in touch. Adoptive

maternal

background.—Owing

to the

adoptive

father's attitude towards the enquiry, and his unwillingness to admit that there was any problem beyond the effect of the adoptive stepmother and child on each other, and possibly a certain lack of responsibility on the part of the patient, it was not possible to make any inquiries into background of his first w i f e . A l l that was learned was that her people were not Jewish (this f r o m the second Mrs. M e y e r ) , and that she was a mother's child! The immediate Adoptive

family

mother.—The

first Mrs. Meyer is described by her

husband as a sweet woman who never once raised her voice. She had been a nurse and was devoted to children. Both she and her husband passionately desired a child, and knowing that she could not have any, they adopted Eleanor. T h e adoptive father says that their lives centered around the child, who was given everything she could possibly desire. Mrs. Meyer died of heart trouble after a long illness, when Eleanor was seven and a half years old. T h e second Mrs. Meyer did not know her, but describes her as a " s a i n t , " and Mr. Meyer speaks of her in terms of great admiration and affection. Adoptive

father.—Frank

Meyer, aged about 40, is a nervous

worried looking man, of medium build. H e was born in the States. H i s health is said to be good, although he describes himself as nervous. His parents were of good standing but he did not receive a college education (stepmother). H e went into the hardware business, and did very well, so that during the life of the first wife, they always had maids and nurses. A f t e r his second marriage, he went into business on his own, with his w i f e , but had not enough capital to weather the slack period, and is now a salesman f o r a firm in the same line of business. Financially they are not well off, and they have a much smaller apartment

I 5

2

ELEANOR

MEYER

and no maid. Neither adoptive parent makes m u c h of this financial reverse. Although a quiet man, he has friends whom he sees more or less regularly, generally in the company of his wife. At home he is (according to Mrs. Meyer) usually gay and will recite and sing, with appropriate actions, for Eleanor, inventing the words as he goes along. When it was possible to get him to discuss his own boyhood, he said he was very happy, and described himself as a mother's boy, always glad to help in the home. From his conversation, it seems that he was very much in love with his first wife, and remembers her with great affection. He says that he married again partly to provide his daughter with a home. He is, however, on very affectionate terms with his present wife (if her account is to be believed), and speaks of her as a most competent housekeeper, and a very good woman. H e says that she must be good to devote her life to the child as she does, although he does not agree with her methods of training. At one moment he described her as like her mother who nagged, b u t corrected himself and said she was overfirm, and allowed herself to be worked up excessively. The adoptive father is devoted to and very proud of Eleanor. H e says that she is the center of his life, that he would do anything in the world to save her any of the rebuffs that must come to her later in life. H e thinks that he may have spoiled her. Patient's achievements on the piano and in dancing are a source of great satisfaction. H e thinks her clever in all except arithmetic. With regard to patient's problem, he does not admit that there is any cause of anxiety. H e thinks her lacking in sense of responsibility which makes her careless of instructions, and leads to useless lies, but does not think she has any faults that growing reason will not cure. The situation at home, however, created by this lack of responsibility, and Mrs. Meyer's methods of dealing with it, are causing serious strain in the family relations. Mr. Meyer may go home ready to be happy, and play with Eleanor, only to find that, owing to some mis-

ELEANOR

MEYER

153

demeanor Mrs. Meyer is not speaking to the child, and that he is expected to follow the same line of conduct. He never knows w h a t the situation may be when he gets home, and this makes h i m very unhappy. He says that he is quite incapable of being angry, and that on the rare occasions on which he has had to punish the child, he has suffered most, and Eleanor knows this. O n c e he starts, he loses control of himself—rages and even strikes patient. Then, realizing what he has done, is overcome w i t h grief. In any case he says he cannot trust himself to punish her. H e is quite sure that, left alone with Eleanor, he could manage her by kindness. Mr. Meyer described himself as an "old maid," but added that he did not expect the child t o have the same temperament. Adoptive

stepmother.—Mrs.

Meyer is thirty-six years old.

She is a good looking woman with a vivacious capable manner. Born in the United States, she is the sixth of seven children. For thirteen years, she was the youngest, when a boy was born. She mothered him, and a niece of the same age, and liked to do everything for him (he was always very delicate, and died when nine years o l d ) . Mrs. Meyer says that when she was younger, children were very fond of her, but that later their attitude changed. She stayed at home until her mother's death nine years ago; they were very great friends, and did everything together. Mrs. Meyer did not keep house for her mother and her help was not needed as they were always able to keep servants, but she was thoroughly trained in all domestic duties, and is particularly proud of her cooking. She was not a very strong child but her health improved as she grew up. O n her mother's death, she went to live with a married sister who went out to work. She had the complete bringing up of this sister's child from the age of three years, and they slept in one room. Mrs. Meyer, however, did not succeed in training her in habits o f orderliness as she would have wished, and one gathers that she did not win her affection. Mrs. Meyer thinks that perhaps she is too severe with children when she has full charge of them.

154

ELEANOR

MEYER

Mrs. Meyer was t h i r t y - f o u r when she was married. Mr. Meyer was introduced to her by her brother-in-law after he had become a widower, and the friendship developed rapidly. The adoptive stepmother keeps in touch with her family, by correspondence, and has a fairly wide circle of friends whom they visit. She had not been in business before her marriage, and has no training that would fit her for a job, although she is sure she has practical ability. The subject has evidently been considered by her quite seriously. In general, however, she does not consider it wise for women to work. Their husbands always come to rely upon their earnings, and difficulties arise if anything prevents them f r o m continuing. In any case as far as she is concerned, she does not think she could do her d u t y by patient if she worked. W h e n she married, Mrs. Meyer was determined to make a successful job of Eleanor, and on the first day explained this to her. She pointed out f r o m the beginning, all the small things in which Eleanor has failed, and when she found that these means were not enough, she was stern, and finally whipped her, although this has never been frequent, and lately has been dropped altogether. The adoptive stepmother is both disappointed and exasperated at her own failure with Eleanor. She blames the adoptive father to some extent, says he sits dumbly by when she is trying to cope with the patient. She has told him that she did not expect to have to deal with Eleanor singlehanded, and accuses him of not cooperating. She feels that she is ruling by fear, and knows that she is often severe. At present she says that she loves the girl, but sees that if the strain goes on, she will come to hate her. Persistent untidiness, disobedience, and lying, seem to her the most serious problems. Mrs. Meyer is very house proud, and says that she cannot bear the slightest disorder; that a thread on the carpet is a source of real agitation for her. She compares herself with her mother in this. She also says that she is highly strung, and becomes almost frantic with exasperation when Eleanor is intractable. Marital relations.—Mrs. Meyer says that they would be ideally

ELEANOR

MEYER

155

h a p p y were it not f o r this one source of friction, but that lately she has felt that her husband's love f o r her is being affected. T h e y are both of them (according to stepmother) demonstrative. Their financial position makes it impossible f o r them to h a v e other children, and at the same time give the best of everything to patient. Mrs. Meyer says that Eleanor must come first, and that therefore, she does not mean to have any children. She has discussed this with her husband, and he agrees. Home and home conditions T h e family occupies an attractive apartment in a very good neighborhood. T h e apartment, however, is small, and patient sleeps on a couch in the sitting room. Financially they are not as well off as before this marriage, but there is no appearance o f poverty, and apparently no feeling of resentment. Eleanor is said not to have noticed the change. The patient Eleanor Meyer was born in Louisville, K e n t u c k y , 4 . 5 . 1 8 , and is now ten years, eight months old. H e r father was killed before her birth, and her mother died in childbirth, and at t w o weeks she was adopted by the Meyers, who sent out notices of her birth to their friends in order that all might believe she was their own child. Eleanor does not know she is adopted. O w i n g to the death of the first Mrs. Meyer, and the somewhat hazy recollections of Mr. Meyer, the factual i n f o r mation about the early years is a little uncertain. For a f e w weeks there was difficulty in finding the right food. There was no difficulty in transferring to spoon feeding, but the bottle continued f o r the child's pleasure up to the age of four or five. This would have been about once a day. She did not suck her thumb, or bite her nails, and she was a good-tempered child. First tooth at seven months. She said " m a m a " and " d a d a " at ten months, but other words did not follow until sixteen months. She walked at nine months. (These entries are in the " B a b y ' s B o o k . " ) She did not have

156

ELEANOR

MEYER

convulsions. Toilet habits were easily established. T h e only food that she would never eat was bananas. She showed no signs of left-handedness. A t t w o years she had m u m p s which lasted only f o u r or f i v e days. A t three, she had tonsillectomy, and measles. Following measles, she had discharging ears which persisted until she had a mastoid operation, one and one-half years ago. Mrs. Meyer does not think she was bad tempered, but admits that she was spoiled. Friends of the f a m i l y have told Mrs. Meyer that she was always the center of the household, and demanded the attention of everyone. T h e adoptive f a t h e r does not remember her as delicate, but says that a f t e r the mastoid operation she blossomed out into a bright and c h e e r f u l child. A d o p t i v e stepmother says that she was moody before the operation. W h e n seven and one-half years old, her adoptive mother died. A d o p t i v e father does not think she was very upset, and is quite sure that patient was not much affected b y adoptive mother's illness. There were maids to look a f t e r her, and she had friends to play with. Eleanor disliked going to boarding school, however, and says n o w that she was v e r y u n h a p p y there, that she wrote asking to be taken a w a y , but that the letters were withheld by the teacher. She had been at the boarding school one year w h e n M r . Meyer married again,

and

brought her home. D u r i n g that year, she was visited regularly by Mr. Meyer and her f u t u r e adoptive stepmother. Sometimes, when the father was " o n the r o a d " Mrs. Meyer called alone, and they became good friends. Eleanor was not told of the i m pending marriage, but at the end of D e c e m b e r , 1 9 2 6 ( a f t e r the m a r r i a g e ) , they w e n t out to the school to bring her home, and Mr. Meyer went in and told her. She ran out to the car immediately, flung her arms around her stepmother's neck, calling her " m o t h e r " and saying how glad she was. It has been " m o t h e r " ever since. W h e n brought home to their new a p a r t ment (smaller than the one they had lived in b e f o r e ) , her first remark was " h o w s m a l l ! " much to the disappointment of Mrs. Meyer, w h o had c a r e f u l l y prepared e v e r y t h i n g .

ELEANOR

MEYER

157

T h e only illness during the last t w o years has been the mastoid operation. Mrs. Meyer t h o u g h t that she had been a good patient when left alone, but that when the dressings had to be attended to, she struggled and f o u g h t . (Hospital has no record of this.) T h e adoptive stepmother said that she is very bad at bearing pain, and when she has to be taken to the dentist, she is never told till the last minute because she makes herself so nervous in anticipation. A friend of the f a m i l y was recently expecting a baby, and Mrs. Meyer made it the occasion to give patient some sex information. She described the conception of the child starting w i t h the flower, but did not feel that Eleanor was, as yet, ready to learn about the f u n c t i o n of the father, nor did she describe the birth process, this for fear of causing her to worry. Eleanor showed interest and came back to the subject more than once. A t first patient was sensitive about being seen naked by adoptive stepmother, but Mrs. Meyer told her that there was no reason for minding, and now she behaves quite naturally. Mrs. Meyer lets her come in when she is in the bath. Eleanor entered public school when five, and her adoptive father thinks that she enjoyed school life. Her reports at this school were as follows: Grade

Conduct

Work

ιΑ

A

B+

iB

A

B+

zA

A

Β

zB

A

Β

W h e n 7 J/2 years old, Eleanor was sent to the De Forrest School, Sunnyside, C o n n . , (principal Miss Eva H a r t l e y ) as a boarder. The school is interdenominational, and they have a number of Jewish children (according to stepmother). W h e n visiting, the adoptive stepmother received the impression that she was not getting on w i t h the staff and other children, and learned from a teacher that she o f t e n had to be punished for disobe-

158

ELEANOR

MEYER

dience. Eleanor says that all the children were frequently punished. Since J a n u a r y 1 9 2 7 , patient has been attending P.S. 66; her reports have been: Grade

Conduct

Work

3A

A

Β

}B A

Β

Β Β+

4

4

b

5Α

ist month 2d 3d 4th

Β B + C

Β+

?

Β+ Α Α

Β

Α

Β

Mrs. Healey, the class teacher, described Eleanor as exceptionally bright, but not v e r y much interested in her w o r k . H e r best subject is English, and her worst, arithmetic. She is outstandingly untidy (desk always in a mess) and does not obey promptly. With other children she adopts a somewhat resentf u l manner, and in consequence is not very popular. When books are passed around f o r correction, Eleanor marks the other girls' books very rigidly, picking on the smallest point, while on the other hand, she resents any corrections of her books. T h e teacher says that she has v e r y nice manners and takes scolding very well. Mrs. Healey had not noticed any special untruthfulness before this had been brought to her notice by Mrs. Meyer, and even now appeared to treat it lightly. She thought the adoptive stepmother somewhat stern, but an excellent mother. T h e teacher f o u n d it impossible not to point out Eleanor, and patient was therefore spoken to. She answered in quite a f r i e n d l y w a y . Personality:—Patient is generally open and friendly, according to both parents, and likes to demonstrate her affection actively. She watches her adoptive stepmother's every movement, and hangs on her mood. In the morning she will look into her eyes when she is awakened, and will comment on

ELEANOR

MEYER

159

her mood. Should Mrs. Meyer give her two kisses instead of the usual one, she will immediately take advantage of this, take much longer over dressing, p u t her things away carelessly, and rush off to school in high spirits. Sometimes she will throw her arms around the adoptive stepmother's neck and be particularly demonstrative. The adoptive father doubts how far this is genuine affection, and how far it is a deliberate attempt to win around her adoptive stepmother, and at the same time gratify her feeling for acting a part. Mrs. Meyer is also a little uncertain of this behavior. Eleanor is untidy and thoughtless, and, as a result, comes in for a great deal of scolding, if not nagging. She is sometimes defiant on these occasions, b u t more o f t e n just waits until she sees her adoptive stepmother smile again, when immediately her spirits bubble over. Frequently the adoptive stepmother, to punish her, will refuse to talk to her for two or three days, and she tries with d o u b t f u l success to prevent her husband f r o m breaking the silence. Mr. Meyer says that when this happens, Eleanor will look f r o m one to the other not quite knowing what to do. Mr. Meyer almost invariably gives way. When in the wrong she will lie carelessly, and show little regret when this is explained to her. Recently in fact, she said that lies were easier than the t r u t h . Eleanor, apart f r o m the first remark about the smallness of the apartment has shown little consciousness of the home. She sleeps in the sitting room, and her only household tasks are p u t t i n g away the bedclothes and dusting the room. She has accepted this as her job, but both adoptive father and adoptive stepmother say that she does it badly, daydreaming over her work. W i t h the exception of squash and bananas she will now eat everything, but this represents a long struggle with her stepmother. Very soon after returning home, Eleanor declared at breakfast that she could not eat cereal. She was told it was that or nothing, and she elected to go to school hungry. A t lunch she found her reheated oatmeal in f r o n t of her, and declared she would not eat it. Mrs. Meyer's response was that again there would be

ΐ6θ

ELEANOR

MEYER

n o t h i n g else, and that m u c h as she regretted it, the oatmeal would have to be carried along to a friend's t h a t evening in order t h a t she might eat it f o r supper. Eleanor capitulated. Meals are, in another way, an occasion for f r i c t i o n . Eleanor eats noisily with her m o u t h open and does not always sit up nicely. W h e n lunching with w o r k e r , Eleanor's manners left m u c h t o be desired, and she was easily excited by another child. W h e n sleeping Mrs. Meyer says t h a t her m o u t h is shut. Patient's chief indoor recreations are reading and a c t i n g . W h e n reading she will lose herself entirely in the book and burst into tears or laugh out loud. A t present she is reading the Elsie books. She is equally emotional when her adoptive f a t h e r recites or if she is taken to the movies ( o w i n g t o her tense a t titude she is rarely t a k e n ) . O n the other hand, Mrs. M e y e r says t h a t she is very little moved by actual events ( n o positive examples o f this could be o b t a i n e d ) . Patient's greatest joy is dressing up and acting. She will act alone, with t h e c o m m u n i c a t i n g doors open, however, and she will talk loud enough to be heard. Sometimes she acts before her adoptive f a t h e r , just now the part o f a doctor or a nurse. Mr. Meyer says t h a t whenever possible she puts on her adoptive mother's clothes; t h a t she talks of wishing to be an actress. W h e n

financially

better off, she had dancing lessons, b u t these have had t o be dropped. Since O c t o b e r , Eleanor has attended Sunday school at the Zeta Synagogue. D r . Finkelstein, the R a b b i in charge, is very m u c h interested in children, and has been studying Eleanor since the episode o f the lost S u n d a y - s c h o o l book. H e has been t r y i n g to develop her sense o f responsibility, and t h i n k s t h a t he has made some headway. Eleanor's Sunday-school teacher had given satisfactory reports o f her before the book episode, although she was not considered a b r i g h t pupil. D r . F i n k e l stein

described

her

as an

8oc/(

child.

When

her

lying

brought patient to his notice, her m a n n e r made him t h i n k at first

that her trouble was organic. She seemed incapable o f

telling the t r u t h , and posed in f r o n t o f him. H e r m a n n e r ,

ELEANOR

MEYER

l6l

however, has become quite natural, and the Rabbi says that he made her promise to come to him if she again got into trouble, and this she has done. Social resources available

for

treatment

Zeta Synagogue where Eleanor attends temple. Neighborhood is a residential one in the suburbs, and no settlement community centers, etc., are available. Psychiatric Social Worker. S U P P L E M E N T A R Y SOCIAL E X A M I N A T I O N

2.14.29 Information obtained f r o m adoptive stepmother. Birth

and adoption.—Eleanor's

mother did not die in child-

birth as stated by adoptive father. Mr. Meyer answered an advertisement in a Louisville paper, and negotiations were carried out chiefly through a lawyer

(friend of mother's)

w h o showed so much interest in the adoption that Mrs. Meyer believed he must himself be the father, in spite of the statement that the father had been killed in the W a r . Such inquiry as was possible was made, and the blood tests proved satisfactory. For a time a f t e r adoption, she had boils on her head, which were disfiguring, but she soon grew into an attractive child, m u c h to the astonishment of Mr. Meyer, who had, it seems, been alarmed at her ugliness. T h e adoptive stepmother appeared to have no feelings about this, but spoke at some length about the beautiful relation between Mr. Meyer and Eleanor, saying that she would not have believed such love possible f o r a child not one's own. Adoptive

stepmother

relationship.—Mrs.

Meyer told worker

that when they moved to their present apartment, she told Eleanor that she did not wish to be k n o w n as her stepmother, that she did not wish patient to forget her mother (adoptive) but, since her mother was dead, she wished her to think of herself as mother, and extracted a promise f r o m the patient never to tell anyone of the step relationship. Yesterday, it came

I 6 2

ELEANOR

MEYER

to Mrs. Meyer's ears that Eleanor had told another little girl w h o also has a stepmother. When Eleanor c a m e home, she taxed her with this, asking her how she would like it if she always referred to her as stepdaughter; that if Eleanor really loved her, she would not have done this, and that she was really hurt. T h i s was followed by the usual silence. Mrs. Meyer t h r o u g h o u t showed that she is extremely sensitive on this subject. Marital

Relations.—The

adoptive stepmother described their

relationship as physically and psychologically perfect, were it not for the occasional misunderstandings over Eleanor. A t first they would have been glad to have another child, b u t now financial considerations have made it out of the question. Psychiatric Social W o r k e r . E X A M I N A T I O N S BY E X P E R T S , A N D A N I N T R O D U C T I O N PART II,

TO

TREATMENT

T E A C H I N G N O T E : For the section Family and its Evolution" and the examinations by experts two procedures seem desirable, one involving the analysis of material in order to prepare for the second; namely, the interpretation, diagnosis and plan of treatment. It does not seem necessary in using the Record for these specific purposes to discuss the evolution of the family in detail. An analysis of all material, examinations and social study, gives the student an understanding of the emotional components of and motivations for the behavior of the patient. The psychiatric, psychological, and physical examinations may be discussed in detail after the above plan has been presented to the group. The specific points selected for emphasis in the discussion of these examinations will be found in a teaching note following each examination. After the discussion of the particular contribution of each examination to the understanding of the case and to the future treatment plan, the students will see that diagnosis and plan evolve from the study of data and create a series of directed objectives for the treatment of the case. As such an analysis and plan is often a new experience for the student, an outline prepared by the instructor may be given the class. " T h i s p h r a s e is u s e d in t h e R e c o r d , as o b t a i n e d in t h i s a g e n c y , f o r t h e s o c i a l or

investigation.

study

ELEANOR

MEYER

163

The outline for this analysis of the family and its evolution, and for the examinations by specialists has been prepared from the topics of the initial conference (Part Π) held by the examiners. This study emphasizes outstanding happenings only in order to suggest the need to relate and weigh all information, and to recognize that a bulk of detailed material will mean a more certain and a clearer picture rather than a complex one. As students work on such an analysis they will be aware that treatment objectives are growing out of their interpretation. This outline can then be given to the class with time allowed in class, for them to read it, ask questions, and possibly give suggestions. Outline for Analysis of Social Evolution of the Family and Examinations by Specialists a. Sift out the outstanding happenings or reactions which created the problems for: the father the stepmother the child b. Evaluate the behavior symptoms of each member of the family as they affect the total situation and have meaning for: the father the stepmother the child c. Plan treatment for the problems revealed by your analysis of a and b of this outline. Note possibilities for success now and at a later date. PHYSICAL

EXAMINATION

2.7.29 Interpretations

and conclusions.—Her

general physical condi-

tion is excellent. T h e ear findings represent the residue of a chronic otitis media cleared up by mastoid operation. Her pulse of 1 2 6 diminished to 1 0 2 a half hour later. The high pulse early in the examination was due to emotional tension. Blood pressure is only slightly increased. However, it may be the result of absorption in infection from the abscessed tooth. A leucocyte count was not made. T h e ear condition is being cared for by her own physician. Teeth need attention at once.

164

ELEANOR

MEYER

The chapped legs are due to the short stockings she wears. Treatment recommendations.—Dental care. Pediatrician. T E A C H I N G N O T E : In social case treatment the social case worker is interested in the physical condition of her clicnt. H e r interest is two-fold in that she wishes to discover physical conditions needing attention and to recognize that physical conditions emotionally colored may block treatment. T h e clinic set-up emphasizes the relation of health to behavior. One other point which may be stressed is that the physical examination indicates the level of physical adjustment at the time treatment is undertaken. W c may discuss the above general points and spend a moment upon the specific physical findings which appear to be negligible. Treatment, therefore, can be concerned with personality adjustment only. PSYCHOLOGICAL

EXAMINATION

I.25.29, 2.7.29 Born: 4.5.18 Present Grade: 5 A Chronological Stanford Binet Performance Β Stanford Achievement

Age Grade Equivalent 10-10 4B 10- 9 4B 10- 2 4A 11- 9 SB

I.Q. 99

Discussion.—The Binet and Performance ratings correspond closely, indicating average intelligence, with approximately equal ability in handling verbal and concrete material. That these are probably minimal ratings is suggested by the higher score on the Achievement test, two near successes on the Binet, and a wide scatter of successes and failures on both the Binet and Performance examinations. For these reasons, the Stanford Achievement results are considered more reliable. According to these results, her rating corresponds to the end of 5B, one half grade in advance of her present placement. Her subject scores are rather uniform, rating her at the fifth

ELEANOR

165

MEYER

or s i x t h g r a d e level in all tests e x c e p t s e n t e n c e m e a n i n g ( 4 A ) a n d l a n g u a g e usage ( 8 A ) . R e e x a m i n a t i o n at t h e e n d of six m o n t h s is r e c o m m e n d e d .

Psychologist.

T E A C H I N G N O T E : All case-work students will find psychological tests or a reference to them in their case work. This record including as it does a routine psychological examination as an integral part of the set-up of the child-guidance clinics, gives the opportunity to ask students to study tests in common use and to discuss in general the relation of emotional unadjustment, of limited training, and of life experience to I.Q. ratings. Psychological tests eliminate negative factors, indicate qualitative differences and positive or potential factors for treatment. W i t h the emphasis that certain groups are placing on the high I.Q. child, it may be well to discuss the intellectual capacity of the normal intelligence—an I.Q. of 90-100. Emotional factors, ability to concentrate, to retain and to verbalize are all of so much importance that they might well be discussed as positive factors in relation to the normal I.Q., and as destructive factors when they exist negatively for the child with an I.Q. of 120 or more. Schools and colleges are now considering interest, taste, temperament, mechanical ability, etc., as well as the I.Q. rating, in their entrance requirements, as indicating capacity for carrying any given curriculum. This particular psychological examination gives the class opportunity to discuss, through a direct question from the instructor, the relation between a Binet rating of 10.9 and a Stanford Achievement rating of 11.9. As the Stanford Achievement test is used as the norm of school achievement, students will readily see that Eleanor is not using her intellectual capacity and, therefore, is probably carrying over an emotional involvement into the school situation. Performance B, testing ability with concrete material, may be considered in relation to vocational plans and recreation needs. Stanford Achievement, a battery of ten educational tests covering all the routine academic subjects, gives insight into particular intellectual abilities and disabilities. Eleanor's emotional fluctuations are shown in her superior response on the more impersonal educational tests. T h e social history leads one to expect higher performance through more individualized attention of the psychologist, such as the Stanford Binet requires. Associations, with their emotional significance, will determine in part the rating of any test. In this case Eleanor's feeling about the school will be a contributing factor in her performance on the Stanford Achievement.

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PSYCHIATRIC EXAMINATION

February 14, 1929 Examiner got Eleanor f r o m the waiting room, and walked around the hall w i t h her. H e k n e w f r o m the history that there probably would be some antagonism to the Clinic, so began to lead up to the discussion of the situation. H e remarked upon the fact that she seemed to k n o w her w a y about. She replied that she had been here before b u t she did not k n o w the office of the examiner. W h e n we got to this, she was directed to the door. T h e conversation was then continued on this lead. She was asked w h a t she had done when she had been down here before. She said, " W e l l , I had some tests." A s k e d what these were for, her reply was, that they were to see if she was bright or not. W h e n asked h o w she thought she did on them, she replied that she t h o u g h t she had done very well. In answer to an inquiry as to w h a t else she came into the Clinic for, she said that she had had an examination b y a doctor, and that she didn't mind it so m u c h , but didn't like to take her clothes off. She talked about her modesty quite some time, and in a childish fashion kept saying that she did not like to undress herself. She stated also that she used not to like to undress herself in f r o n t of her mother at home, b u t had gotten over this now. She did not like to undress in f r o n t of women even that were strangers. She was then asked w h a t she came to see the examiner for. She replied " I came to see you to see w h a t kind of child I a m , " and, to the examiner's " w h a t kind of a child are y o u ? " answered, " I ' m pretty g o o d . " " W h a t do you mean b y pretty g o o d ? " " W e l l , I'm not so good and I'm not so bad. I'm about Β I guess. Mother thinks I'm not a normal child. I heard her say that over the telephone. She said that I needed m y head examined, and I don't like it. Y o u are supposed to report to m y mother w h a t kind of a girl I am, and the Clinic is supposed to report to m y mother w h a t kind of a girl I a m . " The examiner said nothing to this, and she spontaneously said, after a short pause, " I love to get m y mother's goat. W o n ' t you tell her that I'm normal, so as to get her g o a t ? "

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T h e examiner asked why her mother thought she was not normal. She replied, "Because I don't tell the t r u t h sometimes. F o r instance, I say I like arithmetic, but I ' m not good in it, and she says I ' m telling a story. B u t I like arithmetic. I like history best, then arithmetic, and I like geography least o f all. B u t she thinks I dislike arithmetic because I ' m not good in it. I c a n ' t get problems, and I c a n ' t get mental arithmetic, but I can do all the written work well. M y easiest subject is spelling. M y hardest is arithmetic. B u t I like arithmetic second, better than geography and spelling even, and she thinks I ' m telling a story when I tell her that. She blames me all the time. She doesn't give me a chance to explain. She doesn't see m y point o f view. I wish you'd tell her that, and tell her to rest her lungs a little too. She's always yelling at me. She tells m y father sometimes, and he yells at me too. Sometimes she makes me go to bed at live o'clock. I don't mind that, b u t it doesn't give me a chance to learn a n y t h i n g . " Asked if she ever told lies about a n y t h i n g else, Eleanor's reply was, " Y o u can ask me that again. I tell plenty o f t h e m . " " W h y ? " " S h e quits yelling at m e . " T h e n she told a story o f having gone to the R a b b i , but even though she went to the R a b b i , her mother keeps on yelling at her. She says she has t o go to see the R a b b i again tomorrow. T h e n she went into a long story about her mother's being upset recently. H e r mother had not wanted patient to tell people in the neighborhood that she was a stepchild. She said that she didn't mean to hurt her feelings, but she was with Helen Kearney, and she just asked Helen if she had a stepmother, and Helen had said she didn't, and turned around and asked the patient if she had a stepmother, so what could she do but answer and tell the truth. She hadn't meant to tell at all. It was just because Helen asked her, that she had told her that she had a stepmother. A t any rate, the people in the neighborhood knew about it, and it made her mother extremely angry. W h e n asked how she liked her stepmother, she said she liked her as well as the other mother. T h e other mother died when

I 6 8

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she was seven, from heart trouble. "She never yelled at me because I was y o u n g . " She admits daydreaming about the mother. She then said "This mother, it seems she doesn't w a n t me to talk about m y other mother. She is not jealous of her. She thinks it is too bad she had to die, but she seems to t h i n k it is a crime to talk about her. I don't know w h y . " She was then asked w h y her stepmother did not want to be known as patient's stepmother. Her reply was "I don't know that. Because it hurts her feelings."Then she rushed on with this,"Of course, I don't w a n t to hurt her feelings, but sometimes I just have to give a w a y things like that. T h a t ' s the kind of a child I a m . " She was asked if she liked to get her mother's goat, and she replied that she did, and went on to say that she had gotten her goat recently. She had come home and said that she k n e w how to spell "potato" and her stepmother did not. Stepmother had spelled it "potato" and she had told her that there was a new w a y of spelling it and had spelled it "potatoe." The mother didn't believe this was right, and she was asked if she w a n t e d to bet, by patient. The mother said yes, she would bet, and wagered the child a whipping. The child, however, had brought her spelling book, or at least she claims she had, and had showed that she was right. She then went on to say "Sometimes I'm right and m y mother doesn't remember it. She doesn't say 'maybe so' or a n y t h i n g like t h a t . " The patient was asked whom her father liked best. She replied that her father liked "both of us" the same. W h e n asked which one, her mother or herself, she thinks he loved more than the other, her reply was " H e doesn't like me best. He treats us the same. W h e n I get a present, so does m y mother; and when she gets one, I do too." " W h i c h do you think your stepmother believes he likes best?" "She thinks he loves us both the same." "Is she ever jealous of y o u ? " "No, not at all," was her reply. " W e l l , tell me, whom do you think your stepmother likes the best?" "She likes m y father. She acts it. She proves i t . " " H o w does she prove i t ? " "She said it. She said, 'How can I love a bad girl better than a good m a n ? ' " "Does

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she want your father to love her m o r e ? " " N o , she's not jealous at all. She's so lovely in every way. She's not like Cinderella's." T h e examiner then said " I ' l l bet you I know where you heard t h a t . " She said, " W h e r e ? " " I ' l l bet you heard your stepmother say that. I'll bet she said to you ' Y o u ought to be glad I'm not a stepmother like Cinderella had.' " T h e patient replied " T h a t ' s just exactly what she says. I think she is, sometimes, when she hollers at me. I get my temper u p . " " W h a t do you do in a t e m p e r ? " " I get very angry. I throw things about, stamp my feet, and yell at people to get o u t . " " D o you like t o throw t h i n g s ? " " N o . " " W h y do you do it t h e n ? " "Because I c a n ' t control i t . " " W h o told you that you can't control i t ? " " M y self, I tried t o . " " Y o u wouldn't get mad if you didn't want to, would y o u ? " " N o , I'd make up m y mind, and then I just wouldn't do i t . " W h e n asked " W h a t happens at home that makes your mother think you a bad g i r l ? " she replied, " T h a t ' s all, just telling lies and having tempers. She says that otherwise I ' m a perfect girl. She doesn't mind m y daydreaming. She doesn't like me to talk about my mother. It hurts her feelings." " W h y does it hurt her feelings for you to talk about your own m o t h e r ? " " I don't know, and that's what I want to find o u t . " " W h y do you want to find that o u t ? " "Because I'd like to know. I'd like to know if there is a good reason for i t . " " D i d you ever t r y to get even with her? T r y to hurt her feelings?" " N o , I don't do that. I f I wanted to hurt her feelings, I'd do something she doesn't like. She tries to get even with me. She doesn't like for me to wear lipstick, and I like to have m y lips r e d . " T h e examiner asked, " D o you have a sweetheart?" She squirmed about on her seat in a shy and embarrassed fashion, ducking her head down, and twisting her fingers. She wanted to know if that was a secret. Examiner told her yes, that it was a secret, so she replied that David Greenstone was her sweetheart, and that he was ten. H e played rough games though. T h e y are not in the same grade. H e is in the 6 A in the same school. T h e n she begged the examiner not to let the

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mother know, and also not to let her see the notes that he was taking. Examiner then told her that what he told her, and what she told him was a secret between them, and made a bargain on that. She was then asked if she were going to get married. She said she was, when she grew up, and that she wanted to have one child. Then she said, "I know a secret. I know where babies come from." Examiner said "Where do they come f r o m ? " "They come from the hospital. They come from inside the mother." She was asked how they came from the inside of the mother when they went to the hospital. She replied, "Well, they go to the hospital, and they sit down or lie down, then they have pain, and they can have an anesthetic if they want to or not." "But how do they come from inside the mother?" "When they cut them out of the mother." "How do they get inside the mother?" "Well, she eats a lot to have a baby, and the baby grows from that. I used to believe she ate seeds first, but my mother told me that she had to eat lots of food for a baby. I don't think that's so. My mother said it wasn't so. That's a question I have been trying to find out. Will you tell me about that? You're a doctor, you ought to know about that." The examiner told her that he would, if she wanted to know. She said that she did very much. Thereupon the examiner took the remainder of the interview in explaining something about pregnancy and birth to this little girl. She took it very nicely, was very much interested, asking a lot of questions. However, when she got through, she said she didn't know whether she wanted to have a baby or not. The examiner told her that she didn't have to decide about that now, that she could wait until she grew up, but she knew about those things now and it was quite all right to know about them. She was talked to about menstruation, but she had some inkling of this because of a cousin in her teens who has been menstruating. In regard to sex information, before examiner told her anything, she was asked what she knew about it. She told all that she knew. She knew the difference between male and female genitalia because she has seen her father and

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m o t h e r . S h e k n e w n o t h i n g a b o u t t h e f u n c t i o n o f t h e genitalia o t h e r t h a n f o r u r i n a r y purposes, a n d did n o t k n o w a b o u t their f u n c t i o n in c o n n e c t i o n w i t h i m p r e g n a t i o n a n d b i r t h . Psychiatrist. T E A C H I N G N O T E : This interview provides an opportunity for the students to see the psychiatric approach to establishing contact through a conscious plan of meeting the patient at whatever point he may have reached in his thinking and feeling. A knowledge of the social history material as well as of any other contacts will assist the psychiatrist. In this case we have the picture of an insecure child whose parents are treating her on an infantile level. T h e psychiatrist shifts the emphasis, appealing to her ego and treating her as an adult in his assumption that she can and will talk with him in an intelligent and reasonable fashion. Eleanor accepts the psychiatrist although she may suspect at once that he will not "take sides." He is emotionally satisfying as he provides an audience before which she can exhibit her self-love which shows itself repeatedly in her self-approval. As her freedom grows the students will note that she reveals more and more emotional material. At strategic points the psychiatrist interrupts her to assist in interpretation, as progress will come about through the type of understanding which brings with it a shift in her emotional values which in turn affects her behavior. T h e psychiatrist has a strategic position, in that he is disassociated from the every day life of his patients. H e is not emotionally involved, he does not identify with any person in the situation. H e need not blame or judge, and will not be prejudiced in his handling of any issue. As these psychiatric interviews go on we see the same technique repeated, and transference follows the relationship which this interview establishes. 12 T h e above points will be brought out in the discussion by asking the students for their evaluation of the doctor's technique, his immediate objectives for treatment, his relationship with any patient and with Eleanor, the purpose of psychiatric contact, etc. " N o t e the last paragraph o f interview o f 4 . T . 2 9 .

172

ELEANOR PART II.

Initial

conference,

Identifying

SOCIAL

MEYER TREATMENT

2.19.29

data.—Eleanor

Meyer, a girl of ten years and eight

months, was born in Louisville, K e n t u c k y , on 4 . 5 . 1 8 , and when t w o weeks old was adopted by Mr. and Mrs. Meyer

(first

w i f e ) . She is a well built, fair-haired child, with a f r i e n d l y manner. Problems.—Mrs.

Meyer, adoptive stepmother, describes prob-

lem as lying, persistent disobedience, and difficulty of management. Inquiry also brought to light some dawdling or daydreaming, and masturbation (in the past). Clinic

findings

Social;

Physical;

Psychological;

Psychiatric,

see Summaries,

p. 162 f f . Interpretation.—An

interpretation of the patient's behavior

involves, it seems, an understanding of the personalities and attitudes of the father, stepmother, and patient, and their interaction on one another. A complete evaluation of the father is impossible at this time. There are several things that may be noted, though they are somewhat difficult to integrate in the same individual. H e describes himself as a "mother's b o y . " W e have a picture in the first marriage of an "ideal relationship" with the first w i f e in which there seems to have been a great deal of satisfaction, but which, with no more information, is difficult to interpret as to the degree of mature mate adjustment. Since his second marriage, it would appear that he is dominated by his w i f e and perhaps has slipped back into his old mother dependency. This is not entirely satisfactory to him, it would seem, because he disagrees with his w i f e about the discipline of the patient, although he allows her to do most of it. Aside f r o m these theoretical considerations, it is important to remember that here is a man w h o ( 1 ) recalls a f o r m e r ideal marriage, and builds a saintly picture of his first w i f e , ( 2 ) is devoted to the

ELEANOR patient, and spoils her

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(whether because he identifies her

with his first w i f e , we do not k n o w ) , and ( 3 ) whose present w i f e was married, not because of real affection f o r her, but to provide a home f o r the patient. T h e stepmother, on the other hand, presents an interesting picture of the psychology of a stepmother. It seems reasonably sure that the mother identifies herself with her o w n mother, saying that they are as alike as t w o people can be. She recalls disapproving of her mother's methods when a child, but says that she now approves of the dominance and the sternness of her mother, and has modelled herself a f t e r her. She seems to be pursuing that pattern in relation to the father and the patient. The mother had had t w o previous experiences in raising children—her brother, thirteen years younger, and her niece. She admits failure, and the facts would seem to indicate that her method of handling them was somewhat different f r o m the w a y she handles the patient. She is said to have done e v e r y thing f o r them. In interpreting her handling of the patient, several things must be considered, but it must also be recognized that she was immediately faced with a difficult job. First of all, we can see that she is a rival of the patient with the father. We do not k n o w her real feeling f o r the father, but some indication that her unconscious hatred of the patient may not be so unconscious is given in the statement that she loves the girl but will come to hate her. When the stepmother first took charge of the patient, she m a y have had a certain ideal goal she wanted to attain, but she states that she was determined to make a successful job of Eleanor, and on the first day explained this to her. She pointed out, f r o m the beginning, all the little things in which Eleanor had failed. T h e writer believes that she may have had some conscious idea of rearing Eleanor properly, but that this represented a job in which the mother must get some ego satisfaction f o r herself f r o m the success of the job, rather than any feeling of doing it for the patient. This is easily seen in the light of her former

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failures, a n d her unconscious rejection of the child, d e m o n strated so neatly on the very first d a y , when she pointed o u t Eleanor's failings. T h i s served another purpose, since it plainly said to the f a t h e r that his sainted w i f e had not made such a good j o b of Eleanor. Essentially, the situation f o r the stepmother would seem t o be as f o l l o w s : she is in a position of rivalry with the m e m o r y of the first wife, and with the patient in relation to the f a t h e r . She is jealous of the father's affection f o r the patient. She rejects the patient and blames her for the lack of h a r m o n y between herself and h u s b a n d . She punishes her husband b y pointing out indirectly t h a t his first wife did not raise the patient properly, and b y b l a m i n g the patient's behavior on him. She carries into the situation and perpetuates her mother's d o m i nating a n d stern methods, and is only partially successful in d o m i n a t i n g her h u s b a n d (being stopped where the patient is c o n c e r n e d ) , and practically unsuccessful as f a r as the patient is concerned. In regard to the patient, very little is k n o w n about the first seven and one-half years of her life with her mother and father, and of her behavior then. E n o u g h is intimated to give the impression that she was t h o r o u g h l y spoiled, and p r o b a b l y used to h a v i n g her o w n way. H e r father adored her, saw no f a u l t in her, a n d m a d e m u c h of her tricks. W i t h a b a c k g r o u n d o f adult oversolicitousness, created by the adoptive parents, it is easy to anticipate difficulty in a d j u s t i n g in the authoritative setting of a school where she, of necessity, m u s t meet competition. W e do not k n o w whether this was true when she first went to school, but she does not get along with other pupils in school now. W i t h the appearance of the stepmother, she was faced with an almost reverse situation. She had a rival f o r her father's a f fections, a rival who pointed out all her shortcomings, to her and her f a t h e r . In addition, she no longer has her o w n w a y , b u t meets with sternness, n a g g i n g , yelling, whipping, and silence f r o m her stepmother. T h e withholding of affection

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affects her little, save as an indication of what she can get b y w i t h that day. B y her behavior she "gets the g o a t " of her stepm o t h e r , and because of her father's strong attachment to her, does not lose his affections. In other words, it is she who really dominates the situation rather than the stepmother, and one has the feeling that she is quite conscious of this, and gets a great deal of ego satisfaction out of it. T h e t w o naive, spontaneous statements to the psychiatrist illustrate: " I love to get m y mother's goat. W o n ' t you tell her that I ' m normal so as to get her g o a t ? " and " O f course, I don't w a n t to hurt her feelings, but sometimes I just have to do things like that; that's the k i n d of a child I a m . " H e r individual problems seemed to represent v a r y i n g causative factors: H e r lying is to some extent defensive, to excuse herself and avoid disagreeable nagging and yelling by the stepmother. Some of them are of the compensatory t y p e ; f o r instance, boasting of her accomplishments at school, accomplishments which she has not attained. Both of these o f t e n lead to more serious involvement to protect them. Also, they seem to be used to some extent as a psychological weapon against the stepmother to annoy her. T h e question of disobedience involves t w o kinds: ( i )

de-

fiance (a reaction against the stepmother), and ( 2 ) failure to do m a n y things she is told to do. M a n y of these in her period of spoiling never were done. Much of this, as described by the stepmother, seems to be a reflection of her own attitude toward the patient and requirements of perfection in tidiness, promptness, manners, and the like. Her

temper reactions seem rather typically those of

a

spoiled child who does not get her own w a y with other children. B y her daydreaming she gets away f r o m the nagging stepmother, and re-creates her o w n mother. T h e dawdling serves to irritate the stepmother. She is beyond control because her behavior gets the best of

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the mother, both in relation to the father and because it serves to get the better of her stepmother's own ability to remain in command of the situation. Treatment Treatment should proceed more or less simultaneously with all three of these individuals. With the mother.—Eventually, the mother should be brought to see the motives and mechanisms of her own treatment of the child, as outlined above, as well as those operating in the patient. Before she is likely to accept this, she will have to feel more security with her husband. The marriage to this man, for whom she now believes she held no love, created for her a very trying competitive situation with her stepdaughter for her husband's interest and attention. In order for her to achieve a successful adjustment it is necessary to relieve the conflict of the result of the present situation for her, thereby releasing her from continuing the destructive methods of handling the child. She should be encouraged to praise the patient for the good things she does, but when discipline is necessary, to let it be understood that, when certain things are done, certain results follow. She should not let the patient "get her goat," a difficult task until she feels secure with the father. Her standards of conduct for the child should be within the range of accomplishment. It is seen that she will not be able to do this without help from the father, and some work with the child. She may get some security from the social worker. With the father.—It is obvious that the father has been part of the child's experience for years before the entrance of the stepmother who is very much involved in his love for the child. He is therefore a very crucial person in the treatment situation. Because of the important role he plays it is possible to gain a cooperative reaction from him. He can ease the stepmother's tension by making her feel that she has his affection. One would expect that this would increase the child's jealousy of the mother. This might be obviated if the father gave her

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his affection and praise in regard to helping the stepmother, rather than toward her show-off behavior. If he can cooperate with the stepmother in a consistent plan of discipline for the child, this would, in itself, help to give some security to the stepmother and ease her tension. If the plan is too strict, it will threaten the whole pattern of his affectional relation with the child which is so identified with his so-called ideal relation with the first wife. At the same time it would imply forcing him to assume a strictness of attitude which is too like that of the stepmother, who already has become a source of unhappiness to him because of her effect upon his daughter. The plan must not be too lenient, as the stepmother would have difficulties in spoiling a child she doesn't like. The father admits his spoiling and her irresponsibility. As he recognizes these things, it may be possible to get him started from these two points and gradually work in other things. With the patient.—Since the patient verbalizes her attitudes towards the stepmother quite well, interviews with the psychiatrist would seem profitable, an attempt being made to get her to give up, of her own accord, some of her irritating behavior, and thus make the problem for the stepmother somewhat easier. She needs her teeth attended to. Psychiatrist [Syllabus reference: K N O W L E D G E , Diagnosis, plan, treatment.]

Psychiatry,

METHOD,

T E A C H I N G N O T E : The previous assignment given the students, in which all information to date was to be analyzed, brings the student group to the first sentence of the interpretation of the initial conference, " A n interpretation of the patient's behavior involves, it seems, an understanding of the personalities and attitudes of father, stepmother, and patient, and their interactions on one another." Treatment planning, as the next step, may be facilitated if the instructor centers the discussion of the written material which the students will present around such points as the following: 1. In interpreting the child and the parents, what are their personal satisfactions and dissatisfactions? 2. What identifications have they made?

ELEANOR

MEYER

3. In what way is present behavior affected by familiar behavior patterns? 4. W h a t are the difficulties which will get in the way of treatment? 5. W h a t are the positive factors around which treatment can be immediately planned? For the worker we can stress the fact that treatment can and frequently must proceed without the complete evaluation of any person or persons in the family. In this instance history tells us little of the father. Treatment as a continuing revelation, and history material as a point of departure for treatment may be mentioned in this connection. Under the section Treatment we need not hesitate for very long as the interpretation clearly indicates the direction which treatment will take in the immediate future. It will probably be well to discuss the value of simultaneous treatment by psychiatrist and social case worker and so reemphasize the interplay between them, the social case worker handling what are for the child the environmental relationships, the psychiatrist carrying on treatment with the patient. T h e need of adequate knowledge of psychiatry for handling social psychiatric situations is evident. T h e division of responsibility between psychiatrist and social case worker has both an emotional and practical aspect. Simultaneous treatment of parents and child is a sharing process. As doctors and social ease workers are both specialists in two different fields, closely interrelated because of joint responsibility in the handling of treatment processes, it is necessary that there should be a recognition of the degree of common technical knowledge which each possesses and the desirable interplay between the techniques of psychiatry and social work. This last may be called the techniques of child-guidance clinics. T h e starting point for treatment with each member of the family is consciously planned and is a process of which students can well be made aware at an early stage in their training. Frequent evaluation of progress with its relation to stated plans can be indicated, but detailed discussion can wait as has already been indicated in the general plan under which treatment will be discussed. Teaching notes for such a plan follow under the Record heading, Treatment. T h e relationship between any client and any social case worker may be a challenging introduction to the treatment section of the Record. W h a t is the student's interpretation of this relationship? "Treatment should proceed simultaneously with all three of these individuals." Modern psychiatry has assisted case work to a clearer understanding of human relations. It has shown the necessity for the psychiatrist and

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179

social case worker to establish themselves in treatment as personalities to whom the members of the family group will talk freely and from whom they will seek understanding. What are the ingredients for such a relationship? "Executive treatment" is no longer adequate. Its usefulness depends upon its place in the total plan for the personality adjustment of the patient. It must develop from the increasing understanding which comes to the patient as well as to the doctor and the social case worker through their contacts. The requisite degree of identification and objectivity, the use of psychiatric and case-work techniques, may be touched upon here. The previous assignment given the students, in which all information to date was analyzed, prepares the way for the class discussion of the interpretations and for the preparation of the treatment plan. In order to carry out treatment we recognize the need for a constant weighing and evaluating, and in this Record we find that procedure. Treatment is interrupted periodically for a review of progress to date and a discussion of plan from that point forward. Material prepared in this way makes it possible to sharpen the worker's conception of the job of the social case worker, and consequently to clarify her own objectives as a social case worker in training. The record of a mental hygiene clinic assists us at this point, as it has before, by enabling us to concentrate on one major issue, the emotional content in the psychiatric procedure of the record. The teaching notes on Treatment will follow with specific plans for analyzing each entry in treatment. Students, therefore, will discuss the interviews of 2.26.29, 2.28.29, 3.6.29, and then evaluate progress to date in order to compare it with the supervisory conference of 3.11.29. The same procedure will be followed for the interviews of 3.13.29, 4.5.29, 4.15.29, and 4.22.29. The conference of 4.29.29 will supply the objective standard for the group. The interviews of 4.29.29, 5.6.29, 5.13.29, and 5.21.29 may be read and studied in relation to all treatment to date, and to the initial conference and plan of treatment in order at that point to arrive at a plan of treatment for the summer. Such a plan is handled in the record under date 5.23.29. It may be well to reiterate at this point that this record is being used in a limited fashion in order to emphasize "psychiatric-social" work techniques and the use that may be made of emotional material in an attempt to assist in the adjustment of three human beings. It may be difficult to keep the group from discussing the quality of the case work of the record. Such a discussion as the present one will help to eliminate this difficulty. The method of teaching will be similar to that of Part I.

ELEANOR

MEYER

TREATMENT

2.26.29 ( P s y c h i a t r i s t ) : Interview with Mr. Meyer, f a t h e r of the patient. Mr. Meyer came in and began to talk immediately to the examiner about the rainy day that we were having. H e was asked to take off his coat and be seated. A t first he did not think he would be long enough f o r that, but then stated that well, he would probably not feel his coat a f t e r going out. T h e examiner then suggested, since he knew what the situation was about, that he outline things f o r him a bit. M r . Meyer then began by stating that he was very much devoted and v e r y much attached to his daughter, Eleanor. H e began to minimize all of her conduct, and said that recently she has been telling some lies. These he minimized, saying that they did not amount to much, and really she was quite all right, and was a v e r y good girl. H e was also very protective about his w i f e , patient's stepmother, saying that she was a very good w o m a n , that she had excellent intentions, and that she had an ideal which she was t r y i n g to accomplish in the child. H o w e v e r , as the interview proceeded, he became more and more critical of her, stating that she was much too strict and m u c h too stringent in her ambitions f o r this girl. She wanted her to act as though she were an adult, at the age of ten years. H e thought this was too much f o r a ten-year-old child. T h e father also commented on some of her methods of nagging and yelling at the patient. H e said that he does not blame the patient much f o r reacting to this. H e admitted that f r e q u e n t l y they dissented in their opinion about discipline of the patient in f r o n t of her, that she got quite excited, and that he could not say a n y t h i n g then, and the only thing he could do was to keep quiet and calm. If one said anything, she took it as a criticism and it only increased her tension. H e gave in considerable detail a number of petty things which Eleanor does which her mother thinks she should not do. For instance, her mother has been teaching her to clear off the table. H e says there is a maid to do it, but she feels that Eleanor should know how to do these things. She has been told fifty times to take off the butter and cream

ELEANOR

MEYER

l8l

first a n d p u t t h e m in the refrigerator, b u t she always neglects to do the t h i n g s in the proper order. H e also made some c o m m e n t a b o u t her p i c k i n g up books and features o f this sort, her disorderliness and general failure to observe little p e t t y r o u tines w h i c h the m o t h e r has imposed. T h e n he also a t t a c k e d the m o t h e r on t h e standpoint o f her demanding too m u c h f r o m the p a t i e n t and being too e x a c t i n g in these respects. T h e e x a m i n e r t h e n outlined f o r the f a t h e r the situation s o m e w h a t as he saw it, as has been given in the interpretation o f the case, p o i n t i n g o u t to him t h a t he was very m u c h attached to t h e child, and t h a t she was very m u c h attached to h i m , t h a t she had a new situation to meet when he remarried, and t h a t she p r o b a b l y felt t h a t she had a rival for his affections, p a r t i c u larly when this person began to belittle her in his eyes. H o w ever, f o r these reasons—she is reacting toward the stepmother, and has been able because o f her affection for the f a t h e r and the m o t h e r ' s affection for her to win out in the struggle. O n the o t h e r h a n d , the situation in which Mrs. Meyer is was pointed o u t t o h i m : the f a c t t h a t she married him a f t e r a previous marriage, and the f a c t t h a t he was so m u c h attached to his daughter t h a t she had a rival in his affections. T h e f a c t also was t a k e n up, when he said that she had " n o ulterior m o t i v e , " as he expressed it, for treating the patient as she did, that p r o b a b l y unconsciously, she did reject the child as being a rival, b u t t h a t she must have a conscious motive in w a n t i n g to make good in order to keep his affection, since that would be one way o f appealing to the husband's interests. Surprisingly enough, the f a t h e r took this rather readily, and stated that he had o f t e n t h o u g h t of the situation in these terms, and outlined t h e m m u c h as the examiner had. T h e e x a m i n e r then suggested to h i m t h a t he was in the key situation in the f a m i l y , and that neither the mother nor the daughter could be e x pected to c h a n g e her behavior as the situation stood. I f the stepmother became more lenient, and more friendly, the patient would take more advantage o f it, whereas if the patient c a m e anywhere near living up to what the stepmother thought best,

I 8 2

ELEANOR

MEYER

then her feeling of affection for the father would suffer. H e agreed to this situation, and wanted to know what he could do about it. It was suggested that he should give his wife a certain security by backing her in a disciplinary w a y . He felt that he could not do this if she carries on her present regime of nagging and yelling at the patient. He agreed that if a plan could be agreed upon, he would be glad to cooperate, and asked the examiner to talk with her in the same w a y as he had talked to him. He volunteered to come in and be here at the time so examiner could talk to both of them, or that examiner talk to her first and give her a chance to state her opinion, and then see both of them at some future date. Said he would be quite glad to come in at a n y time later—this spontaneously, as he left. The examiner had opportunity to explain his reason for giving patient sex information at the time, and he was quite satisfied with this. His only thought was that she might be worrying over these matters, and when the examiner pointed out to him that she had misinformation, and was worried about that, he was quite satisfied that she had been given proper information. T E A C H I N G N O T E : In the foregoing interview for treatment the students have an opportunity to concentrate on the technique used by the psychiatrist. T h e interview opens, as every interview in social case w o r k or psychiatric social w o r k should, at the point where the father is, in his feeling and thinking, thus establishing contact. T h e following questions may be raised with the students as to the value of the psychiatric interpretation at this early point in treatment: 1. Is the father yet ready to see the relationships in the h o m e as they are and the behavior of the f a m i l y as the psychiatrist reveals them? 2. W i l l interpretation block treatment because it will be given to a person w h o understands but does not feel its truth? 3. T h e father's possible resistances to treatment are not. yet k n o w n . W h a t will be the effect on h i m of a premature explanation of the family difficulties? 4. W h a t will convince him that the doctor is competent to assist him? 5. A s all patients are eager f o r results, is it possible to start treat-

ELEANOR

MEVER

I 8 3

mcnt that the father wilJ recognize as therapy? If so, can he be given a responsible, conscious and specific place in treatment? Throughout this interview the psychiatrist shows himself as a person interested but not perturbed by the situation which is causing the father distress. 2.26.29

( P s y c h i a t r i c Social W o r k e r ) :

Mrs. M e y e r w a s seen

b y w o r k e r b y a p p o i n t m e n t . Eleanor w a s in bed in her p a r e n t s ' room—a

t e m p o r a r y indisposition

w h i c h the a d o p t i v e step-

m o t h e r a t t r i b u t e d to e a t i n g veal the d a y before. W h e n seen b y the w o r k e r at the end of the i n t e r v i e w she was quite c h e e r f u l , and seemed to be on the best of terms w i t h the a d o p t i v e stepm o t h e r . A s k e d w h a t in p a r t i c u l a r she w a s missing in school that d a y , she said a r i t h m e t i c , w h i c h she admitted she did not like, and s e w i n g , w h i c h she does not care f o r v e r y m u c h either. Mrs. M e y e r inquired i m m e d i a t e l y w h a t the result o f the physical e x a m i n a t i o n w a s , and was v e r y m u c h concerned to think that she had o v e r l o o k e d a bad tooth. She then c o m m e n t e d on sex i n f o r m a t i o n w h i c h psychiatrist had g i v e n patient, a n d expressed surprise that, since he said so m u c h to E l e a n o r , p s y chiatrist

felt any

diffidence about

t a l k i n g to Mrs.

Meyer.

W o r k e r explained that this had in n o sense influenced the a r r a n g e m e n t that the social w o r k e r should see Mrs. M e y e r , w h i l e the psychiatrist saw M r . M e y e r , that it was immaterial w h o gave the interpretation, b u t that w e t h o u g h t M r . M e y e r w o u l d p r e f e r to see a man. Mrs. M e y e r said that she had been surprised that such f u l l sex i n f o r m a t i o n had been g i v e n , b u t realized that, since it w a s given in such a technical f o r m , n o h a r m was done, and she had explained this to the a d o p t i v e f a t h e r w h o had v e r y d e f i nitely t h o u g h t that E l e a n o r was too y o u n g . M r . M e y e r added that he did not wish patient to g r o w u p . T h i s e v i d e n t l y had been the subject of m u c h discussion w i t h both Mrs. M e y e r and f r i e n d s . E l e a n o r had been told not to repeat the i n f o r m a t i o n to her f r i e n d s . T h e w o r k e r then e x p l a i n e d to Mrs. M e y e r that, a f t e r E l e a nor had been seen b y the psychiatrist, the whole p r o b l e m had

184

ELEANOR

MEYER

been considered in the light of the i n f o r m a t i o n given by b o t h parents, a n d the f o l l o w i n g interpretation was outlined: Eleanor is physically and mentally sound, and had reached adolescence, but in character development she remained at a m u c h more juvenile stage. T h i s was the natural result of the circumstances of her life, involving an early childhood in which she was subjected to very little discipline, followed by a sudden and complete change to the impersonal atmosphere of a boarding school in which, as a new girl, she would be one of the least i m p o r t a n t . T h e natural regression, a f t e r h a v i n g been the center of affection and attention, to a more infantile level, was explained, and the equally natural exaggeration of the home situation which would have resulted f r o m her lack of happiness. T h e emotional values that both mother daughter

must

have

brought

to

the

and

homecoming—the

mother's determination to m a k e a success of what she felt to be a difficult task, and Eleanor's picture of home as a place without discipline where she was again to be the center of things. It was pointed out that anyone, even the child's o w n mother, would have been f a c e d with a difficult task; that Eleanor m u s t be looked upon as a very y o u n g child, with, however, m a n y of the u r g i n g s o f adolescence, and that she would need to be helped to g r o w up. Worker emphasized the f a c t t h a t Eleanor's c o n d u c t shows that she is looking f o r both love and recognition f r o m her mother; that this indicates an affection on which to build, but that it was most i m p o r t a n t that the satisfaction she o b tained should be on a constructive level. Patient is now securing stepmother's attention t h r o u g h her misdeeds, whereas she needed to obtain this kind of satisfaction t h r o u g h achievement, rather than negatively. A d o p t i v e stepmother agreed t h r o u g h o u t and blamed herself f o r not realizing at the time that her m e t h o d was w r o n g . She seemed to get very little c o m f o r t f r o m the f a c t that the worker told her that anyone else in her position would have done the same. She also blamed adoptive father f o r not being

ELEANOR

MEYER

185

f r a n k when she felt sure he was critical. W o r k e r tried to m a k e her understand t h a t f a t h e r was in the same difficult position and t h a t , although he m a y have felt t h a t he would have tackled the situation in a different w a y , he p r o b a b l y did n o t k n o w why he f e l t like this, and t h e r e f o r e could not urge his conclusions upon her. I t was finally agreed t h a t Mrs. Meyer would t h i n k out a way in w h i c h it would be possible to c h a n g e the emphasis f r o m the negative t o the positive, and n e x t week, when b r i n g i n g patient to the c l i n i c , would c o m e prepared to discuss her plans. W o r k e r then asked t o see the B a b y B o o k again, and they w e n t t h r o u g h it page by page, together. T h e date of birth was verified as 1 9 1 8 , and Mrs. Meyer said she t h o u g h t that the adoptive m o t h e r ' s n a m e was H e l e n S m i t h . A

reference to

Μ . E . S u n d a y school elicited the f a c t t h a t t h e adoptive m o t h e r was a M e t h o d i s t ; t h a t M r . Meyer was t a k e n ill when " o n the r o a d , " and fell in love with his nurse; t h a t she yielded to his pressure and married h i m , w i t h o u t the k n o w l e d g e o f the paternal g r a n d m o t h e r h o w e v e r ; t h a t the g r a n d m o t h e r was very m u c h upset, b u t b e c a m e reconciled as soon as they met, and was subsequently devoted to her. Eleanor was b r o u g h t up a Christian during her first years, and m a y have been influenced by a friend o f the f a m i l y , a Miss R i l e y (since m a r r i e d ) , who lived with t h e m a great deal, and was a C a t h o l i c (Miss Riley did not c o m e to the second marriage, and never called on Mrs. Meyer. T h e y had m e t o n l y o n c e ) . E l e a n o r , however, was transferred to the J e w i s h

religion

during

life o f

adoptive

mother. T h e o n l y other e n t r y o f note in the book was reference to a boil on t h e head at six m o n t h s . Eleanor had made m u c h o f the " s e c r e t " w i t h the psychiatrist, and had evidently aroused Mrs. Meyer's curiosity. Mrs. Meyer asked i f there was a n y t h i n g else in the interview that would help her to handle patient, and w o r k e r said t h a t the interview had borne o u t the general interpretation. T E A C H I N G N O T E : The discussion of {joints referred to below will be put before the class, if they do not volunteer them, when asked to

ELEANOR

MEYER

discuss the similarities between this interview and the previous one between the father and the psychiatrist. 1. What is the emotional implication for the stepmother that the worker should be the interviewer rather than the psychiatrist at this point? 2. What meaning does the stepmother's question " W h y did my husband see the psychiatrist?" have for the class? 3. Does this interview suggest a complete basis of confidence between the stepmother and the worker? It is essential in any treatment plan, such as this one, that all members of the family should accept and work towards the same objectives, therefore, the same interpretation should be given each member of the family when there is no emotional reason for withholding information and delaying interpretation. In this interview we see treatment begin with interpretation of a few treatment objectives. T h e worker attempts to relieve Mrs. Meyer's sense of guilt through discussing child-mother situations as compared with child-stepmother situations. She gives the stepmother the opportunity to create treatment which to her seems desirable and, therefore, will have a greater chance of being successful. W e see the knowledge of the situation which is necessary for treatment constantly growing, for instance, the possible emotional value, for Eleanor, in the shift from one religious faith to another; Mr. Meyer's statement that he did not wish patient to grow up; the increased knowledge of the first Mrs. Meyer, and the opportunity to question the value for the present Mrs. Meyer in her willingness to accept the responsibility for her own behavior with Eleanor. In each of these interviews we see that it is not sufficient for the patient or the parent to describe her feeling about a situation; she must, in addition, discuss the situation which creates the feeling in order to work through her conflict in relation to it, and disassociate the feeling from the fact. Again we see the worker as an external factor objectively participating in the situation. 2 . 2 8 . 2 9 (Psychiatric Social W o r k e r ) : 1. W o r k e r called at P u b lic School 66 and saw the assistant principal, Mrs. Fairfield. W o r k e r had expected that little would be needed beyond a statement that the preliminary examinations had been completed, that the problem was purely one of the home, and that, therefore, it would not be necessary to trouble the school further. W o r k e r f o u n d , however, that Mrs. Meyer had been

ELEANOR

MEYER

187

in t o school (apparently a f t e r the interpretive interview of 2 . 2 6 ) and had told Mrs. Fairfield, among other things, that E l e a n o r is an adopted child. W o r k e r stressed the f a c t that this w a s not k n o w n to Eleanor. She refused to see the class teacher, g i v i n g as her reason that, since the school had no complaint to m a k e of Eleanor, it was much better to avoid even the appearance of associating the Clinic any f u r t h e r with the school in her eyes, which would be inevitable if worker went into the classroom. 2.

A f t e r leaving the school, worker called on D r . Finkel-

stein at his office. She f o u n d that Mrs. Meyer had been to see the R a b b i after her interview with the worker, and had given h i m the Clinic's interpretation, to which he had replied that that was what he had said all the time. H e had also told Mrs. M e y e r that he felt that, since she was consulting the Clinic, it was not advisable to consult him as well. W o r k e r pointed out that it was very natural f o r Mrs. Meyer to call on him, in view of the f a c t that, as head of the Sunday school, he was in constant touch with Eleanor's teachers and occasionally saw her himself. Eleanor had been to see D r . Finkelstein on 2 . 2 7 , because she had been in trouble at school (apparently connected with fidgeting with a watch which she should not have been weari n g ) , and the R a b b i had come to the conclusion that the class teacher, as a result of Mrs. Meyer's action in talking of Eleanor at school, was being specially severe with patient. This he thought undesirable, and had therefore asked Eleanor

to

arrange f o r him to meet the teacher. It seemed to worker too late to prevent this interview, and all she said therefore was that it would seem to be best not to emphasize the problem for fear of giving an exaggerated picture to the teacher. D r . Finkelstein said that Eleanor had spoken of her interview and had told him that she had a secret with the psychiatrist. It was not learned what more she had said. T E A C H I N G N O T E : The discussion of this interview, and the following one of the same date, will center around the question to the class:

ι 8 8

ELEANOR

MEYER

"What is the placc of any source of historical information in treatment?" Any person who has been used as a source of information in the gathering of the social history will probably wish to be informed of the plan of treatment. Where schools are concerned there is educational value in informing them of the result, even when the school will not be needed to participate in treatment. This particular school may need to be used as an active treatment agent as treatment progresses. It is, therefore, necessary to keep them informed. T h e psychiatric social worker will want the school to know of Eleanor's progress from time to time and a reciprocal relation is therefore desirable. The interview again adds to the general knowledge of the case by giving us material which leads us to question the emotional need which led Mrs. Meyer to tell the school of Eleanor's adoption, a fact which, presumably, is not known to anyone. This created an emergency for the worker to meet since, to date, she has not evaluated the relationship between principal and stepmother as it relates to the child. Calling on the Rabbi raises the same general question as has been raised in the call at the school: W h a t is the place of any source of historical information in treatment? In addition we may consider the possible difficulties and assets in a joint treatment plan with a person who feels competent to assist actively with treatment. When such a person has possibly an emotional rather than an intellectual relationship with the family, we may question the desirability of keeping such a person out of the treatment plan, even though he recognizes that he is not technically equipped to handle it as is the psychiatrist. It is interesting to note the recurring picture of Eleanor's use of the childpsychiatrist relationship and to speculate as to its emotional value in relation to the home situation. 3 . 6 . 2 9 ( P s y c h i a t r i c Social W o r k e r ) :

W o r k e r saw M r s . M e y e r

at the C l i n i c f o r a b o u t f i f t e e n m i n u t e s , w h i l e patient w a s still w i t h the p s y c h i a t r i s t . M r s . M e y e r w a s f e e l i n g v e r y

cheerful

about the situation, a n d said t h a t she had a l r e a d y p u t her plan into action. T h i s plan w a s t o g i v e g o l d stars f o r e v e r y t h i n g that was w e l l done. W h e n 1 0 0 stars had been w o n , one dollar w o u l d be g i v e n ,

and w h e n

ten dollars h a d been w o n , the

a m o u n t w o u l d be d o u b l e d . E l e a n o r had been f u l l o f e n t h u siasm

and

was

already

planning

birthday

and

Christmas

presents. T h e a d o p t i v e s t e p m o t h e r m a d e special c o m m e n t of her unselfish plans. W h e n E l e a n o r did a n y t h i n g w r o n g , she

ELEANOR

MEYER

189

was herself to decide how many stars should be cancelled. Worker warned Mrs. Meyer that after the first enthusiasm, patient would probably fall off in her conduct f o r a time, and that she herself must guard against losing interest in the scheme; that, on the other hand, Eleanor would grow beyond the gold star level after a while, and that then a plan could be worked out, which would convert the reward into a regular allowance. Mrs. Meyer felt that she had been successful in restraining herself f r o m giving constant directions, although often only with a very great effort. The adoptive stepmother spoke of her intense devotion to her young brother, and the comments of friends that he seemed to be more her child than her mother's. Her sister, who was three years older, went out to work and had comparatively little interest in the home and the child. T E A C H I N G N O T E : Several items of importance for the student may be stressed in the interview of this date: T h e worker points out dangers in Mrs. Meyer's plan but does not thwart her—in this way she suggests that Mrs. Meyer think of the emotional and practical results of her plans in their practical working out; further insight into the satisfying relationship with her brother reveals the lack of satisfaction, the insecurity and probable guilt attached to the stepmother-child relationship.

3.6.29 (Psychiatrist): Patient was brought in by her mother, and she was on time. She greeted the examiner effusively and began chattering away immediately, as she had something to tell the examiner. He told her, all right—that he would like to hear what it was. She replied that he remembered what they had talked about last time—the secret they had—well, she had had to tell her mother part of it. She referred to the sex information which the examiner had given her. She said there was one thing she had not told, however. Questioned about this, she said it was about the sweetheart of whom she had told the examiner, and which she intended to keep a secret with the examiner. The patient spent a great deal of time telling the examiner just what she had told the stepmother.

19°

ELEANOR

MEYER

She then went on to say that the stepmother hadn't been yelling at her so much, and she wondered if examiner had spoken to her about it. She said that things were more pleasant at home. She then went on to ask the examiner if he was not going to see her mother after she left. Examiner told her that he was; she wanted to know then if he was going to say anything about her. Examiner told her that he would not tell stepmother any of the secrets which they had, but perhaps would talk about making things more pleasant for the patient at home, provided she would help. He then discussed with her a little bit about everybody's having to help, or else there would be friction at home, and it was pointed out to her that, while she had complained of her stepmother's yelling and various other things, at the last visit, undoubtedly she did "get her mother's goat" sometimes, and in this way caused her mother to yell, whereas, if patient had not been so anxious to "get mother's goat," she might not have suffered some of the irritability of the stepmother. The patient agreed to this quite readily, and went on to say that she had tried to be good; she put a great deal of this on a moralistic basis herself. The examiner tried to take it off this moralistic basis and put it on a more practical basis from the standpoint of what her behavior could mean in the way of advantages for herself. Interview with Mother of Patient.—Mrs. Meyer and the social worker on the case, came into the office of the examiner, and a three-cornered conference took place. The mother started out by doing a great deal of blaming of herself, and her methods of handling the child. As the interview went on, however, she became a bit more critical of the patient, telling of this and that irritating thing that the patient had done, at the same time, when asked how she dealt with this, immediately dropped into the blaming of herself for getting overwrought about them. The situation, as outlined in the interpretation, was more or less taken up with her. She agreed to the fact that she and Eleanor were competing with each other for a certain degree

ELEANOR

MEYER

191

o f affection and, c e r t a i n l y , consideration f r o m t h e f a t h e r . She readily accepted the point t h a t it was m u c h b e t t e r f o r her n o t t o c o m p e t e w i t h Eleanor on her level o f c o m p e t i t i o n . F u r t h e r m o r e , she expressed a desire to cooperate w i t h the h u s b a n d . She

gave some indication

of

blaming h i m

for

being

too

l e n i e n t w i t h the patient, b u t said she could never talk such t h i n g s over with him because he just " s h u t u p . " T h e e x a m i n e r took the situation more or less in hand, a n d explained t o her that he had talked with the f a t h e r , and t h a t he admitted he did n o t like quarreling and g e t t i n g

upset.

W h e n she b r o u g h t the patient's behavior to his a t t e n t i o n , he f e l t she was so easily upset t h a t any c o m m e n t he m i g h t m a k e , o r opinions o f his o w n , would be taken as c r i t i c i s m o f her methods and only increase her irritability. T h e m o t h e r adm i t t e d t h a t perhaps this m i g h t be true, b u t she felt that it c o u l d be avoided. T h e e x a m i n e r suggested t h a t t h e y should get together, and work out a combined plan o f t r e a t m e n t o f t h e patient, one in which the father would have t o take more responsibility, and the other in which the m o t h e r would relax some o f her strict standards. H e cautioned her t h a t this p r o g r a m should be outlined w h e n neither one o f t h e m is upset, and so would be sensitive a b o u t criticism f r o m the other, and should be done in the absence o f patient. H e suggested to Mrs. Meyer t h a t her husband should not be expected to c a r r y on some o f the very stern disciplinary measures w h i c h t h e m o t h e r practiced towards the patient in his absence, about some trivial m a t t e r ; i f they had an understanding about disciplinary measures, which should be consistent, he m i g h t be expected t o cooperate when he f o u n d t h a t the patient had n o t observed the regulations. H o w e v e r , it seemed to the e x a m i n e r , that these disciplinary measures should be understood before, and an u n derstanding should be had w i t h the patient t h a t if she did certain things, automatically certain results followed, rather than punishing her in a fit o f emotional irritation and anger. T h e m o t h e r took these things readily and blamed herself f o r doing a great m a n y things w h i c h she has done. As a m a t t e r o f

192

ELEANOR

MEYER

f a c t , she said t h a t she had had to stop w h i p p i n g the p a t i e n t because she realized t h a t she herself got too w r o u g h t u p a n d did n o t realize w h a t she was doing t o the patient. She m a d e some r e m a r k a b o u t the f a c t t h a t it was a good thing people did not k n o w h o w severely she had w h i p p e d the patient o n some occasions, or they would have her in f o r cruelty. T h e interview followed m u c h the same line taken w i t h t h e f a t h e r , only of course, f r o m the mother's point of view. She was given sufficient recognition of the difficult role which she has t o play in the family, and of the difficulties which she u n d o u b t e d l y has to meet, coming in as the stepmother of a r a t h e r spoiled child. O n the whole, the interview promised a fair degree of cooperation f r o m her mother, t h o u g h it is recognized t h a t she will have considerable difficulty in c o m i n g a r o u n d to a t h o r o u g h l y objective h a n d l i n g of the patient's situation. T E A C H I N G N O T E : This interview may be introduced to the class through the question "How does the psychiatrist use the concept of the purposiveness of behavior?" (a) Recognizing that all behavior is purposive and satisfying, with either constructive or destructive results, the psychiatrist, through the lead Eleanor gives him "the stepmother hadn't been yelling at her so much," attempts to have her see satisfactions for herself in a more adult form of behavior. (b) The class may be asked to evaluate this sentence: "She agreed to the fact that she and Eleanor were competing with each other for a certain degree of affection and, certainly, consideration from the father." This should bring out the fact that this is the focal point of the situation with the stepmother—that treatment will be successful only to the degree that she and the father are secure in their relationship, and so able to share Eleanor's happiness and difficulties and make her secure with them. If this discussion does not lead into the problem presented by the father-psychiatrist and child-psychiatrist relationships, the class will be asked to consider the stepmother's natural jealousy of the father-child relationship, which the stepmother indicated in an earlier interview. A treatment question may follow: Will a contact between psychiatrist, stepmother, and worker give the stepmother the much needed

ELEANOR

193

MEYER

security by allowing her to share the experiences of husband and child, as well as through recognizing that worker and psychiatrist meet on a common intellectual level? Will this increase her security with the worker? T h e value of the interpretation for Mrs. Meyer raises questions similar to those already raised for Mr. Meyer. 3.11.29

( C o n f e r e n c e : P s y c h i a t r i c Social W o r k e r a n d S u p e r -

v i s o r ) : T h e f o l l o w i n g points w i t h regard to t r e a t m e n t w e r e discussed: 1.

T h e d r a w b a c k s a t t a c h i n g to Mrs. M e y e r ' s star system.

S u p e r v i s i o n t h r o u g h o u t the 24 hours, and consequent sense of b e i n g w a t c h e d , together w i t h k n o w l e d g e that lapses m e a n t losses. D i s c o u r a g i n g e f f e c t of these losses. Possible f e e l i n g t h a t every " g o o d deed" demanded

financial

r e w a r d , a n d at the

same t i m e the remoteness of the r e w a r d . 2.

F r o m M r s . M e y e r ' s point of view the emotional f a c t o r s

t h a t led to a scheme w h i c h , while it partially c o m p l i e d w i t h the suggestion that a t t i t u d e should be positive, m a d e it possible f o r her to m a k e a c k n o w l e d g m e n t as impersonal as possible a n d , at the same time, m a d e it necessary f o r her to c h e c k u p on a wide r a n g e of actions. 3.

T h e value of this experience to Mrs. M e y e r , p a r t i c u l a r l y

in view of its almost inevitable f a i l u r e , in p l a n n i n g f u t u r e t r e a t m e n t w i t h her. A l s o value to ourselves in s h o w i n g the emotional problems of the mother we are u p against. 4.

I m p o r t a n c e of discussing this w i t h adoptive s t e p m o t h e r

a n d g e t t i n g her to w o r k out her o w n emotional reasons f o r choosing this p a r t i c u l a r plan. j.

N e e d to b r i n g Mrs. M e y e r to the point of l o o k i n g at

her o w n actions f r o m point of view of u n d e r l y i n g unconscious motives. 6.

N e e d to see a d o p t i v e stepmother as soon as possible—

before a n y serious difficulties have a r i s e n — a n d of

arranging

f r e q u e n t interviews. T E A C H I N G N O T E : A t this point students will be asked to review treatment to date, noting success and failure as per treatment objec-

194

E L E A N O R M E Y E R

tives of 2.19.29, and so clarifying objectives for, and methods of, f u t u r e treatment. This may be done in fifteen minutes in class, or be an outside assignment to be brought in for discussion. T h e supervisory conference of 3.11.29 will provide the basis for discussion. T h i s conference is recorded in adequate detail. 3 . 1 5 . 2 9 ( P s y c h i a t r i c Social W o r k e r ) :

W o r k e r called on Mrs.

M e y e r b y a p p o i n t m e n t , and asked her h o w her plans had been w o r k i n g out. She said, not too well, that patient seemed to be m a k i n g the star system an excuse f o r negligence, s a y i n g — " O h , w e l l , I'll get a star f o r something else." W o r k e r reminded Mrs. M e y e r that we had anticipated difficulties; that it was a f a c t that there seemed to be m a n y d r a w b a c k s to her scheme that had caused our lack of enthusiasm w h e n she first explained it to us. T h e adoptive stepmother said that she had come to realize some of the flaws. Patient had w o n 1 4 stars, and then lost 1 0 — w h i c h she had since regained. A t this rate, she c a l c u lated that it w o u l d take at least a m o n t h to reach 1 0 0 . She also recognized the disheartening e f f e c t of losing the 1 0 stars, and readily saw that the k n o w l e d g e that at a n y time another

10

stars m i g h t be lost, w o u l d be v e r y discouraging. W o r k e r asked if she had t h o u g h t out e x a c t l y w h a t had led her to adopt such a scheme, and suggested that possibly the more f o r m a l act of g i v ing a star had presented attractions to her, f o r the reason that it saved her f r o m the more radical change w h i c h w o u l d be inv o l v e d if the r e w a r d f o r good c o n d u c t w e r e unstinted praise. T h i s she was not w i l l i n g to a d m i t , but said that consciously at a n y rate, she had chosen stars because it a f f o r d e d definite opportunities f o r praise. F o l l o w i n g on this, there was some discussion about the i m p o r t a n c e of considering e v e r y line of action, not o n l y f r o m the point of v i e w of h o w it m u s t appear to patient, but also, f r o m the point of her o w n u n d e r l y i n g m o t i v e and the effect that that particular act w o u l d h a v e on her f u t u r e attitude to patient. Mrs. M e y e r said that she realized, more and more, that she had a long w a y to go, and that she w o u l d p r o b a b l y find it more difficult to c h a n g e herself than Eleanor.

ELEANOR

MEYER

195

It w a s n o t d e f i n i t e l y s e t t l e d h o w t h e s t a r p l a n w a s t o b e m o d i f i e d , b u t t h e a d v a n t a g e o f c u t t i n g it d o w n t o o n e s t a r a d a y , dependent on the general c o n d u c t for the day, rather than o n p a r t i c u l a r points, was discussed, the abolition of tions won),

cancella-

( l e a v i n g it m e r e l y t h a t o n b a d d a y s , n o s t a r s w o u l d and

more

frequent,

if smaller, r e w a r d s . Mrs.

be

Meyer

said t h a t E l e a n o r w a s m u c h t o o k e e n t o w i s h t o g i v e u p the s t a r s , t h o u g h she t h o u g h t t h a t she c o u l d e x p l a i n a n y

change

o n t h e basis o f a m o r e g r o w n - u p p l a n . T h e q u e s t i o n o f Eleanor's f a i l u r e in a r i t h m e t i c t h e n

came

u p . M r s . M e y e r w a s v e r y m u c h c o n c e r n e d , as p a t i e n t s e e m s t o be g e t t i n g w o r s e a n d w a s g i v e n 20 f o r b o t h m e n t a l a n d w r i t t e n t e s t s r e c e n t l y . T h e a d o p t i v e s t e p m o t h e r s a y s t h a t she

knows

p a t i e n t h a s g o o d a v e r a g e a b i l i t y i n o t h e r s u b j e c t s , b u t she a p p a r e n t l y t a k e s f r i g h t w h e n she sees

figures,

a n d c a n n o t use h e r

intelligence. M r s . M e y e r sometimes helps her w i t h her

arith-

m e t i c , a n d a d m i t s t h a t she loses p a t i e n c e a n d p r o b a b l y a d d s t o t h e c h i l d ' s f e a r o f t h e s u b j e c t . W h e n it w a s s u g g e s t e d t h a t a h o p e f u l a t t i t u d e o n h e r p a r t w o u l d h e l p , she said t h a t she c o n s t a n t l y t o l d E l e a n o r , " O f c o u r s e , I k n o w y o u c a n d o it if y o u t r y , " in a t o n e o f voice t h a t t o w o r k e r appeared to a d d , " b u t I h a v e l i t t l e h o p e t h a t y o u w i l l t r y . " T h i s w a s d i s c u s s e d in r e l a t i o n t o E l e a n o r ' s sensitiveness t o a t m o s p h e r e , a n d also t o t h e f a c t t h a t it w a s a r e f l e c t i o n o n h e r o w n a t t i t u d e , w h i c h she h a d tried to m a k e more impersonal. W o r k e r emphasized the f a c t t h a t t h i s w a s p a r t i c u l a r l y n e c e s s a r y if t h e r e w a s t o b e c r e a t e d the feeling that c o m m a n d s came f r o m both parents and

not

one. Q u e s t i o n e d as t o w h e t h e r she h a d d i s c u s s e d p l a n s w i t h h e r husband, Mrs. Meyer about

the

said n o , t h a t she h a d t o l d M r .

psychiatrist's

recommendation,

that

same

Meyer night,

h o p i n g t h a t h e w o u l d t h e n t a k e t h e lead a n d t a l k o u t t h e w h o l e subject. N o t h i n g happened, however, m u c h to her disappointment

a n d she h a d

Worker

not cared

to mention

the m a t t e r

again.

suggested that both were nervous, and pointed

out

the advantage of g o i n g to him immediately after w o r k e r ' s de-

196

ELEANOR

MEYER

p a r t u r e (he was in bed w i t h a c o l d ) , e x p l a i n i n g to h i m w h a t had been discussed, and g o i n g o v e r the whole g r o u n d w i t h him. T h e suggestion was not v e r y acceptable, and it is d o u b t f u l whether it will be carried out. Mrs. M e y e r said that his a t t i t u d e had been m u c h more h e l p f u l , and that he had g i v e n E l e a n o r orders once or twice. O n the w a y home, the previous w e e k , Eleanor had said h o w m u c h she liked the psychiatrist and Mrs. M e y e r f e l t t h a t he w a s v e r y definitely helping her to get a more m a t u r e point of view. T E A C H I N G N O T E : Students will be asked to read this interview by the light of the supervisory conference of 3.11.29. The following points may be stressed in discussion: 1. Did the worker use the conference and her relationship with the stepmother to its fullest advantage in helping Mrs. Meyer develop deeper insight into her behavior? 2. Was a discussion of the star system, which was doomed to at least a degree of failure, the point at which to open the interview? Mrs. Meyer suggested meeting Eleanor on a more grown-up level; as this was an ultimate objective of treatment, it might have been discussed in detail. From the final paragraph of the interview "Questioned as to whether she had discussed plans with Mr. Meyer . . . " and "The suggestion was not very acceptable," the class may discuss the worker's technique and the clarity and importance of the case objectives for her, as brought out in the interview of 3.6.29. 3.27.29

(Psychiatrist):

Mrs. M e y e r called the e x a m i n e r on

the telephone on this date and stated that she w o u l d not be able to bring patient d o w n this a f t e r n o o n as her h u s b a n d had just come in f r o m the office, and was quite ill, and she w o u l d h a v e to take care of him. She asked that the social w o r k e r m a k e another a p p o i n t m e n t f o r the patient. T h i s w a s agreed u p o n b y the e x a m i n e r . 4 . 1 . 2 9 ( P s y c h i a t r i c Social W o r k e r ) :

T e l e p h o n e d Mrs. M e y e r ,

a n d arranged f o r Eleanor to c o m e in on A p r i l 5th. W o r k e r explained that she could not be in at that time, b u t w o u l d call at the a p a r t m e n t on A p r i l 8th.

ELEANOR

MEYER

197

4 . 5 . 2 9 (Psychiatrist): Eleanor showed a good deal of the behavior which she has shown all along, and talked in much the same w a y that she has always done. Yesterday had been her birthday and there had been a big party. She was 1 1 years old, and had got a lot of presents. She showed a good deal of restless behavior during the interview, examining objects about the room. Complained that her mother yells too much, and too loud. She said, however, that her mother had not been yelling as loud as she used to do. Patient also claimed she is learning to get her o w n w a y by not yelling any more. She gave an instance of her being rude to her mother. This was about some shoes her mother had taken her to buy. Patient did not like the shoes and said she would not wear them. Then she went on to tell the examiner that they did not fit, and hurt her feet a n y w a y . She said that she had told her mother she was sorry, for being rude to her. She stated that her mother had stopped the system of giving stars f o r good behavior. The reason f o r this was that patient got too nervous when she lost some of the stars. The patient was evidently making a bid f o r sympathy f r o m the examiner and also, apparently, was getting her w a y by appearing nervous and getting by with the behavior f o r which she lost her stars. Examiner asked if she liked people who played sick to get out of things; patient replied that she did not like people who played sick. She says that she talks things over with her mother and has told her not to yell at her so much, but her mother doesn't give her any chance. She says she has plenty of chances f o r f o r giveness, but not f o r any good work. H e r mother is not like orher mothers; she yells too much, but doesn't yell quite so much as she used to. A f t e r some talk on the part of the examiner and patient, it was agreed that the patient could help her mother to stop yelling by giving her less cause to yell. The patient agreed to try this out. Patient says that she doesn't talk things over with her f Jther. There's no reason to talk to him, he never yells at her.

19^

ELEANOR

MEYER

E v i d e n t l y , t a l k i n g to a person means to the patient being assertive a n d telling w h a t she will and will not do. In answer to questioning she said that she talks to him about school and tells him what's happened there. She also asks him for m o n e y . She then said spontaneously, " I do things f o r him. I'm a good girl. T h a t ' s all he wants. I m a k e him c o m f o r t a b l e . " She was asked if she always m a d e him c o m f o r t a b l e . She said, " N o , not a l w a y s . " Q u e s t i o n e d as to what she asked him to do for her, she said she d i d n ' t ask him to do a n y t h i n g ; she just sat down b y his s i d e — a n d then she helped her mother with the dishes every night. H e r mother does not like her school w o r k ; arithmetic is b a d , but her other subjects are all right, however; she is i m p r o v i n g on her arithmetic so she need not worry there. She thinks she uses her brains now more than she used to. It was noticed that patient showed a great deal of s q u i r m i n g and restlessness. When asked a b o u t it, she said that sometimes she gets so restless she can't sit still. She could not verbalize any reasons f o r this restlessness, however. Q u e s t i o n e d as to her attitude to her mother again, patient said that her mother likes her friends. There's one f r i e n d of w h o m she thinks her mother does not a p p r o v e — t h i s is Helen, and the reason w h y she does not a p prove is t h a t Helen uses bad words. There is also another girl, named Nellie, w h o b r a g s about herself a great deal. H e r mother does not care f o r her to play with this girl; she says she does not care f o r her herself because she does not like to hear her b r a g g i n g all the time. T h e n she asked the examiner if she would get in trouble f o r telling this girl's name, apparently feeling g u i l t y about h a v i n g said something of this sort a b o u t another girl. T h e examiner replied that the conversations were confidential and she would not get into any difficulty because she had spoken of the other girl's b r a g g i n g . It m a y be possible too that the other girl does not b r a g and the patient is projecting her o w n b r a g g i n g on to Nellie. A f t e r a good m a n y questions had been asked the patient, she said to the examiner, " Y o u m u s t k n o w every little thing, d o n ' t y o u ? " T h e e x a m -

ELEANORMEYER

199

iner replied that he didn't care and he wanted her to feel f r a n k to talk about things. U p o n questioning, she said she did not m i n d answering questions he asked her. She said, however, that she w o u l d not answer such questions to her father and mother. A t the end of the interview, the patient gave an evidence of the transference she had made b y asking if she could come back in a week and not wait for t w o weeks. She wanted to come back a week f r o m the present appointment.

T E A C H I N G N O T E : Again we see the patient's attempt to establish herself in the satisfying role of the good child in the father-child relationship through attention-getting behavior and the projection of responsibility. T h e psychiatrist allows her this libidinal satisfaction. Upon this basis of security, he gives her an opportunity to accept an adult role by encouraging her to evaluate her own behavior. Is he purposely identifying her with her mother? The interview more adequately reveals that he knows of the separation of her parents into a satisfying parent and an unsatisfying parent. It may be possible to increase the constructive identification through the evaluation of the external and less emotional subject matter of her friends. Some indication of the distance treatment has to go and some of the dangers in her transference to the doctor may be found in her statement "that she would not answer such questions to her father and mother." The following questions will reveal the above interpretation: 1. At this point in the psychiatric contact why does the child need to exaggerate her response to the psychiatrist? 2. What will you (the class) add to the explanation of the child's behavior as given by the psychiatrist: "the patient was evidendy making a bid for sympathy." 3. What was the psychiatrist's purpose in asking Eleanor "if she liked people who played sick to get out of things?" 4.8.29

(Psychiatric Social W o r k e r ) :

W o r k e r called by ap-

pointment and f o u n d Mrs. Meyer alone. H e r husband was now better, but has had neuritis very badly. H i s doctor told him that it was a nervous condition, and that treatment was useless. T h e first inquiries led to an account of the w o r k i n g of the star system. Mrs. Meyer had talked the whole matter over with her husband after worker had last called, and they had decided to m o d i f y the system so that Eleanor should be given one star a

200

ELEANOR

MEYER

day, and at the end of the week these were to be valued at five cents each, and that amount was to be added to the twenty-five cents regular allowance. N o deductions were to be made, and she was to be free to spend the money as she wished. Further inquiry showed that this freedom to spend as she wished had very strict limitations, since candy is barred and patient is expected to ask permission to spend the money. Worker, however, did not lay much stress on this. The holiday week had proved disastrous; no stars were won. Worker suggested that when the offense was an exceptional one the adoptive stepmother should occasionally say that after all this was exceptional, and she was sure Eleanor did not mean to do it, and that she would leave it out of the reckoning in awarding the stars. Mrs. Meyer said that she had pointed out that it hurt her not to be able to give her stars, and did Eleanor not regret that she had not merited any. Eleanor's reply was a guarded yes. This kind of statement was constantly being made in connection with patient's misdeeds. Mrs. Meyer still constantly emphasizes her own anxiety and her own hurt feelings. When the question was raised she recognized quite readily that this was bad tactics, and repeated that it was going to be hard for her to change. She said that as a child she had very much resented in her own mother some of the very things that she was now doing. One of the patient's frequent offenses has been particularly conspicuous during the holidays. She has been told never to bring her friends in with her when asking permission to do something which the adoptive stepmother is likely to refuse. By this means she obtained permission to join two friends, and the maid of one, for a picnic in a wood nearby. They were to be back by 4 : 3 0 , and did not return until 5 : 3 5 . A day or two afterward, when Mrs. Meyer was explaining menstruation to patient, Eleanor told the stepmother that when in the wood they had seen three boys and three girls of about thirteen years old exposing themselves to each other. The boys afterwards

ELEANOR

MEYER

2 0 I

s p o k e t o her p a r t y ( t h e m a i d was s i t t i n g on a r o c k h i g h a b o v e t h e m , a n d a p p a r e n t l y did n o t n o t i c e ) , a n d E l e a n o r had n o t resented this. M r s . M e y e r h a d t o l d Eleanor t h a t she should n o t h a v e w a t c h e d , t h a t w a t c h i n g u n d e r s u c h c i r c u m s t a n c e s was e q u i v a l e n t t o e a v e s d r o p p i n g . She also e x p l a i n e d t h a t boys a n d girls w i t h good h o m e s did n o t d o s u c h t h i n g s . L a t e r , in t h e course of t h e c o n v e r s a t i o n , Mrs. Meyer asked if t h e r e was m u c h in h e r e d i t y . W o r k e r f e l t t h a t she h a d Eleanor a n d this picnic in m i n d , b u t t o o k it u p w i t h r e f e r e n c e t o Mrs. M e y e r , and her m o t h e r , e x p l a i n i n g t h a t a h i g h l y s t r u n g n e r v ous system w o u l d be i n h e r i t e d , b u t t h a t t r a i n i n g a n d e n v i r o n m e n t d e t e r m i n e d t h e a c t u a l reactions, a n d w e r e t h e r e f o r e m u c h more important. Mrs. Meyer feels m u c h h a p p i e r a b o u t h e r h u s b a n d since t a l k i n g o u t the w h o l e m a t t e r w i t h h i m . H e said t h a t he h a d n o t himself spoken because he f e l t t h a t she realized f r o m his c h a n g e d a t t i t u d e t h a t he n o w u n d e r s t o o d t h e s i t u a t i o n . She a d m i t t e d this, b u t was glad t h e y h a d been q u i t e o p e n a b o u t t h e whole m a t t e r . Finally, Mrs. M e y e r asked w h a t line t h e p s y c h i a t r i s t was t a k i n g w i t h E l e a n o r , a n d w o r k e r said, t h a t b y t a l k i n g t h i n g s o u t w i t h her, he was e n a b l i n g her t o see f o r herself a s t a n d a r d w h i c h she wished t o live u p to, a n d at t h e same t i m e she could talk over her f a i l u r e s in t h e c o m p a r a t i v e l y i m p e r s o n a l a t m o s phere of t h e C l i n i c w i t h o u t a n y e m o t i o n a l stress. T E A C H I N G N O T E : T h e first paragraph of this interview allows the instructor to ask a direct question: What is the possible relation between physical and emotional upset, and what may be the effect on treatment? Another point of emphasis is the stepmother's identification with her own mother. The students will be asked to discuss this and its probable ambivalent value. Identification connotes a degree of libidinal security. In this instance we also see guilt and increased failure on the ego level suggested in her statement "that as a child she had very much resented in her mother some of the very things she was now doing." The relation of the following questions to treatment is obvious.

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What meaning docs the strict discipline which she tries to enforce have for her—an opportunity to be authoritative and so possessive? Another opportunity to repudiate her rival, the first Mrs. Meyer, or an unconscious release of her jealousy and possible hatred of the child ? The class will continue to see an intellectual acceptance of much that the social case worker offers, but as yet litde emotional acceptance of it. If the record is complete, it indicates that future treatment must be more intensive and get to deeper levels before an emotional acceptance will be possible and a change of behavior follow. The worker overlooked, or was afraid to accept, many of the treatment leads open to her in this interview. The class discussion as well as the record material will indicate this. It may be profitable to ask the group what factors create such negative leadership, and its constructive or destructive value for the patient. 4 . 1 5 . 2 9 ( P s y c h i a t r i s t ) : E l e a n o r said she had been p l a y i n g and s k i p p i n g rope since the last time she was here. It w a s noticed b y the e x a m i n e r that she i m m e d i a t e l y began to play f o r a t t e n tion. W h e n asked a b o u t this she a d m i t t e d that she w a n t e d to m a k e a g o o d impression, and then said that she had had o n l y one q u a r r e l , and about this quarrel g a v e m a n y excuses f o r h e r s e l f , and b l a m e d the other little girl f o r it. It was noticed that she kept p u s h i n g on her chair and m a k i n g faces, r o l l i n g her eyes up, t w i s t i n g her hair, hiding d o w n b e h i n d the desk, and a n u m b e r of a t t e n t i o n - g e t t i n g devices. T h e e x a m i n e r paid n o attention to her, and let her r u n along f o r awhile, t a l k i n g a b o u t being a g o o d girl, and helping her m o t h e r and d o i n g w h a t her mother w a n t e d her to do, o b e y i n g , and a lot of c h a t t e r of this sort. T h e e x a m i n e r i n t e r r u p t e d her and asked her w h y she w a s c o m i n g d o w n here. She replied that last time the e x a m i n e r had seen her he had talked to her about h e l p i n g her be a good girl and talked to her about her f a t h e r and m o t h e r . It was noticed that her p h r a s e o l o g y o f the last i n t e r v i e w was her o w n s e l f righteous g o o d girl t y p e of t h i n g . She w e n t on to say that she was i m p r o v i n g in her g o o d school w o r k , t h a t her m o t h e r t h i n k s so. T h e reason she k n o w s that her m o t h e r t h i n k s so is that her m o t h e r told her so. H e r m o t h e r k n o w s t h a t she is i m p r o v i n g because the patient showed her her a r i t h m e t i c papers, and also her m o t h e r k n o w s t h a t she is i m p r o v i n g because the patient

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tells of how good she is in school. T h e examiner then asked her if it were possible to tell her mother o f her good behavior in school just to m a k e an impression. She shied a w a y f r o m this question, and twisted her hair, and said that she w o u l d n ' t do a n y t h i n g like that. She then w a n t e d to k n o w if the mother had been told things b y the examiner. T h e examiner assured her that we did not tell her mother the things she told us. She then claimed to have heard her mother say to her father that the e x a m i n e r had said the patient had a good f a t h e r and a terrible mother. U p o n closer questioning, she guessed she m u s t have imagined it, or dreamed it, or else " I m u s t have heard somebody say it, or I w o u l d n ' t Fave imagined i t . " T h e examiner told her that he had not said a n y t h i n g o f the k i n d to her mother, and asked her if she t h o u g h t he w o u l d be likely to say things like that about people. She a d m i t t e d that she did not think so. It appeared to the examiner that what the patient was t r y i n g to do was to get him to agree with her in what she herself actually t h o u g h t about the father and mother. T h e patient stated that the mother had a quarrel with the father about scolding her. She denied that the above attitude of hers, in regard to a good father and a terrible mother, was really her own attitude. She also stated that she does not tell her mother a n y t h i n g but the t r u t h a b o u t school, and that she never makes u p stories. She told a rather inconsistent story about the incident mentioned above. T h e patient thinks she is improving in school w o r k , and that the teachers think the same thing. They tell the patient she is good, that she is i m p r o v i n g in every way, in work and in c o n d u c t , in times absent, and times late. T h e examiner asked her w h y she t h o u g h t she was i m p r o v ing, and she said t h a t she w a n t e d to improve. It was better for her; her mother w o u l d n ' t scold so m u c h . All this self-complimentary talk was accompanied b y a good deal of attentiongetting; in this particular instance b y p u t t i n g her head down almost to the floor, while she still sat on her chair, and then looking u p out of her eyes at the ceiling. T h e examiner then

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asked how it was better for her. She said if she improved her mother did not have to scold her; that she was learning more things in school; and it was a relief to the teacher. She claims that she has not heard comments of this kind from others, and disclaims any showing off. She says that only fresh people show off, and that she likes to have people think she is good; she does this by acting nicely, and not telling other people about it. She says that she can tell by other peoples' faces whether they are fresh or not, and that other people must be able to tell by her face. The patient was asked what her mother thought about her friends. At first she said, "You asked me that before." The examiner said, " W h a t did you say then?" She said, "Well, she doesn't like Helen and Nellie. Mother thinks they show off too much. Helen is greedy." The patient does not like Helen; she hates her; she ignores her; because she is too show off, and is too greedy, and she is a thief—she steals. "She tells people to do things which they shouldn't do. She makes them get mad and glad." Then she said, "Can those things be helped?" The examiner said he thought they could. She said, "Well, then she ought to be helped. She is worse than me. She is worse than I used to be even." Here she got up and walked around the room, handling the examiner's books, rubbing her hands up and down on the glass door until she got them filthy dirty, showing them to the examiner, wiped them on her dress and repeated the performance, then put her hands against the wall and tried to touch her head to the floor by bending backward. Then she said, " W h a t shall I tell my mother we were talking about? I get tired of telling her the same thing over and over again. She gets tired of it. Shall I tell her everything? I don't want to tell her everything. She'll scold me if I tell her everything. She won't like me to talk about her." She was told by the examiner that she should be the one to decide how much she should tell her mother. The examiner would not tell her mother, nor would he tell her how much to tell her mother. The only provision was that, if she chose to tell her mother

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what we had talked about, she should be sure to tell it quite truthfully. She displayed a tendency to show off at this point by hopping around the room as though she had a crippled leg. She wanted to know when she could come again and wanted to come on Tuesday of next week. The examiner asked her why she wished to come in again. She said this was a treat, and kept pushing her hair from side to side, putting her finger in her mouth, in a typical coquettish fashion, and said because she liked the examiner. This the examiner took as part of her attention-getting behavior. Then she ran out of the room, and rapped on Dr. X — ' s door, and ran back again in order to fool him. She said, " I do those things; I'm that type. I've always done things like that." T h e examiner asked her if she didn't think that those were just an excuse for what she wanted to do. She replied to this by wanting to know whether the examiner is a philosopher or a medical doctor. The examiner replied that he was a doctor. She wanted to know if he was a real doctor, one who tied up cut fingers and things like that, and he replied that he was. She wanted to know whether he was a Ph.D. doctor or not, and the examiner told her that he was not. He then asked her what philosophy was, and she replied that it was a man who studied "philiology," which was about children's habits. When asked where she learned this she said that her Aunt Mabel had told her, and then said, " D o n ' t write that down. It'll get me in trouble. Not from you, but from some other doctor. Some other doctor might see it, and he might not be able to keep his mouth shut, or he might tell the desk (meaning the telephone operator) and she would tell my mother. She says I'm too big now, and sometimes she says I'm not right in my head. Have you ever met my mother? Do you think she is nice? D o you?" The examiner asked her in response to this, " D o you think she is nice?" The patient replied to this by asking the same question over again. The examiner asked her why she wanted to know whether he liked her mother or not. She said, "Because she likes you. I know you like her, because you are nice to her. You act it. A man who didn't care

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for m y mother would not see her as m u c h . " Then there was much begging on the part of the patient for the examiner to tell her w h a t he had told the mother. The examiner told her that he kept the patient's confidence, and did not tell the mother w h a t he talked about to her, and he did likewise for the mother; that if she expected the examiner not to tell the mother what patient said to him, then she should not expect him to tell her what the mother had said. The patient then claimed to know w h a t the examiner had talked to the mother about. The examiner then asked her what this was. She stated that the examiner had talked to mother about the fact that patient was a normal child. It was recalled by the examiner that f o r m erly she had begged the examiner to be sure to tell the mother that she was a normal child, in order to get her mother's goat, and it would appear that this statement was merely a wish fulfillment thing on her part. The patient admits that she does not like to talk about w h y she does things. The examiner asked her w h y this was so, and she replied that it annoyed her, she didn't know w h y she did some things. She admits that she does most things because she wants to. She then asked the examiner to persuade her mother to let her stay and write on the blackboard in the waiting room. The examiner told her that he did not know whether this would be possible or not, and talked to her about what her mother had to do after she left here. He got the patient to state that the mother had to get home and get supper, and that it would take as much time as they had left after the appointment to do this. In view of this fact, the examiner said that he did not think it would be fair to ask her mother to stay while she drew on the blackboard when she had to get home and have supper ready for her father. T h e patient then said, " W h y don't you talk to her? W h y don't you tell her to make it easier for me? She is a little hard on me. She doesn't get the point about me at all. She thinks that some things I do are not right. I don't obey her. She punishes m e . " She went on to state that she had been punished recently because she had been supposed

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to stay out in front of the house while she played, but instead of this, she had gone to a forbidden area in the back of the house. She claims that she thought her mother was not home, but she had not gone inside herself. This was also a punishment, as she had been allowed to go somewhere and had been told to come into the house when she returned, so that her mother w o u l d know whether she was at home or not. She gave a great m a n y excuses about w h y she had not gone into the house. She said that the blinds were down, and that she was sure that her mother was away, but that she had not gone in to find out. T E A C H I N G N O T E : A general question in which the class is asked to pick out positive trends in treatment m a y bring out the points that follow. If it does not, specific questions will be asked. F o r the first time the psychiatrist asks Eleanor if she is playing for attention, though he has been aware of this at each visit. H e r obvious security and recognition of the doctor's objectivity with no blame attached to any act of hers, probably enables Eleanor to admit it. H e then uses her admission to develop her responses about the childm o t h e r relationship a n d her school relationship. T h e frankness with which she discusses the stepmother may indicate her feeling and some progress towards her acceptance of her as a mother person. W e may see an attempt to identify Mrs. Meyer with the psychiatrist w h e n the child asks h o w m u c h she should tell her mother, or it may be a bid for backing in her rejection of the mother, a n d keeping her out of what has come to be a satisfying experience; as before, the doctor treats her on an adult level and tells her to m a k e the decision. H e r insecurity with the stepmother is evident in her listening at the door, questions about the doctor-mother contacts, her plan to have her told that she is a "normal child." W e d o not k n o w to what degree the doctor handled this, other than accepting the child's statement "I k n o w you like her because you are nice to h e r " and thereby suggesting a means for securing a satisfying relationship. H e r constant projection of her conduct upon Mrs. Meyer, her admission "that she does not like to talk about why she does things" suggests guilt and insecurity. K n o w l e d g e of the details of her life with the first Mrs. Meyer, especially in its libidinal satisfactions, would give positive leads and treatment objectives at this point. 4.22.29

(Psychiatric Social W o r k e r ) :

Worker called at P.S.

66 and saw Miss White. Patient caught sight of worker and

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w a v e d enthusiastically. Miss W h i t e l e f t the class to speak t o w o r k e r . T h e question o f arithmetic was first discussed, and the teacher said that she was c o n v i n c e d that there was no disability. Eleanor was e q u a l l y bad (or g o o d )

in all branches and her

m e t h o d s were the same t h r o u g h o u t . She rushed at the p r o b l e m a p p a r e n t l y determined to p r o d u c e an answer immediately. T h e answer was generally w r o n g , b u t w h e n made t o stop and t h i n k , she g o t the answer right. Miss W h i t e has g i v e n patient a good deal o f attention lately, and has her at the board a good deal. She feels that she is g e t t i n g some results. Miss W h i t e said that this hastiness ran t h r o u g h all her w o r k . In any lesson, if a question is asked, she will p u t u p her hand w i t h o u t any hesitation even w h e n she does not k n o w the answer. Eleanor's m a n n e r is e x a g g e r a t e d , and theatrical, p a r t i c u l a r l y in recitation. Miss White

attributes

this to her elocution

lessons, w h i c h

she

t h o u g h t bad f o r her, b u t her present lessons o n l y started a little b e f o r e Easter, and patient's m a n n e r was like this before. T h e other girls stare w h e n Eleanor recites. Patient's c o n d u c t has been good e x c e p t f o r the first t w o weeks o f the quarter w h e n she fidgeted a good deal. T h e r e is n o t h i n g o u t s t a n d i n g , and she mixes well w i t h the other girls. T E A C H I N G N O T E : This call can be passed over quickly by asking the students for the points of interest: the familiar picture of attentiongetting behavior, the question of security and the social adjustment with her equals which indicates some degree of emotional adjustment. If we had any knowledge of her friendship relations at boarding school we might be able to evaluate her progress and capacity a bit. Students may stop here to evaluate and discuss treatment in relation to conference of 3.11.29. As before, we may relate material that they bring to the conference of 4.29.29. 4.29.29 ( C o n f e r e n c e : Supervisor and Psychiatric Social W o r k e r ) : Case discussed and the f o l l o w i n g points b r o u g h t o u t : i.

T h e r e seems t o be some danger t h a t the question of

w h a t takes place in Eleanor's c o n t a c t s w i t h the psychiatrist m a y create an issue between Eleanor and her stepmother. It is t h e r e f o r e necessary to explain t o Mrs. M e y e r that, f o r the w o r k

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of the psychiatrist to be effective, the patient must be able to feel that w h a t she says to him is in confidence. T h e stepmother's fears that Eleanor will say things to us about her m a y be partially relieved b y emphasizing that our interest is in h o w the patient feels about things, and that w e recognize that w h a t she says is not necessarily true, b u t it is important because it represents her attitude. Mrs. M e y e r can f u r t h e r m o r e be reassured b y emphasizing that if a n y t h i n g comes out in these contacts which the psychiatrist t h o u g h t the parents should k n o w , he would handle it in such a w a y w i t h the child that it w o u l d be possible to tell them. 2.

It is recognized that there is a danger that Mrs. Meyer

will come to reject the Clinic's suggestions because of the almost unavoidable inference of criticism in our treatment suggestions to her. She was driven to coming to the Clinic because of her o w n f a i l u r e w i t h the p a t i e n t — a n d she m a y interpret treatment in such a w a y as to add to this initial sense of failure. For this reason, it is d o u b l y u r g e n t that our contacts with Mrs. M e y e r be made as positive as possible. This means that even corrective treatment suggestions m a y have to be avoided at times, and the situation handled in such a w a y as to increase Mrs. Meyer's security with the C l i n i c . 3.

T h e question of Eleanor's sex interests seems to be

taking a place in the f o r e g r o u n d of Mrs. Meyer's thinking. While we recognize that these interests are largely s y m p t o m a t i c and can probably be handled effectively w i t h o u t any direct attack, it will be difficult to get Mrs. M e y e r to adopt this point of view. She is almost certain to be unable to ignore t h e m — t h e question then arises as to h o w we can insure that she will handle them in the least destructive w a y . It was felt that it would be wise to discuss this w i t h the psychiatrist before taking u p the question with Mrs. Meyer. 4.

Mrs. M e y e r has seemed interested in the books suggested

—so perhaps it w o u l d be wise to continue this line of treatment. She has read B u r n h a m ' s Normal Everyday

Problems

of the Everyday

Mind

Child.

and Thorn's

It was felt that

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such a book as The Problem

MEYER

Child at Home

would have value

in that, by reassuring Mrs. Meyer that behavior problems are fairly universal, she might get some release from the sense of her own failure. TEACHING N O T E (Conference 4.29.29): The material prepared by the students may be supplemented if necessary by the following elaborations, injected by the instructor: Point One. Discuss the values and hazards for treatment in the confidential relation existing between psychiatrist and patient and the degree to which either may be enhanced or eliminated by weighing the emotional components of the total family picture. Is "our interest is in how the patient feels about things" a generic social-case-work interest? Point Two. The relationship with the mother will be fraught with difficulty. Her husband's dissatisfaction with her way of handling Eleanor implies criticism and puts her at a disadvantage. We find the Clinic in the same role. Therefore, her guilt is increased, her insecurity becomes greater and treatment does not progress. Will a period of intensive treatment be necessary in order to help Mrs. Meyer understand herself and to enable her to put her relationships on a constructive level? Point Three. Indicate the social worker's use of the psychiatrist as an expert resource. Point Four. As is stated, attempts to remove some of the negative values in Mrs. Meyer's relation with the Clinic by emphasizing the universality of parent-child difficulties. This intellectual approach may lead to an emotional acceptance which will begin to release her guilt. 4 . 2 9 . 2 9 ( l a t e r ) : Eleanor was brought in by Mrs. Meyer, and worker took her to one of the interviewing rooms. Worker inquired into health of Mr. and Mrs. Meyer, and learned that the stepmother, as a result of 10 days' diet, had lost 14 lbs. but had regained 6 immediately. Although tired and somewhat irritable during the ten days, she did not feel any the worse for it, and proposed to give it another trial. Mr. Meyer's neuritis had been very bad, causing many sleepless nights. He will get up and walk about or talk right through the night, saying that this is the only thing that relieves him. Stepmother says that he never loses his temper, and is always kind and con-

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siderate, but a f t e r such a night he is worn out, and not fit for work. She attributes this to financial and work worries. O n e gathers that their night talks are of a playful nature and t h a t they are like children together. Mrs. Meyer in talking, m e n tioned several times in which her husband had joined with her in dealing with Eleanor. T h e star system is working with comparatively few hitches now, although Eleanor accuses Mrs. Meyer o f unfairness sometimes. T h e stars are not given each day, but at the end of the week Mrs. Meyer says which days have failed to secure stars, and for what reason. In describing this, and other incidents, the adoptive stepmother more than once showed that she realized when she overemphasized her own feelings, it gave Eleanor the chance to " g e t her g o a t . " She was a little discouraged at the way she repeated the same action, even when she knew she was wrong, and worker had to reassure her by saying that since she now saw so clearly after the event, she would presently see before acting. Eleanor has taken to saying very definitely that she will not do a thing when she is told to, although in the end, o f necessity, she does it. Mrs. Meyer recognizes this as merely a new way o f annoying her, and was doing her best to ignore her. She has also been trying to joke so that the refusal need not be taken seriously. Patient, a few days ago, called Mrs. Meyer into the bathroom and with much pleasure asked her whether she did not notice anything different. Mrs. Meyer said yes, dirty feet; then, that she was getting very fat, particularly in the stomach. Eleanor in desperation said that it was not any o f these things but that her breasts were beginning to develop and that they were very painful at times, and everyone who hit her seemed to hit her breasts. Lately, Eleanor has been playing much more with boys than girls, but is inclined to c r y if hurt, and recently was brought in by a man, crying that she had been hit on the nose, and demanding that her father go out and deal with the boys. T h e man asked Mrs. Meyer not to hit Eleanor (showing that Eleanor had been playing on his s y m p a t h y ) . O n these

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occasions, Mrs. Meyer takes the line that if Eleanor plays rough, she must put up with the consequences, and her husband seems t o cooperate. Thorn's Everyday

Problems

of the Everyday

Child

was re-

turned, and Mrs. Meyer said that she had found the book most helpful. She found it easy t o read, and it had given her a feeling o f rest, which she compared to the feeling she got f r o m going into a Christian Science C h u r c h . F r o m this she went on to the subject o f religion, saying that she was not religious, and kept to little beyond the T e n C o m m a n d m e n t s . She does not think Eleanor is religious either, but she made a great fuss about not being allowed t o stay away from school the first two and the last t w o days o f the Passover. She was kept at home the first day, but made to go to school the rest of the time. ( T h e schools make arrangements for the Jewish children not to write on these days, as that is forbidden by the orthodox tenets.) T E A C H I N G N O T E : This interview may be used to emphasize a frequent happening in social case work; overlooking and not developing positive values because of concentration upon the problems of a given situation. Students may be asked to discuss the satisfying elements in the husband-wife relationship and their value for treatment. Further discussion of the case worker's technique is also indicated in the notes which follow. T o date little is known of the relation between Mr. and Mrs. Meyer except in the child-parent role, neither doctor nor worker has used Mrs. Meyer's statement that "they would be ideally happy were it not for this one source of friction," or Mr. Meyer's statement that "he is on very affectionate terms with his wife." The worker makes the following entry "one gathers that their night talks are of a playful nature and that they are like children together." This suggests satisfactions in the husband-wife relationship which might well be understood and used to offset the destructive nature of the treatment to date for Mrs. Meyer as it revolved around failure. Mrs. Meyer indicates increased insight into her own behavior ("she realized when she over-emphasized her own feelings") and so creates another opportunity for deepening her understanding which the worker lost. The details of everyday events made a natural and easy transition possible.

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4.29.29 (Psychiatrist): The patient came in and made herself quite at home in the office, and began taking the pins out of the map on the wall. She spontaneously remarked that she had been good this past week. She said that her mother had gotten a f t e r her today—her mother scolds too much. " W h a t I did this afternoon was very little," she said, and then went on to state that coming down in the subway there was a woman standing up, and her mother told her to stand up, and let the woman have her seat. The patient had merely said " O h , " and then her mother yelled her head off at the patient. "She shouldn't yell at me. She should question me," was the patient's comment. "She should have asked me first why I said 'Oh.' I didn't mean that I didn't want to stand up. I was only too glad to stand u p . " She went on to say that her mother had also yelled at her for looking out the window, that she has a habit of letting her mouth drop open when she is listening to things, and her mother had said to her "Stand up there, and don't look like an idiot." We then asked the patient if her mother should do that to her, and she said that she was the meanest and most selfish person in the world. The patient said that she is not selfish, but that there are plenty of people who are selfish. Then she admitted, however, that sometimes she is selfish, and finally agreed on saying that she is just about medium, she thinks herself more selfish than her mother, and finally came to stating that her mother is not selfish at all, but she does not think her mother is fair. The reason for this is that she does not consider it fair for her mother to treat her the way she does when she is nice to her mother. She feels hurt about it. She says that her mother doesn't take too much interest in her father, but pays more attention to herself, because she wants the patient to learn things. She likes them both the same. She has told the patient this, and the patient thinks she shows it too. She is good to both of them. Patient states that when she is good, her mother is good to her, but when she is bad, she is bid to her. " M y father is good to me all the time—and she is good to him all the time. Father likes us both the same. I just

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get half his love. I wouldn't want to have it all; that would be too selfish. I would rather have a mother, than be with m y father alone." This was in answer to a question. Her reason for this was that she had had to live in a boarding school, and her father had gone broke paying for the school and the expensive hotel where he had to live. N o w they are in much better financial position since the father married. T h e y have more relatives and more money. She says that if they die, rich relatives will take the patient and care for her. At this point, the patient went to get some water, and it was noticed by the examiner that she was trying to listen in on the mother's conversation with the social worker in the room across the hall. She admitted this on coming in, and said that they were talking about her aunt. When the examiner asked her to tell something more about her father and mother—a general question—the patient stated that she sees her parents kissing and hugging in bed in the morning. T h e examiner asked her what else and she replied, " N o t h i n g else—but there might be something else." T h e examiner asked her to what she had reference. She would not answer this, but picked up a piece of paper and wrote it down. This is what she wrote on the p a p e r — " T h e y might want to get a baby, for m y mother told my father to look at her stomach because there is a rash on i t . " She handed this to the examiner to read, and when he had done so, she said, " D o n ' t you think that's terrible? D o you think my father ought to look at her stomach?" T h e examiner asked her why she thought it was terrible, and she said, "Because my mother hasn't got any clothes o n . " She went on to say, " I know about getting a baby. Before you can get a baby you have to be pregnant." The doctor and the patient then discussed pregnancy, menstruation, intercourse, and birth processes in considerable detail. T h e interview had gone overtime, and the examiner had to see another patient. T h e patient did not want to leave, however, and wanted to ask other questions. T h e examiner suggested that she think up these questions and remember them for the next interview.

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TEACHING NOTE: At this point the students may be asked to question whether or not a change in environment is desirable in order to give the child an opportunity to use such insight as she is getting through her psychiatric contacts. Summer plans may be getting under way. 1. In a complex situation in which three persons are involved, what are some of the positive treatment moves that the social case worker might consider to relieve temporarily the tenseness of the situation? 2. How will the group evaluate the following: The patient's rejection of her mother through her unfavorable comparison with the methods of the doctor, "she should question me," and her statement that her mother "is the meanest, most selfish person in the world,'" in contradiction to her security with her father, "my father is good to me all the time." 3. Do the parents show progress? 4. The direct handling of sex curiosity has been discussed as symptomatic. May it help to release some of the tension in the jealousy situations with the stepmother? 5. What will be the positive and negative value for each member in the family should the worker suggest a possible camp plan? 6. As treatment has been under way four months, it may be well to discuss the relation between depth of emotional conflict, and the breaking down of old patterns and the building up of satisfying substitutes, etc. 5.6.29

(Psychiatric Social W o r k e r ) :

W o r k e r called by ap-

pointment. Mrs. Meyer was not fully dressed and said that she had been feeling poorly. She had given up her reducing diet on the advice of the doctor because last week she developed shingles and he had pointed out that dieting increased the nervous strain. Mrs. Meyer had promptly regained as much as she had lost, and now wondered if it were not a glandular condition. She did not feel that her doctor would be a judge of this, and worker suggested that perhaps the

Clinic

would meet her need. Mrs. Meyer was excited about Eleanor's failure to account for all her allowance, and spoke of one mislaid 1 5 cents which Eleanor had declared she could not remember spending. T h e matter was finally dropped, Mrs. Meyer saying that it was not

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that she wished to control her expenditures, b u t that she felt it was d r e a d f u l not to be able to account f o r all expenditures, but a f e w days later Eleanor had spontaneously said that she had contributed t o w a r d s flowers that had been send to a S u n day-school teacher w h o was sick. O w i n g to the date on which the m o n e y disappeared, it is almost certain that this story was not true, but Mrs. Meyer did not pursue the matter. T h e a d o p tive stepmother realizes that it would be better not to insist on accurate account keeping f o r the present at any rate, and seemed to accept worker's suggestion that there be a recognized m a r g i n of "personal e x p e n d i t u r e s . " Mrs. Meyer said how difficult she f o u n d it not to be over-particular, b u t said that she was really trying, and was g e t t i n g no help f r o m her h u s b a n d . T h e cooperation which he had shown earlier had vanished, and there was c o n s t a n t friction of a childish nature e n d i n g in silence on one side or the other. Mrs. Meyer cried in talking of this, but was not embarrassed, and said she cried very easily. O n e occasion of friction was recounted. Mrs. Meyer had b o u g h t Eleanor an entire new o u t f i t , spending on her so m u c h that it has been impossible to b u y a new spring coat f o r herself, although her old one is very s h a b b y . Eleanor treated her clothes very badly, and finally on S u n d a y played outside in the rain, and the coat was all spotted d o w n the back. In the evening they were g o i n g out to a restaurant f o r supper (this a f t e r both father and mother tried to sacrifice their pleasure to each o t h e r ) , and Eleanor walked in f r o n t , m a k i n g the d a m a g e particularly conspicuous. Mrs. Meyer m a d e the most of Eleanor's sins, and her husband refused to answer. When they reached the restaurant, Mr. Meyer said he was not eating a n y t h i n g (he had been feeling ill e a r l i e r ) , and Mrs. Meyer said t h a t since she had only come out f o r his sake, she would certainly not stay if he ate nothing. She went straight home, and l e f t him with Eleanor. Mrs. Meyer recognizes that these scenes are disastrous, but feels that she m u s t have her husband's s u p p o r t if she is to control herself on these occasions. She added, however, that she

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felt v e r y much better when she was able to talk it all over with worker. She felt that, since the Clinic knew everything, she could talk freely, which she could not do with her friends. T h e question of rivalry was gone into as a possible motive f o r the carping criticism which she could not restrain. Mrs. Meyer said that intellectually she accepted this explanation since we had put it to her; that she had read the books lent to her, and that she could see that she was a rival in the eyes of Eleanor; that Eleanor was her rival, however, she found it difficult to admit. T h e Problem

Child

at Home

was then explained to Mrs.

Meyer, and she was encouraged to make a note of any point she wished to discuss. T E A C H I N G N O T E : "Mrs. Meyer said that intellectually she accepted this explanation . . . she could see that she was a rival . . . she found it difficult to admit." T h e instructor may read this paragraph to the class and ask them to discuss the emotional factors involved in intellectual as well as emotional acceptance of unsatisfying psychiatric concepts. T h e discussion may proceed to evaluate the following, as it relates to the rivalry situation: 1. Mrs. Meyer's constant anxiety indicative of a certain degree of guilt and insecurity—shingles, the result of a nervous condition. 2. "Their financial position makes it impossible for them to have other children and, at the same time, give the best of everything to the patient. Mrs. Meyer says that Eleanor must come first and that, therefore, she does not mean to have any children. She has discussed this with her husband and he agrees. ,, 3. Do we need to know Mrs. Meyer's attitude towards Mr. Meyer's first marriage? How does it affect treatment? Will security with Mr. Meyer release Mrs. Meyer's conflict and so make it possible for her to accept Eleanor? This discussion should emphasize the universality of the types of problems which Mrs. Meyer is attempting to handle. j . i 1 . 2 9 (Psychiatrist): T h e patient met Hilda Blumgart in the waiting room as she came from the office of the examiner. She was very curious about her, and wanted to know if she were nice. Then she said she had talked to Hilda, and found out that Hilda was in 4B, while she was in 5B. She tried to i m -

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press the examiner with this, evidently t r y i n g to show off this advantage in regard to the other patient. T h e examiner asked her what we had talked about the last time she was here. She recalled the incident which had happened on the s u b w a y , then she said that the examiner had wanted to k n o w if her mother or father liked her best, and w h y . She thought a great while, and then said the examiner wanted to k n o w if they punished her, and what f o r . A f t e r a good deal more thought, she said the examiner had talked to her about the mischief she had been doing. A l l this time she was being very coquettish, and making quite certain that the examiner knew that she knew what she had reference to. Finally she said " O h , yes, there was something else" and she had written it down on a piece of paper, and commented on the part about getting a baby. In answer to a question, the patient stated that she has always wanted a brother. She wanted this brother to be younger than herself because she thinks babies are so cute. She has imagined having a brother. She has asked her mother lots of times, but her mother says that she couldn't take care of one, send him to college, buy him clothes, etc. Patient says she wouldn't be jealous because she would pay lots of attention to the baby herself. H o w e v e r , when asked if she thought she would be selfish with the brother, she said she did not k n o w , and goes on to say that she is not very selfish. She tells, however, of being selfish in a restaurant where she takes the best food that her father has ordered. When he gets something that she likes, she will say that she likes it, and then he gives it to her. She was asked if she were ever generous. She says she was generous to her father and mother, and gives as an example of this that she lets them do whatever they w a n t to. " I let them go out, I'm glad they have a good time." She commented on her new dress, saying that she had gotten it on her birthday, on A p r i l 4th. There was much bragging about the number of dresses she has, saying that she has twelve, and describing these dresses. When asked about bragging, she says that she never brags about herself, she doesn't like braggers.

ELEANOR

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2ig

T h e examiner tried to get at what relationship she had with a friend. She says that sometimes she is the leader, and sometimes she is n o t — i t depends on who makes up the game. If t h e y are jumping rope, then the owner of the rope is the "whole cheese" in the game, as she expresses it. She tells of one girl w h o is not nice in this respect. She says that when they p u t someone out of the game they boss them. She admits that she does this when she is the owner of the rope, and says that she does so because she wants to show them that they are not the only people. She remarked that they are the kind of people who have to be yelled at. She says that these girls are stubborn, and if she tried to teach them not to be stubborn, they would tell her t h a t she had no manners herself. Here she remarked that there are plenty of children around the block much better than she is, b u t she tries to be better, and remarks that she is just as good as they are, but in ways they are better. W h e n asked how, she said, " I knew you would ask that question. Some of them are not as bossy as I am. I'm not such a boss because I don't often get a chance. I'm not such an a w f u l boss, I play fair. If anyone cheats, I tell them to get out of the game. I hardly ever cheat myself, and if I do do it, I just do it for f u n . " The examiner asked her if she ever cheated at school. She said that she didn't try to do it—she just absentmindedly did it, once. She said "You know about the gown for the play!" She was asked if there were any other times when she tried to cheat in school. She tells of an occasion when a girl near her didn't have an answer, and she cheated by giving this girl the answer. They simply nodded to each other, and gave each other credit for a problem when they were grading each other's papers. She told the teacher about this girl, and then this girl told the teacher on her, to get even. Patient says "She knew very well I wasn't going to stand that without telling on her too." She claims the other girls play tricks on her—but this doesn't make her mad, because she doesn't mind jokes. She says that she likes them. She says she doen't necessarily t r y to get even with them, but sometimes she does get even about these jokes.

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A t this point the examiner was asked what the difference was between a stepmother and a fostermother. She wanted to k n o w if her mother was a step w i f e to her father. These things were explained to her. T h e examiner returned to the question of her friendship, particularly in relation to boys. She says she doesn't play w i t h boys. There are about ten girls w h o play together, and they usually j u m p rope. She says that all of the other girls go w i t h boys. T h e patient wants to go w i t h them too, to see what they do. She says the other girls pretend that they don't like boys, but she says that they call boys names just in order to make the boys chase them. Most of the girls are her o w n age, some older and some younger. Patient's best friend is Marguerite Beck. She is n

and in 5B. Patient says she likes her because

she is a nice girl. H e r worst friend is Helen Smith. She says that she tells too m u c h , lies, and steals, and things like t h a t — that is the reason she does not like her. T E A C H I N G N O T E : The general trends of the discussion of 5.6.29, with Mrs. Meyer, can be carried on by asking the students to discuss such concepts as the following: 1. The time element in shifting a socially destructive libidinal pattern of long standing to an ego level. 2. The part environment plays in creating any problem and, therefore, the necessary manipulation of the environment in treatment. The class, or the instructor, can be concrete by illustrating as follows: As far as we can see the child's emotional trends have not changed during treatment "she tells of being selfish" "there was much bragging" "that they are the kind of people who have to be yelled at" "some of them are not as bossy as I am" "when he gets something that she likes she will say that she likes it, and then he gives it to her." 5.13.29 (Psychiatric Social W o r k e r ) : Mrs. Meyer seen b y appointment. She had her leg bandaged. She had been knocked d o w n by a car the day before, and, although not seriously hurt, was a little shaken. W o r k e r brought up the question of camps and learned that

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221

Mrs. Meyer had two plans under consideration. O n e was to send Eleanor to a new camp which was being started by a f r i e n d of a friend near Meadowlands. The other was for Mrs. Meyer and Eleanor to go to Canada to the aunt. The drawb a c k to Canada lies in the expense since, not only would the f a r e be heavy, b u t a considerable outlay in extra clothes would be necessary. Mr. Meyer favors this because it would give his w i f e a holiday. While camps were being discussed, Mr. Meyer passed by the open door on his way out. Worker had not known t h a t he was in the apartment. Mrs. Meyer said that on Saturday Eleanor was over an h o u r and a half with the psychiatrist, and was very subdued on the way home. Worker took the opportunity of explaining the psychiatrist's attitude towards the interviews with the patient, and this was accepted apparently without question. Mrs. Meyer was, however, feeling guilty about one episode she t h o u g h t Eleanor would have told psychiatrist, and she had expected him to come and talk to her afterwards. In the middle of the week when she came home Eleanor was in f r o n t of the apartment house, but looked as though something had happened. (Mrs. Meyer says that Eleanor came to her with an expression of guilt on her face in order to be questioned so that she would not have to be the first to broach the subject of her wrong doing). Mrs. Meyer questioned her, and obtained a confession of having played across the road, which was forbidden, b u t with such improbable details that it was quite clear that much of the story was untrue. Eleanor was sent straight to bed, and the stepmother proceeded to verify the story over the telephone. Mrs. Meyer admits that she entirely lost control of herself, and whipped Eleanor. She was feeling ashamed of herself as a result, but apparently had not analyzed her action. Worker discussed with her the effect of the cross questioning of Eleanor after she had once embarked upon a patently untrue story. Mrs. Meyer saw that it served only to cause more lying, and perhaps also gave her an excuse for completely losing her temper. She sees that the punishment must have

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seemed to Eleanor a manifestation o f her own lack o f c o n t r o l , rather than a deserved p u n i s h m e n t . In spite o f the apparent insight, worker did not feel t h a t there had been more t h a n a superficial understanding. T h e last week had been a very m u c h happier one as f a r as relations w i t h her husband were concerned, and e v e r y t h i n g took on a rosy aspect in consequence. Mrs. Meyer t h o u g h t t h a t her husband had realized how very difficult the situation had become the previous week, and had been most considerate in every way since. W o r k e r said t h a t she would like t o see M r . Meyer if he would come in one day. Mrs. Meyer had almost s u g gested this herself the previous week when complaining o f the lack o f consideration and cooperation, and was very glad to undertake to make an a p p o i n t m e n t . Mrs. Meyer told w o r k e r , w i t h every sign o f real pleasure, that Eleanor is to be Alice in a school play n e x t week, and has a very long part to learn. She has also had very m u c h better marks in arithmetic lately. R e f e r r i n g to last week's interview, Mrs. Meyer said t h a t she could now understand w h a t confession must mean t o a C a t h o l i c — t h a t the relief she experienced f r o m t a l k i n g t h i n g s over was so great. W o r k e r then mentioned that she would be leaving the C i t y at the end o f the m o n t h , b u t t h a t Mrs. Meyer need not feel t h a t this made any difference, t h a t whoever took worker's place would k n o w all about the situation, and she could feel equally

free in discussing her difficulties.

Mrs.

Meyer did not seem t o be at all disturbed at the t h o u g h t o f a change T E A C H I N G N O T E : Points for concentration in this interview may be as follows and may be led up to by direct questions: Camp seems to be acceptable to the parents, perhaps in part because so many children go to camp these days, perhaps because of a wish to relieve the friction in which they have been living. They may also recognize the destructive part discipline has played in the situation (for instance, that described in this interview). Camp routine, removed from the emotional atmosphere of the home, will add a constructive element which may lead towards the child's ego adjustment.

ELEANOR

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2 2 3

A period free from the tensions which have blocked them will give Mr. and Mrs. Meyer an opportunity to regain their lost security in each other, and so build for the natural adjustment of Eleanor's return. Mr. and Mrs. Meyer have been happier lately and, therefore, the prognosis is better. Mrs. Meyer's sense of guilt continues to be extreme, "she entirely lost control of herself' "she now understood what confession must mean to a Catholic" Has she fallen so far below her standard for the mother-child relationship that she must punish herself and deserve the position which she thinks she holds with her husband? When she has a basic understanding of her conduct, she will be freed from the present tension, will see herself as a person able to direct and control her motives and consequently able to function in a manner satisfying to herself and to her environment. The interview may be summed up by asking the class if progress is to be noted and if so to relate it to problems as revealed. 5.21.29

(Psychiatric Social W o r k e r ) : Mrs. Meyer was seen

by appointment. She was feeling cheerful, and said that e v e r y thing had run perfectly the entire week—that Eleanor had been " a n g e l i c . " N o t h i n g had been settled about the summer, but Mrs. Meyer said that she feared that both camp and C a n ada would prove impossible f o r financial reasons. T h e a d v a n tages of camp and its impersonal discipline were discussed, and Mrs. Meyer will most certainly do everything in her power to enable Eleanor to go to one. She thinks that possibly, if the new camp near Meadowlands (which she mentioned last w e e k ) is not filled, Eleanor might be admitted on special terms. Nothing of this has been discussed before the patient. Mrs. Meyer said that lately Eleanor has demanded an unusual amount of petting. A f e w evenings back she said she wanted to be loved, and was allowed in her parents' bed f o r a little while, and was hugged by Mrs. Meyer. A f t e r this, she did not want to go to her o w n bed, and was only induced to go by a threat that she would never be allowed into her parents' room again. W o r k e r pointed out that this was very infantile action on her part, and suggested that while not repulsing Eleanor, Mrs. Meyer should let her realize that this

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was babyish, and cut short these physical endearments. Eleanor had on more than one occasion told her adoptive stepmother that she expected gratitude for what she did. This occurred recently after laying the table for breakfast; Mrs. Meyer had taken the line, previously suggested by worker, that all members of the family naturally did things for each other, and that, as she did not expect Eleanor to be constantly thanking her, Eleanor must not expect everything she did to be given special notice—the fact that nothing was said did not mean that her work was not appreciated. Mrs. Meyer expressed her interest in The Problem Child at Home. Worker asked if it did not help her to notice what in her own action provoked a particular response, and whether reading of other peoples' problems had thrown any light on events of her own childhood. It did not seem that she had reached this point, or in fact that she had considered anything as applicable to herself. TEACHING NOTE: What meaning will the class attach to Mrs. Meyer's statement that "everything had run perfectly the entire week." The healing value of time may be mentioned here. How will they evaluate Eleanor's wish for petting as the record has given little of the positive relation that must have existed at times between Mrs. Meyer and Eleanor. Threats, discipline, the extremes that may follow any deprivation may be touched on. Knowing this child, it may indicate a better acceptance of Mrs. Meyer, or it may be largely attention-getting, or it may be an attempt to "get Mrs. Meyer's goat." W e have now come to a normal place for reviewing treatment from the initial conference to date. The treatment conference of 5. 25.29 works out treatment plans for the summer. Students may be given a written assignment in preparation for the class discussion of the conference which they will be asked not to read before coming to class. Treatment

conference,

5.23.29

Participating staff.—Psychiatrist, Psychiatric Social Worker, Supervisor Purpose.—To plan treatment during summer months. Summary of progress.—Treatment since initial conference, has consisted o f :

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225

Interpretation to Mr. and Mrs. Meyer separately. In the

first place psychiatrist saw Mr. Meyer, and social worker his w i f e , but M r . Meyer asked that exactly the same points be b r o u g h t out with his w i f e , and an interview with psychiatrist was therefore arranged. Both parents appeared to accept the interpretations, although the adoptive stepmother hesitated o v e r the suggestion that Eleanor was her rival. 2.

Fortnightly

psychiatric

interviews

with

patient

in

w h i c h psychiatrist has endeavored to make her see that she is not playing f a i r when she deliberately "gets her mother's g o a t . " A considerable amount of time has also been given to answering questions in matters of sex. 3.

Almost

weekly

interviews with

the adoptive

step-

mother, in order to enable her to review her own actions in the light of the response 011 part of patient and, still more, in the hope of realizing her own underlying motives. Help has also been given in planning a positive instead of a negative f o r m of discipline. Response

to treatment.—Mr.

Meyer, according to his w i f e ,

was cooperative at first, but soon returned to the position where he watched Mrs. Meyer's efforts in silence. Relations have o f ten been strained and open quarrels of a childish nature have taken place. Mrs. Meyer appears to have accepted the f a c t that her methods of dealing with patient are at the root of the trouble, and says that she realizes that the hardest part of her task is in changing herself. In reviewing her actions, she sees where she has gone w r o n g while saying that she often cannot restrain herself. O n the other hand, it is d o u b t f u l how near she comes to understanding the motives which are at the root of her failure to control herself, although she attributes much of her irritation with Eleanor to her husband's lack of support. Discussion.—Discussion

was chiefly concerned with plans f o r

the summer months. It was agreed that intensive treatment would be necessary f o r some time, but it seemed undesirable to expose Mrs. Meyer to two changes of social workers. T h e question of whether anything will be gained through inter-

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views with the adoptive stepmother when the source of irritation is removed (presuming that Eleanor goes to camp) was gone into, and it was thought that Mrs. Meyer had gone far enough in accepting the Clinic's interpretation to make occasional interviews desirable. Since she recognizes that her action is largely responsible for patient's conduct, with Eleanor away it might become easier to bring her to the point of accepting the underlying motives which at present make any change in herself almost impossible. The position of the adoptive father was also discussed, and the importance of his cooperation emphasized. Present Position.—Mrs. Meyer has received an invitation from her sister in Manitoba for herself and Eleanor, but for financial reasons, it will probably not be possible for her to accept. Camp for Eleanor has been discussed, and if it can be managed without too great expense, Mrs. Meyer will put this through, but it is unlikely that anything will be settled until late in June. Treatment plan.—Encourage plan of sending Eleanor to camp rather than that of accompanying Mrs. Meyer to Canada (should this prove financially possible). Continue psychiatric interviews with patient every three weeks should she not go away. Arrange three or four appointments for Mrs. Meyer with psychiatrist in the course of the summer. Social worker to review situation with Mr. Meyer and reemphasize part he plays in treatment. Fall.—Renew intensive treatment with Mrs. Meyer through a social worker who can be at the Clinic the entire year if possible·

Psychiatric Social Worker Supervisor

TEACHING NOTE: Students will report on the written assignment. In addition to the points enumerated in the conference, it might be well for the instructor again to stress the slight progress that seems to have been made, the need for intensive treatment on a deeper level, and the probably excellent work done by the two students when it is

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evaluated in relation to their equipment It is possible that trained clinic personnel would have met another series of blockings which would have delayed the attainment of objectives. 5 . 2 7 . 2 9 (Psychiatric Social W o r k e r ) : Mr. Meyer rang u p to say he could not get to the Clinic but arranged to call the f o l lowing day at 9 : 3 0 . 5.28.29

(Psychiatric Social W o r k e r ) : Mr. Meyer called at

1 0 A . M . H e straight away launched into praises of the Clinic and said that everything was now perfect at home, and he would

not have

believed

such an improvement

possible.

W o r k e r had some difficulty in interrupting the flow. She tried to point out that there was still considerable room f o r i m provement, and that, in any case, Mrs. Meyer was having a very hard time; that, if she was to continue her efforts at changing her attitude towards Eleanor, she must be quite sure of his cooperation, that without this the position of rival to her stepdaughter would again become intolerable. W o r k e r then pointed out that he held the key position and must do his share. Mr. Meyer agreed to all this, but immediately joined in again with praises of the Clinic, and one gathered that he felt that the Clinic's advice had agreed with his previous advice to his w i f e on the subject of her attitude towards Eleanor, but that where he had failed to convince, we had succeeded. Mr. Meyer's rosy view of life was probably partly the result of $ 2 0 0 . compensation f o r the accident to Mrs. Meyer. T h e money had come at a most opportune moment, and the amount was considerably more than they had expected. W o r k e r raised the question of camp, and he said that he quite saw that Eleanor would be better away f r o m home f o r a time. Hillsboro at $ 1 0 . would have met with his approval, but it was Christian. H e said that at the boarding school, although Eleanor was accepted as a Jewess, she was made to feel out of things, and had been compelled to go to church. A l t h o u g h not orthodox in religion, he would not like her to go where she would feel in a false position. T h e reduced charge of $ 1 5 0 . for Indian Head C a m p attracted him, but he felt that he must

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ELEANOR

MEYER

think it over, and in the meanwhile he would be glad if the Clinic would inquire whether the camp was run on religious lines. Worker explained that she would be going away, but that the psychiatrist would be in touch with Mrs. Meyer and Eleanor until the fall, when another social worker would be asked to cooperate. Worker emphasized the fact that there was still a long way to go if a relapse was to be avoided. Verbally he agreed and said that of course no one could be made over in a month, but immediately went on to say that, from what he heard of other children, they had little to complain of in Eleanor. 5.29.29 (Psychiatric Social W o r k e r ) : Worker called by appointment. Mrs. Meyer was in a very cheerful mood. Eleanor had been a great success in the play, and Mr. Meyer, without saying anything, had given her the impression that he felt everything was going well. The compensation money also influenced her mood. This was the worker's last interview with Mrs. Meyer, and the situation was reviewed to some extent. Mrs. Meyer thought she was learning how to manage Eleanor, and was checking herself more and more when she was tempted to be over particular. Worker went into the question of the importance, not only of checking her immediate reactions, but of understanding what lay behind these reactions—otherwise the irritation would remain. T o this she agreed, saying that often she boiled inside while restraining herself. The episode recounted last week was again considered, and worker asked Mrs. Meyer if she had thought of w h y she had driven Eleanor to further lies; whether she had possibly wanted an excuse to lose her temper. This was merely taken as an example of the usefulness of getting down to the reason for any particular line of conduct, and Mrs. Meyer said that she was beginning to understand herself better. Worker explained that no social worker would be making a special study of Eleanor now, until the fall, but that the psychiatrist would like to see Eleanor at regular intervals as long

ELEANOR

MEYER

229

as she is in the c i t y and also to see her, Mrs. M e y e r , t w o or three times. Mrs. Meyer quite understood t h a t she could telephone the psychiatrist at a n y time t h a t she m i g h t be in need o f help. C a m p s were again discussed, b u t n o t h i n g could be decided. O n e h u n d r e d and f i f t y dollars e v i d e n t l y seems a great deal t o the s t e p m o t h e r , b u t , if the Indian H e a d C a m p says t h e y can take E l e a n o r f o r this, she will consider w h a t is possible. She may not be able t o come t o a decision u n t i l close on the t i m e f o r c a m p , and realizes t h a t she m a y t h e r e f o r e lose a v a c a n c y , b u t has t o risk t h a t . T E A C H I N G N O T E : The students will be asked if there will be need for further treatment, if Eleanor is happy at camp, and Mr. and Mrs. Meyer happy at home. Can the record to date be analyzed so understanding^ that it will be possible for a new case worker, and possibly a new psychiatrist, to make the reentry to treatment that is positive and satisfying where it has been threatening and disturbing? An advanced class might attempt such an evaluation, a beginning class can speculate about it. In conclusion it will be challenging to ask the class to evaluate the contribution that a mental hygiene record has made to their case-work equipment and possibly to themselves as potential workers. The range of the discussion may cover a wide area. It can be directed towards the Teaching Syllabus which has been used in the Introduction only, as this case concentrates on the Method and Knowledge material. The instructor may work out any specific objectives from the contributions of the individual class members.

CHAPTER V THE

CASE R E C O R D

OF RICHARD

H E A T H

1.

Introduction with analytical comments arranged in accordance with the classification of the Syllabus Page 2. The case record with notations in accordance with the Syllabus Page 3. Record of the home of foster mother, Mrs. Dolby Page 4. Cards suggested for indexing the record if used in a library of case records Page I.

230 242 331 343

INTRODUCTION AND A N A L Y T I C A L C O M M E N T S A.

Indications

AREA O F SOCIAL CASE WORK

of the breakdown

Contributory

1

factors

Death—father,

of social self-maintenance

(I)-'

(a) :

11.30.20.

Mental disease—mother,

12.10.20, 2.7.22,

4.20.22.

*In o r d e r t o o b t a i n r e c o r d s f o r t e a c h i n g purposes w h i c h g i v e a l o n g - r a n g e v i e w o f treacment,

and s h o w t e s t e d o u t c o m e s ,

it is o f t e n

necessary

t o c h o o s e cases

which

c o v e r a c o n s i d e r a b l e period o f t i m e , a n d , in any r a p i d l y e v o l v i n g field, s u c h as t h a t o f social w o r k , t h e p r a c t i c e f o l l o w e d in t h e earlier stages o f s t u d y and

treatment

m a y , as in this i n s t a n c e , be o u t s t r i p p e d b y n e w e r k n o w l e d g e and i m p r o v e d as t h e Richard

case

progresses.

Heath

psychiatric

in

Since

1920,

the early

rapid

advances

knowledge to c h i l d - p l a c e m e n t

contacts have

of been

problems:

the

Children's

made

in

the

methods

Society

the child-placing

in

which

Richard

was t h e n

living

has

of

facilities

t h e a g e n c y , w h i c h w e r e t h e n in t h e i r i n f a n c y , h a v e b e c o m e b e t t e r o r g a n i z e d d e v e l o p e d , and t h e i n s t i t u t i o n

with

application

of and

since been

closed b y a c t i o n o f its o w n b o a r d as i n a d e q u a t e and no l o n g e r n e e d e d . I t is b e l i e v e d , h o w e v e r , t h a t in spite o f s u c h c a s e - w o r k i m p e r f e c t i o n s as t h e m a r c h o f t i m e

may

reveal, this r e c o r d has d e f i n i t e t e a c h i n g v a l u e s . T h e s e p e r t a i n in t h e m a i n t o t h e use o f foster homes f o r the t r e a t m e n t o f child behavior, t h e reactions o f the child and his successive f o s t e r p a r e n t s t o e a c h o t h e r , and t h e i n f l u e n c e e x e r t e d b y t h e social w o r k e r in d e a l i n g w i t h v a r i o u s crises t h a t

arose.

' T h e l e t t e r s and n u m b e r s o f t h i s a n a l y s i s c o n f o r m the Syllabus,

figures

t o t h e l e t t e r s and n u m b e r s

i n d i c a t e m a t e r i a l in t h e case r e c o r d at t h e d a t e s g i v e n .

of

RICHARD

HEATH

2^1

Changes of residence and caretakers—child, 12.10.20, 2.6.22. Behavior responses of child (b): "Screaming" spells. Playing with excreta and other unclean habits, 4 . 1 ^ . 2 1 , 6.22.21, 1.16.22, 3.13.22. Configuration of contributory factors and other circumstances constituting the case (II) Type configuration (a): Broken home, 1 1 . 1 3 . 2 0 , 12.10.20, 4.20.22. Economically dependent child, 2.6.22. Child behavior problem, 4 . 1 5 . 2 1 , 4.22.21, 1.16.22, 3.13.22. Particular configuration (b): A seven year old boy had from infancy been subjected to frequent changes of residence and caretakers. His mother had been in and out of hospitals for the insane, and his father, who appears to have been unstable, was dead. The child had been cared for at different times by his mother, his paternal relatives, friends, and three children's institutions. The last institution, where he had been placed by relatives and where he had lived for about two years, had applied to the Children's Society for his placement in a foster home, because of temper outbursts and unclean habits with which it had been unable to cope, 4.1 j . 2 1 to 1.16.22. B.

T E C H N I C A L METHODS

Case-work processes (I) Social study (b). There is nothing unusual in the Heath record up to the point where Richard was accepted by the Children's Society for foster-home placement. A detailed social history and a physical and psychological examination of the child were secured. The following points pertaining to the social study seem worth noting: The situational inquiry following the family's application

232

RICHARD

HEATH

to the Episcopal Home, 12.10.20.—Here, although the relatives had withdrawn their application at the time of the social worker's call, she took advantage of the opportunity to establish a contact with the grandmother and to secure a sketch of the child's background. This step proved to be of value later, since the grandmother subsequently left the city, and was not available as a source of information when application was later made to the Children's Society for the care of Richard. Use of Experts.—Although Richard was given a physical (1.25.22) and psychological (1.30.22) examination on admission, a psychiatric study was deferred until he had twice failed to make a successful foster-home adjustment, 8.18.22, 8.21.22, 8.28.22. This might be discussed from the point of view of: When is a psychiatric study indicated? May the necessary data for such a study best be secured before or after placement? What are the differing practices of social agencies with respect to psychiatric examination and facilities used? Were there specific community conditions which determined the delay in this instance? Treatment (/): Placement.—The high lights of the record center around the foster-home placement of Richard and the problems that arose in effecting a satisfactory foster-home adjustment. We are permitted to glimpse the child's behavior reactions over a period of two years, along with the influence exerted by three foster families, a social worker, a psychiatrist, and a succession of temporary caretakers to modify that behavior. Of equal interest are the behavior reactions of the foster parents in response to the problems which the child presented. In relation to these phases of the record, " E " ( K N O W L E D G E ) material in psychology and psychiatry is of special significance. The most important question in the record, for teaching purposes, is what was responsible for the failure of the first two foster-home placements, and why did the third place-

RICHARD

HEATH

233

ment succeed? T h e record supplies various clues to the answer. Elements

in the foster

to the success or failure

homes

themselves

of the

which

contributed

placements

Owen h o m e : ' (—)

Foster father unsympathetic toward child. 5

(—)

Tension between foster parents.

(—)

Vacillation and faulty methods of discipline in

treatment o f child. 3.16.22, 4.17.22, 4.18.22, 5.8.22, 5.24.22, 6.12.22, 6.27.22. Helman home: ( + ) Foster mother affectionate and sympathetic, (-f)

Better methods of training and discipline than in

Owen Home. (—)

Foster father and grandmother jealous of boy.

6.28.22,

7.1.22,

7.10.22, 7.20.22, 7.24.22,

8.4.22,

8.9.22, 8.10.22, 8.18.22. Dolby home: ( + ) Foster mother's warmth o f affection which was felt and responded to by boy. ( + ) Pleasant relationship between boy and foster father. ( + ) Consistent discipline. ( + ) Normal varied interests and activities. (—)

Lack of adequate companionship with other chil-

dren. (—)

Emotional attitude of foster mother toward sex

problems. 8.9.22, n.8.22, 11.2j.22,

1.10.23, i-8.23,

3.12.23,

3.23.23, 4.11.23, 7.19.23, 8.28.23, 9.10.23, 10.18.23, 11.21.23, 2.21.24, 7·8·24> 7· Ι 2·24.

10.24.24,

12.4.24, ' F o s t e r - H o m e i n v e s t i g a t i o n s are u s u a l l y r e c o r d e d s e p a r a t e l y b y c h i l d - p l a c i n g a g e n c i e s , and descriptive

entries

concerning

foster

homes

which

o n l y f r a g m e n t a r y digests o f t h e c o m p l e t e f o s t e r - h o m e

appear

in t h i s

record

records kept by the

are

agency.

(See p. 3 3 1 f o r c o m p l e t e r e c o r d o f a f o s t e r h o m e . ) 'See R e c o r d , P a r t 5

II, 3 . 1 6 . 2 2 ,

3.1 8 . 2 2 , f o r a g e n c y ' s p u r p o s e in u s i n g t h i s h o m e .

Plus and m i n u s signs i n d i c a t e i t e m s d e e m e d f a v o r a b l e a n d u n f a v o r a b l e ,

t o successful

placement.

respectively

234

RICHARD

HEATH

Elements in the case work which contributed to the success or failure of the placements: Owen home: ( + ) Supplying escort service to clinics to relieve foster mother, 3.29.22, 3.31.22, 4.2.22, 4.4.22, 4.6.22, 4.7.22. Helman home: (—) Investigation of the foster home failed to reveal disturbing emotional factors which came to light following placement, and which a more adequate inquiry might have elicited, 6.28.22, 7.24.22, 8.9.22,8.10.22, 8.18.22. Dolby home: ( — ) The record does not show the extent to which the choice of this home, which proved successful, was based upon conscious analysis of its strengths and weaknesses. ( + ) Visitor's supervision and planning were probably a more important factor than the record shows in tiding over upsets of the foster mother, 2.8.23, 3-13.23, 2.21.24, 3.26.24, 6.11.24, 6.17.24, 7.8.24. ( + ) Arranging for interim care of boy while foster mother has vacations, 2.28.23, 3.12.23. ( + ) Education of foster mother through literature on child study and sex, 11.30.23, 7.25.24. ( + ) Sex education of boy by psychiatrist, 7.9.24, 7.26.24. ( + ) Arranging camp experience to supply a lack in the foster home of boy companionship and group experience, and to relieve foster mother's tension over sex episode, 7.8.24, 7.9.24, 7.17.24, 8.29.24, 9.12.24. Health and Mental Hygiene Promotion.—Outstanding in this case is the expert physical and mental care provided for Richard. This began with a complete physical and psychological examination as part of the original social study, followed by routine physical reexaminations at definite intervals, and by careful attention to the carrying out of treatment recommendations. Later, when the child failed to make a satisfactory

RICHARD

HEATH

235

foster-home adjustment, psychiatric examination and followup were resorted to. Health Promotion Initial examination, 1.25.22. Follow-up recommendations, 2.13.22, 2.24.22, 2.28.22, 3.3.22, 3.17.22, 3.27.22, 3.29.22, 3.31.22, 4.2.22, 4.4.22, 4.6.22, 4.18.22, 5.2.22,6.20.22,6.26.22,6.28.22, 7.14.22, 8.23.22, 8.24.22, 4.20.23, 8.28.23, 9·4· 2 3· Routine reexaminations and follow-up at the time of each replacement and at other regular intervals, 7.1.22, 8.31.22,11.23.22,1.6.23,2.8.23,3.3.23,3.5.23,3.21.23, 8.28.23, 1 2 . 1 . 2 3 , 3· 2 6 · 2 4> 6.17.24, 7.25.24, 7.29.24. Use of local resources vs. agency resources, 1 . 1 1 . 2 3 , 8.28.23, 9·4· 2 3» 1 1 · 1 5 · 2 3 · Adjustment of school program to health needs and arrangements for escort service, 3.31.22, 4.2.22, 4.6.22. Mental Hygiene Promotion Psychological tests, 1.30.22. Psychiatric interviews, 8.18.22, 8.28.22, 10.25.22, 11.22.22, 1 1 . 2 3 . 2 2 , 11.25.22, 2.28.23,3.20.23,3.21.23, 8.21.23, 8.28.23, 3.20.23, 3.21.23, 8.21.23, 8.28.23, 7.26.24. Technique (II) Observation (b) Some good bits of observation relating to setting and personal appearance are found in two of the early interviews, 12.10.20, 4.22.21 (3 items), and at many points throughout the record there are instances of observation of behavior indicating the social worker's alertness to its significance. Management (d) In addition to the items already cited under Treatment, an instance of skillful management appears in connection with the application made by Richard's relatives for his admission to Colby Academy. Early in the social study the visitor informed herself by communicating directly with Colby what the status of the ap-

236

RICHARD

HEATH

plication was, J.I J . 2 1 . She later learned in an interview with a family friend, 2.6.22, of the family's strong feeling that Richard should go to Colby when he could be admitted. There is no indication that she made any attempt to influence the attitude of the paternal aunt, about sending Richard to Colby, in their telephone conversations of 4.28.21, but when the question came up later, after a good contact with the aunt had been established, the visitor presented her reasons for thinking that such a move would be unwise, and secured the psychiatrist's confirmation of this opinion which she transmitted to the aunt, 1 1 . 2 5 . 2 2 (2 items), 1.22.23, 2.28.23, 6.6.23, 8.27.23. When Richard's name was finally reached on the Colby waiting list, the ground had been prepared for the steps which the visitor then took to avert the transfer of Richard. This action was taken firmly and with avowed intent, but with full recognition of the rights of the relatives, and of Colby, to participate in the decision, 8.28.23 t o 9· Ι Ο · 2 3> inclusive. Another evidence of skill in management of resources appears in arrangements made by the social worker to relieve situations in the foster home which were creating tensions. C.

SOCIAL RESOURCES

Facilities (II) "Social" (b) For Personal Care and Custody (1) institutional Facilities Although the institution that figured in this case, prior to Richard's acceptance by the Children's Society, had very indifferent standards and can, in no sense, be taken as illustrating institutional care at its best, the material in the record, if properly supplemented by available literature in the field of social work, affords a basis for some consideration of institutions as such, e.g.: Intake Practices: Episcopal Home investigation delegated to an agency having field work facilities, 1 1 . 1 3 . 2 0 , 12.29.20.

R I C H A R D

H E A T H

2 3 7

Admission of Richard to Lowell Institute arranged through a Board member, a friend of the grandmother. Nature and extent of the inquiry (?) 12.10.20.

Colby Academy investigation conducted by its own social worker, 5 . 1 5 . 2 1 , 6 . 6 . 2 3 , 6 . 9 . 2 3 , 8 . 2 2 . 2 3 , 8.31.23.

Institution Plants, 4 . 2 3 . 2 1 . Personnel, 4 . 2 3 . 2 1 . Standards of Care, Health—problems of infection and quarantine. Individualizing the needs of children, 1 2 . 1 0 . 2 0 , 4.15.21, 4 . 2 2 . 2 1 ( 2 items), 1 . 1 6 . 2 2 , 2 . 6 . 2 2 , 3.13.22.

Νott-Institutional facilities Foster Homes:—The case illustrates the use of boarding foster homes for long-time care, temporary foster homes for various short-time services, and a summer camp to provide needed group contacts, and to tide over a period of stress in a foster home. I. Owen home First placement 3.16.22 2. Helman Second placement 7.1.22 Temporary placement Morris 8 .18.22 3· Dolby 8 .31.22 Third placement 4· Temporary placement 3.1.23 5· Quarles 3.15.23 6. Hall Temporary placement Temporary placement 3.19.23 7· Murray Return 3.23.23 Dolby Temporary placement 7.15.24 Morris 7.29.24 8. Summer camp Temporary placement Return 9 .14.24 Dolby The relative merits of the temporary foster home and the small institution or "shelter" for short-time care might be considered in this connection. Considerable material on this subject is available in the literature of social work. Camps Relatives and Friends: (in this case relatives and friends

238

RICHARD

HEATH

were used by the social worker, and, therefore were rather a "social" than a "natural" resource or facility as interpreted in the Syllabus). In its contacts with relatives and friends the agency recognized: Their value as sources of information. The psychological value of kinship ties and the desirability of preserving any values which these might have for the child. The possibility of encouraging contribution by relatives towards the support of the child without forcing an unwilling assumption of responsibility. The need of maintaining friendly relations with relatives and at the same time regulating their contacts with the child to avoid disturbing the normal processes of adjustment to new surroundings. 12.10.20, 4.28.21, 6.2.21, 6.8.21,7.27.21,2.6.22, 3.27.22, II.15.22,

3.29.22, II.23.22,

4.I.22,

J.13.22,

II.2J.22,

1.6.23,

J.15.22, 1.22.23,

6.6.23, I 2 . 7 . 2 3 , 4 . I 2 . 2 4 , 6 . I I . 2 4 , IO.24.24,

2.2J.22, II.14.22, 3-28.23,

12.4.24.

Medical, see Β—Health Promotion. Mental, see Β—Mental Hygiene Promotion. D.

PHILOSOPHICAL QUESTIONS

The record affords material for the consideration of several questions of social work philosophy: General questions of human life and human relationships (I) Philosophy of Family Life (b) Parent-child relationship.—The importance of a satisfying parent-child relationship is clearly evidenced in this record as well as the possibility of supplying this through a substitute relationship where the natural ties are broken. The possibility of a too great dependence upon a satisfying foster-parent relationship, following a period of great deprivation, is also apparent, and the responsibility of the social worker for pro-

RICHARD

HEATH

239

v i d i n g adequate security f o r the dependent child and at the same time developing his independence. Kinship

Tics.—Although

Richard was cared f o r outside his

f a m i l y group, the Children's Society was c a r e f u l to maintain contact with his relatives, and his association with them, notwithstanding their instability, represented the one element of c o n t i n u i t y in his life. For this reason, these ties m a y have been of as great importance in his adjustment as were the values in the D o l b y home, where, in spite of the deep attachment that g r e w up between R i c h a r d and Mrs. D o l b y , his security was seriously threatened on at least one occasion

(7.8.24)

and

there are other allusions in the record to the possibility that she m i g h t give him up. Adoption.—Could

adoption have added a n y t h i n g to the

values of the D o l b y home? It hardly seems that it would have increased the affectional element, and, by i d e n t i f y i n g the foster mother more closely with Richard and cutting off her possibility of escape, it might have increased her emotional tension over the sex episodes. It would also probably have eliminated the helpful influence of the social worker in tiding over the periods of stress, since supervision is usually not continued a f t e r the legal steps are consummated. O n the other hand, it is possible that adoption might have added something to R i c h ard's sense of " b e l o n g i n g " and have given him a certain social satisfaction in the possession of a f a m i l y . Substitutes

for the Family.—Although

the record does not

show the possibilities of institutional care at its best, it gives some basis f o r weighing the values of foster homes and institutions as methods of child care. T h e very difficulty in any institution, however good, of giving an adequate affectional relationship and individual treatment to a child as deprived and insecure as Richard makes it d o u b t f u l whether an institution of even the highest type would have offered a solution f o r his problem. T h e odds against it seem great enough to rule it out, at least as a first choice. O n the other hand, it is not possible to determine how much Richard's security may have been threatened by shifts of residence both before and after his

240

RICHARD

HEATH

acceptance by the Children's Society. Nor could one say whether an exceptional institution with special facilities for individualization and with warm personal contacts could have offered more security. The record in its totality suggests that boarding in foster homes, legal adoption and institutional care, as treatment devices, all have possibilities and limitations and that their use in any given instance is indicated less by abstract considerations than by the specific values which each may bring to the individual situation. The value to a child in each of these methods seems to depend less upon the method than upon the personalities with whom the child becomes associated, and possibilities of the establishment of a satisfactory rapport between them and the child, and their ability to deal intelligently and understandingly with his problems. It is true, however, that while no system can insure satisfactory outcome, the inherent values or limitations of a particular system may make it easier, or more difficult, in any given situation to achieve such an outcome. Also, any system is conditioned at all times by the quality of administration available. (II) The Social Workers Philosophy In Relation to the Community (c) The intensive health service provided by the Children's Society suggests the question of the relative merits, practically and philosophically, of a separate, high grade health service maintained by an agency for its clients, as against its utilization for them of the general health resources of the community. And there is the further question of the responsibility of a children's agency for the health care of dependent children, for whom it acts in loco parentis, in relation to the community's responsibility for the health of all its members. E.

FORMULATED

KNOWLEDGE

Psychiatry, Psychology This case touches formulated knowledge in the fields of psychiatry and psychology at almost every point, so that to index the record in detail for these fields would probably be

RICHARD

HEATH

24 I

more confusing than helpful. T h e richness of the material will be readily apparent to anyone following through the d a y - b y day behavior reactions of Richard in relation to the various personalities with whom he came in contact and the experiences through which he passed. T h e crux of Richard's behavior difficulties appeared to lie in his emotional deprivation and insecurity, and the record makes it possible to trace with considerable certainty the emotional lacks in his life and the gradual modification of his behavior

that

resulted

from

the establishment of

a valid,

substitute parent-child relationship in a foster home, on the basis of which reeducation, discipline and progressive development became possible. Social Work

(a)

T h e record f o r the most part exemplifies foster-home care, but in the social study made by the Children's Society prior to its acceptance of Richard, an instance of unsuccessful institution care 6 is revealed which affords some basis, although a very inadequate one, f o r discussion of the t w o methods. It would obviously be u n f a i r , on the basis of a single record, to draw comparisons between these methods, particularly when the standards of the participating institution and the childplacing agency are so unevenly matched. There is, however, a considerable amount of formulated knowledge in social work relating to the two methods of care, and with the aid of such supplementary material some of the values and limitations of both institutions and foster homes may be brought out. Formulated knowledge is also available concerning standards and practice in the medical and mental hygiene services provided by children's institutions and child-placing

agencies

which are well illustrated in this case. 'The

institution

that

f i g u r e s in

this case

B o a r d as i n a d e q u a t e and n o l o n g e r needed.

was

l a t e r closed

by

action

of

its

own

242

RICHARD II.

HEATH

P L A C E M E N T RECORD OF R I C H A R D H E A T H 7

Persons in the Case w i t h A b b r e v i a t i o n s U s e d : Client—Richard

Heath.

F a t h e r — J a m e s , dead. ( F . ) Mother—Catherine,

inmate State H o s p i t a l f o r M e n t a l

Diseases.

(M.) Paternal g r a n d m o t h e r — L o u i s e H e a t h . Paternal a u n t — M r s . Fred Baker. Paternal u n c l e — F r e d Baker.

(P.Gm.)

(P.A.)

(P.U.)

Friend of paternal g r a n d m o t h e r — M i s s First foster m o t h e r — M r s . O w e n .

Second foster m o t h e r — M r s . H e l m a n . Third foster m o t h e r — M r s . D o l b y . Letter.

Drew.

(F.M.) (F.M.)

(F.M.)

(L.)

D e p t . of P u b l i c W e l f a r e .

(D.P.W.)

Child Caring S o c i e t y — ( C . C . S . ) I.

SOCIAL STUDY

1 1 . 1 3 . 2 0 — P r e s i d e n t of Board, Episcopal H o m e for Boys, asks for investigation of application for Richard Heath,

born

2.16.15. Child's father is dead. C h i l d living w i t h grandmother and aunt. [Syllabus reference: AREA, Death of father; Broken home.] 1 1 . 1 3 . 2 0 — S o c i a l Service E x c h a n g e reports no record. 1 2 . 1 0 . 2 0 — P . G m . , Louise H e a t h at H o m e : T h e house is a large one in N o r t h Pittston, a good neighborhood, where onefamily residences of unusually large size have been converted into boarding houses of a high class. P . G m . is a well dressed woman, speaks intelligently, and appears to be well educated. She occupies a large sunny room in the f r o n t of the house, and states that her daughter, Mrs. Baker, lives in the same house. A s soon as the visitor announced the object of the visit, P . G m . stated that she had arranged w i t h a friend, w h o is a member of the Board of Managers at Lowell Institution, to have the ' N o c o r r e s p o n d e n c e o r c l i n i c r e p o r t s , e i t h e r m e d i c a l o r m e n t a l , h a v e been since it w a s n o t

thought

that

these w e r e o f

w i t h the main t e a c h i n g values o f the

record.

particular

importance

in

included

connection

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child admitted there, so she is withdrawing her application. The visitor talked for a time about the child, gathering as many facts as she could and learned the following: T h e child's father was born in Virginia where his parents had lived ( L a w r e n c e ) . When F. was quite young the P . G f . died, and later P.Gm. came to Pittston to live, bringing the three children with her: F., his brother John and the P.A., now Mrs. Baker. P.U. later went back to Lawrence where he holds a responsible position in a bank. F. later became a salesman traveling f o r a firm which sent him all over the country. While in Helmetta, N e w Mexico, he met M. She had one sister and two brothers. One of the brothers had been killed in a railroad accident, when M. was about 18 or 20 years. He had been brought home without warning, and M., who knew nothing of the accident, came upon his mangled body as it lay on the bed in her room. She suffered a severe shock, becoming hysterical, and later had a nervous breakdown which resulted in her having to be confined in an asylum f o r the insane. F. did not know this when he married her, and he and P.Gm. always resented the fact that the Episcopal minister who married them did know it and never made any attempt to enlighten F. concerning this important bit of family history. They were married, 1 . 7 . 1 4 , in Helmetta, and after their marriage F. brought M. to live in Pittston where he bought a home at 4529 Cooper Street. Richard was born in their home, 2 . 1 6 . 1 5 . Almost immediately after his birth M. developed puerperal mania and was removed to Pittston Hospital for Mental Diseases. [Syllabus reference: A R E A , Mental disease of mother.] A f t e r a few months M's condition improved, and she was paroled to F. who again took up residence in their home. It was but a short time after this that M. again became "peculiar," and this time she was sent to the State Hospital. Later she was incarcerated in the hospital at Andersonville. A f t e r her discharge f r o m this latter place, she went to her sister's home in St. Louis. She developed the usual symptoms and this time the

2 4 4

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sister placed her, with Richard, on a train bound for Lawrence, sent a hasty telegram to P.U. telling him of their coming and washed her hands of the affair. P.U. is a single man, and as he did not have a home into which he could bring these unexpected guests, he had a great deal of trouble arranging for their care. M. remained in the sanatarium (in which P.U. was able to place her in Virginia) until a year ago. P.Gm. took care of Richard. The child has been dragged about from one place to another. As long as his mother was in the hospital P.Gm. took care of him, but on her parole, M. always demanded him, and took him. He would then be taken from one place to another, F. not being able to remain with M. to look after them. [Syllabus reference: AREA, Changes of residence and caretakers.] About a year ago, P.Gm. felt she could not give Richard the care he needed as it was necessary for her to support herself, and she placed him in an institution in Warren, New Jersey. She visited him whenever she could and on each occasion noted that he had a rash, which she was told was a form of ivy poisoning. The child seemed to be much neglected and finally she took him away, and then learned from her physician that he had scabies. It was at this time she made her application to the Episcopal Home for Boys. She has an application for his admission to Colby Academy, but he cannot be admitted at present as he is under the age limit. Richard is a lovable child, quiet, obedient. He is of a most affectionate disposition, and can be easily managed with a little kindness. P.Gm. showed the visitor several pictures of him, taken about a year ago, and he was indeed a bright looking, adorable little chap. It was evident that he had the best of care from his personal appearance and the clothing he wore, and not least, the happy expression in his eyes. P.Gm. seemed quite proud of him. She stated that she had learned that he might be admitted to Lowell Institution and, as she wanted to return to Virginia, felt she could not wait for other plans to be made,

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and simply placed him in this place. T h e visitor suggested that it was rather u n f o r t u n a t e f o r such a lovely little child to be among strangers when he had relatives, and asked w h y P . A . did not take him. P . G m . stated that P . A . was in poor health, she had had an operation and it had affected her nerves to such an extent that she could not possibly assume this responsibility. P . A . was not at home, and visitor was told she was ill most of the time. It was f o r this reason that she lived in this fashion rather than in a home of her o w n . 1 2 . 2 9 . 3 0 — R e p o r t to Episcopal H o m e f o r Boys explaining that application was w i t h d r a w n . 4. ι j . 2 1 — M r s . D e v e r , President of Board of Lowell Institution, asks f o r a f a m i l y home f o r Richard, who needs special care in a boarding home. H e has been in the institution f o r some time and is very troublesome. Mrs. D e v c r feels that they cannot keep him any longer. 4 . 2 2 . 2 1 — M r s . Harris, Matron of Lowell Institution, 975 S. 9th Street: T h e Matron is a pleasant woman, with a gentle voice and manner. She talks a great deal about the children, rambling on in her speech, telling incidents in the life of the institution. She no doubt means well by the boys, and is doing all she can to care f o r them, but this appears, f r o m her speech, to be only a superficial sort of care, with no real understanding of the children, and certainly not a v e r y intelligent handling of their problems. T h e home itself gave the visitor the impression of miles and miles of bare hallways and rows of little white beds in large bare dormitories. There was nothing to suggest home to a child w h o had spent the first f e w years of his life in the environment that P . G m . called home, a place cosily attractive with pretty curtains and rugs, and soft pillows, shaded lights, and pictures of the f a m i l y everywhere in evidence. [Syllabus reference: METHOD, Observation.] O f Richard, w h o m Mrs. Harris calls " D i c k , " the visitor learned that he was not trained in habits of cleanliness, and that he was so b a c k w a r d in learning that it required the services of one maid to train him. H e generally uses a basin or the

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wash bowl instead of the toilet, and then plays with the excreta, getting it over doors, chairs, and whatever he touches. He is troubled with enuresis. They have never noticed any signs of masturbation, and believe he has no sex habits. He has a good appetite, and his attitude toward food is normal. He is not clean at the table, and soils everything near him, which naturally gives the other children a chance to tease him. In fact, Richard is too little to be among the other children in the institution, and their ignoring him and scoffing at him makes him unhappy. He is a very nervous child, and knowing his heredity (M's mental condition), Mrs. H. cannot help but believe that this is a proof of his physical and mental inferiority. He is an affectionate child, and is so demonstrative that Mrs. H. has to watch him constantly, because he frequently has a recurrence of the scabies, and they fear he will spread the infection by fondling the others. He is full of energy, and yet has so much trouble with the other boys that when he is not in school, Mrs. H. must keep him with her wherever she goes. This means that he must sit in a room quietly without playthings while she works. [Syllabus reference: AREA, Behavior responses, child. K N O W L E D G E , Psychology and Psychiatry.] Before the visitor left, Richard was called into the room. H e ccrtainly bears little resemblance to the child in the picture. H e has a pinched look in his face that speaks of starved emotions, of a hungry little mind and soul rather than body. He stood quietly until spoken to and then made friends, coming to the visitor quietly and shyly smiling, though he said nothing. He appeared to be very nervous, and stood twisting the buttons on his coat and occasionally twisting his head to one side, with a quick jerky movement. [Syllabus reference: METHOD, Observation.] Mrs. Harris knew nothing of the whereabouts of the boy's relatives except that he had an aunt in the city, and his P.Gm. N o one, however, paid any board for him, and he has few visits from these relatives.

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4 . 2 2 . 2 1 — A t the L o n g f e l l o w School, 9th and Freemont Streets: T h e visitor talked w i t h both the Principal and child's teacher. Miss C a n t w e l l , the former, said that she felt that there ought to be an investigation into the management of the institution, as all the children f r o m the place appeared to be neglected. She spoke with feeling about Richard, saying that he was a most lovable child, and that frequently he came to school so dirty and ragged that the poorest children in the district were c o m fortably clothed beside him. She said that only a f e w days before she had sent him home w i t h a note in which she asked the matron to notice that Richard had attended his classes wearing a pair of rubbers instead of shoes. This had happened more than once, and finally Miss C a n t w e l l called the matron's attention to it. Richard's tcacher w h o is an elderly woman, intelligent and socially minded, said that the child was a forlorn little creature, w h o always made her feel that he needed " m o t h e r i n g . " She had noticed his habit of t w i t c h i n g his head. She does not consider him subnormal, b u t feels that he needs some one to take an interest in him. H e shows this at school b y his behavior in class. H e likes to talk but prefers other subjects than the ones at hand. H e told the teacher that at the institution he has nothing to play w i t h and does not k n o w what to do. H e entered school last term, was in the kindergarten, and did very well. A f t e r his promotion to ist grade, he did not do well, but this was because he was absent f o r about t w o months. For a time the home was under quarantine, and Richard was away with scabies. H e generally has sores on his face, but he is seldom clean so that is not surprising. T h e teacher and Principal both remarked that Richard was being "crushed by his surroundings." Richard was called out of class, to see the visitor, and was quite different in his manner. H e smiled and talked freely, showed no embarrassment, and did not display any of his n e r v ous habits, except that he twitched his head once or twice. 4.28.21—Telephoned P . A . asking for an appointment to talk over the situation. She said that she was leaving t o w n the f o l -

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lowing d a y , as her health had been bad and that she was too busy to see the visitor before she left. She could not understand w h y she should be troubled b y this affair a n y h o w , as Richard was c o m f o r t a b l y placed, and that shortly he would be admitted to C o l b y A c a d e m y , as an application had been made there. She expected to be out of the city all summer and had no idea as to where she would locate in Pittston on her return. If C . C . S . wanted to k n o w anything f u r t h e r , she must refer us to P . G m . who is at present in Virginia. 5.1 j . 2 i — T e l e p h o n e d C o l b y A c a d e m y regarding application f o r R i c h a r d . Learned that the P . A . , Mrs. Baker, had made that application in person, 5 . 1 3 . 2 1 . Richard will probably remain on the waiting list f o r t w o years, and will then be rejected unless he can pass the intelligence test. Tried to reach P . A . b y Telephone. T h e visitor was told that the Bakers had moved. T a l k e d with D r . Rives (Psychologist) about mental test. She will see the child, 5 . 2 4 . 2 1 . 5 . 1 6 . 2 1 — S u m m a r y to D r . Rives (Psychologist). 5 . 2 3 . 2 1 — L e t t e r to Helmetta, N e w Mexico, asking f o r verification of marriage. 5 . 2 4 . 2 1 — M i s s H a n c o c k telephoned cancelling apt. because of physician, re diag. duration of confinement, and condition on discharge of patient. L . to Pittston Hospital, asking f o r above information. 5 . 2 6 . 2 1 — L . f r o m D r . Powers, State Hospital, giving brief summary of patient's medical and social history. Wasserman test was made in this hospital, and blood reaction was negative. (See file.) 5 . 2 7 . 2 1 — L . to P . G m . explaining the situation and asking whether she can help either

financially,

or with suggestions as

to plan f o r Richard. 6 . 2 . 2 1 — L . f r o m P . G m . in which she offers no suggestions, advised visitor to get in touch with maternal aunt, states that she is unable to pay anything toward board as she is in poor health, and dependent on her meager earnings f o r livelihood. She f u r t h e r states that she will get in touch with one of the

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Institution's managers in reference to arranging to have him remain there. 6 . 2 . 2 1 — L . f r o m Helmetta, N e w Mexico, v e r i f y i n g marriage. 6 . 2 . 2 1 — L . to C . A . S . of St. Louis, asking them to visit M . A . , Mrs. Gordon M . Waters. 6 . 2 . 2 1 — L . f r o m C . A . S . of St. Louis: Mr. Waters, husband of M . A . , was interviewed and was unwilling to do anything f o r R i c h a r d . H e stated that M. was at their home until Feb. or M a r c h , 1 9 2 1 , when she l e f t f o r Cincinnati, where she intended visiting a half sister. Before she l e f t her relatives had tried to have her committed to an insane asylum, but were unsuccessf u l . T h e y had not communicated with her since. 6 . 8 . 2 1 — T e l e p h o n e d Lowell Institute re. another appointment. T h e child is not yet cured, and Mrs. Harris will telephone when he is able to come to the clinic. 7 . 1 . 2 1 — T e l e p h o n e d Lowell Institution: Mrs. Harris feels that Richard has improved a great deal, and they wish him to remain at the H o m e f o r the present. Will get in touch w i t h the visitor later. 1 . 1 6 . 2 2 — M r s . Harris at Lowell Institution: She says that she has been talking with Mrs. Dever about Richard and they both feel now that he should be removed. Mrs. H . has seen P . U . several times since last spring. In f a c t , at the time she decided to keep the child she had had a visit f r o m him. P . U . was a well dressed man, with good manners. H e gave Mrs. H . the impression that he was well-to-do and did not w a n t a relative of his wife's to be an object of charity; that if P . G m . was not paying the boy's board, he would. H e never paid anything. Mrs. H . has now learned that P . A . is insane. Someone called on the telephone just before Christmas saying she was Mrs. Baker, and that she was coming to take Richard home f o r the holidays. T h e Matron said that this was against rules and could not be done. A while later another woman telephoned saying that if Mrs. B. came f o r Richard, he should not be allowed to go with her as she was insane, and her relatives were trying to have her committed to the State Hospital. This woman stated that she

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was connected with the Y . W . C . A . or some other agency, but Mrs. H . did not remember her name. Richard has not improved in his habits. He is as dirty as ever, and it is necessary for Mrs. H. to take him with her wherever she goes. Often as he sits in the room while she is at work, he will beg her to let him go, promising to be good, but as soon as he is with other boys, he begins to scream, and she cannot allow this so brings him back to the room. She does not know why he screams, but believes it is just "because he doesn't get along with the other children and takes their toys." [Syllabus reference: A R E A , Behavior responses, child.] Mrs. Dever on Telephone: She is most anxious to have Richard removed, would like us to arrange a psychological examination as she fears the child is sub-normal mentally. If he is not, then he needs such individual care as Lowell is unable to give, as he does not fit in with other children, and is responsible for much trouble there. Mrs. D. would like a thorough med. and mental examination. 1.18.22—Apt. with Miss Brewster (Ass't Psychologist) for 1.25.22. 1.25.22—Richard to medical clinic. Ht. 47, Wt. 44V2—12% underwt. for Ht. Eyesight apparently normal. Purulent discharge from right ear. Complains of having bad earache in both ears yesterday. Ears cleaned out. Tonsils moderately enlarged and cryptic; referred to nose and throat clinic and to ear clinic. Teeth in good condition. Prolonged expiration at right upper lobe anteriorly and posteriorly. Skin healthy, vaccination scar. Abdomen normal. Phimosis should be circumcised. Sh. have qt. milk daily and two eggs. Should be made to rest in afternoon. Returned to clinic in a month ( F V R ) . 1.2j.22—Report to Dr. Rives (Psychologist). 1.28.22—Wasserman report negative. 1.30.22—Report from Miss Brewster (Asst. Psychologist) with recommendations. (See file.) 1.28.22—L. to Associated Charities of Lawrence asking for an investigation.

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1 . 3 1 . 2 2 — T e l e p h o n e Messages f r o m Mrs. Harris stating that she recently learned that P.Gm. is now living at 72 Morris Street, Lawrence. 2 . i . 2 j — L . to Associated Charities, 92 Norris St., Lawrence, giving this additional information. 2 . 2 5 . 2 2 — L . f r o m A . C . of Lawrence: P.Gm. ref. C.C.S. to Miss Eleanor D r e w who is interested in the child. 2.6.22—Miss D r e w on telephone: A p t . made f o r same day. Miss Drew at Pompton Branch of Y . W . C . A . where she is "Housemother." She was formerly associated with P.Gm. as her assistant at the Y . W . C . A . house on C r a w f o r d Street. Miss Drew had no mother, and as P.Gm. was like a mother to all the girls in the boarding house, she, with a few of the others, addressed P.Gm. as Mother. The acquaintance has been one of over 20 years, and has become a deep attachment. Miss Drew left the home about 7 years ago to become Supt. at the Pittston Institution for Babies, and Richard was in her care at this institution f o r almost a year. Of the Heath family Miss Drew said that they were people of good connections, and social standing in Virginia. P.Gm. was left a widow when still young, and being without property had a struggle to make ends meet. There was no insanity in the family. The four children were intelligent, healthy normal children. F. was the only one who gave P.Gm. any trouble, and this was because he was at times addicted to drink. He was an expert telegrapher, and went about the country doing his work, but unfortunately, periodically he would go off on one of these spells, and P.Gm. would be in torment until he was " o v e r " it. She used to fear that he would disgrace her by appearing at the boarding house, in an intoxicated condition, and, as she confided in Miss D., the latter learned of her worries. Except for this vice, F. was a splendid young man. H e was tall and handsome, had charming manners, and was loved by all who knew him. He was clever, and could have made a living in many other ways. Of M. Miss D. said that she was a large woman, the typical

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"outdoors" type. One could see at a glance that she had been accustomed to living in the open country. Her family had kept a boarding house outside the town of Helmetta, and she had spent much of her childhood riding and living in the plains. She was not a cultured woman, and although good hearted, she did not "fit in" with the Heath family because of her different interests. Apparently she and F. lived together happily, for Miss D. knew of only one rupture; that was the incident referred to by Dr. Powers in her letter. M. probably exaggerated many incidents in giving her history, but Miss D. feels certain that she was frequently troubled by F.'s tendency to drink. On one occasion F. went to a saloon and M. fearing that he would become intoxicated and start on a "spree" went after him. F. was shocked that she should come into a saloon, and begged her to go home, saying that in his home in Virginia a lady would have died before entering such a place. M. refused to leave without him, so finally he went home, and on his return took an ornamental dagger which was in the room and stabbed himself under the shoulder blade. It is hardly likely that he intended to end his life as he did not strike at a vital spot, but the wound was sufficiently serious to send him to a hospital. This was the only trouble that Miss D. ever heard about. After the birth of Richard, things did not go so well, for M. became insane within a few weeks. The baby was taken off the breast, and P.Gm. took him for a short time with her. M. was at Pittston Hospital for Mental Diseases for several months and was paroled, in good condition. She then took Richard with her. From this time on she displayed a tendency to neglect her home, also she was passionately fond of the baby and kept him immaculate. As her interest in her home left her, she began to talk about her former work, of which she was very fond. She had been a stenographer and typist, and whenever she became insane, this accomplishment filled her mind. She would talk incessantly about it, and if given the opportunity, would prove her skill and speed. A f t e r she was taken to the hospital the second time F. gave up their home, and placed Richard in the

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Institution for Babies. T h e child was under a year old when admitted and the only sickness he ever had was due to teething. H e was a happy, healthy, beautiful baby. Miss Drew had several pictures of him, taken then and later. In all of them his appearance corroborated her statement. After M. was again released from the hospital, Richard left the Institution. His M. had him for a time; then, following F.'s death he was with P.Gm. About two years ago, P.Gm., who was still employed, placed Richard in the Home at Warren. He was frightfully neglected at this Institution, and when P.Gm. finally took him home, supposedly suffering from poison ivy, his body was literally covered with scabies. Concerning the financial status of relatives, P.A., Mrs. Baker, is unable to help in any way. Her husband is a printer, and is not employed full time, and certainly is unable to assist. These people are living on Hershey Street just now, but have had to give up the house and will soon move. P.A. has had three serious operations in the past year. The most recent was a complete hysterectomy, which has left her in such a nervous state that she is practically helpless, and has had to give up her home. The operations have been pretty costly, and the last one, which was done at the Pittston Hospital as well as one former one, remains unpaid for. It is a fact that Mr. B. likes to pretend that he is in better circumstances than he really is, but he admitted recently to Miss D. that he would not dare to tell P.A. how much he is "up against" it just now. P.U., John Heath, in Lawrence, is not connected with a bank at present, but is in the coal business, and because of the development of the use of natural gas in private homes, he has lost considerable money, and is just about making a living. P.Gm. has been unable to hold a position, because of her health. She has a heart condition and hardening of the arteries, and now is suffering from neuritis. There is not much possibility of getting board from these relatives just now, and Miss D. feels that she herself would like to help the child, but has an invalid sister dependent on her so is unable to do so. She feels sure,

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however, that P . G m . will make clothing f o r him, and send it f r o m time to time as she is a clever seamstress and has always furnished him with clothes. There is a strong feeling that Richard should be sent to C o l b y A c a d e m y when he is ready f o r admission. [Syllabus reference:

AREA,

Economically dependent child,

changes of residence and caretakers.] 2 . 7 . 2 2 — M i s s M c M u r r y , Pittston Hospital, on telephone: In reply to visitor's inquiry, she reported that M. was patient in Pittston Hospital Feb. 1 9 1 5 to Oct. 4, 1 9 1 5 . Diagnosis: Manic depressive. She was discharged f r o m there to State Hospital and f r o m the latter place 1 2 . 1 . 1 5 , as recovered. N o t h i n g was heard f r o m her till 1 9 1 9 when it was learned that she was a patient in the Virginia State Hospital. [Syllabus reference:

AREA,

Mental disease.]

2.8.22—Telephoned Mrs. Harris, Lowell Institution, suggesting that they let us arrange f o r the necessary operations to be attended to while we are deciding on a plan f o r Richard. Mrs. H . will take the matter up when the Board meets on 2.9.22, and telephone visitor their decision. She feels this would be a good arrangement. 2 . 1 1 . 2 2 — T e l e p h o n e message f r o m Mrs. Harris stating that it will be O . K . to plan f o r the operation f o r Richard provided he can be cared f o r until he is well enough to return to the Institution as she cannot give him special care. 2 . 1 3 . 2 2 — C o n s u l t e d D r . Reed regarding operations. A s D r . Reed had stated that the child was 1 2 % underweight, the visitor felt it would be better to find out whether D r . Reed wanted to postpone one operation until Richard would be in better physical condition. D r . Reed said that they would not be serious enough to affect him, that as a matter of f a c t his poor condition might be due to the f a c t that he needed the operations. She advised us to make an appointment at the Children's Hospital, but to bring Richard to the Clinic a f e w days before the operation. 2 . 1 5 . 2 2 — T e l e p h o n e d Miss Lewis, S.S.D., Children's Hospital

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-

f o r appointment . She suggested that we bring R i c h a r d to hospital 2 . 2 4 . 2 2 , at 9 A . M., adding that hospital will admit child on D r . Reed's recommendation, as he will be her patient. 2 . 3 1 . 2 2 — R i c h a r d to clinic. D r . Reed reports that he is O . K . f o r operation. 2 . 2 4 . 2 2 — R i c h a r d to Children's Hospital. Visitor talked with Miss Lewis about the circumcision. She will take the matter up w i t h the doctor in charge and have it done before he is discharged if the doctor thinks it advisable. A t any rate, considering that Richard is to return to an institution where the children have to care f o r themselves to a great extent, she will arrange f o r him to remain here as long as possible. Richard was delighted when the visitor called f o r him. H e recognized the visitor and immediately asked if he were going to the C h i l dren's Society, and seemed greatly disappointed that he was not. H e said he would like to live there, f o r he had had toys to play with, and had enjoyed the puzzles, and books in Miss Brewster's office. 2 . 2 8 . 2 2 — T e l e p h o n e d Miss Lewis, who reports that the doctor thought it best not to p e r f o r m the circumcision at present as R i c h a r d was not in fit condition to take ether again so soon. T h e y will keep the child a day or two longer. H e seems to be v e r y happy in the ward with the other children, and does not w a n t to come home. 3 . 3 . 2 2 — M i s s Lewis telephoned that Richard is ready f o r discharge. 3 . 3 . 2 2 — C a s e discussed in conference with executives of staff. It was decided that the child should be placed by the Society, at least until he is in good condition, when it might be thought wise to make another plan. 3.3.22—Telephoned Mrs. Harris, Lowell Institution that we will bring Richard back to Institution f o r a short time pending the finding of a suitable home. Richard to L . Institution. 3 . 1 3 . 2 2 — M r s . Dever telephoned: Said that " D i c k " must be taken a w a y ; situation has grown more serious since operation. T o quote her—child talks in most foul w a y about operation

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and since then has attempted to get into bed with other boys, a thing he did not do before. She cannot accept psychological report; is sure child is not normal; his screaming spells continue and the very f a c t that he has said he wants to be removed proves his instability, because he tells them he wants to stay. H e was so insistent upon that—namely, that he would not be sent elsewhere, that they had to lie to him to get him into our clinic. O f course, they cannot set the child out on the curb-stone, although they wish they could, but plan must be made at once to protect other children. " D i c k " cannot be saved, that is clear, but surely Society can pay someone enough to make it worth their while to keep him where he can't harm other children. [Syllabus reference:

AREA,

Behavior responses, child.]

T E A C H I N G N O T E : The difficulty of adjusting emotionally disturbed children in institutions with an untrained personnel is indicated by this and previous comments by members of the institution staff. 3 . 1 8 . 2 2 — S o c i e t y to place Richard: Dept. of Public W e l f a r e to be asked to pay $4.25 per week. Society to supplement and furnish clothing. j . 2 9 . 2 2 — L . to Mrs. Ransen, D . P . W . , asking f o r support. 2.

PLACEMENT

RECORD8

3 . 1 6 . 2 2 — M r s . Peter Owen at home, 972 S. 37th Street: T h e Owen home is situated in a pleasant street and is attractively and comfortably furnished. Mr. Owen is Mrs. Owen's second husband. B y her first marriage she had three children, w h o m she has raised successfully. H e r oldest daughter, 26, is employed as a stenographer. Mrs. Owen greeted visitor rather coolly. She seemed very reserved and rather ill at ease. A s visitor was e x plaining the care Richard would need, Mrs. O w e n hurriedly in a whisper asked visitor not to talk of R i c h a r d until Mr. O w e n "Foster-home investigations are usually recorded separately by child-placing agencies and descriptive entries concerning foster homes in this record are only f r a g m e n t a r y digests of the complete foster-home records kept by the agency.

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had l e f t , as he objected to her taking a child to board and was o f t e n very disagreeable. H e had liked the little girl w h o had been there a week or two, but had taken a violent dislike to Edith Long (serious problem case) when she lived w i t h them and had been most u n f r i e n d l y to her. She feels that if Mr. O w e n liked the child, there w o u l d be no difficulty on that score. She w o u l d give Richard care and affection and w o u l d be the first to tell if Mr. O w e n made it unpleasant f o r the child. Mrs. O w e n seems a motherly, kindly soul, capable of g i v i n g Richard the kindly understanding and disciplining that he needs; did not seem particularly disturbed at report of Richard's behavior at the Lowell Institution and was willing to take him on trial. Visitor feels that while Richard needs to be in the city for medical treatment, he will receive affectionate and kindly care in this home. Visitor to n o t i f y Mrs. O w e n when Richard is to arrive. [Syllabus reference: RESOURCES, Foster homes.] 3.17.22—Richard

at Lowell Institution: Visitor called

for

Richard in the Lowell Institution. While in Mrs. Harris' presence, is quiet, speaks only when spoken to. H e wanted to stop to buy candy, a horse and wagon, flowers, etc. H e was delighted w i t h the prospect of coming to the Society and chatted happily the entire w a y . Richard in office to be fitted with clothing. Enjoyed getting the clothes hugely. Remarked: "Gee, they must be rich here!" Visitor noticed Richard's ear was running. H e was taken to the medical clinic and seen by D r . Reed, w h o recommended the ear to be washed out three times a day with boric water. L. f r o m Miss D r e w : Re. information about Richard. 3 . 1 8 . 2 2 — R i c h a r d at Lowell Institution: While waiting here visitor heard Mrs. Harris talking to Richard. Told him he must not cry; that it was because he had been such a bad boy that he could not stay there and perhaps if he would be a very good boy that some day he may have the happiness to return. Visitor expected to see a tear-stained little face appear, but instead Richard was wreathed in smiles. H e seemed very happy indeed

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to be leaving and was apparently relieved when he understood that he was not going to another "Institution" as he called it. 3 . 1 8 . 2 2 — R i c h a r d placed with Mrs. O w e n , 972 S. 37th Street, Board $5 per week. This will probably be a temporary placement. It may be that the unpleasantness between Mr. and Mrs. O w e n may be so decided as to make it an unhappy atmosphere for Richard. Visitor gave directions as to washing the ear with boric acid. Richard seemed well pleased with Mrs. O w e n ' s home. Made himself at home immediately. T o o k off his coat and hat and said he was going to play the piano. H e was told, however, by Mrs. O w e n that he could not play the piano when Mr. O w e n is home, but when she and he were alone they would have a lovely time playing it. [Syllabus reference: METHOD, Placement.] 3.20.22—Telephoned Mrs. O w e n asking her to take Richard to school the following day. Mrs. O w e n said she had not had any trouble over the week end and that things were going pretty well. Was not very communicative, but this was probably due to the f a c t that Mr. O w e n was in the room while she was telephoning. 3.25.22—Mrs. O w e n telephoned: Richard is getting

along

very well. Has not given any trouble so far. H o w e v e r , his ear is still running and Mrs. O w e n will bring him to the office 3.27. 3.27.22—Mrs. O w e n and Richard in office: Mrs. O w e n reports that Richard is very babyish in his behavior. Richard has shown no tendency at all to play with his excreta or to masturbate. Is going to school during the morning session. Richard to medical clinic: referred to ear clinic. Mrs. Baker, P . A . , telephoned; P . A . stated that Miss D r e w had given her Richard's address and that she would like to go out to see him as soon as she felt better. Visitor urged that this visit be postponed for some time in order to give Richard a chance to feel quite at home with F.M. P . A . agreed to this plan and promised to tell visitor when she wished to make the visit. Stated that she had just heard f r o m M., that she was in the c i t y

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hospital, had been there one year. P.A. is to visit her in a day or two and will then telephone visitor again. [Syllabus reference: M E T H O D , Placement.] 3 . 2 9 . 2 2 — L . to F.M. enclosing the medical report for the ear clinic, and a letter to Miss Lewis, Children's Hospital, asking the F.M. to take Richard to the Children's Hospital ear clinic between 1 and 2 o'clock. Telephone from Miss Drew, Pompton Branch, Y . W . C . A . , to advise Society that she thinks visits to Richard by P.A., Mrs. Baker, would be very inadvisable. P.A. has had mental trouble. Has violent fits of temper and is not responsible for her conduct when in one of these fits. Within the past year has had three operations by Dr. Draper. Has had both ovaries and uterus removed. Dr. Kant of the Pittston Hospital for Mental Diseases knows P.A.'s history. She was given opiates in the hospital and after her discharge continued to use drugs. Was very fond of Richard when she took care of him for a period of several days recently, and Miss Drew fears that she may sneak Richard away with her if she is allowed to either take him for a walk or be alone in his company. Advises that we warn Mrs. Owen of this. She, Miss Drew, is extremely pleased with Richard's placement at Mrs. Owen's and is advising the P . A . not to go and see him for several months, telling her that he is in the best place; and that he ought to have a chance to adjust himself without interference by any member of his family. 3 . 3 1 . 2 2 — F . M . telephoned: Took Richard to the ear clinic yesterday. Was told to return twice a week. As F.M. spent almost four hours on the trip, she does not feel that she can give this time twice weekly. Moreover, beginning with the first of April Richard will go to school during the afternoon session and this will mean that he would lose two days schooling a week. Visitor promised to take the matter up with the doctor and see whether some different arrangement can be made. [Syllabus reference: M E T H O D , Management of resources. (See 4 . 2 . 2 2 ) . ] Telephoned Miss Lewis who will see Dr. Hull on Tuesday when Richard is to return and will explain the situation to her

26ο

RICHARD

HEATH

to see whether the condition could be cleared up with intensive treatment for a week or two with Richard staying at the hospital or whether it must necessarily be a treatment to cover a long period of time. 4 . 1 . 2 2 — P . A . , Mrs. Baker, in office: P . A . very much distressed because Miss Drew had told her that visitor had called up to say that she had visited M. in hospital and that she considered the best plan f o r Richard is to be returned to her. Visitor suggested that P . A . must have misunderstood Miss Drew over the phone, because no such conversation had taken place; that visitor had not been to the hospital and had not talked with Miss Drew about any possibility of Richard being returned to M. P.A., however, semed quite confident that this information had been given. Seemed reassured when she understood that such a plan had not been contemplated for a moment. P . A . had seen D r . Shaw, at the C i t y Hospital, who had said the M. is now ready to be discharged, but must leave the hospital in the care of someone who will be responsible f o r her. P.A. had suggested that she be put on a train and sent to M.A., but the doctor would not allow M. to be discharged without being placed definitely in the care of a responsible person. P . A . has written to M . A . and asked her to come and get M. and return with her to St. Louis. Has not had a reply to her letter as yet. P . A . is going to Wildwood until October. Will have position as Secretary in Children's convalescent home in Wildwood. Promised visitor that she would not visit Richard before return from Virginia. Address in Virginia, 72 Morris Street,Lawrence, Virginia. Asked in case any matter comes up that needs consultation with the family that visitor get in touch with her husband, Mr. D . K . Baker, care of Wells & Mason, 7th and Lewis Streets. P . A . referred to the application that she has made for Richard's admission to Colby Academy. She hopes that as soon as he is old enough he will be admitted there. Visitor did not discuss this plan with her since Richard has still a year or two to go before he is old enough f o r admission and it is better to keep on friendly terms with P . A . in order to get the best cooperation.

RICHARD [Syllabus

HEATH

reference: METHOD,

Management

201 of

patient

group.] Telephoned Miss D r e w : Miss D r e w said that, of course, she was the one w h o had given P . A . Mrs. Owen's address as she did not wish to antagonize her. She does not k n o w where P . A . got the idea that she had said that visitor had made plans to return R i c h a r d to M. Feels that this only goes to show that P . A . is mentally unbalanced and does not k n o w w h a t she is talking about. Visitor suggested that Miss D r e w be as f r i e n d l y as possible with P . A . and not let her feel that she is to be ignored in any plans f o r R i c h a r d . 4 . 2 . 2 2 — F . M . at home: R i c h a r d still continues to do f a i r l y well. Mrs. O w e n watches him very c a r e f u l l y when he goes to the bathroom and a f t e r he is asleep at night and can see no trace of masturbation or a tendency to play with his excreta; however, his attention is very flighty. When F . M . reads a story to him or tells him about some f u n n y pictures in the paper, R i c h a r d pays practically no attention, and, when asked to repeat any part of the story, says he just can't remember any part of it. H e plays with children of his own age, but always comes running in f o r s y m p a t h y when the slightest thing goes wrong. Is v e r y slow in dressing and has to be prompted right along as to what to put on next. F.M. is t r y i n g to teach him to do things f o r himself and not to c a r r y tales. H e is quite disobedient in that he will keep right on doing something that he has been asked not to do and, even if he stops f o r a f e w moments, will return to the same forbidden object. Is very babyish in his whole behavior. Talks in a baby w a y and has many little mannerisms that are distinctly characteristic of children of about f o u r years of age. Visitor noticed this during the visit. T h e w a y R i c h a r d sidled u p and asked f o r things; the way he put on his coat and hat, etc. F . M . reports that he never shows any temper. W h e n punished does not seem to take it seriously at all. N e v e r seems excited or particularly interested in anything. Is constantly active, but runs f r o m one toy to another, or f r o m one f o r m of amusement to another. N e v e r sticks at anything longer than a f e w moments. A l w a y s wants

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something other than that which he has, but does not whine and does not seem particularly put out when he does not get it. H a d gone to Sunday school with F.M.'s niece, a little girl of his o w n age, who says she will never take him again because he behaved so badly. K e p t throwing his cap u p in the air, snatching books, talking and kept the class in a turmoil the entire hour. T h e teacher had to speak to him repeatedly, but he did not seem to care and kept on doing as he pleased. M r . O w e n has taken a decided liking to R i c h a r d ; gets impatient with him, but nevertheless likes him. F.M. reports that teacher, Miss D e w e y , has told her that Richard is much behind the children of his age in his school w o r k ; that it is practically impossible to keep his attention. Visitor explained to F.M. that Mrs. Reynolds (Society's visitor-at-large) will call f o r R i c h ard Tuesday, when we will t r y to make another plan f o r his ear treatment. F.M. has been syringing the ear once a day, and dropping in the medicine prescribed twice a day. T h e ear is still running and Richard has complained of pain since his trip to the clinic. F . M . felt that too m a n y students had had a chance at him. T h e diagnosis had been " c h r o n i c purulent otitis media." [Syllabus reference:

KNOWLEDGE, Psychiatry,

METHOD,

Mobilizing resources.] 4 . 4 . 2 2 — R i c h a r d to ear clinic. 4 . 6 . 2 2 — M i s s Lewis, S.S.D., Children's Hospital, telephoned: D r . H u l l feels that it will take at least t w o months' treatment (coming twice a w e e k ) to clear up Richard's ear condition. Possibly could be helped in shorter time by operation, but D r . H u l l would not advise this. Telephoned D r . Reed: D r . Reed thinks treatment

very

necessary. She could not give it at home as instruments in hospital are necessary. Considers school secondary to having treatment. C o n f e r e n c e : It was decided that Mrs. Reynolds should take Richard to clinic Tuesday and T h u r s d a y afternoons for the next t w o months. [Syllabus reference: METHOD, Mobilizing resources.]

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HEATH

263

4 . 7 . 2 2 — L . f r o m D . P . W . : Will pay $4.25 per week. Telephoned F . M . re. above arrangements

for

Richard's

going to clinic. 4 . 1 0 . 2 2 — M i s s D r e w telephoned: H a d letter f r o m P . G m . enclosing letter f r o m Mrs. Ransen, D . P . W . , w h o wrote that they were t r y i n g to locate F . and visitor explained error as to F. in our letter to Mrs. Ransen, and said we were writing to Mrs. Ransen to that effect. Explained that D . P . W . were paying $4.25 a week f o r R i c h a r d and were, therefore, also making an investigation. Miss D r e w says that Mrs. Baker let it be k n o w n that they are paying $5.00 per week f o r R i c h a r d . U p o n being asked if she k n e w when and where F. died, Miss D r e w reported that he died about Dec. 4, 1 9 1 8 in Pittston Hospital f o r Mental Diseases; that he had been living in Pittston f o r some time prior to his death. H a d been in Pittston Hospital f o r Mental Diseases only 3 or 4 days before death. Condition was due to alcoholism. T h e f a m i l y have never wanted to give this information and have kept it hidden. It was f o r this reason that she had not told visitor about it. 4 . 1 0 . 2 2 — T e l e p h o n e d Miss Ferris, S.S.D., C i t y Hospital, re. M. Miss Ferris will send diagnosis and prognosis, and when patient is to be discharged. L . to Mrs. Ransen giving information about F. and M. 4 . 1 2 . 2 2 — F . M . telephoned: Richard needs shoes and hat. G a v e F.M. permission to buy them. 4.15.22—Mrs.

O w e n , F . M . telephoned

(twice):

Richard's

nice ways have changed completely. H e now screams and yells and kicks his heels if he cannot have just what he wants. Is spoiling Mrs. Owen's life. In visitor's absence it was suggested that Richard be left in a room to scream his tantrums out, but Mrs. Owen feels that the neighbors will not understand and will think she is beating the child. Mrs. O w e n was told that visitor would come out M o n d a y and talk it over. 4 . 1 7 . 2 2 — F . M . at home: Visitor arrived to hear Richard yelling at the top of his lungs. F.M. pale and exhausted and quite nervous. F.M. had called Richard as usual at 8 o'clock and had

264

RICHARD

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told him to hurry and dress. Because the room was warmer he had been told to go to Mr. Owen's room to put on his clothes. As usual he dallied and when F.M. called him at 8:30 he was not half dressed. Mr. Owen turned and throwing a sofa cushion at him told him to hurry up. Whereupon Richard started to shriek and had been screaming steadily until the time visitor came at 9 o'clock. When Mr. Owen heard the visitor downstairs he called out that Richard would have to be removed immediately. He was breaking up his home; that he would not keep him another day. F.M. in an undertone asked visitor not to reply, so the storm blew over a bit. F.M. said that this is the way Richard screams every time he is crossed in any way at all. Is very disobedient, never comes home at the time he is told, and has gotten in the habit of going so far from home that F.M. cannot find him. Thinks that maybe a spanking would do him good, but would not like to do this without permission from the Society, especially as the neighbors would probably hear Richard screaming and think she was beating the child to death. Visitor urged F.M. to discipline Richard just as she would discipline her own son and use the measures that she deemed best. F.M. did not know whether she would be able to keep Richard since Mr. Owen objected so strenuously. Visitor promised to try to find a home as soon as possible. After Richard had stopped screaming he came downstairs. When visitor questioned him as to why he had been screaming, Richard remarked quite irrelevantly " I play on one of the boy's express wagons." Practically did not reply with sense to any question put to him. Paid no attention to what was said to him and calmly kept on making hit or miss remarks; for instance, suddenly said: " I like to make 'em laugh—make people think I'm funny and make them laugh." Since Richard had repeatedly told F.M. that she would not dare to punish him in any way because the Society would get after her, visitor explained to Richard that F.M. had perfect right to punish him just as she thought best when he was a naughty boy. [Syllabus reference: K N O W L E D G E , Psychiatry.]

RICHARD

HEATH

265

4 . 1 8 . 2 2 — F . M . telephoned: Mrs. Reynolds took Richard to ear clinic. Ear not discharging. N o t to return for two weeks unless discharge begins again. 4 . 2 0 . 2 2 — L . f r o m C i t y Hospital re. M: Diagnosis "Dementia Praecox." Considerably improved; physical condition good. (For details see file.) 4.28.22—F.M. at home: Visitor arrived again just in time to hear Richard howling at the top of his lungs. A t 1 1 : 3 ο he had been told to come in and get ready for school. Instead of doing so he ran off with a little four-year-old boy into one of the other streets, and F.M. could not find him until 1 2 : 3 0 . When he was brought in and given lunch, refused to eat what was set before him because he said he did not like it and finally, when he was refused a banana, he would not eat his lunch and began to howl. He is just as difficult and naughty as ever. She has given him a little spanking. Cannot bring herself to spank him hard; but it has produced no effect. F.M. has tried splashing him with cold water as visitor suggested, but without effect. When Richard is in a fit of temper he calls F.M. all the ugly names he can think of. Curses and swears. F.M. will wash his mouth out with soap when he does this again. When Richard heard visitor downstairs he yelled down that he was screaming because F.M. would not give him a banana; that he wanted a banana, but he did not want visitor to take him away. Later, when alone with visitor, Richard calmed down and talked very much more sensibly than on previous visit. Said that he screams because he wants things that he can't have. Said that now the mother of the little boy who ran away with him won't even let him play with him, so he supposes he will have to play alone. Wants an express wagon and innumerable other toys. Visitor suggested that if Richard is a very good boy over the week-end, she would bring him out a surprise early part of the week. [Syllabus reference: KNOWLEDGE, Psychology and Psychiatry.] Miss Dewey (School Teacher): Miss Dewey seems to be a

266

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very intelligent woman and had been much interested in Richard. When he came into the class he seemed so very childish and so f a r behind the children of his o w n age that she thought probably he had been out of school a good deal. O n looking u p his card f r o m the last school she f o u n d that in the term he had lost only about one day. Richard is not doing at all well in school w o r k . H i s actions are those of a child of 4, very flighty attention, and extremely poor concentration. Teacher showed visitor one of Richard's papers. H e had gotten one word out of ten written down. There was one attempt, but even the letters were illegible. In all written w o r k he does very poorly. Once in a while in oral arithmetic, when a question is put right to him, he answers quite well and o f t e n gives correct answers to something that he would have failed in utterly if given in written w o r k . H e talks and fidgets in the class room. Does not seem at all interested in any of the work. His marks are about fours and fives. There is not the slightest chance of his being promoted. In going over some of his w r i t ten w o r k , the teacher said that she had wondered whether there could be some slight eye defect since he seldom if ever touches the lines. 5 . 2 . 2 2 — R i c h a r d to Children's Hospital ear clinic: N o discharge. Does not have to return f o r a month. Hearing normal. 5 . j . 2 2 — T e l e p h o n e d F . M . : H a d been unable to come out during the week with surprise f o r Richard who, F.M. said, behaved very well over the week-end but when visitor did not arrive he wearied of doing well. Visitor promised to come 5.9. 5 . 8 . 2 2 — F . M . at home: Richard is still very disobedient, although there seems to be a slight improvement. Spanking has not proved a success and F . M . feels that the best f o r m of punishment is to put him to bed and to let him scream his tantrum out. Will do this whenever Mr. O w e n is not in the house. Visitor brought a little g i f t f o r Richard because he had been a good boy over the week-end. H o w e v e r , F . M . said that, since they have been paying R i c h a r d every time to behave, this f o r m of encouragement had better not be used. H e is getting pennies

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267

to stop crying. H e is taken to the movies to stop shrieking because F . M . has to go out without him. F.M. does not believe in this kind of training, but says that under the circumstances when M r . O w e n is at home, she feels that she must keep R i c h ard as quiet as possible. Richard always wants something else than w h a t he has. Usually wishes f o r something unattainable — s u c h as an aeroplane, automobile, etc. W h e n visiting, no matter how m a n y toys are brought out f o r him to play with, he is not satisfied—wants to k n o w if there aren't other toys that he can see. R i c h a r d is only allowed to go u p and down the pavement in f r o n t of the house. While this restriction is necessary as F.M. feels that she wants to keep him constantly in sight, visitor feels that it is rather a hard thing f o r Richard. R i c h a r d does run off and the other day had hitched his little friend's express w a g o n to the back of a big truck on Gerhart A v e n u e . Visitor feels that just as soon as possible Richard should be placed in the country where there will be much more space, new interests and a home where there is not the nervous tension that exists in the O w e n home. [Syllabus

reference:

KNOWLEDGE,

Psychology

and

Psychiatry.] 5 . 1 2 . 2 2 — P . A . , Mrs. Baker, telephoned (in visitor's absence): L e f t message f o r visitor to call up Monday morning. 5 . 1 3 . 2 2 — T e l e p h o n e d P . A . asking her to come to office later in the morning. P . A . , Mrs. Baker, in office: P . A . was feeling very much better f o r her trip south. W o u l d like to see R i c h a r d , but would not do so if visitor thought that she had better not. Visitor suggested her going out tomorrow. P . A . also said that she has another pathetic letter f r o m Μ. M . A . in St. Louis is not willing to come on for her; P . A . would like to help her but at present cannot do anything

financially.

In a f e w months may be able

to do something. Visitor promised that she would go to the C i t y Hospital and see M. and take the matter up with the Social Service Department there. Visitor explained to P . A . that plans were being made to have R i c h a r d placed in the country in six weeks or t w o months.

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RICHARD

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5 . 1 2 . 2 2 — T e l e p h o n e d F.M. re. P . A . ' s visit t o m o r r o w . 5 . 1 5 . 2 2 — T e l e p h o n e d F . M . : P . A . and P . U . had c o m e o u t yest e r d a y a n d they had had a v e r y nice visit. P . A . said that she h a d n e v e r seen R i c h a r d looking as well as he does n o w . 5 . 2 3 . 2 2 — M i s s H a m p t o n , S.S.D. Mental W a r d , C i t y H o s p i t a l : M . has n o t had a n y reply f r o m her sister in St. Louis in regard t o c o m i n g f o r her. She is not well e n o u g h t o be discharged u n less paroled to someone w h o w i l l be entirely responsible f o r her. V i s i t o r explained that P . A . , Mrs. Baker, is interested in M . , b u t c a n n o t do a n y t h i n g to help financially at the present time a n d c o u l d not be responsible f o r her. In case M. improves to the p o i n t w h e r e she is able to take a job, Miss H a m p t o n will t r y t o secure w o r k f o r her, b u t w i l l n o t i f y visitor b e f o r e a n y such c h a n g e is made. A c c o r d i n g to the record, M . was b r o u g h t into the C i t y Hospital b y a policeman w h o had f o u n d her w a n d e r i n g the streets at 4 A . M . , l a u g h i n g and t a l k i n g a n d not b e i n g able t o g i v e a n y comprehensible answers. 5 . 2 4 . 2 2 — F . M . telephoned: Wishes to keep R i c h a r d a n d says t h a t P . A . had also said that she wished R i c h a r d t o stay w h e r e he was. Said P . A . had promised t o send h i m a suit and other clothes. F . M . feels that she w o u l d n o w like to keep R i c h a r d if he had better clothing. V i s i t o r , h o w e v e r , explained that it w o u l d p r o b a b l y be better t o place the child in the c o u n t r y . 5 . 3 1 . 2 2 — L . to P . A . e x p l a i n i n g situation in regard to M . and e n c o u r a g i n g her to send c l o t h i n g t o R i c h a r d . 6 . 1 2 . 2 2 — F . M . telephoned

(in visitor's a b s e n c e ) : Does

not

w i s h to keep R i c h a r d , w o u l d like him taken as soon as possible as he is a great deal of trouble and a great source o f irritation. 6 . 1 5 . 2 2 — M r s . Stecker, m e m b e r o f Society's Bd. o f Directors, tel.: Mrs. Stecker has k n o w n the H e a t h f a m i l y f o r a l o n g time. Feels that the children of father's f a m i l y were always i n d u l g e d b y P . G m . and decidedly spoiled. Father w a s the black sheep o f the f a m i l y . P . A . , Mrs. Baker, is on parole f r o m t h e Pittston Hospital f o r Mental Diseases; has had several operations, the last one a complete h y s t e r e c t o m y . T h e r e is another P . A . in L a w r e n c e w h o is a trained nurse, w h o was also v e r y spoiled b u t w h o is g e t t i n g a l o n g better n o w . T h e P . U . , in

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Lawrence, is getting along very well and Mrs. Stecker feels that they should be able to contribute somewhat toward Richard's support. P . A . , Mrs. Baker (Mrs. Stecker thinks P . A . is really doing very well and has gotten hold of herself), is very much disturbed because she gets almost daily letters f r o m M. from the City Hospital, asking that P . A . take her out. She has also gotten a letter from S.S.D., C i t y Hospital, about this matter. She is getting very much worried and Mrs. Stecker feels that she should be relieved of this nervous strain. None of the Heath family wish to assume responsibility for M. Mrs. Stecker feels that it is the duty of M.'s family to look after her. 6.20.22—F.M. telephoned: Is very anxious that visitor should remove Richard just as soon as possible. F.M. wished to have a talk with visitor who promised to come 6.22. Visitor explained that Mrs. Reynolds would come this morning to take Richard to the eye and ear clinic. 6.20.22—Richard taken to ear dispensary, Children's Hospital: Does not need to come again. Taken to see D r . R o c k f o r d (occulist): Given drops. Drops to be put in Saturday, Sunday, and Monday mornings and Richard to go to D r . R o c k f o r d again on Monday. 6.21.22—Telephoned Miss Hampton, S.S.D., Mental Ward, City Hospital: Explained to Miss Hampton that P.A., Mrs. Baker, was very nervous and her frequent letters from M. were a cause of great anxiety and worry to her. Miss Hampton reported that no letter had gone off f r o m S.S.D. to P . A . regarding M. They will try to hold up all letters from M. to P.A. that go through the regular channel. Miss Hampton explained that patients often send out letters with visitors and that this correspondence cannot be controlled. 6.22.22—F.M. at home: Visitor arrived again just at the end of another scene. Richard had been howling for an hour because he insisted he could not find his garter. Richard always wants to be waited on hand and foot, and F.M. has decided to let him hunt for garters himself. A t the end of an hour's

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screaming when a neighbor had called in asking that he stop, F.M. went upstairs and found the garter lying on a chair in plain view. A t times Richard has seemed to improve for a day or two, and it has been at these times that F.M. has felt that she would like to keep him, but she has decided that she cannot keep him any longer. Richard has a frightful temper. Screams and yells at the top of his lungs when crossed in any way. Is never satisfied. Always wants something that he cannot have, or insists on having more o f something of which he has already had a great deal. Behaves very badly when he goes visiting. Last week F . M . had taken him to a friend's house. H e had been there but a short time when he began to scream and howl because he wanted his shoes shined. Last Sunday had been taken on a long automobile trip. T h e family had come home about ι ο o'clock, had had their supper and then, when Richard was told to go to bed at 11, he screamed at the top of his lungs because he wanted to ride some more. H e cannot play with children his own age. W i t h children of about four he gets along fairly well. In spite of every morning being told to wash his hands and face before coming to the table, Richard has not once during his stay with F.M. remembered to do this. It takes Richard hours in the morning to get into his clothes. Can never find his clothing although it may be on the chair in front of him. F.M. reports that P.A., Mrs. Baker, told her that this was the way Richard behaved when she had him, that he screamed so terribly that the neighbors thought she was misusing him. F.M. said that one time, when she had taken Richard to get a hat and could not let him have the one he liked himself, he howled at the top of his lungs on the street car all the way home. F.M. feels strongly that Richard is an abnormal child and should be in an institution for the feeble-minded. F.M. seems to be very nervous and visitor feels that there is a good deal o f tension in the home. F.M. wishes Richard to be transferred sometime next week. [Syllabus Psychiatry.]

reference:

KNOWLEDGE,

Psychology

and

RICHARD 6.16.11—Richard

HEATH

271

taken to Dr. Rockwell:

H a s h a d d r o p s in

his e y e s S a t u r d a y , S u n d a y , a n d o n c e t h i s m o r n i n g . T o r e t u r n t h e 28 t h t o g e t p r e s c r i p t i o n f o r glasses. 6 . 2 7 . 2 2 — T e l e p h o n e d M r s . O w e n a s k i n g w h e t h e r she w o u l d be k i n d e n o u g h t o b r i n g R i c h a r d in o n t h e 2 8 t h t o D r . R o c k w e l l . M r . O w e n c a m e t o t h e t e l e p h o n e a n d insisted t h a t R i c h a r d b e r e m o v e d b e f o r e the 4 t h o f J u l y . 6 . 2 8 . 2 2 — R i c h a r d b r o u g h t to D r . R o c k w e l l b y Mrs. O w e n ' s d a u g h t e r , w h o also t o o k h i m t o o p t i c i a n . M r s . R e y n o l d s h a d n o t broXight d a r k glasses, so R i c h a r d h a d n o t w o r n a n y d u r i n g t h e t i m e t h a t the d r o p s w e r e in his eyes. G i r l t h o u g h t

that

F . M . w a s still p u t t i n g in d r o p s . T e l e p h o n e d F . M . w h o said t h a t t h e last d r o p s h a d b e e n p u t in M o n d a y m o r n i n g . Is a n x i o u s t h a t v i s i t o r t a k e R i c h a r d week. Visitor promised to come f o r him Saturday Mrs.

Martha

Helman,

142

Liberty

Street,

N . J., at h o m e ( t h i s is a n e w f o s t e r h o m e ) :

this

morning.

Cliftonwood,

M r s . H e l m a n has

n o c h i l d r e n , a n d she a n d h e r h u s b a n d are t h e o n l y m e m b e r s o f the h o u s e h o l d . H o w e v e r , she k n o w s s o m e t h i n g a b o u t b o y s as she has t a k e n care o f h e r s i s t e r - i n - l a w ' s c h i l d r e n m a n y times. She also h a d t w o c h i l d r e n f r o m t h e Q u a k e r O r p h a n a g e about

f o u r months. T a l k e d

intelligently

about her

for

experi-

ences w i t h these c h i l d r e n . S a i d t h a t she f o u n d t h a t e v e n c h i l d r e n i n t h e same f a m i l y c o u l d be as d i f f e r e n t as n i g h t f r o m d a y ; t h a t she h a d f o u n d t h a t h e r t w o l i t t l e n e p h e w s she h a d had w i t h h e r v e r y o f t e n h a d t o be h a n d l e d j u s t a b o u t in o p p o site w a y s . T h e house is a b u n g a l o w a n d s t a n d s o n an o p e n c o u n t r y street. S u r f a c e d r a i n i n g s . T h e l o w e r p a r t o f t h e street seems r a t h e r o b j e c t i o n a b l e , b u t u p w h e r e t h e H e l m a n

house

stood t h e r e w a s n o u n p l e a s a n t o d o r o f a n y k i n d . T h e r e is c o n siderable g r o u n d a r o u n d t h e h o u s e , w e l l k e p t v e g e t a b l e g a r d e n and

grounds.

They

have

chickens—the

chicken

house

in

v e r y g o o d c o n d i t i o n . M r . H e l m a n is a c h e m i s t a n d has been o n p a r t t i m e , so M r s . H e l m a n has been h e l p i n g o u t b y d r e s s m a k i n g at t h e F r e n c h G o w n C o . , 7 t h A v e . & A l b a n y S t r e e t . T h i s w o r k is o v e r f o r t h e t i m e b e i n g , a n d M r s . H e l m a n f e e l s t h a t

272

RICHARD

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she would like to have children around. It keeps her f r o m being selfish. Does not seem to be a f o r c e f u l person, but said that she likes to tackle rather difficult jobs and she would rather have a difficult child than one w h o was more easily handled. Visitor explained, as carefully as possible, just w h a t Mrs. H e l m a n could expect if she undertook the care of R i c h ard. D i d not seem at all dismayed and would be very glad to take him. D i d not wish anyone to leave a child with her unless they were quite satisfied to do so. Mrs. H e l m a n will call up office tomorrow at 4 o'clock when visitor will be able to tell her whether or not Richard is to be placed there. [Syllabus reference: RESOURCES, Foster H o m e . ] 6 . 2 9 . 2 2 — C o n f e r e n c e : It was decided to try Richard in the H e l m a n home although it was an untested quantity. A s a f a r m home, which w o u l d be more suitable f o r Richard, is not available at this time and, as he has to be removed f r o m Mrs. Owen's this week, he is to be placed with Mrs. Helman on trial. [Syllabus reference: METHOD, " R e - p l a c e m e n t . " ] 7.1.22—Richard

to clinic: W t . 47. Examination

negative.

A l l right f o r placement. R i c h a r d placed w i t h Mrs. Helman, 1 4 2 Liberty St., C l i f tonwood, N . J . (Board $6. w e e k ) : W h e n visitor called to take Richard to Mrs. H e l m a n , Mr. O w e n expressed himself as very sorry to see him go. Asked him to write, etc., and wanted to shake hands with the visitor. Decided contrast to the gruff demand of the last week that Richard be removed at once. Mrs. O w e n reported that Richard had been behaving a good deal better when he heard that he was to leave. Richard seemed rather sorry to leave the Owen home and as he neared the Helman home he grasped visitor's hand and begged her to stay with him. H o w e v e r , Mrs. Helman greeted him

very

kindly and in a v e r y f e w minutes he was as happy as could be. Mrs. H e l m a n had already ordered a croquet set and had kept the little turkeys in so that Richard could feed them when he arrived. Visitor v e r y much more f a v o r a b l y impressed w i t h Mrs. H e l m a n than on her first visit. She seemed more outgoing

RICHARD

HEATH

273

and expressive and her welcome to R i c h a r d indicated s y m pathy f o r his shyness and desire to convince b y affection that he could be happy with her. 7 . 7 . 2 2 — V i s i t o r sent t w o suits of underclothing and a pair of cotton trousers. L. to P . A . re. change of home. 7 . 1 0 . 2 2 — L . f r o m F . M . : " R i c h a r d is all that I was told that he would be. In f a c t I never had a child harder to understand. T o d a y has been m y best day with him. I find that he is a good, bright boy, yet he has been dreadful at times f o r his o w n w a y . I find the best w a y to deal with him is to appeal to the good in him. E v e r y night I tell him that he is a good bright b o y . There has been no screaming and he is now happy. I had been thinking that it is a f a r better w a y to have t w o children than one f o r the child's sake. T h e y learn to be more unselfish." [Syllabus reference: KNOWLEDGE, P s y c h o l o g y . ] 7 . 1 1 . 2 2 — L . to F . M . : Visitor will consider sending another child when F.M. and R i c h a r d have had more time to adjust to each other. Will visit soon. Sending more clothes. 7 . 1 4 . 2 2 — F . M . : Richard brought to D r . R o c k w e l l to see if glasses were adjusted properly. Glasses O . K . F.M. finds Richard a pretty difficult boy to manage, but feels there is a decided improvement already. 7 . 1 7 . 2 2 — L . f r o m Mrs. Baker re. clothing. 7.19.22—Mrs.

Owen telephoned: Mrs. H e l m a n

had been

there yesterday and had asked that they take R i c h a r d back. She has had so much difficulty with him that she did not think she could keep him. 7 . 2 0 . 2 2 — L . to Mrs. H e l m a n re. above. 7 . 2 0 . 2 2 — L . f r o m Mrs. H e l m a n : " R i c h a r d and I have been looking f o r a visit f r o m you this week. H e is not the same boy that you brought here. A t that time his temper was pitiable. I have strongly kept t ® the good in him that today he is not the same boy, yet is a great responsibility and I need to keep a close watch over him. Sleeping on the porch is doing him lots of good as he eats well and seems happy. W h a t I cannot under-

274

RICHARDHEATH

stand is how he became so spoiled when he has such good traits. I have found him both honest and I never need to be afraid of him taking anything." [Syllabus reference: K N O W L E D G E , Psychology and Psychiatry.] 7.24.22—Mrs. Helman in office: Very much distressed over letter. Had only seen Mr. Owen last week. Mrs. Owen was not at home. Had called there because she was in the neighborhood and wanted to thank them for having forwarded the suits which P.Gm. had sent. Told Mr. Owen that she was having a hard time with Richard, but had not mentioned returning him to them. Mr. Owen had held forth at length on all Richard's shortcomings. Had mentioned they had gotten $8.00 per week but that he was worth $50. Visitor explained that the $8.00 had been given because of the report from " L o w e l l " that Richard played with his excreta. If this had been the case, additional laundry would have been necessary, etc. Mrs. Helman said she was quite willing to keep Richard in spite of the fact that he was considerable trouble. On one occasion, because he was crossed, he picked up one of the young turkeys and squeezed it so hard that it died. Another time flung the cat across the room in a temper. Mr. Helman is very jealous, but Mrs. Helman feels she can make things all right. [Syllabus reference: K N O W L E D G E , Psychology and Psychiatry.] 7 . 2 4 . 2 2 — L . from F.M.: "Richard is causing so much trouble between Mr. Helman and I that I wish you could place Richard somewhere else by the first of the month. Mr. Helman's vacation is that week and I would not know what to do. I am so nervous that I cannot sleep at night. Richard's worst fault is talking back. He has an answer for anyone and he will talk back to both my mother and husband. Yet if it were only m y self I could bring that boy up. There is the making of a good man in him. Last night finished Richard. Mr. Helman's people came out in a machine and Richard would not do as he was told. I had gone for a few minutes to my mother's and Richard

RICHARD

HEATH

275

got up in front of the machine and did something. There was no harm done, yet it caused lots of trouble. It is too bad, I feel v e r y sorry, yet do not fail me and for the child's sake have somewhere for him by the first. He is well fixed for clothes. I bought him two pretty wash suits and a sailor hat and he looks so nice in them. He is a very nice looking child—not hard to make look nice. Hoping that I may hear from you real soon." 7.28.22—Visitor called on Mrs. Volk (Mrs. Helman's sister) to talk over the possibity of placing Richard with her since he has already made a contact there and seems to be fond of her. Mrs. Volk not at home. Mrs. Helman not at home, but their mother talked to visitor. Said that she felt they were both too easy with Richard, would ask Mrs. Volk and would have her call visitor Monday at 9 o'clock regarding her decision. 7 . 3 1 . 2 2 — M r s . Helman telephoned (in visitor's absence): L e f t word she is willing to keep Richard a while longer. 8.4.22—F.M. and F.F. at home: In asking Mrs. Volk to take Richard, visitor had evidently stirred up some feeling in the family and visitor feels that the Helmans want to prove to Mrs. Volk that they are just as capable of handling Richard as she would be, and it is partially for this reason that they decided to keep Richard. Mr. Helman remarked that he thought Richard was a hundred per cent better; that at times he was very sweet but then again he would be so irritating that he felt like wringing his neck. The only punishment that is meted out to Richard is to sit in a big chair and also to be shown a whip which would have to be used sometime if he did not behave himself. They had never spanked him and do not feel that they will ever have to. F.M. has put Richard in the position of taking care of her. Has told him that she is nervous and not well and that he must help her. The child has responded to this very well and has shown quite a bit of care and thoughtfulness on different occasions. They are continually trying to get him to think of others and not so much of himself. The other day he had been given two nickels for something that he had done. He had run off and spent the entire

276

RICHARD

HEATH

amount on candy f o r Mr. and Mrs. H e l m a n . A t first R i c h a r d had a good bit of trouble in playing with other children. A l ways wanted to lord it over them and was quite nasty and irritating in his play. H o w e v e r , some of the older boys had lit into him and thrashed him up a bit. T h e Helmans instead of sympathizing with him told him that he would have to stand such treatment if he did not behave himself with other children. There has been a marked improvement in this respect. H e now is much more willing to share his wagon and toys and, on the whole, is getting along quite well with the children in the neighborhood. Visitor feels that F . M . is handling the situation very well and that there is more improvement in R i c h a r d in the short time that he has been with Mrs. Helman than in the months that he spent with Mrs. O w e n . [Syllabus

reference:

KNOWLEDGE,

Psychology

and

Psy-

chiatry.] 8 . 8 . 2 2 — L . to D r . Stone requesting hospital report on P . A . , Mrs. Baker. L. to D r . C . F. Felon, Pittston Hospital requesting hospital report on F . L . to F.M. re. clothing. 8 . 9 . 2 2 — F . M . in office (in visitor's absence): Greatly

dis-

tressed. A neighbor had told her that she discovered that R i c h ard had been abusing her little boy. R i c h a r d has a kind of little place built of rocks in the woods and had been going there every day to play, he said. This little boy had accompanied him. O n one occasion when he came home with his clothes all loosened, his mother questioned him but was unable to get him to tell anything. T h e second time when he came home with his clothes plainly half off his mother decided to get to the bottom of the matter and questioned him v e r y closely. Found out that R i c h a r d had been taking him to the woods and, on several occasions, had been abusing him. This neighbor is highly indignant and insists that F.M. give u p boy immediately. However, she has promised not to mention it to any of the neighbors. F.M. is in great f e a r lest Mr. H e l m a n

RICHARD

HEATH

277

and her mother discover w h a t has gone on, as they are both jealous and would be infuriated. Mr. Helman has been very u g l y to Richard on several occasions and has demanded in Richard's presence that the boy be removed. F.M.'s mother has always been of a jealous temperament and had also taken a v e r y antagonistic attitude towards the boy. (F.M.'s mother on one occasion called visitor aside and told her that she w o u l d love to take Richard because she k n e w that she could handle him infinitely better than either one of her t w o daughters; that they were both too lenient, etc. Begged visitor not to mention this fact to either of the daughters but just to place Richard there as t h o u g h it were visitor's own idea.) F.M. has taken a very fine attitude towards Richard. Feels that he has not committed a heinous crime and feels strongly that, if she were o n l y permitted to care for him without the interference of her husband and mother, she could do a great deal f o r the boy, and that he would really grow up into a fine man. Richard is devoted to his F.M. and she has been training him to be very considerate to her. H e opens the door for her, pulls out her chair and remembers to do many little t h o u g h t f u l acts. F.M. was rather disturbed b y the fact that she had not received her check for last month. Her husband had remarked sneeringly that, b y not even paying f o r the boy, she could readily see how little the Society cared either for her or f o r Richard. Explained again that checks were payable f r o m the first of the month until the last, but did not reach the foster mothers until about the middle of the month. Visitor had explained all this to both Mr. and Mrs. Helman on last visit and they seemed to understand and be quite agreeable to this arrangement. T o l d F.M. that visitor would come out at the earliest opportunity. 8 . 1 0 . 2 2 — F . M . at home: V e r y m u c h worried and upset about the trouble with D i c k . Says that her husband and mother are unbearable. T h e y are so antagonistic towards the boy, and find so much fault with her, that life is quite unbearable. She does not think that the neighbor has told anybody

about the

278

RICHARD

HEATH

trouble w i t h D i c k because she had told her that if she did all the neighbors w o u l d henceforth view her o w n boy w i t h suspicion. F.M. feels that it is absolutely out of the question to t r y to keep Richard there; that in the first place her husband will not tolerate it and, in the second, the neighbor is absolutely insistent that Richard be removed as soon as possible. F.M. has noticed that Richard keeps pulling at himself continually. H e seems to be uncomfortable and it may be that his clothes irritate him, but she is sure they are not too little. Yesterday Richard had tied Mr. Helman's t w o pet dogs together w i t h a big rope and when Mr. H e l m a n came home and found them d o w n the cellar, of course, there was a terrific scene. Visitor asked Mrs. Helman to keep him until the f o l l o w i n g T h u r s d a y . Richard has had trouble w i t h other neighboring c h i l d r e n — h i t one child on the head w i t h a croquet ball. [Syllabus reference: KNOWLEDGE, Psychology

and

Psy-

chiatry.] 8 . 1 1 . 2 2 — L . f r o m Pittston Hospital: H a v e no record of P . A . 8 . 1 4 . 2 2 — L . to F.M. asking her to keep Richard another week. L. f r o m Pittston Hospital re. father. (See file.) 8 . 1 7 . 2 2 — L . f r o m Mrs. H e l m a n insisting that Richard be removed b y Saturday, the 19th. Visitor tried to get F.M. on the telephone to say that she would come for Richard that afternoon, b u t w i t h o u t success. 8 . 1 8 . 2 2 — F . M . at home: Visitor arrived just as Richard was in one of his tantrums. F.M. had had a little lunch party with her little niece and all had gone well until f o r some u n k n o w n reason Richard had flown into an ungovernable temper, swearing, and cursing, and shrieking. Richard yelled m u c h louder when he saw visitor and shrieked that he w o u l d not leave Mrs. Helman. His affection for F.M. is really genuine and it was tragic to see how frightened the child was at having to leave her. Finally quieted d o w n , and a f t e r being dressed to go, seemed in a pretty happy frame of mind. Mr. H e l m a n has not spoken to Richard f o r t w o weeks and the tension in the household has been horrible. F.M. says that Richard is the most difficult child

RICHARD

HEATH

279

to understand that she has ever k n o w n . She cannot feel that he is " a l l there." Seems abnormal. Flies into terrible fits of temper over nothing. Yesterday kept screaming to her that he intended to kill her the first chance he got. C a n be v e r y lovable and dear, and F . M . feels that if she could keep him she could do much f o r him. Is quite sure that he has been masturbating at night. Richard on the w a y to t o w n : R e m a r k e d : " W e l l , I know one t h i n g — I will remember her (meaning Mrs. H e l m a n ) all my life." [Syllabus

reference: KNOWLEDGE, Psychology

and

Psy-

chiatry.] Miss Morris at home: This is a specialized foster home f o r short time or emergency care of children at special rate of board. For R i c h a r d board is to be $ 1 0 per week. Visitor e x plained Richard's trouble with the little boy and cautioned Miss Morris to watch him very closely when little Claude, the three year old French boy, w h o is staying w i t h Miss Morris, is around. [Syllabus reference: METHOD, T e m p o r a r y placement.] Conference with case supervisor: Visitor to get as complete a summary as possible and then make plans to have D r . Eton, psychiatrist at C i t y Hospital, see Richard. 8 . 2 1 . 2 2 — M i s s Eleanor D r e w at home: Visitor called to get f u r t h e r history, explaining the trouble we were having with Richard. For complete s u m m a r y of additional and previous information, see file. 8.23.22—Telephoned Children's Hospital, Miss Lewis, S.S.D.: Explained that R i c h a r d was now in better condition than when in the hospital last March f o r tonsillectomy and Society would like to k n o w whether the doctors think that Richard should be circumcised at this time. Miss Lewis suggested bringing Richard to D r . Katherine B r o w n at 9 o'clock T h u r s d a y morning. Explained that D r . B r o w n usually operated after an examination and that the child is kept in the hospital usually a week or more a f t e r circumcision.

28ο

RICHARD

HEATH

8.24.22—Miss Morris at home: Visitor called to explain that visitor-at-large would come f o r Richard tomorrow. Visitor asked Miss Morris to keep Richard until he could go to the hospital, explaining that it w o u l d probably be a very f e w days before he goes, and then take him back for three or f o u r days after he returns f r o m the hospital, explaining that we were planning to place the child in the c o u n t r y and did not wish to take him out just f r o m the hospital. Miss Morris willing to keep him until admitted to hospital. W i l l let visitor k n o w in a day or t w o whether she will be able to take him on his return. L. to chief surgeon re. information concerning P . A . Telephoned Franklin Hospital for information regarding P . A . T h e y are not permitted to give information concerning private patients. D r . Lane, w h o was in charge at the time of P.A.'s stay in the hospital, is no longer there. T h e y suggested that visitor telephone D r . Develin w h o has taken D r . Lane's place. Telephoned D r . D e v e l i n : D r . D . out. 8.24.22—Children's Hospital, D r . B r o w n : T h i n k s it best not to circumcise Richard. A s prepuce was adherent it was pushed back. Instructions given Miss Morris to push prepuce back and keep clean. C l o t h i n g too t i g h t — i r r i t a t i n g

boy. Should be

looser and f r o n t of drawers sewed up. Chief Surgeon, Pittston Hospital telephoned: Mrs. Baker, P . A . was not his patient, b u t he k n o w s her and says that F. and she are about j o - j o . Suggested w r i t i n g Supt. of Pittston Hospital and Supt. of Nurses. 8.25.22—Telephone D r . Eton (Psychiatrist): W i l l be glad to see Richard M o n d a y , the 28th, at 2 P.M. Visitor purchased new clothing and brought them to F.M. F.M. at home: Has not been having trouble w i t h D i c k . She will keep him until A u g u s t 31st. L . to Supt. Pittston Hospital requesting information regarding P . A . 8 . 2 8 . 2 2 — R i c h a r d to D r . Eton ( P s y c h i a t r i s t ) : Summary to D r . Eton.

RICHARD

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281

Richard in very good spirits. Liked D r . E t o n immensely. Was very anxious to go either to Mrs. Helman or to come and live with visitor. Said that he would be a very good little boy. 8 . 2 9 . 2 2 — L . f r o m Pittston Hospital: P . A . was private patient of D r . Kent. R e f e r s visitor to D r . Kent. Mrs. Marianna D o l b y , W i l m a r , N e w J e r s e y : 9 Visitor called at Mrs. Dolby's home in W i l m a r . Mrs. D o l b y was not there, but her young married daughter received visitor. Mrs. D o l b y has raised two children remarkably well. A son 22 years old, w h o is now a teacher in the district school, and this daughter, 20 years old, w h o had recently married. T h e son and his w i f e live in a house right on the grounds and the daughter has just purchased a little b u n g a l o w across the road. Mrs. D o l b y has quite a good bit of land, lovely trees, a duck pond, horse, cow, etc., an ideal setting f o r D i c k . Visitor explained to daughter something about R i c h a r d and asked that in case visitor did not find Mrs. Dolby in D o v e r she telephone visitor in the a f t e r noon as to whether she would care to take D i c k . H o w e v e r , returning to D o v e r , visitor f o u n d Mrs. D o l b y in one of the stores. Mrs. D o l b y is a middle aged w o m a n , w h o seems to have a kindly, outgoing, optimistic nature, and radiant good health. She is of English birth, educated in E n g l a n d , coming to this country in young womanhood and m a r r y i n g soon a f t e r her arrival. She is obviously of good breeding, with m a n y cultural interests—books, music, and love of nature. A s a young woman had taken vocal lessons and had sung in public. She impressed visitor as a w a r m , virile personality, almost exuberant in the strength of her feelings, yet balanced b y a strong layer of common sense. Visitor went over D i c k ' s story as caref u l l y as possible, telling of his fits of temper, abusing boys, the incident of killing the t u r k e y . Mrs. D o l b y did not seem to be disturbed particularly and said that she would be willing to try him f o r six or seven weeks. Board to be $8.00. [Syllabus reference: RESOURCES, Foster home.] 8 . 3 1 . 2 2 — R i c h a r d to clinic: H t . 48, w t . 4 9 — a b o u t 8 c/c under'Compjete report on this home appended. (See page 3 31.)

282

RICHARD

HEATH

wt. Throat and teeth in good condition. Heart, lungs, negative. Abdomen normal. Skin healthy. Condition

of

ears

apparently all right. He is all right for placement. Richard placed with Mrs. Dolby, Wilmar, N e w Jersey: Board $8.00. [Syllabus reference: METHOD, Re-placement.] 9.2.22—L. from D.P.W. asking for a report on case. 9.2.22—L. from Supt. of Nurses, Pittston Hospital: P . A . was probationer in the Training School. Was bright in her studies but had to leave because of flat foot. Accepted for second trial. Was disobedient and as was not strong enough physically to stand the life of a nurse, was dismissed. P.Gm., a former patient at hospital, was a cultured, attractive woman. 9 . 1 2 . 2 2 — R e p o r t sent to D . P . W . 9 . 1 8 . 2 2 — L . from D.P.W. thanking for report. 10.9.22—F.M.'s niece in office asking that a pair of shoes be sent to Richard. 10.12.22—Shoes sent to F.M. Mrs. Baker in office: Mrs. Baker is feeling fine and says that she is working as secretary f o r D r . Norris, 2041 Hemlock St., every day from 9:00 to 4:00. P.Gm. has returned to Virginia. Visitor promised to let Mrs. Baker hear just as soon as visitor had visited Richard in his new home. Gave P . A . his present address. 1 0 . 2 5 . 2 2 — L . from social worker, Mental Clinic, City Hospital, re. another examination for Richard. 1 1 . 1 . 2 2 — L . to social worker, C i t y Hospital, re. date for this examination. 1 1 . 8 . 2 2 — F . M . and Richard at home: F.M. met visitor at station and drove her to the house. Said that she did not wish to say anything about Dick as he had been very anxious that she should say nothing, but that he should tell visitor all about how he has been getting along. When visitor arrived F.M. made a big fire in the open fire place and left Dick with visitor. Dick climbed up on visitor's lap and immediately launched forth on a rather confused story of how he had been

RICHARD

HEATH

283

sent h o m e f r o m school. H e started to g o to school where Mrs. D o l b y ' s son teaches. D i c k said that he had refused to get some letters that Mr. D o l b y asked him to get and, therefore, had been sent home a n d could not g o back. T h e n told that he had scattered the d u c k f o o d all over the barn floor. H a d not been very nice a b o u t d o i n g " b i g j o b s " f o r F.M. D i d not m i n d little jobs b u t did not like big ones. A f t e r this very short recital of his misbehavior, he immediately said that he was g o i n g to tell visitor of all the g o o d things he had done and, in D i c k ' s m i n d , these f a r out-weighed any o f his misdeeds. T h e boy seemed t o be in very good physical condition and excellent spirits. V e r y talkative and quite a bit religious. T o l d visitor that he o f t e n t h o u g h t of his mother, and wondered if she were dead. Visitor explained to him that his M . was ill; was in the hospital and would p r o b a b l y not see him f o r a long, long time. O n e of the other t h i n g s that D i c k talked a b o u t was an incident that happened while he was s t a y i n g with Mrs. O w e n . It seems that Mrs. O w e n h a d taken him out to visit. H e had misbehaved here a n d the m a n o f the house sent him d o w n the cellar, telling him that there was a great big red t h i n g there who was g o i n g t o catch hold of him. D i c k says that this is the reason he has been a f r a i d o f g o i n g to bed in the d a r k . D i c k b r o u g h t o u t all his toys to show visitor and had a lovely time. T o l d visitor to be sure a n d not take him a w a y f r o m Mrs. D o l b y . Mrs. D o l b y later: W e n t over D i c k ' s story and explained to visitor that at school D i c k had p r o v e d to be such a disturbing element in the classroom t h a t her son did not feel that he could continue to have him, as the b o y was not really in his district. There were not very active bad things that the boy did b u t there was a lack of attention and sort of irritating u n d e r current o f silliness and stubbornness, and he seemed f o r some reason or other always to be keeping the class on edge. H a d done f a i r l y well in his class w o r k in the second grade. If he remains, F . M . insists that he g o to school and would send him to school about a mile a w a y which belongs to the district. T h e teacher here is a y o u n g w o m a n , stern, but with a great deal

-284

RICHARD

HEATH

of common sense, according to F.M. Dick had proved to be quite a bit of trouble. His screaming fits have improved because F.M. has always told him to keep right on screaming; that it annoyed no one. This course of procedure seemed to take a good deal of that kind of behavior away. F.M. feels that the most difficult thing in caring for Dick is a certain blankness about the boy. When he has been disobedient, it seems as though the situation just did not penetrate; that he did not register what was being asked of him. He seems bright enough, and contrary to the reports of the other F. mothers that Dick was so much younger than his years, Mrs. Dolby feels that Dick is older than his years. It is about impossible to get Dick to finish a task. He will start out on it but, in a very short time, just drops it and flies off to something else. Attention and concentration are very poor. However, the other day, for the first time, F.M. felt that she had succeeded in really getting hold of Dick and penetrating into the blankness. He had been told to chop up some shingles and put them in a pile. He played at it for a while, then dropped it to run off to do something else. Kept this up for quite a while until, finally, F.M. told him that he could not come in or could not have any supper until he had finished. This did not seem to have any immediate effect but, as dark came on and Dick realized that she meant what she said, he started in to work. He had never concentrated so well before. Stuck right to the job in spite of the cold and the darkness that came on. F.M. felt sorry for him but still realized that she must stick to her point, so brought him out a glass of warm milk and piece of cake at supper time. Dick kept right on working and it was quite late before he had finished his little job. Instead of feeling any resentment he came in, threw his arms around F.M. and said, "My, but you are good to me." F.M. feels that Dick felt in some vague way that he had really conquered himself and was thankful to F.M. for the help that she had given him. Richard is in the choir in the Episcopal Church at Glen Haven. Has a very nice voice, and it is a great honor for him to have been taken. He also takes up the collec-

RICHARD

HEATH

285

tion plates at the altar. H e has given some trouble in the choir but so f a r they have not complained very much about him. F.M. is willing to keep on f o r a while longer but is not sure that she will w a n t to keep D i c k through the winter. Visitor suggested that she come up and see D r . Eton when D i c k comes u p in a couple of weeks. [Syllabus reference:

KNOWLEDGE,

Psychology.]

1 1 . 1 4 . 2 2 — T e l e p h o n e d D r . Eton's secretary: D r . Eton can see D i c k 1 1 . 2 2 at 1 : 3 ο . 1 1 . 1 4 . 2 2 — T e l e p h o n e d Mrs. Baker, P . A . , re. visit to D i c k and also explained that D i c k needed clothing, asking Mrs. Baker to take care of this matter. Mrs. Baker promised to let visitor k n o w in the morning what could be done. L . to F . M . re. appointment with D r . Eton and clothing. H e a v y underclothes sent to D i c k . ι i . i 5 . 2 2 — P . A . , Mrs. Baker, telephoned: Would go out this morning and get a suit and pair of black shoes f o r D i c k . P . G m . would get a coat in the very near f u t u r e . 1 1 . 2 0 . 2 2 — M r s . Baker telephoned: Will come to the office Wednesday, N o v . 2 2 n d , at noon and take Richard out to buy him an overcoat. 1 1 . 2 1 . 2 2 — L . f r o m F . M . : Will be sure to have Dick at office on Wednesday. 1 1 . 2 2 . 2 2 — L . to D r . Eton reporting on Richard. ( F o r L . see file.) 1 1 . 2 3 . 2 2 — D i c k and F.M. in office: F.M. now reports that Dick's screaming fits have practically stopped entirely. She feels that there is a big improvement in the boy. Most difficult trait is his negativeness. When he heard that he was to see his A u n t Florence, he became quite u n r u l y and remarked several times that if F.M. did not w a n t to keep him he could go and live with P . A . , Mrs. Florence Baker; in f a c t , D i c k had been quite naughty after his aunt had been mentioned to him. H a d been less willing to t r y and, on the whole, less obedient. O n Saturday he had behaved so badly that he was sent to Coventry, as F . M . terms it. This means that all the members of the

286

RICHARD

HEATH

f a m i l y address D i c k very politely but not at all friendly. H e eats alone and goes to bed early. A f t e r going to bed on Saturday evening, D i c k tossed around and did not seem to be able to sleep. F . M . finally went to him and asked him just w h y he could not sleep. Dick replied that it was because he had been so n a u g h t y , and that F . M . had been unwilling to kiss him. F.M. then suggested that D i c k pray, kissed him good night and the boy immediately feel asleep. Last Sunday

during

church D i c k had made so much disturbance in the choir that he is not to be allowed to go this coming Sunday. H o w e v e r , has been told that if he behaves he m a y start again the following week. F.M. was very anxious to have D i c k have music lessons, as visitor suggested, and will find out f r o m the Episcopal nuns in Westover how much one lesson a week would cost. While F.M. was shopping visitor took D i c k to clinic. T h e boy seems to be much more mature in his conversation than f o r m e r l y . Used to talk m u c h like a child of 3 or 4, but now chatters along much as a boy of his own age. Is anxious to see his aunt, but kept repeating to visitor that he wanted to return to Mrs. Dolby. [Syllabus reference: KNOWLEDGE, Psychology

and

Psy-

chiatry.] D i c k to clinic: W t . 5 1 -4. Gained 2 1 / 4 lbs. since last visit to clinic. H e a r t , lungs and abdomen negative. N o discharge f r o m ear. Skin healthy, all right f o r placement. R e t u r n in about 3 months. A f t e r returning f r o m Clinic D i c k was taken to lunch and shopping by P . A . , Mrs. Baker, w h o has supplied shoes, stockings, suit, and overcoat. D i c k has a great deal of f a m i l y pride. H e seems to like to feel that he " b e l o n g s . " Once while with Mrs. Owen, foster mother having become rather impatient because P . A . had not brought some toys promised, remarked " O h , your aunt never brings you anything. She does not keep her promises." Dick became furious and shrieked and shouted that she was not to talk in that w a y about any of his family. [Syllabus reference: PHILOSOPHY, Kinship ties.]

RICHARD

HEATH

287

Later: D i c k taken to D r . Eton's neuropsychiatric clinic, C i t y Hospital. F.M. also met D r . Eton. ( N o t e : W h i l e visiting Mrs. C o o k , another C . C . S . foster mother, last week, she told visitor of a little experience she had with D i c k last spring. It seems that D i c k had been taken to visit by his F.M. to a neighbor's next door to this F.M. H e had come over to Mrs. C o o k ' s porch, yanked all the plants b y the leaves and t h r o w n them on the floor, breaking the petals, had teased and bullied the little children, hitting them and pounding them; in fact, Mrs. C o o k considered him a " c r a z y c h i l d . " ) 1 1 . 2 5 . 2 2 — P . A . , Mrs. Baker telephoned asking if D i c k could come and spend the week-end w i t h her the f o l l o w i n g week. Visitor explained that the child really was very m u c h better off not coming back and f o r t h to t o w n , and especially staying over night; that D i c k should continue the quiet u n e v e n t f u l existence that he is now having without any breaks for the present. Mrs. Baker was very willing to cooperate and visitor suggested that she visit D i c k and explained that Mrs. D o l b y would be very glad indeed to have her come out. P . A . reported that M. had been discharged f r o m the C i t y Hospital last September, and was at present w i t h her sister in Cincinnati (Miss H a m p t o n , S.S. Dept. of the Mental W a r d , C i t y Hosp. had promised to n o t i f y visitor in case M. should be discharged). M. and M . A . are very anxious to have D i c k and are writing to P . A . continually

about it. P . A . is, therefore,

exceedingly

anxious to have D i c k admitted to C o l b y A c a d e m y . Visitor f r a n k l y told P . A . that in our opinion C o l b y A c a d e m y would not at all be a suitable place for D i c k ; that the b o y needed much more careful individual attention than they would be able to give him there. Moreover, it would be very d o u b t f u l whether they would be able to accept a boy presenting such a problem as Dick's. H o w e v e r , promised to take up the matter with D r . Eton and get in touch w i t h P . A . [Syllabus reference: METHOD, Patient group management.] 1 1 . 2 5 . 2 2 — L . f r o m D r . E t o n : " T h i s boy is getting along very well. There is no change in his general appearance since last

288

RICHARD

HEATH

interview. He impressed me as being rather overactive, possibly normally so for a growing boy. States he has practically discontinued his masturbation habit. Social worker and Mrs. Dolby, who is taking care of him, report he is showing definite improvement, that his temper outbreaks and attacks of screaming have practically disappeared. He is not afraid of the dark and is responding to her careful habit training and supervision. We feel that the chances for adjustment in this case are very good. T o return in two months." D r . Eton's L. " I am very glad to enclose the above notes in the case of Richard Heath. We would like to examine him again in two months' time. I feel that the home in which he is placed is ideal, and that this case has received very good attention f r o m the beginning." [Syllabus reference: M E T H O D , Mental hygiene promotion.] 1 1 . 2 7 . 2 2 — L . to F.M. 12.4.22—Telephoned to D r . Eton: Was not able to reach him. 1 2 . 2 6 . 2 2 — F . M . in office in visitor's absence: Brought pictures of Dick in his choir robe. The leg condition is about the same. 1 2 . 2 7 . 2 2 — L . to F.M. explaining that visitor did not remember Dick having any leg condition and asking her to bring Dick to the clinic 1 2 . 2 9 . 2 2 . 1 . 2 . 2 3 — L . f r o m F.M. stating that she was not able to bring Dick last Friday but will bring him next Saturday. 1 . 4 . 2 3 — L . to F.M. asking her to bring Dick Saturday, Jan. 6th. 1 . 6 . 2 3 — F . M . and Dick in office: F.M. reports that Dick has complained of pains in his leg off and on, but that she feels it is probably due to a cold or slight rheumatic condition. Had purchased arctics f o r him but thinks they have not proven very successful as Dick, when he wore them, felt that he could get through snow and water up to his knees and be immune. However, P . A . had sent him some rubber boots. P.Gm. had sent him a lovely new coat and new blouses, and had written him some very nice letters. Dick no longer has his terrible screaming spells but he is very egotistical and thinks of prac-

RICHARD

HEATH

2 8 9

tically no one but himself. Is very inconsiderate, always pulls himself well to the fore and feels at liberty to interrupt any conversation at any time. Visitor explained that this was partly due to the fact that he had been so repressed and under so much restraint at the Lowell Institution. Suggested that, v e r y gradually, F.M. try to have him have a rest period during which time he is to play quietly by himself. F.M. thought that this would be very difficult as Dick is not at all keen about playing by himself but always wants the attention of someone else. He has been getting along very nicely in school. Teacher reported to F.M. that she had no fault to find with Dick, but of course he needed reprimanding, as any other child, but that she had other pupils in the classroom f a r more difficult to handle than Dick. He is to do some work in the third grade. F.M. brought in some papers and there was truly a remarkable improvement over the work and the blank papers and illegible scrawl that Dick handed the teacher in school last spring. [Syllabus

reference:

RESOURCES,

Relatives,

KNOWLEDGE,

Psychology and Psychiatry.] 1 . 6 . 2 3 — D i c k to clinic: H t . 49, wt. 51.8. A b o u t 7 % underwt. for ht. Skin healthy. Throat and teeth in good condition. Heart, lungs, and abdomen negative. General condition seems to be good. F.M. says he has pains in his legs, especially in damp weather. There is no tenderness and no pain at date of examination. Given sodium salicylate to be given three times a day in water if the pains continue. Report of condition to be sent in a month. 1 . 1 0 . 2 3 — D i c k to clinic; L. f r o m F.M.: Explained that Dick is in the third grade in some things but not in all. " T h e grave faults of what you knew about when he came to me are almost a thing of the past, but, of course, as is natural others are coming but less serious. We have a distinct understanding and he does not try to put anything over, but we do have some battles wherein the weapons are looks and silences." 1 . 1 1 . 2 3 — L . f r o m F.M.: Dick has not been well since his visit to town. Is in bed with a nasty cold.

29°

RICHARD

HEATH

ι . ι 1 . 2 3 — L . to F.M. suggesting that F . M . get a doctor in case she is worried about Dick's condition. i . 1 2 . 2 3 — L . to F.M. telling her of visitor's illness and postponing visit. 1 . 1 8 . 2 3 — D r . Eton: Visitor asked, in view of the f a c t that there were so many cases of measles in town, whether it would be all right to postpone Richard's visit, due at this time, until a later day. D r . Eton said it would be perfectly satisfactory to put it off a month or so. 1 . 2 2 . 2 3 — T e l e p h o n e d P . A . , Mrs. Baker: She had been out with her husband to see D i c k yesterday and delighted with Mrs. Dolby's home and with what she was doing f o r Richard. Visitor explained that D r . Eton did not think that C o l b y Academy would be a particularly good place f o r D i c k and P . A . said that they were so pleased with Richard's home and Mrs. Dolby's care that, under the circumstances, it seemed much better to let matters stand as they are—at least f o r the present. [Syllabus reference: METHOD, Patient group management. ] 2.5.23—Letters f r o m F.M., D i c k , and teacher: F . M . writes, " A very good atmosphere prevails and I think, another little v i c t o r y . " D i c k writes that he has been home the last two days at 3 : 4 5 and 5 : 1 5 . Is so glad that he is to remain with Mrs. D o l b y . V e r y well written letter. N o t e f r o m teacher to Mrs. D o l b y as follows: " I n regard to Richard. H e does his work well. H e might apply himself a little more diligently, but a child of his age does not see what they might do. A s f o r his behavior, I have no complaint. If he is disobedient, I correct him as I do the rest. We don't expect children to be p e r f e c t . " Re-examination slip to clinic. 2 . 6 . 2 3 — L . H . L . to F.M. re. T h u r s d a y appointment to clinic. 2 . 8 . 2 3 — F . M . and D i c k to office and clinic: F.M. had planned to go right on to Georgetown this afternoon. Dick to clinic: Report 51 lbs., 4 oz. Child looks rather badly. F.M. says he has been sick since last visit to the clinic. Has a grippe cold. The pains in his legs have been much better

RICHARD

HEATH

291

until last night when he complained. Tinct. of iodine was applied. N o swelling or tenderness. Has been examined in the clinic. Pain had disappeared. Child is slightly knock-kneed. Should see Dr. Love for this condition. His eyesight is apparently excellent. Somewhat deaf in his right ear. If this condition still exists when he returns f r o m his vacation, should return to the ear clinic. Throat and teeth in good condition. Child seems very nervous. A sodium salicylate to be given if necessary. So can syrup ferric iodide. 10 drops 3 times daily. Returning to office after having taken Dick to optician: T o have new lenses in gold frames. F.M. seems disturbed over the suggestion of D r . Reed's that it looked as if Dick were masturbating. F.M., who only a week ago reported that she regarded Dick as a perfectly normal little boy, now remarked that she felt sure that Dick was a very sick little boy, both mentally and physically. Visitor feels that much of this attitude was caused by F.M.'s worry and disappointment over D r . Reed's remark as to masturbation. Visitor asked F.M. not to take this too much to heart and just to see that Dick had many objective interests. Dick seemed rather pale and nervous. This may have been due partly to his recent illness, but visitor also felt that it was quite possible that F.M. had been forcing Dick too strenuously. There is no doubt that Dick has made wonderful improvement in his school work, as well as in deportment, but the punishment, and the strain of living up to the standards set for him, may have been too much for him. F.M. seemed to agree with visitor as to the possibilities of the situation, and seemed to be very glad to cooperate with visitor's plan to let down on Dick and to attempt just as little as possible, and try to get him into better physical condition while he is away on this trip. F.M. will n o t i f y visitor from time to time how Dick is getting along. D r . Reed telephones that it will be perfectly all right to wait with the various recommendations in her report until after Dick has returned from his vacation. [Syllabus reference: chiatry.]

KNOWLEDGE,

Psychology and

Psy-

292

RICHARD

HEATH

2 . 1 6 . 2 3 — L . f r o m F . M . : " D i c k is responding w o n d e r f u l l y . Good appetite, excellent condition and I think I have the little matter well in hand we spoke o f . H e is truly the happiest little boy you ever saw and had a delightful birthday p a r t y . " 2 . 2 8 . 2 3 — P . A . , Mrs. Baker, in office: In visitor's absence, saw supervisor. H a d letter f r o m C o l b y

A c a d e m y re. Richard,

whose name has been reached on the waiting list. Mrs. Baker convinced after conversation with visitor that f o r the present, at least, C o l b y was out of the question f o r the boy. T h a t he was in need of a type of individual care which he could not be given there. Mrs. Baker reported that P . G m . now was exceedingly anxious that the boy be admitted to C o l b y . Supervisor suggested that Mrs. Baker talk with D r . Eton and pass his decision on to P . G m . and U . Mrs. Baker said that M. is dying of cancer, is in Cincinnati with relatives. Doctor has stated that she may not live six months. [Syllabus reference:

METHOD,

management patient g r o u p . ]

Supervisor telephoned D r . Eton (Psychiatrist) explaining relatives' feelings about having Richard admitted to C o l b y . D r . Eton to look case through and give his decision as to advisability of admission to C o l b y . L . f r o m F.M. (in visitor's absence): F.M. feels that it is wiser to have Dick in town in temporary C . C . S . home during her visit to Rochester. Will bring him to the Society, T h u r s day, March ist. [Syllabus reference:

METHOD,

T e m p o r a r y placement.]

3 . 1 . 2 3 — P l a c e d with Mrs. M a r y Quarles, 9 7 1 W . 45th Street, Pittston. Temporary placement. 3 . 3 . 2 3 — T o clinic: R e p o r t — " W t . 52 lbs., has gained 1 2 oz. since last visit to clinic. Has had no more pains in his legs. Did not seem quite so deaf in his right ear today as when last examined. Condition otherwise f a i r l y g o o d . " 3 . 5 . 2 3 — D r . Love to whom D i c k was to have gone f o r treatment f o r his knees, was out of the city f o r 2 weeks. As this was the length of time over which Richard was to be away f r o m his F.M. and as his general condition seems to be O . K . , D r . Reed thought it would be all right to send him to the country.

RICHARD

HEATH

293

3 . j . 2 3 — A s no f u r t h e r medical treatment was necessary, D i c k was placed with Mrs. H a l l , Plainville, R . F . D . , N . J . , until F.M. returned f r o m Rochester. [Syllabus reference: METHOD, T e m p o r a r y placement.] L . to Supervisor: F . M . has been ill, but expects to go to Rochester in a f e w days. Address there 7 5 2 4 Lovett

Ave.

Would like medical report of D i c k . 3 . 6 . 2 3 — L . to F . M . re. medical report. 3 . 1 0 . 2 3 — L . f r o m F . M . : Will call visitor on her w a y home f r o m Rochester M o n d a y , March 1 2 t h . 3 . 1 2 . 2 3 — F . M . in office: H a d a very restful time in Rochester and is looking f o r w a r d to having D i c k come back to her. R e ported that they had had a very lovely time in Georgetown. Dick had seemed to enjoy every minute of it; had had a lot of tun with the other children, coasting, etc. F.M. had followed visitor's suggestion and made the entire trip just one f o r relaxation and vacation time f o r D i c k . H e had had one dancing lesson which he enjoyed immensely, and which F.M. had thought well to give him, to see if it would make the boy less clumsy on his feet. F . M . thinks it would be a good plan to have a f e w dancing lessons if this were possible. Has had several little talks with D i c k about masturbation. Dick has slept on a cot in her room and so she had a good opportunity to watch the child. Felt that he was masturbating and had questioned. Dick had at first denied it, but when F . M . spoke to him in a very casual w a y , D i c k had finally admitted that he did masturbate once in a while. F . M . asked if anyone had talked to him about it. D i c k replied that D r . Eton had mentioned it to him. F.M. told him that she was not exactly sure in what w a y masturbation might be h a r m f u l to him but she did know that it might keep him f r o m being a strong healthy boy. W o u l d like D r . Eton to have a talk with D i c k about this when he does see him next time. F . M . is going to sell her big house and build a little cottage; looking f o r w a r d to being able to give D i c k a good bit of time and thought. Is planning not to urge him on as much as she has been in his school w o r k ; agrees with visitor

294

RICHARD

HEATH

that D i c k was probably forced too much and it would be wise to let d o w n the bars a bit. Visitor feels that although F . M . shows a considerable amount of emotion and tension, these characteristics stand out more just at a time when F . M . is eager to go over the whole situation with visitor, and as an every day routine, the emotion is not at such a high tension. F.M. is v e r y , very f o n d of D i c k and is really doing a remarkably good job. [Syllabus reference:

KNOWLEDGE,

Psychology.]

3 . 1 5 . 2 3 — L . to Mrs. H a l l : Visitor expected to come f o r D i c k Tuesday, March 20. 3 . 1 9 . 2 3 — M r s . H a l l and D i c k at home: D i c k has kept the entire household in an uproar there since his arrival, w r a n g l i n g , disobedient, impudent, f a u l t - f i n d i n g .

fighting, Nothing

suited Richard. Mrs. Hall's cooking was f a r f r o m what he liked, the wall paper did not suit him, etc., etc. Fought continually with T e d Hess, the little ten-year-old boy staying with Mrs. Hall. A l w a y s blamed T e d

f o r everything that went

w r o n g , exceedingly boastful. Was quite adamant on the point that the story of the Three Wise Men had been concocted f o r his benefit alone; insisted that T e d knew nothing of it, nor did anyone else except himself. D i c k was in constant motion. H a d three shrieking spells because he could not get what he wanted. ( H o w e v e r , three shrieking spells in three weeks is a great improvement over the D i c k of a year ago with t w o or three shrieking spells a d a y . ) M r . and Mrs. H a l l had never seen such a b o y ; felt quite frazzled and f r a y e d b y Dick's visit. W h e n visitor took u p his behavior while visiting Mrs. H a l l , D i c k immediately launched f o r t h on a long excuse, blaming everything on everyone else. H o w e v e r , D i c k is looking f o r ward very much to getting back to Mrs. D o l b y ; had spoken of her a great deal to Mrs. H a l l and boasted of her abilities. [Syllabus reference:

KNOWLEDGE,

Psychology

and

Psy-

chiatry.] 3 . 1 9 . 2 3 — P l a c e d with Mrs. M u r r a y , 492 West Hope Street, Pittston, to stay until medical w o r k is completed.

RICHARD

HEATH

295

[Syllabus reference: METHOD, T e m p o r a r y placement.] 3.20.2 j — T e l e p h o n e d Mrs. Murray's niece: asking her to bring D i c k to clinic t o m o r r o w at half-past ten. 3 . 2 0 . 2 3 — T e l e p h o n e d D r . E t o n : For appointment

Wednes-

day, 3 P.M. L . to D r . E t o n : G i v i n g a short report on D i c k ' s behavior since last examination. Medical report slip sent to clinic: 3 . 2 1 . 2 3 — D i c k to clinic to see D r . L o v e : R e p o r t — " C h i l d is slightly k n o c k - k n e e d . T h e inner sides of heels and soles should be wedged about 1 / 8 " . " D r . Reed's R e p o r t : " C h i l d ' s condition as on last visit to clinic. N o need to attend ear clinic if he has no f u r t h e r trouble w i t h his ear." T o D r . Eton: See file f o r report. A s appointment was delayed, visitor took

Dick

t h r o u g h the Museum,

where he

showed great interest in all the industrial processes there pictured. A f t e r visitor explained the m a k i n g of maple syrup and cotton cloth, as shown in the glass cases, he repeated the stories of these products w i t h great accuracy and apparent understanding. H e spent some time feeding the sparrows on the grass in company w i t h the hospital gatekeeper and was f u l l of his new experiences w h e n he was called into D r . Eton's office. [Syllabus reference: METHOD, Mental hygiene promotion.] 3 . 2 3 . 2 3 — R e t u r n e d to Mrs. D o l b y , W i l m a r , N . J . : W h e n visitor called at Mrs. M u r r a y ' s to take D i c k back to Mrs. D o l b y ' s , Mrs. Murray recounted her difficulties w i t h D i c k . H e had been so impudent that she had had occasion to use a strap. Also he had had screaming spells and fits of temper. Richard was quiet and obedient w i t h visitor, but openly glad to leave Mrs. Murray's and wild w i t h delight at the prospect of going home. W h e n , f r o m the train windows, he admired a beautiful house near N o r t o n and visitor suggested that he get out and live there, he turned amazed, reproachful eyes on her and remarked, " N o , Sir, I w a n t to go home to m y mother."

2 9 6

RICHARD

H E A T H

He flung his arms about Mrs. Dolby, nearly crying with joy when he reached there, asking if he ever had to go away again. A f t e r Dick had gone upstairs she told how, shortly before he left, he patted her hands saying that though they weren't pretty hands, he liked them because he knew she loved him. "Other people had me," he explained, " b u t nobody ever loved me before." [ S y l l a b u s r e f e r e n c e : METHOD, R e t u r n p l a c e m e n t , EDGE,

Psychology,

PHILOSOPHY,

Parent-child

KNOWL-

relationship,

adoption.] 3 . 2 8 . 2 3 — L . to F.M. re. shoes. 3 . 2 8 . 2 3 — L . from F.M.: Dick seemed rather fagged out, but he is having a little holiday and is picking up wonderfully. F.M. has made arrangements for him to start music lessons beginning April 7th, from 2 t o 3 , a t $ i - 5 o a lesson. 4 . 1 1 . 2 3 — F . M . and Dick at home: Visitor arrived ten or f i f teen minutes before F.M. arrived from town. Dick came running up the road to meet visitor. Was anxious to show all the work he had done; had helped to make the path and had dug some dirt. Had a hen set on duck eggs. These were to be his hen and his ducks, and he was going to take entire care of them. Told visitor all about possibilities of F.M. selling the cow; remarked that neither Mrs. George Dolby, nor Mrs. Dolby's daughter, nor he wanted the cow to go. Dick felt that it should be kept for him until he grew up. There is no doubt that Dick now feels that he "belongs." Visitor saw no nervous twitchings nor tension in Dick. He seems to be quite well, although still quite thin. F.M. arrived. Had brought with her all sorts of good things for Dick, chops and meat to make beef tea. Remarked that the only thing she wanted to do at the moment was to bring Dick up physically, and she felt that he was getting along in every other way just as much as could be expected. Visitor was struck by the lack of tenseness and the decided atmosphere of relaxation. Felt for the first time the key note of the every day routine was evident. Dick came and went as he wished; ran on

RICHARD

HEATH

297

errands; played with the dog out in the sunshine. H e had evidently had quite a little difficulty with F.M.'s young daughter, Mrs. Geiger. Visitor was very much pleased with F.M.'s attitude in this situation. She really regarded them both as children and smoothed over the situation remarkably well. When D i c k returned f r o m his stay in town F.M. felt f o r the first time as though she really ought to keep D i c k forever. T h e boy seemed almost dazed and it was only after several days that F.M. could get him to tell w h a t was the matter. Remarked that he had been terribly worried f o r fear that he might not come back. Said that if he had not been allowed to return, he would just have died; that he k n e w that she wasn't really truly his mother, but she surely was his mother f o r she had done so much f o r him, and loved him so much. Dick has had rather a bad cold; he has not been going to school. F.M. has been giving him usually four or five eggs and almost two quarts of milk a day. Dick had had one music lesson. T h e man who is giving them, according to F . M . , is a very quiet, lovely soul, and F.M. feels he would be a w o n d e r f u l influence f o r D i c k . H o w e v e r , Dick is not at all keen about practicing. F.M. has told him that no one was going to force him to take music lessons or force him to practice, but if he didn't want to practice he would not be able to play. D i c k told visitor he would like to have another chance; really wanted to learn to play. H e has been earning some money helping round outside. F . M . said, of his own accord, he suggested supplying the children's altar with

flowers.

F.M. finds that D i c k is much more apt to work f o r something if it is f o r some goal outside himself, is not at all interested in working f o r anything f o r himself, but loves to do something f o r someone else. F . M . has not yet gotten the play shoes. She could not get the kind she wanted in town and asked that visitor buy shoes f o r D i c k and have the wedges put in here. [Syllabus

reference:

KNOWLEDGE,

Psychology,

PHILOS-

OPHY, A d o p t i o n . ]

4.20.23—Shoes purchased at Schwartz's: D r . Love's recommendation f o r 1 / 8 " wedges in the heel and sole to be carried out.

298

RICHARD

HEATH

4 . 2 0 . 2 3 — L . to F.M.: Re. shoes. j.2.23—Telephoned mental clinic, C i t y Hospital: For written report of D r . Eton's last examination. 5 . 5 . 2 3 — L . f r o m F.M.: Dick doing very fair with hismusic and likes it. Is improving in many ways. Telephoned P . A . at D r . Newton's office: Found that P . A . had left there. 5 . 2 3 . 2 3 — L . f r o m F.M. re. shoes: Dick is still going on with his music, but as one hour seemed too long a lesson, he is taking one-half hour twice a week and is doing very well. 6.6.23—L. to F.M. re. shoes and suit. 6 . 6 . 2 3 — P . G m . at Y . W . C . A . : A very stately, dignified woman with a prosperous and aristocratic air. P . G m . had been out to see Dick the past Sunday. Miss D r e w had also gone along. They felt that the change in the boy was simply marvelous, a tremendous improvement, not only physically but mentally. Is very grateful for what Mrs. D o l b y has done f o r the child. H a d only one criticism to make and that was she seemed to be too ambitious f o r him in the w a y of music. T h e y felt that he was pressed too much in this direction. Visitor explained that this matter had been talked over very carefully with F.M. and it had been decided that if D i c k , f o r any reason at all, seemed not to want to take lessons or practice, they would be dropped at once and there was to be no urging in the matter. F.M. had expressed herself as having decided to give Dick up at the end of the summer. P . G m . said that they had just heard again f r o m Colby Academy and they felt that this would be a good chance to have Dick admitted as his case was to come up in September. She will not be able to do anything f o r tjie boy and her son, who is entirely responsible f o r her, will also not be able to take him. His mother is now dead. P . G m . feels that it would be better to have D i c k in some institution where he could remain until he is of age. Visitor explained that this matter had been talked over very carefully with Mrs. Baker and D r . Eton had also been consulted last spring when the matter came up, and that neither D r . Eton nor the Society felt

RICHARD

HEATH

299

that it would be at all the wisest plan to have D i c k placed in any institution, and that while the boy had made remarkable progress, he was still f a r f r o m the road of stability and would need extremely c a r e f u l supervision f o r some time to come. When visitor did not seem to care f o r C o l b y , P . G m . suggested Episcopal H o m e and said that F . M . said that this would be a good solution of the problem. Visitor explained that when D i c k came in again to see D r . Eton that the whole matter would again be presented to him and it would be gone over very c a r e f u l l y with the Supervisor and then visitor would write P . G m . the outcome of this conference. [Syllabus reference:

AREA,

Death of

Mother,

METHOD,

Management patient g r o u p . ] 6 . 6 . 2 3 — I n visitor's absence Miss H o u g h t o n , social worker f o r C o l b y A c a d e m y , called in reference to Richard Heath. She would like to k n o w his present address also the school he attends. 6 . 8 . 2 3 — L . f r o m F . M . : Music lessons had been discontinued. F.M. anxious to see visitor the following week. 6.9.23—Miss H o u g h t o n , C o l b y A c a d e m y , in office: T h e visitor gave her a short history of the case and promised to take up the matter again with D r . Eton when Dick comes to see him the next time. Miss H o u g h t o n felt that there was not much chance f o r him to be accepted, but would go on with the investigation and get in touch with visitor later. 6 . 9 . 2 3 — L . to F . M . : Visitor to go a w a y f o r short vacation. 7 . 1 8 . 2 3 — R e p o r t f r o m supervisor of F.M.'s visit to office (in visitor's absence) : Going to visit relatives in Delmar, M a r y land, f o r several weeks. Will take D i c k with her. Wants playmate f o r D i c k in the fall. 7 . 1 8 . 2 3 — P o s t a l f r o m F . M . on w a y to Maryland. 7 . 1 9 . 2 3 — L . f r o m F . M . : D i c k and F . M . arrived in Maryland. Sunday, 3 P.M. D i c k developed a case of poison i v y , but has improved considerably. H a d quite surpassed F.M.'s expectations in conduct and there appeared to be a good deal of comradeship which seemed to be very satisfactory. T h e y have

3 ° °

RICHARD

HEATH

taken a three-room apartment and take dinners out. Dick greatly enjoys copying the little attentions shown by F.F. and the business affairs he sees him do. Dick seems very much at rest, and to have gained in poise and manner. [Syllabus reference: KNOWLEDGE, Psychology and Psychiatry.] 7 . 2 0 . 2 3 — L . to F.M. Box 408, Delmar, Maryland: 8 . 3 . 2 3 — L . from F.M.: Dick is in splendid condition, but teeth need attention. 8.8.23—L. to F.M.: Will try to find suitable playmate for Dick. Must wait until right child is available. 8 . 1 8 . 2 3 — L . from F.M.: T h e y have returned home. Dick is well. 8 . 2 2 . 2 3 — L . f r o m C o l b y Academy: Saying that P.A., Mrs. Baker, wishes to present Richard for examination early in September and asking f o r reports f r o m psychiatrist, etc. Telephoned mental clinic, C i t y Hospital: D r . Eton to see Richard Tuesday, August 28th. 8 . 2 3 . 2 3 — L . to F.M.: re. Tuesday, August 28th. L. to Miss Houghton, Colby Academy, promising report after coming visit to psychiatrist. 8 . 2 7 . 2 3 — L . f r o m P . G m . as follows: " I had a letter f r o m my daughter, Mrs. Baker, today telling me of a letter f r o m Colby Academy asking that Richard be presented f o r examination on Sept. 5th, so I am anxious to know what you have decided to do when Mrs. Dolby gives him up. I am powerless to do anything for him and think if he could be placed in Colby it would mean so much f o r his future unless the service has better prospects f o r him. Will you kindly let me know what you decide upon. I am very grateful for all you have done for him but really hope he can get in the Academy. Most gratef u l l y yours, (Signed) Louise H e a t h . " L. to F.M. 8.8.23—Richard to clinic: Report. H t . 50 1 / 4 ins. W t . 53-8. 1 0 % underwt. for H t . In good condition for circumcision. Eyesight and hearing apparently excellent. Child is not gain-

RICHARD

HEATH

3

0 1

ing in w t . , but general condition is much improved. Much less nervous and seems better balanced. Is getting 1 3 hours sleep every night, plenty of fresh air. T o return to clinic in three months. 8 . 2 8 . 2 3 — F . M . reports: She has made arrangements at Westover Hospital f o r D i c k ' s circumcision. Visiting district nurse will call f o r him in the morning to take him to hospital where he will remain f o r t w o days. Visitor gave Society's consent f o r operation. Telephoned P . A . , Mrs. Baker, asking her to telephone her consent to Supt. Westover Hospital. R i c h a r d to D r . E t o n : Visitor went over very c a r e f u l l y with D r . Eton the desire of the H e a t h f a m i l y to have Richard admitted to C o l b y A c a d e m y if possible; also, that the Society felt that this change w o u l d be very unwise. R i c h a r d had gotten into all sorts of trouble in his institutional life before and there is a good chance of his going all to pieces again in a similar environment. D i c k is a child w h o is v e r y dependent on personal contact. H e does not fit into a group. H e has been improving satisfactorily during the year that he had been with Mrs. D o l b y . A f t e r his first visit to the office, a f t e r his trip south, D i c k seemed better than ever before, much more quiet, more mature. D r . Eton to send written report to C . C . S . immediately. [Syllabus

reference: METHOD,

Management

of

patient

group (to 9 . 1 0 . 2 3 i n c l u s i v e ) . ] Mrs. Baker telephoned visitor explaining that D i c k was to see D r . E t o n this afternoon and that as soon as D r . Eton had sent a report, visitor would get in touch w i t h Mrs. Baker. F.M. and D i c k to lunch with visitor: F . M . reports that while D i c k enjoyed his trip to M a r y l a n d very m u c h , he was very homesick and was delighted when he got back home. H e behaved remarkably well. N o fits of temper, v e r y quiet and happy. F . M . feels that D i c k is getting along very well. She has very little trouble with him now. H e does quarrel with F.M.'s daughter who is now living in the house. A y o u n g woman of

3 °

2

RICHARD

HEATH

20 who, F.Μ. says, expects too much of Dick. However, Dick does not seem to mind the quarrels, is very forgiving and f o r getful and never bears resentment. He is extremely generous. Mr. Dolby is now at home: He is devoted to Dick and Dick to him. They spent most of the day together tramping around the countryside. Dick is a new boy. He is much gentler with animals than he was before. Dick is now earning his weekly allowance. Does little odd jobs around the farm. He buys his own play toys, earns his own church collection, and every week puts aside something for the poor box. In this w a y F.M. feels that Dick is being initiated into his responsibilities as a member of the community. He will resume his choir practice this next week. F.M. still thinks she should like to have a playmate for Dick as soon as a suitable boy can be found. Also after school is started will see what can be done for Dick to have half-hour music lessons a week. This is not only to help him along with his music, but to give him an outside contact. F.M. did buy necessary clothing. [Syllabus reference: K N O W L E D G E , Psychology and Psychiatry.] 8.29.23—Mrs. Baker telephoned: Visitor explained that D r . Eton will send written report. 8.29.23—L. from Mrs. Baker: Suggestion that circumcision be postponed until after examination for Colby Academy. 8 . 3 1 . 2 3 — L . from D r . Eton as follows: "Adjustment is proceeding rapidly according to report. Boy appears normal during interview. The question arises as to whether he had better be placed in Colby Academy or continue in his present satisfactory environment. Since his delinquencies developed in an institutional setting the latter was given as the best disposition and he is to continue in his present home. T o return to clinic in four months." Copy of report sent to Mr. Williams, Colby Academy, also copy to P.A., Mrs. Baker. Mr. Baker telephoned: Visitor read to him over telephone Dr. Eton's recommendations explaining that a copy of same

RICHARD

3 ° 3

HEATH

w o u l d be sent t o C o l b y A c a d e m y . M r . Baker had not as y e t been in t o u c h w i t h M r . W i l l i a m s o f C o l b y A c a d e m y . Visitor suggested that he telephone h i m immediately so that the f a m ily's v i e w p o i n t in the m a t t e r w o u l d be f u l l y represented. Later—Tel.

Mr.

W i l l i a m s ' office, C o l b y

Academy:

Mr.

Baker had just telephoned. T h e placing of R i c h a r d is u p t o the f a m i l y e n t i r e l y . T e l e p h o n e d Mrs. B a k e r : T h e visitor to w r i t e F.M. saying that some one w o u l d p r o b a b l y call f o r R i c h a r d September 5 th. M r . Baker w i l l get in t o u c h w i t h her and either he or Mrs. Baker will call f o r R i c h a r d that day. L . to F . M . re. above. 9 . 4 . 2 3 — L . t o F . M . : R i c h a r d b a c k f r o m the Hospital a f t e r operation f o r circumcision. E v e r y t h i n g w e n t along well. 9 . 7 . 2 3 — T e l e p h o n e d C o l b y A c a d e m y : R i c h a r d had not been presented f o r e x a m i n a t i o n September j t h . T e l e p h o n e d M r . B a k e r w h o seemed surprised that Mrs. Baker had not got in t o u c h w i t h visitor. Mrs. B. had come u p f r o m W i l d w o o d f o r the d a y and they decided that, as Mrs. D o l b y had decided t o keep R i c h a r d , t h e y had better leave him where he is. L. to F . M . i n f o r m i n g her o f this decision. 9 . 1 0 . 2 3 — L . f r o m F . M . e x p l a i n i n g that Mr. and Mrs. Baker had come o u t to see D i c k and take him to C o l b y A c a d e m y . W h e n F . M . explained that she was w i l l i n g to keep D i c k , they were more than delighted. D i c k seems m u c h better since his trip to the hospital. W h e n D i c k had heard that there was a possibility o f his g o i n g to C o l b y he had cried c o n t i n u o u s l y and was h a p p y t o k n o w that he was t o remain w i t h F . M . Mrs. Baker will p r o v i d e d his good suit, overcoat, and shoes f o r the c o m i n g w i n t e r . F . M . writes, " W h o k n o w s , perhaps, b u t that some day I m a y be able to definitely take h i m . " D i c k t o start school M o n d a y . [Syllabus r e f e r e n c e : PHILOSOPHY, A d o p t i o n . ] 1 0 . 3 . 2 3 — L . f r o m F . M . : D i c k has i m p r o v e d v e r y m u c h since his operation and is v e r y m u c h more regular in all things. H e

3 ° 4

RICHARD

HEATH

loves school and goes g l a d l y and seems to have opened his m i n d to t h i n g s more. W i t h o u t doubt he is u n f o l d i n g , b u t F . M . is not u r g i n g h i m on as he seems to use u p so q u i c k l y . She has gone b a c k t o g i v i n g h i m e g g n o g s and a little f o r c e d feeding. 1 0 . 4 . 2 3 — L . t o F . M . : A c k n o w l e d g m e n t of above. 1 0 . 1 1 . 2 3 — L . t o F . M . : V i s i t o r e x p e c t i n g to come o u t T h u r s d a y , O c t o b e r 18 th. 1 0 . 1 8 . 2 3 — F . M . and D i c k at H o m e : D i c k a t s c h o o l . F . M . took visitor f o r a drive f o r an hour or an hour and a half u n t i l school was over. A f t e r his c i r c u m c i s i o n , and after his w o r r y about possibly l e a v i n g Mrs. D o l b y a n d g o i n g to C o l b y A c a d e m y , D i c k had been quite nervous and piqued. F.M. had been f e e d i n g h i m u p on eggs a n d m i l k , and feels that he is i m p r o v i n g . H e n o w gives n o more trouble than an ordinary youngster. Does have c r y i n g spells b u t never shrieks and screams as he did before. F.M. feels that he is g e t t i n g more m a n l y and more independent. F . M . seems t o be g r o w i n g fonder and f o n d e r of D i c k right along, and spoke several times o f rather v a g u e hopes o f t a k i n g h i m f o r her o w n a f t e r P . G m . dies. T e a c h e r in school: T e a c h e r struck visitor as being a rather nervous w o m a n , quite s t r o n g f o r discipline, b u t w i t h some rather good ideas. W h e n D i c k first returned t o school this fall (just a f t e r his c i r c u m c i s i o n ) , he had been v e r y restless and rather difficult to m a n a g e . A t t e n t i o n had been poor. H o w e v e r , he has been i m p r o v i n g r i g h t along and is n o w doing m u c h better. She had f o u n d it necessary to use a stick the other day b u t she f e l t it w o u l d not be necessary again. Visitor pointed out that D i c k was rather a nervous child and should h a v e just as m u c h quiet and rest as possible in his school w o r k . T e a c h e r reported that he was d o i n g m e d i u m w o r k in the second grade. D i c k had rather a good color and seemed better than visitor expected t o find h i m a f t e r F.M.'s report. H e is devoted t o Mrs. D o l b y . F . M . says that D i c k ' s fear o f the dark has g r a d u a l l y been subsiding and w h i l e it returned e v e r y once in a while, still it is p r a c t i c a l l y gone. H e is intensely interested in his choir w o r k .

RICHARD

HEATH

3°5

ι ι . ι 5 . i 3 — L . f r o m F . M . re. expenses. Also D i c k was having trouble with a tooth and F.M. had a dentist there attend to it. D i c k is well and happy. 1 1 . 1 7 . 2 3 — F . M . telephoned re. mistake in expense slip. D i c k is having some trouble in school, nothing very bad, but just general misbehavior. Is doing well at home and is in good health. 1 1 . 1 7 . 2 3 — V i s i t o r spoke to bookkeeper re. expense account. This will be straightened out immediately. 1 1 . 2 1 . 2 3 — F . M . and D i c k at home: D i c k was at school when visitor first arrived. F . M . does feel that the difficulty the teacher has reported is nothing serious. H e is rather nervous and is apt to cause a commotion in the school room by not following the rules f o r quiet. Will stand up and ask a question without being given permission to speak, etc. F . M . does not feel that Dick's nervousness has increased to any appreciable degree because of his going to school. Is extremely anxious that D i c k continue to go to school if it does not seem to be too hard on him physically. A t present, feels that D i c k is really very well and strong. H e is g r o w i n g , eats well, and sleeps well. While he had almost entirely gotten over his fear of the dark, he still gets rather worked u p if he has to sleep any distance away f r o m the rest of the f a m i l y . F . M . feels that Dick has rather a coating of artificiality and insincerity, and it is necessary, therefore, to be v e r y blunt and outspoken with him in order to help him to get rid of these characteristics. H e is a very affectionate and loving child. Seems to have the regular Southern feeling about colored people, and had a fight with one of the little colored girls at school and had come home with a black eye. A s f a r as F . M . had been able to learn, D i c k had called the little girl " a dirty n i g g e r . " F . M . had had to insist that Dick go to school and come home alone, not playing with the little boys w h o live in the house nearby. There are three brothers; the t w o younger boys are rather nice boys, the older boy, however, of about 1 3 , with w h o m D i c k seems to have struck up rather a close comradeship, F . M . feels is s h i f t y and

306

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not to be trusted on sex matters. She had seen him the other night kissing and hugging a girl of ι 2. While Dick is very close to F.M., she still does not feel sure that he would be f r a n k and honest in talking about his friendship with this older boy if it were not all that it should be. Mr. Dolby is now at home and is extremely fond of Dick and F.M. feels that he is quite an asset in Dick's whole life, and they are very good pals. Mr. Dolby helps him with his lessons at home and has an easier attitude toward the boy. Dick came home just as visitor was getting ready to leave. Had good color, seemed very quiet and very happy, like any normal youngster of 10. Dick is not taking music lessons; proved too much of a strain along with his school work. However, he is continuing with his choir work and enjoys it immensely. [Syllabus reference: K N O W L E D G E , Psychology and Psychiatry.] 1 1 . 2 7 . 2 3 — L . from F.M.: School physician sent word that Dick had adenoids. Expected to bring him into town Saturday next. 11.28.23—Pajamas mailed Dick. 1 1 . 3 0 . 2 3 — L . to F.M.: asking her to bring Dick to clinic next Friday. Book Soul of a Child sent to F.M. 1 2 . i . 2 3 — F . M . and Dick to office: F.M. had not received visitor's letter and brought Dick down to meet Mr. Baker who was going to buy him his good winter clothes. Dick has had no further trouble at school particularly, but F.M. feels that he is very lonesome without any pals after school hours. She still feels that he cannot come home with the Foster boys. Of late, Dick has been sullen at times, a new phase for him. F.M. feels that this is due to the lack of playmates. Would like to have another boy in case a suitable one could be found. Thought she might be able to get one through the church in case the Society did not have a suitable boy. Not particularly anxious to have another child, but feels that it is practically imperative. Visitor promised to talk this over with Supervisor. [Syllabus reference:

KNOWLEDGE,

Psychology.]

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307

1 2 . ι . 2 3 — D i c k to Clinic: Report. H t . 56-8. Has gained three lbs. since last visit to clinic. School doctor requests adenoids be removed. Tonsils and adenoids were removed at Children's Hospital in March last year. D o not see the necessity of another operation so soon. Is not wearing his glasses. H a d better continue with these until oculist says they are no longer necessary. General condition is improved. F.M. reports that he is much less nervous. N o longer complains of discomfort in legs. Is getting plenty of sleep, fresh air, milk, and eggs. 1 2 . 7 . 2 3 — L . f r o m F . M . : P . A . had purchased a beautiful suit f o r D i c k . She and Mr. Baker are coming out f o r dinner on Sunday. D i c k is much interested in Christmas at present and so has not complained of lack of playmates. H e is doing f a i r l y well at school and seems fairly submissive to routine. [Syllabus reference: RESOURCES, Relatives.] 1 2 . 1 0 . 2 3 — L . f r o m M . A . , Hester R . Waters:

(well written)

asking f o r D i c k ' s address. Wishes to send him a Christmas present. 1 2 . 1 2 . 2 3 — L . to M . A . giving address and brief report on D i c k . L. to F.M. re. clothing. 1 2 . 1 8 . 2 3 — L . f r o m F.M. re. clothing. Dick had had a stomach upset, but was much better. Is so busy thinking of Christmas has not talked much of having a playmate, but F.M. feels that it is inevitable that this matter will have to be faced in the near future. 1 2 . 2 4 . 2 3 — L . f r o m F.M.: G i f t to Dick. Card to F.M. 1 . 2 . 2 4 — L . to F.M. 1 . 1 1 . 2 4 — L . f r o m F.M.: Dick had a very lovely Christmas. There had been some trouble with the Foster children, which had been settled without much disturbance and to F.M.'s complete satisfaction. Dick is now in very good health and is happy. 1 . 2 1 . 2 4 — L . f r o m F . M . : Dick is doing very well in school and at home. Has taken up music again. Interesting comment on Soul of a Child.

General friendly comment.

1 . 2 8 . 2 4 — L . to F.M.

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2.j.24—As it was pouring rain, was unable to get to Wilmar as planned. 2 . 1 3 . 2 3 — L . to F.M. making new appointment. 2.18.24—L. from F.M. asking to borrow Angelo Patri's Child Training. 2.21.24—F.M. and Dick at home: When visitor arrived, it was very evident by the tenseness of the atmosphere that trouble had been brewing. Dick had come home early from school in order to be there when visitor arrived. F.M. took visitor aside and told the following story: About ten days ago, Dick had forgotten his lunch and Mr. Dolby had taken it to the school for him later. While there, the teacher had told him that she felt that Mrs. Dolby should know something that had come to her attention a few days ago. It seems that the oldest Foster boy had taken a 14 year-old girl who is a mentally deficient pupil in the school, Marion Lockhart, up to a hut in the woods and had had relations with her. Dick had been taken along to witness the performance. The teacher did not think that Dick had had anything to do with it, but she had been much disturbed that he had been present and felt that F.M. should know. Upon getting this information, F.M. went immediately to Mr. Foster. F.M. feels that Mr. Foster is quite an honest, hardworking, well intentioned person, but that his wife is a weak, vacillating type of woman who has no control over her children. Mr. Foster evidently knows this, for he asked F.M. to have a talk with the boys. In this talk it developed that Dick also has had intercourse, or rather tried to have, with the same girl that day in the woods; that on two or three other occasions he had tried to have relations with two little girls who go to the same school. The next step was for F.M. to have a session with Dick. In her own terms, she had "put him through the Inquisition" and told him that unless he told the truth he could not remain with her. At first he had tried to slide out of it, but when he found that F.M. was in earnest, he "came across." He said that about a week before Christmas was the first time that there had been any misconduct along

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sex lines since he came to the D o l b y home. A t that time a 12 year-old girl had asked him to come w i t h her behind a tree. H e at first had not wanted to, but had finally agreed and had tried to have relations w i t h her, b u t had remarked that he could do nothing because he was too little. O n another occasion he had tried to have relations w i t h a little 1 ο year-old girl, and a f t e r this Marion L o c k h a r t had pulled him aside and asked him to have relations w i t h her. O n one occasion the Foster boy had taken him aside and had maltreated him. Outside of these occasions, there had been no other misconduct. N a t u r a l l y F.M. was pretty well worked up. She had taken the whole matter up w i t h the School Board and the 14 year-old mentally deficient girl had been expelled. F.M. f e l t that n o w , as never before, did D i c k need a playmate; feels that there would not be any danger of another child, probably older than D i c k , being contaminated b y him. D i d not approve visitor's suggestion that the y o u n g e r Foster boy be permitted to come over to play. It seems that he is quite a nice little youngster, in f a c t , F.M. says that she does not feel that any of the Foster boys are really bad, b u t they have no supervision. She, however, is not willing to do the supervising and does not want anyone there to play w i t h D i c k w h o is not directly under her control. Visitor felt that F.M. is a bit e x a g gerated on this point, b u t because of the tenseness, and the strong feeling F.M. has on this topic, little could be said at the time. F.M. feels that unless another little boy can be procured, she would not be able to keep D i c k ; does not feel that it is fair to D i c k . It is true that D i c k is very lonely a f t e r school hours. H e wanders around b y himself f r o m about half past three on. Moreover, F.M. feels that he will begin masturbating again after this sex upset, unless his mind is kept occupied and he has decided interests. F.M. wished D i c k to talk over the situation with visitor. H e had said that he w o u l d rather die, but w h e n visitor began to talk to him, he showed no hesitancy or disinclination to talk. T o l d practically the same story that he had told F.M. Says that he feels quite sure that it is never

310

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going to happen again. Probably because of visitor's quiet talk with D i c k , F.M. thought that D i c k had been " p u t t i n g it o v e r " on the visitor and got rather excited, saying that Dick had put on his "angel f a c e " in order to mislead visitor, etc., etc. H o w ever, after a while, the situation became less tense and there was a pretty good understanding between F.M., D i c k , and the visitor. Visitor told Dick in case he was tempted to get into trouble again that she hoped he would come directly to F.M. and talk to her about it. D i c k remarked, " W h a t if it happened first?"

Visitor replied, " W e l l , of course, tell Mrs. D o l b y then,

too," hoping that Dick would always feel that he could come and talk over these things with F.M. F . M . took very strong exception to this remark, and said that there was not going to be another time and that if there was, D i c k was going to leave immediately. Visitor felt this was to be regretted as probably, if another occasion does arise, D i c k will do his best to lie out of it and will not talk the situation over with F.M. [Syllabus reference: KNOWLEDGE, Psychology and

Psy-

chiatry.] 2 . 2 8 . 2 4 — L . f r o m F.M.: " T h e r e seems to be a clearer atmosphere since you came and I think some h e a d w a y . " F.M. would like to have a playmate f o r D i c k . 2.29.24—Clothing sent to D i c k . 3 . 2 4 . 2 4 — L . f r o m F.M.: C o m i n g to Pittston with Richard. 3 . 2 6 . 2 4 — F . M . and Dick to office and clinic: Dick was looking particularly well. F.M. had had him out of school now about two weeks. She has felt that this was absolutely necessary as shortly after visitor's visit, Dick had come home and said the oldest Foster boy had wanted to abuse him again. F . M . felt that Dick's mind was continually upset by the Foster boy and that the only thing to do was to give him a rest f r o m the whole situation. T h e Foster boy repeatedly asked him if he didn't wish Marion Lockhart (the 1 4 year-old mentally defective girl) would return. D i c k had a cold so F.M. was keeping him home on this pretext. Explained the situation to the teacher who was perfectly satisfied with the arrangement. T h e

RICHARD

HEATH

3

1 1

first week D i c k was very restless and irritable, but the last week he has been getting along splendidly. H e has been horseback riding, w o r k i n g the garden and having a w o n d e r f u l time. F.M.'s daughter has left now, but Mr. D o l b y has returned f r o m a short trip. D i c k is lonely at times, f o r instance, the other day had been given some marbles and had complained bitterly because he had no one to play with. H o w e v e r , Mr. Dolby had gone out and played with D i c k and he had cheered up immediately. Visitor went over very carefully w i t h F . M . the matter of a playmate f o r D i c k . Pointed out that it would be practically impossible to place a child there under the existing conditions at this time. F . M . seemed a bit disappointed but went on to say that she had planned to have the little boys f r o m the choir come over every Saturday afternoon f o r a music lesson and they could all have a good time. D i c k is looking f o r w a r d to this tremendously. H e now goes to choir practice every Wednesday afternoon. His aunt has been out to see him and has promised him a bicycle later on. Dick enjoys being out in the garden digging dirt, bringing home the cow, planting, etc. Visitor l e f t to F.M. the matter of how long D i c k was to be kept out of school. H e can have some little lessons at home to keep him f r o m getting down too far. [Syllabus reference:

KNOWLEDGE,

Psychology.]

3 . 2 6 . 2 4 — C l i n i c report: H t . 5 1 , wt. 50.—3'/^ lbs., or underwt. f o r ht. B o y is gaining nicely. Seems to be less nervous than at previous examination. H e a r t sounds normal. L u n g s negative. N o rales heard. Child's general condition excellent. T o continue with extra milk. 4 . 9 . 2 4 — L . f r o m F . M . : D i c k is being kept home a little longer simply to fill a mental need that F . M . feels important to efface mind pictures that were crowding in. 4 . 1 0 . 2 4 — L . to F . M . making an appointment to visit. 4 . 1 2 . 2 4 — F . M . and Dick at home: Mrs. Stecker, one of the Board of Directors, of the C . C . S . and also a friend of the Heath f a m i l y , accompanied visitor. D i c k was delighted to see her. H e has been getting along very well, although F . M . feels

3 ! 2

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that there is a constant consciousness of a lack of playmates. She is trying out the plan of having the boys come over on Saturday afternoons, ostensibly for choir practice but really for companionship for Dick. Dick enthusiastic. F.M. is planning to return him to school Monday as she feels that Dick is beginning to be a bit restless, and also that it is difficult for him to keep up with his school work unless he is constantly jacked up to it. It has been very difficult indeed to get him to write a letter to his M.A. to thank her for a raincoat. He is so careless and so lacking in concentration that attempt after attempt had to be made before a presentable letter had been written. The teacher in the school tells F.M. that the chief difficulty with Dick is his restlessness and his rather infantile way of behaving. It is impossible for him to understand that he cannot talk out whenever he pleases or get up and walk around. His whole attitude at school is that of a much younger boy, although he is making a fair progress in his work. (Mrs. Stecker told visitor that his lack of concentration was quite characteristic of the Heath family.) F.M. is making very splendid tie-ups with Dick's family. Mr. and Mrs. Baker come out periodically. Are planning to spend the week-end a couple of weeks from now. The M.A., Mrs. Hester Waters, since getting in touch with Dick at Christmas time, has written several letters and has sent a very lovely raincoat, rain hat and gum boots. F.M. appreciates the importance of holding these ties for Dick so that he shall have a well-rounded life and not have a feeling of isolation. Dick has developed a very genuine love of nature. He has learned to know the different wild flowers and loves to potter around in the garden. In the old days, when the dream pictures were necessary to calm Dick at night, F.M. often pictured to him the various spots on the farm, hoping in that way to give him a lovely picture of them all and to develop in him a real love for the places. For instance, the little duck pond has more than once been described to Dick with little fairies working around and playing with the ducks, etc. The result is that Dick does love every corner of the place.

RICHARD [Syllabus

reference:

H E A T H

RESOURCES,

Relatives,

3 1 3 PHILOSOPHY,

Kinship ties, KNOWLEDGE, Psychology.] 6.i 1 . 2 4 — F . M . and Dick at home: Dick in high disgrace. He had been sent in the morning to hunt for the horse that had wandered off during the night. F.M. was to take him to Westover to buy him new shoes and to make other purchases. In about an hour and a half one of the neighbors brought the horse back. Dick did not arrive until about two hours later after F.M. had left. He had asked, or had been offered, by one of the neighbors a horse to go horseback riding on to find the Dolby horse. He knew, however, that the Dolby horse had been returned and in spite of this remained away. H e had many excuses, that he had to go back slowly and had to wait for posies f o r F.M., etc., etc. He had also stopped to talk with the neighbor and had come up with a little toy pistol which had been given him. F.M. much disgusted and excited. In the first place, Dick had been very disobedient of late and has also been rather insolent and impudent. He has lost the friendship of Mr. Dolby and of Mrs. Dolby's son who were very good pals before. F.M. said that she does not feel that his shortcomings are so serious, but she feels that she has to exaggerate them to Dick to have them penetrate and to have him understand that he cannot go on flagrantly disobeying. P.A., Mrs. Baker, has rented the little bungalow on Mrs. Dolby's grounds. T h e y had been there about three weeks. Mrs. Dolby says that she has not had any trouble with Dick's behavior, however, because of their arrival, that they back her up on every point. Dick cannot be trusted to be sent on errands off the grounds because he remains a great length of time. He is lonely because he has no playmates. Visitor felt that F.M. was perhaps more distressed because of Dick's behavior today, she felt that he had told too much family news to the neighbor who is a noted gossip. A t any rate Dick was to go to " C o v e n t r y " for three days, meaning that he is to speak to no one and no one is to speak to him except when necessary, and he is to have only bread and water. Visitor felt that this was rather extreme, but as F.M. was

3 M

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much upset it seemed best not to question her decision at that time. The toy pistol that D i c k had gotten f r o m the neighbor he had very carefully hidden and explained to visitor that he intended to keep it hidden until F.M.'s " c r a n k y spell" was over. Visitor suggested that he play fair, giving it up entirely. A f t e r a f e w moments hesitation, Dick decided to go ahead. The pistol was taken away and there was an expression on Dick's face as if he rather regretted his hasty action. [Syllabus reference: KNOWLEDGE, Psychology and Psychiatry.] 6 . 1 2 . 2 4 — L . to F.M.: Requesting that she bring Dick to clinic for reexamination, and expressing concern over bread and water diet. 6 . 1 4 . 2 4 — L . f r o m F.M.: " T h e "Coventry* is very effective so f a r and I have high hopes it will have a lasting good effect. He shows a wholesome and open respect for authority and general good not brought out before, and with no semblance of f a w n ing or crawling out. This I consider a big victory and the culmination of many irritating incidents at school and at home. The only concession I made, so far, was milk instead of water." [Syllabus reference: KNOWLEDGE, Psychology and Psychiatry. ] 6 . 1 7 . 2 4 — F . M . and Dick to clinic and to office: " W t . 58-2. Boy had lost nearly 1 lb. since last visit. Looks well. Heart and lungs negative. Posture good. F.M. says has great difficulty in making him wear his glasses. General physical condition seems to be good; is much less nervous than at previous examination; better poised." Visitor went out with F.M. and Dick to lunch: F.M. had been much disturbed at visitor's letter regarding the bread and water. In fact, told visitor that she had cried when she had received it and she felt that visitor had no faith in her. Visitor explained exactly how she felt about it and the atmosphere cleared up. F.M. said that it had not been just Dick's conduct on that day, as she did not consider it particularly

RICHARD

HEATH

3

J

5

terrible that he had gone off on the neighbor's horse, but it had been just an accumulation of a week or ten days of disobedience and misbehavior. She had been v e r y upset and put out by having to wait f o r his return and then having to hurry to Westover, where she had f o u n d the stores were being closed. D i c k really only lost about t w o or three weeks last spring because of the trouble at school. H e is to be put into the third grade, although the teacher is not sure he can do third grade w o r k . H e still continues to get along v e r y nicely with his uncle and aunt w h o do everything they can to cooperate with F.M. D i c k was very pleased with himself f o r having taken his " C o v e n t r y " nicely. B y " C o v e n t r y " F.M. does not mean that D i c k does not speak to anyone. H e is allowed to speak to her and she talks to him, but he is not allowed to have pleasant conversations with anyone in the house. H e had, evidently, been much disturbed by the thought of the three days C o v e n try. The morning that it had started he had an upset stomach and F.M. felt that it was because he was dreading the next three days. H o w e v e r , she had a talk with him at that time and he cheered up and really had gotten along remarkably well. Friday afternoon they had played the piano and sung some songs, and the thing had ended up very nicely. F . M . felt that punishment had been very beneficial. [Syllabus

reference:

KNOWLEDGE,

Psychology

and

Psychiatry.] 7.8.24—F.M. and D i c k at home: W h e n D i c k arrived, F.M. had not yet returned f r o m Westover, and visitor spent quite a time with him. Dick played records, brought pictures, and played checkers with visitor. It was quite surprising to see how well Dick really played checkers. In spite of the f a c t that he made some foolish moves, he really did concentrate very well and kept his mind on what he was doing. H e told visitor that he was getting along very nicely. The only trouble he has is with his jobs. H e doesn't like jobs—except gardening; he is rather interested in planting, likes this better than anything else; does not particularly like weeding. ( O n former visit F.M. had

β

1

^

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HEATH

told visitor that Dick really did plant very well. It was done evenly and thoroughly,and it was the only thing in which Dick showed persistence.) F.M., however, had another story as to how things were going. Dick has become more and more insolent and overbearing. He has made himself very obnoxious to the other members of the family so that there is a constant tension. F.F. has become so irritated with him that he has felt that the only solution would be to have Dick have corporal punishment; feels that the boy is being ruined because of lack of this. F.M.'s son and daughter are also much irritated with Dick. The other day when F.M.'s son had been there to lunch, Dick asked whether his uncle, who was to spend the night with them could not sleep with him. When F.M. said this could not be, Dick remarked, " O h , well, that is because you want him to sleep with you." F.M., Mr. Dolby, and the son all felt that there was no question as to what Dick meant, that he meant to be just as insulting as he knew how to be. Visitor, however, was not quite so confident of this, felt that there might be a doubt as to whether Dick would be so outspoken in front of Mr. Dolby and the younger Mr. Dolby, and be blatant about insulting Mrs. Dolby. Dick had also begun being cruel to animals again. He will jostle them around and hurt them. F.M. has been suspicious about his behavior with a shepherd dog who was killed some time ago. Every once in a while when Dick was playing with him there would come a sharp cry of pain, but the dog would always run away when F.M. arrived on the scene, and she did not feel that she wanted to go into it too deeply with Dick, and suggest something to him which he had not in his mind at all. There has been a young female dog around the place who is expecting puppies in a short time. The other day the family had heard horrible cries of pain from this little dog and went out to find it writhing in agony and not able to move for twenty minutes. Dick had thrown a big stone at her. He explained that he had just done it to get her off the place, but F.M. thought Dick had coaxed the dog to him and then

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deliberately stoned it. P.A., Mrs. Baker, later in speaking to visitor about this incident said that she did not agree that Dick had deliberately called the dog to him, that he had seen the other members of the family chasing the dog away with stones and had been thoughtless in using a big stone and had not meant to hurt the dog. When Dick spoke to visitor about how the collie dog was run over, visitor was rather struck by the lack of any sympathy or pity for the animal. F.M. had seen no evidences of any sex trouble since the outbreak last spring. Strange enough, in spite of the fact that she talked to her own children at a very early age, read to them, and explained things to them, F.M. does not feel that she should go into sex matters with Dick. Says that she feels that he has such a penetrating persistence that he would keep after her and after her with such minute questioning that it would be impossible to handle the situation. She had never given him any real sex instructions. At the end of the outbreak last spring she very carefully told him certain phases, for instance, explained to him about disease, etc., but at the time her own daughter was having a baby and was living at home she was careful never to mention it to him and told him some kind of a story about their getting a baby from the hospital in time for Christmas. F.M. told visitor that not so long ago when her daughter was there with her baby, the baby had been left on the dressing table for a moment by itself. Her daughter was out of the room and as F.M. came in she found Dick handling the baby's penis. He had looked up and simply said, that he was simply fixing a safety pin. F.M. had not made any remark at all, but had just let the situation pass. With F.M., visitor tried to get at the bottom of Dick's insolence and egotism at this time. Suggested that it might be a defense because of the general atmosphere of disapprobation around him. F.M. does not feel that this is the case, feels that this is just the egotism of a very early adolescence coming to the top and it is not due to any specific condition there. H o w -

3

1

8

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ever, did agree with visitor that it was rather a vicious circle—Dick's upsetting the family and they, in turn, sitting in judgment on him. The last few weeks at school Dick had been a great trial to the teacher; said she could not put her finger on any one difficulty, but there was just a general insubordination. He is to be placed in the third grade but is really not quite ready for that work. F.M. feels very definitely that Dick must leave. At first, she seemed to think that it must be for some length of time, if not for good, and that Dick must realize that he is losing his home because of his conduct. However, after talking for a while, F.M. shortened the time, bit by bit, and finally came down to an absence of about four to six weeks, and agreed that Dick should not be told that this was a final departure, but that he did have a chance of coming back if he would learn to behave himself a bit better. F.M. is expecting a friend with three boys to spend several weeks with her. While she feels it would be lovely to have companionship with these boys, she fears very much that there would be an outbreak if Dick should become insolent to her in their presence. Mr. Dolby would resent this and rather than have him whip Dick, she would bring him to town immediately. She feels herself that it is now time to have a bit of corporal punishment, that talking and moral suasion and looking at him through rose-colored glasses have played their part, and that some change must now be made as they have outlived their usefulness. Visitor spoke to Dick telling him that he would have to go away for a while, but it all depended on him as to when, and whether, he could come back to Mrs. Dolby. Dick's good-bye to visitor was, "Don't you bother about finding another place for me, it won't be at all necessary. I am quite well fixed here, so don't worry and don't go to any extra work hunting another home." Visitor promised F.M. to make some plans for Dick immediately. [Syllabus reference: KNOWLEDGE, Psychology and Psychiatry, PHILOSOPHY, Adoption, PHILOSOPHY, Parentchild relationship.]

RICHARD

HEATH

3

1

9

7 . 9 . 2 4 — C o n f e r e n c e : It was decided to t r y to find a camp f o r D i c k . It would probably be a very good thing f o r him to have a certain routine life, discipline, and an opportunity f o r companionship in a group. D i c k not to be allowed to feel that this was a reward f o r his bad behavior, but that he needed a decided discipline and routine, and these things could be had better in a camp than in a good many other places. H a v e D r . Eton give him some rather definite sex instructions before going to camp. [Syllabus reference:

METHOD,

Management patient group.]

7 . 1 1 . 2 4 — T e l e p h o n e d Y . M . C . A . re. camps. T h e y will send prospectus. Telephoned Miss Morris, special foster mother used f o r temporary care of children; she will be ready to take D i c k temporarily while in town. D i c k spent several days with her about a year and a half ago. L. to R e v . B. W . Sherman w h o has a camp at Sandy Beach, N.J. L . to F . M . asking her to bring D i c k to t o w n , 7 . 1 5 . 2 4 . 7 . 1 2 . 2 4 — L . f r o m F . M . : " A f t e r you l e f t D i c k seemed to fall into a pathetic stage and seemed off feed and low spirited. I then told him that as soon as he had learned to be obedient he could come back home ( f o r indeed, I could not see the child so crushed. It hurt me so.) H e has shown a better and more ready attentiveness since and is looking f o r the boys to come. I'll write again t o m o r r o w . " Friday, 3 P.M.: " H a s had a very nice and healthy time with the boys and they seem to fill a need in him. H e has also gotten a good dose of i v y poison, but all in all conditions are 9 0 % better and much healthier all around. T h e boys are just what he needs and I am tempted to say if he returns a f t e r being away, that a companion will be a necessity. W o u l d like you to see the difference in his general atmosphere f r o m a personal point of v i e w . " [Syllabus reference: ship.]

PHILOSOPHY,

Parent-child

relation-

320

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HEATH

7 . 1 2 . 2 4 — L . f r o m Mr. Sherman re. C a m p A l g o n q u i n at Sandy Beach. G i v i n g rates. Could make room for D i c k . L. to Mr. Sherman making appointment to visit c a m p and tell him about D i c k . 7.1 j . 2 4 — F . M . and D i c k in office late in the afternoon: Seen in visitor's absence. F.M. was quite w r o u g h t up, in tears, and very tense, and emotional. She talked quite a good bit of how she felt about " C o s m i c " forces present in people's lives and what part they play in her o w n relationship to D i c k . She told again the story of the strange way in which D i c k came to her. (She had already told visitor this about a month ago.) Says that she answered the ad. for a child for a friend of hers, giving her own name. She was seen b y someone of the Society. A t that time the child was not placed, and later, out of the clear sky, someone called up and asked her if she w o u l d take a little boy. Then later, when D i c k arrived, she had come upon him alone and he had said, " I have come to stay, y o u are m y m o t h e r . " T h e fact is, that in going over the foster-home record, this home went through the regular routine investigation. Mrs. D o l b y had answered the ad. T h e n later when a c o u n t r y home was wanted for D i c k visitor got in touch w i t h Mrs. D o l b y to see if she would consider taking him. F.M., however, does not seem at all clear as to how Society came to ask her to take D i c k when she felt sure that she had made it clear that she was only answering the advertisement for a friend. D i c k is now sleeping on an open-air porch, with F.M. at one end and he at the other. D u r i n g the night she has heard him patter over to her. H e had asked her if he could lie b y her and put his head on her pillow. She has always felt that D i c k is apt to hang on to her and want to fondle her and she has tried to discourage him in this. Last night she had told him that if he wanted to show his love for her the best thing he could do is to stand with "head b o w e d . " Visitor, however, feels that while F.M. does get on pretty high emotional gear w i t h D i c k at times, that her attitude as to his f o n d l i n g her, etc. is usually one of every-day directness. She will tell him to clear out and

RICHARD

HEATH

3

2 1

n o t h a n g o n h e r — s h e is m u c h too hot. T h e standing w i t h b o w e d head is p r o b a b l y o n l y used o n v e r y exceptional o c c a sions. W h e n F . M . bade D i c k g o o d - b y e they were both in tears. F . M . was p r e t t y well w o r k e d u p a n d tired o u t because they had missed t w o trains. She had to h u r r y off and meet another a p p o i n t m e n t . A s soon as F . M . had l e f t and D i c k had been told o f the prospects o f his g o i n g to c a m p , the tears disappeared; D i c k was j u b i l a n t a n d seemed to f o r g e t all trouble. D i c k has been h a v i n g a w o n d e r f u l time w i t h the three boys w h o are visiting Mrs. D o l b y at this time. H e is like a changed child. F.M. feels that a great part o f the difficulty w i t h D i c k w i l l be cleared a w a y if he can h a v e a suitable p l a y m a t e w h e n he returns in the fall. [Syllabus

reference:

KNOWLEDGE,

Psychology

and

Psychiatry.] 7 . 1 5 . 2 4 — D i c k placed w i t h Miss Morris, 4728 E l m Street, rate of board, $ I . J O a d a y . 7.17.24—Rev.

B.

W.

Sherman,

Camp

Algonquin,

Sandy

Beach, N . J.: T h e A l g o n q u i n C a m p is a v e r y small one. T h e y have about f o u r or five tents on a v e r y r o u g h , dark road, and between t w e n t y and t h i r t y - f i v e boys; f o u r counselors, three of them boys b e t w e e n seventeen and eighteen and one in his early twenties; and a y o u n g Italian c h e f . Visitor was p a r t i c u larly taken b y the nice class o f boys. T h e c a m p was originally started f o r M r . Sherman's o w n choir boys, and later f o r other choir boys; then, g r a d u a l l y , f o r boys outside. T h e c a m p has been in existence f o r the last f o u r years. M r . Sherman likes t o k n o w something personal about each youngster that comes and, for the most p a r t , is able to do this. Some, h o w e v e r , w h o come f r o m a distance, he does not k n o w m u c h about. H e had had a great deal o f experience w i t h boys, as he used t o be head of St. M a t h e w ' s School f o r Boys in Pittston some years ago. Mr. Sherman said that, w h i l e the counselors were v e r y y o u n g , they were v e r y dependable, fine boys. Visitor met three o f them and liked them v e r y well. T h e older one, D r . Sherman's ward, takes a good deal o f responsibility. T h e c a m p is situated

322

RICHARD

HEATH

just at the Inlet so that the boys have surf bathing on one side and fishing and crabbing on the other. They go in bathing twice a day. The smaller boys have an hour's rest after dinner. Most of the boys are between ten and twelve years of age. Visitor went over very carefully with Mr. Sherman Dick's story, of the recent flare-up at the district school and Dick's part in it. He was perfectly willing to have Dick come and was especially interested in him because he was a choir boy. They had not had any sex trouble in the camp this year, except possibly one questionable case of masturbation. The younger boys are closely supervised in their sports. Visitor may bring Dick any day next week. [Syllabus reference: M E T H O D , Temporary placement. R E S O U R C E S , Camp.] 7 . 1 7 . 2 4 — F . M . telephoned about extra clothing for Dick. Permission given to purchase necessary clothing. 7 . 2 1 . 2 4 — L . to Dr. Eton summarizing events since last examination and requesting appointment. Telephoned City Hospital, Mental Clinic asking f o r D r . Eton's report on Dick. 7 . 2 3 . 2 4 — L . to Mrs. Dolby telling her of Camp Algonquin. 7 . 2 5 . 2 4 — L . from Mrs. Dolby asking about Dick. Says she has felt quite lost and frequently when she is doing something interesting she finds herself almost calling to him. [Syllabus reference: P H I L O S O P H Y , Parent-child relationship.] Dick to clinic and to dentist: Dentist finished. Child has small amount of brown stain on lower teeth. If he uses plenty of salt and scrubs teeth daily this would easily come off. Weight 58 lbs. There is very little change in physical condition since last note. Boy is still quite nervous. Tends to bite his finger nails and to be rather twitchey in hands and arms. He impresses the examiner as quite precocious. Is rather an attractive boy but is somewhat spoiled by knowledge of this fact himself. Posture fairly good; teeth in good condition. N o evidences of adenoids at present time. Heart and lungs nega-

RICHARD

HEATH

t i v e ; expansion of chest poor—only

323

l

i / 4 inches; abdomen

s o f t . L i v e r and spleen not palpable. H a d been circumcized. N o physical evidence of masturbation. Knee jerks rather exaggerated on both sides. N o ankle clonus. Pupillary reactions to light are normal. Apparently the boy's home hygiene is good. H e gets plenty of sleep, and meals seem to be regular and of sufficiently good character. H e gets probably a little too much meat. Once a day f o r this would be plenty f o r summer time. 7.2j.24—Discussed

at

case

conference

with

psychiatrist,

pediatrician, and staff: A t t e m p t to be made to overcome F.M.'s revulsion toward sex matters. A s her attitude is not rational but emotional she probably communicates to D i c k a belief that abhorence is the correct reaction toward sex feelings and this probably causes repression, sense of guilt, and lack of frankness. F.M. to be given C i t y Hospital pamphlets on sex instruction to read. Religious feeling probably not u n duly prominent. [Syllabus

reference:

KNOWLEDGE,

Psychology

and

Psychiatry.] Later—Telephoned

Miss Morris, who will purchase the

necessary things f o r Dick's camping trip. 7.26.24—Report

f r o m Mental Clinic, C i t y Hospital:

"As

you k n o w , Richard was interviewed by D r . Eton on 7.22.24. H e felt that there had been a definite improvement. He no longer has any difficulty with enuresis and his fits of temper have decreased. Masturbation

has practically

ceased.

The

patient stated that he had been getting along very well until another boy begged him to do things that were not proper. Following this had a sex experience and has worried about this. The more he thinks about these things the more restless he becomes. H e stated that the boys were very mean to him, that they told lies about him and told lies to him, threw his hat down the toilet and everything. The patient talked f r a n k l y concerning his difficulties and the examiner attempted to clear up many of his sex ideas. However, this reeducation is incom-

324

RICHARD

HEATH

plete and should be c a r e f u l l y followed up. It would seem that sending this boy to Sandy Beach would be of mutual benefit to the child and his foster parents, as it will take him out of the tense atmosphere of the home. T h e progress on this case makes one feel that ultimate adjustment of the child will be obtained. W e certainly would like to see patient in the clinic in six weeks

_•

»J

time. [Syllabus reference: METHOD, Mental hygiene promotion.] L. f r o m Mrs. D o l b y : Choir boys are planning a picnic at beach near Sandy Beach. W a n t to see D i c k while they are down there. 7 . 2 6 . 2 4 — L . to Mrs. D o l b y : G i v i n g directions for reaching Algonquin C a m p . Telephoned Miss Morris: A s k i n g her to have D i c k ready tomorrow morning at 9 o'clock. Miss M . has gotten the necessary clothing, blankets, etc. 7 . 2 9 . 2 4 — R i c h a r d to Clinic and to C a m p Algonquin, Sandy Beach, N . J . [Syllabus reference: METHOD, T e m p o r a r y placement.] Report: W t . 58^4. H a s gained almost a pound since last visit to clinic. T h r o a t and teeth in good condition. Heart and lungs negative. Skin healthy. A l l right f o r camp. Dick most delighted at the thought of going to camp. Miss Morris w i t h w h o m he had been staying about two weeks, said he had been a very good little boy. O n the w a y down, he talked incessantly. O n the trolley going to Sandy Beach, D i c k sat some seats a w a y f r o m visitor. H e carried on a lively conversation with t w o ladies w h o were openly admiring him tremendously, patting him under the chin, telling him that he was an a w f u l l y cute boy, and calling to visitor that they thought he was such an interesting child. D i c k actually preened. A f t e r these women l e f t D i c k moved over to visitor and said, " A m I not a f r i e n d l y little boy? See how easily I make friends. I don't quarrel with people I meet, e t c . , " in a loud voice and looking around to see if the people were listening to him. H e was p l a y ing to the gallery f o r all he was worth. J u m p e d u p and down

RICHARD

HEATH

3

2

5

and clapped his hands when he saw the ocean and q u i c k l y looked around to see if someone had watched him. H e really behaved like a much younger child during the whole trip. H e seemed much delighted w i t h the camp. Immediately got into his c a m p clothes, but still t r y i n g to take the center of the stage and see how much attention he could attract to himself. [Syllabus

reference:

KNOWLEDGE,

Psychology

and

Psychiatry.] 8 . 1 . 2 4 — L . f r o m M r . Sherman: T h a n k i n g f o r check. It will be perfectly all right to have the board paid at the end of the month. D i c k is getting along O . K . C a m p life, with its necessary discipline, seems to have a wholesome effect on him. 8 . 1 9 . 2 4 — L . to F . M . reporting above. 8 . 2 6 . 2 4 — F . M . at home: Mrs. D o l b y had not heard anything f r o m D i c k and had not written, feeling that possibly we did not w a n t her to f o r fear of making D i c k homesick. A t present her daughter and little baby are living with her. Mrs. D o l b y seemed to be perfectly willing to have D i c k return. Later she took a negative position as she always feels that, through cosmic forces, that which is to be is; that if it seemed wise f o r D i c k to return to her she would be glad to have him. She would feel, however, very strongly that it could not be v e r y necessary that someone be f o u n d . F . M . is going to visit in Morrisville, N . J . the first part of September. It was arranged that she would call f o r D i c k at Sandy Beach between the first and the tenth, n o t i f y i n g Mr. Sherman a day or so in advance. Dick is to start school when he comes back to W i l m a r and, just as soon as visitor returns f r o m vacation, every effort is to be made to see if a suitable playmate can be f o u n d f o r him. [Syllabus

reference:

KNOWLEDGE,

Psychology

and

Psychiatry.] 8 . 2 9 . 2 4 — L . f r o m R e v . Sherman: " R i c h a r d is getting along all right and shows real improvement. H e was quite a problem at first as to conduct. Seemed to be in trouble with the boys all the time. H o w e v e r , all is peaceful now and he is h a p p y . " 9 . 2 . 2 4 — L . to Mr. Sherman: Telling him F . M . would call f o r Dick.

326

RICHARD

HEATH

9 . 1 2 . 2 4 — F r o m R e v . S h e r m a n : D i c k is still at c a m p but he is expecting Mrs. D o l b y to call f o r him 9 . 1 4 . 2 4 . O n the whole D i c k has done well and has shown i m p r o v e m e n t . H e is only a little more difficult than the average boy. H e needs strict discipline, w i t h a touch of the masculine, along w i t h plenty of o u t door w o r k and p l a y . [Syllabus

reference:

KNOWLEDGE,

Psychology

and

Psychiatry.] L . f r o m F . M . , Mrs. D o l b y : O n recent visit to D i c k ' s c a m p f o u n d h i m in v e r y good hands; liked M r . Sherman and the c a m p v e r y m u c h ; is expecting to take D i c k f o r a visit to a relative of hers in whose f a m i l y there are several boys of D i c k ' s age. L . to M r . Sherman a c k n o w l e d g i n g his report on D i c k . L . to F . M . consenting to D i c k ' s visit to her relatives. 1 0 . 9 . 2 4 — L . f r o m R e v . S h e r m a n f o r w a r d i n g D i c k ' s glasses w h i c h he l e f t at c a m p . D i c k l e f t c a m p S u n d a y , Sept. 1 4 t h . M r . Sherman said that while D i c k was a problem, he would be glad to t r y him in his o w n home, in case he needed a new home, and keep him in c a m p f o r the summer. 1 0 . 1 0 . 2 4 — L . to M r . Sherman a c k n o w l e d g i n g photographs. 1 0 . 1 4 . 2 4 — L . to F . M . m a k i n g appointment f o r visit. 1 0 . 1 4 . 2 4 — L . f r o m F . M . : T h e r e are good reports f r o m D i c k ' s school w o r k . H e n o w weighs 62 lbs. and has a f a i r appetite. F . M . feels that there is no d o u b t that the c a m p life was beneficial. 1 0 . 2 4 . 2 4 — F . M . and D i c k at home: Practically only good reports of D i c k . F . M . had gone d o w n the first of September to visit D i c k at camp. She was delighted w i t h the c a m p and feels that it has done a great deal to help D i c k . A t that time she had told D i c k she w o u l d return f o r him in t w o weeks. T w o weeks later w h e n she returned several friends w e n t d o w n in the car with her. A s they were nearing the c a m p , b u t were still m a n y blocks a w a y , they spied a little figure standing p e r f e c t l y motionless on the top of the sand dunes. A s they came nearer they saw it was D i c k standing w i t h his arms folded and staring out

RICHARD

HEATH

3

2

7

over the road. E v e r y o n e in the car was much affected, and as they drew up, D i c k threw himself into F.M.'s arms and said in such a w e a r y little voice, " M o t h e r , I thought you would never come, I have been waiting here since the sun came up, I only w e n t f o r b r e a k f a s t . " It was then 1 2 o'clock. F . M . told this story w i t h tears in her eyes and it is evident that D i c k is sealed f o r e v e r tightly in F.M.'s heart. A miracle has happened! A f a m i l y w i t h m a n y children have moved right near the D o l b y ' s and D i c k now has plenty of playmates. H e goes to school with them and comes back with them and they are o f t e n over in the evening to play games with him. H e is getting along f a i r l y well in school, he is now in the third grade and is doing average w o r k ; in f a c t is doing better in his school w o r k than before. A t home he has certain chores that he does, when reminded of them, and does well. H e takes the cow and horses out to pasture and feeds the chickens. H e is getting an allowance every w e k . If he is late coming home f r o m school, he is " d o c k e d , " but can make it u p again if he does an extra little chore. H e is saving some of his money, giving some in the church collection, and spending a small margin. A t home D i c k has been behaving averagely well. H e is anxious to start taking music lessons again, and, just as soon as F.M. feels that it might be a good thing f o r him to start, she will see that he goes to a teacher in town. H e is sleeping very well and has a good appetite. Mr. Sherman had told F.M. that he felt that D i c k ' s chief difficulty at camp had been his desire to dominate over the other boys and to insist upon the center of the stage f o r himself with adults. T h e camp life and discipline and his daily knocks w i t h the boys had done much to help him in these difficulties. The P . A . , Mrs. Baker, w h o is still living in the little cottage on the D o l b y grounds, is planning to go South f o r the winter. Mrs. D o l b y has not been allowing D i c k to go over there too often, as there has been just a little taint of criticism f r o m P . A . regarding Dick's clothes, and F . M . does not think it well to have too much of this. D i c k seemed to have f a i r l y good

328

RICHARD

HEATH

color, but rather thin. P . A . , Mrs. Baker, will get Dick's overcoat f o r him at Christmas. F . M . asked visitor to buy blouses, school pants, shoes, and underclothing. Mrs. Baker rode on the train with visitor f o r a f e w stations. Visitor felt that there was a subtle, underlying criticism in Mrs. Baker's attitude. T h e y had been delighted with the camp. She said that D i c k had never looked so well as when he first came home, but now that she noticed that he had gone down a bit. She also was evidently not altogether pleased with the f a c t that F.M. does not w a n t to have D i c k dressed better f o r school. Visitor pointed out that Mrs. D o l b y felt that, as long as D i c k was w a r m l y and neatly dressed, it was much better than if he dressed better than the other children at school, that this would only tend to make him conspicuous and to add to his egotism. D i c k was really p e r f e c t l y well dressed f o r school. T h e Mackinaw was a bit short in the arms, but it was still in good condition and there was no earthly reason w h y he should not be using it f o r everyday wear. W h e n Mrs. Baker saw that visitor was not particularly anxious to criticize F.M., she dropped the subject very c a r e f u l l y and talked of other things. Visitor feels that it is just as well that P . A . is leaving f o r the winter. [Syllabus

reference:

KNOWLEDGE,

Psychology

and

Psychiatry, RESOURCES, Relatives, PHILOSOPHY, Parent-child relationship.] 1 0 . 2 7 . 2 4 — C o r d u r o y trousers, three blouses, shoes, and underwear sent to D i c k . 1 1 . 5 . 2 4 — L . f r o m F . M . acknowledging clothing. 1 1 . 2 1 . 2 4 — L . f r o m F.M. enclosing D i c k ' s report f o r October: 3rd G r a d e Reading

90

Language and G r a m m a r

90

Spelling

90

Arithmetic

95

Writing

95

Geography

85

Punctuality

99

Application

95

Conduct—Medium

RICHARD

HEATH

329

1 1 . 2 1 . 2 4 — L . to F . M . congratulating D i c k on his splendid report. 1 2 . 4 . 2 4 — F . M . at home: D i c k at school; he is getting along well on the whole. A t times he is inclined to be a bit headstrong and w i l f u l , and sometimes a little aggressive, but really does not give more trouble than an average child. A t school the teacher reports that he is doing good w o r k , not anything unusual, but he is keeping up to his class and his behavior is not outstandingly poor. H e behaves about as the other children do. P . A . and P . U . had now l e f t and gone South. D i c k does not seem to miss them very much. H e had rather resented an occasional criticism on their part against the D o l b y household. T h e y evidently did not feel that the D o l b y ' s had the social veneer that they were accustomed to, and think necessary. T h e other day when discussing his trip to camp last summer, Dick had remarked that he had enjoyed it very much, that he had liked Mr. Sherman, but that he did not want to go another year; did not w a n t to go because he had a fear, all the time that he was a w a y , that he would not get back to see Mrs. D o l b y again. H e has accepted F . M . quite as his own mother. Remarked that when he had been little they had taken him away f r o m his o w n mother, telling him that he would see her again shortly; that he had never seen her; that he had wondered and wondered about her, and now she was dead and he would never see her again. H e did not w a n t this to happen with his second mother. J u s t at this time when he was reminiscing about his mother, he had also spoken about the time he had spent with Mrs. Baker. H e had used to fly into terrible tempers, throw things around, yell and behave a w f u l l y . H e certainly has no desire to go to live with P . A . , Mrs. Baker. She writes occasionally, and had just written asking w h a t D i c k wanted f o r Christmas. D i c k is riding horseback now and is really doing it very well. F.M. thought that he would like to have skates f o r Christmas, that they would be a lot of pleasure f o r him and also be a v e r y good sport, and that D i c k should be encouraged in all sorts of athletics.

33°

RICHARD

[Syllabus

reference:

HEATH

KNOWLEDGE,

Psychology,

PHIL-

OSOPHY, Kinship ties, a d o p t i o n . ] 1 2 . 2 2 . 2 4 — S k a t e s mailed D i c k f o r Christmas. 1 2 . 2 7 . 2 4 — L . f r o m F.M. t h a n k i n g f o r D i c k ' s Christmas g i f t . 1 2 . 3 0 . 2 4 — L . f r o m F.M. re. necessary c l o t h i n g f o r D i c k . D i c k has had a cold, so F.M. did n o t b r i n g h i m t o the clinic as planned. W i l l bring him in at an early date, i . j . 2 j — L . toF.M.:

Acknowledgment.

1 . 8 . 2 5 — L . to F.M. asking clinic a p p o i n t m e n t . S T A T U S O F C A S E AS O F

193Ο

For t w o summers f o l l o w i n g the period recorded, R i c h a r d was sent to a f a r m and c a m p w h e r e he had active c o n t a c t w i t h boys his o w n age. In 1926 t w o boys, one R i c h a r d ' s age and one older, were placed w i t h M r . and Mrs. D o l b y . T h e placem e n t was v e r y successful, both f o r R i c h a r d and the other boys. In the fall of 1927, because o f the foster f a t h e r ' s business and her o w n poor health, foster mother w e n t South f o r the winter. T h o u g h she w a n t e d t o t a k e R i c h a r d w i t h her, it was decided to let him spend the w i n t e r w i t h his paternal aunt and uncle ( B a k e r ) . T h e paternal aunt's health had greatly

im-

proved and the paternal uncle was anxious to have R i c h a r d in their home. T h i s w o r k e d o u t o n l y f a i r l y well. T h e f o l l o w i n g summer he spent w i t h his foster mother, and returned to his relatives in the fall o f 1928, at their u r g e n t request. D u r i n g this period both maternal and paternal relatives took a more active interest in him and he received letters f r o m his h a l f sister w h o , until that time, had not k n o w n o f his existence. A l l this, in addition to foster mother's c o n t i n u e d devotion, helped him to meet fairly adequately the difficulties of a d j u s t m e n t . H o w e v e r , the paternal aunt's health failed seriously, the paternal uncle had finally

financial

difficulties and

increasing

tension

necessitated a change in plan f o r the b o y .

In the spring o f

1930, R i c h a r d

returned

t o his foster

parents' home where he will remain p e r m a n e n t l y as one of the f a m i l y and the contact w i t h relatives will be fostered b y visits.

RICHARD

H E A T H

3 3

1

The intense emotional relationship with foster mother has relaxed considerably. Part of her energy is finding an outlet in her two attractive grandchildren, though this has in no way menaced Richard's security. He is making good progress in school and his social adjustments are those of a fairly normal adolescent boy. III.

RECORD OF T H E H O M E OF FOSTER M O T H E R , MRS. M A R I A N N A

DOLBY

ι 2.3.21—L. of application in answer to ad. in "Bulletin" for boarding home for 13-year-old girl. Rate of board offered $10. as case represented a difficult problem. Letter well written. Stated: "We are a family of four and have a 14 acre place of woods and stream; a home of 14 rooms, hot and cold water, bath, etcJ·' and that two of the members of the family are away a great deal, leaving herself and son, who is a school teacher at Wilmar, alone very much of the time. We would be glad to have the little girl of 13. Gave two references. 12.7.21—Mrs. Dolby at home: Wilmar is a small station about five miles west of Leestown. To reach the house one can either take jitney service from Leestown or walk about 1 '/2 miles on country road from the Wilmar station. The Dolby property was formerly owned by a Mr. and Mrs. Wm. Sloane now of 12 Grant Street, Hilton. Consists of 14 acres, largely open woodland, house, and barns, a dilapidated green-house, a small mill and a second house, which visitor did not see. This latter house is to be occupied by the son, Samuel, in the spring when he marries. The main house, which is located some distance back from the road, is on rising ground at the foot of a wooded hill. A mill stream runs across the property between the road and the house. The acre or two occupied by the buildings, the lawn and garden space, had been cleared from the surrounding woods just enough to make a comfortable outlook. Mrs. Dolby was not prepared for callers. She was dressed in a soiled white middy blouse and black cloth bloomers, from

33

2

RICHARD

HEATH

w h i c h one o f the leg strings had become detached, w i t h old f a r m shoes and a rather j a u n t y f e l t hat w h i c h she wears a b o u t the place. H e r t a n n e d , virile f a c e was radiant w i t h health. W i t h a f e w w o r d s of e x p l a n a t i o n that she had been overseeing some c a r p e n t r y w o r k at the f a r m all the m o r n i n g she dismissed her r o u g h and ready appearance w i t h e x t r e m e good grace and did not allow it in a n y w a y t o i n t e r f e r e w i t h her attitude t o w a r d s the occasion. Visitor's

first

impression of

Mrs. D o l b y , and the one w h i c h she carried a w a y w i t h her, was that she had a good grip o n life and that she had f o r g e d it out o f years o f hard experience, w h i c h she had come t h r o u g h sound and w h o l e — t h a t she had w o r k e d o u t f o r herself a set of values that were universally f u n d a m e n t a l . O n e felt a w a r m , rich nature w i t h something r u g g e d about it that perhaps never had its desired f u l f i l l m e n t , and y e t her c r a v i n g f o r joy and beauty had f o u n d its goal in a realization that a f t e r all, e x ternals are not the b i g t h i n g s ; t h a t life is w h a t one makes it. A l l this was suggested, not so m u c h t h r o u g h a n y t h i n g w h i c h Mrs. D o l b y definitely said, b u t more f r o m the subtle u n d e r c u r r e n t that colored the w h o l e . O f Scotch b i r t h , Mrs. D o l b y came t o the U n i t e d States w i t h her m o t h e r w h e n about 9 years o f age. A

year later she was r e t u r n e d to relatives in

Scotland while, as she expressed it, her m o t h e r w a s " c o n t r a c t ing a n e w m a r r i a g e , " she b e i n g more or less in the w a y . W h e n 12 or 13 she again joined the m o t h e r , the s t e p - f a t h e r h a v i n g died. Mrs. D o l b y ' s schooling was finished in France. She c o n tinued t o live w i t h her m o t h e r somewhere on the outskirts o f W a s h i n g t o n , and married y o u n g . A s a y o u n g w o m a n she had taken vocal lessons and had s u n g in p u b l i c . Is passionately f o n d o f music. Mr. D o l b y was f r o m W e s t V i r g i n i a . B e y o n d the f a c t that at the present time he was e m p l o y e d in g o v e r n m e n t a l service and was seldom at home, visitor gathered little c o n c e r n i n g him f r o m the conversation. S o m e t h i n g about Mrs. D o l b y ' s w a y o f speaking o f her husband g a v e one the feeling that he was not a big f a c t o r in her life, b u t her b o y Samuel and her

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daughter Susan are very close and dear to her. Both are to be married in J u n e and both to live on the place, the son-in-law to build a new home for himself and Susan. Susan is a graduate of the Clyde Hospital and is at the present time on a private baby case. Samuel teaches in the Wilmar school, takes summer courses each vacation period, and is evidently trying to fit himself for a more advanced position. Mrs. Dolby stated that Mrs. Lawson MofFatt, a prominent woman of Wilmar, deeply interested in the school situation and, for that matter, in all civic affairs, would not know what to do without Samuel in the small W i l m a r school where the group is made up of colored and white children, largely from the tenant class. Mrs. Dolby explained that that section was made up of two classes—"those who served and those who were served." The family have been living in their present home for two years. Before that lived for five years at Sussex. A colored boy from the neighborhood assists Mrs. Dolby with the outside work, but she does a great deal of it herself. Just loves the outdoor work and feels that after they get the place into shape, there will be much that she can do to help towards earning the living. Family own the property. All the while that Mrs. Dolby was talking, visitor felt her keen enjoyment in just living; only when her face is in repose does one catch the suggestion of sadness. On account of Mrs. Dolby's work outside that morning the house was in some little disorder. The kitchen, warm and comfortable, with a bright fire in the well polished range, was clean. The dining-room furnishings are substantial, with some interesting old pieces and the arrangement of the furniture showed some taste. One is impressed with the number of good books in the living-room and also in one or two of the upstairs rooms. In the living-room is a large piano and in the large upstairs hall a little organ. A broad front door opens out into the piazza, which has an attractive view down the slope, across the mill brook to the road. The house has several bedrooms, which are not very fully furnished, but the beds

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and bedding were distinctly clean. A large bathroom. O n the second floor is a small room with a desk, which Mrs. D o l b y calls her workroom. T h e house is equipped with running w a t e r and a new f u r n a c e is to be very shortly installed. T h e newer part of the house, visitor f o u n d not very well heated and shut off f r o m the w a r m t h of the kitchen. Mrs. D o l b y explained that with only herself there throughout the day the f r o n t of the house was not much used, but with the new furnace would be used more. It is by no means a shut off house and apart f r o m the heating question the house would probably have been all thrown open, f o r it gave the impression of a house that was lived in. T h e f a m i l y have a large vegetable garden, which Mrs. D o l b y almost entirely cares f o r during the summer months. T h e y have a cow, hens, and pig; use their own eggs, and have plenty of milk. A l s o have a horse, shepherd dog, and three cats. Visitor gathered f r o m several things which Mrs. D o l b y said during the afternoon's conversation that she had mothered a goodly number of boys and girls other than her o w n children. Visitor sketched f o r her the difficulties in Marian L o n g ' s life and the plans that would seem to be conducive to her better development, explaining that she would have ample opportunity later to talk with Miss Frances M a n n , the person w h o was probably closest to Marian. Mrs. D o l b y appeared to understand the situation remarkably well. Felt that she could do a good deal f o r a 1 3 - y e a r - o l d girl if the youngster would enjoy country life and would be willing to enter into their simple home life. Explained that they had f e w outside pleasures— that they created them among themselves. Felt that if the young girl was at all interested in outdoor things she could stimulate a number of new interests. Was certainly willing to undertake it. Said that in taking her it might be possible to secure more outside help and thus have more time to devote to indoor things with her, such as reading and music. T h o u g h t if Marian could learn to drive it would be nice f o r her to drive to the school each day and bring Samuel home.

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Rev. W m . Sanders, independent reference at home: Attitude seemingly rather non-committal. Visitor stated in a general way the type of case for which she needed a home and for which she was tentatively considering Mrs. Dolby. Rev. Sanders said that he could think of no person through all that section of the country more fitted for such a task than Mrs. Dolby—that she had a quality that would peculiarly fit her for the work, and that was a sympathetic understanding of the other person's position. Said that when she lived in Sussex she did a certain amount of community work for him through a neighborhood a few miles away, consisting chiefly of small farm homes of rather humble station. He noticed, then, how readily Mrs. Dolby could bring herself to be one of them. At times he thought her almost too quick to take the defensive for the under-dog, so to speak. Considered her morally sound —a strong character. Would think of her as sane on the question of sex, able to meet a child's questions wholesomely and frankly. A woman of many resources, who has done a good piece of work in bringing up her own two children. Stated that when Mrs. Dolby came to Sussex to live she practically had lost her faith in God; that he restored her faith, and that she and her two children had been confirmed in his church. Explained that Mr. Dolby was of the Roman Catholic faith and he would consider him far less endowed mentally and emotionally than Mrs. Dolby. As far as he knows, Dolby is a good, honest man. Would judge that her married life had not given Mrs. Dolby the happy companionship she craved and that she had gradually found herself through her children— that a very close bond existed between them especially with the son. Knew that there had been a disagreement between her and her husband as to how the children should be brought up and, now that the children have grown, the relationship seems to be between the mother and the children—that the father does not figure very much; that in buying the present property he was not consulted. Dr. Sanders explained that Mrs. Dolby's rich, emotional life sometimes led her into a

33^

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rather visionary view of life, but that on the whole her feet were v e r y firmly fixed on the earth, that her sound practical sense was ballast to her emotions. Stated that f a m i l y did not have much money. Spoke in most favorable terms of Samuel and Susan. T h a t he had his T h a n k s g i v i n g dinner w i t h the f a m i l y and on every occasion, when he has had a meal with them, has f o u n d that they live well. 1 2 . 9 . 2 1 — M r s . ¥ m . Sloane, 1 9 West Street: Mrs. Sloane is a w o m a n of around 55, of fine bearing. She explained that f o r 2 j years she had lived at W i l m a r on the place which Mrs. D o l b y later purchased. Explained that the place was v e r y dear to her heart and she was so happy to feel that a woman of Mrs. D o l b y ' s caliber had taken the place—that Mrs. D o l b y had been able to enter into her feeling of fondness f o r the home and had kept m a n y of the things as they had had them, continuing to call the place as they had named it. Felt that Mrs. D o l b y was a rare w o m a n and one w h o had a peculiar understanding of the other person's experience; that she was a woman of practical idealism with big, spiritual values. Felt that her husband was distinctly of common c l a y — t h a t is, one w h o lacked the fine appreciations of Mrs. D o l b y . A s f a r as she knew, he was a thoroughly honest man. Felt that with her unusual physical strength, Mrs. D o l b y would, undoubtedly, be able to net returns f r o m the property, which they had been unable to make. D r . T h o s . V a u g h a n , o w n reference at his office: Stated that he had k n o w n f a m i l y f o r several years when they lived at R o n d well, that he had not seen much of them f o r three years. H e would say they had lived in R o n d w e l l f o r eight or ten years. Characterized Mr. D o l b y as a roamer—can always find a good job, but never seems to hold it v e r y long. H a s been connected f o r a number of years, in one w a y or another, with the steel industry. A s f a r as he knows, and he has seen him pretty closely, is morally sound. There is nothing in the health condition on either side that he knows of that would denote sexual immorality. Stated that Mrs. D o l b y was a great hand to help

RICHARDHEATH

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her neighbors one way or another. Did various things on the outside while living in Rondwell to eke out the income. The sort of person who would read philosophic books, then try to apply what she had read to practical life. Was very fond of music and, when life pressed too hard, took it out on the piano. Mr. Dolby is a very practical man with no time for reading poetry. Thinks that Mrs. Dolby is greatly disappointed that her children did not turn out to be geniuses. Would feel that she could handle the sex problems of a 13-year-old girl most tactfully—that, although her head is sometimes in the clouds, her feet are always firmly on earth. Suggested as a further source f o r reference Mrs. Maurice, living in R o n d well. 1 2 . 1 0 . 2 1 — S o c i a l Service Exchange reports no record. 1 2 . 2 9 . 2 1 — M r s . Maurice, Rondwell, independent reference, at home: Mrs. Maurice was polite but did not want visitor to come in. Stood in the doorway, half concealed by the door and explained that she was too busy to talk when visitor asked if she was an old neighbor of Mrs. Dolby's and could give some help on the question of placing a young adolescent girl with Mrs. Dolby. Mrs. Maurice promptly recommended Mrs. Lang, next door, as the person to see because she had lived next door to Mrs. Dolby and knew her better than anyone else around there did. Was sure Mrs. Dolby would give any child what she needed. Said Mr. Dolby never home much but both of them fine people. 1 2 . 2 9 . 2 1 — M r s . Hempel, Rondwell (two doors f r o m Mrs. Maurice), independent reference, at home: Mrs. Hempel is a young married woman of a wiry type, perfectly ready to meet your questions. Said that her own married sister had lived in the other side of this house while Mrs. Dolby lived there m d that she, herself, when visiting her sister for months at a time had seen a great deal of Mrs. Dolby. Said Mrs. Dolby was a fine woman and would make a good mother, was ambitious and could do everything. Visitor explained that in placing an adolescent girl it was important that the family relationships

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should be as fine as possible and asked if she or her mother, Mrs. Griffin, then present, could tell visitor anything about Mr. Dolby. They didn't know Mr. Dolby very well. Said nobody saw very much of him; that he was a machinist, could do anything with automobiles. Was a very quiet man. Was lame in his knee,—they thought it was a bone condition, not tubercular. Talked eagerly about Mrs. Dolby. Told how she took care of married sister in the other side of the house, carried her food, made her bed, etc. Said Samuel was "one good b o y " and that the girl was fine too. 1 2 . 2 9 . 2 1 — M r s . Lang, Rondwell (between Mrs. Maurice and Mrs. H e m p e l ) , independent reference, at home: Mrs. Lang is a high strung, talkative young married woman without children. V e r y enthusiastic about the Dolby's. She and Mrs. Dolby had come to live in Rondwell twelve years ago, the same summer. "Mrs. Dolby ought to have been a man. She did everything. Tore down the wall, dug her own cellar, planted that tree in m y yard, took down a chandelier while I was away and joked about the mess she had made, when I came back, helped me plant my garden and always sang when she was washing her dishes. H a d a fine voice and sang sometimes f o r the little church. Did a great deal of sewing and, m y , but she loved Samuel! Samuel was one fine boy. One day Susan stuck her head out the window and called to me that her mother didn't love her, only loved Samuel. But her mother laughed and answered, 'Of course, I love you just the same.' Susan is a splendid girl. She loves children, too." Mrs. Lang thought that Mrs. Dolby was living on her sister's place at Wilmar. Said she had a married sister out there, Mrs. Hixon. Samuel and Susan are both to be married at a double wedding next summer. Samuel engaged to Willa Graham of Rondwell. Willa is an a w f u l l y nice girl who has had one year's training in a maternity hospital. Mrs. L a n g expressed a genuine liking f o r Mr. Dolby. Said he was a very quiet man but an able one. Could manage other men and they thought a great deal of him at the Crescent

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C o m p a n y , ist and W o r t h Streets. C a m e home every night. M r . D o l b y not strong. H a d a v e r y bad spell with his knee when D r . Milton took charge of him while they were still living in Rondwell. D i d not k n o w anything about Mrs. D o l b y before she came to R o n d w e l l . T h o u g h t she lived in Hamerston. T h o u g h t she was Scotch and Mr. D o l b y also. Said Mrs. D o l b y had not been back since she l e f t , but later told visitor that the Greenes were the people she visited. Said she missed Mrs. D o l b y v e r y much, that she was the life of the place. Was always giving parties and everyone liked her. Mrs. L a n g , w h o was the most prosperous of the neighbors, and both Mrs. Maurice and Mrs. H e m p e l , very much simpler and more industrious women, gave visitor impression that they all looked up to and admired the D o l b y s . Were always being helped b y Mrs. D o l b y . K n e w her in the friendliest w a y as neighbors but were not in the least intimate with her and probably knew only what Mrs. D o l b y wanted them to k n o w about her and her f a m i l y . T h e y all agreed to keep visitor's confidence and declared themselves ready to tell anything about the Dolbys that they knew, taking very seriously the thought of the adolescent young girl to be placed with her, and, though visitor made a point of approving their discretion and their loyalty to Mrs. D o l b y , she felt that they were the kind of women who would enjoy making most of her visit. 1 . 4 . 2 2 — T e l e p h o n e d Mrs. Lawson M o f f a t t , Wilmar. 1 . 5 . 2 2 — M r s . Marianna D o l b y , W i l m a r , at home: Mrs. D o l b y came out rather formidable looking, with her swinging stride and expeditious manner, wearing the same dirty middy and bloomers Miss West had first f o u n d her in, her face r u d d y but quite serious as she shook hands and said, when visitor asked if she might come in and talk, " B u t , I don't k n o w who you a r e ! " T h e n she smiled, led visitor through f r o n t rooms to a little " b r e a k f a s t r o o m " and back of that to the kitchen where an open can of paint stood near a newly upholstered, partly varnished chair. Mrs. D o l b y , anxious to talk to visitor about Marian, was reluctant not to finish her upholstering. She had

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put out the fires so that the dust would not get on the paint, had left all her dishes and housework and planned to finish her job that afternoon, but, in spite of the pull, she finished a few last strokes of paint, picked up the whole chair, carried it into another room, quickly made a fire in the kitchen stove, put the kettle on to boil, talking to visitor all the time. She then dashed over to the kitchen sink and began washing the dishes. When a little boy came to the door to tell Mrs. Dolby that her cow and heifer were wandering off in the woods, she found time to ask him about his school and his family and to give him some candy. Then she called to her carpenter who was chopping wood on the hillside and who cheerfully went with the boy after the cow and the heifer. She showed a heater man where to find the bathroom and made it clear to him that she had quantities of radiators and would have one in the bathroom so she could shut the bathroom door. In between these distracting demands on her, she sat down by the table and concentrated on Marian. Then in a twinkle she made tea and buttered toast, which she served in dainty china with napkins and rich cream. Mrs. Dolby wanted to know concretely what Marian's difficulties were. She was not in the least afraid that Marian might get into trouble, and felt that she could ignore the masturbating habit if once she had got Marian's interest and affection. She asked if Marian ever lied or stole. When told that she might lie but never had been known to steal, Mrs. Dolby said she could take care of it if she lied from fear, because of being caught in a tight place, but she thought it almost impossible to help a child who took a real pleasure in being deceitful. She then launched into a dissertation on the power of fear to destroy every good human quality. Told about the "dark hour" lectures she occasionally gave children. Had said to a girl a few days ago, "You let that black demon, that horrible thing, fear, spoil everything you do. You keep pushing it away, but it always comes back. If you face it and take your courage in your hands, you would be a free and

RICHARD

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3 4

1

glorious creature. Fear destroys all the beauty we see in life, all the fine things we might do if we only had the courage to recognize it and let it go." Mrs. Dolby is a born preacher b u t with her intense desire to make the world over she combines an unusual practical energy and, just at the point where she might over moralize, her sense of f u n and her interest in other people come to the rescue and save the day. In talking of her children, Mrs. Dolby said, "I have never lost m y children's confidence. We are so happy together. When they marry they are just going on living. We are m a k ing no preparations. We do not want our home life disturbed by any such frantic activities. Both Samuel and Susan are afraid the other one will get married first. They may do it in March. I had thought it might be better not to take any child until afterwards. W e talk so freely and intimately about the babies who will perhaps be here next Christmas, but Samuel says he does not think that would h u r t any child, and of course generally I believe that is the wholesome course to p u r sue. I had a serious talk with Samuel the other night. Samuel was discouraged about the educational situation and thought he could not do much in this hole by staying here another year. I have worked so hard to make Samuel understand there is something in life that we must do. I have feared that something might happen to me before Samuel could take his part. I said to him, 'Samuel, you must take my mantle on your shoulders. You have undertaken the responsibility here and you would never be happy if you deserted.' Samuel promised that he would take my mantle." When Mrs. Dolby talks this way her whole manner is that of an inspired, religious enthusiast. She believes she is called. She would certainly burn at the stake for an ideal with her head held high. In her attitude toward Samuel, she clearly shows that she herself has not learned to let another person develop in his own way, but Samuel, on the other hand, has a quiet, humorous way of taking his mother and seems to have the strength to be himself. Mrs. Dolby wants intensely to express herself but never

3 4

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HEATH

could do any harm to a child like Marian if she made her entirely over on her own pattern. She cares so intensely about real living on her own resources within her home, and looks forward to a time when she can make more happiness within the house, using books and music. It is possible a child like Marian would be a profound disappointment to her. Visitor asked her if she would not rather work on the type of child who definitely promised development, but Mrs. Dolby's attitude was that many a child was ruined at an early age by fear and stupidity on the part of her elders and that Marian, perhaps more than any other, needed what she had to give. The heater is to be put in the house inside of two weeks. Mrs. Dolby will then take Marian if we wish her to. She is willing to think of it as an experiment, is anxious to keep her at home with her the rest of this school year and believes that she would not be afraid to let her go to the country school next fall if she has first established a relationship between herself and Marian. Says that Samuel has cleaned out that little school; that every child is on his honor; that they hold court and try every youngster for any misdemeanor, or any such foolishness as kissing in the basement. Since he has been there conditions have entirely changed. Mrs. Dolby is unquestionably interested in working with children, and her one idea is to make them see such glories as hard work, service to one another, pleasure in things that are beautiful and to despise false appearances. Her home is beautifully adapted to the bringing up of children. She would undoubtedly take one more, perhaps two, if we needed to send them to her and the group could be unified. There would probably be no question of loneliness or boredom on the place, because of Mrs. Dolby's own vivid interest and varied abilities. 10 When she is not making life a moral drama, she certainly makes a game of it. Before visitor left, Mrs. Dolby took her along to feed the chickens and the ducks, to pat the horse and turn loose I0This

f o s t e r h o m e as t h e R e c o r d

indicates, was originally sought

n e e d e d s p e c i a l a t t e n t i o n , b u t it w a s l a t e r used f o r o t h e r c h i l d r e n .

for a girl

who

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the heifer, talking to all these animals as if they were m e m b e r s of her own f a m i l y , with a m i x t u r e of tenderness and h u m o r . She w a n t e d to hitch u p the horse and drive her to the station, b u t compromised by showing her the long w a y a r o u n d so she could see the stream her boys had d a m m e d u p , and the sunset. She walked all the way to the station with visitor, hoping to encounter Samuel on the w a y and finally met him just at the station. She had declared that when he saw her he w o u l d disa p p r o v e o f her costume. H i s greeting was, " H e l l o , m o t h e r ! A r e you down here like t h i s ? " B u t , he looked more pleased to see her than concerned about her appearance. Samuel m a d e an excellent impression on visitor. H e is most a t t r a c t i v e — b l a c k hair, very fine blue eyes, full of humor and appreciation. H e looks as honest as you m a k e them, and quite sensitive, b u t not the least bit effeminate. H e is magnetic enough for any girl to fall f o r , b u t too wholesome and fine to m a k e a mess o f it. H e was very anxious to visit T h e C o u n t r y School. H i s own library is filled with books and pamphlets about experimental schools b u t had never visited one and wished that, instead of drilling children over and over again so that they almost went t o sleep, he could give them more things to make that would interest them. Mrs. D o l b y would not leave visitor until her train c a m e along, even though she had to cook dinner when she reached home. Visitor promised to write her as soon as possible o f our decision about Marian. IV.

C A R D S S U G G E S T E D FOR I N D E X I N G T H E R E C O R D

T h e index cards suggest one w a y in which the teaching material in a case record library m a y be rendered accessible b y a system of cross indexing. Each record is given a key card (of a specified color) bearing the case name. O n this card are indicated all of the topics illustrated by the case that seem to have significance f o r teaching purposes. Topics of primary importance are entered in capitals, those of lesser importance in small type, and there is a brief descrip-

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tive Statement indicating the main teaching values of

the

record. A cross i n d e x c a r d ( o f a d i f f e r e n t c o l o r ) is p r o v i d e d f o r each m a j o r a n d each m i n o r t o p i c . T h e m a j o r topics a p p e a r in capitals w i t h brief descriptive statements of the material to be f o u n d in the record. T h e m i n o r topics a p p e a r in small t y p e w i t h o u t such d e s c r i p tive statements. T h e analysis of c o n t e n t a t t a c h e d to the case record itself supplies f u l l e r i n f o r m a t i o n c o n c e r n i n g the e x t e n t and n a t u r e of the material on each of the topics. i.

Key

card

H E A T H , RICHARD

Age 7

BEHAVIOR PROBLEM ( C h i l d )

I n s t i t u t i o n a l standards

11.13.20-1930

E c o n o m i c a l l y d e p e n d e n t c h i l d H e a l t h services of B r o k e n home

child-plac-

ing agencies

FOSTER HOMES

Philosophy of family life Management

C h i l d d e p r i v e d at an e a r l y age o f n a t u r a l f a m i l y ties b y the i n s a n i t y of his m o t h e r a n d subsequent death of his f a t h e r a n d subjected to n u m e r o u s c h a n g e s o f residence and caretakers, resulting in emotional

deprivation,

insecurity,

and inconsist-

ent t r a i n i n g a n d discipline, m a n i f e s t i n g themselves in violent temper outbursts,

excretory,

and sex

activities.

B e h a v i o r m o d i f i e d t h r o u g h adjustment

in a boarding

foster

home a f t e r an u n s u c c e s s f u l institutional experience a n d t w o u n s u c c e s s f u l f o s t e r - h o m e placements. R e c o r d f u r n i s h e s m a n y clues as to elements in the foster home and in case work which of the

placements.

contributed

to the success and

failure

RICHARD 2.

Cross

345

HEATH

reference HEATH,

FOSTER

Bearing failure

RICHARD

HOMES

of emotional of

factors

in foster

homes on success

and

placements.

T h e record shows with considerable certainty the emotional lacks in the child's life, and the gradual modification of his asocial behavior f o l l o w i n g the establishment of a valid substitute parent-child relationship in a foster home. 3.

Cross

reference HEATH,

BEHAVIOR PROBLEM

RICHARD

(Child)

Economically dependent child Broken home Emotional deprivation and insecurity manifesting themselves in violent temper outbursts, excretory and sex activities. T h e record makes it possible to trace with considerable certainty the emotional lacks in the child's life and the gradual modification of behavior following the establishment of a valid substitute parent-child relationship in a foster home. 4.

Cross

reference HEATH,

RICHARD

HEATH,

RICHARD

HEATH,

RICHARD

Broken home Economically dependent child BEHAVIOR PROBLEM

5.

Cross

reference

Economically dependent child Broken home BEHAVIOR PROBLEM

6.

Cross

reference

Institutional Standards

34^ 7.

RICHARD Cross

HEATH

reference HEATH, RICHARD

Health Activities of child-placing agencies 8.

Cross

reference HEATH, RICHARD

Philosophy of f a m i l y life 9.

Cross

reference HEATH,

RICHARD

HEATH,

RICHARD

Dependent Child See Economically dependent child 10.

Cross

Management

reference

CHAPTER

VI

T H E C A S E R E C O R D OF J O H N A N D HELEN THEOCRATES Particular

configuration1

This is a case of a Greek family consisting of a woman, age 28, a preschool-age child and a baby, the husband having been sent away, because of advanced pulmonary tuberculosis, to a sanatorium in Arizona. The two-year-old boy has tuberculosis of the skin. There is a language difficulty, and the whole situation is strongly colored by Greek habits and customs. Type

configuration1

Disability of the breadwinner. Family life interruption. Persons in the case2 Family make-up: John Theocrates, age 29, in Phoenix, Arizona. Helen Polydoros or Polio, age 29. Mike, born 1 . 1 1 . 2 7 . Achates, born 9.22.29. Other persons: Dr. Nikolas, private physician. Mr. and Mrs. Blank later called Mr. and Mrs. Zelim. Mr. Polydoros or Polio, woman's father. Mary Polydoros or Polio, woman's sister. Nick Polydoros or Polio, woman's brother. Teaching

objectives

This case has been selected, chiefly, because it presents discussion points in the handling of a common type of relief prob'See Chapter II, and A p p e n d i x . ^Regular f a c e card is o m i t t e d .

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lem. Family welfare cases tend to be involved, and this record, despite its brevity, reveals m a n y features, both in study and treatment, within the economic context characteristic of more elaborate situations. This case might have been handled either by public or private agency, and, in fact, falls within the class of eligibility for a mother's allowance in the state where Mrs. Theocrates resided. The local circumstances which brought the case to the attention of a private society, rather than to the public bureau, cannot easily be shown, and are not of great consequence. It m a y be taken for granted that most cases within this class would have been handled on the basis of referral for a mother's allowance. The development of case work in connection with categorical relief is an interesting matter for discussion, both in its philosophical and technical aspects. The question m a y be asked, does the need for relief indicate a n y t h i n g whatsoever with respect to the need for case work? W o u l d there be any difference between recipients of mother's allowance and those of other classes of pensions? A large class of cases is taken by f a m i l y welfare agencies, public and private, in which a normal home is threatened by the illness, unemployment, or death of the bread winner. Are there case-work elements in such a class and how m a y these elements be determined? Maintaining homes in which children m a y grow up has always been thought of as preventive and constructive social effort, but how much individualizing is necessary or desirable beyond establishing eligibility? (See also final teaching n o t e ) . However w e m a y approach the larger problem, the fact that the distress in the Theocrates case is precipitated by external circumstances, tends to shape the course of study and treatment f r o m the beginning. Area In an apparently happy Greek immigrant f a m i l y tuberculosis arrives, incapacitating the father and necessitating his removal for an indefinite period to a sanatorium. W e have thus a temporarily broken f a m i l y , the mother being left to bring up

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a runabout child and a baby. This problem o f family life interrupted by the disability o f the wage earner is complicated by the ill health of the older child (tuberculosis o f the s k i n ) , and further complicated b y Greek methods o f familial organization and group financing, so likely to be baffling to the inexperienced. Subtle cultural undercurrents and overtones are present throughout, influencing the action o f the client. T h e barrier of language adds to the difficulty of penetration by the case worker. T h e sick husband, moreover, accustomed as he is to managing all the family affairs, does not take his own wife completely into his confidence, and so appears as a somewhat " w i l y Ulysses." Method Technically the case may be regarded as transitional in method. Students who expect an exacting ritual o f investigation may think that the situational facts are too little explored. Is this ignorance or wisdom, extravagance or strategy? Is common sense sacrificed to the building up of a so-called "good c o n t a c t ? " Is not any contact likely to be good if relief is freely given? Is there too much or too little management of the situation? Is there an apparent conflict between the necessary investigation to determine the existence of need and resources, and the kind of interviewing in which the client is the sole source of information? T o what extent can c'ients participate in an examination of their social problems? H o w should this participation be expressed? T o what extent can the client be helped to overcome his natural resistance to exploring, with the worker, his actual practical condition, as well as his own feelings about his condition? T o some students the idea of the existence of "natural resources" is fantastically improbable, especially in hard times. Others may be aware o f resources in the village neighborhood but are unprepared to look for them in the city. Others still, with a philosophy of mutual aid, collectivism, or any large group responsibility may feel that relatives and friends should not be asked to assist. In all these

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points of view, the fact that relatives and friends are assisting must be assimilated, and the operation of these invisible relationships, even apart from the financial context must be scrutinized. The case reveals more of what is called "executive" or sometimes "social manipulative" treatment than any other. Resources are mobilized, the children are taken to clinics, naturalization processes are begun, and so on. A certain amount of direct teaching and interpretation, both in health and budget matters, is undertaken. The type of interviewing most used may be described mainly as discussion, although all interviewing is made difficult because of the language barrier. "With so intelligent a client and so practical a situation this would be a most usual method of interviewing. The discussion type of interview may be contrasted with the interview of katharsis in which the case worker is a listener rather than discussant. But this case is not a good illustration of the therapeutic approach as such. Although the treatment is more in the nature of social manipulation than of fundamental character changes, nevertheless a slow change of attitude in Mrs. Theocrates may be traced. Contact is well sustained, and participation of the client both in the study and in the treatment increases. All treatment efforts focus, in the light of the husband's uncertain prognosis, to the end of increasing self-reliance and self-direction in this woman, so little accustomed to manage the affairs of the family. Throughout the study and treatment the worker's lack of knowledge of cultural traditions seems to result in a technique not sufficiently sure footed, but this should not be confused with those points at which, clearly, the worker is assuming a quiet role, that is, we see the case suspended, as it were, between a technique concerned with mobilizing and interpreting resources for the client, and a technique which involves patient watching for the client to reveal herself, her needs, and her wishes. The question may be asked, in how far is verification of a family's need compatible with the subtle sort of study and

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1

treatment concerned, most of all, with the release of forces within the client? The old emphasis on private initiative and self-help, characteristic of all case work, as in Edward Denison's famous phrase, " N o man can save his brother. H e can but throw him a plank," would seem to be reinforced by recent psychiatric contributions in which the will of the client to reorganize himself comes to have a greater and greater significance, Professional

Knowledge

and

Philosophy

Because of the subject matter, we have chosen to index chiefly those points at which a knowledge of Greek culture and of the habits of immigrant groups is indispensable. Supplementary reading on Greek life itself, as well as practical experience with the immigrants, should be offered by the class since there is so little cultural material in the record itself. A whole tapestry of concepts, attitudes, and action, foreign to the American-born community, lies behind the objective narrative. T h e student is more likely to be disturbed by the worker's expenditures, or interested in the worker's ability to establish a contact in a psychological sense, than sensitive to the lacunae in the worker's knowledge of Greek mores. Duplicity in the client may be discussed as an ethical problem or as a problem in "resistance," but its significance may be even greater when the question is raised as to whether duplicity in one type of mores is duplicity in another. T h e knowledge demanded, in the case worker, of the literature o f medicine and general hygiene, as well as of the hygiene of contact cases in tuberculosis, may be pointed out also. There is little psychiatric content, as such, and what there is may be found coloring the approach of the worker. Some knowledge of social legislation and of home economics is called for. In the philosophy of method itself we have already spoken of the relation between case work and relief. T o what extent can personal initiative be reconciled with public maintenance? W h a t contribution can case work make to the understanding

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of emotional dependency in maintenance problems? H o w m a y the pensioner be assisted to make a social contribution? W i t h this fairly self-sufficient woman, how rounded a piece of education is needed beyond what she herself might ask f o r ? Does her foreignness create any special problems f o r her or f o r the community? Is there any responsibility f o r service beyond the actual meeting of the relief problem? H o w can we avoid, in the relief situation, putting clients in the passive position of one being helped or rescued? W e k n o w that relief does not create dependency but it may bring to the surface latent dependencies. W e realize that m a n y clients have capacities f o r socialized activities which m a y be developed. T h e need f o r research to reveal ways of eliciting activity and a socialized performance in clients who have fallen w h o l l y into the role of recipients may be indicated. T h e most interesting " v a l u e " point in the case has to do with the attitudes shown by the case worker and client towards Mrs. Theocrates' dishonesty. This is alluded to in teaching notes 8 and 1 3 . T o what extent does the case worker take a neutral attitude towards conduct problems? Does case work treat problems of financial need, ill health, or anti-social conduct with equal objectivity? D o we permit stigma to attach to certain behavior? H o w

do we approach enuresis, temper

tantrums, stealing, cruelty? T o what extent is it possible to ignore the valuations of the c o m m u n i t y of such behavior? Should we ignore the c o m m u n i t y standards and attitudes? Has the case worker any obligation to help the client to be his best self, or merely to be himself? If we grant that we start f r o m where the client is, and w i t h what he has, do we expect progress f r o m him? The social worker's concern with such concepts as the good, the desirable, the constructive may be f r a n k l y faced and debated. T H E O C R A T E S RECORD

Ι Ι . Ι 9 . 2 9 — M r s . Theocrates at Registration Bureau to ask f o r assistance. H e r husband has been ill with tuberculosis f o r

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about a year, and six months ago was sent to Phoenix, Arizona, by his Union. [Syllabus reference: K N O W L E D G E , Medicine, communicable disease.] The Union has been supporting the entire family during this time. They have now told Mrs. Theocrates that while they will continue to help Mr. Theocrates, they cannot do anything for her. Mrs. Theocrates is unable to go to work because of two small children. Social Service Exchange reports no record. Telephoned district referring case and a call was promised. 11.22.29—Visited. Mrs. Theocrates is a short, dark little person with typical Greek features. She had paid little attention to her appearance, as her oily black hair was pinned carelessly and her clothes, though fairly clean, gave an effect of disorder. She was pale, even through her dark olive skin, and her manner was nervous and worried, which did not add to the comprehensibility of her inadequate English. Home:—The apartment consists of three rooms—kitchen, bedroom, and living room of medium size. Four windows open on the street. Furniture is crowded, piles of clothes were about, and the general effect was disorderly but not dirty. The kitchen arrangements, shelves, etc., were neater than those in the other rooms. Mrs. Theocrates was evidently greatly disturbed by her situation, and by the necessity of asking aid, though she wished to be assured immediately that relief would be forthcoming. She was willing to tell her story, but her incoherence made it hard to follow and she showed throughout indefiniteness as to names, dates, and addresses. [Syllabus reference: M E T H O D , Social study.] She was born in Greece, Mr. Theocrates in Turkey. Both came to America at the age of 18 (c. 1 9 1 9 ) though at that time they were not acquainted. Her brother, Anthony Polydoros, had been in America some years when she arrived, but now he is in Greece.

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[Syllabus reference: KNOWLEDGE, Cultural b a c k g r o u n d . ] Mr. Theocrates has had no relatives in America. Mrs. T h e ocrates lived f o r some years in B r o o k l y n , where she still has many friends. She supported herself by sewing; worked f o r the B a b y Dress Co. M r . Theocrates got a position as a printer and stayed with the same c o m p a n y f o r 1 0 years. Five years ago they sent him to Philadelphia, where he stayed a year or so; then he returned. It was a f t e r this return that she met M r . Theocrates and they were married J a n u a r y 16, 1 9 2 7 , in the Greek Catholic C h u r c h . T h e y settled in the apartment where Mrs. Theocrates now lives. Mr. Theocrates had never been strong, but he had worked constantly, and at the time of his illness last winter was m a k i n g $ 3 0 a week. There seems to have been some employment dissatisfaction, f o r Mrs. T h e ocrates said several times that he should have been making $65 a week but he was not given the usual number of machines to run. Visitor gathered that his employers considered him too delicate to do f u l l w o r k , but Mrs. Theocrates said he did extra jobs to help others and might as well have got the pay. H e had had a cough f o r some time and finally she persuaded him to go to a doctor (name and address u n k n o w n ) who gave him treatments f o r enlarged tonsils, but did not stop the cough. Then he went to D r . Nikolas w h o immediately took X - r a y s (fee $ 1 5 ) and pronounced M r . Theocrates tuberculous. [Syllabus

reference:

KNOWLEDGE,

Medicine,

communi-

cable disease.] D r . Nikolas had attended Mrs. Theocrates at her first confinement,

and she had confidence in him. T h e report sent to

the Union resulted in plans to send M r . Theocrates immediately to the Union's H o m e , Phoenix, Arizona. T h e Union paid his expenses and his firm gave him $ 1 0 0 . H e went in May. Mrs. Theocrates was five months pregnant with her second child. She lived on money that Mr. Theocrates had saved, and her friends helped her, notably Miss Mary Polydoros. D r . Nikolas attended her at the confinement September,

1929,

and charged her $ 2 5 . She was confined at home. She has been

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under the care of D r . Nikolas since that time, and owes him at present $ 1 0 , her only outstanding debt. Mrs. Theocrates evidently confused, in this conversation, the ideas of what the (Jnion had done and it was impossible to get a clear idea of this situation. A t least she can now get no help f r o m the Union. She reported to the Family Society, at the suggestion of Miss Polydoros, since she is without resources except f o r $ 1 0 in cash. She had hoped to be able to move, since she feels that $35 is too high a rental, but the babies have kept her tied down and even now she does not see how she could manage to move. T E A C H I N G N O T E : In this case we have presented a situation involving a request for financial assistance because of presumable resourcelessness. Mrs. Theocrates claims that she is without means and looks to the community for aid. Theoretically the skilled worker should distinguish a case of practical need from one suggesting emotional need, permit the client to state his needs as he sees them and assist him to evaluate his own resources as rapidly as possible. Actually we sec that the case worker is not accustomed to consider Union benefits, is unfamiliar with cultural customs as to help from friends and neighbors, tends to take the statements at their face value without leaving enough responsibility with the applicant. Cultural barriers and language handicap tend, moreover, to slow up the necessary penetration by client and case worker into the real nature of the disturbance. Achates:—The

younger child, 2^2 months, is an attractive,

healthy-looking baby. H e howled through the interview e x cept when visitor or his mother held him. Mrs. Theocrates nurses him, and wants to continue to do so—one reason she feels that she cannot w o r k now. She said that since she became so much worried the baby has been cross; before that time he was good. Mike:—The

older child was asleep in the little bedroom. H i s

mother described him as " a little d e v i l , " so he must be active and mischievous. H e had a bottle, and when visitor expressed surprise at this Mrs. Theocrates said he did not like to drink out of a cup. H e eats everything his mother does. Mrs. T h e -

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ocrates expressed fondness f o r the children, but feels that the responsibility is too much for her. "Married 3 years, 2 babies. T o o quick. T o o much, me alone," was her analysis. She is evidently devoted to M r . Theocrates. She showed with pride his picture in a fez. She tries not to w o r r y over his condition, but thinks he would keep the worst f r o m her. H e writes that he is feeling well. She had many letters from him, but could not find the one in which he referred definitely to his foreman at the printing establishment. She seemed to feel that in Mr. Theocrates' case the prognosis was favorable but she was not sure, and realized that tuberculosis is very serious.

TEACHING NOTE: In this case we see that, aside from the knowledge of community resources, local conditions, etc., the case worker should have a reasonable familiarity with Greek mores. It is not so helpful to observe that a person has "typical" Greek features as to notice the peculiarity that Mr. T. is said to have been born in Turkey, is represented as wearing a fez, etc., or to be prepared for a good deal of kinship supervision of a Greek woman living alone. The student may be referred to The Polish Peasant, by Thomas and Znaniecki, for the methodological note in the Introduction to Volume I. The student may indeed find this case useful in understanding what social personality, as distinguished from individuality, is, and that one cannot treat persons or families in vacuo. Professional knowledge, other than of ethnology, would include enough medicine to understand the general characteristics of tuberculosis, communicability, hygiene, regimen, and immunity building for the children, the question of climate and how to use medical reports. As we may see, by referring to the correspondence of April 18th, the medical interpretation is neither adequate nor illuminating. 1 1 . 2 5 . 2 9 — T e l e p h o n e d M r . C o x of the Union who said that in J u l y M r . Theocrates came to the Relief Department of the Union much disturbed over his condition, and insistent that he be sent a w a y immediately. M r . C o x had to show him that appearance before the Union Committee

and a statement

from their doctor was necessary. T h e case turned out to be urgent, and M r . Theocrates was sent to the Union H o m e at Phoenix. [Syllabus reference: RESOURCES, Labor unions, hospitals.]

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357

I t is not the practice of the U n i o n to subsidize families. Because of Mrs. Theocrates' exceptionally needy condition she w a s g i v e n $ 2 5 about a m o n t h ago, but no regular relief has been g i v e n . Telephoned secretary of the U n i o n as per M r . C o x ' s instructions, and f o u n d that there is no record of M r . Theocrates* h a v i n g been e m p l o y e d in a p r i n t i n g establishment f r o m J a n u a r y , 1 9 2 9 . In f a c t , f r o m that time he paid to the U n i o n the vacation rate of $ 6 . 1 4 a m o n t h , w h i c h w o u l d be evidence that he was either w o r k i n g at another business or was not w o r k i n g . Health.—11.26.29—Dr.

N i k o l a s has k n o w n the Theocrates

f a m i l y only six months. Mrs. Theocrates came to him w h e n she was pregnant w i t h Achates. H e first saw M r . Theocrates 7 . 8 . 2 9 . A t that time M r . Theocrates' s y m p t o m s were w e a k ness, loss of w e i g h t , night-sweats. H e had been going to v a r i ous doctors f o r some months, and D r . N i k o l a s could not understand w h y tuberculosis had not been immediately diagnosed. E x a m i n a t i o n revealed rales in both upper lobes of lungs, and the diagnosis was bi-lateral tuberculosis w i t h

positive

sputum, [Syllabus

reference:

KNOWLEDGE,

Medicine,

communi-

cable disease.] D r . N i k o l a s helped to rush the case, as he f e l t that immediate removal f r o m this climate was necessary. H e receives reports f r o m A r i z o n a . M r . Theocrates is at present showing improvement. H e is out of bed, and is being allowed to g o about t o w n . H i s f e v e r has subsided. D r . N i k o l a s feels h o w ever that recovery, if it occurs, will be a matter of years. Mrs. Theocrates is not aware of the seriousness of her husband's condition. She herself greatly feared i n f e c t i o n , but D r . N i k o las considers her a strong w o m a n , in good condition. H e delivered Achates at a nominal fee. Mike, the older child, has tuberculosis of the skin. A t D r . N i k o l a s ' advice Mrs. Theocrates took him to the X a v i e r H o s pital, but D r . N i k o l a s f e l t that the treatment was superficial, and advised her to take him to the skin clinic at Y o r k e H o s pital. H e does not k n o w whether or not she has done this.

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[Syllabus reference: KNOWLEDGE, Medicine, contact case.] D r . Nikolas k n e w v e r y little of Mr. Theocrates' employment situation, except that he had apparently aggravated his condition by overtime and extra work. H e knows that the Theocrates have many friends, but is not personally acquainted with any of them. H e thinks that the Theocrates have been improvident, living u p to every cent of their income when Mr. Theocrates must have earned a good wage. H e mentioned a brother of Mr. Theocrates' w h o is living in Jamaica. D r . Nikolas did not k n o w his address, but has been trying to get hold of the brother, as he suspects him to be likewise tuberculous. D r . Nikolas said that the brother is penniless and shiftless, and that the Theocrates have probably been ashamed of him. 1 1 . 2 6 . 2 9 — V i s i t e d . M r . and Mrs. Blank, a nice looking y o u n g Greek couple, were present, evidently awaiting call. T h e y are intimate friends of the Theocrates', having k n o w n them f o r over three years, and are disturbed over the present situation. Mr. Blank's English is f a i r , but Mrs. Blank's main contribution to the conversation was dramatic gestures and repetition of " H e l p this w o m a n . " A c c o r d i n g to M r . Blank the Theocrates have always lived well and been independent. M r . T h e ocrates was a hard w o r k e r , devoted to his f a m i l y . M r . Blank did not k n o w , off hand, the firm f o r which Mr. Theocrates worked but volunteered to find out f r o m friends. T h e discovery of the serious nature of Mr. Theocrates' illness came like a thunderbolt, and Mr. B l a n k had to help persuade Mr. Theocrates that there was nothing f o r him to do but to get to another climate. Mr. Theocrates cried like a baby over having to leave his w i f e in her condition, seven months pregnant. Mr. Blank did not mention specific aid given Mrs. Theocrates, but implied that he had helped as a matter of course, and Mrs. Theocrates added to the effect b y repetition of "these

good

f r i e n d . " M r . Blank has f a m i l y responsibilities, a two-year-old child, and his w i f e is 8 months pregnant. H e r condition has kept her f r o m helping Mrs. Theocrates with her w o r k . T h e Blanks visit Mrs. Theocrates f r e q u e n t l y and he can be sum-

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359

moned as interpreter when necessary. H e seemed to agree that Mrs. Theocrates is paying too much rent, but saw no possibility of her m o v i n g within the near f u t u r e . H o w e v e r , should she decide to do so, the Blanks will help as they can. A t visitor's mention of M r . Theocrates* brother in Jamaica, Mr. Blank immediately became defensive, he k n e w nothing, nothing about him, has never seen him, has heard only that he cannot help. Mrs. Theocrates* eyes snapped when

she

understood the subject under discussion, and she talked e x citedly in Greek to M r . Blank. A p p a r e n t l y she was not pleased over the discovery of this relative. Visitor said f r a n k l y that D r . Nikolas had mentioned him. Neither M r . Blank

nor

Mrs. Theocrates k n e w the brother's address. Mrs. Theocrates seemed to say that f o r over a year she had not heard of him. Mrs. Theocrates had only $2 l e f t of her $ 1 0 , so visitor left $3 to cover running expenses until 1 1 . 2 9 . 2 9 . Both 2-year-olds were required to shake hands, and Mr. Blank and Mrs. Theocrates shouted appreciation f r o m the upper hall until visitor reached the f r o n t door. 1 1 . 2 8 . 2 9 — S t a t e m e n t issued by Supreme C o u r t First Judicial District showed that J o h n Theocrates filed a citizenship petition. [Syllabus reference:

KNOWLEDGE,

L a w , immigration.]

T E A C H I N G N O T E : The need of understanding social legislation both in theory and in practical administration may be noted. Naturalization procedures, immigration regulations, eligibility for Mother's Allowance become part of the case worker's every-day knowledge— frequendy or infrequendy called upon. In this record steps in various applications are omitted because of identification elements. 1 1 . 2 8 . 2 9 — C a l l e d at Board of Child W e l f a r e and learned that Mrs. Theocrates will be eligible f o r an allowance. [Syllabus reference:

RESOURCES,

Organized practice.]

1 1 . 2 9 . 2 9 — V i s i t e d . M a r y , a sister of Mrs. B l a n k , was with Mrs. Theocrates helping with the babies. She speaks no English. Mrs. Theocrates was eager to get Board of Child W e l f a r e allowance, but a little resentful over the idea of taking out citizenship papers, since Mr. Theocrates is a citizen. H o w e v e r ,

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she agreed to make the application if visitor will help her. Visitor asked to see Mr. Theocrates* papers. Mrs. Theocrates at first seemed to think he had them with him, hesitated and became confused. Visitor said that she would write to Mr, T h e ocrates but that it w o u l d mean a delay in the allowance. Mrs. Theocrates

then reluctantly

produced a statement

which

showed that the father of M r . Theocrates is an American citizen, which means that M r . Theocrates did not even have to be naturalized. H a v i n g previously been told that M r . Theocrates had no relatives in America, visitor showed much surprise over the statement. Mrs. Theocrates became agitated, and stated that her father-in-law hates her, did not w a n t Mr. Theocrates to m a r r y her because that would absorb M r . Theocrates' income, part of which had before been paid to the father. Mrs. Theocrates said repeatedly that the father-in-law would not give a cent, and she seemed to fear that visitor would reveal their condition to him. H e is now in Florida—she does not k n o w the exact address. H e has not helped his son at all in this illness. " B a d trouble. H e no like m y husband no m o r e , " said Mrs. Theocrates. It seemed best to let the matter drop f o r the present. Mrs. Theocrates does not k n o w the name and address of her landlord, but she promised to have him write them on a slip of paper when he calls. 1 2 . 1 . 2 9 — M r s . Theocrates seems to feel more strongly than before that she cannot move just now. She has a great deal of f u r n i t u r e , which would not fit into a smaller apartment, and she did not see when she could get out to look f o r other rooms. She did not mention the f a c t that the lock to the f r o n t door of the building works f r o m her rooms upstairs, but visitor feels that this is a great attraction to her, as she is nervous about being alone with the babies. [Syllabus

reference:

KNOWLEDGE,

Ethnology,

cultural

background.] L e f t Mrs. Theocrates $ 1 0 f o r food until 1 2 . 4 . 2 9 ; also this is to cover a milk bill f o r $3 due 1 2 . 1 . 2 9 . 1 2 . 5 . 2 9 — T e n t a t i v e plan. T e m p o r a r y allowance is to be ar-

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3^1

ranged f o r Mrs. Theocrates, not including rent. $ 3 5 is too high a rental, but it seems advisable to keep Mrs. Theocrates where she is f o r at least a month longer as she is timid about moving into u n k n o w n quarters and feels that this might be dangerous f o r the babies at this season. A l l available resources should be investigated with a view to making u p this rent. Miss N o r m a n of International Institute will perhaps give practical i n f o r m a tion regarding Greek resources. Friends m a y help, and M r . Theocrates' U n i o n can be approached. 1 2 . 5 . 2 9 — V i s i t e d . Mr. Blank was present, having been summoned by Mrs. Theocrates to address a package to M r . Theocrates in Arizona. M r . Blank acted as interpreter f o r the

filling

out of the application f o r first citizenship papers f o r Mrs. Theocrates. Discussed the matter of rent with Mr. B l a n k . H e agrees that Mrs. Theocrates is paying too much, but felt, a f t e r a discussion with her, that it would be advisable f o r her to remain where she is until the weather is warmer. She is afraid to move the two babies into u n k n o w n quarters at this season. In the Spring a different arrangement can be made, and Mr. Blank thinks that Mrs. Theocrates will be willing to get janitress work to cover part of her rent. Mr. Blank has already seen the landlady, and has promised her that he will see to the payment of the rent. H e can get other friends to help and believes that the Union will likewise contribute something. A d d e d to what the Family Society can do, the amount will thus be made up. Clinic card f o r X a v i e r Hospital f o u n d f o r Mike. Mrs. Theocrates wishes to continue treatment f o r Mike under advice as to clinic. L e f t Mrs. Theocrates tentative planned allowance of $9 to cover food, fuel, milk f o r one week. She particularly asked Mr. Blank to express to visitor her gratitude. A r r a n g e d to call 1 2 . 7 to take Mrs. Theocrates f o r picture required in connection with application f o r first citizenship papers. [Syllabus reference:

METHOD,

Executive treatment.]

Relief $9. Called Committee f o r Tuberculosis Relief. R e f e r r e d to Free Milk F u n d f o r Mike.

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T E A C H I N G N O T E : The class may be interested in distinguishing the several kinds of treatment used and discussing the validity of each. We have just seen the case worker engaged in the executive mobilizing of resources and may consider whether too much responsibility is assumed, too much relief offered, etc. We also sec the beginning of another sort of treatment in the health care of the children. Here the actual arrangement of clinic service is supplemented with teaching and interpretation by the case worker as to the use of medical facilities. And we also may distinguish one of the oldest of social case-work treatments—"not alms but a friend." The value of the slow-growing relationship here furnishes a good point of discussion. Is the social worker merely an indulgent parent or is something more developing for the client emerging? It is clear that "social manipulation" rather than "therapy" is characteristic of the course of treatment as a whole. 12.7.29—Visited. While Mrs. Theocrates prepared to go out to have her picture taken, she discussed the development and intelligence of Mike. Mike started talking at eleven months; at twelve months he walked. H e has never been really ill. A t birth he weighed eight pounds, and Mrs. Theocrates nursed him until he was nearly a year old. Mrs. Theocrates showed a long list of records f r o m the B a b y Health Station, showing that she took Mike there regularly. A t the last recording, he weighed thirty pounds. H e did not start teething until late ( 1 0 mos.) and then got his teeth very rapidly—at the rate of one a week. H i s gums had to be lanced several times. A t present he has f o u r teen teeth. Though he will not be two until 1 . 1 1 . 3 0 , Mike speaks Greek very fluently, and knows many English words. H e learned immediately that visitor does not

understand

Greek, so always addresses her in English. Mrs. Theocrates wishes him to learn both languages. [Syllabus reference: METHOD, Social study, developmental history.] O f her own accord Mrs. Theocrates discussed the apartment, and said that in several ways it is not satisfactory. There is no place to keep any quantity of coal, so she has to b u y h u n dred pound bags, though she knows that this is not economical. The coal stove provided by the landlord does not draw

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well, and Mrs. Theocrates finds it necessary to light the gas oven f o r heat when she is bathing the baby. She is not allowed to keep the baby carriage in the hall. She will not be sorry to move when the time comes. While waiting in the kitchen, visitor counted the cooking pots in evidence, 1 6 in all; ten were hanging on the wall, immaculately scrubbed even to the bottoms. T h e clothes which Mrs. Theocrates produced for the baby and f o r Mike were spotlessly clean. She does all her own washing. T o o k Mrs. Theocrates to Studio, f o r identification picture. Greek woman friend, sister of Mrs. Blank, stayed with baby. She took Mike, clad in a nice-looking white wool coat which she herself had made. Mike could not walk all of the w a y , but Mrs. Theocrates refused to let visitor help with him, saying, " H i s mother get tired, all right. N o t you get tired." Paid $ i f o r pictures, five f o r money order accompanying application. Paid $6. 1 2 . 9 . 2 9 — T e l e p h o n e d various places and

finally

established

Mrs. Theocrates' entrance and manifest number. Application sent to District Director of Naturalization. 1 2 . 1 1 . 2 9 — C a l l e d on Mr. L a k e at Union asking that the U n i o n contribute toward Mrs. Theocrates' rent. Explained our reasons f o r feeling that Mrs. Theocrates should be allowed to remain

at present address until warmer weather. Mr.

Lake

agreed that the Theocrates f a m i l y deserves help. H e will be glad to give advice or information when he can, but the matter of f u r t h e r relief rests with the Benefit Committee. Mr. Lake's records show t w o donations to Mrs. Theocrates of $25 each, dated respectively 8.9.29 and 1 1 . 8 . 2 9 . Letter dated 1 2 . 1 1 . 2 9 to Free Milk F u n d for Babies. 1 2 . 1 2 . 2 9 — L e t t e r to X a v i e r Hospital asking f o r report on Mike: A client of ours, M i k e Theocrates attended y o u r clinic, 8 . 3 . 2 9 , and received attention f r o m D r . M . H i s clinic number is 9000. M i k e was at that time about 18 months old. H e was sent to the clinic by Dr. Nikolas.

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May we have a diagnosis of Mike's condition at that time, and also a prognosis to help us in future treatment of this case? Was Mike's condition infectious? This is important as there is now a younger baby in the family. Mrs. Theocrates speaks broken English and may not have understood instructions as to special care Mike might need, so we should appreciate your advice on this matter. The Theocrates case has only recently been referred to us. Thanking you for any information you will be able to give us.

1 2 . 1 2 . 2 9 — V i s i t e d . Discussed Mike's diet with Mrs. Theocrates. Mike eats a general diet, drinks a good deal of milk, and always has a good appetite. Mrs. Theocrates has been giving the baby six ounces of milk and water, half and h a l f , every six hours in addition to his breast feeding. H e showed a tendency to vomit her milk, so D r . Nikolas, to w h o m she telephoned, prescribed this supplement to his diet. T h e condition is improved and the baby is less restless at night. Mr. Theocrates' improvement is encouraging. A t first the doctors did not consider him strong enough to stand "injections f o r the purification of the blood," but now he is having three a week and is standing them well. 3 H e is feeling well, and is continuously able to be more active. Mike responded as usual to the mention of daddy and pointed to his picture and the latest letter. Mrs. Theocrates says that when no letter comes in the morning Mike goes straight to his father's picture and asks him " h o w come no letter, d a d d y ? " A l l her friends tell her that Mike's development is precocious. T h e Blank child, three months older, says only a f e w words. (It is typical of Mrs. Theocrates' English that at first she said the child was three. It was only because worker knew that this was not true that she got the correct age.) Mike refers to this child as " c u c k o o " when he docs not answer. Mrs. Theocrates produced t w o bills, gas (one m o n t h ) $ 1 . 3 8 , ' W e h a v e n o t i c e d the p h r a s e " i n j e c t i o n s f o r t h e p u r i f i c a t i o n of t h e b l o o d " used b y t h e c l i e n t . W e m a y a s s u m e t h a t t h e w o r k e r is also f a m i l i a r w i t h t h e c o l l o q u i a l i s m , and that

she q u e s t i o n s its s i g n i f i c a n c e . T h i s

suggests t h a t the social w o r k e r

must

not o n l y h a v e some k n o w l e d g e o f m e d i c i n e , b u t m u s t b e a l e r t t o t h e c l i e n t ' s i d i o m s f o r e x p r e s s i n g his d i f f i c u l t i e s .

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electricity ( t w o months) $ 2 . 6 6 . She was able to explain the expenditure of her last week's allowance, and seemed to feel some pride in the achievement. L e f t $9 as usual, and told Mrs. Theocrates that some arrangement would be made for the payment of her fuel bills. Mrs. Theocrates thanked visitor heartily. A s her confidence grows she is becoming increasingly cordial. H e r manners show evidence of breeding. She insisted on hanging visitor's coat on a hanger and carefully selected the warmest place in the kitchen so that it would dry as much as possible. A l w a y s she calls Mike to bid visitor goodbye, and insists jokingly that the "good hand" be presented if handshaking is in order. [Syllabus reference:

KNOWLEDGE, Ethnology,

manners.]

Paid $9.00. 1 2 . 1 3 . 2 9 — L e t t e r to newspaper asking for assistance: Mr. Lake of Union has referred us to you regarding the situation of Mrs. John Theocrates. Last J u l y Mr. Theocrates was sent to the Union's Home in Phoenix with tuberculosis. On 1 1 . 2 0 . 2 9 , Mrs. Theocrates applied to us f o r aid, and since that time we have been arranging for the maintenance of the family, which at present consists of Mrs. Theocrates and two babies under two years of age. When Mrs. Theocrates gets her first citizenship papers she will be eligible for an allowance from the Board of Child Welfare, but this matter may involve some months. She is paying thirty-five dollars a month for rent, which is more than we usually consider advisable for a family of this size. She has been unable to move because the younger child was born only in September, and we feel that it would be unreasonable now to urge her to take her two babies into unknown quarters in midwinter. Moreover, she has been so protected up to this time that it is hard for her to adjust to her new responsibilities, and she feels more secure in the home in which she has lived for all of her married life. She does plan, though, to find another home when the weather is warmer. Would it be possible for your Benefit Committee to assign some funds to help this situation? We feel that this family is in every way deserving, that Mrs. Theocrates with her unusual responsibilities complicated by inadequate English, needs special help at this time.

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In your reply we should greatly appreciate a statement of the places where Mr. Theocrates was employed for the year preceding his departure. T o date it has been impossible to get this information. We shall greatly appreciate your cooperation in these matters. [Syllabus reference: RESOURCES, Facilities, relief f u n d s . ] 1 2 . 1 3 . 2 9 — L e t t e r from Xavier Hospital: Mike Theocrates was brought to this clinic on August 3rd, j t h and 12th, 1929. The diagnosis was pustular dermatitis. Ammoniated mercury ointment was prescribed, and a special printed diet list was given to his mother. A week later the patient returned to the clinic and was slightly improved. He has not been seen since August 12th, so it is impossible to say what his condition is now, or to give any prognosis. He should be brought to the clinic again with someone who understands English, in order that more complete instructions and information may be given. 1 2 . 1 6 . 2 9 — L e t t e r from newspaper: In reply to your letter of December 13 th will have same brought to the attention of the Shop Club Members this Friday night. Mr. Theocrates had worked for A. and A . for the past three or four years. If the Board of Governors should take any action, at our meeting of the Shop Club this week, I will be pleased to inform you of such. 12.18.29—Called

on Miss N o r m a n , International Institute.

She said that the priest at St. Sophia, the church which Mrs. Theocrates attended, is known to be generous with relief, but that the Greek Catholic Church has no organized system for dispersing funds, since no regular payments are required of parishioners. She couldn't suggest other resources which might be used for Mrs. Theocrates and remarked that it was strange that Mr. Theocrates had not already appealed to St. Sophia, as the Greeks usually exhaust all possibilities within their own race before appealing for charity. She advised a visit to St. Sophia but suggested that it be postponed until after the Christmas rush. She feels that Mrs. Theocrates pays far too

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much rent and that she m a y be taking r e f u g e in the m y t h , " W e Greeks do not move in w i n t e r . " She suggested w a r m sunny apartments on the East Side near other Greeks; these m a y be procured f o r about $20 per month. Explained about Mrs. Theocrates' present heavy responsibilities, her insecurity, and her promise to move in the spring. Miss N o r m a n took Mrs. Theocrates' present address. One quart Grade Β milk to be sent daily to Mrs. Theocrates f r o m Free Milk Fund. 1 2 . 1 9 . 2 9 — T e n t a t i v e plan. It was decided to let friends and other resources—Union, employer—take f o r the present the responsibility f o r Mrs. Theocrates' entire rent. Visitor will communicate with Mr. Blank concerning this matter. Mrs. Theocrates can pay her gas bill f r o m the allowance since her milk bill will be reduced, and the payment of bill f o r electricity will be postponed until early J a n u a r y . Visited. Assured Mrs. Theocrates that Grade Β Milk is satisf a c t o r y f o r Mike, and that it was not sent b y mistake f r o m the Free Milk F u n d . Explained the use of the milk tickets, as Mrs. Theocrates was unable to understand the letter sent f r o m Free Milk Fund. Mrs. Theocrates proudly reported that her expenditure f o r food f o r the week came well within her allowance, but added that she would keep the surplus f o r food, as she might have to spend more on staples in another week. H e r own appetite is good, and she realizes the necessity f o r eating well and regularly while she is nursing the baby. She readily grasped the idea of paying the gas bill f r o m the milk money saved, and visitor took over the bill f o r electricity. Paid Mrs. Theocrates $9. [Syllabus reference: METHOD, T e a c h i n g . ] Mrs. Theocrates did not react f a v o r a b l y to the proposition that she might take a lodger to help with her expenses. She has no friends whom she might receive, and she feels that it would be impossible in her present apartment to provide privacy either f o r herself or f o r a stranger w h o would be renting the room. This is a reasonable objection, as she has no hallway and

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her rooms all open into each other. A l s o Mrs. Theocrates feels t h a t the p r o b l e m o f g e n t l e m e n guests f o r any lady lodger w o u l d be i n s u r m o u n t a b l e . She is sure that M r . Theocrates w o u l d n o t w a n t her t o have strange men in her house. T E A C H I N G N O T E : Here, after a month under care, we may ask whether the worker understands the situation enough for practical purposes; whether relief was wisely given or should have been withheld; whether the language difficulty justifies the slowness in getting under the resistances of the client? At what point in a case should an allowance be arranged? Was the suggestion that Mrs. Theocrates take a lodger naive, or a piece of interviewing strategy? What is the practice of the class as to direct questions? Is there a place for direct questions in social study or should one wait until the client reveals himself and his needs of his own volition? 1 2 . 2 3 . 2 9 — C a l l e d at office o f A . and Α . , f o r m e r employers of M r . Theocrates. Miss Jones, o f the e m p l o y m e n t

department,

remembered M r . T h e o c r a t e s as a good w o r k e r and a t h o r o u g h l y likable person. She is h o l d i n g some m o n e y f o r him in the E m p l o y e e s F u n d , b u t its disposition is n o t in her hands. She will c o n f e r w i t h her employers about a p p l y i n g this s u m — s h e did n o t disclose the a m o u n t — t o the u r g e n t matter of

the

T h e o c r a t e s ' rent, a n d she thinks that additional aid m a y be f o r t h c o m i n g f o r this purpose. She was m u c h interested in the w h o l e T h e o c r a t e s situation. She promised to w r i t e or to phone visitor c o n c e r n i n g the result o f her c o n f e r e n c e w i t h her e m ployers. 1 2 . 2 6 . 2 9 — V i s i t e d . Mrs. B l a n k was calling. G a v e Mrs. T h e o c rates envelopes f o r the various items included in her b u d g e t — gas, coal, electricity. E x p l a i n e d about s a v i n g b y the week f o r the m o n t h l y bills, and asked Mrs. Theocrates t o write " g a s , " " e l e c t r i c i t y , " etc., in G r e e k on the envelopes. She was i n t e r ested, b u t seemed t o feel that the savings of such small sums is trivial. [ S y l l a b u s r e f e r e n c e : METHOD, T e a c h i n g . ] She has received an a c k n o w l e d g m e n t o f her application f o r citizenship papers, b u t visitor explained that this is not the papers themselves, nor does it entitle her to Board of C h i l d

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Welfare allowance. Mike walked into the dark dining-room and called his mother in Greek to show visitor the Christmas tree. Mrs. Theocrates explained that the Blanks had trimmed it f o r her, using articles purchased last year. Mike climbed in a chair by visitor and touched her purse, whereat Mrs. Blank slapped him sharply. Mike was dismayed, evidently being unused to such treatment, and Mrs. Theocrates was not pleased, though she tried to pass the matter over. Paid $9.00. 1.2.30—Visited. Mrs. Theocrates reports that they have all been sick, Mike and the baby with slight colds and vomiting, she with a kind of grippe. A f t e r Mike had had two sleepless nights with a slight cough, which worried her because it was like Mr. Theocrates', she took him to D r . Nikolas. He said that a belated tooth was causing irritation, and that the cold was negligible. He advised her not to nurse the baby until she herself feels better, but to feed him the half and half milk and water, which agrees with him. He fears that Mrs. Theocrates* milk may be too rich for Achates. Mrs. Theocrates took both children today to the Baby Health Station, and found that they had made satisfactory gains in weight, and are in good condition generally. Mike now weighs 30 lbs., 8 02.., and Achates 10 lbs., 6 oz. Again the doctor at the station told Mrs. Theocrates that Mike's skin condition is not serious, but she wishes to take him for clinic treatment. Arranged to call for Mrs. Theocrates and Mike 9:30, 1 . 1 0 . 3 0 , so that he can attend clinic at Xavier Hospital. Mrs. Theocrates produced an elaborate menu of the Christmas dinner at Union's Home, sent to her by Mr. Theocrates. He is, at last report, feeling not quite so well, but he is still able to have the three injections weekly. Paid $9.00. 1.4.30—Telephoned Miss Jones of A . and Α . , asking f o r a report of her conference, regarding aid for Mrs. Theocrates. Mr. H . felt that since the Family Society is helping with the case he would prefer not to interfere. Explained that there is no question of interference, but rather of cooperation f o r a

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short time, in view of Mrs. Theocrates' urgent rent situation. Miss Jones felt that she had made the matter of the rent clear, but that he has decided not to help f u r t h e r . A t the time M r . Theocrates was sent to Arizona the firm gave him $200.00. T h e money held f o r Mr. Theocrates in the Employees F u n d , result of a raffle carried on at the office, was sent to Mrs. T h e ocrates 1 2 . 2 7 . 2 9 . It amounted to $30.00. Miss Jones was surprised that Mrs. Theocrates had not informed visitor of this donation. Miss Jones promised to communicate immediately with Society should she get any f u r t h e r information on the Theocrates situation, or should circumstances seem favorable f o r another appeal. Visited Mr. Blank. T h e Blanks live in a clean, respectable apartment house, on fifth floor f r o n t . T h e y appear to share a five- or six-room apartment with another Greek f a m i l y b y the name of Z. M r . Blank knew nothing of the donation to Mrs. Theocrates f r o m A . and Α . , but explained that he had not been able to visit Mrs. Theocrates f o r over a month. H e works f o r the Belmont Restaurants, and of late has been p u t ting in extra time. Described efforts to get help toward the Theocrates rent f r o m the Union and Mr. Theocrates' employers, and explained that we have been waiting to hear f r o m these sources before communicating with him. Told him to have Mrs. Theocrates understand that we would assume that the money f r o m A . and A . had gone toward the rent. H e agreed to do so, and seemed to feel that, since the Family Society is providing f o r Mrs. Theocrates* weekly expenses, it is only f a i r that the rent be made up f r o m other sources. P r o m ised Mr. Blank to let him k n o w of help that may be f o r t h coming f r o m Union or the C h u r c h , since he still appears to feel responsible in the rent matter. In telling of the recent illnesses of the Theocrates children, f o u n d that Mr. Blank agrees with the verdict of the doctor at the B a b y Health Station, w h o m he consulted about Mike's trouble. " T h e y feel that Mrs. Theocrates gives Mike too rich a diet, especially too much c a n d y . " T o l d Mr. Blank of plans to follow up Mike's trouble

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at X a v i e r Hospital where f u l l advice as to diet will be given Mrs. Theocrates, and asked him to cooperate in interpreting instructions to her and in helping her to realize the importance of carrying out the instructions to the letter. M r . Blank is greatly encouraged over M r . Theocrates' condition, as revealed in recent letters f r o m him. THEOCRATES

SUMMARY,

1.3.30

1 1 . 1 9 . 2 9 — M r s . Theocrates, a well bred Greek w o m a n , speaking little English, applied f o r assistance. She was practically without f u n d s f o r the support of herself and t w o babies under t w o years of age. M r . Theocrates has been, since 7.8.29, in the Union H o m e , Arizona. Economic

factors.—The

economic difficulty is paramount, as

there is no earner in this f a m i l y . Mr. Theocrates' illness completely incapacitates him and, though Mrs. Theocrates earned her living sewing before her marriage, she cannot work now because of the t w o small children. Mrs. Theocrates' attitude towards her husband's relatives, father and brother, is distinctly negative; their addresses are not available, and the brother, at least, is himself

reported destitute. T h e

rent,

t h i r t y - f i v e dollars a month, is disproportionately large f o r this f a m i l y , but it seemed inadvisable to aggravate Mrs. Theocrates' general feeling of insecurity in her situation b y forcing her to move her t w o babies into u n k n o w n quarters in midwinter. Health.—Mike,

aged two, though in good general condition

has tuberculosis of the skin needing careful attention. Mr. T h e ocrates' pulmonary tuberculosis was well advanced when first diagnosed, 7.8.29, and he was sent to the Union's H o m e f o r at least a year. T h e outlook is guarded f o r recovery. Assets.—Friends

are willing to help generously, and

both

Union and employers have a high opinion of Mr. Theocrates, both as a person and a worker. T h e y have in the past given financial

aid. Mrs. Theocrates has cooperated in arranging her

budget. She is able to make the children's clothes and is an ex-

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cellent homemaker. The reputation and status of the family are excellent. They have always lived well and paid their debts promptly. Mrs. Theocrates herself and baby, Achates, are well and strong. Interpretation.—A non-English speaking Greek woman, not a citizen, is left without support for herself and two babies, owing to the hospitalization of her husband who is suffering from tuberculosis; the older child has tuberculosis of the skin. The woman, being accustomed to depend on her husband for direction and financial support, now leans heavily on friends and on the Family Society. [Syllabus reference: M E T H O D , Diagnostic procedure.] Treatment, to date.—A temporary budget has been planned for Mrs. Theocrates' current expenses, exclusive of rent, and payment has been made on a weekly basis. Free milk was procured for Mike from Free Milk Fund. Application for first citizenship papers for Mrs. Theocrates was filled out and sent to Board of Naturalization so as to make her eligible for mother's allowance. Various resources— Union, Mr. Theocrates' employers—were approached with a view to their helping with the rent for the Theocrates family. Present situation and outlook.—Mrs. Theocrates is devoting her entire energy to the care of her home and children, and she seems to feel a little more secure in facing her problems. She conscientiously budgets her temporary allowance and gets along on far less than she spent when Mr. Theocrates earned $30 a week. Her correspondence with Mr. Theocrates is detailed and regular and she tries to keep Mike, an unusually bright child of two, from forgetting his father. She tries not to worry over Mr. Theocrates' condition but does not realize its seriousness. Her friends visit her but she goes out little and does not at present seem to feel the need of more recreation. She is not at present hospitable to the idea of supplementing her income by her own efforts, and considers her days well filled. She knows that she is expected to move in the Spring and has not objected to the plan. She appears intelligent and reasonably self-direct-

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ing b u t the outlook f o r the f a m i l y will depend in large part on the husband's condition. Platt.—To

c a r r y through the B o a r d of C h i l d W e l f a r e allow-

ance plan. T o arrange temporarily f o r p a y m e n t of rent f r o m other sources than the F a m i l y Society. W i t h independence f o r the f a m i l y as a goal, to arrange f o r Mrs. Theocrates ultimately to supplement her B o a r d of C h i l d W e l f a r e allowance by either doing janitress w o r k in a new location, or home sewing, and to encourage all e f f o r t s at selfdirection. T o check upon Mike's skin condition, and see that Mrs. Theocrates carries out instructions of X a v i e r Hospital and to continue dietary supervision. T o write M r . Theocrates e n c o u r a g i n g l y about his f a m i l y . T E A C H I N G N O T E : This summary or analysis is somewhat elaborate for the nature of the material, and suggests a student exercise. Just as earlier records contained all steps in social study written out in full, so we see in current records, under the drive to improve our diagnostic thinking and ability to interpret studies after we have made them, occasional over-emphases on analytical and evaluation summaries. As the diagnostic habit is acquired, however, just as when the general principles of social study are mastered, records, like the case-work study itself, become simpler, more flexible and more natural instead of cumbersome and self-conscious. The practice of recording treatment objectives may be discussed. T o what extent is it advisable to set down definite "goals"? Does this clarify thinking or stereotype action? 1 . 4 . 3 0 — O n the w a y to the clinic M i k e f r e t t e d , Mrs. T h e o c rates produced a small package of f r u i t drops f o r him. She stated, however, that he cares little f o r c a n d y , and would rather play w i t h it than eat it. H i s first move was to pass the package to visitor, and when he finally extricated a piece he insisted on t u c k i n g it into her hand. T h o u g h he kept the p a c k age thereafter he ate no c a n d y himself. Mrs. Theocrates was radiant over his good manners. W h i l e dressing Mike, Mrs. Theocrates told excitedly of her o w n accord of the donation

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f r o m A . and Α . , which she said arrived the day a f t e r visitor's last call. She said that she paid the rent " q u i c k , q u i c k . " The messenger, a Greek, brought the money, and said that A . and A . would help her f r o m time to time when she needs it, if she will let them k n o w herself. Congratulated Mrs. Theocrates and asked her to consider the help they would give her as part of the rent, and also to tell visitor and Mr. Blank of donations she might receive. She agreed with every evidence of sincerity to do this. Paid $9.00. 1 . 1 6 . 3 0 — W e n t with Mrs. Theocrates and Mike to Out-Patient Clinic of Y o r k e Hospital. H a d Mike listed as a free patient. T w e l v e doctors were called in to observe Mike's skin condition and although they did not state that his ears are now involved, they seemed to suspect trouble there f o r three or f o u r of them examined them thoroughly. A n ointment was prescribed to be applied to the sores 3 times daily and Mrs. Theocrates was instructed to keep Mike's ears warm. N o diet recommendations were made. [Syllabus reference:

METHOD,

Executive treatment.]

Mrs. Theocrates remained well-poised throughout the t r y ing ordeal with the doctors, during which Mike howled incessantly, but she wept quietly when she came out of the hospital saying, " I hope m y baby be w e l l . " Though she has not had Mike's condition explained to her, she suspects that his trouble resembles Mr. Theocrates'. Mr. Theocrates received f r o m his Union $2 as a weekly allowance, and he sends Mrs. Theocrates what he can save f r o m this sum. Last week he sent her five dollars, which represented a month's savings. Mrs. Theocrates bought some much-needed shoes f o r Mike, and a woolen cap f o r Achates. She says that Mr. Theocrates' great concern is f o r the children, that he writes her continually about their care. Mrs. Theocrates replied, " I tell him and tell him 'care f o r babies' that's what's doing all t i m e . " She asked visitor not to mention taking Mike to the hospital in the letter to Mr. Theocrates.

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Mrs. Theocrates believes that she can rent a room to an elderly Greek man whom she knows quite well. She would apply this money on her rent and would be glad to have such a person in her apartment. T E A C H I N G N O T E : T h e treatment in this case may be said to be largely of an "executive," "social manipulatory," nature, that is to say, concerned with the mobilizing of resources, management of a health program, etc., in which the purpose is meeting a material or physical need. W e find, however, definite steps in teaching and interpretation in regard to budgets, hygiene, American citizenship, etc. W e also find beginning a relationship—see entries 1.4.30 and 1.16.30—1.31.30 in which Mrs. Theocrates finds it more possible to be frank. It is quite evident that Mrs. Theocrates , circumstances might have been understood earlier by a more direct approach and the value of a simple and matter-of-fact technique in evaluating needs and resources should be discussed, but we may also observe those places in which the client's reserves and resistances break down voluntarily and a desire to reveal herself more honesdy seems to arise. Just as the student may distinguish methods of treatment, so too he may notice variations in social study ranging from an extremely restrained and controlled type of interviewing derived from psychological and psychiatric disciplines to an outgoing, objective investigation. T h e student mav see, even in so uneventful a case as this, that social case work permits at all points the highest degree of participation between client and worker, and whether the worker may be said to cooperate with the client or the client with the worker depends on a delicate balance of problem, time, capacity, and circumstance. Paid $9.00. 1 . 2 3 . 3 0 — V i s i t e d . Mrs. Theocrates white and worn with anxiety over Mike who became violently ill 1 . 1 7 . 3 0 , and on 1 . 1 8 . 3 0 was taken by D r . Nikolas to Y o r k e Hospital where he is still staying. H e had a high fever, his ear ran yellow pus, and blood appeared in the urine. W e n t with Mrs. Theocrates to Y o r k e Hospital. Found that Mike was entered as a free case. The nurse on the Babies W a r d said that Mike is improving, that his fever has subsided. The diagnosis is nephritis. The ear has stopped running. T o l d her of the tentative diagnosis given at Xavier Hospital. Mike will be kept at the hospital until his condition is cleared up; it is impossible to tell how long that

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will take. The nurse especially requested Mrs. Theocrates not to go to Mike as he becomes unmanageable a f t e r she leaves. For two afternoons after her visits he has cried until evening and upset the entire ward. Made Mrs. Theocrates understand this, and she agreed to peep at Mike only at a distance, so that he would not see her. Mike, realizing that other parents were calling and that his did not appear, cried quietly f o r his mother, but the nurse said that this was nothing compared to his performances on the other days. She pronounced him a much-spoiled child, but admitted that allowance must be made f o r a baby of t w o w h o has never been separated f r o m his mother, and cannot understand much of what is said to him. She arranges f o r a small Greek boy in the ward to talk to Mike occasionally, but says that Mike has usually no difficulty in letting them k n o w what he wants. Tried to reassure Mrs. Theocrates on the grounds of Mike's strong body and the improvement he is making in the attractive, sunny ward. Encouraged her to telephone visitor of any f u r t h e r developments. Paid $9.00. 1 . 3 1 . 3 ο — M r s . Theocrates at office with Achates. She reported that Mike is better, but that he has lost a good deal of weight. Tried to explain that this is favorable in Mike's case as his kidney trouble meant that the body was water-logged. She was happy to have been allowed to see him and talk with him, and said that she was able to make him eat more than he would take f r o m the nurse. Also that he cries not so much. Mrs. Theocrates' lodger now has his room in her apartment. She asked visitor if she thought seven dollars a month was good pay, and at visitor's suggestion that she ought to get at least ten dollars f o r the room, she said that this man is old, not making much money but that he would help her off and on as he could, and that she would rather have less money f r o m him than more f r o m someone she did not know. 4 'See Teaching N o t e (p. 375.)

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A b r u p t l y and w i t h some embarrassment Mrs. Theocrates seized worker's arm saying she must tell again about Mr. Blank who, it seems, is actually Mr. Zelim. Blank is the name of his w i f e ' s father, and the confusion probably arose f r o m Mrs. Theocrates' t r y i n g to make clear her long acquaintance with Mrs. Zelim as B l a n k . Mrs. Theocrates said f r a n k l y that she did not think it mattered, but that Mr. Zelim was eager to have the matter made clear to visitor. " I tell him sure you unders t a n d , " said Mrs. Theocrates with a broad smile. 5 T h e doctor at B a b y Health Station has given Achates a new f o r m u l a which is agreeing with him. Mrs. Theocrates e x plained her preparation of the oatmeal gruel. T h e proportions of the f o r m u l a are: milk 20 oz., gruel 14 oz., milk sugar 3 oz. Promised to go with Mrs. Theocrates to Y o r k e Hospital 2.6.30. Paid $9.00. 2.6.30—Visited. " M o r e trouble," called Mrs. Theocrates f r o m the bedroom. D r . Nikolas was examining Achates w h o lay wheezing on the bed. H e has double bronchitis and is likewise suffering f r o m a digestive disturbance, f o r his stomach was distended with gas. D r . Nikolas and Mrs. Theocrates kept up a running fire of rapid Greek. H e prescribed medicine f o r the baby and was evidently advising an enema. As he was about to leave, Mrs. Theocrates cornered him and asked a series of imperative questions. E v i d e n t l y she was trying to force him to give an opinion about Mike's skin condition. Finally D r . N i k o las asked worker to give an account of the visit to Y o r k e H o s pital and advised getting f r o m them a detailed diagnosis also getting the opinion of the dermatologist. H e said that he himself is practically sure of the tubercular nature of Mike's sores but he believes that several opinions should be obtained. W e n t with Mrs. Theocrates to Y o r k e Hospital, stopping on the w a y to purchase a small carton of ice cream f o r Mike. In spite of her accumulated difficulties, Mrs. Theocrates was in good spirits and told gaily of an amusing letter f r o m her husband. O n being requested to kiss his babies each one thousand 'Ibid.

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times f o r him, she had countered first with lack of time, and then that she had eaten garlic. H e had reminded her of the time of their courtship when he had always asked her to kiss him before she ate garlic. Mr. Theocrates always prefaces his remarks to her with a generic salutation as " w i f e " or " m o t h e r . " In his last letter he said " w i f e , who goes out w i t h you and helps with citizen papers and a l l ? " She answered, " I have Miss f r o m the Society. She always g o . " When worker suggested that friends helped also, Mrs. Theocrates stopped dramatically on a street corner and said, "Friends? That's good. T h e y help sometimes. B u t Miss f r o m the Society, she say she come, she come. She say pay money, she pay money. T h a t ' s better." Paid $9.00. [Syllabus reference: METHOD, Recording, style.] H O M E ECONOMICS O U T L I N E ,

Income.—The

2.6.30

Theocrates have had no regular income since

7.29, at which time Mr. Theocrates was sent to Arizona b y his Union because he had pulmonary tuberculosis. A s a printer he had made f r o m $ 3 0 to $35 weekly. Friends have given financial aid and one in particular has made himself responsible f o r the payment of the rent, $ 3 5 . 0 0 . The former employer of Mr. Theocrates gave assistance before, and since we have k n o w n the f a m i l y , has contributed thirty dollars toward the rent and given Mrs. Theocrates to understand that more aid will be forthcoming as she needs it. Mrs. Theocrates has a lodger, an elderly man w h o pays her seven dollars a month f o r his room. She thinks that he will pay more as she needs the money. Housing.—There

are four medium-sized rooms, all with out-

side windows. T w o rooms have two windows each, the other two have only one each. In the kitchen there is running water in a white sink and t w o stationary tubs of ordinary size. Water is heated by means of a boiler attached to the coal range. T h e toilet adjoins the kitchen, and is used only b y the Theocrates. Mrs. Theocrates has a small bathtub in which she bathes the babies.

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f u r n i t u r e is substantial a n d in v e r y

g o o d condition. In the kitchen are a r o u n d o i l - c l o t h c o v e r e d table, three g o o d kitchen chairs, a high chair f o r the b a b y , a small ice chest, and a c a n a r y

in its cage. T h e

dining-

r o o m is c r o w d e d w i t h a large b u f f e t , square table c o v e r e d w i t h a b r i g h t tapestry cover, a china closet, f o u r chairs, a n d a d a y bed on w h i c h Mrs. T h e o c r a t e s ' f r i e n d Miss Z e l i m sleeps w h e n she comes to stay w i t h the children. M r s . T h e o c r a t e s sleeps w i t h the b a b y in a large bed, and M i k e , aged t w o , has a small c r i b . T h e beds are kept v e r y clean, the b e d d i n g used consists of blankets and quilts in good condition. T h e beds are made a l w a y s in the m o r n i n g , and the sheets, etc. are r e m o v e d f r o m the d a y bed w h e n it has been used. T h e best f u r n i t u r e is in the r o o m w h i c h Mrs. Theocrates lets. She is a good housekeeper, and w h i l e the rooms appear o v e r c r o w d e d w i t h b u l k y f u r n i t u r e , mementoes, pictures, etc., t h e y are n e v e r d u s t y , and are not usually disorderly. Mrs. T h e o c r a t e s has both a coal and a gas r a n g e . She uses 2 5 0 to 3 0 0 lbs. of coal a w e e k , and this provides heat f o r the a p a r t m e n t . In cold weather she uses a little gas heater. H e r average e x p e n d i t u r e f o r gas and electricity is the same, $ 1 . 4 0 . She has an unusual n u m b e r of c o o k i n g utensils, sixteen of v a r y ing sizes, most of them h u n g against the w a l l a n d all shining w i t h cleanliness. T h e r e are the remnants of t w o sets o f dishes. O n e t y p e is k e p t in the kitchen wall c a b i n e t , a n d others in the d i n i n g - r o o m . T h e " b e s t " set is dark blue a n d gilt. T h e r e are f o u r or five kitchen towels in good c o n d i t i o n . T h e c l e a n ing e q u i p m e n t , b r o o m , s o f t brush, d u s t p a n , dusters, is k e p t in a small kitchen closet. Mrs. T h e o c r a t e s has an old sewing machine w h i c h she uses i n f r e q u e n t l y . Mrs.

Theocrates

changes of

and

the t w o babies all h a v e

clothing, i n c l u d i n g

complete

at least t w o sets of

night

clothes. Mrs. Theocrates makes an occasional g a r m e n t f o r the babies, b u t most of their c l o t h i n g has been b o u g h t

ready-

made. It is k e p t mended, and Mike's o u t g r o w n t h i n g s are used f o r the b a b y . Mrs. T h e o c r a t e s does all of her o w n w a s h ing, and dries it on the roof w h e n the w e a t h e r p e r m i t s .

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The Theocrates do not buy on the installment plan. Food is bought for cash, and Mrs. Theocrates does her own marketing. With no regular income except the weekly allowance, she is not able to save regularly. Food and nutrition.—Mrs. Theocrates buys the bulk of her supplies from the A . & P. keeping an eye out for sales. She buys a week's supply at once, and plans her meals in advance, though as she is the only adult in the family, they are not large or varied. She is fond of milk and cereals, soups, and canned vegetables, and, now that she is alone, she does not cook the elaborate Greek dishes that she made for Mr. Theocrates. She usually buys meat with an idea of making soup for Mike, and now and then cooks a chicken in this way for herself and Mike. Frequently there is cake on the buffet, and fruit. Mike has a skin infection which has been tentatively diagnosed as of tubercular origin, but the doctors have prescribed no special diet. A quart of Grade Β milk was procured for him from the Free Milk Fund. Mrs. Theocrates buys the baby a quart of Grade A in addition to this. Recently the doctor at the Baby Health Station, prescribed the following formula for the baby: milk 20 oz., oatmeal gruel 14 oz., milk sugar 4 oz. Mrs. Theocrates cannot always get the two babies out of doors every day, but she manages to do this at least every other day. She bathes the baby every day, Mike three times a week, and herself at least twice, changing underwear after each bath. She does not open her bedroom window more than a couple of inches at night, as it is north exposure. She herself has a good digestion, and sees that each of the babies has a bowel movement each day. [Syllabus reference: M E T H O D , Special study.] Expenditures.—An allowance has been given Mrs. Theocrates based on the following tentative plan: Food Milk Fuel Coal

$5.00 1.15 2.1 j

Gas Elect.

$ .35 .35

$9.00 Weekly allowance, $9.00

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2 . 1 0 . 3 0 — L e t t e r to X a v i e r Hospital g i v i n g report on Mike. 2 . 1 1 . 3 ο — W e n t with Mrs. Theocrates to complete arrangements f o r naturalization. C l e r k said that since Mr. Theocrates is a citizen Mrs. Theocrates can file application f o r second papers. 2 . 1 4 . 3 0 — T e l e p h o n e d Children's W a r d , Y o r k e Hospital, asking f o r report of Mike. H e is getting along nicely, and would be discharged in a f e w days were it not f o r the quarantine, due to a suspected case of scarlet fever. T h e doctors at Y o r k e H o s pital do not feel that Mike's skin trouble is of an acutely serious nature. There is no dermatologist on the staff, so they recommend a return to X a v i e r Hospital when Mike is well enough to go. Hospital social worker expressed regret that Mrs. Theocrates had not i n f o r m e d the doctors of the tuberculosis in the f a m i l y at the time that Mike was admitted. E x plained the language difficulty, and Mrs. Theocrates' distress over Mike's high temperature at that time. T o l d worker of having reported the health condition of the Theocrates f a m i l y immediately to head nurse on children's w a r d , in the absence of a physician. [Syllabus reference: METHOD, Interpretation.] Hospital social worker said that Mike has quieted down a great deal, and is quite f r i e n d l y with the nurses and the other children. H e still objects to drinking out of a cup, however. 2 . 1 4 . 3 0 — L e t t e r to U n i o n asking f o r a letter in re. Board of Child W e l f a r e application. 2 . 1 6 . 3 0 — L e t t e r f r o m J o h n Theocrates: I c a n n o t let g o u n n o t i c e d y o u r kindness t o m y w i f e a n d me, so I a m t a k i n g this o p p o r t u n i t y to express m y sincere a p p r e c i a t i o n of all that y o u h a v e done f o r us. A n y o n e so t h o u g h t f u l of the w e l f a r e of others deserves the highest praise, and I assure y o u t h a t y o u r e f f o r t s to m a k e o u r present s i t u a tion a little less hard to bear, h a v e filled o u r hearts w i t h the deepest gratitude. I t makes me f e e l t h a t there really is a Santa C l a u s , a f t e r all. W i t h best wishes, I a m ,

2.19.30—Visited. Mike at home looking thinner, but seeming

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alert and well. Mrs. Theocrates unable to complete application proceedings at Board of Child Welfare as she must take him to clinic at 2 P.M. She is very business-like in meeting obligations of this sort and is eager to follow the directions of the doctors. She fears, however, that because the nurse would not give Mike a bottle at the hospital he did not get enough milk, as he is stubborn in his dislike of drinking out of a cup. Her plan is to give him no milk in the morning when he is hungry until he will take it from the cup, and gradually to stop the bottles. She reported that after a good deal of argument on the subject Mike said in Greek, "Oh, give me the bottle when I go to sleep and I won't cry other times." Asked about diet recommended for Mike. He can have soups, chicken, mashed potatoes, orange juice and green vegetables. Noticed a dishpan of fresh greens in the sink. Mrs. Theocrates is pleased that Mike's appetite is better than it was before he went to the hospital, but she says he is nervous and fretty as he has never been before. He will not be comforted when she leaves him even for a few minutes. Achates' troubles appear to be over. Mrs. Theocrates nurses him only at night, and during the day feeds him a formula prescribed by Dr. Nikolas: 16 oz. milk, 9 oz. water, and four tsp. Dextri-Maltose. A f t e r a week of the oatmeal gruel formula he seemed to become constipated. He no longer vomits after eating. Asked Mrs. Theocrates about her rent and other expenditures, when she spoke of not being able to pay Dr. Nikolas yet. She owed only one month's rent, as with what her friends could do for her and what she saved during the absence of Mike she was able to make up the amount for January. But now she evidently finds that friends as resources are wearing η little thin. In her own words: "When you have money they look up at you. When poor they no see you." Asked specifically about Mrs. Blank and Miss Blank (now Zelim). Mr. Blank is not pleased because his sister, Mary, has chosen to leave his home and come to live with Mrs. Theoc-

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rates. He was very "fresh" to her, said Mrs. Theocrates, when she had no work. Four or five days ago she left him for good. Moreover, the hotel where he worked was recently raided and closed down, so he is temporarily out of work himself. Mrs. Theocrates is glad to have Mary Blank with her, as she can sleep on the couch in the dining room. She plans to charge her "not for sleep but for eat." Mary has already bought orders of groceries, etc. to pay for her keep. She has the promise of a position as fruit-packer in ten days or so. Asked whether her father-in-law had returned from Florida. As usual Mrs. Theocrates' eyes flashed. She told of a letter from Mr. Theocrates this morning in which he remarked in answer to some suggestion of hers (probably that he write his father) " M y father can go to hell!" However, Mrs. Theocrates seemed certain that Theocrates Senior is still in Florida. Mrs. Theocrates plans to make another appeal to the Union. She feels that the sight of herself with the two babies should be affecting, and plans to invade Mr. Lake's office with the offspring. Advised her to go first to the offices of A. and A. as they had signified willingness to help. Asked Mrs. Theocrates if she did not now want visitor to go to church of St. Sophia. Obviously she did not—the reason appeared to be that she is ashamed of having had to receive charity. Mr. Theocrates apparently took some part in the church services. Told her that this might make the priest all the more willing to help. She does not care to go herself yet, as she has not been able to attend church since she went through the cleansing ceremonies after Achates was born. Finally she rather grudgingly told visitor that maybe it would be just as well to make a visit. Called at parish house. Was ushered with some ceremony into the office of the secretary, Mr. D. As he already had another visitor, obviously a well-to-do Greek, hesitated to state errand, but finally went ahead, as Mr. D. made it clear that the person was a church official. The Theocrates, father and son, were known to both men. The man visiting Mr. D. took

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up the cudgels for Mr. Theocrates Senior before visitor had hinted at any strained relations between father and son. He kept repeating dramatically "The father, he is a fine man, too, and no matter what the trouble, still, he will remember that he is a father." He seemed inclined to blame the third wife of Mr. Theocrates Senior for the trouble, though he would not give details. He thinks that Mr. Theocrates Senior has returned from Florida, and advised visitor to see him. However, he could give no address nor could he tell where Mr. Theocrates' brother lives. He did not care to talk about the brother. When it was evident that no more information about the relatives was forthcoming told of Mrs. Theocrates and the children—her untiring care of them, her courage, dependability, devotion to Mr. Theocrates. Both seemed to be impressed by the gravity of the situation and asked about Mr. Theocrates' condition and the possibility of his return. Again they advised making a contact with Mr. Theocrates Senior. Stated that Mr. Theocrates himself did not desire this, that Society prefers to visit relatives only with the consent of the client. The church official finally said that he thought he could find out the address of Mr. Theocrates Senior and would send it to visitor through Mr. D. He was eager for visitor to visit the father at all costs. Visitor got the impression that he himself would impart to Mr. Theocrates Senior the news given in the interview. After a rapid fire of Greek, for which Mr. D. apologized, the official departed. Mr. D., left to himself, was much more equivocal about the relatives. He has known Mr. Theocrates Senior for some years, before this last marriage. He is fairly well off, but probably will not be eager to help John. Instead of giving any account of the trouble between the father and the son, when questioned, Mr. D. went off into praises of the son. "John," he said solemnly, "was a very laborious child, an excellent child. In fact, so to speak, he was the best child of his mother." Apparently John was independent at an early age. Mr. D. did not know how far he had gone in school, but always he was

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" s m a r t . " T h e brother was apparently " l a z y , " though M r . D . used no such simple w o r d . H e had had to be supported b y the f a t h e r f o r years, even a f t e r he had married a Polish w o m a n u n k n o w n to M r . D . T h o u g h M r . D . has not seen brother in some years, and has not his address, he understands that he is now self-supporting. T h e r e was likewise a sister w h o turned out badly and is now out West somewhere. M r . D . gave the impression that when J o h n disappointed the f a t h e r the f a v o r ite son was lost to him. H e did not think that the quarrel arose o n l y because of the marriage, but there was a question of m o n e y involved. More than this, Mr. D . , ponderously polite, would not say. H e expressed s y m p a t h y f o r the Theocrates f a m i l y , and stated that the church w o u l d be able to give some

financial

assistance, but not regularly. W h e n questioned specifically he said, " M a y b e one dollar one week, next five, n e x t t e n . " U r g e d him to do all that is possible, and stressed again Mrs. T h e o c rates' cooperative attitude. M r . D . promised to write or telephone visitor if he can get the address of M r . Theocrates Senior, or of the brother. 2 . 2 1 . 3 0 — L e t t e r f r o m "A

righteous w o m a n " :

I respectfully beg to inform y o u that a Greek w o m a n named A . Theocrates is not a poor w o m a n and in destitute. A t first, her husband is insured f o r $ 5 0 0 0 and her C o m p a n y gives to her a compensation of $ 6 5 per month. Second: She has a f a t h e r named Polydoros and he o w n s a C o n f e c t i o n e r y and F r u i t - s h o p , and w h o pays

$20

f o r home rent and lives w i t h her p a y i n g all her expenses. She has an unmarried sister named M a r y w o r k i n g w i t h her f a t h e r and w h o also lives w i t h him and helps her sister as well. She has a brother w h o has good business, named N i c k Polio. H e also helps her. She has a married sister, helping also this w o m a n . H e r husband is a member of the Union. H e has resumed to send her husband to A r i z o n a Hospital, and he helps her e v e r y week. H e also played a L o t t e r y (this is u n l a w f u l ) f o r her behalf on last C h r i s t mas and gave to her $ 5 0 0 . T h e milk-station sends to her every d a y milk and lot of other

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things for nothing, so such women are not entitled for help, and who are trying by falsehoods and false pretences to rob the people. It is pitty that you try to naturalize her to have more advantages from the City, so it is better to arrest her to send her to the jail for such lies she confesses. It is shame to help such women. She has also a friend ( m a n ) who offers her four dollars every day. Be careful! There are other families which are starving and trying to find a piece of bread. These are entitled for help, and not such dirty women and prostitutes as the above. I am a neighbour (woman) and know everything. [Syllabus reference: PHILOSOPHY, Ethics.] T E A C H I N G N O T E : T h e letter of 2.21.30 raises an interesting question. The community, so little envisaged by most urban case workers, is now taking a hand in the Theocrates financings. T h e perspicacious reader has long been wondering about the Blank family who became the Zelim family, about the lodger who was so unlikely to be a stranger, and about Mrs. Theocrates' guarded but still obvious admissions. N o w that an accusation is made, how is it to be handled, and still more important, what attitude is to be taken towards the deception? Concealment for reasons of practical advantage are common in all relief situations. What can we expect in the way of sincerity? Is "resistance" in the money area different from other kinds of reticences and resistances, of evasions and rationalizations? As trustee of funds has the social worker any special responsibilities? Should the lying client be punished for his exploitation by the withdrawal of relief? T o what extent may a slow tempo in working up a case be justified on the grounds of heavy case load, acute interrupting conditions such as ill health, etc. Is the interview in which Mrs. Theocrates is confronted with the facts skilfully done? Is there any evidence that the relationship built up between the client and the worker bears the strain of disclosure? What other courses of action might have been pursued from the beginning? Visited. Mrs. Theocrates apologetic about not being able to go to the Board of Child W e l f a r e as Mike must be taken again to clinic. It is especially important that he go today, as the doctor must check up on a subcutaneous injection given him on 2 . 1 9 . 3 0 . A red spot as large as a 50 cent piece surrounds the

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place on his arm where the needle was used, and he has been very nervous and f r e t t y . Mrs. Theocrates told of the fuss made at the hospital. H e shrieked throughout the clinic hour, before, after, and during the session with the doctor. T h e nurse was quite sharp with her, telling her that it was her f a u l t that the child made such a disturbance, and Mrs. Theocrates tried to explain that he not only fears that she will leave him at the hospital again, but he has really been hurt b y the doctors, and a f t e r all is only a baby of two. She thinks that because Mike is large f o r his age the nurses expect too much of him. Also she has been worried because his bowels have moved f o u r or five times daily, in spite of the f a c t that she always boils his milk. Advised her to tell the doctor all of his s y m p toms, and be sure that she understands his directions as to diet. T o l d of visit to St. Sophia and of the probability that Mr. D . will call on her. Suggested that both officials interviewed at the church felt v e r y strongly that her father-in-law should know of her situation. Immediately she became excited, repeating again and again the statement that Theocrates Senior hates her, that " a l l time only big fight," that she knows " t h a t man will do nothing, n o t h i n g . " T h a t Mr. Theocrates wishes her to have nothing at all to do with his father. Suggested that a person outside of the f a m i l y circle, such as visitor, might give M r . Theocrates Senior a new idea of her, and convince him that at least he ought to do something f o r his g r a n d children. She then changed her tactics and began to implore visitor not to go. Promised at least not to go without her knowledge, but said that her husband's opinion of the matter would be asked. She did not like this, but said very little more, except that she was sure a n y w a y that Mr. Theocrates Senior is still in Florida. She did not feel that w i f e number 3 is responsible f o r any of the trouble. Mrs. Theocrates has seen her only once. In the days of the " b i g

fight"

the Theocrates

Senior lived somewhere on West Street. Mrs. Theocrates told of having improved the bargain with her lodger, who has agreed to pay $ 1 0 a month. H e has not

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occupied the room this week, so M a r y has been sleeping there instead of on the daybed in the dining room. Asked to see h o w Mrs. Theocrates has arranged the room. It is bare, w i t h only a double bed, small chest and a chair in evidence. She has m o v e d some of the f o r m e r f u r n i t u r e into her dining room, and she apparently makes no e f f o r t to heat it. She shrugged and said, " O l d m a n say all r i g h t . " Achates looks well again. H e weighs nearly 16 lbs. A s k e d Mrs. Theocrates if she w o u l d not like to have visitor arrange f o r a nurse to visit her sometime, instead of paying $ 3 to D r . Nikolas. If either child became ill the services of a doctor w o u l d be available. E x p l a i n e d that p r o b a b l y a Greek speaking doctor w o u l d not be obtainable, but Mrs. Theocrates said that was all right, as she had become used to m a k i n g visitor understand. 2 . 2 4 . 3 0 — V i s i t e d as arranged, preparatory to Board of C h i l d W e l f a r e trip. Mrs. Theocrates was hastily dressing Achates. M a r y washed the b r e a k f a s t dishes. Mrs. Theocrates does not allow M a r y to dress either of the children, and she always v e r y c a r e f u l l y plans A c h a t e s ' nap before leaving him; wraps him in his blue blanket, fixes his bottle and sees that he is off to sleep. She is decidedly the mistress in her o w n house. M a r y got a sharp calling d o w n w h e n she came into the dining room to put a bottle of milk outside the w i n d o w , and without a w o r d she retreated to the kitchen again. T h e landlady was h a v i n g a new stove p u t in " f o r s u m m e r " ! laughed Mrs. Theocrates. Mike is m u c h better. T h e doctor at the hospital told Mrs. Theocrates that G r a d e Β milk m a y not be good f o r him, but she herself thinks that his bowel condition is better since she stopped g i v i n g him large helpings of ice-cream, f o r which he has cried since he l e f t the hospital. A d v i s e d her again to be sure to boil his milk. J u s t before Mrs. Theocrates l e f t Mike made a demand in G r e e k , and she gave him some lady fingers, first asking visitor if that k i n d of cake is good f o r him. A d vised her to get the doctor's opinion on e v e r y t h i n g Mike eats,

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but stated that this is the best type of cake for him, if he can have cake at all. Meanwhile Mike, grinning, insisted that visitor have one of his cakes, and did not start eating his until she had taken one. Mrs. Theocrates talked at length about her husband. In a recent letter she asked him to ask the doctor there whether or not he could ever "make more babies." He replied that he would not ask the doctor about such a matter, that it was his own business, but that his own feeling is that they have enough children. Mrs. Theocrates also feels that way. Mr. Theocrates had had some hope of coming East in a few months, but the doctor discouraged him. His final verdict is "Wife, no come home quick, come home late, but come home well to you and babies." While waiting in the Board of Child Welfare rooms Mrs. Theocrates launched forth of her own accord into a dramatic description of the trouble between the families at the time of the marriage. According to her, things went well up to the time that Mr. Theocrates Senior made the usual paternal call on her brother, who was acting in place of her father. Mrs. Theocrates rehearsed his very words, "My son love your sister and wish make marry." Her brother liked John, but drew fire from the old man when he said, "What money have your sons laid up? If sick or die what have my sister?" Then apparently John had demanded a life insurance policy that his father had cashed in (perhaps when he was a minor) and some money left by his mother. He got nothing, though according to Greek custom he had paid his wages to his father until he left the paternal home. Then what particularly infuriated Mrs. Theocrates was Mr. Theocrates Senior's taünt, "What you wish my son? He only poor man!" She gave the impression that her brother returned to Greece soon after the marriage, and said that the father was now living in Athens with him, Mike Unfortunately resembles his grandfather Theocrates. Mrs. Theocrates explained how he had to be named for the

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g r a n d f a t h e r , according to Greek custom, and in regard to his resemblance, shrugged and said h o p e f u l l y , " M a y b e c h a n g e . " T h e second son had to be named f o r her father. When her turn came with the investigator, Mrs. Theocrates showed poise, and answered m a n y of the questions without intervention. She was amused over the various renderings of the name, and gave an imitation of Mike's attempt at pronouncing it. O n being asked whether she or M r . Theocrates had ever before been married she said quickly, " O n c e e n o u g h . " O n her being asked whether M r . Theocrates had seen w a r service, visitor had to p u t the question into other words, " H a d your husband fight f o r c o u n t r y , 1 9 1 7 ? " She answered with twinkling eyes " o n l y with w i f e . " She gave her father-in-law's address as Miami, Florida, and corroborated the statement, already made to visitor that she has no relatives in this country. Miss G . , the questioner, was pleased with Mrs. Theocrates' humorous remarks, and her general alertness. She stated that the case should be put through promptly, as soon as the banks and insurance companies have been investigated, and the n a ture of M r . Theocrates' illness proved by a letter to the Union's Home. U r g e d her to speed the process, as the delay is due a n y w a y to a misunderstanding with Board of Child W e l f a r e on the matter of Mr. Theocrates' citizenship. Miss G . said that payment in this case will probably be m a x i m u m — $ 2 5

a

month per child, and that if granted it will continue until Mr. Theocrates is home and the f a m i l y on its feet again. Mrs. Theocrates said, at leaving visitor, that she thinks the doctors "look h a r d e r " at Mike when visitor goes to clinic with her, and asked that the call be made 2 . 2 5 . 3 0 instead of 2.26.30. 2 . 2 5 . 3 0 — V i s i t e d . A s it was raining hard, Mrs. Theocrates did not wish to take Mike and Achates out. Explained that visitor had not expected she would, in view of the weather, but that this day had been more convenient f o r call. T h e babies were sitting opposite Mrs. Theocrates at the kitchen table, and she was eating her lunch—fish, saturated in oil, and lettuce salad. Mike began to c r y when visitor appeared, and his mother e x -

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plained thac he thinks that either he must go to the hospital or that visitor will take his mother a w a y . H e could not be induced to shake hands, but a f t e r he had gone into the next room and danger seemed over, he peeked roguishly around the door, grinned and threw his ball invitingly at visitor, w h o has played " c a t c h " with him. Promised to call 3 . 5 . 3 0 to go to clinic at Y o r k e Hospital with Mike and Mrs. Theocrates. She would like to delay the visit to X a v i e r Hospital f o r at least a week longer, since she feels that the excitement and c r y i n g are very bad f o r Mike. She seems to think that because the doctors at Y o r k e Hospital were not alarmed over the skin condition, it may not be serious. Paid $9.00. T E A C H I N G N O T E : The importance of satisfying experiences may be indicated and use of mental hygiene concepts in the handling of Mike. This might have been indexed under knowledge but the use is so lighdy sketched in by the writer that it may be more easily discussed as an ingredient of "leadership treatment." The attempt to establish pleasant associations with a child with whom one goes often to clinics is worth remarking even though obvious. All the uses made of friendly relationships, contact, etc., as a basis for certain changes of response may be indexed for discussion. 2 . 2 7 . 3 0 — I n view of anonymous letter sent to office (received 2 . 2 5 . 3 0 ) started checking information given therein concerning Mrs. Theocrates. Telephoned office of Union. A c c o r d i n g to their records only $50 has been given Mrs. Theocrates in t w o payments of $25 each. Telephoned Health Station. Mrs. Theocrates last brought Achates to the Station two weeks ago. T h e y consider him a fine baby, and Mrs. Theocrates a c a r e f u l mother, and she realizes that it is almost impossible f o r Mrs. Theocrates to appear regularly with the t w o babies. T h e Health Station has never given Mrs. Theocrates milk or other supplies. T h e y do not have the money to make such donations. A t J Street there is a small f r u i t store and confectionery and the proprietor is a short, dark Greek, w h o seems to bear a resemblance to Mrs. Theocrates.

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3.4.30—Called on Mr. D. of St. Sophia asking for address of Mr. Theocrates Senior. He has had no word from his friend, though he has been expecting "hourly" to hear. He will see him in a few days, find the address and send it to visitor. Pressure of work has kept him from calling on Mrs. Theocrates but he still intends to visit her. He gave no further details about the rift in the Theocrates family, though on visitor's intimation that a question of money was involved, he said that he had also understood this. Evidently he is personally not as well acquainted with Mr. Theocrates Senior as with John, and today visitor got the impression that he really does not know definitely about the trouble. He stated that his connection with St. Sophia was made only a year or so ago. He has never heard of relatives of Mrs. Theocrates and is not even sure that he could recognize her. He said that the name "Polio" is so common that it means nothing. It is adopted by every Greek whose name is difficult. Mr. D. was cordial, and promised to send worker the address as soon as he gets it. 3.5.30—Visited. Mrs. Theocrates was eating a lunch of crabs and ripe olives, and with her at table sat an older Greek woman, unpleasant-looking, with drooping eyelids and tufts of dark hair on her face. She spoke no English and Mrs. Theocrates' only voluntary introduction was: "She come sometime." Visitor remembered having seen her in the hall some weeks ago. Mrs. Theocrates did not address her during the conversation, but Mrs. M. seemed to watch worker closely. The children have been ill, both with bronchial coughs and sore throats. When Mike's temperature was 100 Mrs. Theocrates called in Dr. Nikolas who prescribed for both children. Mrs. Theocrates does not feel that Mike should make the trip to the clinic today. She showed a card which reported that an X-ray was taken of Mike's lungs, and in her dramatic manner described the "nervous doctor." Mike evidently shrieked as usual throughout the examination. Mrs. Theocrates is anxious to take him to the clinic on 3.7 and asked visitor to accompany her. If the day is pleasant she will take Achates also for a blood test.

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The doctor at the hospital has said specifically that Mike must have Grade A milk, so Mrs. Theocrates is using Β for herself and giving A to Mike. Dr. Nikolas corroborates this opinion. Mike was running about, coughing only occasionally. He assured himself that visitor's call did not mean a trip to the hospital before he allowed himself to be cordial. Called on Dr. Nikolas. First asked his opinion about the illness of the children. He said that these last attacks were not alarming, and would soon pass. However, he is not satisfied with Mike's general condition. He had a strong positive reaction to the tuberculin test, and his recent marked irritability is not a good symptom. Dr. Nikolas in his case fears miliary tuberculosis, and undermining of the entire system. He thinks that Yorke Hospital should keep a careful check on his symptoms. Dr. Nikolas thinks that Mrs. Theocrates means to be conscientious in following instructions about the children, but that she is lenient in giving Mike what he wants. He mentioned the fact that she has given Mike the bottle again. He advised visitor to check when possible on Mike's diet, and to try to influence Mrs. Theocrates to give up the bottle. Asked about Mrs. Theocrates' relatives, he said that he knows nothing about them. He added reflectively that Mrs. Theocrates is a "mystery woman" to him. Visitor remembers her various excited tirades to him and her method of getting him into a corner. He went on to say that she tells him tales of her past, for instance, about a wealthy suitor who was stolen from her by a girl friend. Yet he thinks that she is devoted to her husband. Dr. Nikolas thinks that the injections they are giving Mr. Theocrates at the Union's Home must be for syphilis. Yet the last report he received stated that good progress was being made with the tuberculosis condition. He described Mr. Theocrates as a very stunted individual, with heavy features and coarse hair, almost the cretin type. Dr. Nikolas himself took Wassermans of Mrs. Theocrates and Achates at the time of the baby's birth, and both tests were negative.

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T E A C H I N G NOTE: The class may raise the question as to whether out-of-town investigation should not have been made to get clear medical prognosis and a contact with Mr. Theocrates directly through social workers there. He asked visitor if she could interview another Greek woman who needs assistance. Told him to send her to office. D r . Nicholas will be glad to discuss the Theocrates situation with visitor at any time. 3.6.30—Telephoned. Mrs. Theocrates' rent is paid to date. Landlady appears to be surprised that Mrs. Theocrates was receiving aid, but she knows very little of the situation, as she was not even sure that Mr. Theocrates is ill. She mentioned Mrs. Theocrates' poor English. The apartment is rented to Theocrates, but the agent has seen an elderly man there whom Mrs. Theocrates introduced as her father. 3.7.30—It was decided to await further evidence before confronting Mrs. Theocrates with our knowledge of her relatives. In view of Mike's condition and the services exclusive of relief that can be rendered to this family, retaining the contact would seem to be desirable. A t present we know that she is not receiving assistance from the Union or the Milk Station; the matter of the insurance is doubtful, and the business is not owned by her brother. Considering her very apparent devotion to Mr. Theocrates and the children and the presence of Mary, whoever she may be, in the home, the accusation that she entertains another man seems doubtful. Abruptly discontinuing the relief might precipitate matters prematurely. (Later) The owner of the small fruit store and confectionery at J Street said that his name is "Polio." He seemed perplexed by the inquiry. A woman answering to the description of Mary was assisting him. Telephoned social worker at Tuberculosis Clinic, Yorke Hospital. Though Mike's reaction to the tuberculin test was positive, Miss D does not fear that he suffers from an acute condition. The chest X-rays were taken only because he cried continuously and so the doctor could get no normal reactions

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f r o m his lungs. T h e X - r a y s were negative. Social worker seemed to be chiefly disturbed over Mike as a badly behaved child. Explained to her his fear of the hospital caused by uncomfortable experiences he has had there, and reminded her that he is only t w o years old. Social w o r k e r wished Mrs. T h e ocrates to bring Achates f o r a test on a Wednesday, in fact she would like to get the whole f a m i l y onto a Wednesday schedule, so it will not be necessary f o r Mike to go to clinic today. [Syllabus reference:METHOD, Interpretation.] Visited: Mrs. Theocrates

had Mike

in bed. H i s

cough

sounded deep and she said he had kept it up continuously during the night. H e has been perspiring profusely. Suggested that she had him very w a r m l y clad, and she took off a flannel jacket, which revealed another one underneath. Achates also has a cough, but his is m u c h less violent. Mrs. Theocrates has just heard that her husband must have a tonsillectomy, which news depresses her. She feels that her f a m i l y is f a t e d to be ill. She realizes now that Mike no doubt has " t h e Father's trouble." Pathetically she tried to make light of the tuberculin reaction, which D r . Nikolas had explained to her. T o l d her that even if this is indicative of the disease Mike can get the best care the city affords, and visitor will see that all explanations as to his care are made clear to her. [Syllabus reference: METHOD, Interpretation.] Mrs. Theocrates recently received $ 1 5 . 0 0 f r o m A . and A . when she visited the office herself. She applied the money toward her rent. Voluntarily she went into a discussion of her father-in-law, beginning f r o m the statement that her husband said specifically in his last letter that he wishes nobody to approach his father. Mrs. Theocrates is sure that Theocrates Senior knows of his son's illness as the brother, A . knows, and is " i n g o o d " with his father. Theocrates Senior is not now very well o f f , as his barber shop has not done well. T h e only new light her recital threw on the situation was that the money contributed

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to the household by J o h n before his marriage went to help pay f o r a house, which Theocrates Senior made over to his third w i f e soon a f t e r their marriage. H e had led J o h n to believe that his rights were being protected, but when J o h n demanded to see the deed he f o u n d the entire property in the name of his stepmother. In the middle of one of her long speeches Mrs. Theocrates stopped and said smiling, " n o w I talk English good—see? Y o u m y teacher." She does speak much more fluently and shows an increasing quickness in understanding. She patted w o r k e r appreciatively on the arm. [Syllabus reference: METHOD, Relationship.] Paid $9.00. 3 . 1 2 . 3 0 — V i s i t e d . Mrs. Theocrates, in bedroom slippers with her hair done up in curlers, was superintending Mike's lunch. H e sat in the high chair, eating spinach and a little minced fish, with a whole wheat cracker. Mike feeds himself neatly, using a small f o r k of his own. H e still objects to drinking out of a cup, but his mother says she induces him to use one m o r n ings by pretending to pour coffee into the little red cup she bought at Woolworth's. Advised her not to give him a n y coffee at all. Mike as usual wishes to share his spinach with visitor, and kicked his feet delightedly when she thanked him, explaining that she had already lunched. Mary appeared, to take charge of Achates in Mrs. Theocrates' absence. A s the weather was uncertain she decided not to take him to the hospital, since he has a slight cough. She wished to finish Mike's examination as soon as possible, so she got him ready to go. X - r a y showed a slight congestion of the lungs, but nothing suspicious. Social worker said that since Mrs. Theocrates had the order, another picture might as well be taken, and perhaps Mike will be more quiet. His Wasserman and that of Mrs. Theocrates were negative, and though the doctor could not examine him thoroughly on the earlier visit, he does not suspect active tuberculosis in spite of the positive skin reaction. T h e small unhealed sores have not impressed him as serious.

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Hospital w o r k e r said that Mike's c r y i n g upset the entire clinic, and that Mrs. Theocrates had not been pleasant over taking him outside to wait his turn. Explained Mike's unpleasant hospital experience, when he had been separated f r o m his mother. F o u n d Mrs. Theocrates entirely pleasant about waiting in the anteroom. Mike only whimpered n o w and then during the half hour of waiting. H e did cry when summoned to the doctor's office, and the head nurse blamed Mrs. Theocrates, saying, " Y o u ' r e a nice w o m a n , but a bad m o t h e r ! " Mrs. Theocrates shrugging, said, " W h a t to do, kill b a b y ? " and the nurse interpreted this as defiance. Explained that Mrs. Theocrates only felt that Mike's c r y i n g is inevitable, that his hospital experience greatly increased his irritability a n y w a y , and that a baby of two w h o does not understand everything that is said to him would naturally fear the experience. Finally Mrs. Theocrates got him quieted and visitor l e f t as the examination proceeded. Bureau of Vital Statistics reports that maiden name of Mrs. Blank or Zelim was Polydoros, which practically proves that she is the sister of Mrs. Theocrates. Since we are sure at least of the identity of Mrs. Theocrates' father and one sister, she may be confronted with the knowledge, and be asked to correct her statement made to Board of Child W e l f a r e . T h e relatives cannot be expected to support her entirely, since her father has only a small f r u i t stand and Mr. Z. is a dishwasher, but the Board of Child W e l f a r e must be i n f o r m e d of their existence. Making Mrs. Theocrates feel that the F a m i l y Society still wishes to help her get her allowance will preserve the contact which is desirable, since the f a m i l y obviously still needs assistance, even if not financially. 3 . 1 5 . 3 0 — V i s i t e d . Mrs. Theocrates was g i v i n g Mike a bath. H e stood up in the tub, while she poured a saucepan of water over him. She said that this is the first time she has really soaked him in the tub since his hospital experience, as she has been afraid of his catching cold. T h e n she added, " I wash with cloth every d a y . "

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The doctor at the clinic gave Mike a very thorough examination, and Mrs. Theocrates was pleased to report that he behaved much better. Then she said, " Y o u see lady doctor she scold me? She do all time. Listen. Me big woman, have thirty years, and heart go—how you say—when go to hospital." Told her that Mike would learn not to be afraid, and that she might begin preparing him for the trip long before his next visit. She does not think that Mike will have to return regularly to the clinic, but they wish her to bring Achates to be examined. She will do this. She reported that the Board of Child Welfare visitor arrived 3.13.30 and asked "so many questions." This gave visitor a chance to confront her with knowledge of her father. 6 Her surprise was at first quite convincing. "Who tell that news?" she asked. Told of conversation with Landlady trying to make it clear that Landlady had not been talking maliciously about Mrs. Theocrates. Then brought the identity of Mrs. Blank into the conversation. Mrs. Theocrates explained volubly that the reason Landlady thought that Mrs. Blank was her sister was that when Mrs. Theocrates went to the hospital to "born" Achates, Mrs. Blank had stayed in the apartment with Mike. "Lady upstairs talk all time." When visitor was not convinced, Mrs. Theocrates became slightly defiant, and said, " G o ask man with store on corner if my father!" " G o ask lady upstairs about me!" Visitor in her turn became dramatic and said emphatically that since she and Mrs. Theocrates were such good friends she refused to go to anybody, spying, and suggesting that Mrs. Theocrates had not told the truth, because she believed that Mrs. Theocrates would tell her whether or not these things were true. Mrs. Theocrates shrugged and looked sheepish. Visitor added that we had found out that Mrs. Blank before her marriage was Polydoros. This was the last straw, and Mrs. Theocrates pouring ever more saucepans of water over Mike, said, " I say all time find out. All right! 'S true." Visitor said that while she was very sorry that Mrs. "See Teaching Note (p. 386.)

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Theocrates kept back this information, and it made bad trouble with the Board of Child Welfare, she was not angry with Mrs. Theocrates but would like to have her explain w h y she had done this. Mrs. Theocrates explained with vigor. From her account it appeared that a gathering of her friends and relatives had put her up to applying to the Society. They said to her " W e can no help all time, but help little. Y o u say you have somebody, get nothing. Y o u say nobody, maybe get something." T o her protest that the deceit would be discovered, they had said, " L e a v e to find o u t . " Then she added briefly, " A f t e r I tell those, I sorry." [Syllabus reference: KNOWLEDGE, Ethnology, habits and customs.] She added that her father has only a small business, and is 6 5 years old, unable to help her largely. Asked her how much she really pays for the apartment, and she said that he pays ten and she pays thirty-five, that she has two more rooms that she does not live in in winter. She sighed, and said, " W e l l , anyway, I pay only thirty-five." Explained that the only way she can get her Board of Child Welfare allowance now, and the best thing to do anyway, will be for her to go down there to correct her statement. She said, " W h y not leave to find o u t ? " Visitor pointed to the fact that Society had found out, and though we would not desert her on that account, the Board of Child Welfare is a State affair, much more likely to throw the whole application overboard. Also said that when they did find out they could justly blame the Society for not telling them, and the worst of it would be that they might feel that other mothers with babies whom we took to them would not deserve help. Mrs. Theocrates got the point at once, and said she would go, if visitor would accompany her. Relief $9.00. 3.15.30—Letter to Mr. Theocrates: Thank you very much f o r your gracious letter of appreciation for the assistance we have tried to give Mrs. Theocrates. Personally I

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have greatly enjoyed w o r k i n g with her, she is so bright and alert and so eager to do w h a t is best f o r the babies. She insists that our long conversations have improved her English, for now she can make me understand much more easily than she could at first. W e talk so m u c h about you that I really feel as if I knew you, too. W e have been somewhat perplexed over Mrs. Theocrates' violent objection to our communicating w i t h your father. Since she may be only extra sensitive about this " t r o u b l e " between families, we are eager to get your point of view in the matter. Please remember, though, that even if this uncertainty about your father's helping does complicate matters f o r us, we shall not rush into the situation against your will. W e only wish to k n o w your attitude. I think your son, Mike, is a remarkably bright two-year-old. H e never makes the mistake of talking to me in Greek, and is always eager to share his little cakes or candies. Achates is a fine child, too, and I flatter myself that he knows me, though that is expecting a great deal of a six-months-old child. A t any rate, he is very polite about letting me hold him. Please write me again and I shall be glad to answer. I shall, of course, continue to keep in touch with Mrs. Theocrates. It is good to k n o w that you are feeling so much better. H a v i n g lived in Arizona myself I k n o w about that fine climate. I know how m u c h it will do for you, and sincerely hope that before very long you will be coming back East, well and strong. 3.19.30—Letter from Mr. Theocrates: Y o u r letter of March 1$ has just been received and read w i t h interest. I note w i t h pleasure w h a t you have to say about my children, Mike and Baby " A c h a t e s . " T h a n k you very much. I flatter myself that they are "chips off the old b l o c k . " In regard to the matter concerning my father, I regret to say that m y w i f e is right objecting to his being brought into our affairs. I have done m u c h for m y f a t h e r — w o r k e d hard and made great sacrifices for his welfare, and in return he has been very antagonistic. H e has not accorded me the kind attention that a father o u g h t to give his son, especially when the son has tried to be a help instead of a burden. Since m y 6 months stay in Arizona he had been but once to see his grandchildren and he was forced to do so by me on account of m y

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writing him that the children were sick. Well, I hope that you will understand from this, that it would be much more agreeable to me and my wife if you will not communicate with him, " m y f a t h e r . " Thanking you again for your interest in my f a m i l y , and with best wishes, I am, P.S. Love and kisses to my Mike and Baby " A c h a t e s . "

Miss C . of the Board of Child Welfare at office asking for report on Theocrates. Miss C. has found that Mr. Theocrates receives $68 monthly as disability insurance. 3.20.30—Telephoned Miss C . at Board of Child Welfare. She was out, but left message to the effect that f u l l report will be made in person to Board of Child Welfare 3 . 2 1 . 3 0 . Visited. Mrs. Theocrates could not take Mike to clinic, as Mary could not stay with the baby, and she cannot easily take both children. She is reassured about Mike, who seems better than he has been for months. Advised her not to give up the idea of taking him back to Xavier Hospital as he should have treatment by dermatologists until the sores heal. She will see that he goes sometime. She said that Mr. Theocrates' brother turned up last night. He has been taken on at A . and A.'s and called to reprimand her for a letter that had been received there f r o m the Board of Child Welfare stating that John had died and that she was trying to get an allowance on that basis. She had assured him that a mistake had been made, and, when he had been angry, she had told him that she would be the last person in the world to say that her husband was dead. He had stayed only a few minutes. "More big fight!" said Mrs. Theocrates. She said that visitor could reach the brother by asking f o r him at A . and A.'s. She insists that she has not his address. Asked about Mr. Theocrates' insurance, she said that she did not know about it, and repeated the story about the trouble with the father-in-law over some old insurance that John had. But she thought that was "all gone." Told her about the money being sent to her husband, and her eyes flashed. " I f I have that, why go downtown?" Meaning the Board of Child Wei-

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fare. She said that when letters came to her husband she sends them to him, and does not know what is in them. Told her that she had better tell the Board of Child W e l f a r e all about that, too. She asked visitor to talk to brother about it. H e r courage has not weakened about the trip to the Board of Child Welfare, but she thinks it will be embarrassing. Borrowing visitor's own tactics, she said ingratiatingly, "Listen, we friends! W h o tell you about m y sister?" Without telling definitely about the "righteous w o m a n " letters, told her that the information came f r o m an unknown source. She pointed upstairs and said, " I know w h o . " She now admitted to the Brooklyn brother and to the fact that Mrs. Zelim is her sister, but said that her people tell her that since she is married she is responsible f o r her own f a m i l y , and will not help her much. H e r brother has had much sickness in the family this winter, and had had to borrow $500 f r o m his partner. His store is in Brooklyn. H e likewise sells ice cream and fruit. Mrs. Theocrates agreed to be ready at nine A . M . Telephoned A . and Α . , asking to speak to N i c k . H e is not allowed to come to the telephone, so left message asking him to call visitor, giving convenient hours. N o w o r d f r o m him. 3 . 2 1 . 3 0 — W e n t with Mrs. Theocrates to the Board of Child Welfare. H e r only comment on the trip was " I think shame to go here again and say I tell w r o n g . " Admitted that it was too bad, but convinced her that she was doing the right thing. B . C . W . worker first showed the correspondence about the insurance. Mrs. Theocrates repeated her version of the matter, and protested that her husband has not been sending her any such amount of money, only five dollars here and there. She said again " W h y I come here, then?" B . C . W . worker said that Mr. Theocrates should send her at least $ 5 0 of the allowance, and advised visitor to take it up with him. She stated that the Board of Child W e l f a r e would have to close the case, in consideration of the insurance. H o w e v e r , since Mrs. Theocrates had come all primed to tell about her relatives, visitor asked worker to take the additional information in case it

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would ever be used. Mrs. Theocrates had a bad moment, and said to visitor " Y o u s a y . " Visitor shook her head, and

finally

Mrs. Theocrates leaned over the desk and said "Listen! I have father in N e w Y o r k . " Then she went on down the list of relatives, visitor helping only with the addresses.

B.C.W.

worker made her tell w h y she had concealed them, but was not severe. She appeared to be secretly amused as the account proceeded, and evidently apprecitted Mrs. Theocrates' telling of them herself. She did not consider the relatives imposing as resources, and intimated that Mrs. Theocrates could not expect to get f u l l support f r o m them, but the application was discarded on account of the insurance. Outside, Mrs. Theocrates wept over what she insists is her husband's deceit in holding back the money. She said that he had told her once to make her own f a m i l y help her, and it was he who insisted that she go to the Board of Child Welfare. She intends writing him today of her findings, and asked visitor to do the same. She also asked visitor to see her brother in Brooklyn and her father about help, after visitor explained that if all would help regularly, even a little, she could be sure of an income. Explained that she could have her allowance, today, but that future plans could not be made until all of her income was explained. She thanked visitor tearfully and went off talking about the letter she will write J o h n . Relief $9.00. 3.26.30—Letter f r o m Mr. Theocrates: I received a letter f r o m m y w i f e telling me that you understood that I have an Insurance Policy of $6 J . It is true that she did not k n o w about that P o l i c y , as I have never told her, because I k n o w that it did not amount to m u c h , so I had that as a secret between m y father-in-law. O u t of that money I pay m y f a t h e r - i n - l a w the rent f o r m y home, I pay an insurance f o r m y w i f e and Mike. So you see that it cannot go very f a r . A s m y w i f e has w r i t t e n me m a n y times about money I told her to appeal to State W e l f a r e Society as I have understood that it pays a m o n t h l y compensation to every child born in the State

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whose f a t h e r is disabled f o r life. Later m y w i f e i n f o r m e d me about y o u r interest in her and I w r o t e her to see you, as to w h a t she has t o do t o get that. N o w I am asking you this f a v o r . Y o u k n o w that m y w i f e c a n n o t speak E n g l i s h well and that it will be too hard f o r her t o investigate. So if you look in this m a t t e r f o r her I shall appreciate it. I am sure t h a t w i t h y o u r assistance she will g e t the proper help. N o w as f a r as her and m y relatives are concerned I d o n ' t e x p e c t a n y t h i n g f r o m them, as they have their o w n families to support. T h a n k i n g you in advance f o r a n y t h i n g that y o u m a y do c o n c e r n i n g this matter. J O H N THEOCRATES P.S. L o v e & kisses to M i k e and Baby A c h a t e s .

3.27.30—Visited. A l t h o u g h it was afternoon, Mrs. Theocrates and Mary were finishing a big washing. " W a s h every d a y , " said Mrs. Theocrates. She then added that she has been feeling ill. A n d then, "So big fight is bad." T a k i n g visitor into the dining-living-room

(a dinner table is there, but the family

evidently always eats on the oil-cloth-covered kitchen table) she began an account of the big fight. But first she said: " Y o u help to f i g h t ? " and added ingratiatingly " O n l y you to h e l p ! " She patted visitor's hand. W o r k e r tried to indicate that she is at any rate on Mrs. Theocrates* side. [Syllabus reference: METHOD, Recording, style.] Mrs. Theocrates described herself as going, weeping, directly to her father f r o m the encounter at the Board of Child Welfare. Evidently she intended to reproach him for his part in sanctioning her marriage to John. She said " I thought to marry honest m a n ! " Her father only laughed. A t last she said " H o w that? I c r y , you laugh! H o w t h a t ? " H e r father then told her that John had been sending him f o r t y - f i v e dollars every month for the rent. She said that her father has been making her think this was a loan that John would eventually have to repay. She was furious at the deception. She held up her t w o forefingers together and said, " M y father and m y husband close like this!" Then she pointed to herself and waved

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her arms. "Nowheres. I write my husband nice letter, nice, don't forget that! He write and say 'Well, anyway, wife, I take care for you and babies!' Fff!" She literally blew this away. "He no trust. He no trust at all. He make fool of me. If not two kids I like say, 'Go to Hell'!" She was nearly crying. Suggested that perhaps it was not so much that John did not trust her, but that he wished to make sure through her father that the rent was paid, and that he thought she might get more help from others if she did not know that he had the money. She brushed this aside, saying rather grandly, "Who to trust, if not wife?" To divert the conversation, asked what John claimed to be doing with the rest of his insurance money. She said rather shamefacedly that he had sent her a little, sometimes five, sometimes ten dollars a month—never more than fifteen. Then he has her insurance to pay—she said, she did not know about this, either—amounting to about twelve dollars a quarter. Asked why her father did not pay some of the expenses of the home out of his own pocket, she replied, "Listen, that man he no care for nobody." She then gave a jumbled account of some arrangement made with him by John. It seemed to be that the father pay ten dollars toward the rent and that the Theocrates' occasionally give him "to eat." John had said largely, "Wife! He is old and have small business. No can pay much." Also, before the babies were born Mrs. Theocrates had helped her father in the store, and he had paid then, altogether, thirty dollars. But she did not admit that her father is now contributing toward the home. She said that Miss C. of the Board of Child Welfare had called on him at the store and asked "Why no help your girl?" She called in to Mary to tell what the father had replied. Mary drew her face down and said gruffly, "He say 'No spik Englis!' " Visitor said that she intended to visit Mr. Polio herself, perhaps with an interpreter, and this idea did not seem pleasing to Mrs. Theocrates, though she did not openly object. She went on to say that at times her father bought "to eat," but not regularly. Then he would feed Mike unwisely, Mike would be ill, and he would not care.

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Told Mrs. Theocrates that it would seem that she could get along nicely if her relatives would help a little, regularly, that it was too hard f o r her not to k n o w definitely what to expect. She agreed to this, but proceeded to run over the possibilities, telling w h y they are not hopeful. Mr. Blank is the most generous of the lot, but he has been out of w o r k f o r three months. H e has said to her " Y o u give me job, I give you m o n e y . " H e r brother in B r o o k l y n has three children, and they have been ill this winter so that his expenses have been heavy. H e has told her that if she will give him money he will give it back, but he has none f o r her at present. M a r y contributes a little, usually ten dollars a month, and she helps a good deal with the house and children. Mrs. Theocrates k n o w s that business in the little store is not good. Visitor got the impression that the allowance is about all, aside f r o m the rent, that Mrs. Theocrates has actually been able to count on as her o w n . G a v e her the nine dollars today, but made her understand that while she will not be l e f t without a plan, the money cannot probably long be continued, as the Family Society has m a n y other mothers with little babies who have nobody at all to help them. H e r only answer to this was one of her deep shrugs, and the question " W h a t to d o ? " Visitor repeated that with J o h n ' s insurance money sure, if all would help a little she could get along nicely. She wishes to take Mike to X a v i e r Hospital 4.3 if the weather is fine. H e seems well, but she thinks he sweats too freely, especially at night. 4 . 1 . 3 0 — C a l l e d at the store of M r . Polio, father of Mrs. T h e ocrates. It is a small, overcrowded place, with a door and a small w i n d o w opening on to street. He sells cigarettes, candies, small cakes, crackers, and drinks. T h e f r u i t is displayed in a stand on the sidewalk. M r . Polio is a nice-looking, dark man of medium height, unmistakably

Greek. His hair is only

touched with g r a y , and he does not look sixty-five. There is a decided resemblance between him and Mrs. Theocrates. H e was talking w i t h a younger Greek man, w h o sat on the only chair, smoking a cigar. Visitor first addressed Mr. Polio, intro-

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ducing herself, and making sure that he understood that she was the representative of Society, of whom his daughter had told him. His English is indeed limited, but he finally nodded several times and pointed to the young man, saying, "he say." Since Mr. Polio, after understanding visitor's identity wished the friend to interpret, asked the friend to tell him that visitor had received a letter from John concerning the payment of the Theocrates rent, and had called to discuss with Mr. Polio plans for his daughter. Mr. Polio looked embarrassed when this was relayed to him, shrugged, and apparently told the friend to say that she had been doing pretty well, but needs help from everybody. The friend added of his own accord "Sure, everybody help sometime," as though Mrs. Theocrates' situation was well known. Told him that we know that Greeks are usually very generous in helping their countrymen, and he seemed pleased. He knows John, and intimated that the entire colony was grieved at his illness and departure. Then he started pleading for Mrs. Theocrates on his own account, begging visitor "Please to help." Assured him that we have been helping. Meantime Mr. Polio evidently got the drift of the conversation, for he looked at visitor and nodded repeatedly. Since the friend seemed to know a good deal about the Theocrates situation, let him talk on. He figured briskly that Mrs. Theocrates needs over a hundred dollars to live on, "She must pay rent." Visitor countered that John sent the money for that from Arizona, and the friend was so little surprised that he probably knew that beforehand. Following this line, said that in making a plan it would help to know what Mr. Polio was able to pay for his lodging. The friend finally put this question and reported that Mr. Polio could pay only ten dollars monthly as business is poor, and he is old. He eats with his daughter only on Sundays, and then buys the food; also he provided the children with shoes. Usually he eats at the shop. (In the rear of the store are a small stove and a cot.) No embarrassment in either man was visible over these disclosures.

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They seemed bent on making a good case f o r Mr. Polio. H e has to pay $53 rent, and buy his goods in advance. Business has been very bad. T h e friend then launched into a discussion of the poor, who "die many times." Visitor remarked that there are many who do not have as much as Mrs. Theocrates has. However, Society thinks a good deal of Mrs. Theocrates as she has been brave in hard circumstances and is devoted to her babies. Asked the friend to be sure to tell Mr. Polio this. As visitor was about to leave, Mr. Polio offered her a bottle of Coca Cola, and smiled cordially as she drank it. With sweeping gestures, he refused payment. H e could not even understand the simple question " H o w long in America?" until the friend helped him out. He has been over here seven years. Several customers appeared during the conversation, however, and he seemed to understand quickly what they wanted. 4.2.30—Realizing that the two are sisters, one can detect in Mrs. Zelim a resemblance to Mrs. Theocrates. She is likewise short, dark, olive-skinned, very Greek in type. Her house dress was freshly laundered, though pinned together at the neck by a huge safety pin. H e r rooms were beautifully kept, though sparsely furnished. T h e floors were bare, a fact f o r which she later apologized on the score of Mr. Zelim's unemployment. Sitting opposite Mrs. Zelim, with the bright-colored oilcloth-covered table between, visitor braced herself f o r a struggle to make her understand, as when she had first been introduced, as Mrs. Blank, she had said " n o spik Englis," and had made little attempt to talk. However, after visitor's announcement of the purpose of the visit, Mrs. Zelim began talking quite comprehensible English, more composed and coherent than Mrs. Theocrates'. She said that she and her husband had helped, and would be glad to continue to do so, but that he had been out of work for three months, and they were having difficulties themselves. Replied that Mrs. Theocrates had reported his unemployment, that of all her relatives she

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seemed to feel Mr. and Mrs. Zelim the most generous and sympathetic, that visitor wished especially to get their advice just now. Said that at the time of the other call on the Zelims visitor had not known that Mrs. Zelim was the sister, "which of course makes a great difference." Mrs. Zelim looked decidedly sheepish at first, but finally broke into a grin and hid her face in her hands. Throughout the conversation visitor always spoke of "your sister," Mrs. Theocrates. Mrs. Zelim at first referred only to "Mrs. Theocrates" in quite an impersonal manner, but gradually she came to use "Helen," and at last she said " m y sister." No other reference to the deception was made, and Mrs. Zelim gave information about the other relatives without hesitation, and with no show of surprise over visitor's knowledge of their existence. [Syllabus reference: METHOD, Interviewing.] Stating that the father's English is quite inadequate, asked Mrs. Zelim f r a n k l y what she considers that he might be able to do for Mrs. Theocrates. She shrugged, saying that she knows him to be "stingy," and now that business is not good, to be especially so. Also she is sure that he is saving money to return to Greece to end his days with the son there. Reminded her that at any rate he is living in Mrs. Theocrates' apartment and should pay something for his room. She said "Maybe ten a month." As far as she knows, he does not usually eat with Mrs. Theocrates. Asked about the Brooklyn brother, saying that as yet it has been impossible to visit him. Mrs. Zelim threw up her hands. She is sure that he will do nothing for Helen. Has not she herself gone to him in vain for a loan, telling of Mr. Zelim's unemployment? He "say he is sorry, but no can give." His business is better than the father's, but two of his three children have been in the hospital this winter, and he is now in debt. Moreover, both he and the father feel that Helen made her own bed when she married John against the better judgment of her people. Asked what was their objection to John. She said, "no money," and intimated that the other "sweetheart"

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selected by Nick and the father was well off, but Helen would have none of him. Consequently Nick now turns her appeals down with vengeance. She hinted at trouble with Theocrates Senior, over the match, so that the lovers had to "stand alone." She shrugged again and again, as though to say "what can she expect now?" Remarked that Mr. Zelim seemed to be on very friendly terms with John, and she nodded, "Good man, have sad time." She thinks that Mary is not able to contribute in cash to the Theocrates household, but she helps about the house and buys some of the food. Mary has been out of work. Occasionally she helps the old man in the shop, but he does not really need her, and pays but little. Moreover, Mary is to be married, which will remove her from the household. "But of course!" she said in answer to visitor's look of surprise, for Mary looks to be much older than either Mrs. Theocrates or Mrs. Zelim. In returning to the idea of definite plans for Mrs. Theocrates, described the difficult position of the Family Society in the matter. Appreciating thoroughly Mrs. Theocrates' problem, admiring her industry and energy and wishing to stand by her, we yet feel that, in view of the sixty-five dollars a month being paid John and of relatives able to help a little, we cannot continue to give financial assistance. The insurance matter was news to Mrs. Zelim. She said that she is sure her husband does not know of that either, and that Helen would undoubtedly have told them had she known. Rather regretfully she said, " A n d my husband paid all for her to 'born' the last baby." Brought the talk around again to the rent, saying that from the amount of insurance, forty-five dollars for rent is quite too much to pay. She agreed that something should be done. Told her that the insurance would probably keep Mrs. Theocrates from getting the Board of Child Welfare allowance. Mrs. Zelim again shook her head over the insurance. In the front room, through which Mrs. Zelim took the visitor to look at the babies sleep, was a large picture of Mr. and Mrs. Theocrates in bridal array. Mrs. Theocrates wore a large head-

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dress which made her tower over her husband. Both wore an air of triumph, and Mrs. Theocrates' mouth was firmly set. " G o o d days," said Mrs. Zelim. Stated wish to call again sometime, and she said, " S u r e . T h a t ' s g o o d . " 4 . 3 . 3 0 — I t was decided that Mrs. Theocrates' allowance be given f o r this week, since it has been her most stable income in a very uncertain situation, and since her understanding and concurrence in m a k i n g a plan with Society might be jeopardized b y a too sudden withdrawal of such aid. It will be advisable to reduce it gradually, as she becomes accustomed to the idea of living within available means. Visited. As the weather was uncertain and Mrs. Theocrates w e a r y after another large washing, she decided to postpone the visit to X a v i e r Hospital yet another week. She took Mike to Y o r k e Hospital yesterday, and the doctor spent a good deal more time looking him over. Mrs. Theocrates beamed over the f a c t that Mike's fear of the hospital seems to have departed. H e walked into the place and actually held out his hand to the doctor, to the great surprise of all the "other doctors" (hospital social worker and nurses) who have heard him scream before. She had suggested that he thus greet the doctor, but did not dream that he would really do it. She admitted that she had begun to "tell about to g o " a long time before. She believes that Mike is now sold to the idea of going to the clinic calmly. H e enjoyed the milk and the fig newtons which were passed around at the end of the hour, and showed the nurses that he can drink out of a cup. [Syllabus reference: METHOD, Leadership treatment.] T o d a y Mrs. Theocrates was f a r happier than visitor has seen her f o r some weeks. She produced a letter f r o m her husband, a " s e little letter," because sometimes he writes "three, f o u r , five papers," in which he said that he was sorry to have made her " n e r v o u s " and worried, and asked her to control herself f o r the sake of the babies, a n y w a y . She feels that his contrition has been brought about b y her convincing him of how " b a d " it was that he made " f o o l and liar" out of her. She cried when

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she got the letter, so that Mike had to console her, but now she feels "more better." Told of visit with her sister, and said she had not been able to get up there for some time, but that Mary gave her the news. She added that she understood that Mrs. Zelim had gone for help to the brother in Brooklyn, and had not got anything. She added, "You go too, but I think maybe waste time." Regarding the visit to the father, she said, " H e no like I send, but I say you go a n y w a y . " Mentioning the ten dollars which her father said he contributes to the household, started to plan Mrs. Theocrates' expenses with her. She said with flashing eyes that he does not pay ten dollars regularly, and that when there is any discussion about it he goes to sleep in the little cubby back of his shop. Also she said that Mary does not contribute regularly in cash, and repeated the analysis of Mary's situation given by Mrs. Zelim. Tried to make Mrs. Theocrates see that as long as both are in her household she is giving that much that she cannot afford to give; that this would be fine and generous if she had John here making good money, but that now it adds to her problems. [Syllabus reference: METHOD, Interviewing discussion.] In returning to the idea of moving, suggested that she ought to try to get a place where the babies could get some more sun, as they get none at all from the north windows. This argument greatly impressed her, and she agreed to go with visitor some day to look for such a place, leaving the matter of the furniture for the moment. She agreed that since the time of Mr. Theocrates' return is still very indefinite, that may also be temporarily disregarded, with an eye to saving the rent. In the whole discussion Mrs. Theocrates stated her objections frankly, but was quite willing to talk over, and to listen to visitor's arguments. She semed to grasp the purpose of the Society's plan, and to realize that it does not mean the arbitrary withholding of relief. As Mary appeared, to take the baby, questioned her about her own situation. Mary's English has also shown rapid im-

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provement f r o m the time when she used to walk about the kitchen shaking her head, " N o understand." When asked about the possibility of her contributing to the f a m i l y , she said clearly, pointing to her much mended hose, " Y o u think shame to not have dollar f o r n e w ? " She has a promise of employment, but is not sure of getting it. She has "sweetheart in pressing business" but cannot m a r r y until " m o r e

mon."

Father says he cannot help. In accordance with the plan, gave Mrs. Theocrates the allowance. In receiving thanks f o r the luncheon, Mrs. Theocrates said " W h o to help in the city, if not y o u ? " Then she added " A n y time you get h u n g r y come to m y house f o r eat." Relief $9.00. 4 . 1 0 . 3 0 — I t was agreed that it will now be best to reduce Mrs. Theocrates' allowance, since we k n o w of resouces within the situation which, if they cannot swing the entire budget, j u s t i f y our contributing less than the nine dollars of the plan. It was recognized that ideally Mrs. Theocrates will realize that this is f a i r , and in view of all the circumstances, especially the "other mothers with babies," it is hoped that she herself will decide to get along on less money. Telephoned social w o r k e r at the Tuberculosis Clinic, asking f o r complete report on the examination of Mike. N o evidence of pulmonary tuberculosis has been f o u n d . There is a diagnosis of bronchitis. T h e Wasserman was negative, as was Mrs. Theocrates'. Mike has gained slightly in weight since his hospitalization, this time solid flesh and not pounds caused b y his nephritic condition. T h e doctor would like to check on him about once a month. Treatment f o r the skin condition at Y o r k e Hospital advised. O n

the w a y to the clinic—Mrs.

Theocrates wheeled Mike in his little carriage—complimented Mrs. Theocrates on her consistent and indefatigable care of the babies. She was pleased, and said that some of her friends thought she takes too m u c h trouble with the youngsters, but she feels that this is her job, that she alone has it to do. " S u p posed to be when m a r r y ! " she said.

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She discussed m o v i n g as an immediate possibility, b u t said that she w o u l d like to get some idea o f when her husband will return, as she w a n t s to leave the city then, for his good and that of the babies. She is not particularly attached t o her present location, b u t being alone, would like a " g o o d h o u s e . " She would be satisfied with b a c k rooms, provided they were clean and s u n n y . She would like to have a r o o m in which the babies m i g h t sleep b y themselves. Social worker felt that the condition of J o h n and her general fear o f infection accounts f o r this desire. A g r e e d to look f o r places in which she m i g h t be interested. She said that she w o u l d like to keep in Social W o r k e r ' s district, as " y o u k n o w now all m y sorrow and t r o u b l e — n o like to tell all to o t h e r . " T h e n she added, " I have only you to come and say ' H o w babies?' and help to fix if w r o n g . Brother, sister, no come s o o n . " Social worker felt that this does express the very real need f o r interest and advice which Mrs. Theocrates has shown. [ S y l l a b u s reference: METHOD, Interviewing, discussion.] Reviewed with her in a general w a y the financial situation, again stressing the " f a i r " t h i n g t o do f o r Mrs. Theocrates, considering t h a t she already has as m u c h as some mothers get along on. She said that her h u s b a n d sent her only fifty dollars last m o n t h , which again b r o u g h t u p the matter of the big rent. She reviewed some o f his expenses—new spectacles, a w a r m sweater, a typewriter which he has recently purchased to learn on a n d give him something to do. Visitor mentioned situation as regards M a r y and the father, who obviously should contribute something. Mrs. Theocrates countered as usual, in no a n g r y or unreasonable m a n n e r . O b v i o u s l y she more or less got visitor's point of view, t h o u g h the appeal of the usual nine dollars was strong. She d o d g e d m a k i n g a definite decision when visitor suggested the possibility of her deciding to get along on five dollars, b u t finally said, " T r y seven." She was pleasant a b o u t visitor's rejoiner that it m i g h t be well t o split the difference and " t r y s i x , " t h o u g h she sighed and recounted her expenses. Visitor told her t o describe the whole situation

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as she understands it to her father, and to remind him that he mentioned to visitor his contribution of ten dollars a month. A l s o advised her to make the matter clear to M a r y . [Syllabus reference: KNOWLEDGE, E t h n o l o g y , habits and customs.] TEACHING NOTE: W e see the case worker learning by experience something about the Mediterraneans and so trying bargaining. It is easy to say that inexperience with the Greeks proved cosdy but the question may also be raised whether the constructive withdrawal in this case does not show the value of the contact built up and a change in the woman's attitude about accepting all the help she can get. Having started relief it is not always simple to terminate or even reduce it but on the other hand, perhaps she is still getting more than she expected to. The technical elements in letting the client solve her own problem so far as possible are not easily distinguishable in a case where resourcefulness is fairly high, but there is evidence that the method adopted by the social worker is part of a definite purpose. A f t e r the matter was settled, Mrs. Theocrates made a particular point of t h a n k i n g visitor more cordially than usual, and of seeing that M i k e did the same. Visitor felt that this was not only a matter of policy, b u t that it represented a real e f f o r t to have visitor realize that she understands. T h e same salve was prescribed at the clinic for Mike's sores, and he is to return in a month for examination. Relief $6.00. A p r i l 18, 1930 Union Home Phoenix Arizona Gentlemen: W e have been h e l p i n g the f a m i l y of John T h e o c r a t e s , at present an inmate of y o u r home, and shall c o n t i n u e to do so. H o w e v e r , in m a k i n g plans, a report of his condition and a s t a t e m e n t of the probable l e n g t h of his stay w i t h y o u w o u l d be of great value t o us. It w o u l d also help us in g e t t i n g a clear picture of the resources of this f a m i l y t o k n o w w h a t allowance he receives f r o m y o u . M a y w e have this i n f o r m a t i o n ? Mr. T h e o c r a t e s is c e r t a i n l y f o r t u n a t e in being placed in y o u r lovely

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home. It is a great c o m f o r t to his w i f e to k n o w that he is receiving such good care. A s y o u m a y k n o w she has been l e f t in rather a diffic u l t situation, w i t h the responsibility of t w o small babies. W e shall certainly appreciate your i n f o r m a t i o n as helping us w i t h our end of the situation. Sincerely yours, Social W o r k e r

4 . 2 3 . 3 0 — L e t t e r from Union Home: Dear Madam: M r . J o h n Theocrates, a resident of this institution, is not doing v e r y well. I n f a c t , he m a y never be able to return to w o r k , and his length of s t a y here will be indefinite. V e r y t r u l y yours, (Signed)

Superintendent.

j . i . 3 ο — L e t t e r from John Theocrates, Union Home, Phoenix, Arizona: M y dear Miss

:

I received y o u r letter several days ago, but have neglected to answer as p r o m p t l y as I should have. I understand f r o m y o u r letter that y o u are under the impression that m y f a t h e r - i n - l a w gives m y w i f e ten dollars a m o n t h , b u t this is not true, as f a r as I k n o w , though he does help in other w a y s , such as b r i n g i n g things to the children and, most of all, looking a f t e r them. Considering all this it is impossible f o r me to ask him f o r f u r t h e r help. A c c o r d i n g to his letters to me his business is such that he is unable to give m y f a m i l y f u r t h e r assistance. In regard to M r . Z e l i m , I wish to say that f o r several months d u r ing m y absence he was letting m y w i f e have money in small amounts g i v i n g me the impression that it was a g i f t , but now that he is out of e m p l o y m e n t he claims that this money was a loan, and is c o n tinually asking m y w i f e when she is to repay him. T h e amount that he let her h a v e is about $ 1 7 0 . 0 0 . I w o u l d appreciate it if y o u w o u l d ask him not to annoy m y w i f e any f u r t h e r w i t h this m a t t e r , and when I am able to r e t u r n to w o r k I will repay him. A s f a r as our relatives are concerned, d u r i n g m y absence they

J O H N

A N D

H E L E N

T H E O C R A T E S

4 * 7

haven't offered to help me, even though they know all the circumstances. In the meantime you can call on my brother-in-law, Mr. Polio, if you don't mind. According to my wife you are the only one who has offered her assistance in any way, financial or otherwise, and I wish you to know that I am very g r a t e f u l . O f the allowance that I receive f r o m my union I try to save a little to send home, but f r o m two dollars a week you can see that it is very hard for me to save any. In regard to moving to a cheaper apartment I leave all that to m y wife, though I think it would inconvenience her considerably, as we have f u r n i t u r e for a certain number of rooms, and moving to a smaller apartment would necessitate disposing of some of the f u r niture. It would also probably mean getting away f r o m my fatherin-law who, as you understand, is a great company for the children. In regard to my returning home I am rather uncertain, as the doctors will not give me any definite information. H o p i n g this letter will find you in the best of health, Sincerely yours, (Signed)

JOHN

THEOCRATES

P.S. Love and kisses to Mike and Achates f r o m their daddy. J· 5 . 1 2 . 3 0 — L e t t e r to Mr. Theocrates, Union H o m e ,

Phoenix,

Arizona: My dear Mr. Theocrates: T h a n k you for your letter and for the Easter card. I am sure that we are as pleased as you are over the allowance recently granted your wife by the Board of Child Welfare. T h e worker who conducted the investigation told me that they finally decided that the thirty dollars should be given as a supplement to your insurance money, but this is a great concession, as I know that at first they felt that the amount you are receiving made it impossible for them to give aid. O f course this grant will make it possible for Mrs. Theocrates to get along without financial assistance f r o m us. However, as I told you before this in no way affects our interest in your family and our desire to be of service to Mrs. Theocrates. I shall follow your suggestions in regard to seeing Mr. " N i c k " Polio, whom I missed when I called at his store, and Mr. Zelim, with whom I have already had several pleasant conversations. I think he cer-

4 I 8

JOHN

AND

HELEN

THEOCRATES

tainly will understand that Mrs. Theocrates is at present in no position to repay the loan. A t present we do not have his new address. Y o u r son, Achates, looks f a t t e r and healthier than ever. H e held out his arms to me yesterday. His mother says that he understands Greek better than English, but he " g e t s " a f e w English words, I notice. Mike was having his afternoon nap so I did not talk to him. T h e mats you wove are v e r y pretty and certainly are beautifully made. I should be interested in hearing about the kinds of w o r k you do. T h e indefiniteness in regard to your stay in Arizona is v e x i n g of course, but I am sure you realize that resolution to get well and determination not to worry are big assets in the long pull. Sincerely yours, Social Worker Hand-made Leather W o r k with Hand-tooled Monograms and Initials % Bill Folds J K e y Pourses

J Coin Pourses Jf V a n i t y Pourses

$ Wallets, f o r Business Man (single or double f o l d s ) } Handbags, Ladies Sporting (black and white) # Memo Pad Pourses

# A l l types and sizes

Should anyone want any of the above mentioned, I will be glad to fill their order. A n d I will put in any kind of design or monogram desired. Also any diagram that you may furnish of any articles that you wish made of leather. A l l this leather is of the best material and may be secured in any color. A s f o r the prices, I cannot say, f o r I don't know the kind of work or leather the customers want. JOHN

THHOCRATES

SUMMARY AND E V A L U A T I O N , 1 . 3 . 3 0 to 5 . 2 9 . 3 0 Treatment.—The

m i n i m u m relief c o v e r i n g f o o d and fuel e x -

penses f o r Mrs. Theocrates was continued until the c o m b i n a tion of M r . Theocrates' insurance p a y m e n t s and the B o a r d of C h i l d W e l f a r e allowance g r a n t of $ 3 0 a m o n t h made it u n -

JOHN

AND

HELEN

THEOCRATES

4

1

9

necessary. Before the Board of Child Welfare grant, however, the Society's relief was reduced with Mrs. Theocrates' consent f r o m $9 to $6 weekly. In view of the anonymous information about Mrs. Theocrates' relatives and resources ( 2 . 2 1 . 3 0 ) a good deal of checking on these matters was done, and Mrs. Theocrates was persuaded to revise her statements made to the Board of Child Welfare where the insurance payments had already been discovered. Mrs. Theocrates' application for second citizenship papers has been managed. The health of the family has of necessity received a good deal of attention. Mike was hospitalized at Yorke Hospital, 1 . 1 8 . 3 0 , for three weeks with acute nephritis. Mrs. Theocrates and the two children were entered for tests at the Tuberculosis Clinic of that hospital, where they still go periodically. Mike was returned to the hospital for his skin trouble and the treatment prescribed there has been followed up with Mrs. Theocrates. The milk from Free Milk Fund was continued, and report was made of Mike's progress. Mrs. Theocrates has been given diet advice for the babies and hospital instructions have been explained to her when she has not understood them. Correspondence with Mr. Theocrates has been carried on with a view to keeping him informed about his family and to enlisting his cooperation in plans for them. Evaluation.—The discovery that Mrs. Theocrates has more backing than she had informed us o f , enabled us to reduce relief even before the Board of Child Welfare grant, but this was not done immediately because, in the light of Mrs. Theocrates' many problems, it seemed desirable to preserve the contact. Also it was recognized that she had been very cooperative in the difficult matter of adjusting the misstatements to the Board of Child Welfare and it seemed best not to reward this attitude with an abrupt cut in funds. While the fact that Mrs. Theocrates' father and sister live with her may indicate that the actual insecurity of her situation was overestimated, their lack of English and meager knowledge of American life prevent their being a strong re-

420

JOHN

AND

HELEN

THEOCRATES

source for her. Her confidence, initiative and independence have obviously increased, as has her use of English. Her energy, intelligence and responsible attitude are enabling her to carry through unaided the clinic programs and health care for the babies, and only guidance has here been necessary. The move into cheaper quarters has not materialized because Mrs. Theocrates seems to wish to have her father with her; the present location is convenient for him and the family is averse to reducing the standards of living by taking an inferior apartment. Since the family is adjusted financially with the insurance and the Board of Child Welfare grant, it is not necessary for Mrs. Theocrates to earn, but she is willing to do so should the necessity arise. Present situation.—Mrs. Theocrates to continue to devote her entire energy to the home and children, and to be contented in so doing. She is showing increasing ability to manage her own affairs competently. She does not yet realize that her husband has both tuberculosis and syphilis and that the prognosis is not good, but she is on the alert for inherited trouble in the children. She keeps up a regular correspondence with him, and wishes to help him by selling articles he makes. The babies appear to be thriving and Mrs. Theocrates is faithful in carrying out clinic instructions. As far as is known, she receives no regular allowance from relatives, but her father seems to help her when she needs extra money. Treatment objective.—In the light of the doubtful prognosis for Mr. Theocrates we must work for as much independence and social responsibility as possible in the wife, encouraging affectional ties through correspondence and conversation. Plan.—To move Mrs. Theocrates to cheaper quarters, if a suitable and acceptable place can be found. To help Mrs. Theocrates carry through the citizenship requirements arranging for her to enter a class if it seems advisable. To watch the health of the babies, particularly of Mike.

JOHN

AND

HELEN

THEOCRATES

421

T o keep u p the correspondence w i t h Mr. Theocrates and to find a market f o r his products, i.e., h a n d - t o o l e d leather work. W i t h independence for Mrs. Theocrates as a goal, to e n courage her t o manage her o w n affairs so that w i t h i n a f e w m o n t h s the case can be closed in the care of a hospital. [Syllabus reference: METHOD, Inter-agency practice.] TEACHING N O T E : The functional relationship between the Hospital Social Service and the Family Welfare in this case calls for comment. This case might have been handled entirely by the hospital caring for the children—or it might be done joindy as here and then transferred to the appropriate agency. Division of labor may profitably be discussed and the philosophy that each agency should give the relief incident to its treatment. (Reference, Milford Conference Report, in "Social Case Work, Generic and Specific" published by the American Association of Social Workers.) j . ζ J.3ο—Letter f r o m Mr. Theocrates, U n i o n H o m e , Arizona: My dear Miss : You see that I am late again, as usual in my correspondence, but I am sure that you will excuse me. I want you to know that your letter made me feel quite joyful, knowing that arrangements have been made to take care of my family during my disability. Of course I have you to thank for all this. You have done more for my family than many people do for their own loved ones. I am glad that you think my children are doing so well. Such a favorable report as you give makes me feel good all over. In closing I wish to thank you again for all that you have done for my children, and to extend my best wishes for your welfare. Love and kisses to my darlings, Sincerely yours, ( S i g n e d ) J O H N THEOCRATES

SUMMARY AND EVALUATION, 5.29.30 to

Summary.—Mrs.

9.18.30

Theocrates and the babies have spent a c o m -

fortable summer, w h i c h included a week in the c o u n t r y with the family of her brother, N i c k Polio. H e r application for

4 2 2

JOHN

AND

HELEN

THEOCRATES

second citizenship papers w a s postponed because of the failure of one of her witnesses to appear. M a r y has now gone to live with the Brooklyn brother w h i c h leaves Mrs. Theocrates w i t h the entire care of the babies. Mr. Theocrates still writes r e g u larly. H e is not m a k i n g health progress, and has for some weeks been confined to a hospital. Treatment.—The small a m o u n t of t r e a t m e n t given d u r i n g these weeks has been directed t o w a r d e n c o u r a g i n g Mrs. Theocrates' initiative so that office can w i t h d r a w . T h u s the m a t t e r of application for second citizenship papers was left in her hands, and this seemed especially advisable in view of the appearance on the scene of her m a t e r n a l uncle. T h e Brooklyn brother is also cooperating w i t h Mrs. Theocrates in this matter, and that relationship seems to have been strengthened. Since Mrs. Theocrates now obviously does not wish to move, and is able to manage financially in her present residence, w i t h some help f r o m her father who lives w i t h her, it does not seem worth while to urge this change. Health supervision for the children is no longer necessary, as Mrs. Theocrates has made a good contact w i t h Y o r k e Hospital, and has shown herself capable of u n d e r s t a n d i n g instructions and conscientious in c a r r y i n g t h e m out. Provision for Mr. Theocrates by the U n i o n is adequate. Free m i l k is still being sent in for Mike. A possible m a r k e t for M r . Theocrates' leather w o r k was found, and arrangements for h i m to do his o w n bargaining were made. Evaluation.—Treatment d u r i n g this period w o u l d seem to have been effective m a i n l y because of Mrs. Theocrates' alert intelligence and sense of responsibility. She is quick to recognize the value of suggested resources, and has throughout shown ability to c a r r y t h r o u g h a plan w i t h a m i n i m u m of guidance. It is recognized that situations m a y arise in regard to the babies' or to Mr. Theocrates' precarious health in which Mrs. Theocrates m a y need advice or help, but she will feel no hesitancy in a p p l y i n g as contact is excellent. Observation will be continued for the present.

JOHN

AND

HELEN

THEOCRATES

423

T E A C H I N G N O T E : T h i s case-work episode of six months in the life of the Theocrates family suggests a discussion in closing as to the place of case work in Mothers' Allowance. Should Mothers 1 Allowance cases be supervised or should case work be offered? Are the services of health interpretation and social education to be generally available or is the responsibility to the client and community discharged by a mere determination of eligibility? This case suggests certain other transitional features in the case-work process itself. On the one hand we may analyze the check-up type of investigation and, evaluating the case only in these terms, find the worker inexperienced in Union benefits, insurances and "invisible" natural resources; on the other hand we may discern the beginning of a more conscious realization of the client's obligation to participate in the determination of her own eligibility, a more conscious use of contact or relationship, a slow moving process in which the client's plans for herself are respected even if not fully elicited and finally an attitude towards behavior as objective as that displayed towards health problems. Deceptions, syphilis, and deliberate lies are met with tolerance, an absence of praise or blame and an attempt to understand their meaning for the client. That the methods used are not in control or perfecdy balanced may be explained partly by the date of the record which lies on the thresholds of a period of extremely rapid adaptation of psychological concepts. Since 1929, technical developments in the application process have been marked, both as to franker determination of eligibility and the handling of the relationship element.

CHAPTER VII

THE CASE RECORD OF THE GRIEG FAMILY T E A C H I N G OBJECTIVES

From the two actual experiences in using this record in class, these primary emphases have emerged. First, negatively, it has not been found of special value in teaching the basic allaround techniques of generic social case work. Second, positively, it offers many opportunities for the discussion of special questions of METHOD which need to be faced, not only by a foster-family child welfare agency caring for children away from their own homes, but also by any social-case-work agency working with families who need help to care for children in their own homes. Again it challenges students to observe and study the data necessary for the sound evaluation of emotional and other values that, for both children and adults, grow out of the experience of knowing and living in close touch with their blood kin. Still further, the use of this record gives an incentive to compare, in class, the range of alternative RESOURCES for the care of children like Ann and Jane that are actually available in one state and community compared, not only with the state and community where the record was made, but with others known to different members of the class. Incidentally, more because of what was not done than by the excellence of what was done, the importance to the social case worker of as much KNOWLEDGE as possible of the resources of medicine and psychiatry is thrust upon the attention of students throughout the whole record. Finally, the length of time covered by this record—almost eight years—affords an opportunity for the individual reader, and for the class as a whole, to note with conscious honesty the

THE

GRIEG

FAMILY

4

2

5

degree t o w h i c h the sequel o f later years in the lives o f A n n a n d Jane, a n d o f M r . and Mrs. G r i e g , proves t o be like, or d i f f e r e n t f r o m , the prognoses w h i c h were more or less c o n sciously made as the first reading o f successive portions o f the record was completed. F r o m this point of v i e w , the record as a w h o l e suggests the q u e s t i o n : D o w e and can w e have an adequate realization o f the i m p o r t a n c e of the time f a c t o r in the lives o f those children t o w a r d whose stretching f u t u r e years w e , w i l l y - n i l l y , direct their uncertain feet? C O N T E N T OF T H E R E C O R D

T h i s record gives a time perspective o f nearly e i g h t y e a r s — f r o m J a n u a r y , 1924, to D e c e m b e r , 1 9 3 1 . It deals primarily w i t h the experiences o f a J u n c t i o n C i t y C h i l d W e l f a r e A g e n c y ( r e f e r r e d to in the record as C . W . A . ) in its efforts to help the f a t h e r , Charles G r i e g , and the m o t h e r , L e n a G r i e g , to care more adequately f o r their t w o girls, A n n and Jane, w h o were respectively 7 and 6 years old w h e n the story opened. [Syllabus reference: AREA.] Family

story.—In

brief the story o f C h a r l e s G r i e g , o f Lena

G r i e g , and of their f a m i l y situation in J a n u a r y , 1 9 2 4 , was as follows: T h e mother, Mrs. G r i e g , a native o f S w e d e n , was orphaned in i n f a n c y . Mrs. G r i e g

had been b r o u g h t

u p in

Upland,

Sweden, p a r t l y in an institution f o r dependent children and p a r t l y in foster homes. In one of these homes she had, b y a son o f the f a m i l y , borne a child o u t o f w e d l o c k that had died in i n f a n c y . O f this experience the C . W . A . did not learn until a m o n t h or more a f t e r it first met Mrs. G r i e g . Mrs. G r i e g had also borne a second child o u t o f w e d l o c k since she came t o the U n i t e d States and b e f o r e she met M r . G r i e g . T h i s child she had g i v e n in its i n f a n c y to a social a g e n c y w h i c h had given it f o r adoption to a home n o t k n o w n t o her. In J a n u a r y , 1924, the m o t h e r was so u n w e l l as t o need b o t h

4 2 6

T H E

G R I E G

F A M I L Y

medical and surgical treatment. The father, Mr. Grieg (also born in Sweden) during the year 1 9 2 3 , had taken A n n and Jane, then six and five years old, with him, had left his w i f e and gone to another city. A t the time of this application to the C . W . A . in J a n u a r y , 1924, he had come back to Junction C i t y with his daughters. H e was ill, possibly from venereal disease. He was not true to his wife. He was rather incompetent in his work. Mr. and Mrs. Grieg had quarreled repeatedly, had broken up their home, and were living separate from each other and from the two girls who were in a boarding family home 1 that was unsatisfactory to both parents. The father had a prosperous brother in Junction C i t y , the details of whose business were unknown, but it was thought to be of doubtful legality. This brother thought there was little hope of a successful reuniting of the Grieg family group. There was also a sister of the father near Junction C i t y , a married woman in poor financial circumstances, who shared the above views of her prosperous brother. So f a r as Mr. and Mrs. Charles Grieg had religious affiliations, they were Protestant. With such a combination of factors within the A R E A of social work that were contributory to the breakdown of social self-maintenance as a background, application was made 1.23.24, by the father, Charles Grieg, to the C . W . A . , a foster family boarding-out agency, to place his two girls, A n n , 7, and Jane, 6, at board in a foster-family home under the agency's supervision, but with the father's promise to pay their board. The names and dates of birth of the members of the family as given by the father were: Charles Grieg Lena Grieg A n n Grieg Jane Grieg 1

born 6. 4.88 born 5 . 1 1 . 8 6 born 2 . 1 7 . 1 7 born 8 . 1 8 . 1 8

This boarding family had been found by the Griegs before they consulted any

agency.

THE General

explanation

GRIEG

4

FAMILY

of the case record as here

2

7

printed.—The

record is g i v e n in f u l l f r o m the date o f application o f M r . G r i e g to the C . W . A . , J a n u a r y 23, 1924, u n t i l the end of that calendar year. F r o m J a n u a r y 1, 1 9 2 5 , t o J a n u a r y 3 1 , 1926, o n l y the record as s u m m a r i z e d b y the C . W . A . at the later date is given. A t t h a t time the case was t r a n s f e r r e d to the Family W e l f a r e Society

( F . W . S . ) . A f t e r some investigation

and experience o f their o w n , the F . W . S . made a D i a g n o s t i c Summary, January

6,

1 9 2 6 , an outline o f

which,

giving

"liabilities and assets" is g i v e n here. T h e story o f t r e a t m e n t b y the F . W . S . w i t h some cooperation b y the C . W . A . , f r o m J a n u a r y , 1926, u n t i l June 30, 1 9 2 7 , is then v e r y briefly suggested b y editorial c o m m e n t and b y t w o closing entries f r o m the F.W.S., M a r c h 2, 1 9 2 7 , a n d June 30, 1 9 2 7 . F r o m these dates until the present, D e c e m b e r , 1 9 3 1 , the original C . W . A . has been the social w o r k a g e n c y recognized as responsible f o r the case. F r o m O c t o b e r

29,

1929, u n t i l D e c e m b e r ,

1931,

the

record of the C . W . A . is again g i v e n in detail. In table f o r m , these f a c t s as to auspices, c h r o n o l o g y , a n d degree o f detail o f the record as herein printed, are s u m m a r i z e d as f o l l o w s : — DATES

AGF.NCY

TYPE OF

IN C H A R G E

Jan. 23, 1924 to Jan. Jan.

1, 1925

C.W.A.

i , 1925 to Jan. 3 1 , 1926

C.W.A.

RECORD

Complete Summary by

Jan. 31, 1926 to M a r . 2, 1927

F.W.S.

C.W.A. F.W.S.

summaries a n d editorial notes Mar. 2, 1927 t o O c t . 29, 1929

C.W.A.

Editorial

O c t . 29, 1929 t o D e c . , 1931

C.W.A.

Complete

notes record G E N E R A L T E A C H I N G N O T E : As the experiences of the social-case-work agencies with the Grieg family were actually divided into definite successive chronological sections, it is suggested that,

428

THE

GRIEG

FAMILY

so far as possible, the members of the class be asked to make, at the end of each section and before reading the record further, some individual and class criticism of the social case work already done, and also some constructive suggestions of what should next be done. There are also two similar opportunities for critical and constructive discussion within the first year, namely: first, at the end of the period of original investigation, and second, when plans were made to put the two girls in care of the mother in an apartment. The first assignment may well be a careful reading of the record from the beginning to the close of the entry of 2.18.24, when the children were accepted for placement in a boarding foster home, pending further study of the physical and neurological condition of both Mr. and Mrs. Grieg, as a preliminary to the half-formed plan of the C.W.A. to bring mother and children together in a rented apartment. Two specific questions for each member of the class to answer in writing before coming to class for discussion of this first section of the record might be these: 1. In what respects was the information secured from interviews and investigations, prior to 2.18.24, adequate, and in what respects inadequate as a basis for any plan of treatment? 2 2. What further or alternative plan of procedure would you recommend at this point? Why? FAMILY AND FOSTER-HOME

Case record of Grieg

RECORDS

family

A p p l i c a t i o n , 1 . 2 3 . 2 4 , to C . W . A .

T E A C H I N G N O T E : While reading the record of application, and of interviews immediately following, the student should note evidences of case-work content such as: incompatibility in family, insecurity, neglectedness; definition of problem, social study, interviewing, diagnosis or interpretation; personal and community resources. 1 . 2 3 . 2 4 — A p p l i c a t i o n w a s made b y father, Charles G r i e g , at the office w h e n he stated that he w a s not living w i t h his w i f e , that his children w e r e p o o r l y cared f o r in their present b o a r d ing home, and that he w o u l d like to have t h e m placed b y the C.W.A.

u n d e r the supervision of a visitor. H e w a s

poorly

' A l t h o u g h n o t m e n t i o n e d in t h e r e c o r d , it is of i n t e r e s t h e r e t o n o t e t h a t a l e t t e r a s k i n g f o r i n f o r m a t i o n h a d e v i d e n t l y a l r e a d y been sent t o U p l a n d , S w e d e n , f o r a letter was received

3 . 2 9 . 2 4 , in a n s w e r t o s u c h a n i n q u i r y .

THE

GRIEG

4

FAMILY

2

9

dressed, seemed very much discouraged, and said that he was ill. Social Service Exchange reported no information concerning the case. 1 . 2 3 . 2 4 — I n t e r v i e w with father at office. This is the first m a r riage of both Mr. and Mrs. Grieg. T h e ceremony was performed

2 . I J . 1 6 . It appears that in 1 9 0 6 the mother became

involved with a young man called J i m A c k e r l y , and in 1 9 0 7 gave birth to a child. It is impossible to tell w h a t has become of this child as the mother said she placed him in an institution and since that time he has been adopted. Mother and father have not lived together since M a y , 1 9 2 3 . Mother claims that father has deserted her several times. Father's

story.—Father

is Scandinavian. H e was born in U p -

land, Sweden, 6.4.88. His father was a f a r m e r and owned a small f a r m outside Upland and he was sent to school until he was about 1 2 years of age. H e reads and writes his native language and since coming to this country has learned to read and write English, although he does it poorly. H e described his home as a v e r y simple one. His f a t h e r was a v e r y strict disciplinarian, rather cruel, and not v e r y companionable.

His

mother was a hard worker but had little real friendship with the children, although she cared f o r them well f r o m a physical standpoint. Father speaks with great affection of his mother and seems to care very little f o r his father. Father's health has been rather poor during the last f e w years, although until he was married he seemed to have been perfectly well. H e was sent b y worker to College Clinic. 3 Father appeared to visitor as being v e r y nervous. H e cried twice without any apparent cause and said he had had no w o r k f o r some time. H e told visitor that when he first arrived in Junction C i t y he went to live w i t h his brother, Herbert, and was first employed at the Hotel Central. There he worked as a tray b o y and later became a porter. It was while at the Hotel 3

The

above

paragraph

was

evidently

dictated

after

the

mother,

f a c h e r , h a d b e e n seen. T h e r e c o r d is h e r e p r i n t e d as in t h e o r i g i n a l .

as

well

as

the

4 3 °

THE

GRIEG

FAMILY

C e n t r a l that he learned t o speak English. H i s brother then b o u g h t f o r h i m a small shop where he sold groceries. T h i s failed and was sold b y the creditors. Father's position then was that of a waiter. T h i s position was also secured f o r him b y his brother H e r b e r t , and this time his brother said t h a t he had proof that Charles had no stability as a w o r k e r and this was the last time paternal uncle, H e r b e r t , was w i l l i n g t o p u t money

into f i n d i n g h i m

an occupation. Charles has

now

learned the clothes c l e a n i n g and pressing business and belongs to the cleaners' union. In D e c e m b e r , 1922, he returned to U p l a n d , Sweden. H e spent six m o n t h s there, a n d w h e n he returned he b r o u g h t b a c k his sister, Mrs. G o l d m a r k . H e was at first v e r y reticent c o n c e r n i n g his marriage. H e said he had met the mother w h e n she was a servant in the house where one of his friends was w o r k i n g . She was a p p a r e n t l y a hard w o r k i n g girl and decent, b u t he did not k n o w then of her previous sex experience. H e did not admit that there was any i m m o r a l i t y before their marriage b u t he said that soon a f t e r his marriage he f o u n d o u t that she did not k n o w h o w to care f o r m o n e y , and that she was suspicious and jealous. A f t e r the birth o f the first child, things seemed to g o better f o r a time, b u t the father has g r o w n t o feel that she is most irresponsible and he can no longer care f o r her. H e says that it was f r o m an i n j u r y sustained f r o m a k i c k she gave him at the time ό ί a quarrel last June, that he is in such bad nervous condition. F r o m the history he gave, w o r k e r t h o u g h t that he m i g h t have gonorrhea, and it was because he was so discouraged and o u t o f w o r k that he was w i l l i n g to g o to C o l l e g e C l i n i c f o r various physical e x a m i n a tions. Father claims that he l e f t mother in June and that he will not live w i t h her under any conditions. H e says that mother has poisoned the minds of the children against him. H e does not make a v e r y g o o d impression. H e is tall, spare, w i t h reddish hair, blue eyes, and a weak m o u t h . H e has a v e r y pleasant smile and a g o o d speaking voice, and talks w i t h a slight lisp. Paternal

uncle's

story.—When

visitor t a l k e d w i t h

paternal

THE

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43*

uncle, Herbert Grieg, she found his family living in a very luxurious apartment. It is in a poor neighborhood, and the apartment house is badly cared for, but the Grieg family live very comfortably. They have a servant and all the furniture is new. Paternal uncle, Herbert, is a very fine looking man. H e does not commit himself in any way. He told visitor that, as f a r as he knows, nothing could be done to bring father and mother together. He said that the marriage from the beginning had been a mistake and they were incompatible. Part of that is due to the fact that the mother talks too much, has no money sense, is not willing to economize, and part of the trouble is due to the fact that the father has never taken the proper responsibility f o r his family. Paternal uncle spoke with great feeling concerning the promise father had shown in his early days, said he could not account f o r the latter's apparent social breakdown, that he, personally, could not take the children into his home, but that he would be glad to pay any shrinkage on board up to about $25.00 providing father did not know where the money came f r o m . H e will assist in clothing the children. Mrs. Herbert Grieg has been previously married and has two grown sons by this marriage. The younger children are attractive, well dressed, and of average intelligence. Doctor's story.—Visitor interviewed the family doctor and found that he remembered the Grieg family very well. He said Mr. Herbert Grieg had only since prohibition attained such material comfort and, though he was not willing to say that Mr. Grieg dealt illegally in liquor, he was willing to imply as much. He said it was not difficult to run such a business in the district where Mr. Herbert Grieg lives. He remembers quite well Charles and Lena Grieg, and said they lived poorly. He said he attended the mother after one abortion operation and found her very queer. He said she took good care of her children but he felt the father was not much good. Paternal aunt's story, 1.28.24—Visitor's interview with paternal aunt, Mrs. Goldmark, verified practically all of the above statements concerning father.

43

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T E A C H I N G N O T E : The above suggestion by the Doctor as to the possible nature of the business of Herbert Grieg is never followed up. The moral and civic obligation upon a social work agency in such a situation could, of course, be discussed if the teacher or students thought a discussion could be made valuable. One approach to such a discussion might be to inquire what the attitudes of different persons to such a situation are:—for example, lawyers, confidential religious advisers, social case workers, police, voters, etc. [Syllabus reference: PHILOSOPHY, Social worker's d u t y to law e n f o r c e m e n t . ] Mother's

story,

1 . 2 9 . 2 4 — V i s i t o r interviewed mother at her

place of employment and f o u n d that she was a children's nurse, receiving $70.00 a month. Mother is small, rather stocky, and is very nervous in appearance. She speaks English very well, has a f r i e n d l y manner, and was quite willing to talk. She told visitor the following story concerning her life: She was born in U p l a n d , Sweden. H e r mother had come of a good middle-class f a m i l y , and her mother's people had been small tradesmen and teachers. D u r i n g her mother's pregnancy her father deserted, and her mother went to the home of a friend, where she stayed until her child, Lena, was born. She died t w o days afterwards. Lena continued to live with her mother's friends until she was six years old, when she was taken to the orphanage in U p land. She stayed there six months and later was sent to a very wealthy f a m i l y . For some reason, she did not make good in this f a m i l y and was later placed out at service. A t 1 2 years of age she had an accident, a slight fall, and until she matured she had seizures resembling epilepsy. These passed a w a y at the time of her maturing and she has never had them since, although she admits that she has been subject to hysteria. "When she was t w e n t y a letter came f r o m her foster mother in America, stating that she would be glad to send passage money f o r Lena to come to J u n c t i o n C i t y . T h e letter was signed, " Y o u r loving m o t h e r , " and this led Mrs. Grieg to believe that this woman was a f t e r all her o w n blood relation. Officials at the orphanage told her that her o w n mother was not living and that

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433

they would not allow her to come to America until she was 2 i . In the meantime, they had given her considerable education and she finished what would be termed the 8th grade in America. According to her own statement, she did very badly in mathematics, and received many punishments because she could not learn readily. She came to America to her first foster mother, Mrs. Peterson, only to be disillusioned and to find that Mrs. Peterson was not her own mother. She then secured a position as a governess, and from that time until her marriage she worked in private families. For two years she was in the same place, with a Mrs. See in Junction City, and from this house she was married. At first she was not very frank concerning her affairs with Jim Ackerly, but she later told visitor that he was a chauffeur, that she met him through friends, and that she loved him as she had never loved anyone else. She gave her baby away to please him and he promised to marry her but he disappeared and was killed during the World War. Mother was sure Mr. Grieg had a court record before his marriage, but the records do not show this. She also told in some detail concerning father's immorality. Summary of home life and conditions, 1.29.24—The family have always lived in small tenements, once on a residence street, but most of the time in the business area in Junction City. They have had two- or three-room apartments, meagerly furnished but clean. It appears that mother and father have quarreled since the birth of their first child. Mother is unusually suspicious and stubborn, but underneath all this lies a consuming loneliness because she has no one in the world. Mother is devoted to the children, although she is not always wise with them. Father is also very much attached to the children. It is a question in the mind of worker whether either of the parents is fit to care for the children. Children, 1.29.24—Visit to boarding home where father had placed the girls. Ann is rather tall for her age, 7 years. She is a good-looking child with light hair and a lot of color. Indications that she is in need of dentistry and a tonsil and ade-

434

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noid operation. Ann entered school in the fall of 1922. She is now in Grade 2-A and likes arithmetic best. Jane is a small child, rather more delicate in appearance. She also seems in need of a tonsil and adenoid operation. Both children are fairly easy to manage. It is said that both have bad sex habits that they learned from their mother. 4 This worker was unable to v e r i f y and personally does not believe this statement. Relatives.—Paternal aunt, Mrs. Goldmark, has a small, meagerly furnished, but spotlessly clean apartment, and her children were well cared for. Her husband is an unskilled carpenter and his work is irregular. She would be unwilling to take the children, and visitor thinks it would be unwise for children to be placed in the home of paternal uncle, Herbert. There are two other paternal uncles, Henry and Justin Grieg, both living in Sweden. They are single and their present addresses are unknown. 2 . 1 3 . 2 4 . — A n n Grieg, born 2 . 1 7 . 1 7 , was examined by the C . W . A . doctor and found to be 16'/< below weight. There was a sty on her right eye and the physician confirmed the visitor's opinion that her teeth needed attention, and that she is in need of a tonsil and adenoid operation. In general she appears very nervous. Jane Grieg, born 8 . 1 8 . 1 8 , was also examined, the same day, by the C . W . A . doctor; report practically negative except that she was underweight zc/< and her tonsils and adenoids enlarged. Both girls were at once entered in Tonsil Hospital for clinic examination and treatment. 2.14.24—Father came to office. He has been in every two or three days since the case investigation started. He talks in a very plausible manner, always tells his family troubles, accuses his wife of infidelity and showed visitor a picture that mother had taken when she was in the country visiting. This ' T h e r e is no i n d i c a t i o n o f m a d e to v e r i f y it.

t h e s o u r c e o f t h i s i n f o r m a t i o n o r o f t h e k i n d of e f f o r t

THE

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435

FAMILY

picture showed her, dressed in overalls, in a rather lewd position. H e later took this picture away with him. H e tells visitor that he will never live with his w i f e , that he no longer loves her, and he is continually explaining away his o w n deficiency

in providing a home f o r his children. H e paid the

board of his children in advance. Mrs. Grieg has also come to the office at different times, alw a y s to tell her f a m i l y troubles and to beg visitor not to have her children kept a w a y f r o m her. She appears to be more and more mentally irresponsible, talks in disgusting fashion before her children, but at the same time appears to be very f o n d of them. Mr. Grieg says mother masturbates and mother accuses father of bad sex habits. Several efforts have been made to secure reports of tests at College Clinic but worker has been told each time that these tests were not completed. Acceptance

for placement

at board,

2 . 1 8 . 2 4 — A n n and J a n e

were accepted f o r care and placed at board with Mr. and Mrs. N e w t o n Southworth, 5 1 6 2 Clock Street, T r u c k t o w n , father to pay board at $5.00 each per week, also furnish clothing; paternal uncle, Herbert, to guarantee shrinkage on expense to amount of $ 2 5 . 0 0 ; Mrs. Southworth is to give special care and feeding. She has been instructed to have A n n keep early bed-time hours and take regular periods of rest during the day. Tonsil and adenoid operations have been performed, and the nurse is to visit regularly to keep in close touch with children's physical condition. This does not interfere with the work of the regular visitor. We are trying to find out the nature and cause of the physical and neurological condition of Mr. and Mrs. Grieg in order that, if possible, we may place the children back in a little home with their mother, the father to pay their support and to be allowed to see them under supervision. T h e children will need to remain in the care of the C . W . A . a f t e r they are returned to their mother. This plan must, of course, rest upon the final decision of the College d e s c r i p t i o n of S o u t h w o r i h

h o m e a p p e a r s in t h e r e c o r d

infra.

43^

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FAMILY

C l i n i c as t o w h e t h e r o r n o t t h e m o t h e r ' s nervous s t a m i n a is sufficient 8 t o w a r r a n t her c a r i n g f o r her o w n c h i l d r e n . T E A C H I N G N O T E S : In the discussion of the adequacy or inadequacy of the investigation up to this point, as a basis for a permanent plan of care for Ann and Jane, it should be clearly noted that the C . W . A . itself regarded this plan as a tentative one while they were "trying to find out the nature and cause of the physical and neurological condition of Mr. and Mrs. Grieg." From the record thus far, and frequently throughout the record, it is not clear how fully the C . W . A . is conscious of the need to recognize and evaluate, not only the degree and nature of any actual physical or mental diseases that Mr. and Mrs. Grieg might have, but also of the need to understand and evaluate their subtler emotional tensions and maladjustments which colored all their contacts with each other and with Ann and Jane. In the face of such clear evidence of insecurity, marital incompatibility, and emotional immaturity as well as of desertion, inadequate employment, disease, and neglectedness, there was need of a high degree of understanding of the real basis of all these factors and of their probable effects upon the lives of Ann and Jane. Granted that each type of agency was fully alert to the importance of getting at the roots of the social-case-work problems above suggested as present in the Grieg family situation, there is value at this point, and later, in a recognition of some of the most evident qualifications and limitations different types of community agencies have for giving care to children from family situations similar to that of Ann and Jane Grieg. [Syllabus reference:

RESOURCES.]

For example, is there need, in general, of at least a minimum amount of maturity and economic stability in at least one parent, to make the service of the day nursery, the family welfare society, or the so-called mothers' pension plan of care practicable? Again, is the child-welfare agency that confines itself to the placement of children for permanent support in what are called free foster-family homes, whether with or without legal adoption, most successful in serving those children who have, when so placed, the fewest kinship ties with adults or siblings to be broken by a permanent separation? Can both institutions for the "Query:

Could such a judgment

f o l l o w s o l e l y on t h e basis o f o n e o r t w o

examinations? W o u l d not the case-work

data obtainable by C . W . A .

clinical

f r o m its o w n

e x p e r i e n c e s w i t h , and i n v e s t i g a t i o n o f , M r s . G r i e g be f u l l y as e s s e n t i a l ?

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437

residential care of children (often incorrectly referred to as orphan asylums) and child-welfare agencies that pay board for children in foster-family homes give temporary care to children and, at the same time, if they so wish, recognize and build upon whatever is valuable in the kinship relations between the child and his parents, and also, upon that between the accepted child and his siblings who are elsewhere? Unless, therefore, the evidence up to this point is convincing that Ann and Jane ought to have been permanently separated from both parents—and perhaps from each other—was the choice of a free foster-family home method of care, possibly by legal adoption, the one to have been made? Similarly at the outset, as the natural home had been broken up was there then an opportunity to help Ann and Jane by merely supplementing their care with their parents? There is, therefore, usually, general agreement, after bringing out these points in class discussion, that if any help was to be given to Ann and Jane at the time of the father's application, the choice would lie between an institution and placement in a foster-family home with some payment for board. Either one of these tentative plans of care permitted further study of the fitness of either or both parents to resume personal care and education of the girls without any implication that another family home had gained any claim to permanent custody and personal relationship to them. Testimony at this point by students from different parts of the country as to the degree of availability of all the different types of care for dependent and neglected children in their several states has been found stimulating. For example, the United States Census Volume of 1923, "Children in Institutions," shows in Table T w o that in twenty-two states, of all the dependent and neglected children being cared for away from their own homes on February 1, 1923, less than 1% were cared for in boarding foster-family homes, and, in thirty-two states, less than 5 % . In the discussion of next steps in investigation—plan and treatment— it has been found helpful to try to reach some substantial class agreement as to what further social, medical, and mental hygiene data are needed before the temporary plan of treatment gives way to a relatively permanent plan. It should be clearly noted that the n e x t f e w pages of the record were written by a w o r k e r in a division, or d e p a r t m e n t , of the C . W . A . , devoted almost entirely to the f i n d i n g , investigation, and evaluation of b o a r d i n g f o s t e r - f a m i l y homes f o r

43**

THE

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children, and that this worker, at the end of her report, did not have Ann and Jane, or any other particular children, in mind. Investigation of foster home 2.13.24—Report of investigation of home in which Ann and Jane were placed. A f t e r directions for reaching the home, the report followed: [Syllabus reference: M E T H O D , Child placement—investigation.] Environment.—Trucktown is a new community which is being developed on the edge of Junction City. The houses are all new bungalow and cottage style. Directly across the street are open fields and just beyond are woods. The neighbors are a rather ordinary class of people. On one side of the Southworths lives a chauffeur's family, and the man on the other side of them works at the factory in Junction City. Interview with foster mother.— (Church and school privileges.) The Southworths have not yet become affiliated with any church in Trucktown since they have lived there only three months. They attended the Dutch Reform Church in Junction City. There are several Protestant Churches within fifteen minutes walk of their house and Mrs. Southworth agreed that the children will be sent regularly to Sunday School at one of them. There is a fine grammar school directly across the street. General conditions of the place.—The house is a new story and a half cottage style, not quite finished. There is still some varnishing to be done, and a bit of plastering in one room. On the first floor are the living room, dining room, kitchen, two bedrooms, bath, and a sun parlor on the front of the house. The second floor is a large unfinished room which the family use as a storeroom at present. The sun parlor was comfortably furnished with two or three reed chairs and a table. The living room contained a pianola and several comfortable looking chairs, and the room appeared to be used very little. The family probably sit in the dining room, which is a very

THE

GRIEG

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439

sunny, pleasant room. It was furnished in a fair quality of oak. The bedrooms were both furnished with iron beds, dressers, and chairs. There were two windows in each bedroom, cretonne curtains, and covers on the beds and bureaus to match the curtains. They were in rather poor taste. The living room floor was covered with a bright blue rug, rather gaudy, but of good quality. The rug in the dining room was in shades of tan and in very good taste. There were a few pictures, cheap prints, no books or magazines. The kitchen was a typically modern kitchen, and was immaculate. The house is very light and airy, with sunshine all day. It was meticulously clean and neat. Mrs. Southworth is evidently an excellent housekeeper. There was not the odor of strong coffee and vegetables that one frequently finds in small houses. The Southworths own a small yard at the front and one at the back, and intend to have a vegetable garden in the summer. Occupation.—Mr. Southworth is an electrician. He works for the Utility Electric Company in Junction City. Mrs. S. does not have any employment outside of her home. Finances.—Mr. S. earns $40.00 a week. The family own their house. Visitor judged that Mrs. S. is very careful in the spending of their money. They have apparently lived economically for a long time and saved their money for their house and furnishings. Visitor would judge that it is not necessary for the family to supplement their income by boarding children, but Mrs. S. probably expects to get her pin money in this way. Family.—Mr. Southworth is 35 years old. He is a Scandinavian. He was born and has always lived in Junction City. He finished the grammar school but did not go to high school and has always worked as an electrician. He is said by references to be a very quiet man, devoted to his home and family, a man of clean habits and good morals. Mrs. S. is about 3 5 years old. She is of medium height, rather stout, and has a dark complexion. She was neatly dressed and her hair was neatly combed. She is jolly, fat, and loquacious, and has a foreign accent. She stated that she and Mr. Southworth were in very

44°

THE

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good health and she certainly has the appearance of being very strong and healthy. She was born in a small place not far from Junction City, and is the daughter of a farmer. She went through only the jth grade in school and when rather young went to work in a box factory and worked there until her marriage. Until her marriage she lived in small places near home. Following her marriage they lived at 51 25th Street, Junction City. Mr. and Mrs. S. were married seven years before their daughter, Dorothy, was born. She is the only child. This home was in a congested district of Junction City, and Mrs. S. said she always thoroughly disliked living there. She is now very happy that they are able to have a home in the country. Mrs. S. is very friendly. Visitor would judge that she would be cooperative in following directions given by the Society. Her own child seemed very well cared for. Mrs. S. uses some incorrect English but on the whole made a favorable impression. Dorothy, the only child, is three years old. She is rather an attractive, normal appearing little girl. There appeared to be real affection between D. and her mother. Family and community life.—The Southworths have lived in the neighborhood only three months and as yet are only slightly acquainted. They have not become affiliated with any church or other organization. Mrs. S. spoke as if she intended to get out later and try to make friends, and visitor judged that she would do so rather easily. Room the child would occupy.—Mrs. S. wished to take two children, who would occupy the bedroom on the front of the house. When seen, it contained a double bed but she said she would put in a three-quarter bed and a couch so each child could sleep separately. There is a large closet in the hall for the children's clothes and the bathroom is just next to the bedroom. The room which Mr. and Mrs. S. occupy is directly across the hall. Family's plan for child.—Besides Mrs. S.'s experience with her own child, she has cared for the child of a friend. This was

THE

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44

1

previous to the birth of D o r o t h y . T h e neighbors at 1 5 th Street stated that she cared f o r this child as if it were her o w n , was exceedingly patient and k i n d , and was c a r e f u l in feeding it. Mrs. S. claims to w a n t t w o children to board f o r the sake of companionship f o r D o r o t h y . T h e r e are only t w o children in the neighborhood w i t h w h o m she wishes D o r o t h y to play, and they are both considerably older. Mrs. S. will take t w o children, brother and sister, or t w o sisters. She will take children f r o m t w o to ten or eleven years. Children will h a v e a splendid opportunity f o r p l a y i n g out of doors. T h e r e is the usual moving picture theater and only the opportunities f o r recreation which a small suburban t o w n offers. Interview

with foster father.—Mr.

S. was seen b y visitor at

his place of e m p l o y m e n t at the U t i l i t y Electric C o m p a n y . Mr. S. is of medium height, slender, and has a sandy complexion. H e was, of course, dressed in his w o r k i n g clothes, w h i c h were neat and whole. F r o m his facial expression, one w o u l d not judge him to be a strong character but a man w h o is quiet and moderate in temperament. H e was v e r y f r i e n d l y , is deeply interested in the children w h o are being placed in his home, and was v e r y cooperative in helping make plans f o r transferring the children. H e said he was p e r f e c t l y willing to bring them in w i t h him w h e n he came in to w o r k if it were not too early f o r them to arrive in the city. H e seemed pleased that there were to be other children in the home as companions f o r his own child. H e said that his daughter had been afraid of dogs and he w a n t e d her to overcome this fear so he bought a Belgian police dog and has taught the child to overcome her fear of the dog and n o w they are great pals. Visitor was f a v o r ably impressed w i t h M r . S. and his understanding of children. Testimony

of references.—The

references gave this testimo-

n y : Their J u n c t i o n C i t y minister, w h o had k n o w n them three years, said they lived happily together and their f a m i l y standards were high. A w o m a n , a city neighbor w h o had k n o w n them f o r 20 years, said their home would be a good place f o r children and

44

2

THE

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that their character and standing are very good. T h e y have a fine comfortable home and are loving people toward children. Another city w o m a n w h o had k n o w n them f o r ten years said their home was desirable f o r a child whoever the child m i g h t be. T h e Assistant Superintendent of Schools in T r u c k t o w n said he had k n o w n the f a m i l y f o r 1 2 years and that their home would be " A N o . 1 " f o r a child. Still another neighbor w o m a n w h o had k n o w n the f a m i l y f o r five years said Mrs. Southworth is an exceedingly kind-hearted woman and has a great amount of patience with children. Both M r . and Mrs. Southworth are of fine character. H e does not drink, has no bad habits, is very quiet, and is devoted to his home. She recommended the home as an excellent one in which to place children to board. Visitor's

recommendation

Visitor recommends this home as a boarding home f o r a brother and sister, t w o brothers, or two sisters f r o m t w o to ten years old, ordinary children. T E A C H I N G N O T E : Since the home-finding worker who made the above report did not have Ann and Jane in mind, there is a chance for class discussion of the process by which the worker who actually placed Ann and Jane in the Southworth home gained her knowledge of that home. Was it merely by a hasty reading of the home-finder's report? Was it merely by a thoughtful reading of the report? Was such a reading supplemented by a personal conference with the home-finder? How far was any one of these supplemented by a conference with either Mr. or Mrs. Southworth or both, including in this conference the special Grieg family situation and individual needs of Ann and Jane? What should have been the procedure at this point as a basis for the best possible service of the Southworths to Ann and Jane, to Mr. and Mrs. Grieg, and as a basis for the best cooperative relationship between the C.W.A. and the Southworths in the direction of a more complete understanding of the whole Grieg family situation? Mother asks to get children back 2 . 1 9 . 2 4 — T e l e p h o n e f r o m Y . W . C . A . saying that mother has applied to them to see if they can get her children back to her

THE

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443

at end of two months. They referred the case back to the C.W.A. 2.23.24—The nurse visited Ann and Jane at home of Mrs. Southworth. Ann's throat condition improving, and she was apparently well but for an extreme nervousness. She was constantly licking finger tips and moving about. Mrs. S.'s attention called to it. Instructions were given Mrs. S. to see that Ann has plenty of fresh air and very nourishing diet. Jane's throat also improving—same instruction as for Ann about fresh air and diet.7 Case Record of the Grieg Family

(continued)

Report on health of father, 2.27.24—A report from College Clinic states that father's medical examination revealed a nervous, chronically ill young man complaining of pain in the region of the left testicle. He appeared to be poorly nourished, flushed, and generally ill at ease. His teeth were poor. A fine macular rash was noted over his chest and back. Heart and lungs were negative. Abdomen was negative. Extremities showed a few scars on both shins and exaggerated knee jerks. The hands had a moderate coarse tremor. His Wasserman was negative. The urine was also negative. Urological examination revealed a chronic prostatitis and a chronic epididymitis. We wanted to have psychiatrist see him but have not been able to get him to come back for this examination, so that we are unable to report on mental status. Sorry. Report on health of mother, 2.28.24—A report from College Clinic states that "the patient, Mrs. Grieg, was seen in College Clinic February 6th, at which time a provisional diagnosis of slight hyperthyroidism was made. A Wasserman was called for, which was negative. She was seen in Gynecology, where a diagnosis of cystocele and relaxed vesicle sphincter was made. T

The C . W . A . had its own social-case-work visitor, but the references to visits b y

2 nurse require this explanation. A t the time A n n and J a n e were placed the C . W . A . was w o r k i n g in cooperation w i t h an agency in that locality that supported a visiting nurse. F o r health problems, t h e r e f o r e , this nurse as well as the C . W . A . visitor went into some of the same boarding f o s t e r - f a m i l y homes.

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THE

GRIEG

FAMILY

There was a note to the effect that if the blood Wasserman was negative, operation was advised. O n the 21st D r . M c G o w a n saw the case and concurred in the operative advice. She was treated in the surgical department for paronychia of the right thumb. D r . M c G o w a n felt that unless an operation were performed the condition would become progressively worse and that local treatments would be of no particular benefit. H e feels that she probably needs three weeks in the hospital and one week of convalescent care; he believes that her nervousness may be aggravated by the pelvic condition. 3 . j . 2 8 — T e l e p h o n e message f r o m College Clinic stating that Mr. Grieg had reported again f o r treatment and that the doctor was t r y i n g to persuade him to have a spinal fluid test; that there is a question of syphilis, and there are many symptoms of a disease of the nervous system that would come f r o m syphilis alone. A f t e r the test is made they will continue with the N e u rological examination and will send a report. 3 . 6 . 2 4 — N u r s e visited A n n and Jane. Mrs. Southworth reported A n n much improved. H e r appetite is more normal and nervous condition lessened. W o r k e r visited Ann's school. A n n seemed interested and her general appearance satisfactory. Jane's physical condition is good. H a d complained of earache the previous day, a f t e r a visit f r o m her mother; no discharge f r o m ear. Mrs. Grieg sent word that she had taken a position with Mrs. Buttenheim, 16 Chestnut Street, Suburbia, near J u n c tion C i t y . 3 . 1 4 . 2 4 — M r s . Southworth telephoned that A n n had cold. Advised doctor be called, and that nurse would call soon. 3 . 1 7 . 2 4 — N u r s e visited A n n and Jane. Mrs. Southworth had not called doctor but had given A n n a physic and sweat. A n n had responded well and no sign of cold was in evidence. H o w ever, general appearance was not satisfactory. H e r appetite is poor. H e r general behavior is good but she is dreamy. Mrs. Southworth says she frequently finds her sitting down and staring into space. Visitor talked to A n n and asked her if she

THE

GRIEG

445

FAMILY

w e r e h a p p y and w h a t was the cause of her w o r r y . She said t h a t she w a s t h i n k i n g of her m o t h e r all the time a n d wished she could be w i t h her and help her. She seems to c r a v e a f f e c t i o n and a l w a y s shows great pleasure at o u r visits. V i s i t o r called u p D r . J o h n B u r n s of B u r k e v i l l e and reported the case. D r . B u r n s said he w o u l d be v e r y g l a d to see A n n a n d asked that M r s . S o u t h w o r t h take her to his office on that d a y at 5 o ' c l o c k . A n n is sleeping well in the r o o m w i t h her sister, J a n e , a n d Mrs. S.'s d a u g h t e r D o r o t h y , in separate beds. M r s . S. w a s questioned about the sleeping habits of A . and she said that she had w a t c h e d c a r e f u l l y and had not seen a n y evidences of mast u r b a t i o n and is quite sure t h a t such is not the case. L u n c h w a s set on the kitchen table a n d consisted of c h i c k e n a n d v e r m i celli soup, beans, b r o w n bread, a n d m i l k . A n n ' s

appetite,

t h o u g h poor, is s h o w i n g a t e n d e n c y to become n o r m a l . H e r c r a v i n g f o r s a u e r k r a u t and pickles is less, b u t she is still v e r y f o n d of lollipops. H e r teeth are well cared f o r a n d are brushed three times a day. V i s i t o r t h o u g h t it best to d e f e r u n t i l a little later the visit to the dentist. 3 . 1 7 . 2 4 * — J a n e is v e r y h a p p y , was a n x i o u s at first because she t h o u g h t visitor had come to t a k e her a w a y . She p l a y s w e l l w i t h D o r o t h y S o u t h w o r t h and seems about the same t e m p e r a m e n t . She is outdoors most of the d a y . She eats v e r y w e l l and sleeps all n i g h t . She is a l w a y s a n x i o u s to g o to bed and o f t e n asks to be put to bed as early as 7 o ' c l o c k b u t is not a l l o w e d to, because then she w a k e n s too early. H e r teeth are in v e r y good condition. She shows evidences of v e r y good care. ' D a t e s o f v i s i t s to A n n a n d J a n e in t h e S o u t h w o r t h

h o m e are f r e q u e n t l y

repeated

f o r the reason t h a t t h e o r i g i n a l c a s e r e c o r d has s e p a r a t e f o l d e r s f o r e a c h g i r l . what

extent

pood

case

involved

a separate record

work are

for

the

questions

of

sheet

family

as

f o r each a unit,

case-record

member

of

a family

and

how

large

technique.

The

C.W.A.

some c h a n g e s in t h e d i r e c t i o n of c o n d e n s a t i o n o f

records.

an

contributes

expense has

factor

recently

To to is

made

44^

THE

GRIEG

FAMILY March 18, 1924

Mrs. Lena Grieg c / o Mrs. Buttenheim My dear Mrs. Grieg: I have not heard from you since you went away and I am anxious to know how you are getting along. Is your thumb giving you any more trouble? They have told me at College Clinic that you need to have a slight operation and I think we can arrange this for you so that it will cost you practically nothing. I know it is your hope to have the children with you at the end of another month or so, and it would seem to me that if you attempt anything so difficult you should put yourself in excellent physical condition before we make the appeal to Mr. Grieg. They tell me at the Clinic that the operation is very slight but that you will need some time to recuperate. The next time you have an afternoon off, would it be possible for you to come to see us? If this interferes with your visit to the children, I would be glad to come to see you if you will tell me at what time it will be convenient for you to entertain a caller. It is almost impossible f o r me to visit you in the evening, but I could do so almost any day next week, providing you let me know ahead of tiroe. Yesterday, our nurse went to see the children. Jane is gaining in flesh and is perfectly well. A n n has had a cold and it was for this reason I sent the nurse to see her. The nurse made an appointment for her to go to see a local doctor and get a tonic, and we will go out to see her again next week. I am very much pleased with the cooperation you have shown and I know that your chief interest in life is your children and their future welfare. Let me hear from you. Very sincerely yours, C . W . A . Worker [ S y l l a b u s r e f e r e n c e : METHOD, M a n a g e m e n t . ] 3.30.24 Mrs. Lena Grieg c / o Mrs. Buttenheim My dear Mrs. Grieg: I have just talked with College Clinic and they will see you next Thursday morning, April 5, at 1 0 : 3 0 o'clock. I know this is an early

THE

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447

hour, but they are giving you a special appointment and it is the only time they can see you. I think if you try to make arrangements w i t h your employer she will understand and will be glad to help you keep this appointment. Very sincerely yours, C . W . A . Worker

3.24.24—Mr. Grieg called at the office and said that he was working. He is doing pressing and cleaning for private individuals and has a position through his union. Mr. Grieg looked very well, was well dressed and said he had not been going to College Clinic because they were so slow in making his tests. A f t e r further talk with him, he considered the necessity of continuing treatment and promised to do so. He was very cooperative concerning the children's allowance and very gratef u l for what was being done for them. Further discussed with him the possible plan of putting the children with the mother, father paying for their support through the C.W.A. He said he was perfectly willing to do this, providing C.W.A. would continue supervision. He said that he did not think Mrs. Grieg was capable of caring for the children unless there was someone to make plans for her. Miss Mill of College Clinic came to the office and discussed the Grieg case. She said she did not feel that Mr. Grieg's psychiatric examination was as necessary as his physical treatment. She gave us to understand, without doubt, that Mr. Grieg had syphilis. A lumbar puncture would be the only thing that would rebuild his physical condition. Miss Mill felt that the plan for the children was an excellent one and said she would be very glad to give the psychiatric examination on April 25, 1924. She asked if the information had come from Upland, Sweden concerning Mrs. Grieg's history, and that, if information came it be forwarded to the Clinic. 3.26.24—C.W.A. worker visited Mrs. Grieg in Suburbia, where she is working as a nursemaid. She is living in very comfortable quarters, well cared for, and says she enjoys her work

44^

THE

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but that she feels she needs the operation, as the condition is a constant source of irritation to her. She again went over the history of her life and told visitor that she had been " p u r e " since her marriage. She was very nervous and excited and would not listen to visitor at first, but a f t e r she had discussed her own plans f o r a half hour she became calm and would do anything visitor recommended. She agreed to keep her appointment on A p r i l 5, at 9 : 3 0 . Report

about Mrs. Grieg from Sweden,

3 . 2 9 . 2 4 — A report was

received f r o m U p l a n d , Sweden, concerning the record of Lena Grieg. T h e report stated that Lena was born in Upland, May 1 1 , 1 8 8 6 , that her mother whose husband had deserted, died t w o days after Lena's birth. T h e child then became a ward of the state and was placed with Mrs. Peterson, where she remained until September 2 2 , 1 8 9 3 . Mrs. Peterson then went to America and Lena was placed out at service. In 1 8 9 7 Lena was brought to the hospital f o r something that was termed fits. She was put under observation and her history f r o m 1898 to 1 9 0 0 was under the doctor's care. A f t e r she matured she did not have these seizures. O n February 4, 1 9 0 1 , Lena was visited by a mental expert w h o pronounced her intelligence " n o t norm a l . " It was then decided that these fits had been epilepsy, although Lena had had no seizures since 1900. In N o v e m b e r , 1 9 0 3 , Lena gave birth to an illegitimate son; father of this boy was Emil Root, and no effort was made to secure a marriage and no settlement was made f o r the child. This baby died April 4, 1906. In 1 9 0 7 Lena came to America. T h e report contained no information concerning Lena's school record, and no information concerning her behavior. Sent report f r o m U p land to the College Clinic. 3 . 3 1 . 2 4 — M r s . Buttenheim, where Mrs. Grieg is employed, telephoned that Mrs. Grieg was very much upset concerning her own physical condition, and Mrs. B. would like to k n o w details concerning pending operation. She was very cooperative and f r i e n d l y and very much interested in the plan f o r Mrs. Grieg.

THE 4.2.24—Mrs.

GRIEG

FAMILY

G r i e g c a m e t o the office a n d

449 lunched

with

C . W . A . w o r k e r . She seems m u c h calmer and more reasonable and is v e r y anxious to have the children w i t h her. She is w i l l ing t o have her operation w h e n it is necessary; says she is not f e e l i n g v e r y w e l l ; she has pains in her b a c k and stomach. She w e n t t o C o l l e g e C l i n i c f o r her mental e x a m i n a t i o n and f o u n d it v e r y amusing. Visitor telephoned C o l l e g e C l i n i c f o r a p p o i n t m e n t f o r operation, and the C o l l e g e C l i n i c promised t o telephone C . W . A . A p r i l 7 t h . R e p o r t was received f r o m C o l l e g e C l i n i c , c o n t a i n i n g the following information: The examination of Lena Grieg in the Department of Psychiatry today fails to reveal any organic brain disease. Her intelligence, allowing for language difficulty, was normal (she passed most of the fourteen-year-old Binet test and part of the average adult). The mental status shows only a mild depression which seems in proportion to her situational difficulty. There was no psychiatric reason brought out as to whether she was a suitable guardian for her children, and the decision as to her competency in that direction should depend on the actual facts and the sociological considerations. There are no psychiatric counter-indications to the surgical procedure. [ S y l l a b u s reference:

KNOWLEDGE,

Psychiatry.]

T E A C H I N G N O T E : This information regarding Mrs. Grieg is worth special note, for, as far as the record shows, it seems to have been accepted by the agency as evidence that mentally Mrs. G . was a fit person to have control and guidance of her children. What sociological information would be adequate to supplement this report from the Department of Psychiatry? Record

of children

in foster

home

4 . 4 . 2 4 — C a l l e d on A n n ' s teacher, Miss Roberts, P.S. 1 1 . A n n is in Β class w i t h a rating o f " B . " Miss R o b e r t s said that A n n was so b a s h f u l at first that she c o u l d not learn. She seems rather slow even n o w b u t plays w i t h the other children in a normal manner. Later: Saw Mrs. S o u t h w o r t h ; she said that A n n c o u l d n o t understand her lessons at first until she helped her and t o l d

45°

THE

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FAMILY

her w h a t the words meant. Since then A n n seems to enjoy her home w o r k . She has a glass of milk at recess time every m o r n ing, and eats heartily. She has a bath every Friday and her hair washed every t w o weeks. Visitor f o u n d A n n in the back y a r d playing with the little girl next door. A n n said she was happy and did not w a n t to go home. She has not been to Sunday school because her coat was too thin. A f r i e n d of Mrs. Southworth's has now given her a second-hand coat and A n n ' s coat will be used f o r J a n e . Mrs. Southworth has made a skirt f o r A n n out of an old dress. Mrs. Grieg gave Mrs. Southworth $3. f o r clothes last week. She bought some Pebeco T o o t h Paste, some garters, and t w o Windsor ties, total $ i . $ o . Mrs. Southworth said that A n n used to talk to herself saying, " O h , m y M a m a . " Mrs. Southworth f o u n d that she was a f r a i d her mother or father would take her a w a y . A f t e r she was reassured and told that she w o u l d stay there, A n n got over talking to herself. A n n sleeps on a cot which is folded u p and kept in the closet during the daytime, because Mrs. S. has no chintz to make a cover to match the rest of the hangings, but the room looked very pretty and neat. T h e dishes had not been washed, although it was a f t e r noon, because Mrs. S. had been shopping in the morning; she was doing the sweeping. Mrs. Grieg has started a bank account of $ 3 2 . 5 0 f o r each child in the T r u c k t o w n Bank at Mrs. Southworth's suggestion. Saw J a n e at the home of Mrs. Southworth. She was playing with D o r o t h y , m a k i n g m u d pies, and looked well but was quiet. Mrs. Southworth said that she had a w o n d e r f u l appetite. She showed visitor her doll. She has not been to Sunday school because of the cold weather. 4 . 1 4 . 2 4 — M r s . Grieg was admitted to the C a l v a r y Hospital on 69th Street, where she received the f o l l o w i n g treatment: P y e litis, urethrocele, peritoneal adhesions, varicose veins of broad ligaments, bronchitis. Complications, D . & C . sept, of adhesions, operated

f o r urethrocele anterior colporrhaphy, sal-

pingocoph. left. Last k n o w n condition, ligation of veins of

THE

GRIEG

FAMILY

45

1

broad ligaments. Condition upon discharge, excellent; prognosis, good. Mrs. Grieg was visited three times while in the Hospital by C . W . A . workers. She seemed cheerful and made a good recovery. T h e last week she was in the hospital the children were brought to see her. She had a very happy time with them. T w o days a f t e r her discharge she was sent to a convalescent home in the c o u n t r y , where she remained ten days. She then came into the office and requested that the regular C . W . A . worker place her in an apartment with the children. Arrangements were made f o r Mr. and Mrs. Grieg to meet at the office f o r a conference on J u n e 2 3 d . 4 . 2 3 . 2 4 — V i s i t e d A n n at the home of Mrs. Southworth. I t was during the holiday week and both children were at home. Mrs. Southworth was dressing the children to take them d o w n t o w n shopping. A n n looked very well indeed. She was neatly dressed in a spring coat and summer hat. She wore good-looking shoes. Physically A n n looks much better than when she went to the Southworth home. She is not plump, in f a c t she is a little thin, but her cheeks are red and there is a healthy look to the skin. Mrs. Southworth said she had been very well except f o r the occasion when the nurse was called when she was first there. H e r appetite is good. She is having the following d i e t : — I n the morning she has cooked cereal, sometimes an egg, and milk to drink. She usually has oatmeal or farina. In the middle of the forenoon she eats an apple or an orange. For lunch she has either meat or fish, potatoes, t w o fresh vegetables and a simple dessert. For supper she sometimes has a poached egg or some scalloped potatoes, an omelette or some similar dish; a glass of milk with each meal. She keeps good bedtime hours; she goes to bed always at eight and often at 7 : 3 0 . Mrs. S. has been bathing the children only once a week but said she would hereafter bathe them t w o or three times a week. T h e children usually take their o w n baths but she has to scrub their ears and necks. Mrs. Southworth likes the children v e r y much. She says A n n is less affectionate; she is a more timid child than J a n e and less demonstrative, yet

45

2

THE

GRIEG

FAMILY

seems to w a n t as m u c h affection. When she first came she feared that she would be taken a w a y again and it made her quite nervous. Mrs. Southworth has assured her that she would stay until her mother has recovered and is able to take her home again. She seems to feel assured now that she is to remain in the home and is less nervous. A n n takes little interest in her school w o r k ; she goes regularly but Mrs. Southworth feels that she does not do as good work as she is capable of doing. Mrs. S. helps her at home, but it is hard to make her concentrate on her work. Mrs. S. tries to encourage her and make her more ambitious b y telling her that she must learn and get as much education as possible so that she can help her mother when she is older. Mrs. S.'s attitude is v e r y kindly toward A n n ; she seems to have patience and understanding. A n n has not been to Sunday school yet. Mrs. S. gave as an excuse that she had just gotten around to looking u p a Protestant C h u r c h . She was surrounded by C a t h olics and had to make special inquiry to find out about a Protestant C h u r c h . She agreed to send the children the f o l l o w ing Sunday. A n n ' s room was in good order; the children are sleeping separately. A n n sleeps on a cot while J a n e sleeps on a big bed because the latter is more restless. On the bureau were many Easter eggs and bunnies and t w o large Easter baskets, one f o r each child. T h e baskets were brought b y the uncle, Herbert Grieg, on Easter Sunday, and the other things were given to the children by Mrs. Southworth's friends and relatives. Visitor feels very well pleased with the adjustments these children are making in this home, and with the real motherly attitude which the foster parents take toward the children. 4 . 2 3 . 2 4 — V i s i t e d J a n e in the Southworth home. Mrs. S. was dressing her to go shopping. She was wearing a little spring coat made of some sort of blue material, new shoes, and stockings, which her father had just bought f o r her. Mrs. S. explained that their uncle had given her some money on Easter Sunday w i t h which to buy things f o r the children.

She

planned to get a new hat f o r Jane. Physically J a n e is in v e r y

THE

GRIEG

FAMILY

4 5 3

good c o n d i t i o n . She has gained in flesh; she is p l u m p a n d her color is v e r y good. She has been v e r y w e l l , a c c o r d i n g to M r s . S.'s s t a t e m e n t , e v e r since she has been in the h o m e . H e r a p p e tite is g o o d indeed. T h e f o l l o w i n g is the list of the diet: In the m o r n i n g (see 4 . 2 3 . 2 4 A n n ) . She sleeps v e r y well. She u s u a l l y r e m e m b e r s to b r u s h her teeth. J a n e g e n e r a l l y p l a y s w i t h Mrs. S o u t h w o r t h ' s little girl a n d w i t h her sister A n n . S o m e t i m e s the n e i g h b o r ' s c h i l d r e n , t w o houses a b o v e , c o m e to p l a y w i t h them. T h e y seem q u i t e a s e l f sufficient little g r o u p a n d do not a t t e m p t to g o a w a y f r o m the house. T h e y h a v e a nice y a r d a n d there is an open field across the street w h e r e t h e y sometimes p l a y . J a n e has not been t o S u n d a y school y e t because M r s . S. has just settled u p o n the c h u r c h to w h i c h she intends to send the c h i l d r e n . She agrees to h a v e t h e m go r e g u l a r l y h e r e a f t e r . Mrs. S.'s a t t i t u d e t o w a r d J a n e is v e r y good indeed. J a n e is d e m o n s t r a t i v e and w a n t s a lot of a f f e c t i o n and M r s . S. meets this response. She says her o w n child is a little jealous, yet she e n j o y s h a v i n g the c h i l d r e n there a n d says so q u i t e f r a n k l y . T h e y all p l a y w e l l together. T h e situation in the h o m e is v e r y s a t i s f a c t o r y . T h e child seems to fit well in the home and is h a p p y . T h e f o s t e r parents are t r u l y interested in her. 5 . 1 0 . 2 4 — V i s i t e d A n n at the home of Mrs. S o u t h w o r t h . She has been c o m p l a i n i n g a b o u t her teeth. O n e of her u p p e r molars is loose a n d she has an abscess on t w o other teeth. A n n also had a s t y on her right eye. V i s i t o r advised hot boric acid dressings f o r the eye and a c a t h a r t i c at b e d t i m e . M r s . S. has g i v e n A n n a coat w h i c h was g i v e n to her o w n little g i r l ; it fits A n n v e r y nicely. A n n looks v e r y clean a n d neat and has good m a n n e r s . She is g o i n g to school and is d o i n g good w o r k . Visited J a n e at the home of Mrs. S o u t h w o r t h . She is well and h a p p y . She p l a y s w i t h her sister and Mrs. S o u t h w o r t h ' s little girl. 5 . 1 4 . 2 4 — V i s i t e d the home of Mrs. S o u t h w o r t h . A n n is still c o m p l a i n i n g about her teeth. V i s i t o r looked u p a dentist, D r . C o n s t a b l e , and took her there. W h e n visitor a r r i v e d at the

454

THE

GRIEG

FAMILY

home of Mrs. S., Ann was at school; waited about a half hour until Ann came home. She had a glass of milk and sponge cake before going to the dentist. The dentist treated two six-yearold molars, right and left. They were both abscessed. She has another appointment with the dentist for Monday. Mrs. S. will take her there then. 5.16.24—Met Mrs. Southworth at the Trucktown Station with Ann. Brought her to the Junction City Board of Health. Had a Wasserman test taken. Took her back home in the afternoon. Ann's report came back doubtful. It will be necessary to have another report. Met Mrs. Southworth at the station with Jane. Brought her to the Board of Health in Junction City. Had Wasserman test taken. Took her back to Mrs. S. in the afternoon. Report was negative. 5.29.24—Took Ann to the Board of Health for a second Wasserman test; result four plus. 5.31.24—Brought Ann and Jane to the Calvary Hospital in Junction City to visit their mother. The mother seemed very pleased to see them. They stayed there an hour and a half, from 1 1 : 0 0 A.M. until 1 2 : 3 0 A.M. 6.13.24—Visited Ann at the home of Mrs. Southworth. Found her condition such that it seemed best to have her come to office. Suspicious vaginal discharge. Brought Ann to the office. Smear taken. Dr. Dawson examined her. She weighed 53 lbs., condition nervous. Took her back to Trucktown. 6.17.24—Visited Ann at the home of Mrs. Southworth. She had just returned from school when visitor arrived. The child gives the appearance of having gained a great deal in weight. Her color is much better than it has ever been but she is still rather thin and small for her years. She had a sty on either eye, which disfigured her face a great deal. Visitor had never seen the child so spontaneous and full of life as she appeared to be at this time. The Southworths have an Airedale and she is particularly fond of the dog. They were romping and play-

THE

GRIEG

FAMILY

455

ing together during the time visitor was there. She produced her reading book and wanted Jane to play school with her. She tried to teach Jane a rather difficult poem. Jane was not interested and A n n was quite disgusted with her. Visitor had never seen the child show so much initiative in play. She is evidently quite at home and very contented at Mrs. S.'s. Mrs. S. says she plays out-of-doors almost every minute she is not in school. She is eating fairly well and sleeps well. She "picks" at her food a little but what she does not eat of solid food she makes up by drinking milk. She always has one and sometimes two glasses of milk at each meal and another glass of milk just after she gets home from school in the afternoons; to this Mrs. S. adds a little bit of Horlick's Malted Milk. Ann looks forward to the visit of her father every Sunday. The father comes regularly. He has not missed more than one or two Sundays since the children have been there. He plays ball with them and goes walking with them. He is very companionable. He tells Mrs. S. that he wants the children to stay with her until they are ζ ι years of age, and will never let them go back to the mother. The children do not know that the father does not intend to let the mother take them. They are counting very much on being with their mother again. Ann, particularly, seems to be dependent upon her mother and the mother seems to show favoritism to Ann. The child is attending Sunday school regularly now at the Lutheran Church. She seems to enjoy going. Her sleeping room was in good order. Two windows in the room were open. She is still sleeping on the single bed in the room with Jane. Visitor feels that this home is very satisfactory for this particular child. Talked with Ann alone in the yard. She spoke enthusiastically of a walk and picnic in the woods, where she had just been with the scholars of her class and with her teacher. The child was neatly dressed in a plain gingham. She looked clean. Her hair looked especially well, as if it had been shampooed frequently. She presents the appearance of a happy and wellcared-for child.

456

THE

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V i s i t o r t a l k e d w i t h A n n ' s t e a c h e r , Miss R o b e r t s , at P . S . A n n is in i - B a n d w i l l be p r o m o t e d to 2-A

11.

on J u n e 3 0 t h . She

d i d not do g o o d w o r k at first b u t her w o r k averages a b o u t as follows: Conduct—A

Effort—A

Work—Β

Miss R o b e r t s says t h a t she reads r a t h e r p o o r l y . She does n o t seem to u n d e r s t a n d the m e a n i n g s of some of the w o r d s . S h e l a c k s the p o w e r o f c o n c e n t r a t i o n . She is t r y i n g m u c h h a r d e r w i t h her w o r k t h a n she did at first a n d seems m u c h m o r e i n t e r ested in it. She is m o r e s p o n t a n e o u s a n d n a t u r a l w i t h the c h i l d r e n . A t first she stood a p a r t f r o m t h e m a n d seemed t o e n j o y l o o k i n g at their p l a y , b u t n o w she joins in w i t h t h e m a n d has b e c o m e a g o o d m i x e r . Miss R o b e r t s said A n n a l w a y s looks v e r y w e l l c a r e d f o r ; that M r s . S o u t h w o r t h has been v e r y h e l p f u l a n d she k n o w s t h a t she helps her w i t h her school w o r k at home. 6 . 1 7 . 2 4 — V i s i t e d J a n e at the h o m e of M r s . S o u t h w o r t h . She has really g r o w n p r e t t y . H e r f a c e is p l u m p . She has almost b r i l l i a n t color a n d is the p i c t u r e o f h e a l t h . She w a s p l a y i n g w i t h M r s . S.'s little girl in the b a c k y a r d . She w a s r a t h e r s h y w i t h visitor a n d had little to say. M r s . S. says t h a t J a n e likes t o look w e l l a n d is f a i r l y clean a b o u t her person. T h e c h i l d r e n h a v e almost d a i l y baths n o w a n d f r e q u e n t c h a n g e s o f u n d e r clothes d u r i n g the w e e k . J a n e gets a l o n g v e r y w e l l w i t h M r s . S.'s little g i r l , D o r o t h y , a l t h o u g h D o r o t h y is still q u i t e jealous o f her. J a n e m a d e the r e m a r k r e c e n t l y t h a t " w h e n y o u r m a m a is sick, y o u can c o m e a n d live w i t h us a n d o u r m a m a w i l l t a k e c a r e o f y o u . " H e r a t t i t u d e is that she is j u s t s t a y i n g w i t h M r s . S. u n t i l her m o t h e r is able to h a v e her at h o m e . M r s . S. says t h a t she eats v e r y h e a r t i l y a n d d r i n k s one glass of m i l k w i t h each meal. She is not as f o n d of m i l k as A n n a n d depends m o r e on solid f o o d . She is a t t e n d i n g S u n d a y school r e g u l a r l y at the L u t h e r a n C h u r c h a n d is learning a piece w h i c h she is t o speak at S u n d a y - s c h o o l exercises soon. T h e sleeping r o o m w a s o r d e r l y a n d w e l l - v e n t i l a t e d . T h e c h i l d is m a k i n g a g o o d a d j u s t m e n t to this home.

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457

6 . 1 9 . 2 4 — R e p o r t of A n n ' s vaginal smear, positive. Went to T r u c k t o w n and brought A n n to Junction C i t y . Took her to C a n t e r b u r y Hospital f o r treatment. 6.23.24—Telephoned to the Hospital. Last vaginal test was positive. She will have to remain in the hospital f o r at least a month. Mr. and Mrs. Grieg

(in

conference)

A t this time M r . and Mrs. Grieg discussed their f a m i l y affairs. Mrs. Grieg conducted herself with a good deal of dignity and said it w o u l d be quite impossible f o r her to go back and live with her husband unless he considered her in a different light. Mr. Grieg lost his temper, seemed very nervous, and looked very bad. Both Mr. and Mrs. Grieg were dressed in their best clothes and had taken a good deal of pains with their personal appearance. T h e conference ended by Mr. Grieg's agreeing to pay $ 5 0 0 . a year toward the support of his children, that sum being payable to the office of the C . W . A . , and to be given the mother in weekly allowances. Mrs. G r i e g agreed to this and agreed to supplement this income by doing part-time work as a nursery maid. Mr. Grieg said he thought the children had better school advantages in T r u c k t o w n . A t this time both Mr. and Mrs. Grieg discussed quite f u l l y A n n ' s 4 plus blood test and her future treatment. T h e y both seemed to feel very badly about it. 6.24.24—Mrs. G r i e g came into the office and nearly had hysterics, saying she could not live without her children and would not allow M r . G . to see them if she had them in her o w n apartment. She became so unreasonable that visitor sent her away and told her to return when she could talk in a more reasonable manner. 6.26.24—Mrs. G r i e g came to the office and said she would take a position with J a n e during the Summer and when A n n was ready to be discharged in the Fall she wanted C . W . A . worker to find an apartment f o r her. Both Mr. and Mrs. Grieg were making a great m a n y visits to A n n , and both had agreed at

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this time that Mr. G . should have a chance to visit his children at the M a r y Smith H o m e

9

each Sunday afternoon, providing

the plan to have the children with their mother was successful. It was thoroughly understood by both Mr. and Mrs. Grieg at this conference that if the mother failed in the care of her children, the children would again be placed in a boarding home and both parents would be allowed to visit them. Employment of mother 6 . 2 7 . 2 4 — A position was offered Mrs. Grieg as assistant cook at Liberty House, Sunrise, where she would be allowed to have Jane with her and would receive $ 3 5 . a month. She at first refused this offer and was very impatient to get into her own apartment. She returned the following day to say that she would accept the position, and on 6 . 2 7 . 2 4 she went to Sunrise to take the position. (Visits were made each week to A n n b y both parents and the C . W . A . nurse.) [Syllabus reference: METHOD; PHILOSOPHY; KNOWLEDGE.] T E A C H I N G N O T E : At this point there is a good opportunity for the class to discuss the whole procedure to date. Thus far the treatment process has really been a continuation of the social study or investigation period. What does the class now think of the adequacy of the various kinds of evidence and of the philosophy on which the C.W.A. is basing the decision to place Ann and Jane in an apartment with the mother (after Ann can be discharged from the hospital), and with the further understanding that the father is to help pay for the support of the girls and have the privilege of seeing them? Some acquaintance with the history of child-caring philosophies and practices would be valuable to the student at this point. At one time and locality a philosophy as to the value of institutional care for such children as Ann and Jane was so dominant that evidence as to values of alternative plans of foster-family care in either free or boarding homes would not have been fairly and objectively weighed. At another time, in the same and other localities, the same could be said for the dominance of the free foster-family home philosophy. And at still another time, in the same and other localities, the same could be said about the dominance of the boarding foster-family home philoso9

T h e M a r y S m i t h H o m e is near the C . W . A . office and has d o r m i t o r y and other

facilities f o r the temporary stay o f children. I t would therefore afford opportunity f o r Mr. Grieg to see A n n and J a n e without conflict with Mrs. Grieg.

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phy. During a long period of years the same agency sometimes shifts from one dominating philosophy to another. The C.W.A. at the time it was asked to help in the Grieg case, was on a rising tide of belief in the importance of maintaining kinship ties and in the special value of the boarding foster-family home to this end. How objective in its philosophies can and should a child-welfare agency be? In comparison with the attention given by the C.W.A. to physical health of the mother and of Ann and Jane, to schooling, to church attendance, to companionship, etc., what docs the class think of the agency's understanding of the behavior drives that motivate the reactions of all four members of the family to each other? How clearly do Ann and Jane stand out as personalities? [ S y l l a b u s reference: KNOWLEDGE, M e d i c i n e ;

psychiatry.]

What further could the C.W.A. have done meanwhile to gain a better understanding of these drives? If at least some members of the class can be kept from reading further in the record before this discussion takes place, it has been found stimulating to ask such persons either to defend the plan for further treatment proposed by the C.W.A., or to formulate one or more alternative plans for procedure from this time on, with their reasons for them. In any event, it should be again urged that each reader make notes of his judgment of the treatment of the family at the time he reached this point in his reading, for comparison with sequels disclosed later by the record. 7 . 1 4 . 2 4 — M r . G r i e g c a m e to the office and said he had c h a n g e d his m i n d about s u p p o r t i n g his children w i t h the mother. H e did n o t think M r s . G r i e g w a s a suitable person to have the children. T h e previous week she had b r o u g h t J a n e in to t o w n on a v e r y hot d a y and the child had been ill. H e c h a n g e d his attitude before the end of the i n t e r v i e w , and visitor gave h i m a c a r d to the L e g a l P r o t e c t i v e Association to see if he c o u l d find out about a legal allowance and separation f r o m his w i f e . L a t e r that d a y M r . G r i e g c a m e b a c k and asked the C . W . A . w o r k e r to find o u t f r o m M r s . G r i e g w h a t allowance she w o u l d think sufficient f o r her s u p p o r t and that o f the children. 7 . 1 5 . 2 4 — V i s i t e d J a n e at L i b e r t y H o u s e and f o u n d that she was in excellent condition, p l u m p and b r o w n . H e r diet is excellent although v e r y simple. J a n e is sleeping in a room w i t h

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her mother, on a separate cot. She gets on well with the rest of the children and seems very happy. A t the time of visit, mother was dissatisfied with her position and wanted to return to Junction C i t y . She believes that her husband should support her and that it is unnecessary f o r her to w o r k . She said she felt that Mr. Grieg was paying m o n e y to the C . W . A . to keep the children f r o m going back to their mother. 7 . 1 6 . 2 4 — V i s i t e d A n n at the C a n t e r b u r y Hospital. N u r s e reported that child was happy and contented. A s the w a r d was in quarantine f o r measles, A n n could not be seen. A n n is being treated at the hospital f o r G . C . vaginitis. Last Wasserman test negative. 7 . 1 8 . 2 4 — M r s . Ellen, w h o is President of the Committee at Liberty House, reported that Mrs. Grieg was doing very well, and that she was an unusually clean and nice w o m a n , satisf a c t o r y in every w a y . She also gave her child excellent care. 7 . 2 9 . 2 4 — M r s . Grieg came into the office. She had called the day before, and, not finding Mrs. Streeter (the E x e c u t i v e D i rector of the C . W . A . ) or the visitor, had gone to the F a m i l y C o u r t herself. She had been told to get father's address and come in again. A lawyer had joined her and insisted that he be allowed to take her case. She, however, did not sign any paper and was sure she was not bound to consult him. [Syllabus reference:

RESOURCES,

Legal.]

She is staying, while in town, with a Mrs. Pennington, a friend of other days, at 1 4 7 East South Street. Mrs. P. is to move shortly and Mrs. Grieg can stay with her only until A u g u s t 4th. It m a y be that she can go with Mrs. P. when the latter moves. She made arrangements with visitor to go into the C o u r t on A u g u s t 4th. J a n e , w h o was with her mother, behaved very badly. She did not w a n t to be left in an outer room while visitor talked with her mother, and howled at the top of her lungs f o r a f u l l half hour while her mother was out of the room. Mother explained that it was because she was afraid she would be placed a w a y f r o m her mother again. When mother brought her in at another time, however, she was quite willing to stay in the other room when she f o u n d she had to.

THE

GRIEG

FAMILY

7 . 2 9 . 2 4 — J a n e left Liberty House and returned with her mother to Junction City. 7 . 3 1 . 2 4 — M r . Grieg came to the office. As he had not seen visitor before, he was quite anxious to talk over mother's shortcomings and was somewhat surprised to be cut short. H e said that he would be willing to go into the Court and have an order for support placed upon him, provided the mother could be ordered to stay away f r o m him and he would be allowed to see the children. H e agreed to go direct to the Court on the morning of 8.4.24. 8.2.24—Telephoned Canterbury Hospital and inquired regarding condition of A n n Grieg. Condition has not yet cleared up. Ward is still in quarantine for measles; otherwise child is doing well. 8.4.24—Mrs. Grieg came to the office. She was much excited and rather hysterical. She said that she had been at father's sister's home on 8.3. Father had gone there, had taken her out into the street, and had walked her about a mile and taken her to a police station. She said she could not stand such actions any longer and was going to have him arrested and locked up. 8.4.24—Mr. Grieg at Court. He was also excited and in a disagreeable state of mind. He said that the mother had gone to his sister's house and waited until he came. When he tried to get away she had followed him and the only way he could get rid of her was to take her to the police station and ask the police to prevent her f r o m following him. T h e y were at sword's point, both very excited, father sneering and laughing at mother and egging her on to greater excitement and hysteria. It seemed as though it would be impossible to come to any agreement. The Family Court interviewer, Mrs. Moss, allowed mother to tell her story and then asked the father certain questions. Mother at first made a very good impression but later on, when father began to talk and say certain things about her, she showed quite plainly how excited, unreasonable and nagging she is. Mrs. Moss succeeded, however,

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in d r a w i n g u p an agreement which she was about to have signed when mother demanded support f o r herself, to which father objected. She then asked mother w h a t amount she wanted, but mother w o u l d name no amount. Father then volunteered $ 1 2 . 0 0 a week. This was perfectly satisfactory t o the mother, and neither one objected when the agreement was read stating that the support was f o r w i f e and children. Both signed and it was not necessary to go before a judge. The agreement stated that f a t h e r was to see the children at such time and place as the C . W . A . should find convenient. It also stated that neither mother nor father was to molest the other. Father was put on probation to M r . O'Brien of the C o u r t . Signed by C . W . A . Visitor T E A C H I N G N O T E : Aside from the continuation of data for further discussion of medical and mental hygiene problems, the appeal of Mrs. Grieg to the Family Court here challenges some discussion of its powers and administration and of the procedure for helpful cooperation between this court and the C.W.A. on family social problems. 8 . 5 . 2 4 — M r . Grieg came to the office. H e thanked visitor f o r going into C o u r t with him and " g e t t i n g a separate." Visitor took u p with him the matter of f u r t h e r physical treatment. H e had objected to going to the Clinic because of losing time f r o m w o r k , but as he was not w o r k i n g today, being out of a job, he agreed to go. Visitor made arrangements f o r him to attend N e w t o n Clinic, as was advised by Miss Mill of College Clinic. Mrs. Grieg telephoned. She had gone over to Park C i t y to an E m p l o y m e n t Bureau to find w o r k and look f o r an apartment. She had apparently not been successful, f o r she got quite hysterical over the telephone so that visitor was unable to understand her or to make any headway. She then spoke of putting the t w o children in an institution, which is exactly what the father said she would do as soon as she got a court order. 8.6.24—Mother in the office. She is worried because J a n e has a vaginal discharge and she is afraid that J a n e m a y have the

THE

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FAMILY

4^3

same trouble as A n n . Arrangements were made f o r her to take J a n e to the Children's Hospital f o r a smear. T h e report was negative. 8 . 8 . 2 4 — M o t h e r in the office. She has searched in the north section, in south section, and in the west section f o r apartments, and discovered two, one at $ 2 6 . a month consisting of f o u r furnished rooms. T h e man w h o had it w o u l d sell the f u r n i t u r e f o r $ 1 0 0 . , and mother was determined to take this. T h e other was a f o u r room apartment which rented at $ 3 0 . In case of taking either of these t w o apartments, Mrs. Grieg wanted to rent out one of the rooms. W h e n visitor discouraged this she again became hysterical. I t was v e r y hot and had been f o r several days, and mother was all worn out. She laughed and cried, and said she would put the children in an institution. 8 . 1 3 . 2 4 — T e l e p h o n e d the Hospital to inquire about A n n . She is not yet ready to be discharged f r o m the hospital; otherwise doing well. 8 . 1 5 . 2 4 — M o t h e r has been in the office a number of times, reporting her progress in finding rooms. She finally discovered t w o three-room tenements on South Side. T h e rental is $20. a month, but she must pay one month's rent as security and sign a lease f o r a year. Visitor saw the rooms and talked with the janitor. T h e y are little dark rooms, but the house is clean and the families have most of them lived there f o r a number of years. T h e janitor was clean and had a spotless home of her own and two well-kept children. Mother had learned that in order to remain under the jurisdiction of the C o u r t she must live within its district. Visitor verified this and felt it unwise f o r her to be transferred because of the personality of Mrs. Moss, w h o talked with mother in the Court. She is a very fine and sympathetic person, with judgment. She was interested in the case and willing and able to give intelligent cooperation. Mother had looked at rooms on West Side but felt it was too f a r f r o m the district where she was likely to get w o r k . The neighborhood seemed strange and rough, and the schools were at least three blocks distant. Against visitor's advice,

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mother w e n t off to T r u c k t o w n and w i t h d r e w $64. f r o m the B a n k , in order to m a k e $40. p a y m e n t on the rooms. Visitor called on paternal uncle, Mr. H e r b e r t G r i e g , in order to discuss plans with him. H e and Mrs. Grieg both were quite cordial to visitor b u t f e l t that, before they w e n t into the matter of f u r n i s h i n g the house, no matter how simply, they must have father's approval and cooperation. T h e y told visitor of one experience a f t e r another of launching this f a m i l y in business and housekeeping. E v e r y time the undertakings failed, and they are skeptical about the success of this attempt. Visitor urged the a d v a n t a g e of h a v i n g a neutral and responsible outside agcncy interested in the plan and the arrangement, w h i c h has not been tried before, of having father and mother separated. H e r b e r t G r i e g tried to reach f a t h e r to bring him into the interview, but he could not be f o u n d . 8 . 1 6 . 2 4 — F a t h e r in the office, in a very stubborn and disagreeable f r a m e of mind. H e was on his w a y to the N e w t o n Clinic, where he says his m i n d is being examined, " t o see if he is c r a z y . " H e had seen H e r b e r t but was u n w i l l i n g to go into the matter of getting f u r n i t u r e f o r mother until he had settled other matters w i t h his brother. A s visitor f e l t convinced that no progress could be made without a f a m i l y c o n f e r e n c e ; one was arranged f o r this a f t e r n o o n at paternal uncle's ( H e r b e r t G r i e g ' s ) home. (Later, at paternal uncle, H e r b e r t ' s . ) W h e n the matter was talked over with f a t h e r , he gave in on every point. Agreed to allow mother to have the children and take care of them in her o w n rooms, and to let paternal uncle, H e r b e r t , provide very simple f u r n i t u r e . H e also agreed to give visitor correct list of the articles of household f u r n i s h i n g s which he had in his possession. A s usual he gave instances, one a f t e r another, of the mother's flighty behavior and irresponsibility. H e harps continually upon her shortcomings. It was agreed that mother should m a k e a p a y m e n t on the rooms on 8 . 1 8 . 2 4 ; that a search should be made f o r second-hand f u r n i t u r e , and an estimate given as soon as possible. [Syllabus reference: METHOD.]

THE

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4^5

8 . 1 8 . 2 4 — F a t h e r in the office, bringing with him a list of articles which he said he had had in storage. T h e y are now at the home of Mrs. G o l d m a r k , paternal aunt. Father had sold t w o down comforters dear to mother's heart, which had cost $28. each. These " q u i l t s " are a favorite topic of conversation f o r both parents, father harping upon mother's extravagance in insisting upon b u y i n g them, and mother enlarging upon their beauty and raving at father's meanness in parting with them and using the money. Father expressed extreme skepticism of mother's ability to stick to any plan which involves effort and perseverance on her part. Mother went to the R e n t i n g Office of Addison & C o . and paid $20. deposit, to be returned when she leaves the rooms, or forfeited when she breaks the lease, and she also paid $20. rent in advance, dating f r o m 8.20.24. I n order to get the rooms she was obliged to sign the lease f o r the year. Telephoned Hospital. V a g i n a l condition of A n n still positive. Child doing well otherwise. 8 . 1 9 . 2 4 — V i s i t o r took mother to the Salvation A r m y Salvage Store and bought f u r n i t u r e according to enclosed list. There was a hard struggle over the beds, as mother insisted on new bedsteads and springs, as well as new mattresses. She

finally

gave in, however, when she saw the w a y the beds had been sterilized and made spick and span with white enamel. A r rangements were made f o r all the f u r n i t u r e except the beds to go into mother's rooms on 8.20.24,

an