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"AN EXPLORATORY STUDY OF SOME OF
THE FACTORS CHARACTERIZING
INTENSIVE CASEWORK IN THE

BATTLE CREEK, MICRIGAN VETERANS
aDMINISTRATION HOSPITAL"

by
William Francis Nicholas

 

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AN EXPLORATORY STUDY OF SCH; OF THE FACTORS
CHARACTERIZING INTENSIVE CASEWURK IN THE
BATTLE CREEK MICHIGAN VETERANS ADEINISTRLTICN HOSPITAL

by
William Francis Nicholas

A PROJECT REPORT

Submitted to the School of Social Work
Michigan State University
in Partial Fulfillment of the
Requirements fo; the Degree
0

MASTER OF SOCIAL 4ORK

May 1956

Approved:

 

    

 

irector offSchoo

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VG

ACKNOWLEDGEEHTS

The author wishes to express his sincere
appreciation for the aid and encouragement given him
by Dr. Gordon Aldridge in the writing of this project.
Appreciation is also due Mrs. Rachael Somers and
Er. Kanfred Lilliefors for their valuable assistance
and suggestions.

Grateful acknowledgment is also extended to the
entire staff of the Battle Creek Veterans Administration
Hospital for their suggestions and guidance. Particular
appreciation is due hr. Ted Chavis and Mrs. Harriet
Brigham for the generous assistance given in judging
thirty-six case records as well as for the penetrating
thinking which they readily applied to the project.

' Finally, sincere thanks to my wife who labored
long and diligently on the typing of the paper as well
as to my children who relinquished the attentions of

their father while he completed the project.

TABLE LF CONTENTS

f7?" f‘“ ‘7‘ ""‘"‘.‘T' C"
1&UJLX4.IU";LLDLILI'L.'..JL‘.Pu ocoo...00.000000000000000.0..

LIST OF TILBLES 000......OOOOOOOOOOOIOOOOOOOO.

CHAPTER

I. PROBLEK 1ND CONTEXT 00.000.000.000...

II. AbSUEPTIONS AND M: HTDOLOGY .........
III. PRESENTATION ANL ANALYSIS OF DATA....
IV. CONCLUSIONS L33 ECCULIENDAIIONS .....
AFFE EIX ....................................

BIBLIOGRAJHY 0000000000000.000000000000000...

iii

Page
ii

iv

16
34
50
56
67

Table
l.

2.

3.
4.
5.

6.
7.
8.

LI(‘ m I"~ ffi T 'A p Tfilfi
u 4. ’vl‘ shaggy

Frc1uency of Direct Interviews With

Patients.......o...................no...

Frequency of Interviews With Relatives
Of .EatientSOQOoocococo-0.000000000000000

Source of Referral for Social Service...
Techniques Used in Working With Patient.

Number of Xonth Patient was in Hosgital
Before Interview by Caseworker..........

marital Status of Patients..............
Age Of Patients.........................

Medical Diagnosis of Patients...........

iv

Inge

35

39
43

45
46
47
47

CHAPTER I

PROBLEM AND CONTEXT

This was an exploratory study of some of the
factors characterizing the practice of casework in the
Battle Creek Veterans Administration Hospital. The
hospital is a 2,056 bed neurOpsychiatric treatment center
located in the now deactivated Fort Custer, approximately
six miles west of Battle Creek, Michigan. The Social
Service staff is composed of twelve professionally
trained social workers and five secretaries, as well as
a varying number of graduate social work students from
Iichigan State University, University of Michigan and
Smith College. Emphasis is placed on the team approach
of psychiatrist, psycholoList, and social worker,
although the respective functions are not rigidly defined.
A working relationship exists between the aforementioned
departments as well as between the other departments
such as nursing, occupational therapy, and educational
therapy.

Although it cannot be said that the research
here represented is typical of social science research
in peneral, it does rest upon many of the assumptions

hich are common to the brOad area of social science.

Without going into detail, the most obvious of these
assumptions are: that behavior is knowable and purposeful,
that although no exact measurements are possible in the
social sciences statistical measurement is meaningful,
and that the solutions to problems based essentially
in the realn.of behavior will be found both in empirical
observation and rationalistic generalization.1 Another
assumption Which is often overlooked but is an implicit
component of social science is that pertaining to
develoPment. It is sometimes felt that the whole of
social science research is useless due to the inadequacies
of its findings and the nature of its inquiry. Hans
Reichenbach states that "The philosOpher speaks an
unscientific language because he attempts to answer
questions at a time when the means to scientific answer
are not yet at hand."2 At present much of social science
inquiry is philosoPhical. However, it may be that the
means are not yet at hand.

This study was not concerned with the broad
issues facing the whole of social science, but rather

with some of the problems confronting social work.

Social work, as a profession, is wrestling with many

 

lHans Reichenbach, The Rise of Scientific
Philosoghz (Berkeley: University ofCalifornia Press,

21b1d., p. 25.

problems of definition, not only of function but also

of knowledge which it holds uniquely. Within this

context there are also several assumptions upon which

this study rests. One of these is that social work
represents a professional area of practice based upon

a body of knowledge that is transmittible. Social work

is in the early stages of develOpment but it has now
reached a point where definition and varied research
focuses may be attempted. A factor which plays a

primary role in defining the theoretical context for

this study is that social wOrk has been historically

and is at present, essentially an area of clinical
practice. Social work has not concerned itself with

the evolving of new, basic knowledge, but has rather

been occupied with the effecting of change. The specific
focus has been on attaining goals in terms of techniques
which have been clinically tried and in some cases
evaluated. The particular type of transmittible

knowledge which social work possesses rests in.methodolOgy
or conversion of knowledge which.has been eclectically
borrowed from.many areas and converted into practice.1
Although social work is advancing toward.more exact
knowledge as a whole, it is not progressing evenly in
terms of specialties within the profession. Social

‘1

David G. French, An A roach to Measurinv Results
in Social Work (New York: EqumEIa University Brass, I§52).

 

casework has tended to develop much faster than many of
its generically related siblings. In addition to this,
social casework has had a longer history and has
consequently reached a point where the rate of develOp-
ment is increasing.

This study was theoretically situated in the
area of social casework and was directed toward an
identification of the methods used in social casework.
It was concerned with the way in which an eclectic
fund of knowledge was converted into practice. It was
not concerned with an evaluation of the practice, but
rather with the identification of the method. However,
as indicated in the title, this was an attempt to
identify only one aspect of casework, that which is
here called intensive. Intensive casework was a term
found in use at the hospital by the caseworkers and
which was found in use at sixteen other major Veterans
Administration hospitals by the social service staff.1
This study was an attempt to identify on a practice
level some of the characteristics of intensive case-
work and to determine whether or not intensive case-

work was a homogeneous grouping of factors.

 

1See Appendix A.

REASON FOR STUDY

There were essentially five reasons for this
study being conducted. The first of these was found
when an examination of the literature was made in an
attempt to find meaning for the term "intensive case-
work". No literature was found which lent itself
directly to an explanation of the term. Iowever, the
implicit assumption in the se of the term intensive
is that it refers to something closely aligning itself
to psychotherapy. Many articles have been written
attempting to differentiate psychotherapy and casework.
One common characteristic of he articles is the ambiguity
which surrounds the definitions of the terms. Kaplan
stated that "There is general agreement that social
Casework is a less intensive and a more supportive
treatment than intensive psychoanalytic therapy."l
There is a certain degree of case associated with
definitions in extremes. However, the definition
in extremes tends to avoid the basic issue of essential
difference between social casework and psychotherapy,
if such a difference exists. Marmor stated that:

We must face the fact that there is a significant

1Alex H. Kaplan, "Psychiatric Syndromes and the
Practéce of Social Fork", Social Casework, harch, 1956,
p.10.

area of overlapping in the techniques of casework
and brief psychotherapy, an area in which.more or
less identical approaches are utilized by caseworkers
in social agencies and by short-term psychotherapists
in mental health clinics. At the casework end of
the scale, however, there is an area in which
environmental manipulation is utilized to an extent
that is beyond the scOpe and capacity of the average
psychiatrist; while at the psychiatrist's end of the
scale there is a group of patients with whom.deep
uncovering techniques are utilized to an extentlthat
is beyond the scepe of the average caseworker.

In.much the same vein Coleman explains that for
terminological and administrative clarity:

I see no value in calling casework anything but
casework, even though it is a genuine psychotherapeutic
endeavor, since casework has potentially a broader

and more elastic field of usefulness than psycho~
therapy practiced by psychiatrist. In other words,
casework is a form of psychotherapy with special
orientation, differential aims, and a particular
methodology; in effect, it is an application of
psychotherapeutic prinicples in a sefiting and in

a manner which is uniquely its own.

Anether article related to this area came as a result of
an analysis of forty-three cases at the Mental Hygiene
Clinic, Veterans Administration, Seattle, Washington.

In this study a section was devoted to factors in
supportive treatment (seemingly supportive treatment
aligned itself with total casework treatment) in.which

 

lJudd Memor, "I dicstions for Psychiatric
Therapy or Social Casewor ", Social Casework, February,

19559 Pa 61.

Jules V. Coleman, "Psychotherapy and Casework”,
(Presented at s Symposium.on Psychotherapy and Casework,
sponsored by the Boston Psychoanalytic Society, Boston,
February 19-20, 1949).

they felt that:
Here the term 'supportive therapy' by and large is
used in juxtaposition to 'insight therapy' or
'interpretative therapy'.- As a rule, we use the
words ‘supportive treatment' or 'supportive therapy'
in the sense of focusing attention on the clients'
present reality problems and minimizing efforts to
give the patient insight into the unconscious
courses of behavior.

The theme which evidenced itself consistently
in the articles which were reviewed was that casework
was not clearly defined but seemed to be similar to
psychotherapy. The only article which attempted to
relate some general statements to specifics was that
of Coleman in which professional training was cited as
a differential factor.2

A statement which seems appropriate at this
point (in relation to professional training as a
differential factor) is "When ignorance is universal,
the degree of inexpertness is secondary."3 One of the
outstanding problems confronting the specific answering
of a question such as "Is this psychotherapy being done
by a caseworker?” is the lack of definitions of the term

psychotherapy. As evidenced in the articles cited.

 

tiFritz Schmidl, ”A Study of Techniques Used in
Supportive Treatment”, Social Casework, December, 1951.

ZColeman, op. cit.

3Herbert Sanderson, Basic Conce,ts in Vocational
Guidance (New York: WsGrew ompany, ,
P0 41.

   
 

definitions were being attempted in a comparative

manner when both factors were variable; this presents

a philosophically difficult task. In order to adequately
relate casework to another framework, it is necessary

to be able to specifically and empirically define what

is meant by the term.

The second.major reason for this study was that
the workers in the agency gave the impression that they
were able to communicate with each other when using the
term ”intensive casework“. Statements such as, "I feel
that this patient would profit from intensive casework,"
were used when the workers were discussing cases, and
statements such as, ”This patient will receive intensive
casework',were found in the records. Many of the workers
felt that intensive casework was an individually defined
concept. However, the degree of communication achieved
served to refute this. The thinking which was stimulated
by this was that perhaps there was a good deal more
inconsistency on the verbal level when discussing
intensive casework than there was on the practice level.
This would be somewhat contradictory to the findings of
a survey of some major principles of casework in which
it was felt that inconsistency may be found on the

theoretical level but this was not reflected in practice.1

 

410allman Rauley, "A Sampling of Expert Opinion on
Some Principles of Casework", Social Casework. April, 1954.

The third factor which prompted this study was
that the term ”intensive casework" was being used
differentially by the workers for particular cases.

It was felt that intensive casework was applicable

to certain types of patients or situations and that it

was not apprOpriate for others. This was also evidenced
in other Veterans Administration heapitals by the indicat—
ing of factors such as: (l) willingness to participate

by client, (2) age of patient, (3) length of hospital-
isation, (4) patient's past adjustment, (5) worker‘s
interest in the case or feeling toward patient, (6) the
patient's capacity to relate to the worker.1 All of
these factors tended to substantiate the presence of a
differential use of the term "intensive casework".

It would seem.necessary to be able to adequately describe
a term which was being used differentially in practice

in order to evaluate it as well as to refine the practice.

The fourth factor which underscored this study
is the pressing need for research in treatment. "The
very fundamentals of therapeutic interpersonal relation-
ships remain with scientific validation."2 In this

article four questions were posed for basic research:

 

VISee Appendix B.

zKurt Freudenthal, ”Need for Research in the
Area of Treatment Relationship", Social Casework,
OCtOber. 1955’ P0 3690

10

(1) Who can benefit from relationship therapy? (2) When
has maximum.benefit from relationship therapy been
achieved? (3) In cases of improvement or regression,

is relationship therapy causal? (4) Does the approach
represent differentiated therapeutic areas which

justify referral? In the Social Work Yearbook reference
was made to the need for continuing study and evaluation
of the function and scope of social work.1 In the

same volume Fletcher listed as one of four objectives

of social work, research to improve and enlarge the
techniques of diagnosis and treatment as they are used
in social work practice.2 The most profound need of
social work research (as well as all social science
research) is the development of concepts. "Our greatest

need is a frame of reference and a system of concepts
which will generate testable hypothesis and will

encourage precise observation and analyses.”3 The

need for basic research in social work is promoted in
numerous articles and lectures so much that it has
become a cliche in social work to indicate the need for
research. Although this was continually emphasized,

 

lClyde E. Murray, "Social Work as a Profession”,

Social Work Yearbook 1255, ed. by Russell A. Kurtz,
ew or : AAS .

2Social Work Yearbook Staff, "Research in Social
Work", Social Work Yearbook 1225, ed. by Russell A. Kurtz,
(New Yor : AASV .

3Morton B. Ring, Jr.,"Some Comments on Concepts",
Social Forces, October, 1955.

ll

few such pieces of research have evolved. This leads
to the fifth reason for this study.

There has been in social work research the
vestige of a historical past, namely, an emphasis on
results. Social work research has tended to grasp at
this same emphasis as evidenced by the dearth of studies
examining practice and the emphasis on followaup or
evaluation.1 The value of studies such as these is not
to be underrated. However, this type of study should
be considered as only one aspect of a total research
prOgram. One of the.maJor objections to the follow-up
study is the inability of the research design to control
variables which.may be more causal than the assumed case-
work process. This is a problem which is inherent in
social science research; however, other disciplines such
as psycholOgy have attempted to cope with it by identify-
ing as precisely as possible the object under study. It
is difficult to control the variables in social case-
work for there have been few attempts to identify the
components of this practice on an empirical level. As a
result, we know a good deal about peeple and problems
receiving social casework and something of what happens

afterward, but very little of what happens in between.2

1For example see: Dorothy Levy, "A Follow-up
Study of Unmarried Mothers", Social Casework, January, 1955.

2For example see: Margaret Blenker, J. Mo V. Hunt,
Leonard S. Kegan, "A Study of Interrelated Factors in the
Initial Interview with New Clients", Research Programs and

Projegts in Social Work, FSAA, 1953.

 

12

The material which related itself directly to
a definition of social casework defined goals rather
than process. Gordon Hamilton, one of the foremost
interpreters of social casework,noted the process as

". . . the release of resources in the immediate

"1

environment and capacities in the individual. This

partial definition seemed to be representative of most
definitions. It placed an emphasis on removing blocks
to the individual whether these blocks were within the
individual himself or more broadly defined in terms of
his immediate environment.

The process of social casework and its usefulness
rests upon a conviction of accepting people as they
are, respecting their rights to live their own lives
according to their best lights, and a willingness to
work with them on their plans rather than to make
their plans for them. The worker's effectiveness
lies in what he does in helping people and how he
does it. He does not take over their difficulties
nor their own share of responsibility, rather he
helps them to face their difficulties and to carry
what is their part of the load. Casework is a
skillful way of working with peeple in trouble.

It is not the only way. It is one way that has
proven its value by helping people to develop their 2
own capacities for usefulness and satisfying living.

As one moves from the more broad conceptual

material portrayed above to the more specific, the

1Gordon Hamilton, Theor and Practice of Social
Casework (New York: Columb a n varsity Press, 1951).

2Arthur E. Fink, The Field of Social work
New York: Henry Holt & Company, '

 

 

13

definitions are still philos0ph10al. ”The casework
relationship is the dynamic interaction of feelings
and attitudes between the caseworker and the client
with the purpose of helping the client achieve a
better adjustment between himself and his environment.";
It was on this philosOphical level that a
schism develOped in social work. One approach to social
work became known as the functional2 and the other as
the organismic. The theoretical foundations for these
areas have evolved from the theories of Otto Rank and
Sigmund Freud, respectively. It has been felt by
several persons that the primary separation of these
two approaches is in theory, although a recent publica—
tion contests this‘thinking,3 and that a comparison of
practice would not exhibit the schism. This again
emphasizes the need for an eXamination of the casework
process.
There seemed, then, to be a lack of consistency
in definition of social casework as well as a degree of

defensiveness on the part of the profession in the

 

1Felix P. Biestek, "An Analysis of the Casework
Relationship", Social Casework, February, 1954.

2Herbert H. Aptekar, Basic Concepts in Social
Casework, (Chapel Hill: Universr y 0 or are ina
Pr985’1941)0 .
3Herbert H A 1n“ ~
. ptekar, The D amiss of Casework

and Counseling, (New York: Ho ' on mifflin Company,
C

 

14

psychotherapy—casework controversy. This lack of
consistency was represented theoretically and has not
been evaluated empirically; that is, there is a lack
of studies examining practice. Although this study
did not attempt to examine the total area of casework,
it did examine a particular aspect of it. While
intensive casework may be defined theoretically (this
author did not find this to be true), it has not been
examined empirically. '

The purposes of the study fell into two
categories. The first was that it was felt that
communication could be improved both within and outside
the profession. The foremost research need in social
science as well as in social werk is the need for
construction of concepts. It was hoped that this
study would provide at least a partial movement
toward construction of a concept of intensive case-
work. There was recOgnition that the construction
of a total concept of intensive casework would not be
feasible at this time, due to factors of time and
develOpment of research technique; however, partial
solidification was attempted. If concepts could be
developed which are meaningful on the practice level
as well as on the theoretical level, the task of

communication between workers as well as the enormous

15

job of interpretation to other disciplines and the
public would be.made much easier. It was felt that
research technique as well as subject matter could

be explored in an attempt to provide a research

base from which improvements and refinements could

be made. In scoordance with this, the study hepefully
will focus attention upon an examination of social

work process on the empirical level.

CHAPTER II

ASSUXPTIONS AND HETHODOLOGY
Hypothesis

In order to systematize an approach to this
study and to provide a framework in which to examine
the practice of intensive casework, the following
hypothesis was formulated: the factors which characterize
active casework also characterize intensive Casework
but distribute themselves bi—modally. It was felt
that a series of factors would manifest themselves
in both intensive and active casework but that in
each of these cases seas of the factors would be more
pronounced in one than in the other.

For purposes of this study the terms "intensive
case" and"active case" were determined by the workers.
An intensive case was one which the individual worker
indicated as being intensive. All other cases in
which the worker had performed some activity but did not
feel that it Constituted intensive casework were labeled
active.

The hypothesis stated above was used for several
reasons, the most fundamental being that some control

was needed to differentiate intensive casework. It

17

would not have been meaningful to extract factors

from cases in which intensive casework only was believed
to have been practiced for there would have been

nothing to make these factors different from those

found in active casework. By using a fruucwork such

as the one implied in the hypothesis a control group

was incorporated in the design.

Another basic reason for the use of the hypothesis
was that the literature and the discussions which were
held with the workers gave reason to believe that there
were no distinct factors in either intensive or active
casework. A generic base was found to exist in the
philos0phical definitions of casework and also in the

material found in the psychotherapy-casework controversy.

Assumptions

Three assumptions provided the base for this
study. The first of these was that casework is an
analyzable process with distinguishable characteristics.
In attempting an exploratory study of factors character-
izing intensive casework, it would be necessary to
assume that such factors were accessible. There is a
good deal of controversy regarding the measurement of
dynamic, intangible, conceptual material with the tools

we now have available. It has been stated that casework

18

is an art based upon a science and that perhaps the
art may never be meaningfully measured. In terms of
these limitations, the title of this study points out
that this is a study of some of the factors character-
izing intensive casework and makes no claim to measuring
or identifying all of them. The assumption as stated
eE3ve, however, is located more apprOpriately in the
ilos0phical base of social science research and

represents a goal rather tlan a specific entity, namely,
that behavior is measureable and knowable. Our inability
to measure behavior at any particular point in time
rests in the lack of adequate tools rather than the
inaccessibility of the product.

The second assumption of this study was that
the separation of cases by individual workers (into
intensive and active) provided two groups which were
distinguishable. Although the completion of this
study will serve toward validating this assumption,
the literature supported the view that the two groups
were somewhat different. This assumption was border—
line between a hypothesis and an assumption, for the
reason stated previously. However, it was necessary
in that the study was directed primarily at an identifica-
tion of factors Characterizing one of the groups. This

assumption also became necessary due to the absence of

19

any tangible separation of cases in terms of administra-
tive procedures or policies.

The third assumption defined the source of the
data: case records contain data which identify factors
characterizing intensive and active cases. It was
recognized from.the beginning of the study that all of
the factors could not be identified. Nevertheless,
case records represent at least partial recording of
casework process. In this sense it would be conceivable
that characteristic factors would be evidenced in the
records. There are many limitations to the use of case
records for social work research. In many studies it
has been necessary to define the recording to be done by
workers as part of the study design; however, this
methodOIOgical tool could easily provide a sample which

was not representative.

Plan of Study

In its simplest form this study consisted of a
selection of intensive and active cases as defined by
the individual workers, construction of a schedule for
gathering recurring factors in these cases, application
of this schedule to the case by three observers (author
and two workers in the agency) and a classification of
the factors as they were found. The same schedule was

applied to both active and intensive cases in order to

20

obtain a basis for comparison of the two groups; that
is, the schedule served as the standardizing instrument.

As indicated in the assumptions stated, the
data for the study were gathered from case records in
the agency. The cases were selected on the basis of
requests to the individual workers for cases which
they felt were intensive and those which they felt were
active. Many requests were made by the workers for
clarification of what the author meant by intensive,
feeling that perhaps the terms was one which they alone
used. In each of these cases the explanation given was
that the study was concerned with what they felt
intensive casework was rather than what the author
felt it was. The only other stipulation was that the
cases which were submitted be closed; that is, either
the patient had left the hospital or it was felt that
no further casework services were needed. Aside from
these two qualifications no other information was given,
although a great deal of pressure was exerted on the
author to do this.

Numerically, thirty-six cases composed the
group which was examined. This group was divided into
eighteen active and eighteen intensive cases. The
number of cases used was dictated by the number of

intensive cases which could be obtained. The cases

21

were obtained from the workers and were available
only on the basis of workers' recall. Eighteen
intensive cases constitued the group which they
submitted and this was used as the sample. There
was no such limitation on active cases since the
supply was unlimited.

The reason for using this method in selecting
the cases was that the study was concerned with an
examination of a relatively undefined concept which
was being develOped by the workers on a practice level.
No administrative or formal method had been utilized
which allowed for classification; consequently, no
method other than this would have allowed for a non—
skewed group.

This method of selection, however, introduced
several limitations to the study. Since this group was
not in any way selected from.a pOpulation of intensive
cases and there was no way of knowing precisely what the
total population of intensive cases was, it was impossible
to speculate as to how representative this group was of
the total population. This limited the degree of
generalization which could be made on the basis of the
conclusions of the study. Closely related to this
factor was that of memory as being the basis upon which

the workers selected the cases. In other words, they

22

had no method for submitting the cases other than
the submission of ones which had been recalled by
them. The flaws involved in perception may have skewed
the group toward cases in which the workers had derived
a certain degree of satisfaction rather than ones in
which they practiced intensive casework. Another
limitation in the use of this group is that there was
no attempt made to determine how representative this I
group was of groups in other agencies. Although data
have been collected indicating the differential use
of the term intensive casework, it is conceivable that
this may be an agency centered rather than generic term.
Although these are severe limitations, they do
not negate the findings of the study. As suggested in
the introduction one of the fundamental purposes of
the study was to provide a basis for further research.
In this sense the study offers a basis for comparison
in other agencies and with different groups of cases.
In order to systematically extract information
from the case material, a schedule was constructed.1
The basis for construction of the schedule came from

three sources: a survey of Veterans Administration

Neuropsychiatric Hospitals, written submissions and

 

1See Appendix C.

23

interviews with the agency workers, and a review of the
records.
A letter asking an Open end question, "What are
SOme of the factors which the workers feel characterize
the practice of intensive casework," was sent to thirty-
one Veterans Administration NeuroPsychiatrio Hospitals.l
Several responses reflected factors resulting from.staff
meetings held to discuss the question and arrive at a
group definition. In other cases the answers reflected
the Opinion of the Chief of Social Service. The factors
which applied to the intensive casework method rather
than factors noted in differential use of the method
appeared to be: (1) continuing interviews, (2) scheduled
interviews, (3) focus on emotional and personality aspects
of the total problem, (4) formulation of goals, (5) collab—
oration with other disciplines, (6) frequency of interviews.2
The second source of information consisted of
interviews with staff personnel and written statements
from the staff.3 The standard question in the letter to
the hospitals was used to obtain responses from the staff.
The characteristics suggested by this group were:

(1) focus on personality, (2) planned contacts,

 

1
2

See Appendix D.

See Appendix B.
3See Appendix F.

24

(3) structured purpose, (4) considerable emotional
investment by worker.

The third source of information was found in
a review of the records which had been submitted by
the workers. The factors which seemed to be consistently
evident in the records were much the same as those
found in the survey and discussions with staff personnel.
Another source of material used in develOping the
schedule was the literature. Although no specific
mention was made of the degree of emotional invest—
ment by patient and worker in intensive casework, this
was implied throughout.l In response to this, a
question was included on the schedule which indirectly
reflected this factor.

In summary, the factors which seemed to
characterize intensive casework were: (1) continuing
interviews, (2) structured interviews, (3) focus on
personality, (4) more emotional involvement by worker
and patient, (5) formulation of goals, (6) inter-
disciplinary coordination. Many of these factors could
not be directly observed on the basis of material

contained in records. However, when interpreted in a

 

1Intensive casework is being interpreted as
similar to casework as this was interpreted in the
articles discussing psychotherapy and casework.

25

configurational manner the factors found pointed toward
several of the unobserable factors mentioned. In order
to avoid confusion in the analyses, the factors noted
are defined in the following material.

Definition of terms and source of material.

Age - The age to the nearest whole year at the time of
admittance to the hospital.

Medical Diagnosis - The final diagnosis given a
patient by the staff doctor. Patients are always
given an admitting diagnosis which.may or may not
be the one which is finally reached by the staff
doctors after study. Final diagnosis is usually
determined through c00perative efforts of the
Psychology Department, Social Service, and the
medical staff.

Marital Status — Status at the time of admittance.

Referral - Defined to include any way in which the
social worker became involved in the case. It
was divided into six specific parts:

(1) Formal staff meetings. All cases in which
a staff meeting had been called by one of
the team to diagnose the problems and evolve
treatment planning or to evaluate prOgress
and alter treatment planning for a particular

patient. The cases included were those in

26

which reference was made to a direct referral to Social

Service Staff at the meeting.

(2)
(3)

(4)

(5)

(6)

Request from patient. Self Referrals.

Doctor. Those cases in which a formal

staff meeting had not been held but the

staff doctor had made an informal request

for Social Service.

Other Social Service Staff. Designated

those cases in which a referral for social

service was made by a previous worker upon

transfer of the case to a new worker as

well as those in which service was suggested

by another worker on the staff.

Worker. Cases in which the worker defined

the need for service and instigated action.

Other hospital personnel. Included all

the referrals from.hospital personnel not

included in other categories. Examples:
clothing clerk, special service worker,
routine administrative referral upon

admission.

Frequency of contacts per six month period - Contacts,

for purposes of the study, referred to face to

face contacts with the patient. An attempt was

made to obtain the number of contacts; however,

27

this was not possible. The contacts were stated

in the records as being on a weekly, daily, or

less frequent basis, rather than actual chronological
interview by interview recording.

Scheduled or non-scheduled. The terms are self explana~
tory. Statements were contained in the records
referring to the absence or presence of scheduled
interviews. A case was considered non-scheduled
if such a statement was not in the record.

Primary focus of direct contacts with patient. The
term primary was used to indicate the overall
focus rather than focus at any specific time.

Two categories were used for this question.

(1) Environmental. Cases in which the focus
of the contact was primarily on the externals
of the patient's adjustment. Examples:
finances, arranging for visit with relatives,
obtaining clothing.

(2) Personality. Cases in which the focus of
the contact was primarily on the internal
problems of the patient's adjustment.
Examples: anxiety feelings, delusions or
hallucinations, sexual problem.

There was no way of determining an exact point at

which a particular case became one or the other: however,

28

the problems which the worker focused on provided a
basis for overall differentiation. A similar classifica-
tion was utilized in a study conducted by Ripple and

l in which they defined the categories in terms

Alexander
of the problem as presented.
The problems fall into two categories: (1) those
in which the problem for solution involves external,
that is, environmental maladjustments or deficiencies
and, concomitantly, the problem solving process
contains at least some element acting upon that
environment; and (2) that in Which environmental
circumstances per so have minor, if any,place in
defining the question for solution and, consequently,
the problem.solving process to be set in operation
does not involve acting upon that environment.
Since this classification was largely subjective,
a board was used to make a judgement. This technique
is explained later.
Termination of direct contact. This classification
was divided into two categories: (1) planned,
(2) unplanned. Planned termination included
those cases in which termination was discussed
with the patient and plans were made for referrals
to other agencies, follow-up reports, or some other
activity. Unplanned termination included those
cases in which contact ended abruptly as in the

case of a patient being discharged or leaving the

 

lnillianRipple and Ernestine Alexander, “Motivation,
Capacity, and Opportunity as Related to the Use of Casework
Services Nature of Client's Problem", Social Service Review,
M’aI'Chg ‘,.,,,:g P0 400

29

hospital without notice.
The final factor was concerned with the technique
used in working with the patient. The classification of

1 The four

techniques was borrowed from Hollis.
techniques which she listed were: (1) modifying the
environment, (2) psycholOgical support, (3) clarifica-
tion, (4) insight. Her description of the terms was
found to be impractical for the purposes of this study.
However, they did provide a basis for further refinement.
The terms as finally used were defined as follows:2
(1) Environmental Manipulation.
Altering with the patient his environmental
situation. Providing concrete services for
the patient. Examples of this technique would
be: taking the patient to employment office,
arranging tranSportation for patient's return
to his heme, finding a job for the patient.
(2)'Clarification.
Examining and evaluating with the patient the
.major problems surrounding the social, physical,
or emotional illness and his attitudes toward

1Florence Hollis, "The Techniques of Casework”,
Social Casework. June, 1949.

2Although the terms used to classify techniques
were derived from Hollis, much of the interpretation was
derived from.an unpublished report received by Battle
Creek Social Service from.Veterans Administration Central
Office.

(3)

(4)

3O

them to determine what goals are to be set

and what action taken. Interpretation of
hospital function and restrictions. Examples:
intake interviewing, explaining administratively
determined alternatives for leaving the hospital.
Support.

Selective use of acceptance, interest, and
encouragement to utilize and reinforce ego
strengths in order to promote the patient's
confidence in his ability to handle his situation
and to function better. Allowing or encourag-
ing the expression of charged feelings around a
pressing, immediate need. Encouraging expression
of charged feelings through a planned, channeled
process on the part of the worker related to

his awareness of patient's situation, his under—
lying longstanding needs, and the meaning of

the experience to him.

Insight.

Helping the patient to see his feelings and
attitudes on a conscious or preconscious level
and to see his own responsibility for functioning
in relation to his social problem; descriptive
addition of separate episodes in an orderly

arrangement so that the patient can see the

31

same themes in his reactions; helping patient

understand the nature of his emotion in the

present situation, the situation that stimulates
it, the inappropriateness of it to a situational
demand and the undesirable mechanisms by which
the patient attempts to handle his feelings;
helping the patient to utilize self-knowledge

in order to avoid stress situations for him.

Example: patient finds that present feelings

and thinking regarding doctor are similar to

his feelings and thinking about his father.

The definitions did not provide a system.which
allowed a cataloguing of specific activities as evidenced
in the records. It was used to provide a framework of
interpretation for the purposes of the study. In addition,
it was recognized that these categories are related and
could be manifested at one time or another in a
particular record. The basis for classification was
the overall technique used, or more specifically, the

technique used for the problem to be solved.1

Gathering of Data
The schedule was used in two ways. All of the

questions were answered by the author. Two of the questions,

1Ripple and Alexander, op. cit.

32

focus of direct contacts with patient and technique

used, were derived subjectively. In these two questions,
two staff workers were used to provide responses. Each

of the two workers has had.more than five years experience
in social work and holds a.Master of Social Work degree.
At the time of the study one was a supervisor and the
other a ward.worker. They were selected primarily on

the basis of interest in the study, understanding of

the problem, and experience in intensive casework. The

two workers were given a definition of the techniques

and what was meant by focus of interviews.

Limitations

There were several limitations to the schedule
used in the study. The most prominent was that no
measure of feeling tones was obtained. This is an area
which has eluded measurement in all research of inter-
personal contacts. The usual method used to cepe with
this problem was utilized in this study, namely, the
indirect measurement. An assumption was made that the
presence of contacts focused on personality, use of
insight or supportive techniques would indicate a more
involved relationship than the absence of these factors.
In essence, this constituted the indirect measurement of

feeling tones.

33

Another limitation of the schedule was that no
measurement of inter—professional, inter—agency, or
correspondence contacts was obtained. There were many
indications that these factors may have provided a basis
for distinction between intensive and active casework. -
This points up another limitation. The case records
did not display systematic or consistent methods of
recording. It would have been easier to obtain data
(particularly questions of frequency and structure of
interviews) if the contacts had been noted individually
and chronologically. For purposes of this study,
however, enough information was obtained to come to

conclusions regarding the questions mentioned above.

CHAPTER III

PRESENTATION AND ANALYSIS OF DATA

In the preceding chapter six factors were listed
as characterizing intensive casework: (l) continuing
interviews, (2) structured interviews, (3) focus on
personality, (4) formulation of goals, (5) interdisciplinary
coordination, (6) emotional involvement by worker and
patient. The data gathered from the case records
indicated directly or indirectly the presence or
absence of these factors in the records.

The first factor, continuing interviews, could
be interpreted in two ways: (1) by amount of time elapsed
during treatment, or (2) number of interviews with the
patient. In many cases it was difficult to ascertain
the total time span due to summary recording. However,
in.most of the records it was possible to find statements
indicating frequency of contact; consequently, this factor
was utilized.

All of the active cases were found to have direct,
face to face interviews with the patient once a.month or
less. Two of the active cases had direct interviews with

the patient once a month. In sixteen of the active cases

35

direct interviews with the patient were held less than
six times per six.month period of time. All of the
intensive cases had direct interviews with the patient
from one to five times per week with nine, or half
of them, falling in the once per week classification.
The active cases, then, were characterized by direct
interviews with the patient less than once a week and
the intensive cases by interviews one to five times per
week. The coefficient of contingency when cases were
compared in this manner was‘—l indicating a significant
difference.

TABLE

FREQUENCY OF DIRECT INTERVIEWS WITH PATIENTS
W

 

 

Number of Contacts Active Intensive
Per Week Cases Cases

5 cocoeooooetoo O 2

4- 000.000.00.00 0 0

3 coco-ocean... 0 l

2 00.00.000.00. 0 5

1 cooeooooeooeo 0b 9
L988 than]. cocoa-coco 18 0

Total ooocooeoc 18 17

 

8One case did not clearly indicate the
frequency of interviews.

bTwo of these cases were seen once per
month, twelve were seen less than once per month.

It was felt that the frequency of direct interviews
with the patient did not provide a complete picture, for

in some cases the problem.may have been evaluated with the

36

patient's family. In order to control this an attempt

was made to obtain the frequency of interviews with relatives.
Two-thirds, or twelve, of the active cases showed

no interview with the relatives. Over two-thirds, or

thirteen, of the intensive cases had interviews from one

to twelve times per six month period. It is interesting

that no active cases had interviews with relatives more

than three times per six month period, while the intensive

cases indicated four such instances. However, no

significant differences were found between active and

intensive cases in terms of frequency of interviews with

relatives.1

TABLE 2

FREQUENCY OF INTERVIEWS WITH
RELATIVES OF PATIENTS

 

 

 

 

Number of Contacts Active Intensive
Per Sileonth Period Cases Cases

0 0000000000000... 12 5
1’3 ooeocooeeeoecooo 6 9
4‘6 coo-00000000000. 0 2
7-9 ooeeeeo-oeeoeeoo 0 1
10-12 cocoa-000000.00. 0 1
Total ........ 18 18

 

The second factor, structured interviews, was

interpreted as the presence or absence of scheduled or

 

1Coefficient of contingency of +.8I;was found
when the cases were compared on the basis of presence
or absence of interviews. When the cases were compared
in terms of less than 3 or more than 3 contacts, Q 3-1.

37

non-scheduled interviews. The recording usually stated
whether the interviews were held on a scheduled basis;
if no statement was made to this effect it was assumed
that the interviews were not scheduled. A significant
difference was found when the cases were compared in
this manna-,1 In two-thirds of the intensive cases
interviews were held with the patient on a scheduled
basis. In all but one of the active cases interviews

were held on a non-scheduled basis.

 

 

2129 of Interview Active Intensive
Cases Cases
Scheduled 1 12
NonPScheduled l7 6
Total I3 I8

These findings support those found in a measurement of the
frequency of contacts. A higher number of non-scheduled
interviews would be anticipated where fewer contacts had
been.made.

The third factor, formulation of goals, could not
be measured directly. If the psycho-social diagnosis had
been used in practice over a long period of time this
could have been utilized to measure formulation of goals.
However, the psycho-social diagnosis is only beginning to
be used at this agency and consequently was not found

consistently in the cases. Two factors were used to

 

1Coefficient of contingency -.94.

38

indicate indirectly the formulation of goals: (1) source
of referral, and (2) planning or lack of planning in
termination of direct contacts with the patient. In
the active cases five-sixths or fifteen of the cases
were referred from."other” sources. This means that
hose cases were referred from non-professional staff
and in many instances were administrative referrals in
which_the case was not discussed with other hospital
personnel. No intensive cases were found in the ”other"
category. Seven, or almost half of the intenSive cases
were referred at a formal staff meeting. In all but
four intensive cases there was some communication with
professional hospital staff when the case was referred.
In four of the cases the referral came from the patient.
A significant difference was found when the cases were
compared on the basis of referral from.non~professiona1
or professional (including self-referrals).l The source
of the referral then would indicate that the intensive
cases were more often discussed with professional

hospital personnel when referred. 2

1Coefficient of contingency - 1.
2See Table 3 on p. 39.

TABLE 3
SOURCE OF REFERRAL FOR SOCIAL SERVICE

Active Intensive

 

Source of Referral

 

Cases Cases
Formal staff «0000000000 1 7
Self 0.0000000000000000. 0 4
500181 Semice 0900.009. 0 3
Worker 00000000000009... 0 3
DOOtOI‘ coeoooeoooeooeeoe 2 l
0ther*.................. 15 O

 

Total m 18

 

*

Includes administrative referrals and
referrals from departments other than Social
Service, Medical, or Psychology.

No significant differences were found when
termination planning was considered.1 Thirteen of the
intensive and ten of the active cases were found t.

have planned termination of direct contact with the

 

 

patient.
Type of Active Intensive
Termination Cases Cases
Planned lO 13
Not planned 8 5
Total 18 18

These findings may be in part due to the way this category
was defined. The presence or absence of planned termina-

tion was based on the presence or absence of social
planning with the patient. One of the responsibilities
of the Social Service department is to effect social

 

1Coefficient of contingency +.35.v’

4O

planning; consequently, most cases in which the patient
leaves the hospital the Social Service department would
record social planning and the case would therefore be
classified as planned termination.‘ The difference may

be found in the preparation of the patient for leaving
rather than in actual leaving. In relation to evaluating
formulation of goals, however, this is interesting. It

is indicative of conscious social work practice with

a difference between intensive and active perhaps found
more in the type of problem.and the methods used to evolve
goals. In both active and intensive cases goals are
formulated in working with the patient; however, there

is some indication that other professional hospital
personnel are utilized in formulating the goals in the
intensive case.

Focus of direct contacts with patient was indicated
by attempting to judge whether the focus was environmental
or personality. In both intensive and active cases the
focus was on personality. The findings indicated no

significant differences.1

Active Intensive

 

£3235 - Cases Cases

Personality ‘ ‘ 17 16

Environmental l 2
Total 18 18

 

1Coefficient of contingency +.36. «-

41

Since this factor was dependent largely upon a
subjective evaluation, a board of three was utilized to
give a judgment. The final determination was made by
selecting the category which was chosen by two of the
three judges. Total agreement was found in twentynone

of the thirty~six cases judged, with.more agreement in

 

the intensive cases than the active cases.1
Active Intensive
igéggggfig Cases Cases
Total agreement 6 15
Disagreement 12 3
'i'é" “is"

It is difficult to evaluate the factor being measured

in terms of the lack of consistency found in the
judgments. The findings indicate that the categories

of personality and environment may not have been sharply
enough defined in order to reach total agreement; however,
it may also indicate that in subjective evaluation percep-
tion is a highly important variable to be controlled.

The answers to these questions may be found in other
attempts to utilize the board judgment in evaluating

the two categories. It was felt, however, that the results
obtained were indicative of some consistency and were
consequently useful.

The findings are interesting in their implications.

 

lThe disagreement came largely from.the same
individual on the board.

42

They tend to support the belief that social casework is
a working with peeple around realistic problems on a
tangible level.. Even though a problem may be defined
in a tangible manner, such as arranging for a pass, the
help which is given is primarily concerned with the
individual in relation to the tangible service being‘
rendered. As in the case of goals no differentiation
can be made in terms of focus on personality.

The fifth factor, interdisciplinary coordination,
was not directly indicated due to limitations in the
recording. A good deal of communication is known to
take place between.members of the professional depart—
ments; however, due to the frequency and informality of
the contacts they are seldom recorded. The only source
of information which would be indicative of the depree
of coordination is found in the source of referral.1
As indicated previously the intensive cases were
characterized by more referrals from the hospital's
professional staff. This would provide some basis for
feeling that the other disciplines would be more apt to
define their respective roles in the intensive cases than
the active. In addition, seven intensive cases were
referred from.formal staff meetings which would require

a discussion of what discipline would take part in

 

Tgee Table 3, p. 39.

43

particular activities. In this sense there is some
evidence to support a higher degree of coordination
in the intensive cases.

The final factor to be considered is the amount
of emotional involvement by caseworker and patient.
The technioue used in the cas e was judged in an attempt
to get some indication of the degree of emotional involve-
ment. Four categories were used to classify the cases:
insight, support, clarification, and environmental manipu-
lation. All but one of the intensive cases were placed
in the insight or support categories. Five of the active
cases were placed in the insight or support categories.
Thirteen of the active and one of the intensive cases
were placed in the clarification or environmental
manipulation categories.

TABLE 4
TECHNIQUES USED IN WORKING WITH PATIENT

 

 

 

 

Active Intensive
Technique Cases Cases
InSight cocci-cocoa. l 6
Support coccccoococc 4 ll
Clarification ...... 6 0
Environmental
manipulation .... 7 l
TOtal 090000000. 18 18

 

The significant difference is that the intensive cases

more often used insight and supprrt while the active cases

44

more often used clarification and manipulation as
techniques.l Although most of the active cases were
classified as clarification or environmental manipula—
tion five of the active cases were found in the support
and insight categories. gnlv one of the active cases
was classified as insight, however. If we can assume
that these categories can be placed on a continuum.of
increasing involvement between the worker and patient,2
the findings would point toward intensive casework
having a higher degree of involvement.

As in the case of focus, this factor was largely
a subjective evaluation and was similarly Judged. Total
agreement was found in thirteen of the cases while
twenty-three of the cases were agreed upon by two of
the members of the board. These findings, as well as
those in the discussion of focus, would lead one to
wonder if the categories are meaningful. As in the
previous case, however, this method was utilized to
reduce subjectivity of interpretation without attempt-
ing to validate the concepts used. The variation
which was found in the active cases could be due to
this factor. If, however, the findings are interpreted

in the extremes and in relation to the findings regarding

 

1Coefficient of contingency -.96.'

 

O
‘insight, support, clarification, environmental
manipulation

45

structure, frequency of contact and source of referral,
the statement above referring to the higher degree of
emotional involvement would seem to be justified.

Some material was gathered which did not lend
itself directly to the casework process but rather to
characteristics of the patient. There was no significant
difference found between intensive and active cases when
time interval before first contact with the patient was
considered.1 In eleven of the intensive and fifteen of
the active cases interviews with the patient were held
within one month from time of admittance to the heapital.
In four of the intensive and three of the active oases
interviews were held after the patient had been in the
heapital six months.

TABLE 5

NIH-{BER OI" L'ZONTI‘S PATIENT WAS IN HOSP TAL
BEFORE INTERVIEW BY CASE’JJORKLR

 

 

 

 

 

 

Months Active Intensive
Cases Cases
L883 than 1* cocooo:ofi 15 11
1’3 000.000.00.000. 0 1
4‘6 ooocooooooaoooo 0 2
Over 6 .............. 3 4
Total 0.0000000. 18 18

 

*Included estimates of time interval as
indicated by date of dictation on intake history.

 

1A coefficient of contingency of +.52 was found
when the time interval is divided into less than 1 month
or more than l.month.

II

 

 

No difference was found when marital status of
the intensive and active cases was compared.
TABLE 6
MARITAL STATUS OF PATIENTS

 

 

 

marital Active Intensive
Status Cases Cases
Married 0000000000000 I 7 8
3111316 00000000000000 8 7
Divorced 000000000000 2 3
Separated ........... l O
TOtal 00000000 18 18

 

Eight of the active cases and one of the intensive
cases were found in the age group over forty.1 It appears
that the patients which are involved in intensive case-
work are a somewhat younger group than the patients
involved in active casework.2 It may be that the younger
patient is more able to utilize techniques such as
insight and support; however, the sample which is here
represented is not large enough to draw such an
inference.

The medical diagnosis of the patients in the
sample group did not provide any basis for distinction
between intensive and active cases. If a larger sample

had been utilized some distinctions might have become

 

1See Table 7 on p. 47.

2Coefficient of continbency -.86 when compared
on basis of under forty or over forty years of age.

47

evident. It was interesting to find that when cases

were divided into schiZOphrenic and other categories,

the intensive cases had more echiZOphrenic diagnosis

than the active. The difference,however, was not significant.1
TABLE 7

AGE OF PATITNTS

 

4

~ Active Intensive
Age Cases Cases

 

16-20 000000000000
21‘25 000000000000
26‘30 000000000000
31’35 000000000000
36-40 000000000000
41-45 000000000000
46‘50 000000000000
51-55 000000000000
56*60 000000000000
61’65 000000000000

Total 000000 1

“JFWJCbfiflvflOUMN(D
CDCWJCHDRDOKHuM»

 

GD
...:
CD

 

TABLE 8
EEDICAL DIAGNOSIS OF PATIENTS

     

Diagnosis Active Intensive

 

 

Cases Cases
SchizoPhrenic
Simple 000000000 1 O
Hebophrenic 0000 O l
Paran01d 0000000 5 7
Catatonia 000000 0 2
Unqualified .... 4 5
Brain Damage 0000000 4 1
Anxiety Reaction ... 0 l
Manic-Depressive ... l 1
Sexual DeViate 00000 1 O
Alcoholic Psychosis. ‘ l 0
Character Disorder.. 1 O
TOtal 00000000 18 18

 

1Coefficient of contingency -.60.

43

Summary
If a chart were drawn showing the major
differences between intensive and active cases it

would appear as.follows:

 

 

 

 

 

Factor .Acttve Intensive
Cases Cases
Contacts with‘ . Less than 1 1-5 per
patient . per week . week
Referral ' " Non-proffesional Proffession-
personnel al personnel
Scheduled " ' Non-scheduled Scheduled

Non - scheduled

 

Technique ' Clarification Insight
Environmental Support
manipulation

The factors which were listed at the beginning
of this chapter were in large part substantiated, with
exception of focus on personality. The hypothesis which
was utilized for the study implied that factors would be
evidenced which were common to both intensive and active
casework, but that they would distribute themselves
biemodally. Specifically, this would mean that if each
of the factors noted in the study were arranged on a
scale of increasing intensity a frequency distribution

would evolve which would be bi-modal in form. This

49

would also imply that intensive and active casework are
not separate and unique entities. The hypothesis was in
part borne out. In measuring the individual factors it
was found that each factor was found in both active and
intensive cases but some factors were found more
frequently in one type of case than in the other. This
could be related to the research design not being precise
enough in the definition of the categories, or it may be

indicative of a scale of relative intensity.

CHAPTER IV

CONCLUSIONS AND RLCOEHENDATIONS
Conclusions

In the cases which were used as a sample,
intensive casework is characterized by more frequent,
usually one to five per week, scheduled interviews. The
source of referral is usually professional hospital
personnel or the patient himself. Insight and support
tend to be the techniques used in workinb with the patient.

Active casework, as seen in the sample, is
characterized by less frequent, usually less than one
per month, interviews. The interviews are more often
held on a non—scheduled basis and the referral usually
comes from non—professional hospital personnel. The
techniques used in working with the patient are usually
clarification or environmental manipulation. Intensive
and active casework did not provide mutually exclusive
categories in terms of the factors which were considered
in the study.

One significant point was Lroubht out in the
study. It is evident that intensive casework is not
merely an increase in activity. It would seem to be

only an increase in activity when factors such as

51

frequency of interviews are considered. However, as
the technique used is examined a shifting is found.
If support and insight may be eguated with more emotional
involvement, a higher level of emotional involvement is
found in the intensive cases. It would be interesting
to know if the nature of the presenting problem changes
in the same manner. In other words, it seems that in
the intensive cases a different technique is used to
c0pe with the problems presented. This would involve
a differential diagnosis. Some of the factors which
were felt to characterize this differential diagnosis
were summarized in Chapter 1.1 Among them were:
(1) willingness of client to participate, (2) worker’s
interest in the case or feeling toward the patient,
(3) length of hospitalization, (4) Patient's capacity
to relate to the worker. It is notable that no mention
is made of the problems involved, but rather an emphasis
is placed on the patient's characteristics. This
would lead one to wonderaif the shift in technique is
a function of the problem or of the caseworker's
interest and need.

Although not conclusive, some evidence was found

to support a generic view of casework. Two factors,

 

1Chapter I, p. 9.

52

planning of termination of contacts with the patient
and focus of interviews (personality and environmental),
were found to be insignificant in distinguishing between
intensive and active casework. Since termination
planning is a function of the Social Service department
in this hospital, the absence of this factor would
reflect on the quality of the casework. With reference
to focus on personality it is recognized that tangible
problems which are presented to caseworkers are
dynamically related to the individual and would consequently
involve working with the individual and his need in
relation to the tangible problem. If a service, such
as arranging for transportation, were presented to the
patient, with.no involvement of the patient, the quality
of the casework service would be highly questionable.
These two factors, in all probability, represent a small
part.of the total generic area of casework. It is in
this area that studies of evaluation might be conducted.
Two goals for this study were indicated in the
first chapter: (1) to work toward construction of a
concept of intensive casework, and (2) to provide a
basis for further research of the casework process.
The first goal has been attained. Intensive casework
has been examined on an empirical level and some factors

have evolved which characterize intensive casework.

53

The limitations of this study, in part, provide for the
attainment of the second goal in that three fundamental
questions were raised.

The first of these is related to the characteristics
of the patients and workers who become involved in
intensive casework. Since this level of casework is
seemingly used in a differential manner, it would be
valuable to know more about the'basis for the decisions.
This study has, in part, defined the cases which can be
used for research of these characteristics.

0n the other side of the problem and in relation
to the other parts, an evaluation of this level of
casework is needed. As shown in the study, an investment
of time and energy is required for the practice of
intensive casework which is greater than that found in
active casework. It seems feasible to wonder if this
investment is warranted in terms of the results obtained.

The final question raised is an old one. How
does intensive casework differ from therapy in other
disciplines? The factors which were found to characterize
intensive casework align themselves closely with many
of the factors which are discussed in the literature as
characterizing therapy in other professions. Perhaps
there is no difference. It may be, however, that the

concepts which are being used for purposes of comparison

are fluid enoubh to prevent comparison. This factor

was mentioned in relation to the discussion of techniques
and particularly with reference to the board judgment.

It may be that what social work calls "insight" is quite
different from what is called insight by other professions,

and the same may be true for the other techniques mentioned.

Recommendations

The recommendations which evolve from a study
of this type are usually related to the need for further
research, and this study is no exception. The need for
further research falls into two major categories.

The first is the need for refinement of the
study. The classifications which were used could be
further broken down and more specifically defined.

There is a reasonable amount of evidence to make one
doubt the utility of using the case records in this
agency as the sourceibr data for a study of this type.
Perhaps the recording should be defined for research
purposes; however, the dangers of bias and skewing are
well known when this procedure is utilized.

The most prominent research need is for further
investigation of the techniques mentioned in this study.
It is not believed that these techniques should provide

for a casework classification system. It would seem

U1
\I'I

more appropriate to define levels of casework, using
particular techniques, than to have the technique
define the level of casework.

The second need is for this study and approach
to be applied in different settings and with different
groups of cases to pet some indication of reliability.
Until this is done, few generalizations may be drawn
from the study. This is directly related to one of
the outstanding problems in social work, namely, the
difficulty and confusion found in attempts to provide
a basis for effective recording. Until such time as
concepts can be used which will be meaningful and
relatively conclusive, social work recording will
continue to be an unorganized description of events.
Concepts which reduce the need for bulk descriptive
recording would be helpful.

Intensive casework may be used as a term to
describe a level of casework possessing characteristics
which tend to differentiate it substantially from
generic casework. The findings of this study need
further evaluation but lend support to intensive

casework as a meaningful concept.

APPEImIX

57

EFL“ ND IX A

This was a survey of thirty-one Veterans
Administration neurOpsychiatric hospitals. The hospitals
constitued the total pepulation of Veterans Hospitals
devoted to neurOpsychiatric disorders. A letter was
sent (see Appendix D) to the Chief of Social Service
of each hospital asking for the staff's cooperation in
answering two questions: -

(1) Do the individual workers make an informal,
non-administrative separation of some cases into those
in which they engage in intensive casework and those in
which they are actively working but no on an intensive
basis; and (2) what are some of the factors which the
workers feel characterize the practice of intensive
casework?

Twenty-three responses were received from the
hOSpitals. Two of the responses were incomplete, that
is, they did not answer the questions, leaving twenty—
one meaningful reports. The response to question one
broke down as follows:

Used the differentiation ..............16

Did not use the differentiation ........5
The re3ponses to question two are noted in appendices

Band E.

APPENDIX B

Factors Considered in Selection of Cases
for Intensive Casework as Reported by
Social Workers in VAH NeurOpsychiatric

 

 

 

 

 

 

 

Hospitals
Frequency of

Factor Noted Notation*
Willingness of patient 4

to participate
Age 2
Length of hospitalization 3'
Past adjustment 3
Worker's interest 1

in patient
Patient's capacity to 6

relate

 

 

*Frequency of factor being listed in response

from.hospitals.
Source: See Appendix A.

APPENDIX C

SCHEDULE FOR THE STUDY 0? FACTORS CHARACTERIZING INTENSIVE

2.

3.

4.

5.

6.

7.
8.

9.

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Code No.

MEDICAL DIAGNOSIS

 

AGE MARITAL STATUS: single divorced
widowed separated

AT THE TIEE F CONTACT EATIENT HAD BEEN IN IOSEITAL:
years months days

REFERRAL CAME FROM: formal staff meeti request
from patient social service staff doctor

other hospitEI personnel

AVERAGE FREQUENCY OF CONTACTS PER SIX MONTH PERIOD:
Direct with patient
Direct with relatives

 

PRIMARY FOCUS 0F DIRECT CONTACTS WITH PATIENT WAS:

EIWIROIEJENTAL
(finances, arranging weekend pass,eto.)

PERSONALITY
IanXIety feelinbs, delusions, sexuaIEEBFIem)-

INTERVIEWS WERE ON: Scheduled basis non-scheduled

TERLINATION “F DIRECT CONTACT WITH PATIENT WAS:

Planned with patient

Unplanned (patient leaving hospital abruptly,
not returning for interview, etc.)

PRIMARY METHOD USE DUE NG CONTACTS ON CASE:

Insight

Support

Clarification

Environment Manipulation

APPER'IX D
February 14, 1956

To: Chief of Social Service
Veterans Administration Hospital

Subject: Study of Factors Characterizing Intensive
Casework

I am a second year graduate Social Work student
attending Michigan State University and doing my field
work at the Battle Creek Veterans Administration Hospital.
As partial fulfillment of the requirements for a Master
of Social Work degree I am conducting a study of the
factors characterizing intensive casework.

I would appreciate you and your staff's cooperation
in answering two questions which I plan on incorporating
in the thesis:

(1) Do the individual workers make an informal
non-administrative separation of some cases
into those in which they engage in intensive
casework and those in which they are actively
working but not on an intensive basis?

(2) What are some of the factors which the workers
feel characterize the practice of intensive
casework?

Intensive casework at this hospital seems to be
thought of in terms of more frequent contacts between
patient and worker, scheduled interviews, focus on
personality adjustment, etc.

In that this project is to be completed early in
March, I would appreciate your response before March 7,
1956. Your c00peration will be highly appreciated and
any additional comments you wish to make will be welcomed.
Thank you.

Sincerely,

61

APPENDIX E

FACTORS CHARACTERIZING INTENSIVE CASEWORK AS
REPORTED BY SOCIAL WORKERS IN VAH
NEUROPSYCHIATRIC HOSPITALS

 

 

 

 

 

 

 

, Frequency of
Factor Noted Notation*
Interviews continuing 6

overtime

Scheduled interviews 9

Content of interviews 11
focused on personality

Formulation of goals 9
Staffing of cases 3
Collaboration with 5

other disciplines
Frequency of interviews 3

 

*Frequency of factor being listed in
response from the hospitals.
Source: See Appendix A.

62

APPENDIX F

INTERPRETATICIS OF INTQNS E CASEWORK BY THREE
BATTLE CREEK VETERANS ADMINISTRATION HOSPITAL
SOCIAL SERVICE CASEWOFCERS
A

This method of casework, first of all, pre-
supposes a knowledge of human dynamics, personality
structure and complete diagnosis of the person and/or
problems being treated. Intensive casework has as its
main focus a change in personality and/or attitude
(the inner man) so as to enable him to react with his
environment in a more satisfying manner.

A complete diagnosis is particularly important.
since it is impossible to treat and/or change a personality
unless one knows what to treat. Through a knowledge of
human dynamics the object relationship and the diagnosis
can be established. The techniques used in this form
of treatment involve use of transference in the relation-
ship, use of ego strength, modifying inappropriate ego
defenses, strengthening approPriate defenses, limited
interpretation of unconscious material, handling
external dangers which generate anxiety and weaken the
ego, and re-education.

Some examples of the foregoing statements may be
helpful, particularly with regard to limited interpretation.
This calls for a thorough understanding of the ego.

63

Certainly dynamic interpretation as used in "insight"

or "deep psychotherapy" would be inappropriate with a
person with a crumbling, weak ego structure. Conversely,
a person deeply concerned with his ordinarily unconscious
strivings does not need to have them.reemphasized-—a
kind of wading through the id. In intensive casework

I often find it appropriate to strengthen apprOpriate
ego defenses. I am.reminded of a schiZOphrenic who
experienced a psychotic break almost immediately after
marriage. Study revealed that the break was definitely
related to the marriage and the patient'e inability

to tolerate a.marital relationship. When he develOped
the rationalization that he would not get married again
until he had.purchased and elaborately furnished their
own home, owned an eXpensive automobile, and had a

high paying job, I supported this rationalization. I
knew first,another marriage would precipitate another
break and I know too that there was little likelihood
that he would acquire all the wealth prerequisite to
another marriage.

Sometimes it is necessary to modify existing
attitudes and patterns of behavior. This is done simply
by minutely examining existing attitudes and reviewing
frustrations because of attempted ways of handling one's
problems. Many times honest persuasion to try another-
method is sufficiently gratifying after trial to induce

64

different approaches to a hitherto very vexing problem.

I am.often impressed.with the frequent incident
of simple request for information. Clarification of
these requests clearly points to a body of mis-information
harbored by the patient. It is not improbably that one
will encounter transference in this area. The mis-
information has often been imparted by a well meaning
parent or parent surrogate. Re—education in these
instances of necessity and definition brings into play
the transference phenomenon.

In intensive casework the idea of contact,
both with regards to incident and duration comes up.
This is probably purely academic. I have found that
a great deal can transpire to change an attitude or
pattern of behavior in a relatively short time or even
in one contact. One cannot measure the intensity of
feeling or the amount of movement solely with the
yardstick of time. I must say, however, that a planned
approach to inherent problems and planned contact is
vital to the relationship, the medium through which

intensive casework goals are realized.

6 5 |

B

Intensive casework is that form of direct
social work with clients where there is acme form of
conscious focus and structural purpose in offering
this therapeutic service.

This process is carried on through a series
of regular scheduled interviews held by the caseworker
where the primary focus is emotional and personality
adjustment. Intensive casework takes place in a
dynamic caseworker-client relationship with both
having considerable emotional investment which is
controlled and used by the worker.

PsychOIOgical support, understanding,
clarification, etc.,.are used in dealing with the
client's problems. The client is guided to participate
to his fullest capacity in helping to understand and
modify his behavior.

66

C

In a broad concept casework is the giving of
practical service to an individual in relationship to
the existing social or emotional problem for which he
is asking help. These problems, to a varying degree,
are psychosocial. Some individuals are capable of
rec0gnizing feeling, or sensing themselves as an
integral part of the existing problem.

With time, motivation, and professional
assistance, these persons may achieve solution or
resolution of the existing difficulty. In a professional
social work relationship these individuals are candidates
for intensive casework treatment.

Other individuals, and perhaps the vast majority,
are able to accept and utilize social work services
only to a limited degree. They may have the inability
to see themselves as a part of the problem, and a
considerable need to externalize the existing difficulty.
Because of emotional or physical damage an individual
may be unable to use an intensive approach to the
difficulty. Motivation_may be lacking, time insufficient
or other factors may enter to indicate that only
limited goals or a manipulation of the environment
are practical. In this broad sense these cases can

be construed as active social work cases.

BIBLIOGRAPHY

CW
(.30

BIBLIOGRAPHY

Aptekar, Herbert H. Basic Concepts in Social Casework.
Chapel Hill: University of”North Carolina Press,
1941.

Aptekar, Herbert H. The Dynamics of Casework and
Counselin . New York: Boughton m1 ifflin Company,
Igbgo

Fink, Arthur E. The Field of Social Work. New York:
Henry Holt and Company,‘1952.

French, David G.
Social Work.

 

Hamilton, Gordon. Theor and Practice of Social Casework.
2d ed. revised. ew York: Columbia University
Press, 1951.

Reichenbach, Hans. The Rise of Scientific Philosophy.
Berkeley: University of—California Press,_I951.

 

Sanderson, Herbert. Basic Concentsi nVocational
Guidance. New or : thraw- 00 Company,
1954.

Articles

 

Bi es tok, Felix P. "An Analysis of the Casework
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Blenker, Margaret, Hunt, J. Mb V., Krogan, Leonard S.
"A Study of Interrelated Factors in the Initial
Interview with New Clients," Research Prorrams
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Coleman, Jules V. "Psychotherapy and Casework,"
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, I
a
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I
c,
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o

e3

Freudenthal, Kurt. ”Need for Research in the Area of
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Hollis, Florence. "The Techniques of Casework," Social ,
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Kaplan, Alex H. "Psychiatric Syndromes and the Practice
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Levy, Dorothy. “A Follow-up Study of Unmarried.Mothers,"
Social Casework, January, 1955.

Marmor, Judd. "Indications for Psychiatric Therapy or
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fiurray, Clyde E. "Social Work as a Profession,“ Social
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Rauley, Callman. “A Sampling of Expert Opinion on Some
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1954.

Bing, Morton.B. Jr. "Some Comments on Concepts," Social
Forces, October, 1955.

Ripple, Lillian, and Alexander, Ernestine. "Motivation,
Capacity, and Opportunity as Related to the Use of
Casework Service: Nature of Client's Problem,"
Social Service Review, March, 1956.

Schmidl, Fritz. "A Study of Techniques Used in Supportive
Treatment," Social Casework, December, 1951.

Social Work Yearbook Staff. "Research in Social Work,“
Social Work Yearbook 1954, Edited by Russell A. Kurtz.

 

 

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