DIRECT TREATMENT IN SOCIAL CASE WORK*

PAUL SLOANE, M.D.Philadelphia

T HE course of the case-worker's quest for a solution of her client's problemshas been a devious one. At first the client's needs were met on the level at

which they were presented. This proved to be successful in a certain number ofcases) but it was found that often the presenting complaint was only an indicationof a deeper problem for which the client was really seeking help. If the worker wascontent with ordinary manipulation of the environment in such cases) and wasnot prepared to help the client with his real need) she frequently failed in herefforts. It was then observed that when clearing up the actual situation did notproduce the desired effect, the problem lay not in the situation itself, but in theindividual's attitude toward it. This realization led to the direction of effortstowards meeting the psychological problem. I t is not necessary to trace all thesteps in the process) but suffice it to say the discovery was made that by allowingthe client to talk freely about himself without direction or interruption, some­thing occurred within him. This was manifested by a greater flow of confidences,the emergence of emotional conflicts to the surface associated with a dischargeof feeling) the appearance of greater self-sufficiency and effectiveness in makingadjustments, and a relief of symptoms. The success of the method seemed todepend upon the ability of the individual to accept responsibility for his situationand make an attempt to change it, as well as upon his positive feeling for theworker.

This phase of case-work procedure may be termed indirect treatment of per­sonality difficulties. The method was described in a paper which I read beforethis Society last year.' It is characterized by the fact that the worker offers littleor no interpretation and depends upon the positive transference to provide themotive power for the treatment situation. The presence of a benign superego inthe person of the worker affords the client considerable relief of tension. In addi­tion) the worker displays confidence in the client's ability to make good by en­couraging him to take active steps in making adjustments and providing himwith the means to do so. This helps him to assume responsibility toward realityand favors his successful accomplishment. As he continues to make good hethereby gains greater confidence in himself and learns to compensate for his feel­ings of guilt. It is essential that such an adjustment take place since it serves asa firm foundation for the time when the worker steps out of the picture) and theclient becomes self-sufficient.

It is obvious that the method is applicable in cases where the client's emotionalproblems are near the surface) that is) in the preconscious). and free discussion

• Presented at the 1937 Meeting. From the Community Health Centre and Mount Sinai Hospital1 "The Use of a Consultation Method in Case Work Therapy." THE AMERICAN JOURNAL OF

ORTHOPSYCHIATRY, Vol. VI, p. 355,1936.

182.

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with someone helps him to see them more objectively and to analyze them.Where, on the other hand, the real emotional situation is concealed by the pa­tient's defenses, there results an endless repetition of material through which nolight penetrates and the case ends in a stalemate. In other words, as long as theindividual does not face his unconscious tendencies, permanent improvementcannot occur. The conflicts continue to be repressed and result in the formation ofnew symptoms. In order to get beyond the patient's defenses it is essential thathe gain insight into his problems and resistances. The worker must therefore be­come more active and be prepared to handle transference feelings by direct inter­pretation. To this procedure the name of direct treatment has been applied.

Many workers soon discover the inadequacies of indirect treatment and wishto attain a feeling of greater effectiveness in handling all types of cases. It isunderstood that these workers have been fairly well grounded in the theories ofmental mechanisms and that they are personally endowed for this type of work.Granting that an emotional appreciation of the principles involved is all impor­tant and that technical details are secondary, it is nevertheless important forthe worker to have definite guidance in the practical application of these details.In seeking specific information about the technique of direct treatment theseworkers are frequently at a loss because of the lack of source material. Unlessthey are fortunate enough to have frequent personal contact with a psychiatristor skilled supervisor, they must rely upon their reading of case reports and psy­choanalytic literature and attempt to correlate it with their own experience. Thepresent paper is an attempt to fill this need. In it the general problems that ariseduring the course of treatment are outlined and a method of procedure suggested.

The advisability of encouraging the case worker to assume the responsibilityof direct treatment has been questioned. It may be pointed out, however, thatmany case workers have virtually been forced into the field because of the paucityof adequate psychiatric clinics and that many of them have done an excellentjob in treating emotional problems. We are furthermore dealing in many in­stances with the type of patient who refuses to visit a psychiatrist and seems toderive a great deal of security from his relationship with the worker. If theworker were not available such patients would have to go without treatment.It is to the distinct advantage of the mental health movement to be able tospread therapy over as wide a field as possible, under proper psychiatric super­vision. Psychotherapy will always remain inadequate if we depend upon the di­rect treatment of patients by psychiatrists. It is too much to expect thatpsychiatrists will give up their time at a great financial sacrifice to see all of thesepatients, nor can the state afford to pay for necessary psychiatric services, sincethe problem is too widespread. As psychiatrists interested in these problems, weshould welcome whatever assistance we can obtain and aim to increase the effi­ciency of our aides. This places a great responsibility upon the physician, butthe possible results are well worth the effort.

A word of caution must be expressed against the danger of overestimating the

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written word and making it a sort of fetish. It is hoped that as the worker gainsexperience she will begin to realize that all the implications of the simple wordcannot be set down in print and that she must develop her own ingenuity as shegoes along. It should be remembered that rules of technique do not make thegood therapist, that the best psychiatrists have been the intuitive ones and thatit is best to rely upon intuition until difficulties arise. Technical knowledge mayhelp to overcome such difficulties. One cannot do a good job if she is too consciousof the rules of the game, and just as she must not be disturbed by anxiety abouther job, or the need to make good, so must she avoid being hampered by a list ofrules and the fear of making a mistake.

SELECTION OF CASES FOR DIRECT TREATMENT

When the client first presents himself it may be difficult to determine what hisneeds are. Very few clients come to the worker with their emotional difficultiesclearly expressed. Their real motives may be effectively concealed by the present­ing complaint, and it is up to the worker to recognize what lies beneath the latter.When this is done it may be discovered that simpler methods of treatment areapplicable. One must not be too rigid in handling clients and should be preparedto meet their needs on the level at which they seek assistance. Thus, we may bedealing with an ordinary health problem which can be taken care of in a medicalclinic. On the other hand, it may be decided that simple financial relief, assistancewith employment, or provision for household management, recreation or educa­tion may be sufficient. In other cases a type of relationship on the basis of a posi­tive transference (indirect treatment) may answer the purpose. These methodsmay even be tried in doubtful cases and if they fail to solve the problem, directtreatment may then be instituted.

In other words, before a case is taken on for direct treatment, it is assumedthat an accurate diagnosis has been made, that there is no physical disease andthat simpler methods of treatment are not applicable. In general, direct treat­ment is indicated in the case of patients who present perplexing personality prob­lems, who are sufficiently disturbed to seek assistance of their own accord andwho are not seeking some outside advantage, since only under these circum­stances will they be willing to cooperate and accept the implications of directtherapy. This does not necessarily mean that they are conscious of the existenceof emotional problems within themselves. They may be worried by what seemto be purely external situations and it is only with the assistance of the workerthat they see these to be merely particular aspects of their life problem. Thechoice of direct treatment depends upon the recognition of these factors. It maybe said that here we are mainly concerned with the individual who is able tomanage his every day affairs, but who is troubled by emotional problems. Severepsychoneurotics and abnormal personalities are best left to the psychiatrist.

METHOD

It is taken for granted at the start that very little is known about the patientand it is our duty to learn as much as we can before any interpretation is offered.

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It is therefore wise to permit him to talk freely without interruption. The work­er's attitude should be one of relaxed attention and patient inquiry, relying uponthe tendency of the unconscious material to break through the client's guard andreveal itself. Only in this manner will it be possible to reconstruct a reliable pic­ture of the patient's past. The client should be allowed to direct the interview,since his choice of topic is obviously of diagnostic import. It is not what we thinkhe ought to discuss that is important, but what he himself brings up. One shouldnot be too ready to interrupt, or become impatient if factual material is not forth­coming. It is much more advantageous to get down to those matters whichpossess emotional significance to the patient, since this will invariably open thesluice gates and facilitate the work of the therapist. Furthermore it is not thenature of the experience itself, but the patient's emotional reaction to the ex­perience, which has meaning. Factual material which does not come out freely,but upon pressure from the therapist, is of no significance, since many uncon­scious resistances are apt to be aroused in this manner. Otherwise we would bejustified in taking formal histories and directing the discussion along rigid lines,thus obtaining just what we were after. In this way, however, we would be boundto lose sight of many factors which go into the formation of symptoms and ob­tain a rather perverted and prejudiced view of the situation. On the other hand,if we allow ourselves to be guided by the things which the client emphasizes dur­ing the interview we will frequently gain insight into aspects of his personalitywhich we would never have suspected. The make-up of personality is too com­plex for anyone to grasp without relying upon the assistance which the patientcan give.

We must therefore approach the interview with an air of expectancy, preparedto discard any preformed notions and to allow the patient's drama to unfold itselfaccording to its own specifications. The worker must continually ask herself,What does the client mean by this? Why does he bring it up at this time? Howimportant is it to him? These questions can frequently be answered by studyingthe relationship of the subject to the context, the emphasis which the patientplaces upon it and the amount of feeling which he manifests. Thus, if the patientstarts the interview with an outburst of anger or lack of interest, the workermust seek the cause either in the events of the preceding interview or the intervalsince then, and not be content until she has localized it. In this way she attemptsto reconstruct the history of the patient's emotional development. A number ofhiatuses will naturally arise, and it may be necessary to interrupt the patientoccasionally in order to clear up certain points.

The patient is encouraged to talk by pointing to the fact that the basis of hisdifficulties lies in his emotional life and that getting well depends upon the un­covering of the roots of his difficulties. He must agree to cooperate fully and beprepared to discuss matters of the greatest emotional significance to himself.The one rule of treatment is that he must talk freely, without reserve. He maybe reassured that his statements will be held in strictest confidence. Many clientswill balk at this requirement for various reasons. For instance, most people in

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trying to preserve and defend their self-esteem are inclined to exclude from con­sciousness anything which might arouse self-reproach. In such instances it maybe pointed out that the therapist is not a critic nor is she concerned with moralvalues, but rather that she is interested in learning the motives of behavior. Thismay reassure the patient sufficiently to proceed. Others may resent what theyconsider an intrusion into their private affairs. They may actually say that givingup their confidences means a sacrifice of their individuality and the yielding ofpower and authority to another person. To this type of individual, the attitudeof the therapist must be one of readiness to step out of the picture. The patientmay be informed that he is not under any obligation to continue, but that if hedoes, he must abide by the principles of treatment. If he lacks confidence in thetherapist, he is at liberty to choose anyone whom he prefers. Some people willstate quite sincerely that they can think of nothing to say. In such instances, onemay wait for the client to take up the thread of discussion again or the conversa­tion may be directed along lines previously indicated by emotional tension. Theworker must be careful and unhurried. She must not sit in judgment or in therole of sage adviser and critic. We must realize that the patient's attitude andbehavior are the resultants of a number of inner and outer forces, and althoughthey seem unreasonable to us, it behooves us to be very humble in the presenceof these manifestations of powerful instinctive forces over which the patient haslost control. We are not called upon to cut the Gordian knot with our superiorintelligence, but rather to enable the patient to understand his instinctive tenden­cies and thus learn to harness their force. The worker must be dispassionate andobjective and must rigidly avoid any sympathy or identification with the patient,just as she avoids condemnation. Otherwise she cannot properly evaluate thepatient's reactions.

Direct questions and requests for advice and relief are to be treated as symp­toms. The worker must seek out the patient's reason for asking the question atthis particular time, and if the reason is not immediately apparent, he may beasked directly or indirectly. When one is in doubt the safe procedure is to turnthe question back on to the patient. In general one should be wary about givinginformation or advice freely without first understanding the patient's motives.It may be accepted as a good rule to refuse whatever request the patient makes,since it is likely that he is seeking to repress a certain amount of anxiety orsatisfy some unconscious need in this manner. Likewise, one must never intro­duce an idea that is new to the patient or which has no relationship to what hasgone before. Discussion should be confined to the material which the patient hashimself presented or which it is obvious that he understands.

It is best to set aside a definite time for the appointment, as often as is deemednecessary, certainly not less than once a week. An hour should be devoted to theinterview which begins and ends on time. If the patient arrives late he may haveonly as much of the hour as-remains, even though it be a few minutes. Patientsas a rule learn to tell their story within the allotted time. Any contact before or

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after the interview, or in some other setting, should be studiously avoided. Atthe end ofthe hour the worker may terminate the interview by announcing thenext appointment or by rising. It is advisable to have the patient come to theoffice for the interview, since the sacrifice he must make in this way will empha­size the importance of treatment. In addition, there will be no danger of interrup­tion by members of the family or by household duties which must be completed.A professional relationship must be insisted upon despite the patient's efforts tointroduce a more personal note. Gifts should be tactfully, but firmly, refused.

THE TRANSFERENCE SITUATION

The worker's success depends upon her ability to handle the various aspectsof the treatment situation-invite and hold the patient's confidence, assure himof her interest in his welfare, show a tactful consideration and understanding ofhis problems and offer interpretation in terms which he can understand. To doso she must be aware of his relationship to her at any given moment. Since wedo not deal with static material, diagnostic rubrics are not desirable except ina very broad way and only insofar as they afford insight into the client's reac­tions. We deal with definite concepts, it is true, but they may be manifested ina variety of forms which must be understood. Of these the most important is theproblem of transference.

As soon as the client meets the worker it is observed that he adapts himself toher according to his habitual mode of reaction. He may be aggressive or submis­sive, distrustful or credulous, hostile or friendly, rebellious or dependent. As thecase unfolds itself it will be discovered that his attitude represents his childhoodrelationship with his parents. In other words, he attempts to recreate a situationto which he is accustomed and in which he feels comfortable. The worker is ontrial from the very start. The patient may be likened to an ameba which testsits environment by sending forth pseudopods. If the foreign body with whichit comes in contact seems inviting, the organism is encouraged to proceed further;if the body is hostile the ameba withdraws and tries another approach, until bytrial and error it finally learns to make the adaptation. The patient's preliminaryapproach has been to prepare the groundwork, as it were, to see what nature ofperson he is dealing with. The worker can facilitate this period of introductoryadjustment by appearing as the patient and understanding listener, who is asobjective as possible.

At first, then, the patient's attitude towards the worker is a replica of his at­titude towards his parents. As he progressively reveals his instinctive tendencies,however, and finds that he is not being condemned, he becomes more bold inregard to his conscience and may even discard it in favor of the therapist whothen begins to take on all the characteristics of the superego. This transferenceof authority is favored because the therapist is more lenient and tolerant than thepatient's conscience. As long as the patient feels that the therapist is favorablyinclined towards him, the transference partakes of the nature of a great outpour-

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ing of positive feeling. When, on the other hand, he feels that he is being let downbecause of the interpretation of repressed material or some imagined slight, hisfeeling for the therapist may turn to anger or hatred (negative transference).We can thus, by studying the worker-client relationship, see in pantomime thewhole emotional drama of the patient's childhood, his love, hate, jealousy, fear,and feelings of guilt and inferiority. It is clear then why an understanding of thetransference situation is so essential to the successful conduct of the case.

It is important that the client have confidence in the worker if he is to obtainany feeling of security in the relationship. Periods of upheaval will arise, but thepatient's sheet anchor is the firm personality of the worker, which enables him toaccept these periods of unrest without too much alarm.

It may be that the worker will frequently be tempted to identify herself withthe patient and sympathize with him. She may occasionally feel inclined to offeradvice and reassurance. As a result she will soon find, however, that such an at­titude helps the patient cover up his uncomfortable feelings and continue to re­press them, and that the treatment process subsequently degenerates into a longdrawn out affair, in which the patient receives a great deal of positive satisfactionand has no real desire to probe into his actual problems. The worker in whomthis counter-transference arises is definitely handicapped, since she is unable tobe objective in her judgments. This tendency can of course be overcome by apersonal analysis or by frequent conferences with the psychiatrist.

INTERPRETATION

Until now we have been considering methods of helping the patient expresshimself fully. Before he can be relieved of symptoms, however, it is also necessaryfor him to understand the meaning of his symptoms. In other words, the goalof therapy is to make the patient aware of his unconscious mental processes andthis is done by offering interpretation which is applicable to the situation underconsideration. If the worker fails to give timely interpretation, it will be foundthat forward movement soon ceases, and after a period of dissatisfaction andstrained relationship, the discussion begins to go in circles. This may keep upendlessly until treatment comes to a standstill out of sheer exhaustion of eitherthe worker or client, or both. If progress fails to take place one must stop to con­sider just what has gone wrong. Most often it will be found to depend upon theway interpretation has been handled or neglected.

By interpretation one aims to bring the ego face to face with the repressedtendencies, since it is only after the latter have been made conscious that theycan be brought in contact with the rest of external reality. If the interpretationis successful it usually leads to an increased recollection of repressed material ex­tending back into childhood. This is particularly true when the interpretationsucceeds in pointing out a fundamental pattern which constitutes the client'slife problem. The patient finds that with the increased insight he can bring theemotional forces under control and redirect the energy more efficiently in making

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healthier and more satisfactory adjustments. This is reflected In the changeswhich he effects in his environment and social relationships.

Before offering interpretation it is essential that the therapist herself have athorough understanding of the patient's mental mechanisms. She is thereforein no position to offer any interpretation or advice until she has accumulatedenough data to formulate a clear conception of the patient's personality. The artof interpretation lies in describing to the patient exactly what is going on in hismind. The therapist is usually far ahead of the patient in her understanding of thelatter's motives and on this account must guard herself against expressing toomuch at one time. The patient can understand only what is nearest his conscious­ness at the moment. If we attempt to burden him with material too far removedfrom consciousness he will be unable to grasp it and it will consequently have nomeaning for him. If by chance, such far-reaching and premature interpretationshould be effective in breaking through the patient's elaborate defenses, he mayfind the burden of self-knowledge too great to endure. His reaction may then beone of building hasty substitutive defenses and retreating into his shell or break­ing off the therapeutic contact entirely with increased resentment against theworker. If his defenses fail altogether, acute anxiety may appear and in extremecases, even psychotic symptoms. We must consequently keep in rapport with thepatient and be guided by his approach. As he advances it will be observed thathe cautiously feels his way and is wary about exposing his weak points. He maydo this by continuing to discuss his physical symptoms, relief problems, projec­tions or compulsions, or presenting signs of dependency or rebelliousness. It isthe duty of the therapist to respect the patient's caution and encourage him tobecome more bold. We must aim to attack the outer breastworks first and onlylater the secondary defenses. If the patient responds favorably to early inter­pretations, he is more likely to withstand an assault upon his deeper problems.In other words, interpretation must be offered on the basis of the material whichthe patient presents, and only after he himself delves into the past can the inter­pretation become more general and comprehensive.

There is another reason for deferring interpretation at the onset, namely, thatone must be certain of the patient's feeling for the therapist. If the therapistintervenes before there has developed some degree of positive transfer, the pa­tient may be inclined to resent the intrusion. On the other hand, once the transferhas occurred, the therapist may allow herself much greater latitude in discussingthe patient's problems. The transference situation is the only aspect of the pa­tient's life which the worker can thoroughly understand and control. In addition,it is something of which the patient is immediately aware. It is therefore not sur­prising that interpretation of the transference situation is the most direct andeffectual way of breaking through the patient's defenses.

We must be constantly on the lookout to gauge the effect of interpretationupon the patient. Is he assimilating it or is it increasing his anxiety unduly? Onthe other hand, we must guard just as vigilantly against the tendency of the pa-

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tient to reach a state of contented equilibrium in which he makes no effort touncover his unconscious motives. The therapist by her interpretation mustarouse sufficient anxiety to keep the patient's productions at fever heat withoutoffering so much that the patient is unable to assimilate it. Treatment has beendescribed as a form of progressive immunization against the unconscious by theadministration of small and increasing doses of unconscious material.

To guard against faulty interpretations it is advisable to be cautious by allow­ing the patient to lead here too. The worker should not be eager to impress thepatient with her insight or attempt to force her interpretations upon him. It isa much wiser policy to temporize by asking the patient what the material meansto him after the therapist has attempted to clarify it by the proper sort of dis­cussion. It is much more important to the patient if he can express himself thanto accept the therapist's interpretation which he does not fully understand. Ifthe patient disagrees with the worker's interpretation and becomes argumenta­tive it may be better to allow the matter to drop for the time being. Furtherassociations may help to make the matter clearer to him. On the other hand, ifthe subject matter is very obvious the worker must attempt within reasonablelimits to press her interpretation. The patient may deny the validity of an inter­pretation, only to indicate his acceptance of it later on. When in doubt it is betterto remain silent and await enlightenment which may come from the patient'sfurther productions or from the psychiatrist in conference.

AIMS OF TREATMENT

The purpose of treatment is to release the energy tied up with the patient'srepressions so that it may be redirected towards making an efficient adjustmentin respect to reality. It is true that we never uncover all of the mechanisms atwork, but it is not essential that we do so. In this respect we permit ourselves tobe guided by the patient. If, following the partial recognition of unconscioustrends, there results a disappearance of certain symptoms or undesirable modesof reaction, the patient may desire to terminate the treatment at that point. Insuch instances, the worker should go along. It is our duty merely to see thatmovement takes place in a forward direction. This is evidenced by increased feel­ing on the part of the client for the worker, greater production of unconsciousmaterial and a tendency to adapt himself to the environment in terms of greaterawareness of his problems.

From what has been said, it is clear that treatment continues as long as the patientdesires it and as long as progress takes place. It is not up to the therapist to urgethe patient to go on with treatment when he appears reluctant. We do not aimto solve the patient's fundamental problems or to effect a change in his personal­ity, but merely to free him sufficiently from his conflicts so that he can lead ahappier life. In this respect we adhere to the principle of giving the client onlywhat he asks for.

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DISCUSSION

Charlotte Towle: Dr. Slaone has presented a clear differentiation of certain areas oftreatment in which the social case worker can function. He has depicted in considerabledetail direct treatment in case work which in his opinion the well qualified social workercan carry under the guidance of a psychiatrist. It is gratifying to us have a psychiatristgraciously open the gate to this field of service. To be sure many of us have been explor­ing this field, some of us quite tentatively with a feeling either of treading on forbiddenground or of hesitation rooted in awareness that we were not too well prepared for the taskwhich we had undertaken. Others of us less well oriented perhaps have been romping withconsiderable abandon on these same grounds. Dr. Sloane's description of this service inwhich he has defined certain limitations and safeguards, now gives us legitimate entranceto controversial areas and his presentation is timely because it brings them into the openfor frank discussion.

His point of view apparently has been determined by recognition of wide need for ex­tended psychiatric service and by experience with social workers who through force ofcircumstance as well as perhaps through predilection have pioneered in this kind of thera­peutic effort. That he sees this work as a function of the social case worker suggests thathis experience with members of our profession has been a fortunate one. The opening of thegate to us to share with psychiatrists this therapeutic area comprises a challenge to ourprofession. Now a challenge is that something for which social workers have a great weak­ness and it is to be hoped that in arising to this occasion we will not crash the gates. Forthis reason I wish to express agreement with the safeguards which Dr. Sloane has setnamely-The application of this method to a selected group of cases which in turn impliescareful diagnosis. Continual consultation with the psychiatrist for clarification of diag­nosis, and for guidance in treatment particularly at those points where movement is ob­structed. I wish to add the further safeguard which presumably has existed in the past andwhich hopefully will be assured out of our deep realization of professional responsibility:that social case workers will be sufficiently well oriented and objective to acknowledgetheir limitations, thereby not launching into this kind of work prematurely.

In the selection of cases Dr. Slaone asserts that "It is assumed that a correct diagnosishas been made and that there is no physical disease and that simpler methods of treat­ment are not applicable." One would need to be sure here that simpler methods have notworked because of factors inherent in the patient's condition rather than because of theineptitude of the worker in effecting simpler forms of treatment. I mention this becauseof the common tendency to strive for more complicated solutions when we ourselves arefailing in applying basic principles through more usual case work procedures. This tend­ency has been particularly noticeable in the period from which we are just emerging.Frustrated by immodifiable environmental situations many of us have sought directtreatment measures through the misconceived hope that by going "deeper" we might en­able the individual to endure an untenable reality. Dr. Sloane states also---"many workerssoon discover the inadequacies of indirect treatment and wish to attain a feeling ofgreater effectiveness in handling all types of cases." In this connection it is to be hoped thatcase workers will be motivated by the needs of the case as revealed in discriminative diag­nosis, rather than by personal need to feel more effective. Again I say that when we feelineffective the obstructing factors may be within ourselves or within the agency's functionrather than within the method utilized or within the patient's situation. Such possibilitiesas this, and there are many others too numerous to mention lead us to a consideration ofthe criteria which might help determine whether or not a case worker is ready to assumethis kind of treatment responsibility. Several obvious points emerge.

First-Adequate training which today means a master's degree or its equivalent re-

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ceived from one of the member Schools of the American Association of Schools of SocialWork. The trend in most of these schools is that of giving an adequate professional founda­tion without emphasis on specialization. There is an effort to impart a body of knowledgeand certain skills which all social workers should possess. Even the student majoring insocial psychiatry has not received the technical training which would prepare him to func­tion effectively in the work described by Dr. Sloane. He has only received a foundation forthe subsequent acquisition of such skills.

Second-Experience, varying in extent with individuals in which however the personhas demonstrated a capacity to function adequately in the so called simpler forms oftreatment. I say "so-called" because actually if one performs these kinds of treatmentwith a degree of skill which would be essential in direct treatment methods, the same ma­ture orientation would be implied. If "simple" social manipulative services are renderedwith discrimination, that is with awareness of the needs of the patient and with under­standing of the interplay of the various personalities in his situation, the same deep under­standing of the dynamics in the case is essential. There may be required also equal skillin following the feelings of individuals if the service is to be fully effective. Likewise in"relationship therapy" in which the worker offers little or no interpretation and in whichshe depends upon the positive relationship to provide the motive power for the treatmentprocess the same knowledge of the dynamics of the case is required as well as an equalcapacity to relate herself to the patient. It is not that lesser skill is required in theseforms of treatment if they are to be conducted with the expertness essential in this directtreatment method. The distinction here is that these other forms of treatment can be per­formed experimentally with less skill, and with less effective results, without the samedangers to the client or patient. For this reason I would say that direct treatment as de­scribed by Dr. Sloane should not be attempted without assurance for the patient of aconsiderable degree of skill on the part of the worker. It is therefore not a method for thenovice and I would therefore have other forms of treatment serve as the proving ground.A reasonable expertness in these areas presupposes a sound orientation in social casework, a basic understanding and emotional acceptance of the principles of human be­havior, in short an adequate knowledge, and certain skills, together with a capacity forrelationship as predetermined by self knowledge and self acceptance.

Third-In many instances a personal therapeutic experience will have been involvedin the fulfillment of the second requisite.

Dr. Sloane has stated in response to questions as to the advisability of case workersassuming the responsibility of direct treatment that they have been virtually forced intothis work by the scarcity of psychiatrists. The pressure of need for this kind of servicethen becomes one major justification for their activity in this area. When one considerscarefully the limitations which Dr. Sloane has set, principally that such work should beconducted under the supervision of a psychiatrist, together with the qualifications whichI have outlined it becomes clear that the pressure situation cannot be relieved to any greatextent in the very near future. One sees here a demand for exceptionally well qualified caseworkers who have had considerable experience together with a predilection for this workand who are so situated that psychiatric consultation service is available. In looking to theimmediate future when a greater number of such case workers will be obtainable one fore­sees another dilemma-in fact this awkward situation is now an actuality in certainareas-the lack of psychiatrists not only to treat patients but also to supervise adequatelythe social workers who are assuming that responsibility. How indefinable that element ofpsychiatric consultation can become has already been demonstrated in some situationswhere the psychiatrist is serving as consultant in name only-either because he is too busyto do otherwise, or because he has no particular interest in developing social workers tofunction as psychiatrists. One sees at this point a breakdown in the well fortified situation

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of the past. Social case workers will be assuming this responsibility without adequatedirection and the training available under the former protected circumstances will becomea random factor.

In the past and for the most part in the present, direct treatment in social case workhas been and is being practiced on a few selected cases, by a few exceptional case workersin consultation with a few very exceptional psychiatrists. It is to be hoped that for thepresent this practice will be confined within these limits. In connection with further de­velopments to meet the pressure of increased demand for such service one confronts theneed for post graduate training for social case workers. Dr. Sloane's paper makes us feelthat the time has come for some of the schools of social work to meet this issue. Thoseindividuals who have pioneered in this practice could make a contribution to these schoolsby conveying to them not only the demands in the field but also their thinking aboutessential curriculum and clinical experience. Some of the schools of social work are awareof this need-and may have made first steps in this direction. One school with which I amparticularly well acquainted is contemplating the establishment of a few interneships forpost graduate students in order that they may receive well formulated training for workof this sort. Certainly the preparation of social case workers for this work should emergefrom random experimentation to well defined professional training. This I believe con­stitutes a problem for the schools of social work.

We are indebted to Dr. Sloane for such a comprehensive description of this work. Toread his paper is to realize that in responding to his recognition of our ability to serve inthis area we must feel deep professional responsibility. This implies an awareness of ourlimitations and a recognized need for sound professional preparation.