A Historical Perspective on Medical and Psychiatric Social Work: Thrust and Orientation

Dr. Banerjee was the architect and builder of Medical and Psychiatric Social Work in Tata Institute of Social Sciences. She was the one who asked in 1946 the million dollar question: "What is Medical and Psychiatric Social work?" It was the occasion when Dr. Kumarappa, the then Director asked Dr. Banerjee to start the specialization of MPSW in response to the recommendation of the Bhore committee. After asking the question, she herself set about finding an answer and shaping MPSW over the next 24 years.
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If I am allowed to use biblical language, I can say that Dr. Banerjee planted and nurtured the plant of MPSW for 24 years and it was my privilege to maintain and just water it for the next 13 years and I am happy about it. 

The MPSW field has been influenced by the same field as it existed in the United Kingdom and the United states of America. The first paid medical social worker was appointed in the Royal Free Hospital of London in 1898 as a result of the efforts of Sir Charles Loch who was a sociologist and also Secretary of the Charity Organization Society. The Medical social workers at that time were known as almoners. One of the earliest books on almoners state that the first almoner was appointed to provide the link between the treatment given to the patient in the hospital and the realities of the world in which the patient lived. I think it holds good even today. The first Medical social worker of U.S.A. was appointed in Massachusetts General Hospital, Boston. Dr. Richard Cabot, one of the physicians of the hospital, was instrumental in starting the Social Service Department. He convinced the authorities of the hospital about the importance of medical social work, the treatment of patients would be more effective if there was an additional functionary who could investigate into the social aspects of illness and also explore the psycho-social problems. What is significant to remember is that MPSW started in the field before it became an area of academic programme. Between 1918 and 1955 there were two separate associations in the u.s.A. one for Medical Social Workers, that is, American Social Workers, and the other America Association of Psychiatric Social Workers. They ceased to exist in 1955 with the starting of the National Association of Social Workers. The National Association of Social Workers had a council on Social Work in Medical and Health Services till 1976. In 1976, all these separate councils were eliminated. The current situation is this. In U.S.A. there is an American Society for Hospital Social Work Directors, which has collaboration with the American Hospital Association. There is a Journal of Social Work in Health. Similarly, there is a Journal for Medical Social Work published in United Kingdom.

Now, about the development of MPSW in India. There have been some factors besides the western influences. The central idea basic to MPSW is the need to recognize the impact of illness on the individual, the role that psycho-social aspects play in the causation of the disease, in the progress of the disease and in treatment. Paying attention to the psycho-social problems of the sick is not new to the Indian Culture. Ayurvedic medicine always considered mind and body as one unit. I am told that Buddhist monasteries which took care of the sick also gave importance to this aspect. The joint family of our Indian culture to some extent was able to meet the psycho-social needs of everybody in the family. After the advent of the allopathic system of medicine in India, it was the missionary hospitals Le. Christian missionaries and Ramakrishna Hospital which tried to offer relief to the social and emotional difficulties of the patients to start with. Early in the century there two organizations working to fight against the spread of leprosy and tuberculosis. These organizations tried to develop enough public awareness as regards emotional and environmental problems of the people afflicted by these two diseases. These organizations were geared to the eradication of leprosy and tuberculosis. The British Empire Leprosy Association was started in 1925 which later became the Hind Kusht Nivarana Sangh. Then the anti-tuberculosis fund which was started in 1929 later became the Tuberculosis Association of India. Gandhiji's work for leprosy patients was also a significant feature in this context. After the war, the concept of social and preventive medicine crystallised in the formation of preventive and social medicine departments of teaching medical colleges in the country.

A very major factor in the creation of MPSW was the recommendation in 1946 of the Health Survey and Development Committee under the chairmanship of Sir [oseph Bhore. The committee has clearly stated the need for medical and psychiatric social workers. The major objective if outlined was to hasten and safeguard the recovery of the patients and help to prevent the recurrence of the disease. Medical social workers were supposed to be assisting doctors in the diagnosis and treatment and also in the analysis of the psycho-social problems. In the report, the duties of medical social workers and public social workers have been clearly specified and most of the needs are relevant even today. The committee had met the Director Dr. Kumarappa, to find out whether the Institute which was then called the Sir Dorabji Tata Graduate School of Social Work could start a specialisation in medical social work and psychiatric social work. It also studied the syllabus of the Institute and they found that more courses were necessary for MPSW specialisation. It was in this context that Dr. Kumarappa asked Dr. Banerjee to ask the famous question: what is Medical Social Work? The committee recommended that for some time, faculty may be sent abroad for special training. That's how Dr. Banerjee went to u.s.A. and stayed in the University of Chicago and she made use of her opportunity to learn all that is available in u.s.A. about medical social work and psychiatric social work. It is important to remember that MPSW was started by the Institute in response to a specific need identified by a higher level committee. I am emphasising this because very often this factor is underplayed by people who are against specialization. When Dr. Banerjee was studying in u.s.A. medical Social Work and Psychiatric Social Work were two different fields. It was her innovation that she combined the two into one field when she started this specialisation in the Institute implying thereby the very close connection between the body and mind which cannot be separated. As in the United States and United Kingdom, medical social work started in the field before it became an area for the academic programme. The first medical social worker was appointed in J.J. Hospital in 1946. The first social worker was appointed in the child Guidance Clinic in 1937 and that is Mrs. Indira Renu, alumnus of the first batch of TISS.

Specialisation started in 1948 the field was an important component of MPSW It was not easy to convince the Deans of the medical colleges in Bombay about the importance of medical social work. Dr. Banerjee had to do a lot of field work. She made a kind of contract with the hospital deans that she could start the services for a period of time with the help of the students. When the deans were satisfied that it was effective, it would be their responsibility to appoint medical social workers. She had started the tradition of being present in the hospital along with the students who were placed there for field work. There have been many anecdotes about her enthusiasm. I remember one of the graduates telling me: "Dr. Banerjee was fieldwork and fieldwork was Dr. Banerjee." I remember some students talking about an incident. I think it was during 1948-50 batch. One day, it rained so badly that the buses were all stopped. Dr. Banerjee walked from Andheri to J.J Hospital but she found no students there. She was quite furious but the students were very ashamed that they could not be there when she could be there. Rain or storm never kept Dr. Banerjee from the field. She was always there. After her initiation of field work in the hospitals in Bombay when the deans found that hospital social work was useful, they started appointing social workers. Dr. Banerjee had also two or other demonstration projects, one in B.J. Wadia hospital for children. The hospital staff claimed that they had no money to appoint the social workers , She thus agreed to collect funds for the appointment of social workers and MPSW students started their annual fund-collecting campaign in aid of the social work department of the hospital. In course of time, the hospital undertook the responsibility and paid their social worker and met the expenses of their departments from their own funds. Next was the extension of the Child Guidance Clinic services to a school. It was a project, a contract for five years and the Child Guidance Clinic staff extended ser- vices in terms of school social service. "After five years, the school began appointing social workers on its own. The Child Guidance Clinic was started in 1937 and it was located in Nagpada Neighbourhood House. It was shifted in 1947 or 1948 to the B.J. Wadia hospital for children at the invitation of the administrator. It was originally under the direction of a psychiatrist. Later on Dr. Banerjee took over the administration and thus it became a part of the MPSW Department.

There have been some misconceptions about MPSW which I have dealt with from time to time. I thought this is the best platform to present them. One misconception is that MPSW is plain case work which is not true. It is true that case Work was the first method to develop in social work, It is also true there is a good scope for case work in medical settings but MPSW is a field where all the methods have to be used according to the situation and according to the needs of patient clientele. The second misconception is that MPSW as it has been developed in the Institute has excluded prevention and commu- nity health. As early as I remember there has been a course on Preventive MPSH which had topics related to prevention, promotion, community health, etc. and from year to year the content has been modified to suit the needs. Students have been given placements in community health projects whenever it was available where it was felt that students could have a good learning experience. Child Guidance Clinic had a community mental health project as early as 1963. It was called the Krishnanagar project. It developed from a mental health project for children. Mrs. Kaushik was running this project in 1963-65 and I asked her how it came to be closed. She said it was because some faculty had protested against MPSW having a community project, Things have changed so much during the last two decades. There has been growing I awareness about the need for prevention and promotion.

A third misconception is that special competencies are not necessary for working in the hospital. I think certain competencies are necessary. for example, use of the knowledge of organisational administration of health and delivery systems in the country, use of the characteristics of health and diseases both in mental illness and physical illness and the psycho-social impact, public health and preventive measures, inter-disciplinary team functioning and consultation, skills specific to rural aspects with reference to MPSW tasks, health policy and planning and advocacy with special reference to users of health services. In practice, case work has been frequently used in hospitals because the one to one relationship has been useful in clinical settings. Besides, as already mentioned case work has been the first method, Case Work also has had definable strategies which can be taught easily in the class-room which can also be transferred easily to the practice settings. Group work and community organization have been slow in entering the field of Psychiatric social work because the strategies were less precisely defined and more difficult to transfer to the practice setting. Besides, these strategies require a longer time for practice compared to short term case work treatment. But now both group work and community organisation are also a part of MPSW field work. They are specially useful in the strategy of self help. Their usefulness has also been recognised in prevention and promotion work in community health projects.

There has been a criticism that preventive and promotive aspects have been neglected in the specialization. I already refuted that. Nevertheless it has to be acknowledged that the concept has been slow in taking root. There have been reasons. Though prevention is accepted it is not easily marketable, People may believe in the dictum but it is not easy to make people take action based on the dictum, for example, cigarette-smoking , Everybody knows that cigarette-smoking is dangerous, but how many will stop it. Look at the large amounts of money spent on advertising campaigns. Why does the Government allow it? It is difficult to convince the people to take action to anticipate a possible and favourable event in the future because the experiential element is missing. On the other hand if a man is sick and he has uncomfortable symptoms, he will definitely take curative action because of the experience of pain. The lack of experiential elements in prevention is I think a problem particularly with reference to work among the lower socio-economic groups. Another important factor is that preventive and promotive strategies are not easily definable. Some of them are quite ambiguous; thus specific and precise methods have to be devised before we can convince the people about the need for prevention.

The term 'health' is more difficult to define than disease. 'Health' has so many definitions. If you take community health it is even more confusing. I remember to teach students community mental health, for how many hours I burnt the midnight oil to get some ideas which I could transmit to the students which they could understand. Another factor is that prevention of diseases and promotion of health needs a multi-disciplinary approach and professionals of one discipline by themselves can- not do much. These were some of the major factors which delayed the development of preventive and social medicine as a branch of medicine. Preventive and social medicine is less glamorous than pediatrics or surgery among medical students. Furthermore the potentialities of social and preventive medicine as an income producing branch of practice are nil. So unless there are more doctors imbibed with a goal and philosophy of prevention, there will not be much support in the medical profession for prevention. On the other hand, the goal and philosophy of prevention of diseases and promotion of health channels well with the philosophy of social work. Community health is very popular among MPSW students today as psycho-analysis was 30 years ago. It was not so some years ago. There were only very few medical psychiatric social workers who found the field of prevention a fascinating field.

I remember one of my own friends who was our graduate in the department , She is no more now. She was Shashi Kuruvilla. She went to U.S.A. in 1961 for an additional social work degree and she was disappointed. She said she did not learn much by the additional degree from an American School of social work. What she did was to take a second master's degree in public health. She was thrilled. I remember her telling me that the combination of social work and Public health was the best combination and that it was going to stand her in good stead. She joined the public health department of the Canadian Government. She convinced me about the importance of getting a public health degree which unfortunately I could not do because the Institute did not give me leave. Besides, I had no intention of staying back in the United States.

There is good scope for developing community health in the field of MPSW; that is going to be one of the future trends. Some universities in the United States have a joint degree for public health and social work. The public health school and Social Work School of Minnesotta University have collaborated to develop a combined academic programme. In community medicine in some of the other medical colleges in United States, Social Workers have a very close involvement. They are even involved in developing the syllabus for the medical course. Mount Sinai School of Medical Social Work in Newyork has established a chair in community medical social Work, to develop medical social work as a part of community medicine. I am aware that the Medical and Psychiatric Social Work Specialisation is not perfect; it has many imperfections. It is seminars of these kinds which deal with this imperfection and which bring about change. But before I close I would like to point out two things which are important in strengthening the MPSW field. One relates to developing more knowledge regarding MPSW. The second is about finding ways for establishing accountability.

What is knowledge? Put in a nutshell, knowledge consists of facts, relationships among facts, explanation of relationships, predictions, principles etc. There are a few knowledge building strategies which are within the operational possibilities of medical and psychiatric social work, for example,

( i) reviewing what we know already,
(ii) describing what we do,
(iii) making observations of what we see and developing relationships,
(iv) discovering the outcomes of services and strategies,
(v) conceptualising relationships,
(vi) developing hypothesis about relationships,
(vii) testing hypothesis,
(viii)putting the knowledge derived from testing hypothesis back into practice.

Establishing accountability would involve role articulation in such a way that we are able to communicate through other professionals and the management how we spend our professional time in the health setting. It would imply ongoing evaluation of our roles, modification of tasks to meet patient's needs and judicial use of our professional time. It will answer our own questions. How accountable we are to the patients, to the management and to ourselves? The outcome will be a better role, visibility of medical and psychiatric social work, and a better image.
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Edited version of a Lecture delivered of the Golden Jubilee Seminar Department of Medical and Psychiatric Social Work, Tata Institute of Social Sciences, Mumbai. December 1985.
 
Dr. (miss) Grace Mathew 
Rtd. Professor, Tata Institute of Social Sciences, Mumbai.
Excerpted and Edited by
Shankar Pathak
Rtd. Professor, Dept. of Social Work, Delhi University, Delhi.