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The interpretation of stress in relation to families of hospitalised mental patients : an exploratory… Sharpe, Francis Noel Brian 1963

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THE INTERPRETATION OF STRESS IN RELATION  TO FAMILIES OF,HOSPITALISED MENTAL PATIENTS An Exploratory Analysis of a Sample of Mentally 111 Patients and Their Closest Relatives Crease C l i n i c , Vancouver, 1962-63 by FRANCIS NOEL BRIAN SHARPE Thesis Submitted i n P a r t i a l Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK . i n the School of S o c i a l Work Accepted as conforming to the standard required for the degree of Master of S o c i a l Work School of S o c i a l Work 1963 The University of B r i t i s h Columbia In presenting this thesis in p a r t i a l fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make.it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department o f ^ U W oj k§c*/k The University of British Columbia, Vancouver 8, Canada.. Date /p^MGIA^, / " f eS  > ABSTRACT The complexities of man's current s o c i a l universe permit l i t t l e opportunity for him to function i n a s o c i a l environment that i s undergoing constant change, without experiencing stress. Those who are unable to adapt or adjust to the stresses of modern l i v i n g f a l l prey to the ravages of mental i l l n e s s . Changing pro-fe s s i o n a l perspectives and the research of s o c i a l s c i e n t i s t s , are re-awakening professional eyes to the si g n i f i c a n c e of the patient i n r e l a t i o n to his s o c i a l environment. The experience of mental i l l n e s s and a l l i t ' s ramifications are also the experience of those who shared i n a re c i p r o c a l role relationship to .the patient. I s o l a t i o n - the remedy of old - today i s a l o s t cause. For s o c i a l work, current theories of s o c i a l dynamics promise to add a new dimension, by which to understand the s o c i a l structure of the mentally i l l person and those who in t e r a c t with him. The new theory requires inspection and testing. This thesis i s an attempt to examine some of the c l i n i c a l applications of a theory that might well have great consequences for s o c i a l casework. S o c i a l role theory i s reviewed as background, and the concepts of role and stress are explored i n r e l a t i o n to the family, when one of i t ' s members becomes mentally i l l and requires h o s p i t a l i s a t i o n . To examine c l i n i c a l l y the effects of h o s p i t a l i -sation on family and patient, using role concepts, a small group of families was selected and studied. Structured interviews were used to e l i c i t both descriptive d e t a i l s and feelings about the family, as well as the meaning and e f f e c t of h o s p i t a l i s a t i o n . The sample group was drawn from both female and male sections of the Crease € l i n i c of Psychological Medicine; and, where possible, both the patient and a reci p r o c a l (close r e l a t i v e ) were i n t e r -viewed. The questions were directed p a r t i c u l a r l y . t o roles and relationships before and a f t e r admission. The study reveals that patients and t h e i r reciprocals experienced stress i n two phases: (a) when the patient i s mentally i l l , but l i v i n g at home and (b) when,the patient has been hospi-t a l i s e d . In the former, stress centres around changes i n per-ception and performance i n an e f f o r t to continue functioning, i n spite of the maladaptive roles of the mentally i l l family member. In the l a t t e r , stress centres around the absence of the family member, whose absence displaces role and relationships upon which the s o c i a l structure of the f a n i l y network i s highly dependent. The study also reveals that h o s p i t a l i s a t i o n i s r e l i e v i n g for both patient and rec i p r o c a l s , and i n some cases leads to the resump-ti o n of ce r t a i n roles discarded during the presence of the mentally i l l member at home. A K N Q W L E D G E M E N T S I wish to express my thanks and appreciation to those whose assistance and support made thi s thesis possible. I par-t i c u l a r l y acknowledge with thanks the en-couragement and help of Dr. Charles W. Mc Cann, and Dr. Leonard C. Marsh both of the School of S o c i a l Work, University of B r i -t i s h Columbia. To Mr. Robert McGregor Ross, Supervisor of Crease C l i n i c S o c i a l Service Department, my sincere thanks are due for his help and in t e r e s t during the research. TABLE OF CONTENTS Chapter I Role Concepts Relevant to S o c i a l Work Page The Problem:- General and S p e c i f i c . S o c i a l Work and Role Theory. The Concepts of S o c i a l Role, Range, Role Perception, Interrelatedness of Roles, Role Network, Reciprocity, Role Performance Modification. The Concepts of Stress, Stress Factors, Value Threatened,.Reaction to Stress. The S o c i a l Environment - The Total S i t u a t i o n . Significance of the Study for S o c i a l Work. Scope, Hypotheses, Setting 1 Chapter II Methodology Applied to the Cases • The Interview. The Interview Format. Sampling and Selection C r i t e r i a . The Study Method. Limitations of the Study. Recording 25 Chapter III Role and Stress: P r i o r to and During H o s p i t a l i s a t i o n Roles P r i o r to Ho s p i t a l i s a t i o n ; Married Woman with Children, In the Home, S o c i a l l y ; Married Man with Children, In the Home; Children, In the Home. Problems of H o s p i t a l i -sation; E f f e c t s on Role.Performance,. Adaptations, Patient Perception. Attitudes in.Relation to Reciprocals' Role Performance at Home, S o c i a l l y . Leaving the Family - Dis-placement. The Patient and the Hospital; Adjustments .to the C l i n i c . The Reciprocal and the Hospital Regime. Patients, Relatives, Friends 43 Chapter IV C l i n i c a l Application of Role and Stress Role as a Determinant of Stress, Patient and Reciprocal. Reformulation of Hypotheses. Measurement of Stress. Areas for Further Study , 87 Appendices Appendix A i I n i t i a l Interview Format Model 108 Appendix A2 Interview Format for Interviews with Patients and Reciprocals... 110 Appendix B Verbatim Responses of Patients and Reciprocals , 115 Appendix C Sample Medical Record (Ward Notes) 162 Appendix D Bibliography 173 Chart I Chart II CHARTS Case Information. Stress*., Continuum 43A 100A THE INTERPRETATION OF STRESS IN RELATION TO FAMILIES" OF HOSPITALISED MENTAL .-PATIENTS CHAPTER I - ROLE CONCEPTS RELEVANT TO SOCIAL WORK The Problem - General " The s o c i o - c u l t u r a l revolution that characterises our time has spurred mistrust and fear among the nations, altered the face of family l i f e , and unsettled estab-l i s h e d patterns of i n d i v i d u a l , family, and community. No piece of earth, no person, no community i s immune. Human beings and human relations have been plunged i n t o a state of turbulence, -while the machine surges f a r ahead of man's wisdom concerning himself. The shrinking of space and the cramped intimacy of people ^ l i v i n g i n clashing cultures c a l l s for new understanding, a new v i s i o n of the relations of man to man and man to society." 1 Ackerman's statement of contemporary world c r i s i s , i s one of many appearing more frequently i n s o c i a l s c i e n t i f i c l i t e r a -ture. Terms and phrases such as 'anomie', 'affluent society', 'the organisation man', 'mass society', 'the decline of the west', are becoming a l l too. f a m i l i a r . They give expression to the i n t r i c a t e complexities of mid-century l i f e and problems. Even the issues of present day mental health r e f l e c t the turbulence of the kind of society of which we are a part. Mental i l l n e s s i s no longer the concern of the sick i n d i v i d u a l , but involves the entire structure of the community, immunity from the problems of mental i l l n e s s i s an unreality. The human devastation of mental i l l n e s s and i t ' s i n c a l c u l a b l e damage to family l i f e and the welfare of the community, have i n recent years stimulated public i n t e r e s t i n the urgency of the problem. This i n t e r e s t has been expressed i n allotments of public moeny for research and t r a i n i n g i n the f i e l d of mental health. Because of the frequency of mental i l l n e s s , the s o c i e t a l 1 Ackerman, Nathan W. (M.D.) The Psychodynamics of Family L i f e Basic Books Inc. New York, 1958, ..Page 3 . " - 2 -attitude towards i t has changed, d e f i n i t i o n s have changed, and the f perception and treatment of mentally i l l persons have changed. Today we are s t r i v i n g away from the approach of considering what goes on p s y c h i c a l l y within one person, and moving i n the d i r e c t i o n of considering what happens between a person and his environment and what i s distorted i n the s o c i a l processes of that environment. This new d i r e c t i o n i s expressed i n the writings of Reusch who says "Today we conceive of the i n d i v i d u a l as a l i v i n g organism whose s o c i a l relations are combined in t o a complex orga-n i s a t i o n , whose inner world of experience i s c l o s e l y related to his s o c i a l operations, and whose soma mater-i a l l y makes possible his various a c t i v i t i e s . " 1 This thesis i s a part of that general trend i n mental health to move into that r e a l i t y which serves to see the mentally i l l patient, h i s c o n f l i c t s , problems and dynamic way ofy l i f e as an integer of his s o c i a l environment and his i n t e r a c t i o n with the components of that s o c i a l environment of which he remains a part. The Problem - S p e c i f i c This thesis i s an exploratory attempt to investigate and analyse the s o c i a l e f f e c ts of the h o s p i t a l i s a t i o n of mentally i l l persons, using the concept of stress as a t h e o r e t i c a l frame of reference. I t w i l l s p e c i f i c a l l y examine the ways i n which the character and qu a l i t y of family roles and relationships are affected by the i l l n e s s and h o s p i t a l i s a t i o n of a member of a family. I t attempts i n a broad perspective to integrate two highly relevant p r i n c i p l e s arousing considerable thought i n the f i e l d s of s o c i a l 1 Reusch, Jurgen Toward^ a Unified Theory of Human Behaviour ed. Grinker, Roy R. Basic Books, New York, 1956, page x i . - 3 -work, psychology and psychiatry - the renewed p r i n c i p l e s of family, and the new s o c i a l role theory. This together with the s t r a t e g i c importance of mental i l l n e s s i n western society established p r i m a r i l y the relevance of the study. The pattern of s o c i a l relationships within any one family i s a dynamic one, and the subtle changes may be continually occurring, e s p e c i a l l y i n what may be described as the emotional toning of relationships. However, i n order to study more r e a l i s t i -c a l l y the e ffects of i l l n e s s and h o s p i t a l i s a t i o n on a family i t i s necessary to examine data from a s t a t i c viewpoint i n time. Such an abstraction often obscures the dynamic q u a l i t y of family re-l a t i o n s h i p s , and i t i s the b e l i e f of the writer that the very content and q u a l i t y of s o c i a l r o l e theory offers a s t r u c t u r a l framework which gives expression to the dynamic aspects of re-l a t i o n s h i p . Rose i n a study of r e l a t i v e s * attitudes and mental h o s p i t a l i s a t i o n makes s p e c i a l note of the scant consideration i n l i t e r a t u r e given to the attitudes of r e l a t i v e s , he states: "Observations by those who work with r e l a t i v e s of patients have increasingly suggested that these attitudes may be a factor i n maintaining the i l l n e s s and prolonging the h o s p i t a l i s a t i o n . When a p s y c h i a t r i c patient i s hospita-l i s e d , h i s r e l a t i v e s develope d i s t i n c t attitudes towards the i l l n e s s and the h o s p i t a l . " 1 I t was the problem of these attitudes which led to the study undertaken by Rose who postulated that .... 1 Rose, Charles L. "Relatives' Attitudes and Mental H o s p i t a l i -sation" Mental Hygiene. A p r i l 1959, Volume 43, No. 2, Page 194. "The removal of the i l l member through h o s p i t a l i s a t i o n brings about further attitude changes d i s t i n c t from those which were apparent when the i l l member resided at home.11 1 He studied the attitude of r e l a t i v e s that were associated with prolonged h o s p i t a l i s a t i o n , and his analysis points to the fact that there were very d i s t i n c t attitudes i n r e l a t i o n to hospita-l i s a t i o n . This thesis i s equally concerned with r e l a t i v e s , more s p e c i f i c a l l y family members' attitudes towards h o s p i t a l i s a t i o n . A question that frequently emerges as to how well we are applying the current theories of s o c i a l role and relationships to mental patients i n mental h o s p i t a l s , or whether we are s t i l l thinking i n the old terms of the i n d i v i d u a l i n i s o l a t i o n . As Murphy and C o t t e l l have said: "When c l i n i c a l psychiatry appeared as an e n t i t y , i n the hands of Emil Kraepelin; the disease was i n s i d e the patient, j u s t as an ulcer or a tumor was i n s i d e him; ... with Freud the phenomena of transference began to make embarrassingly c l e a r that two persons were involved i n every symptom and i n every step towards cure, the analyst serving as temporary surrogate for the persons who were or are the physosocial r e a l i t y of the patient; and with S u l l i v a n the conception of a disease i n s i d e the person, carried around by him i n t a c t from one s i t u a t i o n to another was frankly abandoned, with a c l e a r recog-n i t i o n that a l l we r e a l l y see and deal with i s a career l i n e of interactions between i n d i v i d u a l s ; and .... i f this be so, i t i s the r e l a t i o n s h i p s , not the i n d i v i d u a l s that become our concern." 2 1 Ibid. Page 195. 2 Murphy, Gardiner and C o t t e l l , Elizabeth The Contributions  of Harry Stack S u l l i v a n , ed. Mullahy, Patrick, Hermitage House, New York, 1952, Page 162. - 5 -This thesis i s one of many attempts to f i n d a way of applying s o c i a l r ole theory to mental patients and t h e i r effected family, and move away from the rather l i m i t e d and conservative approach of thinking i n terms of the i n d i v i d u a l i n i s o l a t i o n . None of us l i v e s h i s l i f e alone, not even the patient. Upon admission the patient enters a new and unfamiliar world. How does the mental h o s p i t a l environment d i f f e r from the home environment? I t i s evident that no matter how well organised the h o s p i t a l may be, the environment i s an abnormal one compared to that which the patient i s f a m i l i a r . The f i r s t thing that happens to a patient i s that he loses temporarily his l i b e r t y , he sees barred windows, and his personal sentimental emotionally valued objects are taken away. Though these may be eventually restored, the i n i t i a l impact i s great. The patient cannot immediately structure the h o s p i t a l environment. There i s a loss of i d e n t i t y , and the patient becomes as often do his r e l a t i v e s , where t h e i r contributions i s minimised i n the treatment of mentally i l l patients, one of many. Kaplan and Wolf observe that "There i s from the beginning, a loss of i d e n t i t y ; our patient becomes one of many." 1 and i n t h e i r study of "The Role of the Family" i n r e l a t i o n " t o h o s p i t a l i s a t i o n f i n d that there i s "a d i r e c t relationship between the patient's acceptance .of or resistance to loss of i d e n t i t y and h i s reaction to his family." 2 1 Kaplan, Arthur and Wolf, Lois "The Role of the Family i n Relationship to the I n s t i t u t i o n a l i s a t i o n of Mental Patients" Mental Hygiene, October 1954, Volume XXXVIII, No. 4., Page 637 2 Ibid. Page 637 The inference i s quite c l e a r , h o s p i t a l i s a t i o n e f f e c t s the patient and the family. This thesis i s pr i m a r i l y concerned with this problem. In a paper by Bentner and Brauch they a f f i r m the current view that r e l a t i v e s are c r u c i a l to the patient's i l l n e s s and t r e a t -ment. They also observe that scant attention has been afforded the question of r e l a t i v e s i n l i t e r a t u r e . "Whether one enjoys facing i t or not, the problem i s there and i t i s more than a question of public relations or personal discomfiture. I t i s a demonstrable f a c t , a problem c r u c i a l to the patients' i l l n e s s and to the treatment of i t . And while the l i t e r a t u r e has accorded i t t h i s recognition, i t also has afforded i t scant discussion." 1 Other reports have emphasised the importance of the family's attitude, for theraupeutic as well as for administrative reasons. For instance Kaplan and Wolf2 see the family as the patients sole remaining l i n k with the outside world - and one which must be studied i f the patient i s to be helped to return to that world. There appears to be l i t t l e doubt that the co-operation of family and r e l a t i v e s i s fundamental i n working with patients, as there i s l i t t l e doubt that h o s p i t a l i s a t i o n poses problems - stress for the patient and his family. Improvement and deterioration i n a patient's condition often seems to hinge d i r e c t l y on relationships with family and r e l a t i v e s , t h e i r attitudes towards i l l n e s s and h o s p i t a l i s a t i o n , the changes and adjustments that are made by the patient and h i s family, and f i n a l l y the stress which they a l l experience i n many areas of functioning as a r e s u l t of h o s p i t a l i s a t i o n . 1 Bentner K a r l R. (M.D.) and Brauch, Russell, "The P s y c h i a t r i s t and the. Patient's Relatives", The Ps y c h i a t r i c Quarterly, January 1959, Volume 33, No. 1, Page 1. 2 Ibid. Pager 636, Kaplan, Arthur and Wolf, Loi s . S o c i a l Work and Role Theory In recent years the development of a body of knowledge within the f i e l d of s o c i a l work, promises to open up a new chapter of p r a c t i c e and understanding for the professional s o c i a l worker, engaged i n s o c i a l casework at mental hospitals. The s o c i a l worker i n mental hospitals has for some time been pr i m a r i l y concerned with the family of mentally i l l patients. Today he i s s t i l l concerned, and the new knowledge promises to make him more concerned i n the ., future. Like most new knowledge i t comes i n a highly abstract and t h e o r e t i c a l form, and i t ' s eventual integration w i l l depend on i t ' s a p p l i c a t i o n and usefulness i n pr a c t i c e , i n i t i a l l y deter-mined through s o c i a l research. In i t ' s present form the theory i s better known as 'Social Role Theory'. I t remains generally untested and therefore of li m i t e d p r a c t i c a l value, however many s o c i a l workers have attempted to apply aspects of the theory and indicate that i t has proven useful i n s o c i a l diagnosis, and found to be an aid to casework. Vesper 1. makes use of role theory i n her treatment of marital c o n f l i c t which she interprets as "marital role reversal". S i m i l a r l y McCoy 2 translates aspects of role theory i n r e l a t i o n to the problems of foster parenthood, and provides a useful d e f i n i t i o n of the role of foster parent. 1 Vesper, Sue "Casework Aimed at Supporting M a r i t a l Role Reversal". S o c i a l Casework June 1962, Volume XLIII, No. 6,. 2 McCoy, Jacqueline "The Application of the Role Concept to Foster Parenthood", Social.Casework May 1962, Volume XLIII, No. 5. - 8 -McCann i n h i s t r e a t i s e on s o c i a l role theory and profess-io n a l r e s p o n s i b i l i t y deals very e x p l i c i t l y with the question of s o c i a l work and s o c i a l role theory. "Our i n t e r e s t i n new t h e o r e t i c a l formulations i s fostered by our professional- orientation which i s both s c i e n t i f i -c a l l y and-philosophically rooted. Our professional aspirations c l e a r l y i n d i c a t e , however, that we have a d e f i n i t e r e s p o n s i b i l i t y to examine new theories c r i t i -c a l l y i n the hope that they might strengthen any work and f a c i l i t a t e the r e a l i s a t i o n of our goals." 1 S o c i a l role theory extends a new and " r e v i t a l i s i n g modus opporandi, for s o c i a l caseworkers, i t establishes a t h e o r e t i c a l apparatus which i s s o c i a l l y oriented and makes i t possible to move away from the l i m i t i n g procedure of personal diagnosis. I t provides a framework for studying the dynamic patterns of social"stimu-l a t i o n and response, and the dynamic structure and q u a l i t y of an i n d i v i d u a l and his s o c i a l environment. Sabin says of role theory " Role theory attempts to conceptualise complex behaviour .at a high l e v e l of abstraction. The theory attempts to show the i n t e r a c t i o n between the i n d i v i d u a l and his environment by l i n k i n g psychological, s o c i a l and c u l t u r a l phenomenon. Role theory encompasses concepts of"the i n t e r n a l organisation of the i n d i v i d u a l , his needs, his responses, and his aspirations. I t also encompasses the environmental forces that a f f e c t his behaviour. According to the theory the person i s acted upon by the environment and at the same time i s changing the environment." 2 In a sense role theory i s not that new to s o c i a l work, for s o c i a l workers, have been constantly involved with the problem of the i n d i v i d u a l and his environment, ph y s i c a l and s o c i a l . 1 McCann, Charles W. "Social Role Theory and Professional Responsibility", The S o c i a l Worker, June 1961, Volume 29, No.3, p.16. 2 Sabin Theodore R. "Role Theory" Handbook of S o c i a l Psychology  Volume I Theory and Method Gardiner, Lindzey, Ed. Addison.Wesley Publishing Co. Inc. Caimbridge Mass. 1954, Page 225. - 9 -Inadvertantly or not they work i n p r a c t i c a l l y every problem solving s i t u a t i o n , with a person's rel a t i o n s h i p s , his roles and his r e c i -procals d i r e c t l y or i n d i r e c t l y . However, the approach has been determined by the influences of psycho-analytic theory, which misses much that i s t r u l y s o c i a l . Bowers, sensi t i v e to the impact of s o c i a l role theory on s o c i a l work writes "There i s a change coming about i n s o c i a l work, a good and healthy change, a going back to s o c i a l work's o r i -g i n a l emphasis on the family and on the c r u c i a l s o c i a l roles that ex i s t within this primary group and primary environment." 1 The primary group refers to the i n d i v i d u a l and h i s family. The work of the curriculum study gives p a r t i c u l a r prominence to s o c i a l role theory, and i t ' s s i g n i f i c a n c e for s o c i a l work, since the goal of s o c i a l work i s considered to enhance s o c i a l functioning where-ever the need for such enhancement i s either s o c i a l l y or i n d i v i d u -a l l y perceived. The content of s o c i a l role theory i s perhaps more than s u f f i c i e n t l y summarised i n the d e f i n i t i o n of s o c i a l casework as reported by Boehm. "Social casework can be defined as a method of s o c i a l - work which intervenes i n the physo-social aspects of a person's l i f e to improve, restore, maintain, enhance his s o c i a l functioning by improving his r o l e performance. Interaction occurs when the person, or members of his group or h i s community, r e a l i s e that his r o l e performance i s hampered or threatened. The intervention takes place through a professional relationship between the worker and other in d i v i d u a l s whose i n t e r a c t i o n with the person affects his role performance. Since s o c i a l functioning i s the product of i n t e r a c t i o n among intrapsychic, somatic and s o c i a l factors, s o c i a l caseworkers involves assessing the i n t e r n a l and s o c i a l forces which impair or threaten the person's role performance and helping him to f i n d 1 Bowers, Swithern, "The Future of S o c i a l Work", The S o c i a l  Worker, January 1960, Page 36. - 10 -"and use the somatic, psychic and s o c i a l resources at his disposal to eliminate or reduce malfunction and to enhance functioning i n s o c i a l roles. " 1 Boehm defines s o c i a l functioning as " the sum of the individ u a l s a c t i v i t i e s i n i n t e r a c t i o n with other in d i v i d u a l s and situations i n the environ-ment. " 2 The Conceptual Framework One of the important concepts e x p l i c i t i n s o c i a l role theory i s the concept of stress. T h e o r e t i c a l l y i t has been found useful i n examining and understanding more f u l l y the nature of ce r t a i n types of c o n f l i c t where this concept i s the outcome of role i n t e r a c t i o n s , perceptions and performance. Because the concept of stress i s so i n t e r r e l a t e d with the concepts of r o l e , l e t us deal with the question of role. The Concept of S o c i a l Role The concept of s o c i a l role i s derived mainly from the f i e l d s of s o c i a l psychology, sociology and s o c i a l anthropology, where considerable attention has been given to ro l e i n the function-a l analysis of pr i m i t i v e s o c i e t i e s . For the purposes of th i s study the concept of role i s used to describe i n d i v i d u a l behaviour as determined by the i n t e r a c t i o n of the i n d i v i d u a l (somatic and psychological) and s o c i a l factors. The concept i s a dynamic one i n the sense that change i n one of the factors produces change i n other factors. S o c i a l 1 Boehm, Werner W. "The S o c i a l Casework Method i n S o c i a l Work Education", Council on S o c i a l Work Education Volume X, New York 1959, Page 44 - 45. 2 Ibid. Page 94. - 11 -roles are a c t i v i t i e s and tasks which an i n d i v i d u a l i s expected to perform and are patterned and prescribed by s o c i a l norms such as custom, t r a d i t i o n and convention. S o c i a l roles as do s o c i a l relationships, have a manifest and latent content. I t i s the manifest content which i s of importance to s o c i a l work and to t h i s thesis, the latent content i s the f i e l d of psychiatry and psycho-logy, i t ' s use to s o c i a l work i s only so f a r as providing an appreciation of the manifest content. The concept of s o c i a l r o l e has a number of components, expertly documented by Boehm i n report of the curriculum study. Though we are not immediately occupied with a study of these components, they bear an important r e l a t i o n -ship to the concept of st r e s s , and so require b r i e f examination. Range This refers s p e c i f i c a l l y to the s o c i a l l y accepted ways of s a t i s f y i n g needs. Role Perception This i s the manner i n which a role i s viewed by an i n d i v i d u a l performing the r o l e , or by a r e c i p r o c a l person. Per-so n a l i t y , c l a s s , culture, values w i l l determine an ind i v i d u a l ' s perception of roles. Interrelatedness of Roles This component refers to the repercussions and effects of change i n performance on one role upon the performance of the other roles. - 12 -Role Network >, T h i s component combines the concepts o f r o l e i n t e r r e l a t -edness and r o l e r e c i p r o c i t y and p r o v i d e s a view of the c l i e n t as an i n t e r a c t i n g u n i t i n a system o f r o l e s . I t r e f e r s t o a l l the c l i e n t ' s s o c i a l r e l a t i o n s h i p s . R e c i p r o c i t y R e c i p r o c i t y r e f e r s to an i n d i v i d u a l who stands i n a r e l a t i o n s h i p to another i n d i v i d u a l . R ole Performance M o d i f i c a t i o n s T h i s r e f e r s t o changes i n r o l e behaviour which may r e s u l t from new p e r c e p t i o n s o f the r o l e , assumption o f new r o l e s , or change i n r o l e e x p e c t a t i o n s . I t can c l e a r l y be seen from the d e s c r i p t i o n o f s o c i a l r o l e that i t has d e f i n i t e v alue i n p r o v i d i n g s o c i a l a n a l y s t s an understanding o f an i n d i v i d u a l s f u n c t i o n i n g i n h i s r o l e network, and any changes t h a t may come about i n th a t network. The Concept o f S t r e s s F o r the purposes o f t h i s t h e s i s the major i n t e r e s t l i e s i n the concept o f s t r e s s . I t i s intended t o accomplish i n e x p l o r a -t i o n o f the e f f e c t s o f h o s p i t a l i s a t i o n , the task o f i d e n t i f y i n g s t r e s s , a n a l y s i n g s t r e s s , and examining those f a c t o r s which make f o r s t r e s s i n the l i g h t o f s o c i a l r o l e theory. The term s t r e s s i s f a m i l i a r i n many d i f f e r e n t f i e l d s o f s c i e n t i f i c and m e d i c a l endeavour. I n t e l l e c t u a l l y the concept g i v e s the p i c t u r e o f an o b j e c t s u b j e c t e d to o v e r l o a d i n g p r e s s u r e . When the p r e s s u r e becomes g r e a t e r than the o b j e c t can contend w i t h , - 13 -something s i g n i f i c a n t l y happens to the o b j e c t , i t may break, be-come weakened, of no f u r t h e r use, or of l i m i t e d use. Expanding t h i s i d e a t o i n c l u d e human b e i n g s , the p i c t u r e remains the same except t h a t the o b j e c t becomes a person, the p r e s s u r e , t h a t which i s e x e r t e d from w i t h i n a person, and without a person by h i s s o c i a l environment. Bernard d e f i n e s s t r e s s as "a s i t u a t i o n i n v o l v i n g t h r e a t ; and we break i t down i n t o t h r e e component elements: (1) the stress, f a c t o r , which t h r e a t e n s (2) the value which i s b e i n g t h r e a t e n e d , and (3) the r e a c t i o n s , i n d i v i d u a l and c o l l e c t i v e , to the . - t h r e a t . " 1 The concept i s q u i t e c l e a r l y r e l a t e d t o the concept o f r o l e and may be thought o f as any s i t u a t i o n which produces a t h r e a t to the performance o f a s o c i a l r o l e or r o l e s . The concept i s not, however, congruent w i t h the concept of a n x i e t y , which r e f e r s more t y p i c a l l y t o the s t r e s s r e a c t i o n . Boehm adds " t h a t s t r e s s f a c t o r s may o r i g i n a t e i n e i t h e r realm o f the i n t e r a c t i o n a l f i e l d s o c i a l o r i n d i v i d u a l : t h a t they may not be c o n s c i o u s l y p e r c e i v e d , but manifested i n the i n d i v i d u a l ' s response to them and t h e r e f o r e d e t e c t e d o n l y through changes i n the r o l e performance." 2 The concept of s t r e s s i n c l u d e s c e r t a i n e s s e n t i a l components:-S t r e s s F a c t o r s S t r e s s f a c t o r s are t h r e a t s which a r i s e w i t h i n the i n d i v i d u a l o r from the environment, w i t h i n h i s network of r o l e s o r the s o c i a l system. From the viewpoint o f s o c i a l work i t i s those t h r e a t s from the s o c i a l environment that are the concern 1 Bernard, J e s s i e , S o c i a l Problems at Midcentury. H o l t , Rine h a r t and Winston, New York, 1957. Page 70. 2 Boehm, Werner W. I b i d . Page 107. - 14 -of social workers. Any pattern of maladapted role functioning i n the nature of impairment w i l l provide yet a secondary source of stress. In considering the component, stress factors, the question arises as to whether this component can be measured. In social casework some value i s often assigned arbitrarily to stress factors, • A and they are frequently seen as severe, great, mild. Obviously these value connotations are highly subjective i n spite of the fact that they may be correlated with the individual's ego strengths, individuality, and personality. Bernard postulates about the measurability of stress "When we speak of stress factors as greater or less at one time as contrasted with those of another time, we imply that the threats can be measured i - . . Actually, however, threat may be thought of as having degrees which may be measured i n terms of probability, both objective and subjective. 1' 1 This thesis i s particulary concerned with the problem of measurability and hopefully intends to explore the possibility of measurement. Value Threatened Bernard considers that l i f e , health, property, privilege, freedom, security, status, self-respect, opportunity, future pros-pects - a l l as related to one's own self, to one's loved ones, or to one's group, or to a l l three are values that may be threatened. Conceivably a threat to any value of significance to the individual may produce stress. The value may have varied significance to the individual, however i t i s the subjective value that determines to some extent, the degree of reaction. It i s the meaning of the 1 Bernard, Jessie. Ibid. Page 74. - 15 -value to the person which i s of consequence, threat to a p a r t i c u l a r value held by two individuals may have d i f f e r e n t consequences for each of them. Reaction to Stress Responses made by the i n d i v i d u a l with the goal of maintaining the l e v e l of s o c i a l functioning which existed p r i o r to the occurence of stress, i s what i s meant by reaction to stress. Most human behaviour which expresses i t s e l f i n terms of role performance consists of reactions to stress, and i s an attempt b i o l o g i c a l l y - p s y c h o l o g i c a l l y - s o c i a l l y to a t t a i n s o c i a l symbiosis which might involve re-establishing a previous l e v e l of functioning, or attaining a new l e v e l of functioning which i s s a t i s f a c t o r y either i n d i v i d u a l l y or s o c i a l l y by adapting to stress s i t u a t i o n s . Some types of reaction may or may not lead to problems depending on the manner i n which the stress i s a l l e v i a t e d or eliminated. The -Social Environment In any analysis of stress, the question of s o c i a l environment i s a f o c a l issue. The s o c i a l environment comprises of the ind i v i d u a l ' s s o c i a l s i t u a t i o n . By s o c i a l s i t u a t i o n i s meant those persons who form part of an ind i v i d u a l ' s role network, and refers to individ u a l s i n the group of which he i s a member, and with whom he interacts f a i r l y i n t e n s i v e l y . Reference groups are s i m i l a r l y important and refers to those persons with whom an in d i v i d u a l i d e n t i f i e s . Their importance l i e s i n the fact that an indivi d u a l ' s values, standards and aspirations w i l l be determined by the reference group. S o c i a l resources and material goods which - 16 -are needed for e f f e c t i v e role performance constitute part of the s o c i a l environment. Other relevant components would be s o c i e t a l ideologies, economic, p o l i t i c a l , p hysical and f i n a l l y the s t r a t i f i -cation p e c u l i a r to a society of which one i n d i v i d u a l i s a member. The To t a l S i t u a t i o n Some reference needs be made to the t o t a l s i t u a t i o n which i n terms of s o c i a l role theory would be viewed more t y p i c a l l y as the s o c i a l environment. This thesis focuses attention on stress factors r e l a t i n g to the h o s p i t a l i s a t i o n of mentally i l l persons, that i s , the removal of a person who i s considered to be mentally i l l from his' customary s o c i a l s i t u a t i o n to a s o c i a l s i t u a t i o n of a p a r t i c u l a r type. Relative to the patient or r e c i p r o c a l , s o c i a l s i t u a t i o n may be thought of as being synonomous with the term s o c i a l environment. The h o s p i t a l community of Essondale of which Crease C l i n i c i s a part, i s viewed as a s e l f - s u f f i c i e n t and s e l f - i n t e g -rating unit despite the d i f f i c u l t i e s of i t ' s space time margins* I t i s a patterned and patterning system with functions and compo-nents. T h e o r e t i c a l l y i t appears to s a t i s f y the s o c i o l o g i c a l c r i t e r i a customarily used for establishing the status of s o c i a l organisations, complexes and groups, described by Young i t "(1) occupies a t e r r i t o r i a l area "(2) i s characterised by common inte r e s t s and (3) common patterns of s o c i a l and economic r e l a t i o n s ; (4) de rives a common bond of s o l i d a r i t y from the conditions .. of i t ' s abode; (5) has a co n s t e l l a t i o n of s o c i a l i n s t i t u t i o n s ; (school, o K > recreational centre, shops, church etc.) and. (6) i s subject to some degree of group control." 1 1 Young, Pauline V. S c i e n t i f i c S o c i a l Surveys and Research 3rd E d i t i o n , Prentice-Hall, Englewood C l i f f s , J . J . Page 471. - 17 -The h o s p i t a l environment i n many respects has character-i s t i c s which are adequately expressed by Mtken, when he refers to the ship as a community, since an "extraordinary f e e l i n g of kinship, of unity, of s o l i d a r i t y f a r closer and more binding than that of nations or c i t i e s or v i l l a g e s was s w i f t l y uniting the t r a v e l l e r s ; the ship was making them a community." 1 In terms of theory then, Essondale would be accorded the status of community. C l i n i c a l l y , however, i t i s viewed more as a part of the thereaupeutic mileau of the h o s p i t a l . I t ' s various s o c i a l i n s t i t u t i o n s are there by s p e c i f i c design, and to be under-stood as thereaupeutic instruments complementing and supplementing the treatment patients receive within the walls of each h o s p i t a l unit. This view establishes Essondale as more t y p i c a l l y a s o c i a l i n s t i t u t i o n , meeting the c l a s s i f i c a t i o n c r i t e r i a discussed by Young i n her chapter t i t l e d "A Study of S o c i a l I n s t i t u t i o n s . " 2 For-purposes of t h i s thesis, the writer prefers to com-promise with the d i f f i c u l t i e s involved i n c l a s s i f y i n g the s o c i a l environment of the h o s p i t a l , and therefore views Essondale as both community and s o c i a l i n s t i t u t i o n . As a s o c i a l i n s t i t u t i o n i t i s a function of the communities surrounding i t , and as a community i t has a high degree~of interdependence with those communities surrounding i t . As a s o c i a l i n s t i t u t i o n i t i s part of the t o t a l s i t u a t i o n of patient and r e c i p r o c a l s . They are aware of i t ' s existence. They may never d i r e c t l y have any involvement with the 1 Aitken, Conrad, Blue Voyage, Charles Scribner's Sons, New York, 1927, Page 33. 2 Young, Pauline V. Ibid. - 18 -i n s t i t u t i o n , but i n d i r e c t l y they contribute to i t f i n a n c i a l l y , p o l i t i c a l l y , and s o c i a l l y . As a community i t may be regarded to be somewhat removed from the t o t a l s i t u a t i o n of patient and re-c i p r o c a l . S i t u a t i o n a l l y , whatever c u l t u r a l status i s assigned, the fact i s that the freedom permitted both patient and r e c i p r o c a l at Crease C l i n i c by way of weekend leave, day p r i v i l e g e s , frequent v i s i t i n g , i t i s the opinion of the writer that the patient i s never r e a l l y removed from the t o t a l s i t u a t i o n when he i s hospi-t a l i s e d since he enters a community or s o c i a l i n s t i t u t i o n which i n many ways i s a model of the larger community i n which he func-tioned p r i o r to his i l l n e s s and h o s p i t a l i s a t i o n , but probably better structured and more highly organised. For both patient and family i t means t h e o r e t i c a l l y extending or broadening the s o c i a l environment, and i n a sense they have to contend with two s o c i a l situations temporarily. The r e a l issue on discharge, i s not so much that the patient returns to the t o t a l s i t u a t i o n , since he was always a part of i t , but that he re-adapts and re-adjusts himself to that part of the t o t a l s i t u a t i o n with which he was f a m i l i a r p r i o r to his i l l n e s s and h o s p i t a l i s a t i o n . I t i s useful to remember that the i n d i v i d u a l i s constantly reacting and adjusting or adapting to a complex and dynamic t o t a l s i t u a t i o n which i s r e l a t i v e to himself. Significance of the Study for S o c i a l Work I t has been stated that s o c i a l role theory i s new to the f i e l d of s o c i a l work generally. Any new theory requires that - 19 -i t be subjected to testing and experimentation i f i t i s to be V adopted for use as a method i n the problem solving process. Regensburg expresses this viewpoint when she writes . "The framework i s not to be viewed as a f i n a l product; much of i t w i l l undoubtedly be reformulated as experi-mental work proceeds. The choice of this p a r t i c u l a r concept of s o c i a l functioning and of other concepts which l o g i c a l l y precede and follow i t , i s a matter for thorough testing and research. ... Granted that there w i l l be much floundering and t r i a l and error while further study and research proceed. I suggest that even so the gains of s o c i a l casework pr a c t i c e can be great." 1 This thesis i s an attempt to experiment with an aspect of s o c i a l r ole theory, i t i s a pioneer study which has as i t ' s aim, the purpose of making a contribution i n discovering the usefulness of a small component of s o c i a l r ole theory, and f u l -f i l l i n g the r e s p o n s i b i l i t i e s of a professional s o c i a l worker i n r e l a t i o n to new theories. Schlesinger i n his thesis on "Soc i a l Casework i n the Mental Hospital" writes that "When the patient enters h o s p i t a l , r e l a t i v e s are frequently ^rnore confused and upset than he i s . They may have needless fears that the patient i s being 'put away for l i f e ' or may need help to face the fact that the patient w i l l remain i l l for an extended period. They f e e l responsible for the patient's breakdown, and may be affected by g u i l t feelings about committing the patient to h o s p i t a l ; or they may show r e l i e f at getting r i d of the r e s p o n s i b i l i t y of caring for the patient ... A l l these feelings and attitudes have a disrupting influence on the patient and the e f f e c t i v e functioning of the family." 2 1 Regensburg, Jeanette "The Curriculum Study: Implications fo r the.Practice of S o c i a l Casework" S o c i a l Casework January 1960 2 Schlesinger, Ernest S o c i a l Casework i n the Mental Hospital Master of S o c i a l Work Thesis, University of B r i t i s h Columbia, 1953 Page 2. - 20 -This thesis by virtu e of i t ' s focus, w i l l be re-examining some of the problems mentioned by Schlesinger i n the l i g h t of s o c i a l role theory, and hopefully add yet another dimension by which to understand the causes and origins of problems caused through hos-p i t a l i s a t i o n . For i f i t can be proven that fear, confusion, g u i l t feelings and other problems - responses to stress, are related to a network of inter-dependent and i n t e r r e l a t e d s o c i a l factors, the study has important s i g n i f i c a n c e for s o c i a l work, and i n e v i t a b l y enable s o c i a l workers i n the p r a c t i c a l f i e l d to be of greater value i n helping the patient and reciprocals. This study furthermore, aims at discovering ways i n r e l a t i o n to s o c i a l work theory of; (a) helping caseworkers understand, i d e n t i f y and assess c e r t a i n behavioural phenomena as perceived through an ind i v i d u a l ' s role performance, r o l e functioning and role relationships. The behavioural phenomena which i s of i n t e r e s t i s that associated with the admission of an i n d i v i d u a l to a mental h o s p i t a l of a p a r t i c u l a r kind. (b) helping to explain and understand cert a i n s t r u c t u r a l J changes i n s o c i a l role functioning, c e r t a i n types of responses, following the admission of an i n d i v i d u a l to a mental h o s p i t a l . Scope of Thesis The thesis i s intended to focus attention on what happens to the s i g n i f i c a n t network of roles and role relationships i n a family, when one of the members i s displaced from the network. - 21 -To do t h i s the concept of stress has been chosen as the c r i t e r i o n of examination and analysis. By taking a look at role functioning, i t i s expected that i t w i l l be possible to i d e n t i f y s i g n i f i c a n t areas of stress, the degree of stre s s , r e s u l t i n g from the displacement of a family member from his s o c i a l network. Furthermore i t i s intended to attempt to explain what happens to the ho s p i t a l i s e d member, and his reciprocals i n terms of role functioning, when he i s displaced from his customary s o c i a l s i t u a t i o n . Hypotheses For purposes of most experimentation and research, a model of operation requires at the outset, a framework of assump-tions which w i l l focus the whole nature of the research into stress and h o s p i t a l i s a t i o n . For the purpose of establishing a hypothetical framework, the following assumptions i n r e l a t i o n to the area of in t e r e s t have been set up. Assumption 1 When a member of a family unit i s displaced 1 from his network of roles and relationships with reciprocals which make up his s o c i a l network, a threat i s produced and results i n stress. Displacement i n thi s context w i l l be i d e n t i f i e d as a stress factor. Rose observes that "When a p s y c h i a t r i c patient i s ho s p i t a l i s e d his r e l a t i v e s ^develope d i s t i n c t attitudes toward the i l l n e s s and h o s p i t a l ... With h o s p i t a l i s a t i o n , these attitudes become more e x p l i c i t , and are elaborated to include attitudes toward the h o s p i t a l treatment program and the hospital's respon-s i b i l i t y i n the custody and care of the patient." 2 1 The term displacement i s used by the writer to refer to the removal.of an i n d i v i d u a l from h i s usual physical and s o c i a l en-vironment. 2 Rose, Charles L. Ibid. Page 194 - 22 -Assumption 2 That the i n d i v i d u a l patient and his family reciprocals reacts to this stress or threat brought about through displacement, by changing, adjusting and withdrawing from roles and ro l e r e l a t i o n -ships. The reaction to stress may be p o s i t i v e or negative. Assumption 3 That displacement bringing about new roles and r e l a t i o n -ships for the ho s p i t a l i s e d family member produces stress for the family r e c i p r o c a l s , as well as for the patient. Assumption 4 That displacement to a s o c i a l environment of a p a r t i c u l a r kind - the h o s p i t a l community, i s both s t r e s s f u l to the patient and his family reciprocals. Restating the major focus of the thesis, i t may be said therefore that i t i s pri m a r i l y concerned with stress - the nature of s t r e s s , the reactions to stress, the pattern of reactions, i n what way stress may be interpreted, analysed, measured, and i n what way the concept may be u t i l i s e d i n treatment. Setting of The Study The Crease C l i n i c of Psychological medicine has been selected as the setting of the study, because of a combination of factors. F i r s t l y , as an i n s t i t u t i o n for the care and treatment of mentally i l l patients, i t i s i n some degree a compromise between the P r o v i n c i a l Mental Hospital and the day c l i n i c . I t therefore assumes the p o s i t i o n of a half-way type of treatment i n s t i t u t i o n . - 23 -Secondly, i t i s an i n s t i t u t i o n where prevention of more serious mental i l l n e s s through early treatment i s the aim. I t serves more the needs of the acutely i l l than the c h r o n i c a l l y i l l , as well as the needs of emotional disorders. The p o l i c y manual of the P r o v i n c i a l Mental Hospital and Crease C l i n i c states "... the function of Crease C l i n i c i s to treat acute cases 'of mental and emotional disorders." 1 and l i s t s the following types of mental patients acceptable for admission. "1. early psychosis .2. psychoneurotics 3. psychosomatic d i s a b i l i t i e s 4. a l l paychotics, except those of long standing duration and those demonstrating marked deterioration and hav-ing a poor prognosis." 2 T h i r d l y , the period of h o s p i t a l i s a t i o n i s r e l a t i v e l y short "Persons who are considered suitable for admission are those who w i l l respond to treatment i n a period less than four months and who can then return to the com-munity ... I t i s to be noted that the average period of treatment i s about two months." 3 At the time the study was being conducted, the period of treatment was approximately f i v e to seven weeks. Fourthly, Crease C l i n i c i s more open than P r o v i n c i a l Mental Health Hospital and the patients tend to require somewhat less supervision, and are granted much more freedom and many more pr i v i l e g e s than patients i n s t i t u t i o n a l i s e d at P r o v i n c i a l Mental Health. 1 Policy Manual, P r o v i n c i a l Mental Health Services, P r o v i n c i a l Mental Hospital and Crease C l i n i c , Page 32. 2 Ibid. Page 33. 3 Ibid. Page 32. - 24 -F i f t h l y , because of the type of patient admitted to Crease C l i n i c , they are more amenable and suitable for interviews of the type used i n this study. Geographically, the Crease C l i n i c of Psychological Medicine i s situated adjacent to the buildings making up the units of the P r o v i n c i a l Mental Hospital. The c l i n i c i s part of the ad-mi n i s t r a t i v e organisation of the larger h o s p i t a l , although i t functions seperately as a treatment unit. The h o s p i t a l community i s c a l l e d 'Essondale' and i s located i n a r u r a l area approximately twenty miles from downtown Vancouver. Essondale includes, apart from the h o s p i t a l units, r e s i d e n t i a l units for s t a f f , a post o f f i c e , store, Credit Union, two cafes, recreational and community centre, farm, and i s set amid well kept parkland. Crease C l i n i c i t s e l f has a l i b r a r y , hairdresser^ and recreational therapy unit. Crease C l i n i c was established i n 1948 under the terms of the " C l i n i c s of Psychological Medicine Act", and o f f i c i a l l y opened i n November 1949. The West wing of the building housing male patients and the East wing female patients. To each ward i s assigned a p s y c h i a t r i s t , s o c i a l worker, psychologist, occupational therapist, and a team of p s y c h i a t r i c nurses. CHAPTER II - METHODOLOGY APPLIED TO THE CASES Case Study Method Young introduces her chapter on "The Use of Case Data i n S o c i a l Research" with a quotation from Charles H. Cooley, who states that: "Case study deepens our perception and gives us a clearer in s i g h t into l i f e .. I t gets at behaviour d i r e c t l y and not by any i n d i r e c t and abstract approach." 1 In designing a research experiment, which intends u t i l i s i n g an abstract theory such as s o c i a l role theory, the experimenter must natu r a l l y give serious consideration to the question of what method of s o c i a l research i s best suited for the p a r t i c u l a r kind of material that i s to be handled. In t h i s study we are exploring and analysing a process, which i s highly dynamic, we are also examining a set of s o c i a l units. We are studying i n t e r r e l a t i o n s h i p s of one unit to another, at a p a r t i c u l a r moment i n time. For thi s kind of data, Young considers the case study method most useful. "... through the case method the s o c i a l researcher .attempts to see the variety of factors within the s o c i a l unit as an integrated whole." 2 As a method i t i s most useful i n research exploring a variety of factors, where the researcher i s working with a limi t e d number of cases and working alone. The case study makes no attempt to change the condition of the c l i e n t or that of the treatment; the c l i e n t i s observed i n a c l i n i c a l s e t t i n g . The p a r t i c u l a r research design used i n this study i s infused with t h i s quality. 1 Young, Pauline V. (PhD) S c i e n t i f i c S o c i a l Surveys and Research Prentice H a l l Inc. Englewood-Cliffs, N.J. 1956, Page 229 2 Ibid. Page 229. . , - 26 -S o c i a l work i s p r i m a r i l y concerned w i t h s o c i a l behaviour i n r e l a t i o n to the s o c i a l environment. I n d e a l i n g w i t h such sub-j e c t i v e s i t u a t i o n s , the q u e s t i o n o f b i a s and o b j e c t i v i t y f r e q u e n t l y emerge. We are aware t h a t the appearance o f the i n t e r v i e w e r and the way the i n t e r v i e w was conducted w i l l i n f l u e n c e the responses obtained from an i n d i v i d u a l . I t i s known t h a t when there i s i n t e r -a c t i o n between p a i r s o f people changes i n mind may r e s u l t from p e r s u a s i o n . I n a s e t t i n g such as a mental h o s p i t a l - , the mood, treatment, amount of d i s o r g a n i s a t i o n and nature of the i l l n e s s w i l l determine the s o r t o f responses a person makes when he i s asked q u e s t i o n s . While i t i s p o s s i b l e to c o n t r o l many of these h i n d e r i n g f a c e t s i n the s e r v i c e o f o b j e c t i v i t y , i t may not be e n t i r e l y pos-s i b l e to l i m i t t h e i r e f f e c t s on the r e s u l t s of the experiment, however, a knowledge o f them i s i m p e r a t i v e i n the f i n a l a n a l y s i s . I n i n v e s t i g a t i n g s o c i a l behaviour the r e s e a r c h t o o l s are somewhat l i m i t e d , i t may be necessary to borrow the t o o l s o f other s c i e n c e s . I n s o c i a l work we are doing t h i s c o n s t a n t l y . A r g y l e expresses t h i s view i n h i s book "Methods o f S t u d y i n g S o c i a l BehaviourV and goes on to s t a t e "The student o f s o c i a l behaviour has two measuring "instruments ... These two are the d i f f e r e n t k i n d s of i n t e r v i e w and q u e s t i o n a i r e , and the techniques o f con-t r o l l e d o b s e r v a t i o n . " 1 The measuring instrument used i n t h i s t h e s i s study i s the i n t e r -view. 1 A r g y l e , M i c h a e l The S c i e n t i f i c Study o f S o c i a l Behaviour Methner & Co. L t d . , London 195/.,. .Page 14. - 27 -The Interview It i s indeed impossible to conceive of any better instrument to use i n conducting this research, other than the interview. In essence i t i s largely the topic of the thesis which determines the type of instrument to be used i n research. To investigate the material discussed i n Chapter I i t i s essential to have face to face contacts. The quotation from Gordon Allport introducing the chapter on "The Interview as a Tool i n Field Exploration" by Young adequately expresses this theme. "If we want to know how people feel, what they experience, .and what they remember, what their emotions and motives are ... why not ask them." 1 What people feel about themselves and others, what they experience and what their emotions are in relation to social roles i s precisely the theme of this thesis. In the research conducted for this thesis use has been made of an interview format which i s in fact a combination of types of interview design. Use has been made of the standardised inter-view, and "questions are presented with exactly the same wording and i n the same order." 2 The reason for standardisation i s to ensure that a l l individuals are replying to the same question since "Differences in question order can also influence the meaning and implications of a given question." 3 1 Young, Pauline V. Ibid. Page 205 2 S e l l t i z , Claire. Jaho.da, Marie. Deutsch,Marbou. Cook, Stuart W. Research Methods in Social Relations, Henry Holt & Co. 1960, Page 255. 3 Ibid. Page 255. ' ) - 28 -In conducting the research use has been made of "open-ended" questions, which are designed to permit the person being interviewed the opportunity to answer i n his own terms and i n his own frame.of reference. S e l l t i z , Deutsch and others consider that the distinguishing c h a r a c t e r i s t i c of open-ended questions i s "that they merely rais e an issue but do not provide ;or suggest any structure for the respondent's reply." 1 The general type of interview used i n thi s research study might well be c l a s s i f i e d i n terms of "the focused interview" so designated by Merton and h i s associates. They indicate that this type of interview i s d i f f e r e n t i a t e d from other types of interview i n that "(1) i t takes place with persons known to have been i n -'.. . volved i n a p a r t i c u l a r concrete s i t u a t i o n ; (2) i t refers to situations which have been analysed - . p r i o r to the interview; (3) i t proceeds on the basis of an interview guide which . outlines the major areas or enquiry and the hypotheses which locate pertinence of data to be secured i n the interview; (4) i t i s focused on the subjective experiences, attitudes , and emotional responses regarding the p a r t i c u l a r con-crete situations under study." 2 From the point of view of t h i s study the advantage of the focused interview allows the interviewer "to explore reasons and motives, to probe further i n directions that were unanticipated." 3 Together with some of the other aspects make i t the most p r a c t i c a l research instrument for conducting t h i s thesis study, i n terms of the data to be handled. 1 Ibid. Page 257.. 2 Merton, Ralph R. "The Focused Interview" American Journal of  Sociology, Volume LI, May 1946, Page 541 - 542. 3 Ibid. S e l l - t i z , Deutsch and others. Page 264. - 2 9 -The I n t e r v i e w Format R e l y i n g p r i m a r i l y on the t h e o r e t i c a l hypotheses as a f o u n d a t i o n f o r developing an i n t e r v i e w schedule, q u e s t i o n s were i n i t i a l l y formulated u s i n g the terminology o f s o c i a l r o l e theory, and phrased i n t e c h n i c a l language. S i n c e we were i n v e s t i g a t i n g two s o c i a l u n i t s , one comprising of the i n d i v i d u a l p l a c e d i n a p a r t i c u l a r s o c i a l environment, and the o t h e r , comprising of an i n d i v i d u a l ' s r e c i p r o c a l , f u n c t i o n i n g m a i n l y i n a d i f f e r e n t s o c i a l environment, two i n t e r v i e w formats would be r e q u i r e d , o r i e n t e d to the s o c i a l s i t u a t i o n r e l a t i v e t o each s o c i a l u n i t . D e s p i t e the c o n s t r u c t i o n of two d i f f e r i n g i n t e r v i e w formats the procedure used i n d e s i g n i n g them remained the same. As d e s c r i b e d i n Chapter I , the concept of s t r e s s i n s o c i a l r o l e theory bears a d i r e c t r e l a t i o n t o the concept o f s o c i a l r o l e and i t ' s component p a r t s . The study of s t r e s s r e q u i r e s t h a t we a l s o study s o c i a l r o l e . The i n t e r v i e w format g i v e s e x p r e s s i o n to t h i s p r i n c i p l e , and s t a r t s w i t h questions intended to p r o v i d e a background of i n f o r m a t i o n about r o l e s , r o l e e x p e c t a t i o n s , r o l e p e r c e p t i o n s , r o l e performance and range. A comparison of both formats i n r e l a t i o n to the above components would then be expected to p r o v i d e i n f o r m a t i o n concerning the i n t e r r e l a t e d n e s s o f r o l e s i n r e s p e c t of p a t i e n t and h i s r e c i p r o c a l s . S i n c e r o l e f u n c t i o n i n g i n v o l v e s i n t e r a c t i o n between an i n d i v i d u a l and r e c i p r o c a l s w i t h inter-dependant r o l e s , r e l a t i o n -s h i p , and f e e l i n g , a s e r i e s o f q u e s t i o n s were designed to e l i c i t responses t h a t would g i v e some a p p r e c i a t i o n o f these t h r e e f a c t o r s . - 30 -For example i n the 'Interview Format f o r Interviews w i t h P a t i e n t s ' the f o l l o w i n g q uestions were asked. "13. Can you d e s c r i b e your r e l a t i o n s h i p w i t h your w i f e / husband? 9. What d i d you f e e l about l e a v i n g your f a m i l y ? 6. I n your o p i n i o n , what are your f e e l i n g s about the > th i n g s you do at home?" 1 Then f i n a l l y t h e r e were those q u e s t i o n s which would p r o v i d e data about t h e f p a t i e n t and the r e c i p r o c a l s adjustments and a d a p t a t i o n s or l a c k o f them, to the environment, f e e l i n g s about change and the new s i t u a t i o n g e n e r a l l y . F o r example i n the 'Interview Format f o r Interviews w i t h R e c i p r o c a l s ' , the ques t i o n s asked were: "6. Can you e x p l a i n the s o r t o f changes t h a t were neces-sary i n your way o f l i f e ... as a r e s u l t o f your wife's/husband's admission t o Crease C l i n i c ? 5. What i s your view of what happened to the th i n g s you d i d ... when your wife/husband was admitted to Crease C l i n i c ? 23. What are your f e e l i n g s about your c o n t a c t s w i t h the h o s p i t a l s t a f f ? " 2 I t was to be expected t h a t i n responding t o some o f the quest i o n s the p a t i e n t and h i s r e c i p r o c a l s would be a b l e to v e r b a l i s e some of the s t r e s s e s experienced as a r e s u l t o f h o s p i t a l i s a t i o n , and where a p p r o p r i a t e q u e s t i o n s were i n s e r t e d f o r t h i s purpose. However, i t was a l s o accepted t h a t i n many areas of f u n c t i o n i n g n e i t h e r p a t i e n t or f a m i l y member might be aware o f s t r e s s . T h i s would come from an a n a l y s i s o f r o l e f u n c t i o n i n g , and s t r o n g l y support the need t o ask questions which p r o v i d e data about the p a t i e n t ' s f u n c t i o n i n g as w e l l as the f u n c t i o n i n g o f each f a m i l y 1 Appendix A j . 2 Appendix A2. - 31 -member. When the two interview formats were completed one for the patient, and one for the r e c i p r o c a l , but phrased i n professional terminology, the writer set about t r a n s l a t i n g each question into more useable and simple language. This proved extremely d i f f i c u l t and made manageable p a r t l y through experimentation with four sub-j e c t s , a l l having experience of h o s p i t a l i s a t i o n i n a mental i n s t i -tution themselves. Following experimentation the interview format was further analysed and restructured i n the l i g h t of the results obtained. For example, the i n i t i a l format asked the question "What were your roles p r i o r to your wife's/husband's h o s p i t a l i s a t i o n ? " 1 A f t e r t r a n s l a t i n g 'role' i n terms of useable language the question asked "(a) Could you describe the j obs you did at home before ". - - your wife/husband entered Crease C l i n i c ? (b) Could you also describe your s o c i a l a c t i v i t i e s before . _ your wife/husband entered Crease C l i n i c ? " ^ Following experimentation and i n the l i g h t of experience and the results obtained while engaged i n experimentation, i t be-came necessary to change the question to "1. Before your wife/husband entered Crease C l i n i c , can you describe the things you did (a) at home (b) i n the community (c) s o c i a l l y . " 3 Obviously the question of semantics i s extremely impor-tant i n the design of an interview format, and can quite considerably pose as a very l i m i t i n g and impedimental factor i n research, using 1 Appendix Aj_. 2 The above i s a sample of the questions contained i n the experimental format for interviews with reciprocals. The ex-perimental format has not been included i n the Appendix. 3 Appendix A£. - 32 -the method adopted i n this study. I t i s e s s e n t i a l that where the question of semantics a r i s e s , that experimentation be done with a f a i r l y large sample, before entering the actual research experiment. In t h i s study i t was not p r a c t i c a l to use a large sample for pre-liminary exploration. In view of the fact that the problem of se-mantics proved so i n t e r e s t i n g , the writer inserted a few questions asking for d e f i n i t i o n s of terms commonly used by s o c i a l workers, involved with a c l i e n t ' s roles. Sampling One of the advantages of the case study method i s that i t permits the use of a small sample, In the research area of this thesis a small sample was used. The rationale behind sampling l i e s i n the acceptance of the r e a l i t y factor that to study some phenomenon i n d e t a i l would involve such a mass of data as to render the task of analysing almost impossible. A sample, as the name suggests, i s a representative of a larger whole, and an e s s e n t i a l part of a l l s c i e n t i f i c procedure. Young says a sampling i s "One of the most important as well as the most d i f f i c u l t problems i n s o c i a l research." 1 I t ' s importance l i e s c h i e f l y i n that i t makes fa r easier management of s o c i a l research projects and has the q u a l i t y when used i n s t a t i s t i c a l research of f a c i l i t a t i n g measurement of results and when applied constructively i t acts as a c o n t r o l l i n g agent of bias. 1 Young, Pauline V. Ibid. Fage 301. - 33 -At the outset of the thesis, the -writer's intention was to make use of purposive samples. S e l l t i z , Deutsch and others write "The basic assumption behind purposive sampling i s that .with good judgement and an appropriate strategy one can hand-pick the cases to be handled i n the sample and thus develope samples that are s a t i s f a c t o r y i n r e l a t i o n to one's needs." 1 In p r a c t i c e , the sampling though p a r t l y purposive tended to f a l l generally within the non-probability sampling category, due mainly to a variety of l i m i t i n g factors imposed on the research by the experimental environment. From time to time the writer had to resort to accidental sampling. S e l l t i z , Deutsch and others con-sider that "In accidental samplingi one simply reaches out and takes .the cases that f a l l to hand." 2 The sample i n i t ' s f i n a l form comprised of nine cases -four from the female and f i v e from the male sections of the Crease C l i n i c of Psychological Medicine respectively. Cases were intended to be selected according to ce r t a i n predetermined c r i t e r i a decided on by the writer as being e s s e n t i a l for the purpose of conducting research i n terms of the focus of the study undertaken. However, due to circumstances over which the writer had no control, only four cases actually s a t i s f i e d the requirements of s e l e c t i o n c r i t e r i a , so that the sample i s not considered representative, and therefore stands as one of the many li m i t a t i o n s of the study. The sample i n i t ' s f i n a l composition represented 12.8% of the patient pop-ul a t i o n , but this has no r e a l s i g n i f i c a n c e . The other l i m i t a t i o n s of the sample and study are also apparant. 1 S e l l t i z , Deusch and others. Ibid. Page 520. 2 S e l l t i z , Deusch and others. Ibid. Page 516. - 34 -. As a result of renovations, and a shortage of medical staff, the patient population at Crease Clinic had been substantially reduced at the time of conducting the research. The female ward East 2, normally serving the needs of an average thirty-six patients monthly, had eighteen patients. One complete ward on the male side of the c l i n i c was closed vfor renovations. Furthermore many of the patients who might have qualified i n terms of the c r i t e r i a for selection of cases were incapacitated through treatment, or too grossly disturbed, suffering memory impairment as a result of electro-convulsive therapy, or in the process of being discharged before satisfactory arrangements could be made to interview them. Selection C r i t e r i a 1. Since the study i s family oriented a l l patients selected had to be married and living with their spouses prior to hospitalisation, and the parent of children or of a child who were living at home. This criterion was determined i n large measure by the natural focus of the study, and the set of hypotheses developed for the thesis. 2. The current admission was to be the patient's f i r s t admission to a mental hospital. This requirement was selected for the obvious reason that the f i r s t admission to a mental hospital would be expected to have an important impact on the patient and family. Such an impact would tend to highlight areas of stress i n relation to displacement, and enable the researcher to inves-tigate stress more easily. Role functioning and feelings were - 35 -considered to be somewhat d i f f e r e n t l y affected at the f i r s t ad-mission than would be the case with re-admissions. I t was not possible, however, to r i g i d l y apply t h i s requirement, due to the fact that the patient population was so small, and the .numberrof patients well enough to become involved i n research interviews, yet suitable i n terms of the s e l e c t i o n c r i t -e r i a was even smaller. 3. That the patient should have been i n h o s p i t a l for a period exceeding two weeks. This would allow the family time to react to the displacement of the patient from the home, and become acquainted with the ho s p i t a l environment. 4. That the patient be well enough to handle a research interview without experiencing too much d i f f i c u l t y , as well as have a f a i r l y i n t a c t memory. Since the interview deals quite s u b s t a n t i a l l y with pre-hosp i t a l i s e d roles and role r e l a t i o n s h i p s , i t was important that the patient be able to give a f a i r description of h i s roles and role network i n response to questions asked by the interviewer. Furthermore, as the interview involves a two-way communication it»s success would depend on the a b i l i t y of the patient to com-municate verbally. 5. That the patient customarily resides i n the Lower Fraser Valley-Vancouver region, and would include any other area f a l l i n g within a radius of 35 miles from the h o s p i t a l community of.j. Essondale. This c r i t e r i o n would serve to f a c i l i t a t e interviews with family, and also permit the researcher to assess how family members perceive the h o s p i t a l community. In only two instances - 36 -was t h i s r e q u i r e m e n t w a v e r e d , w h e n p a t i e n t s w e r e s c a r c e . O n e p a t i e n t came f r o m C h i l l i w a c k a n d t h e o t h e r f r o m E d m o n t o n . T h e S t u d y M e t h o d A s a n e c e s s a r y p r e l i m i n a r y , p e r m i s s i o n t o c o n d u c t t h e r e s e a r c h was o b t a i n e d o f t h e c l i n i c a l d i r e c t o r o f C r e a s e C l i n i c . T h e s c o p e a n d p u r p o s e o f t h e r e s e a r c h was t h e n t a b l e d i n a memo-r a n d u m b y t h e c l i n i c a l d i r e c t o r , a n d p a s s e d t o t h e u n i t d i r e c t o r s . T h e memorandum s e t o u t b r i e f l y t h e c r i t e r i a o f s e l e c t i o n , a n d a s k e d f o r c o - o p e r a t i o n i n r e f e r r i n g p a t i e n t s f o r u s e i n t h e r e s e a r c h . D i s c u s s i o n s w e r e s i m i l a r l y h e l d w i t h t h e c a s e w o r k s u p e r v i s o r o f t h e s o c i a l s e r v i c e d e p a r t m e n t , a n d t h e w r i t e r s e t o u t i n a m e m o r a n d u m , t h e f o c u s o f t h e s t u d y , a n d t h e c r i t e r i o n t o b e u s e d i n t h e s e l e c t i o n o f p a t i e n t s f o r i n t e r v i e w s , a n d t h e n u m b e r o f p a t i e n t s r e q u i r e d b y t h e w r i t e r t o c o n s t i t u t e t h e s a m p l e . T h i s i n f o r m a t i o n was t h e n p a s s e d t o s o c i a l w o r k e r s i n e a c h o f t h e r e s p e c t i v e w a r d s o f C r e a s e C l i n i c . I n d i s c u s s i o n w i t h t h e s u p e r v i s o r i t was d e c i d e d t h a t w o r k e r s w o u l d d i s c u s s t h e m a t t e r w i t h w a r d d o c t o r s a n d r e f e r c a s e s t o t h e s u p e r v i s o r , who w o u l d t h e n r e f e r t h e m t o t h e r e s e a r c h e r . A f t e r a p e r i o d o f a p p r o x i m a t e l y s i x w e e k s i t was f o u n d t h a t t h i s a r r a n g e m e n t w a s . n o t p r o v i n g e f f e c t i v e , a n d t h e r e s e a r c h e r d e c i d e d t o l i s t a l l new a d m i s s i o n s f r o m J a n u a r y o f p a t i e n t s m e e t i n g t h e c r i t e r i a o f s e l e c t i o n . T h e s u p e r v i s o r w o u l d t h e n d i s c u s s c a s e s a t t h e u n i t m e e t i n g , a p p e a r i n g s u i t a b l e f o r r e f e r r a l t o t h e r e s e a r c h e r , s p e c i f i c a l l y c h o s e n i n t h e l i s t . T h i s a r r a n g e m e n t d i d n o t p r o v e e n t i r e l y s u c c e s s f u l e i t h e r , a n d t h e r e s e a r c h e r d e c i d e d t o h a v e d i r e c t c o n t a c t w i t h w a r d d o c t o r s i n o r d e r t o o b t a i n r e f e r r a l s . - 37 -I n i t i a l l y i t was arranged that the ward doctor would b r i e f l y discuss r e f e r r a l with the patient, and gain h i s or her approval. !.The ward s o c i a l worker would then outline the purpose and nature of the research to the selected patient. This procedure was considered 'necessary to a l l a y any fears that the patient might have about the interviews and the research. I t was also considered a useful procedure i n that the patient would be adequately prepared for the interview s i t u a t i o n , and thus minimise the amount of time that would normally be spent i n the process of introduction and establishing rapport. In each case, the patient was to be asked whether he approved of interviews with a member of his family. This l a s t procedure was not however, carried out, and the i n t e r -viewer was required to discuss this matter at the conclusion of the interview. Only i n one case did the patient r e s i s t the idea of interviews with a r e l a t i v e or member of the family. The arrange-ments for the doctor and s o c i a l worker to see the patient p r i o r to the interview worked out reasonably well for the f i r s t four cases referred, but the pra c t i c e was not maintained and i n the l a s t s i x cases the interviewer was required to discuss very b r i e f l y the reason why the patient had been referred, and for what purpose. O r i g i n a l l y , a l l interviews with patient and r e l a t i v e were scheduled to take place at the c l i n i c , however th i s was not possible for an assortment of reasons. (a) On the days when the interviewer would be available at Crease C l i n i c - Wednesday, and Friday afternoons, i t was not con-venient for the family to v i s i t . - 38 -(b) Ex t ra r e s p o n s i b i l i t i e s , and lack of t ranspor tat ion made i t inconvenient for fami ly members to v i s i t except on Sundays. (c) When an interv iew was poss ib le wi th a fami ly member during v i s i t i n g hours, no o f f i ce was ava i lab le for use by the researcher. (d) The pat ient was discharged very shor t l y a f te r the i n t e r -view, and family members did not wish to t r ave l " a l l that way" now that the pat ient was home. Therefore, i n the case of f i ve r e f e r r a l s , interviews with the fami ly rec ip roca l took place i n t he i r homes. In the case of two re fe r ra l s where the pat ien t had been discharged f a i r l y soon af ter h i s or her in terv iew, the pat ient showed reluctance to l e t the interv iew with the rec ip roca l proceed without s i t t i n g i n . I n i t i a l l y contact wi th the p a t i e n t ' s rec ip roca l was to be made by the ward s o c i a l worker, th is was done In four out of ten of the cases re fer red. In respect of the remaining s i x cases, t h i s was not done, and the interv iewer made the contact wi th the rec ip roca ls h imsel f . The reason for th i s i s probably a t t r i bu tab le to the fac t that these s i x cases had at no stage of h o s p i t a l i s a t i o n been referred to the s o c i a l serv ice department, or been picked up by the s o c i a l worker assigned to the respect ive wards i n which the pat ient had been p laced. A l l contacts wi th rec ip roca ls were made over the telephone, and the purpose of the research communicated to them as wi th the pa t ien t . Over the telephone arrangements were also made for an in terv iew. P r i o r to each interv iew wi th the pa t ien t , the interv iewer met the pat ient on the ward and engaged i n l i g h t conversation whi le - 39 -conducting the patient to the interview room. The reason for this procedure was to lessen any anxiety which the patient might be experiencing about the research interview, set him at ease, and enable both researcher and patient the opportunity of adjusting to each other. In the case of the reciprocals, the interviewer engaged i n l i g h t conversation, and then casually led the conver-sation i n the d i r e c t i o n of the research. In two instances, and rather i n the s p i r i t of an experiment, the ward was contacted and asked i f a nurse would escort the patient to the interviewing room. Interestingly, there was a noticeable difference i n the i n i t i a l stage of the r e l a t i o n s h i p , the patients escorted by the nurses to the interview room, tended to be less at ease, seemed uncom-fortable i n t h e i r chairs, tense and cautious. For the f i r s t f i v e minutes they appeared somewhat l o s t and apprehensive. This s i t u a -t i o n changed quite r a d i c a l l y ten minutes a f t e r they entered the . o f f i c e . In each interview, the researcher introduced the focus of the interview, b r i e f l y summarised the purpose of the research, and the reason why the research was being conducted. Each respon-dent was informed that no names would appear and that the i n f o r -mation provided by him or her was not intended for h o s p i t a l use. The introduction used was structured i n a guide attached to the interview format, and was the same for each interview whether with - r patient or r e c i p r o c a l . The respondent was t o l d that the format was a guide and would be referred to during the interview. Should the respondent wish to ask any question i n r e l a t i o n to the questions put to him i n the interview, he or she should f e e l free to ask. Few questions were actually asked by respondents, those that were, were requests for c l a r i f i c a t i o n of the meaning of the question, - 40 -o r r e q u e s t s t h a t t h e r e s e a r c h e r r e p e a t t h e q u e s t i o n . I n o n l y o n e i n s t a n c e , i n t h e i n t e r v i e w w i t h M r . M . - a p a t i e n t ' s h u s b a n d , a f t e r h e h a d ansx^ered t h r e e q u e s t i o n s , w e r e q u e s t i o n s a s k e d a b o u t t h e i n t e r v i e w e r ' s p o s i t i o n a n d s t a t u s i n r e l a t i o n t o t h e h o s p i t a l . W h e n q u e s t i o n s a s k e d w e r e f o r c l a r i f i c a t i o n , t h e i n t e r v i e w e r g a v e a s t a n d a r d e x a m p l e o f w h a t was m e a n t b y t h e q u e s t i o n . I n t h e p r e l i m i n a r y p r o c e s s o f f o r m u l a t i n g m e t h o d , i t was a n t i c i p a t e d t h a t t h e w r i t e r w o u l d b e p e r m i t t e d t o c o n d u c t a l l i n t e r v i e w s w i t h p a t i e n t s a n d r e c i p r o c a l s . T h i s a s s u m p t i o n was b a s e d o n t h e f a c t d u e t o t h e s m a l l s i z e o f t h e s a m p l e a n d t h e u s e o f a s t a n d a r d i s e d i n t e r v i e w s c h e d u l e , t h e i n t e r v i e w e r s h o u l d b e t h e same f o r a l l i n t e r v i e w s s o a s t o l i m i t t h e a m o u n t o f b i a s i n t h e r e s e a r c h . H o w e v e r , i n t h e c a s e o f two i n t e r v i e w s w i t h p a t i e n t s , M r . C . a n d M r . R . , t h e s u p e r v i s o r f e l t t h a t t h e w o r k e r s h a d a v e r y g o o d r e l a t i o n s h i p w i t h t h e p a t i e n t , a n d c o n s i d e r e d a t t h e t i m e i t i n a d -v i s a b l e t o i n v o l v e t h e s e p a t i e n t s i n a n i n t e r v i e w w i t h a n y o n e o t h e r t h a n t h e i r s o c i a l w o r k e r s , a s i t m i g h t l e a d t o some c o n f u s i o n . T h e w r i t e r d i d n o t o p p o s e t h i s s u g g e s t i o n m o r e p a r t i c u l a r l y a s h e was g i v e n f u l l o p p o r t u n i t y t o e x p l a i n t h e f o c u s a n d p u r p o s e o f t h e t h e s i s t o t h e s o c i a l w o r k e r s , d i s c u s s t h e n a t u r e o f t h e q u e s t i o n s s t r u c t u r e d i n t h e i n t e r v i e w f o r m a t . F u r t h e r m o r e t h e u s e o f a n i n t e r v i e w f o r m a t i n c o n d u c t i n g t h e i n t e r v i e w w o u l d t e n d t o e l i m i n a t e t h e b i a s o f t h e i n t e r v i e w e r . H o w e v e r , t h e i n v o l v e m e n t o f a d d i t i o n a l i n t e r v i e w e r s r e p r e s e n t s a n a d d i t i o n a l v a r i a b l e a n d p o t e n t i a l l i m i t a -t i o n . B e s i d e s t h e p r e l i m i n a r y c o n t a c t s w i t h t h e p a t i e n t a n d r e c i p r o c a l , d u r i n g t h e p r o c e s s o f t h e i n t e r v i e w , t h e w r i t e r u s e d - 41 -consistently communication intended to lend support to the person being interviewed, and gain his or. her co-operation. For example the individual was asked to help with the study, the writer was sympathetic in those situations which were and had been stressful. When individuals wondered whether they were giving the right i n -formation, the writer responded by saying that "what you are telling me is invaluable", " i t sure is important". At the end of the interview, the individual was asked by the writer "Are there any comments you would like to make?", "Is there anything else you would like to say in relation to the questions you have been asked?" The patient or reciprocal was then thanked for their co-operation and help. In a l l the interviews the respondents thanked the writer, and hoped that the information would be of help, four respondents offered further help, and two respondents said that they were pleased the writer had come, that i t was "nice to have someone they could talk to". Generally the interviews were from sixty minutes to seventy five minutes in duration, and covered fairly adequately the f u l l range of questions. Finally in view of the horizontal character of the research method, the writer obtained recordings of the patient's history, compiled by the ward psychiatrist to provide for the vertical dimension. This was done in view of the rationale underlying social.,role theory, as well as to facilitate analysis of the data obtained by the writer in terms of physical and psychological functioning. - 42 -Limitations of the Study Throughout th i s chapter frequent reference has been made to the question of l i m i t a t i o n s . That these l i m i t a t i o n s seriously hindered the research has been f a i r l y well established. In most ... instances, they rendered c r i t e r i a i n e f f e c t i v e ; they required un-q u a l i f i e d changes i n method; they minimised the si g n i f i c a n c e of the sample because the f i n a l sample had to be made up of cases not meeting s e l e c t i o n c r i t e r i a , thereby making i t highly unrepresentative. F i n a l l y some point should be made about the setting. Presently, Crease C l i n i c suffers from an acute shortage of o f f i c e s and interviewing rooms. In many departments, o f f i c e s are shared, and the chance of obtaining an o f f i c e i n which to conduct an i n t e r -view i s a matter of 'pure luck*. On three occasions patients had to be kept waiting, and on four occasions the time of the i n t e r -view had to be changed. Such problems as these can detract from the value of the research and may i n the broadest sense be a measure of the i n s t i t u t i o n ' s i n t e r e s t i n research generally. Recording Since the major portion of the study depended highly on the interview, the question of recording was extremely important. The use of a f a i r l y well structured interview format somewhat aided recording i n the interviews. Each question i n the format i s numbered so that responses could be numerically tabulated. In most instances the recording i s i n verbatim form, except i n the interviews con-ducted by someone other than the writer. Recordings of the i n t e r -views appear i n the index of the thesis. CHAPTER II I ROLE AND STRESS: PRIOR TO AND DURING HOSPITALISATION The following chapter presents a descriptive analysis of the data obtained i n interviews with both the patients and a reci p r o c a l family member - the spouse. No attempt i s made to use the whole body of material obtained and only those responses which are f e l t to be of s i g n i f i c a n c e i n terms of the study have been selected for presentation. I n i t i a l l y the writer discusses the roles as perceived and performed by the patient and his reciprocals p r i o r to and a f t e r the admission of the patient to mental h o s p i t a l . So that areas of stress can more e a s i l y be i d e n t i f i e d , an exposition follows of the attitudes to r o l e adjustment, and adaptations made by a l l members of the family to displacement. 1 In order to d i l u t e the tendency of the study to somewhat ignore the broader s o c i a l network of i n t e r r e l a t i o n s h i p s with people other than the family, the matter of r e l a t i v e s and friends are b r i e f l y referred to i n r e l a t i o n to mental i l l n e s s and h o s p i t a l i s a t i o n . Throughout this chapter and the following chapter, re-ference w i l l be made to Chart 1. The chart i s a summary of those factors f e l t to have a bearing on the study and includes information extracted from h o s p i t a l f i l e s pertaining to the patient and the family members. Each family has been designated a case number ( 1 - 9 ) and an alphabetical l e t t e r . Reference w i l l either be made to the alphabetical l e t t e r (eg. Mrs. F.) or case number (eg. Case 1). To f a c i l i t a t e presentation, cases w i l l be discussed i n d i v i d u a l l y , o r i n groups, whichever i s the most convenient i n terms of the data being referred to. 1 See Chapter I, Page 21, Footnote 1. Pt. Age Diagnosis Date of Adm. Treatment No. of .Prev. Adm. Occupation Marital Reciprocal i Other Family Reciprocals Residential Area < Social Serv. active. Date of Interview. Mrs. F. Gasel 27 Catatonic Schizophrenic Reaction Mar JO 1963. Cert. E.C.T., Chemo Therapy 2 Housewife Husband (army sargeant) four sons (5-9 yrs.) Camp Shile, Manitoba No Patient A p r i l 1963 i Mrs. M. Case 2 43 Psychoneurotic in an emotionally unstable person-a l i t y . Mar. 29 1963 Vol. Insulin, Chemo thsrapy group psyh> therapy 2 Housewife Husband (labourer) 3 sons 1 daughter (son aged 4 at home) Burnaby No Patient A p r i l 1963 Mrs. D. Case 3 31 Neurotic Depressive Reaction A p r i l 10th, 1963 Vol. E.C.T. Chaic Therapy 1 Housewife Husband (school teacher) 1 daughter 2 sons ( 7 months - 8 years) Chilliwack No Patient A p r i l 1963 Reciprocal Ap r i l 1963 Mrs. Case 4 43 Chronic Undifferentiated Schizophrenic Reaction March 28, 1963. Cert. E.C.T., Chemo Therapy 2 Housewife Husband (Delivery van driver) 2 sons aged 9 & 6 years Vancouver No Patient A p r i l 1963 Mr.B Case 5 24 Depressive Reaction i n Schizoid Unstable Personality March 1st, 1963 Vol. E.C.T., chem and group psycho-therapy 0 Drifter-unemployed 12 months wife separated 2 daughters ( 3 months & 1 year) Burnaby Yes (intake) Patient A p r i l 1963 Mr. Ch. Case 6 52 Psychotic Depressive Reaction Feb. 19th, 1963 v o l . E.C.T. 0 Unemployed 6 months Wife (saleswoman) 3 sons 1 daughter (9-19 yrs.) New Westmin-ster Yes Patient Ap r i l 1963 Reciprocal Mr. R, Case 7 44 Paranoid Schizophrenic March 22nd, 1963 Vol. E.C.T., chemo therapy 0 Unemployed 6 months Wife (housewife) 1 daughter 2 sons (5-11 year^ Port Kells No Patient Ap r i l 8, 1963 Reciprocal A p r i l 26, 1963 Mr. C. Case 8 4 0 Chronic Brain Syndrome Post Traumatic Personality Disorder Feb. 2.1st, 1963 Cert. Chemo Therapy 0 Unemployed 16 months Wife (housewife) 3 sons 1 daughter (8-16 yrs.) Richmond No Patient A p r i l 1963 Reciprocal Mr. E, Case 9 37 Sociopath!c-Sexual Deviation Homosexual. Depressive Neurotic Reaction March 10th, 1963. Vol. Group pjsydxK-individual-Recreational Occupational Therapy 0 Shoe Salesman Wife (Carting clerk) 1 son 2 daughters ( 1 0 -15 yrs.) Vancouver No Patient A p r i l 1963 Reciprocal CHART I - 44 -DEFINITION OF ROLES  Roles Prior to Hospitalisation The Role of Married Woman with Children  In the Home Of the eight -women interviewed, four of which were hospitalized patients, the tendency was to generalize the compon-ents of a particular role using a common descriptive word -"housework". With the exception of Mrs* E. (case 9) who described her role i n the home thus: "The same things I've always done, perhaps more crankier than usual. Working, looking after kids, taking care of everyday l i v i n g . " 1 The remaining seven women, added a brief description containing the following common elements: cleaning, washing, cooking food, looking after children, shopping at least once a week. Mrs. C. who has an invalid husband added to these: "Looking after husband, seeing that he changed his clothes, washed, went to bed and awoke at the right time." ^ Mrs. R. who lives i n a typically rural area added: "attending to„the animals, milking the goats, feeding the fowls." J 1 Excerpt from Case 9, interview with reciprocal, response to question 3(a). Appendix. 2 Excerpt from Case 8, interview with reciprocal, response to question 3(a). Appendix. 3 Excerpt from Case 7, interview with reciprocal, response to question 3(a). Appendix. - 45 -In the interviews with husbands whether reciprocals or patients, the same pattern was repeated, they generalized the comp-onents of the woman's ro l e , and i n five<of the seven interviews gave b r i e f descriptions which corresponded exactly with the descript-ions applied by t h e i r wives. Of the remaining two, i t was not possible to interview the wife of one patient, and i n the case of Mr. E. he supplied a description of his wife's role which she had not given i n the interview with her. "She does everything, the dishes, ironing, washing, cooking, making clothes for the family, shopping, the ent i r e gamut. Looking a f t e r the chil d r e n . " 1 which corresponds highly with the descriptions given by seven of the female informants. S o c i a l l y S o c i a l l y there was not a great deal of v a r i a t i o n i n the s o c i a l l y oriented roles of female respondents. A l l eight reported contact with a neighbour or fr i e n d , four had an additional s o c i a l a c t i v i t y . Mrs. Ch. c u r l i n g , Mrs. R. piano lessons, Mrs. S. walking with sons, Mrs. C. bowling. Of the remaining irour, one reported no other a c t i v i t i e s , while the other three reported at lea s t two or more a c t i v i t i e s . Mrs. M. "attending church and women's c i r c l e , playing cards, drives with friends". Mrs. F. "dances, dinners, playing cards". Mrs. E. "dancing lessons, the Diabetic Association". ( i n which she holds the p o s i t i o n of Secretary/ -Treasurer) 1 Excerpt from Case 9 , interview with patient, response to question 3. Appendix. - 46 -Where husbands were describing the roles of t h e i r wives, there was p a r i t y of description. For example i n the case of Mrs. M. she described her s o c i a l l i f e thus: "I spent a l o t of time with Mrs. Ms., stayed there on ;weekends. Went to church on Sundays, i n the morning had coffee with one of two neighbours, watched T.V. i n the evening, s i t i n the corner reading to stop thinking. Played cards on the weekend with Mrs. Ms., and went fo r drives with her. Went to a church women1s c i r c l e . " Mr. M. described h i s wife's s o c i a l a c t i v i t i e s thus: "She spent weekends with Mrs. Ms., watched T.V., went .to church, was always v i s i t i n g two neighbour friends, reading, went to ladies church c i r c l e . " The Role of Married Men with Children  In the Home Two of the seven respondents gave no actual description of t h e i r role i n the home, a further two gave a very b r i e f descript-ion, and the remaining three descriptions were i n more d e t a i l . " T e l l Edna (wife) the r i g h t way of going about l i f e , as I understand-it. -If she had l i s t e n e d to me there would be no need for her to go (to h o s p i t a l ) . I do my own sand-wiches, make my own breakfast, take wife a cup of tea i n bed i n the mornings, get my own cup of tea at night. When my wife was at Mrs. Ms.'s made my own supper. Mrs.M. was against i t . I washed up the dishes, washed the f l o o r s , washed the kitchen f l o o r . When I came home from work spent most of my time with my son. On weekends I was with him most of the time. She (wife) couldn't stand him (son) around." 3 i- :Excerpt from Case 2, interview with patient, response to . question 2. Appendix. 2 Excerpt from Case 2, interview with r e c i p r o c a l , response to question 3(b). Appendix. 3 Excerpt from Case 2, interview with r e c i p r o c a l , response to question 3. Appendix B. \ Mrs. M. i n her description of her husband's role i n the home, gave a response which correlates with Mr. M. »s description of hi s r o l e . "He eats supper, washes up, makes h i s own sandwiches, .washes f l o o r s , and washes the kitchen f l o o r . Cares f o r son and plays with him i n the garden, messes around i n the basement. Made his own breakfast, when I was away made hi s own meals." Mr. D. described his home a c t i v i t i e s : "I help with the dishes, most of the time I spend working .on another houses I put my daughter to bed. I d i s c i p l i n e children when I see.the s i t u a t i o n . T do anything I am asked to do. Sometimes I do a b i t too much to the_frust-ra t i o n of my wife. Spend a l o t of time reading." * Mrs. D. i n less d e t a i l showed a degree of p a r i t y i n her description of her husband's a c t i v i t i e s i n the home. "He helps with the dishes, baby-sits, spends a l o t of time building a new house. Spends a l o t of time reading." 3 Mr;.E.«s description of his role a c t i v i t i e s correlated with Mrs. E. »s description. "Upkeep the gardening, washed dishes occassionally, take .wife shopping. General d i s c i p l i n a r i a n f or family. With the children i n the evening, while my wife i s at work. I t a l k to the children and play with them. I w i l l clean the c h e s t e r f i e l d and rugs." ^ Mrs. E.»s description of husband's a c t i v i t i e s i n the home. "Washes the dishes, works i n the garden, d i s c i p l i n e s the .children, l i s t e n s to records, spends time with the children. Cleans the rugs, takes me shopping." 5 1 Excerpt from Case 2, interview with patient, response to question 3. Appendix B. 2 Excerpt from Case 3, interview with r e c i p r o c a l , response to question 3. Appendix B. 3 Excerpt from Case 3, interview with patient, response to question 3. Appendix B. 4 Excerpt from Case 9, interview with patient, response to questional. Appendix B. 5 Excerpt from Case 9, interview with r e c i p r o c a l , response to question 3. Appendix B. - 48 -S o c i a l l y Seven out of seven of the men interviewed reported no s o c i a l l i f e of any account. They v i s i t e d a fri e n d or friends only occasionally. Responses to questions about the s o c i a l l i f e of husband tended to correlate completely without exception. Mr. D. stated that he did do enough s o c i a l l y . Mr. M. stated that his s o c i a l l i f e had changed i n the l a s t four months. Mr. E. explained that he was not able to lead a f u l l e r s o c i a l l i f e because his wife worked at nights. The Role of Children 1 In the -Home Case 1 Mrs. F. has four sons ranging i n age from 4 years to 8 years. Three sons go to school, and the youngest attends kindergarden. The 7 year old son attends a Child Guidance C l i n i c . The two eldest boys make t h e i r own beds, and when home, keep an eye on the youngest. The three eldest sons attend swimming classes, take part i n cubs, and they a l l play with friends. They play with t h e i r trains and ping pong. They help wash the dishes. Case 2 The M. family have one c h i l d aged 4 years l i v i n g at home. Mrs. M. has three other children by a former marriage. One i s adopted and the remaining two are i n the Navy. 1 See responses to question 3, interviews with rec i p r o c a l s . See responses to question 4, interviews with patients. Appendix B. - 49 -Mrs. M. reports that he plays with toys, and the neighbour's children. He spends a considerable amount of time at the home of Mrs. Ms. (a f r i e n d ) . Mr. M. added to t h i s d i s c r i p t i o n that his son goes for walks with him, and plays with him i n the garden. Case 3 The D. family have three children ranging i n age from 7 months to 8 years. One c h i l d i s at school. They do not have many friends. They play together. Mrs. D. takes the eldest son to the l i b r a r y . Mr. D. added that the son builds models, reads, and the daughter plays with cats. Case 4 The S. family have two sons- aged 6 years and 9 years. Both attend school. They dry dishes, t i d y up clothes, l e a r n carpentry i n the basement. They play with friends a l o t . One son i s a cub. Case 5 The B. family have two children. Mr. B. oould give no description of the a c t i v i t i e s . Case 6 The Ch. family have four children ranging i n age from 9 years to 19 years. Mr. Ch. related that the eldest son works, the others attend school. They have few friends, belong to no groups or clubs. They help i n the home, with dishes, cooking. - 50 -They do not go out much. Mr. Ch. added to his wife's description: "Children look a f t e r t h e i r own rooms; watch T.V. a great deal of the time." 1 Case 7 The R. family have three children ranging i n age from 5 years to 11 years. The daughter aged 11 years i s mentally retarded due to emotional stress, and was a patient at the Burnaby Children's C l i n i c . Two of the children attend school. Mrs. R. stated that the eldest daughter takes music lessons, clears the table. They a l l make t h e i r own beds, help feed the an i -mals. The two sons feed t h e i r pet rabbits, help clean the f l o o r , and burn papers. They do not have many friends to play with. They play together. Mrs. R. explained that i n the past s i x months the children have not been allowed friends by father (patient). Mr. R. gave a f u l l description of the a c t i v i t i e s of the children. G i r l - "helps with dishes, and the housework, helps feed the rabbits, plays with friends - school friends, v i s i t s with them and they v i s i t with her. I'm a f r a i d I made i t pretty tough on them when I quit my job." 2 Boy - " t r i e s to be h e l p f u l , pretty good l i t t l e k i d -same as older s i s t e r , has friends." 2 Youngest - "exceptionally sociable. I think he takes a f t e r his mother, always playing around the barn, looks a f t e r his rabbits, asks me i f he can help, usually works •with me." 2 1 Excerpt from Case 6, interview with patient, response to question 4. Appendix B. 2 Excerpt from Case 7, interview with patient, response to question 4. Appendix B. - 51 -Case 8 The C. family have four children ranging i n age from 8 years to 16 years. They a l l attend school. Mrs. C. says: "the two eldest boys go f i s h i n g , hunting, the second eldest plays g o l f . The two older boys take turns washing the dishes, they t i d y t h e i r rooms. Made i t a necessity, figured they should have done i t a long time before, but mother-in-law i n t e r f e r e d . " i Mr. C. i n response to questions about the children said: "They do help with domestic chores, they're always : out of the house." ^ Case 9 The E. family have three children with ages ranging from 10 years to 15 years. A l l attend school. Mr. E. stated that: "The children do nothing i n the home, they don't help "mother. They have a great many friends, the eldest goes to dance p a r t i e s , i s a scout. The older daughter goes to g i r l friend's parties and i s , a Pioneer. The younger daughter spends a l o t of time at home with -daddy." 3 Mrs. E. just f e l t they were good children. 1 Excerpt from Case 8. Interview with r e c i p r o c a l , response to question 3. Appendix B. 2 Excerpt from Case 8. Interview with patient, response to question 4. Appendix.B. 3 Excerpt from Case 9. Interview with patient, response to question 4. Appendix.B. - 52 -D i s c u s s i o n C a s e 1 I n r e l a t i o n t o t h e r o l e a c t i v i t i e s d e s c r i b e d b y M r s . F . , p r i o r t o h o s p i t a l i s a t i o n s h e t h o u g h t t h a t s h e s h o u l d m e n d h e r w a y s i n c o o k i n g , k e e p h e r s e l f s m a r t , m a k e t h i n g s e a s i e r a t h o m e . S h e f e l t s h e w a s t o o s t r i c t w i t h t h e c h i l d r e n a n d t o o h a r d o n h e r h u s b a n d . S o c i a l l y s h e e x p l a i n e d s h e h a s o n l y t w o o r t h r e e f r i e n d s , a n d h a s t r o u b l e k e e p i n g t h e m . T h e y n e v e r come t o t h e h o u s e , b e c a u s e s h e k e e p s t h i n g s t o o c l e a n . T h e r e a s o n f o r t h i s w a s t h e f a c t t h a t h e r h u s b a n d , a s e r g e a n t i n t h e a r m y , w a s a l w a y s i n s p e c t i n g h o u s e s , a n d s h e f e l t o b l i g e d t o k e e p u p a p p e a r a n c e s t o s e t a n e x a m p l e , a n d l e s t h e f o u n d s o m e t h i n g w r o n g . T h e i n f e r e n c e may b e d r a w n t h a t M r s . F . h a s some c o n f u s i o n i n h e r r o l e o f h o u s e w i f e d u e t o h e r c o n f u s e d p e r c e p t i o n o f h e r h u s b a n d ' s r o l e . M r s . F . s t a t e d t h a t s h e s t a r t e d w o r k i n g a s a N u r s e s A i d e a m o n t h p r i o r t o h e r h o s p i t a l i s a t i o n , b e c a u s e o f f i n a n c i a l p r o b l e m s . S h e w o r k e d f r o m 6 a . m . t o 3 p . m . H e r h u s b a n d a s s u m e d t h e m a t e r n a l a c t i v i t i e s o f s e e i n g t h e c h i l d r e n g o t r e a d y f o r s c h o o l , a n d t h e d o m e s t i c - a c t i v i t i e s o f c o o k i n g b r e a k f a s t a n d c l e a n i n g u p a f t e r w a r d s . A r r a n g e m e n t s w e r e m a d e w i t h a woman t o c a r e f o r t h e y o u n g e s t c h i l d . M r . F . e x p r e s s e d h i s d i s a p p r o v a l o f M r s . F . w o r k i n g , f e a r i n g t h a t t h e p r e s s u r e o f w o r k a n d h e r d o m e s t i c , m a r i t a l , a n d m a t e r n a l r o l e s w o u l d l e a d t o m e n t a l i l l n e s s . G e n e r a l l y M r s . F . g a v e e v i d e n c e o f b e i n g q u i t e s a t i s f i e d w i t h t h e r o l e p e r f o r m a n c e o f h e r h u s b a n d a n d c h i l d r e n , b u t f e l t t h a t t h e c h i l d r e n s h o u l d s p e n d m o r e t i m e o n t h e i r h o m e w o r k , a n d t h a t h e r h u s b a n d b e i n g m o r e e d u c a t e d t h a t s h e , s h o u l d h e l p t h e m w i t h - 53 -t h e i r homework. The inference i s that there i s i n t h i s area a prob-lem of role expectation. Neither the children or husband are performing i n terms of Mrs. F. «s role expectations. In r e l a t i o n to Case 1, and i n terms of the descriptions of roles, and comments made i n r e l a t i o n to role functioning, the following stress areas are i d e n t i f i a b l e p r i o r to h o s p i t a l i s a t i o n . 1. The stress of Mrs. F.»s cleaning a c t i v i t i e s c a r r i e d out i n her role of housekeeper. At night when her husband was at home she c a r r i e d on cleaning, u n t i l her husband stopped her. She says now that she i s i n h o s p i t a l she feels "glad to get away from cleaning."! Her role perf-ormance was s t r e s s f u l to her and her husband. 2. The stress of lack of finances to meet b i l l s . Mrs. F. f e l t lack of finances prevented s o c i a l l i f e . ^ Mrs. F. responded to the stress created by the f i n a n c i a l problem, by assuming an additional r o l e , which we assume created stress for her husband and h e r s e l f . For she explains that her breakdown "could have been due to the s t r a i n of working."3 Case 4 Mrs. S. i s the wife of a P o l i s h immigrant. She states that he was an a l c o h o l i c u n t i l he started a job with the Sun eight months ago. She says that she i s treated l i k e a servant and that 1 Excerpt from Case 1, response to question 12, interview with patient.. Appendix B. 2 Excerpt from Case 1, response to question 2, interview with patient. Appendix B. 3 Excerpt from Case 1, response to question 24, interview with patient. Appendix B. - 54 -t h i s i s because P o l i s h men treat t h e i r wives i n this fashion. She feels treated l i k e a servant because of the manner i n which he talks to her. He i s constantly cranky. "I am not contented at home, I hate the way he talks to me. .I'm treated as a servant." 1 There i s quite c l e a r l y a c o n f l i c t of r o l e expectation for Mrs. S.'s responses i n f e r that her "husband's role functioning i s not considered appropriate i n terms of her perception, and furthermore she i s i n c o n f l i c t with h i s perception of her role i n the family. Consequently" the c o n f l i c t has led to stress. Mrs. S. t r i e d to adapt to the stress by abandoning her r o l e , however, "They reunited three months ago because she had no other place to go, not because she wanted to. She came back on h i s condition that she must obey orders. Since the reunion she has been upset and hearing voices." 2 It may be i n f e r r e d therefore that there i s severe marital stress, which Mrs. S. t r i e d to resolve through r o l e abandonment, th i s proved unsuccessful and eventually led to the development of symptoms. Mrs. S.'s r o l e descriptions t e l l us of her very l i m i t e d s o c i a l network. "As to her s o c i a l and recreational l i f e , she says that she could be happy but that her husband won't l e t her, that anything she undertakes he makes sneering remarks about and i s very c r i t i c a l . " 3 Thus her r e c i p r o c a l i s acting i n such a way that he Is impairing Mrs. S.»s role functioning. 1 Excerpt from Case 4, interview with patient, response to question 6. Appendix B. 2 Ward Notes, Mrs. S. Case 4. Appendix C. 3 Ward Notes, Mrs. S. Case 4, page 2. Appendix C. - 55 -Case 2 Mrs. M.»s expectation and perception of her husband's role and relationship i s the cause of stress f o r her. "I would l i k e my husband to s i t and t a l k , give under-standing, comfort. He s i t s i n the kitchen reading sexy books. I am ashamed of him, he's nothing but a ditch digger." 1 Concerning her performance of domestic, marital roles Mrs. M. said that: "I got very bored and i t made me b i t t e r . I wanted to go out but couldn't, when I went out i t was with Mrs. Ms., but her way of l i f e i s d i f f e r e n t to mine. I refuse to go to my husband's club. I l i k e people, but I couldn't drive myself to go.• I don't l i k e housework but had to be t i d y . This got on.my husband's nerves, but I did the housework nevertheless. I didn't want to go out with my husband, he makes me f e e l so embarrassed.".2 Mr. M. i s not s a t i s f i e d with either his wife's domestic, maternal, marital r o l e functioning i n the relationship she has with him. Mr. M. i s i n c o n f l i c t because his wife does not perform accord-ing to h i s expectations. Because of the stress and dysfunction of role i n t e r e l a t i o n s h i p s , Mr. M. no longer feels i n a p o s i t i o n to continue his s o c i a l l y oriented ro l e s . He has for the four months p r i o r to h o s p i t a l i s a t i o n , given up roles i n the s o c i a l environment . and taken on additional roles i n the home which he feels are essent-i a l l y ones which his wife should perform. E s s e n t i a l l y then the stress i s related to ma r i t a l , maternal and domestic performance relationships, which have i n turn impaired s o c i a l r o l e s , and created more stress. 1 Excerpt from Case 2, interview with patient, response to question 2 Excerpt question 5. Appendix B. from Case 2, interview with patient, response to 6. Appendix B. - 56 -Case 3 Mrs. D. f e l t her role performance and relationships were very d i f f e r e n t when she was mentally i l l . "While sick, I was d i s s a t i s f i e d with everything, everything was a tremendous e f f o r t , went to bed and c r i e d ... s t i l l went v i s i t i n g ... the family didn't mean anything." 1 I n i t i a l l y i n describing her roles at home and s o c i a l l y she tended to give descriptions at period before her pregnancy and i l l n e s s - 16 months ago. When she had a f a i r l y broad role network. "I went to the Women's I n s t i t u t e Sewing C i r c l e , P.T.A., .attended meetings of the h o r t i c u l t u r a l and Alpine Club once a month. V i s i t e d frequently." 2 The onset of pregnancy and l a t e r mental i l l n e s s . While there i s no substantial evidence to suggest that the i l l n e s s may have been caused through stress engendered by role t r a n s i t i o n , i t remains an unproved p o s s i b i l i t y . I t i s true however, that Mrs. M. had a very active broad role network, and a wide range of s o c i a l l y accepted ways of meeting her needs, she also says that: "Pregnancy l a s t year stopped me from doing a l l these things." 3 From th i s i t could therefore be i n f e r r e d i n terms of s o c i a l role theory, that Mrs. M. was i n a state of rolessness. This could conceivably have caused stress. Mr. D. expressed s a t i s f a c t i o n with h i s role functioning and the roles of a l l other members of the family. He explained that he l i k e s his work as a teacher, has a s o c i a l l i f e that i s 1 Excerpt from Case 3, interview with patient, response to question 6. Appendix B. 2 Excerpt from Case 3, interview with patient, response to question 2. Appendix B. 3 Excerpt from Case 3, interview with patient, response to question 2. Appendix B. - 57 -enough for himself, and was generally happy to be doing things together with.others i n the family. Mrs. D. expressed the same theme. Case 6 From the responses obtained i n interviews with Mr. and Mrs. Ch. i t was strongly evident that there was no general d i s -crepancy i n family r o l e perceptions. However, i t was most apparent that Mr. Ch.«s role expectations f o r himself were creating consid-erable stress. Since the collapse of hi s plumbing business i n Calgary, and Mr. Ch.«s migration to New Westminster to escape his debts, he has not been i n employment. He feels extremely badly that he cannot provide f o r h i s family. Mrs. Ch. has had to f i n d employment as a sales woman i n order to cope with some of the economic needs of the family. Thereby displacing Mr. Ch. as "breadwinner". She i s unhappy and misses her former l i f e i n Calgary, and therefore i s i n a state of rolelessness. The c h i l d r e n are also unhappy, and have had problems at school, due to the difference i n educational programs between Alberta- and B r i t i s h Columbia. S o c i a l l y they have not been able to develope a s a t i s f a c t o r y r o l e network i n New Westminster i n any way comparable to the ro l e network they had i n Calgary. "They have not met friends, and want to return to Calgary." 1 Like mother they are i n a state of rolelessness. 1 Excerpt from Case 6 , interview with r e c i p r o c a l , response to question 3. Appendix B. - 58 -In p r a c t i c a l l y a l l the responses about role functioning p r i o r to h o s p i t a l i s a t i o n , Mr. and Mrs. Ch. talked about what they and the children did at home and s o c i a l l y while i n Calgary. I t i s cle a r that i n the family's i n t e r a c t i o n with the present s o c i a l environment they are experiencing considerable stress. The family finances which are poor are a source of stress. School for the children i s also a source of stress. The stress s i t u a t i o n i s adequately expressed i n Mrs. Ch.'s statement that "We don't go out, my husband's business f e l l apart, we have f i n a n c i a l worries. I t has an e f f e c t on the children. We have a l l had to give up a l o t . My husband has had to give up work. I am very d i s s a t i s f i e d with things." 1 1 Excerpt from Case 6. Interview with r e c i p r o c a l , response to question 4. Appendix B. - 59 -Case 7 The s o c i a l roles of Mr. R. »s reciprocals i n the family have l a r g e l y been determined by Mr. R. «s periods of i l l n e s s . Mrs. R. states that her husband's i l l n e s s has been evident for seven years. The family have learnt consequently to adapt to those periods when he has been disturbed at home. Despite t h e i r a b i l i t y to adapt t h e i r s o c i a l l i f e and roles to his periods of i l l n e s s and reason-ably healthy functioning, Mrs. R. finds the s i t u a t i o n s t r e s s f u l . "When my husband was i l l , i t was pretty awful, he could be dangerous, he argued a l l the time. When he went into a depression he would drink, become v i o l e n t , destroy the house." 1 " V i s i t i n g neighbours stopped l a s t September. A l l winter .long I saw nobody, he objected to my going out, now he i s i n . h o s p i t a l things are back to normal, and I have retained contacts with neighbours and friends." 2 The s i t u a t i o n was s l i g h t l y d i f f e r e n t with the children, and Mr. R. l e t them see only c e r t a i n people. Mrs. R. reacted to the stress caused by her husband's most recent pathological functioning and behaviour by leaving him. This made things s t r e s s f u l f o r him, and when he saw his wife .;he: said that he would go to Crease C l i n i c i f she returned home. Of Mr. R. »s role functioning, Mrs. R. feels that he has not been a father to the children, and i s incapable of taking care of himself without her help. ., "My husband can't do anything alone, he can't function without me - i t ' s unnatural, but I have got used to i t . " 3 1 Excerpt from Case 7, interview with r e c i p r o c a l , response to question 4. Appendix B. 2 Excerpt from Case 7, interview with r e c i p r o c a l , response to question 3. Appendix B. 3 Excerpt from Case 7, interview with r e c i p r o c a l , response to question 21. Appendix B. - 60 -In t h i s case the major area of stress i s i n r e l a t i o n to the adaptations family members have to make when Mr. R. (patient) becomes disturbed at home. I t can only be postulated that Mrs. R.'s assumption of some of her husband's roles at home, have created stress for him, and stress for her, although she gives no conclusive evidence that t h i s i s the case. Case 8 Mr. C. has a long h i s t o r y of h o s p i t a l i s a t i o n following a serious accident i n the winter of 1962. He was discharged as an i n v a l i d i n December 1962 from Shaughnessy Hospital. Mrs. C. maintains that she has adapted to her husband's condition, and only sought his admission to Crease C l i n i c following stress caused when "he became aggressive towards h i s wife so that she had .to c a l l i n neighbours to quiet him down." 1 Since his accident and i t ' s physical and mental con-sequences Mr. C.»s range and s o c i a l network have become ser i o u s l y l i m i t e d and impaired. He has not been able to meet the expect-ations of his role as father, breadwinner,, husband, nor gain any measure of independence i n his functioning. He was u n t i l h i s h o s p i t a l i s a t i o n completely dependant on the family. Mr. C.»s response to format question 5 was inappropriate " n i l , not thought about i t - as long as I don't get .trouble." 2 1 Ward Notes, Mr. C. Case 8. Appendix C. 2 Excerpt from Case 8, interview with patient, response to question 5. Appendix B. - 61 -However he was able to verbalize his feelings about his s o c i a l role s i t u a t i o n . "I'm never s a t i s f i e d , I would l i k e to do machine work, repair work, spend more time with the children. Have more s o c i a l l i f e . I had a l o t of friends i n Richmond. I t would be easier for my parents i f we moved." 1 Mr. C. would appear from t h i s response to have some perception of his role functioning. The C. family l i v e with Mr. C.»s mother and stepfather. Mrs. C. does not have a good relationship with her mother*in-law, and resents both, l i v i n g with them, though circumstances dictates that they must, and mother-in-law's interference i n family r e l a t i o n -ships. Concerning Mrs. C.«s r o l e s , and her assumption of new ones i n the family - nurse to husband, father as well as mother to the children, she does not appear to be experiencing stress i n these r o l e s , since circumstances dictate that she must adapt, which she appears to have done. She continues to maintain her s o c i a l l y oriented r o l e s , "I went out more often - i t was a form of escape to get to someone I could t a l k to - i t was the only thing that kept me going."2 The inference may be made however, that the new roles she was required to assume, together with her customary roles were st r e s s -f u l , but that t h i s stress was somewhat re l i e v e d by the range of 1 Excerpt from Case 8, interview with patient, response to question 6. Appendix B. 2 Excerpt from Case 8. Interview with r e c i p r o c a l , response to question 6. Appendix B. - 62 -her role a c t i v i t i e s . She may be said therefore to have established at that point i n time a symbiotic role network. Identifying therefore possible areas of stress i t may be stated that Mr. C. finds his s o c i a l r ole impairment s t r e s s f u l , and Mrs. C. finds her role functioning i n r e l a t i o n to her mother-in-law s t r e s s f u l . Case 9 Mrs. E.'s s o c i a l and family role functioning i s deter-mined i n part by her: working role - counting clerk on night s h i f t . When her husband Mr. E. i s at home i n the evening, she i s working. The husband-wife role relationship i s therefore somewhat impaired. Any stress i s defended against by the fact that both marital partners want more money. Mrs. E.'s s o c i a l l y oriented roles are also impaired by her working ro l e , but she does not appear to be having any stress. "I was doing just what I wanted to be doing, wish we had more money." i In the case of Mr. E., he i s d i s s a t i s f i e d with his working r o l e , s o c i a l r o l e , and marital r o l e , which he c o r r e c t l y perceives i s related to the need for more money, and h i s wife's working role. "He would l i k e to obtain a more s a t i s f a c t o r y and more . f i n a n c i a l l y rewarding employment so that his wife could quit work and therefore the lonely evenings at home would be avoided which have contributed to the release of t h i s mechanism, (excessive drinking and homosexuality)" 2 1 Case 9 , excerpt from interview with r e c i p r o c a l , response to question 4. Appendix B. 2 Discharge Synopsis, Case 9 . Mr. E. Appendix C. - 63 -His perception of hi s wife's r o l e , and her present role performance i n r e l a t i o n to himself are therefore a source of stress. His own s o c i a l role i s impaired because of Mrs. E.«s working role. This has produced stress which eventually has sought release i n path-o l o g i c a l behaviour which i s s t r e s s f u l to his wife because h i s drinking i s considered by her to be inappropriate and threatens her relationship with him, and i s s t r e s s f u l to him, as i t threat-ens his marriage. Mr. E. i s quite s a t i s f i e d with his wife's role perform-ance i n a l l other areas of family functioning. She meets his expectations of her maternal and homemaker roles. Parental roles i n r e l a t i o n to the children appear to be s a t i s f a c t o r y , from the perceptions of Mr. and Mrs. E. THE PROBLEMS OF HOSPITALISATION Affe c t s on Role Performance - Adaptations In the interviews with re c i p r o c a l s , they a l l reported that there was no a l t e r a t i o n i n t h e i r s o c i a l and home ro l e s , or those of family members. Mrs. C. said there was "Just as much r e s p o n s i b i l i t y , perhaps more when he was home. I t was a r e l i e f . " 1 Mrs. Ch. said there were no changes, as did Mr. D., Mrs. R. and Mr. M. Mrs. E. explained that "the children don't know (about Mr. E.'s admission to Crease C l i n i c ) we a l l took i t as a matter of course, i t had to be., I carr i e d on as before, except that I had to do a l l the worrying myself - c o n t r o l l i n g the. kids. I got a driver's license as a necessity." 2 1 Case 6. Interview with r e c i p r o c a l , response to question 5. 2 Case 9. Interview with r e c i p r o c a l , response to question 5. - 64 -However, t h e i r i n i t i a l responses were somewhat modified by a s l i g h t l y d i f f e r e n t l y worded question. Where there were very small children, not of school age, environmental changes were necessary and the s o c i a l network of the c h i l d altered, establishing new relationships for the c h i l d , with an undoubted change i n the s o c i a l and family roles and relationship within the nuclear family unit. In the case of Mrs. D. and Mrs. M. not only were they displaced from the family network, but so were one of th e i r children. Where there were older children, attending school and requiring some supervision, arrangements were either made with a frie n d to look a f t e r them u n t i l the p a t i e n t 1 s r e c i p r o c a l returned from work, or for a r e l a t i v e to l i v e with the family, thereby assuming some of the maternal and domestic roles formerly performed by the hosp i t a l i s e d patient. In the case of Mrs. D. Case 3 "Nothing altered, I took on extra r e s p o n s i b i l i t i e s .(cooking) and did.a minimum of everything. I loved the kids more than usual. I did everything that had to be done, reserved my strength, spent a l i t t l e less time working on the new house, continued my s o c i a l l i f e . The baby went to my mothers i n New Westminster and the younger son Is with a neighbour u n t i l I get home from work." 1 and Mrs. F. Case 1 "My husband had to take time o f f from work to look a f t e r the children u n t i l my mother-in-law arrived from Vancouver. It's working w e l l . " 2 Temporarily Mr. F. had to give up a rol e , and take on more family and home ro l e s , that was usual, u n t i l his mother arrived. 1 Case 3. Interview with r e c i p r o c a l , response to question 6 and 7.. Appendix B. 2 Case 1. Interview with patient, response to question 7. Appendix B. - 65 -In the case of Mr. M., immediately p r i o r to Mrs. M.»s admission to Crease C l i n i c , she made arrangements for her four year old son to l i v e at home, and spend the day with a neighbour. Mr. M. finding the extra r e s p o n s i b i l i t y too s t r e s s f u l made alternate arrangements shortly a f t e r his wife's h o s p i t a l i s a t i o n , for the c h i l d to l i v e with Mrs. Ms., a friend. This unburdened Mr. M. of a home role he found impossible to cope with, as well as a l l his other roles. Mrs. E. was fortunate i n the sense that any family changes or changes i n role functioning were anticipated because of her husband's planning p r i o r to his admission to Crease c l i n i c . Changes la r g e l y affected t h e i r role performance. She was required to modify her working role, by adjusting working nights from s i x to two a week. Mr. E. »s son was required to assume his father's gardening role,"on orders from father." "My wife's s o c i a l l i f e stopped, and any spare time she .had she comes out to see me - three or four times a week." 1 Mrs. E. vaguely described that " a l l members of the family had to take on extra respons-. i b i l i t i e s and they a l l had to watch money closer." 2 This was necessary as the family were required to l i v e on s o c i a l assistance, while Mr. E. was i n h o s p i t a l and not working, and Mrs. E. was working only two nights a week. Mr. E. made a l l the arrangements with S o c i a l Welfare p r i o r to his h o s p i t a l i s a t i o n . 1 Case 9. Interview with patient, response to question 8. Appendix.B. 2 Case 9. Interview with r e c i p r o c a l , response to question 7. Appendix B. - 66 -Any adjustments to r o l e functions took place e a s i l y and without stress. Mrs. Ch. f e l t there were no s i g n i f i c a n t changes, i t meant extra r e s p o n s i b i l i t y i n decision making, but she had become adjusted to this function, performed by her husband i n his r o l e as father, and head of-the family, u n t i l he became mentally i l l four months p r i o r to admission. Since, Mrs: Ch. has a very f u l l range of roles, i n r e l a t i o n to her home, family, and employer, she was only able to v i s i t her husband on her day o f f and Sunday. I t i s s i g n i f i c a n t however, that the eldest son began work shortly a f t e r his father's h o s p i t a l i s a t i o n . I t may be i n f e r r e d therefore, that as a r e s u l t of the stress engendered from economic factors, which attributed to father's mental i l l n e s s , he reacted to the s i t u a t i o n - threat of no money, clothes, food, by assuming a working r o l e . Mr. Ch.'s perception of h i s family r o l e s , now that he i s i n h o s p i t a l i s expressive of the stress he i s experiencing over his displacement from the family network. He says that he feels i t i s : "Not a pleasing thing to think about, I f e e l i t i s very hard on my wife. I don't l i k e to think of my son s e l l i n g shoes. But there i s nothing I can do." 1 The eldest son's working role i s not therefore i n congruence with father's expectations. 1 Case 6. Interview with patient, response to question 8. Appendix.B. - 67 -Mr. C o r the family were not s i g n i f i c a n t l y affected i n t h e i r range of role functions, neither was the family r o l e network s i g n i f i c a n t l y affected. I t would seem adequate to explain this as a consequence of the family's f a m i l i a r i t y with h o s p i t a l -i s a t i o n . Mrs. C. says that "We were not affected, as we have had the same thing f or ;ten months. The children are not f u l l y aware how father a c t u a l l y i s , they don't understand. When he was home he used to get mad at the children, used to say they broke his tools, so I would think they were relieved he returned to h o s p i t a l . " I I t w i l l be seen from t h i s description and previous reference to Mrs. C.»s attitude to her husband's h o s p i t a l i s a t i o n , that role i n t e r e l a t i o n s h i p s with reciprocals i n the family r o l e network, were s t r e s s f u l to the recip r o c a l s . Consequently, hosp-i t a l i s a t i o n as i t proved to be i n t h i s s i t u a t i o n , was stress r e l i e v i n g f o r the reciprocals i n the nuclear family unit. The release of stress, would suggestively not require any change i n role functioning, except release Mrs. C. of the r e s p o n s i b i l i t i e s of nursing role i n r e l a t i o n to dependant, invalided husband. 1 Case 8 . Interview with r e c i p r o c a l , response to question 9 . Appendix B. - 68 -PATIENT PERCEPTION, ATTITUDES IN RELATION TO RECIPROCALS  ROLE PERFORMANCE, AT HOME, SOCIALLY Referring specifically to eight selected cases, four of the patients (three males and one female) were satisfied with arr-angements at home. In the case of Mr. E. Case 9, he s t i l l retained, despite his absence from home a measure of control. Of the nine cases i t was the only case, which suggested to the writer the con-cept of the invisible father, which w i l l be discussed in the fourth chapter. "I phoned my wife every day, the family put off any decisions, signing of cheques, until discussing i t with me and obtaining my approval, i f the children wanted to do something they phoned me at the hospital. For example when my wife refused permission for my son to take some records to school i t was necessary to phone me f i r s t . " 1 In the remaining four cases (three female and one male) the three female patients were satisfied with arrangements but with some reservations. Mrs. D. "I am happy about the baby being with my mother-in-law, but not too happy about my husband looking after the children, after he has had a whole day at work." 2 Mrs. F. has a bad relationship with her mother-in-law, who is taking care of the home and children "but grateful that she i s there." 3 Mrs. M. feels quite satisfied about the domestic roles that her husband i s now performing, but ... 1 Case 9. Interview with patient, response to question 7. 2 Case 3. Interview with patient, response to question 8. 3 Case 1. Interview with patient, response to question 8. Appendix B. - 69 -"I object to the arrangements he has made for my son, because he refused to cope with the child. He does take care of the child i n the weekend." 1 One patient, Mr. Ch. made no comment, but implied that he was not happy about arrangements, because of the hardships his hospitalisation imposed on the family. 2 LEAVING THE FAMILY - DISPLACEMENT THE PATIENT Case 1 Hospitalisation for Mrs. F. did not immediately mean being displaced from the family network. She was en route to Vancouver to join her mother, who had written to request that she come to Vancouver, because her step-father had suffered a heart attack. Her husband was very opposed to the idea and "very hurt" that she wished to leave the family. When she l e f t Edmonton on the bus she became very distressed. "I was crying half the way - I f e l t lonely - I didn't want to leave the family, but mother sent a ticket. Mother and I are not too close - I went against my w i l l . " 3 She misses the family, and worries about the condition at home "but glad to get away from cleaning."4 When she see's children visiting on the ward she cries and feels very sad. This seems to indicate that Mrs.F. i s missing her maternal role in relation to her children. 1 Case 2. Interview with patient, response to question 8. 2 Case 6. Interview with patient, response to question 8. 3 Case I. Interview with patient, response to question 9. 4 Case 1. Interview with patient, response to question 10. Appendix B. - 70 -Case 2 Patient Mrs. M. was glad to get away from her husband and son. "I was glad to leave my husband ... home. I have no feelings about son, he gets on my nerves.1-' 1 This response accurately sums up Mrs. M.'s feelings about dis-placement from the family network of role relationships. She does not miss anything. She was admitted voluntarily to the hospital, she has no relatives of any import, and would appear to have sought refuge and "escape" from the stress of her marital, maternal, and domestic roles, and relationships. Case 2 Reciprocal Mrs. M.«s re-admission to Crease Clinic made Mr. M. "a frustrated housewife." 2 he was not happy about her re-admission and feels that her problem i s "a problem a person can fight by themselves." 3 In a sense he considered that since this was her third admission i t was a matter of "the same old routine". He tended to agree i t was an "escape" for his wife, from reality. Case 3 Patient Mrs. D. admitted herself voluntarily to Crease Clinic and appeared to be aware of her il l n e s s . She states that: 1 Case 2. Interview with patient, response to question 9. 2 Case 2. Interview with reciprocal, response to question 8. 3 Case 2. Interview with reciprocal, response to question 15(a). Appendix B. - 71 -"I had to leave home, I was doing a t e r r i b l e l o t of damage .to my husband. I was.too sick to worry about what leaving the family meant." I This i s Mrs. D.*s second admission, and she described the c l i n i c as a shelter. She was relieved to be back i n h o s p i t a l because she r e a l i z e d she was f a i l i n g i n her role performance at home. She i s "eager to go home, st a r t i n again with the family. I .can give more to the children now that I am cheerful." 2 Case 3: Reciprocal We have already seen that the family roles on Mrs. D.»s re-admission were not r a d i c a l l y changed. There was no p a r t i c u l a r stress evidenced i n the network due to h o s p i t a l i s a t i o n . Her husband compensated for her, and i n Mr. D.»s opinion s a t i s f a c t o r i l y . Nevertheless, the children missed t h e i r mother. Perhaps more i n the area of relationship than i n role performance, was the s i t u a t i o n s t r e s s f u l . "I was bored, making time. I t was l o n e l i e r for me. Inconvenience of extra domestic chores and the f e e l i n g of i n e f f i c i e n c y bothered me - I didn't remedy i t . " 3 I t i s reasonably obvious that Mr. D. did not resent h i s wife's admission, but we can see from the above response that her displacement i n t e r f e r r e d with the interrelatedness of t h e i r r o l e s , and placed Mr. D. i n a state of rolelessness i n r e l a t i o n to h i s wife. This was s t r e s s f u l as were the inconvenience of the domestic 1 Case 3. Interview with patient, response to question 9. 2 Case 3. Interview with patient, response to question 28. 3 Case 3. Interview with r e c i p r o c a l , response to question 9. Appendix B. "housewife" roles he was required to assume. I t i s i n t e r e s t i n g to note that he became more loving towards h i s children. The inference may be made that this was compensation f o r temporary loss of his wife. Case 4 Patient Mrs. S. was c e r t i f i e d to Crease C l i n i c . She did not give any idea what her feelings might be about displacement i n those questions designed to e l l i c i t such a response. Instead she des-cribed her husband's meanness and the consistent manner i n which he referred to her as insane. Things that she did, .which she now misses were: "I miss looking a f t e r the home, miss my children, I love my children. I t was a long time before I had children and they mean a l o t to me." 1 Displacement, however, appears to have threatened her relationship to her children and her maternal and domestic roles. Just immediately p r i o r to the interview with Mrs. S. the nurse remarked that she was always try i n g to get weekend leave or day leave to see her children. Her responses generally suggested that displacement from the role relationship she has with her children has been s t r e s s f u l . Case 5 Patient Mr. B.»s responses to questions pertaining to displace-ment from family through h o s p i t a l i s a t i o n were i r r e l e v a n t i n terms of this study, since he has been seperated from h i s wife for some 1 Case 4. Interview with patient, response to question 12. Appendix B. - 73 -months p r i o r to h o s p i t a l i s a t i o n . Generally he was relieved to be i n h o s p i t a l , and aware of his i n a b i l i t y to provide a background of stable and s a t i s f a c t o r y role relationships i n a family s i t u a t i o n . Case 7 Patient Mr. R. »s feelings about leaving the family were that he " f e l t lonesome and sorry not to be there (home) to help .them." 1 he misses " a l l the work around the house." He misses the home environment, and his network of role relationships i n that envir-onment, however at the time of admission he f e l t "confident and r e l i e v e d . " 2 Mr. R. expressed concern that h i s wife might v i s i t a neighbour .. "She has men i n when her husband i s away, not that I think she'd get involved but ..." 3 Throughout the interview with Mr. R. he was constantly expressing concern about his wife and family, t h e i r hardships and welfare. He says he f e l t the family "were shoving me o f f ... wanted to see me better." 4 Together with these i l l u s t r a t i v e examples, many of h i s responses to questions conclusively indicated that despite his voluntary admission, displacement from the network of family r o l e r e l a t i o n -ships was s t r e s s f u l . 1 Case 7. Interview with patient, response to question 9. 2 Case 7. Interview with patient, response to question 25. 3 Case 7. Interview with patient, response to question 26. 4 Case 7. Interview with patient, response to question 10. Appendix B. Case 7 Reciprocal Mrs. R. did not express any feelings that she was finding her husband's displacement^from the home s t r e s s f u l . She expresses r e l i e f , for i t has enabled her and the children to resume t h e i r s o c i a l relationships and roles with the neighbourhood community which were cut o f f when Mr. R. became i l l s i x months before his admission to Crease C l i n i c . Her fear i s rather that he w i l l be returned to ;the family role network before he i s well again. "He might take a notion I put him i n h o s p i t a l and come "back and hurt me. He threatened my l i f e when I asked him to see a doctor." 1 I t w i l l be remembered that i n the section of t h i s chapter dealing with role d e f i n i t i o n s , Mrs. R. carried most of her family r o l e s , as well as most of her husband's. H o s p i t a l i s a t i o n would tend therefore to be less s t r e s s f u l i n such a s i t u a t i o n . Case 6 Patient Due to the effects of electro-convulsive therapy Mr. Ch. cannot remember his feelings about leaving the family. He misses not being able to do anything about his a f f a i r s , and this i s pre-sumed to mean that he misses his employment r o l e , for his h i s t o r y indicates that he has regarded h i s working role as the most important i n the complex of h i s s o c i a l roles. He states that his h o s p i t a l i s a t i o n i s very hard on his wife, which i n a sense may be r e a l i s t i c , however the interviewer states that Mrs. Ch. was relieved to have her husband admitted. He misses being without his family and the lack of privacy. 1 Case 7. Interview with r e c i p r o c a l , response to question 15(b) 2 Ward Notes. Case 6 Mr. Ch. page 1. Appendix C. - 75 -The interviewer who conducted the interview with Mr. Ch. and who has had previous contact with a r e c i p r o c a l other than his wife reported that his father was "continually worried about being a f a i l u r e as a father." 1 Mr. Ch. expresses the theme that he has f a i l e d his family, made i t hard for them. "When business started to go down h i l l the patient .borrowed against the children's education p o l i c i e s and lo s t them, for which he now regrets. He says h i s children are his l i f e , he has set great store by t h e i r future and he has now ruined i t for them." 2 While there i s no d i r e c t i v e proof, the character of Mr. Ch.«s responses appear to suggest that displacement has further threatened his r o le as father to his children, and a consequential source of stress for him i n h o s p i t a l . Case 6 Reciprocal Mrs. Ch. apparently responded to her husband's displacement but compensated i n her role functioning. "I f e l t kind of l o s t , but I was so busy I didn't worry about i t . I missed his presence i n the.home, but you have to make the most of things." 3 The whole family miss him, and the eldest son did not want to say goodbye to his father. Mrs. Ch. f e l t that her husband did the right thing, and f e l t r elieved from the stress of his presence and i l l n e s s , while at home for four months. 1 Case 6. S o c i a l Worker's comments at end of interview with patient. Appendix B. 2 Ward Notes. Case 6 Mr. Ch. page 1. Appendix C. 3 Case 6. Interview with r e c i p r o c a l , response to question 17. Appendix B. - 76 -Case 8 Patient Mr. C. was c e r t i f i e d to the Crease C l i n i c "he minds being away from the family." X and f e l t that the children " f e l t upset for a while. No daddy around."2 He doesn't know why he i s at the c l i n i c , and would rather be at home. He constantly talked about working with tools. I t was f e l t that Mr. C. i n view of h i s i l l n e s s was not cognisant of displacement factors, and that one type of nursing had been replaced by another type of nursing. Case 8 Reciprocal Mrs. C. has i n fact been f u l l y conditioned to displace-ment factors as a re s u l t of her husband's long periods of hospit-a l i s a t i o n since his accident. She says i n fact that her husband's return to ho s p i t a l "didn't a f f e c t my fee l i n g s , he gets proper care and .attention. He-:hasspent a whole year i n h o s p i t a l -and has not been a husband or a father for a long time." 3 Case 9 Patient Mr. E. was a voluntary patient, who spent a week planning for himself and the family before admission. He i s an effimate i n d i v i d u a l , with problems of homosexuality. I t i s i n the l i g h t of these facts that displacement should be understood. Perhaps Mr. E.»s role, s i t u a t i o n i s best expressed i n his own words. 1 Case 8. Interview with patient, response to question 9. 2 Case 8. Interview with patient, response to question 15. 3 Case 8. Interview with r e c i p r o c a l , response to question 17. Appendix B. - 77 -"At home I am the court of l a s t resort. I f e e l that.I am the father i n the house." In terms of Mr. E.»s personality and the structure of his role i n t e r r e l a t i o n s h i p s with family r e c i p r o c a l s , he attaches considerable value to his r o l e as father i n the home. Displacement from the family network with i t ' s consequential implications could there-fore pose as a threatening factor, producing stress. To some-what a l l e v i a t e the threat, Mr. E. continued to control and vi c a r i o u s l y i n t e r r e l a t e with members of the family, by arranging to function i n the role of father, though ac t u a l l y removed from the home environment i n person. This he did by "Phoning my wife every day, the family put o f f any 'decisions, signing of cheques, u n t i l discussing i t with me and obtaining my approval, i f the children wanted to do something they phoned me at the h o s p i t a l . For example when my wife refused permission for my son to take some records to school, i t was necessary to phone me f i r s t . " 2 Furthermore i t would appear that he considered that were the children to know he was at Crease C l i n i c , t h e i r perception of him might be changed, and so damage the image of father. Con-sequently the children "don't know I am at Crease C l i n i c , but they know I am i n h o s p i t a l . " 3 In r e l a t i o n to hi s wife, he explained that t h i s was the " f i r s t time i n twenty years that I have been away from home. I t went against a l l general p r i n c i p l e s to discuss my problem with my wife (who i s not aware of i t except her husband's drinking).- I f e l t I had to come. I f I didn't my family would.break up. .1 was unhappy about 1 Case 9. Interview with patient, response to question 6. 2 Case 9. Interview with patient, response to question 7. 3 Case 9. Interview with patient, response to question 16. Appendix B. - 78 -"leaving my family - you can't f e e l nothing when you leave them. But i t was necessary to y i e l d to the i n e v i t a b l e . " 1 Mr. E. mentioned that he missed a "goodnight k i s s " . Displacement evidently was threatening to Mr. E.*s s o c i a l and family role re-lationships. Case 9 Reciprocal Mrs. E. supported her husband's plans to enter Crease C l i n i c . She missed her husband, which she describes by sta t i n g "I d i s l i k e d being alone, l i v i n g alone, but I adjusted to hi s absence." 2 "home needs a man to keep i t going." 3 While Mr. E. was i n h o s p i t a l , Mrs. E. appeared to be experiencing the stress r e s u l t i n g from his displacement from the family network of role r e l a t i o n s h i p s . She v i s i t e d her husband at least three or four times a week, and i n her responses seems to suggest that stress was a t t r i b u t a b l e to the absence of a husband to i n t e r a c t with her role of wife. In t h i s sense she was exper-iencing a degree of rolelessness. THE PATIENT AND THE HOSPITAL Seven of the nine patients, constituting the sample of th i s research, expressed p o s i t i v e attitudes towards the h o s p i t a l . Mr. E. thought that i t was "the most marvellous place i n the world. The longer I .am here, the better i t seems. The people.are wonderful. 1 Case 9. Interview with patient, response to question 9. 2 Case 9. Interview with r e c i p r o c a l , response to question 6. 3 Case 9. Interview with r e c i p r o c a l , response to question 15(c). Appendix B. - 79 -"I t gives a sense of well-being. I expected a great deal more r e s t r i c t i o n . Before I was i l l - i n f o r m e d , the h o s p i t a l needs more p u b l i c i t y . People's thinking out of l i n e , they see i t as a 'nut house', but the majority are capable. " 1 On admission he experienced a sense of r e l i e f , with some fear of what was to come i n the way of treatment. 2 Mr. R. f e l t that "the s t a f f were pretty reasonable and very considerate. .(The c l i n i c ) i s an awful l o t better than St. Marys i n Montreal - here we are kept more occupied." 3 and on admission he was confident and relieved. Despite the fact that Mr. B. thought i t was more l i k e a j a i l , he was surprised with the c l i n i c and was relieved to be there. Mrs. F. found the s t a f f easy to get on with, and said that she didn"t mind the c l i n i c , was treated well and enjoyed l o t s of freedom. 4 Mrs. D. thinks the c l i n i c i s a wonderful place and has the f i n e s t regard for the h o s p i t a l . Mrs. M. relates that " I t i s a very nice place, I l i k e i t and I am happier here (than at home)." 5 The remaining two patients expressed a number of negative feelings to the c l i n i c . Mr. Ch. considered that the 1 Case 9. Interview with patient, response to question 21. 2 Case 9. Interview with patient, response to question 25. 3 Case 7. Interview with patient, response to question 21. 4 Case 1. Interview with patient, response to question 21. 5 Case 2. Interview with patient, response to question 20. Appendix B. thought of being i n "th i s kind of i n s t i t u t i o n bothered me. The lack of .privacy. I d i s l i k e having to ask the nurse to get my personal belongings." 1 to which he added that "the c l i n i c t r i e s very hard, but can only do so much1.1 2 Mrs. S. i s not able to appreciate the c l i n i c , because of the i n t e n s i t y with which she misses her home and children. She has been refrained from leaving the c l i n i c against medical advice on two occassions. At the time of the interview she related that she was glad she did not leave. Adjustments to the C l i n i c 3 Those patients who had had previous experience i n the c l i n i c as patients, had l i t t l e trouble adapting themselves to the routing and t h e i r new roles. Mrs. F. took a week and a h a l f to adjust, Mrs. M. a week and i n i t i a l l y r e s isted attempts to encourage her to mix s o c i a l l y with others. Mrs. S. and Mrs. D. said that they j u s t f i t t e d i n . The remaining f i v e patients, a l l f i r s t admissions to Crease C l i n i c had l i t t l e problem adapting to the h o s p i t a l environ-ment, with the exception of Mr. Ch. who expressed negative attitudes to the c l i n i c . From the point of view of time, Mr. E. adjusted i n two days, Mr.,R. - four days, Mr. Ch. - two weeks, Mr. B. - one week. 1 Case 6. Interview with patient, response to question 20. 2 Case 6. Interview with patient, response to question 21. 3 A l l Cases. Interview with patient, responses to question 19. Appendix B. - 81 -Four patients considered v i s i t i n g hours l ' t o be adequate, three patients expressed no judgements, mentioned t h e i r v i s i t o r s . Two of t h i s group of three patients reside at a distance from the ho s p i t a l . One patient, Mrs. S. expressed the opinion that she found v i s i t i n g i n a room f u l l of people disturbing. THE RECIPROCAL AND THE HOSPITAL  Worries about the Hospital 2 Four of the f i v e reciprocals expressed no worries about the h o s p i t a l (Mr. D., Mrs. Ch., Mrs. C., Mrs. E.). One re c i p r o c a l (Mrs. R.) was concerned that the h o s p i t a l might l e t her husband return home mentally disturbed. Another r e c i p r o c a l , Mr. M. was h o s t i l e towards the h o s p i t a l "The h o s p i t a l should administer reverse treatment .instead of soft treatment, i t only encourages her to stay there, and prevents her from facing up to her r e s p o n s i b i l i t i e s . " 3 Weekend Leaves, V i s i t i n g Hours, Day P r i v i l e g e s 4 A l l six reciprocals were s a t i s f i e d with v i s i t i n g hours and day p r i v i l e g e s . In the case of weekend leaves, a l l s i x re-ciprocals thought they were s a t i s f a c t o r y , however, Mrs. E. f e l t that the family should be prepared f o r the f i r s t weekend. Mrs. C. that the weekend should not be too long, Mrs. R., that i n her case "they l e t him come home too soon. He was very d i f f i c u l t , buried the money." 5 1 A l l Cases. Interview with patient, responses to question 16. 2 A l l Cases. Interview with r e c i p r o c a l , response to question 15b. 3 Case 2. Interview with r e c i p r o c a l , response to question 15b. 4 A l l Cases. Interview with r e c i p r o c a l s , response to question 22. 5 Case 6. Interview with r e c i p r o c a l , response to question 22. - 82 -Mr. M. f e l t that i n some cases weekend leave, was good, as i t helped patients reintegrate into t h e i r community. Mr. D. f e l t less removed from his wife as a consequence of weekend leaves. Contact With Hospital S t a f f 1 Five of the s i x reciprocals related that they were sat-i s f i e d with contacts with h o s p i t a l s t a f f . One r e c i p r o c a l Mrs. R., who has no-one to discuss her problems with, other than neighbours, which she considers i s a bad p r a c t i c e i n a small community, would have l i k e d more contact with the doctor, and someone to talk to at the h o s p i t a l . Mental I l l n e s s and H o s p i t a l i s a t i o n Five of the six reciprocals related that the problems, worries, and changes i n the family had occurred before h o s p i t a l i s -ation, at the onset of mental i l l n e s s . Mrs. Ch. considered that J "the family problems and worries were more i n connection .with my husband's i l l n e s s . " ^ Mrs. C. stated that the s i t u a t i o n had changed at home some months after her husband's f i r s t h o s p i t a l i s a t i o n , following his accident. Mr. D. related that the problems experienced by the family, and any worries they had had were more evident a f t e r his wife became mentally i l l , p r i o r to her f i r s t h o s p i t a l i s a t i o n , s i m i l a r l y i n the case of Mrs. R. The remaining r e c i p r o c a l f e l t that there were no problems or changes i n respect of her husband's h o s p i t a l i s a t i o n as he had 1 A l l Cases. Interview with r e c i p r o c a l , response to question 23. 2 Case 6. Interview with r e c i p r o c a l , response to question 19. Appendix B. - 83 -taken care of most arrangements for tae family, one week p r i o r to his admission to Crease C l i n i c . Relatives and H o s p i t a l i s a t i o n In the nine cases studied f o r t h i s research, r e l a t i v e s played no part i n h o s p i t a l i s a t i o n . Five of the cases reported that they had no r e l a t i v e s of s i g n i f i c a n c e residing within reachable distance. Mr. E. has a brother, but he i s not of importance to the family structure. Mrs. C. was the only r e c i p r o c a l to r e l a t e that r e l a t i v e s played a s i g n i f i c a n t role i n the family network. This was p a r t l y due to the fact that the C. family reside i n the home of the patient's mother. "My mother-in-law caused a rumpus when my husband was admitted. I arranged a l l the d e t a i l s of admission, and t o l d my mother-in-law an hour before he was to leave for the c l i n i c . During that hour she spoke to him, and r e a l l y upset him.". 1 Where r e l a t i v e s were available they played more of an important role a f t e r h o s p i t a l i s a t i o n , by taking on some of the r e s p o n s i b i l i t i e s of maintaining the family as i n the case of Mrs. F., or of assuming care for one of the children, as i n the case of Mrs. D. Friends and H o s p i t a l i s a t i o n Case 2 Mrs. M. had up u n t i l her re-admission to the c l i n i c only one friend of s i g n i f i c a n c e . This p a r t i c u l a r friend had approached the p s y c h i a t r i s t and ... 1 Case 8. Interview with r e c i p r o c a l , response to question 21. Appendix B. - 84 -"pleaded with him to l e t my wife remain at home and f i g h t i t out." 1 Mr. M. »s friends were "shocked" to hear that h i s wife had been re-hospitalised. Generally, friends had played a more s i g n i f i c a n t role i n the pre-admission stage. When Mrs. M. arranged for neigh-bours to care for her son during the day, and i n the post-admission phase, when one friend had offered to have Mr. M.»s son l i v e with her during the week. Case 3 Mr. D. described t h e i r c i r c l e of friends as "sympathetic, understanding, and very supportive." 2 They phoned to o f f e r to care for the children, i n v i t e d the family to meals, and promised to v i s i t Mrs. D. on her return from h o s p i t a l . Case 4 Mrs. S. related that "the wives i n the block where she l i v e s s t i c k together 'and blamed her husband for her admission." 3 In t h i s case i t i s r e a l i s t i c to i n f e r that they were supportive to Mrs. S. Case 5 Mr. B. said that his friends were probably not aware of the fact that he was i n h o s p i t a l . 1 Case 2. Interview with r e c i p r o c a l , response to question 13. 2 Case 3. Interview with r e c i p r o c a l , response to question 13. 3 Case 4. Interview with r e c i p r o c a l , response to question 27. Appendix B. Case 6 The Ch. family have only two friends i n Vancouver, and encouraged Mr. Ch.: to seek p s y c h i a t r i c help. Case 7 Mrs. R. related that most of her friends knew about her husband's i l l n e s s , and f e l t that his h o s p i t a l i s a t i o n was the best thing, since many of them had had trouble with him. "My friends help me with the animals, do repair lobs i n the house, babysit when I go to the h o s p i t a l . " 1 Case 8 Mrs. C. had found that her friends were very supportive and agreed that her husband should be admitted to Crease C l i n i c . Case 9 The E. family kept Mr. E.«s admission to Crease C l i n i c a secret, and to some extent t h i s created a value problem for Mrs. E. I t would appear that i t was la r g e l y Mr. E. «s decision to keep his h o s p i t a l i s a t i o n a secret. Mrs. E. says that - "no-one knew where he (husband) was, they knew he was "in h o s p i t a l , but tha t - i s a l l . . I hated being caught up with l i e s . " 2 Mrs. E. went on l a t e r i n the interview to explain that "Most people are narrow minded, I was reluctant to t e l l people, they always ta l k about i t . " 3 1 Case 7. Interview with r e c i p r o c a l , response to question 14. 2 Case 9. Interview with r e c i p r o c a l , response to question 15. 3 Case 9. Interview with r e c i p r o c a l , response to question 28. Appendix B. - 86 -Mr. E. on the other hand, f e l t that t e l l i n g friends of his actual whereabouts would depress his wife. Furthermore h i s action i s best explained i n terms of his response to a question asking what he f e l t about the h o s p i t a l . "Stress made me seek help, I ruled out everything else. I don't care shat people think. People's thinking i s out of l i n e . They see i t as a nut house. But the majority of patients here are capable." I Displacement therefore threatened the role Mr. E. maintained i n r e l a t i o n to his friends, and h i s reaction to the stress engendered by the threat was to avoid making his actual whereabouts known to his network of friends. 1 Case 9. Interview with patient, response to question 21. Appendix B. CHAPTER IV - CLINICAL APPLICATION OF ROLE AND STRESS In the previous chapter, where appropriate, an attempt was made to i n t e r p r e t some of the data described. In t h i s chapter the major emphasis has been focused on analysis and i n t e r p r e t a t i o n of the data described i n Chapter I I I . Despite the l i m i t a t i o n s of the study and the s i z e of the sample, there appears to be a considerable amount of information available for analysis and i n t e r p r e t a t i o n , however, the sample does not allow conclusive generalisations, but i t does permit specu-l a t i o n , and i t remains the task of another interested researcher to subject the assumptions and interpretations to further testing. A f t e r a discussion of selected material the hypothesis was re-examined, and where not applicable i n terms of the findings, reformulated. The writer also attempts to measure stress using a con-tinuum scale. One set of continuum scales measures stress for the patient, and another for the r e c i p r o c a l . The scale i s rather primi-t i v e . Stress i n terms of the measurement used appears to be f a i r l y consistently d i s t r i b u t e d , in^the case of r e c i p r o c a l s . For patients i t i s subject to a considerable amount of v a r i a t i o n . In f i v e out of the s i x cases subjected to measurement the degree of stress experienced by the patient was not very d i f f e r e n t i n degree to the stress experienced by the r e c i p r o c a l . F i n a l l y , some suggestions are made about areas requiring V further study. - 88 -Role As a Determinant of S t r e s s I t i s c l e a r to the w r i t e r , and adequately confirmed i n the responses obtained from the p a t i e n t ' s c o n j u g a l r e c i p r o c a l s t h a t the problems, w o r r i e s and changes which c o n f r o n t e d the f a m i l y n e t -work of r o l e s and r e l a t i o n s h i p s developed at the onset o f the p a t i e n t ' s i l l n e s s , sometime b e f o r e a c t u a l admission to a mental h o s p i t a l . T h i s i s understandable w i t h i n the framework o f s o c i a l r o l e theory. The development of mental symptoms w i l l undoubtedly f i n d e x p r e s s i o n i n the c h a r a c t e r o f an i n d i v i d u a l ' s r o l e performance and r o l e r e l a t i o n s h i p i n r e l a t i o n to those r e c i p r o c a l s comprising h i s s o c i a l network. They w i l l be p e r c e i v e d by the r e c i p r o c a l s as b e i n g d i f f e r e n t , and demand t h a t some a d a p t a t i o n be made. T h i s e s s e n t i a l l y r e q u i r e s that those r e c i p r o c a l s a f f e c t e d by the changes i n a p a t i e n t ' s r o l e f u n c t i o n i n g a d j u s t t h e i r p e r -c e p t i o n s and e x p e c t a t i o n s i n r e l a t i o n to themselves and to the p a t i e n t . Such an adjustment w i l l be d i f f i c u l t f o r the average p e r -son, e s p e c i a l l y when he has grown accustomed to i n t e r a c t over a p e r i o d o f time w i t h an i n d i v i d u a l i n a p a r t i c u l a r way, and d i s -covers t h a t the customary way l e a d s to d i s s a t i s f a c t i o n and con-f l i c t . T h i s d i s c o v e r y c r e a t e s s t r e s s f o r the r e c i p r o c a l , and may produce a v a r i e t y of d i f f e r e n t r e a c t i o n s . I n t h i s study i t would appear t h a t the r e c i p r o c a l s made adaptations i n order to s u s t a i n a r e l a t i o n s h i p w i t h the p a t i e n t , but i t i s c l e a r t h a t these a d a p t a t i o n s were not c o n s i d e r e d s a t i s -f a c t o r y and g e n e r a l l y proved to be s t r e s s f u l . So t h a t when the p a t i e n t was f i n a l l y h o s p i t a l i s e d , r e c i p r o c a l s f e l t r e l i e v e d . - 89 -In cases 7 and 8 where this was particularly noticeable, the re c i -procals reverted to their previous mode of social functioning. In similar fashion' the potential patient who discovers that he i s unable to function in relation to the functioning of the healthy or unhealthy reciprocal, i s confronted by a stressful situation. If he i s aware of his maladaptive functioning, he may use his previous functioning as a reference of comparability and develop feelings of inadequacy, which in verbalized expression might include such remarks as - "I have let you down", "As a father I have failed you", "Why don't you leave me and marry some-one else", "I'm no good to you", as occurred in cases 3, 7, and 8. If he is unaware of his maladaptive functioning he may find i t impossible to continue to interact with his role reciprocals, experience further stress, thereby leading to further role patho-logy, and react by escaping, becoming destructive, violent and withdrawn, as in the cases 2, 5, 6 and 8. Where patients have at least some awareness, both processes may operate. There may be instances where the potential patient, i n the period prior to the onset of mental illness was functioning healthily but was subjected to a considerable degree of stress.for a long period. Naturally, the ab i l i t y of the potential patient to adopt and adjust by suppressing patterns of healthy functioning and the stress that results from doing so, i n the interest of values, and a relationship that may have emotional significance, w i l l be determined by relevant bio-psycho-social components. Following from the data available in Chapter III, i t appears that after a period of time, the stress of adapting to an - 90 -unhealthy r e c i p r o c a l , may lead to stress and f i n a l l y mental i l l n e s s . There i s some evidence to suggest a chain reaction of threat, stress, adaptation, 1 repeated a l l i n respect of one r o l e , with important ramifications for other roles because of the current concept of the interrelatedness of roles. 2 For instance, a husband who i s not performing his role according to the expectations and perceptions of the p o t e n t i a l patient; may cause the p o t e n t i a l patient to f e e l that her role of wife i s threatened. She may adjust to the stress therefrom, by adapting her role to her husband's pattern of role functioning. The consequences of t h i s adjustment and adaptation may lead to impairment i n other rol e s , thereby threatening her role p o s i t i o n and relationship i n respect to them, i . e . she may f i n d her roles of neighbour, mother, hornemaker threatened, and experience new areas of stress. She may react to the stress and make adjustments and adaptations that lead to a state of rolelessness, by with-drawing from some of the roles important to her role network and functioning. The threat or lack of these roles may sub s t a n t i a l l y e f f e c t her i n d i v i d u a l role homeostasis and lead to mental i l l n e s s , impair a large range of roles and relationships, and re-threaten her role relationship to her husband, and therefore her role as wife. Stress i s l i k e l y to r e s u l t . Should she face h o s p i t a l i s a t i o n her role of wife, as w i l l be her other r o l e s , w i l l be threatened, adding further s t r e s s , or increasing the stress p o t e n t i a l . In the 1 See "Areas for Further Study", Chapter IV, Page 106, Point 5. 2 See "The Concept of Interrelatedness of Roles", Chapter I Page.11. - 91 -cases studied this s i t u a t i o n was f e l t to be e s p e c i a l l y applicable i n Case 4, and variations of i t were f e l t to be apparent i n Cases 1, ,2, and 5. The writer -was i n c l i n e d to f e e l , however, that the c y c l i c process of threat, stress, adaptation, s t r e s s , threat etc. was apparent i n respect to at l e a s t one r o l e i n the majority of cases. The process was also f e l t to be applicable to both patient and r e c i p r o c a l i r r e s p e c t i v e of who was i l l or o r i g i n a l l y the primary pathological agent. The degree to which a r e c i p r o c a l i s able to adapt as a consequence of a p a t i e n t 1 s i l l n e s s and the degree to which he can contain his resistances to s t r e s s , w i l l depend on the b i o l o g i c a l , psychological, and s o c i a l c o n s t i t u t i o n of the r e c i p r o c a l , e s p e c i a l l y the range of s o c i a l roles which function as a support, or outlet. Other influences that w i l l determine adaptation and adjustment, and set up resistances to seeking help, w i l l include such things as the a v a i l a b i l i t y of s o c i a l resources such as money, ho s p i t a l s , food, etc., the patterns of socio-economic class structure, the ideas and values of the reciprocals reference group, ignorance and current ideologies p r e v a i l i n g i n society. In a l l cases at least one of the above factors mentioned were f e l t by the writer to explain the reasons why a f a i r l y lengthy period of time (from four months to seven years) elapsed between the onset of symptoms and a patient's admission to h o s p i t a l . How-ever, i t i s c l e a r that despite the influence of these factors, there came a stage when the stresses f e l t by either r e c i p r o c a l or patient - 92 -could no longer be contained and the family or the patient was re-quired to think i n terms of h o s p i t a l i s a t i o n i n the b e l i e f that help would l i k e l y make a change, thereby sustaining any stress resistances they have. This was confirmed by the responses made by patients and reciprocals i n a l l cases. In Case 9 for instance, the perceived attitude and values of the reference group, the lack of s o c i a l resources - money, combined with the threat of weakening his role p o s i t i o n i n the family network by submitting to treatment i n a psy c h i a t r i c c l i n i c , the patient set up natural resistances to the stress he f e l t about his own problem (homosexuality). When he could no longer sustain these resistances, because the adjustments he made were pathological (heavy drinking) and a further source of stress, he f e l t obliged to act i n spi t e of the continued existence of value threats, which had i n i t i a l l y helped erect resistances, i n the b e l i e f that help would a l l e v i a t e the stress he was experiening. His marriage was threatened. In other words, he f e l t threatened because of the fear of losing his r o l e s , and the reciprocals on whom his roles were dependant. However, the fact that the influence of the s o c i a l environment continued to have an e f f e c t on the patient's attitudes i s re a d i l y apparent by the p a r t i c u l a r arrange-ments he made while i n h o s p i t a l . The writer assumes that this role s i t u a t i o n may have a relationship to the c l i e n t ' s p s y c h i a t r i c problem. The responses obtained from family r e c i p r o c a l s , both i n the area of role performance, role relationship and fe e l i n g indicate that the period before h o s p i t a l i s a t i o n , when the family member i s - 93 -mentally i l l and not functioning adequately i n the role network, i s most s t r e s s f u l and problematical for a l l concerned. Therefore any stress l i k e l y to occur when the patient i s h o s p i t a l i s e d i s moderated by the sense of r e l i e f i t immediately brings to those family members, who can appreciate the s i t u a t i o n , and constitute the r e c i p r o c a l units i n the family role network. However, the f e e l i n g of r e l i e f does not mean that the r e c i p r o c a l experiences no stress as a r e s u l t of the patient's displacement from the family role network. That stress i s apparent may be r e a l i z e d , when consideration i s given to the meaning of such responses, e l i c i t e d i n interviews, as to the length of period the patient i s l i k e l y to be i n h o s p i t a l , whether he can be helped and whether he i s l i k e l y to recover. Such responses appear to i l l u s t r a t e that the Stresses generated i n the period before the patient was h o s p i t a l i s e d have not been completely resolved. In a sense the r e c i p r o c a l seems to be asking for the assurance that the family member w i l l return to the family network on discharge and be able to resume his role s i t u a t i o n and function i n the manner he functioned before the onset of mental i l l n e s s . Accepting the p r i n c i p l e that the patient's maladaptive role patterns and relationships were threatening to the family reciprocals, i t i s not unnatural to expect them to be experiencing stress, i n case the patient should return to the family network unchanged. The facts collaborated by the writer show that stress experienced by family reciprocals i s i n c l i n e d to r e l a t e more to mental i l l n e s s than to displacement. In only one instance, Case 9, - 9 4 -where the patient was functioning r e l a t i v e l y w ell i n the family, and whose i n t e r n a l problems had not yet reached the stage where they seriously impaired his r o l e performance and role r e l a t i o n s h i p s , was the stress of displacement Intense. In general, most reciprocals adjusted r e l a t i v e l y quickly and i n a short period of time, i n d i c a t i n g that they were able to sublimate what stress h o s p i t a l i s a t i o n brought, i n the i n t e r e s t of a far more desireable goal, namely, the hope that treatment would cure or change the patient so that he could return home and resume his s i g n i f i c a n t role s i t u a t i o n i n the family structure. The arrangements made to cope with the absence of a wife of husband, mother or father, hornemaker or breadwinner, were gen-e r a l l y s a t i s f a c t o r y and working reasonably well according to responses made. In three cases where the person chosen to perform some of the roles previously performed by the displaced family member, did not have a good relationship with the patient there was a degree of stress. Five out of s i x reciprocals reported inconvenience at having to assume extra r o l e s , and reported f e e l i n g uncomfortable, nevertheless maintaining that they had adjusted to the s i t u a t i o n . The absence then of a r e c i p r o c a l who performed c e r t a i n roles expected of them i n the network, eg. hornemaker, mother, constitutes a threat, to which the r e c i p r o c a l reacted by adjusting and adapting, by assuming at l e a s t some of the components of displaced family members' roles. In the case of a female patient, her husband would give up functioning i n c e r t a i n roles temporarily, and take on c e r t a i n new rol e s , as i n ease 3 for example, where the patient's husband gave up temporarily, his role of builder of a new home i n order to per-- 95 -form domestic roles. In the case of a male patient as i n Case 6, the oldest son gave up his role of school boy, i n order to perform the role of breadwinner. This adjustment i n role was necessary to a l l e v i a t e stress caused by the threat of poverty. There w i l l there-fore, l i k e l y be some modification of ro l e performance i n other areas of functioning as well. The assumption of new roles temporarily may increase the number of roles performed and overburden the ind i v i d u a l ' s network of i n t e r r e l a t e d r o l e s , thereby creating stress for him. A f f e c t i v e l y he may respond to such a s i t u a t i o n by f e e l i n g inconvenienced. Such inconvenience may strongly cause him to wish for the displaced family member's return to.the family role network. Such a desire on the part of a reci p r o c a l may set up an ambivalent c o n f l i c t , be-cause the degree of inconvenience w i l l make him wish for the return of the patient as soon as possible, but at the same time he desires that the patient remain displaced, u n t i l well enough to resume customary family roles. This was found to be the case s i t u a t i o n i n respect to Cases 1, 3, 6, 7, and 9. In Case 1, for instance, the s i t u a t i o n athome was expressed i n l e t t e r s to the patient, from the r e c i p r o c a l husband, who also related that i f she didn't come home, she should consider not coming home at a l l . He further posted money for the necessary transportation arrangements. The patient f e l t threatened at the p o s s i b i l i t y of losing her role as wife, mother and homemaker and attempted to leave the h o s p i t a l before the p s y c h i a t r i s t f e l t she was ready to do so. In Case 7, i t was the c h i l d who expressed his desire that father return home quickly. The patient f e l t h is father role threatened as a re s u l t - 96 -of his displacement and handed i n his notice at the h o s p i t a l which he l a t e r retracted. When there i s modification of role performance and re-ciprocals verbalize t h e i r feelings i n r e l a t i o n to the new roles they are performing, or advertantly express the functions performed by the patient i n the. family network, that they are missing or having d i f f i c u l t y with, or had d i f f i c u l t y with, the writer considers that the r e c i p r o c a l i s possibly r e l a t i n g that he or she i s experienc-ing stress i n the performance of the new r o l e s , because he or she i s using as a frame of reference f o r performance, t h e i r perceptions of what the displaced family member used to do. The new roles are foreign to the r e c i p r o c a l s , and they may eventually experience stress as a r e s u l t of role confusion or role ignorance. Such con-fusion and ignorance i n the case of a l l reciprocals whether wife, husband and children are l i k e l y to r e s u l t i n stress. Cases 2, 3, 6, 8, and 9 confirm this i n t e r p r e t a t i o n . In Case 6, when the eldest son started assuming more of the roles t y p i c a l l y performed by displaced father, other r e c i p r o c a l s , including father, set up resistances, and were unable to in t e r a c t successfully with the new roles assumed by the son. The two roles, father and son, to his r e c i p r o c a l s , comprising mother and s i b l i n g s , were i n -compatible arid led to confusion and subsequently stress for the son and the rest of the family. In Cases 2 and 3, for example, i t was d i f f i c u l t for father (reciprocal) to move from his set roles as father and breadwinner to the set of roles performed by the patient before h o s p i t a l i s a t i o n . This created confusion. Apart from the - 97 -c o n f u s i o n he was, as he p o i n t e d out, i g n o r a n t about cooking, and g e n e r a l l y d i d what was immediately necessary. The c h i l d r e n complained about the cooking. He f e l t "the inconvenience o f e x t r a domestic chores and g e n e r a l f e e l i n g s o f i n e f f i c i e n c y . " 1 The r e c i p r o c a l i n Case 2 expressed h i m s e l f as a f r u s t r a t e d housewife, and g e n e r a l l y f e l t t h a t the displacement o f h i s w i f e from the f a m i l y network, t h r e a t e n i n g to the marriage, and continued e x i s t e n c e o f the home. In a p s y c h i a t r i c h o s p i t a l attempts by p a t i e n t s to l e a v e without p e r m i s s i o n , or through the submission o f f i v e days n o t i c e o f i n t e n t to d i s c h a r g e themselves a g a i n s t m e d i c a l a d v i c e , con-s t i t u t e s a major problem f o r the c l i n i c a l s t a f f . I t i s "fr e q u e n t l y thought t o be due to one or more than one o f the f o l l o w i n g reasons: 1. R e s i s t e n c e to treatment. 2. D i s s a t i s f a c t i o n w i t h the h o s p i t a l g e n e r a l l y . 3. Pressures e x e r t e d by the s o c i a l environment. 4. R e f u s a l t o accept mental i l l n e s s . 5. Fear o f stigma. I t i s t h e r e f o r e extremely d i f f i c u l t to i d e n t i f y the a c t u a l reasons for. s e l f - d i s c h a r g e . However, i n the l i g h t o f f a m i l y problems r e l a t e d to r o l e f u n c t i o n i n g d i f f i c u l t i e s and f a m i l y problems o f i n t e r a c t i o n w i t h the s o c i a l environment due to the displacement of a s i g n i f i c a n t or key f a m i l y member from the f a m i l y network, the r e s u l t a n t s t r e s s experienced by the f a m i l y i s f r e q u e n t l y communi-cated to the p a t i e n t , who then f e e l s threatened t h a t h i s c o n t i n u a l 1 Case 3. In t e r v i e w w i t h r e c i p r o c a l , response to q u e s t i o n 9. Appendix B. - 98 -absence from the family w i l l lead to i t ' s disintegration. His reaction to threat w i l l be to arrange discharge or weekend leave, and i f either one or the other i s refused, seek self-discharge. In Cases 4 and 7, this problem was f e l t to be the primary reason why the patients gave notice. For example, in Case 4, the patient feared that her alcoholic husband was neglecting (1) the home which she tried so hard to maintain, and (2) the children she had to wait a long time for. She was also aware of some d i f f i c u l t i e s i n arranging for a housekeeper. Despite the evidence suggesting that the major areas of stress are related to mental i l l n e s s , there is also evidence to suggest that displacement i s threatening and leads to stress in eight of the nine cases studied. It is also clear that there i s evidence to support the assumption that displacement bringing absent new roles and inter-relationships i n relation to the new roles assumed, are stressful for both patient and his family reciprocals. Measurement of Stress One of the important issues raised i n this thesis revolves around the question of measurement of stress. That this i s an extremely d i f f i c u l t task i s well recognized when the researcher approaches the d i f f i c u l t y of analyzing highly subjective responses. Normally i t i s a relatively simple matter to identify stress in terms of 1. factor causing stress 2. the value threatened 3. the reaction to stress - 99 -and since i t can be determined by differences i n role d e f i n i t i o n and expectation, and by the character of adaptation i n role per-formance, and adjustments to role perception i n response to r o l e c o n f l i c t . I t can also be i d e n t i f i e d i n the type of a f f e c t i v e response an i n d i v i d u a l makes i n the process of communication between himself and others. Therefore i f one i s to r e t a i n some degree of o b j e c t i v i t y the researcher w i l l tend to select as a framework for i d e n t i f i c a t i o n and analyzation data pertaining to role performance -role expectation, role perception, and may where possible correlate the results with the subject responses. In t h i s p a r t i c u l a r study such a method i s l i k e l y to pro-duce u n s c i e n t i f i c results i f one takes c a r e f u l note of the components of the sample. F i r s t l y , s i x of the nine patients (Cases 1, 3, 4, 5, 6, 7) had a l l undergone electro-convulsive therapy and therefore l i k e l y to be suff e r i n g some degree of memory impairment. One of the following three patients (Case 8) has such severe memory im-pairment due to chronic brain syndrome associated with brain trauma sustained as a resu l t of an accident. Inevitably one i s led there-fore to question the v a l i d i t y of many responses obtained i n the interview s i t u a t i o n . Secondly, i n view of a test question to study i n very limited content the r e l i a b i l i t y and c o r r e l a t i o n of f a m i l i a r terms and concepts, the writer obtained such a v a r i a t i o n of responses in d i c a t i n g and confirming the findings of many well known researchers that the same words have d i f f e r e n t meanings to d i f f e r e n t i n d i v i d u a l s . There i s l i t t l e value to be obtained i n analyzing a f f e c t i v e responses si n g u l a r l y i n an attempt to develope a schema for measurement. Th i r d l y , the general poorness- i n description and vagueness of - 100 -responses did not provide s u f f i c i e n t information to make i t possible to organize the data i n such a manner to make i t of use i n develop-ing a s a t i s f a c t o r y scale of measurement. Nevertheless, the writer considered that some experimen-ta t i o n i n the area of stress measurement would be of value i f only to indicate that stress was a measureable en t i t y . In order to measure stress the writer used a rating continuum with s i x assigned values (0 - 6). In each instance only those cases where both patient and r e c i p r o c a l were interviewed, each threat to role functioning and the network were l i s t e d and assigned a value p o s i t i o n on the continuum. The numerical values for each threat were averaged and divided by the t o t a l number of threats, the average then was viewed i n terms of the o v e r a l l reaction to stress and rerated on the stress continuum to give a f i n a l measurement rating . In spite of the sub-j e c t i v e judgemental factors, the writer when comparing the numerical p o s i t i o n designated stress on the continuum with the subjective value responses i n terms of a f f e c t i v e response, they correlated highly. The writer i s of the opinion that an approach to the measurement of stress using a rating continuum may be found to be of p r a c t i c a l value and make a worthwhile contribution to the problem of stress measurement. The system of continuum rating as used i n this study i s extremely p r i m i t i v e and therefore the f i n a l evaluation of stress should be weighed i n terms of the primitiveness of the measurement used. PATIENTS Case 2 Case 3 Case 6 Case 7 Case 8 Case 9 RECIPROCALS Case 2 Case 3 Case 6 Case 7 Case 8 Case 9 STRESS CONTINUUM l - j -i 3 -tr t 5 — f i |, • , k D , i ,-1 . i — i — . 1 — 8-CHART II - 101 -RECONSIDERATION OF THE HYPOTHESES IN RELATION TO THE RESEARCH DATA Assumption 1 When a member of a family unit i s displaced from his networks of roles and relationships with reciprocals which make up his s o c i a l network, a threat i s produced, and results i n stress. Displacement i n this context w i l l be i d e n t i f i e d as a stress factor. In that section of this chapter dealing with role as a determinant of stress, we discussed the p o s i t i o n of this hypothesis i n r e l a t i o n to the data acquired i n interviews with the patient and rec i p r o c a l . I t was confirmed that the assumption made i n the f i r s t chapter of this thesis has value, however, i t became cle a r that the stress produced by the stress factor - displacement of an i n d i v i d u a l from his s o c i a l network, i s minimized by the over-riding stress related to mental i l l n e s s and the effects that i t has on the s o c i a l network before h o s p i t a l i s a t i o n . I t would appear relevant to think of stress due to displacement as secondary, and the stress related to mental i l l n e s s as primary i n the immediate period of h o s p i t a l i s a -t i o n , but that the longer the patient remains i n h o s p i t a l , the more l i k e l y that the secondary stress w i l l i n point of fact become p r i -mary. Furthermore, i t i s important to understand the relationship h o s p i t a l i s a t i o n has to mental i l l n e s s . In the c u l t u r a l setting i n which we l i v e , mental i l l n e s s i s becoming less of a stigma, and the community attitudes to the i l l n e s s are slowly changing, however, i t would appear that changes i n attitude towards the mental h o s p i t a l are taking place at a slower rate. This may explain i n some degree why families wait so long before seeking p s y c h i a t r i c help. Despite - 102 -these problems, i t i s clear that h o s p i t a l i s a t i o n , though s t r e s s f u l , i s also a r e l i e f to the family burdened with the maladaptive r o l e functioning of a family member for a long period of time. R e l i e f i s bound to lessen the stress of displacement, and perhaps one of the reasons why so few of the cases sampled seemed to show any high or intense degree of stress. Assumption 2 That the i n d i v i d u a l patient and his family reciprocals reacts to this stress or threat brought about through displacement, by changing, adjusting and withdrawing from roles and role r e l a t i o n -ships. The reaction to stress may be p o s i t i v e or negative. There i s no conclusive evidence to suggest as postulated by t h i s suggestion that the i n d i v i d u a l patient or his family r e c i -procals react to the stress of displacement by withdrawing from roles and role relationships. The evidence strongly supports the assumption that there i s change and adjustment. In the h o s p i t a l , the patient appears to adjust f a i r l y soon, and would be required as part of the treatment to engage i n ro l e a c t i v i t i e s and r e l a t i o n -ships. The patient i s i n point of fact not permitted to withdraw. As f a r as the reciprocals are concerned the adjustments made to the family network of r o l e s , as a r e s u l t of displacement st r e s s , often include the taking on of new roles and experiencing new r e l a t i o n -ships i n r e l a t i o n to the roles they perform. In terms of these facts i t i s necessary to reformulate this hypothesis. That the i n d i v i d u a l patient and his family reciprocals reacts to the stress or threat brought about through displacement by changing, and adjusting roles and relationships to meet the de-mands of the s o c i a l environment. - 103 -Assumption 3 That displacement bringing about new roles and r e l a t i o n -ships for the ho s p i t a l i s e d family member produces stress for the family r e c i p r o c a l s , as well as for the patient. The research undertaken by the writer did not, however, substantiate the value of t h i s assumption i n terms of ho s p i t a l i s e d patients. There was evidence that some patients had d i f f i c u l t y functioning for a b r i e f period shortly a f t e r admission to Crease C l i n i c . Three patients and one re c i p r o c a l interviewed a c t u a l l y experienced mild s t r e s s , and severe stress respectively as a re-sult of the new roles a ho s p i t a l i s e d family member assumes. The assumption as f a r as the writer i s concerned has value, but i t ' s value as a general hypothesis i s questionable. Assumption 4 That displacement to a s o c i a l environment of a p a r t i c u l a r kind - the ho s p i t a l community, i s both s t r e s s f u l to the patient and his family reciprocals. The evidence strongly refuted t h i s assumption. Without exception, displacement to the ho s p i t a l community brought r e l i e f , and a general lessening of the stress accumulated over the months the patient spent at home mentally i l l , and i n most cases unemployed. S i m i l a r l y , patients were also relieved. Assumption 4, may there-fore be reformulated thus -That the displacement to a s o c i a l environment of a p a r t i -cular kind - the ho s p i t a l community, i s both stress r e l i e v i n g and stress reducing for the patient and his family r e c i p r o c a l s , p a r t i -c u l a r l y when patients were mentally disturbed and remained at home for a long period of time. - 104 -Areas of -Further Study 1. The writer has only touched on the problems of measuring str e s s , however, i t would appear to be of professional i n t e r e s t i n the f i e l d of s o c i a l work. As to what would ac t u a l l y be accomplished i n such a study remains to be discovered, and to •what extent a measurement scale would be of value to the p r a c t i s i n g caseworker remains to be explored. i 2. Folio-wing from the remarks made by three indiv i d u a l s interviewed for the purposes of thi s study, an area that would conceivably be of inestimable value to s o c i a l workers i n the f i e l d of mental health i s a study of community attitudes to mental i l l n e s s , and p s y c h i a t r i c h o s p i t a l i s a t i o n . Such a study might analyse present methods of educating the pub l i c , and the usefulness of them. I t was i n t e r e s t i n g to note the references made by informants to mental ho s p i t a l . Two informants c a l l e d i t the "nut house" and three i n -formants were generally surprised that Crease C l i n i c was not what they thought i t would be l i k e , i n f e r r i n g perhaps that they expected i t to be something l i k e the mental hospitals of past years. In a society such as ours, where the stresses of mid-century l i v i n g are increasing the admission rates of persons to mental h o s p i t a l , i t would seem highly desireable to c u l t i v a t e a healthier community attitude and understanding of one of the major health problems of an era. Such an understanding could well pave the way to early arrestation of the symptoms of mental i l l n e s s , which i f l e f t untreated are known to cause chronic deterioration to the extent that the i n d i v i d u a l may suffer impairment of his s o c i a l roles for the remainder of his l i f e . - 105 -In the f i r s t sections of Chapter I I I , i t seemed apparent that the majority of cases were aware of c o n f l i c t , c l i n i c a l l y s t ress, before the onset of mental i l l n e s s . (Cases 1, 2, 4, 5, 6, 7). For example i n cases 2, 4, and 5, there had been stress over marital role functioning for a long period. In case 6, eventual stress was caused by a stress factor over which the in d i v i d u a l who became mentally i l l had no control- economic depression. Further study and research i s needed to confirm the significance role pathology has i n symptom formation. I f i t has sig n i f i c a n c e , then observations such as the ones mentioned suggest a vast f i e l d awaits the professional attention, a f i e l d i f exploited to the f u l l e s t may prevent to a large degree, the problem of mental i l l n e s s . 3. An area that seems to require considerable attention i n r e l a t i o n to s o c i a l role theory i s that area of semantics. How does one communicate role and role concepts i n a manner that w i l l be understood by c l i e n t s . How does the c l i e n t express his roles and role relationships. When we ask questions about role function-ing - role perception, role performance, what meaning i s placed on the s o c i a l workers t r a n s l a t i o n of these professional terms. Such a study might also c l a r i f y some of the ambiguities inherent i n the d e f i n i t i o n and description of role and stress concepts. 4. In Chapter I I I , reference has been made to the idea of the i n v i s i b l e father 1 (Case 9), where Mr. E. arranged a s i t u a t i o n where he carried on his roles and relationships i n the home i n such a manner, as i f he was there, i n spi t e of the fact that he was at Crease C l i n i c . I t would appear that i n ce r t a i n types of disorder, 1 See Chapter I I I , Page 68. - 106 -such a p o s s i b i l i t y i s more than just an idea. I t may also be due to the p a r t i c u l a r set of c h a r a c t e r i s t i c s p e c u l i a r to Crease C l i n i c with i t ' s open atmosphere, and p r i v i l e g e s for mentally i l l patients I t may haye both p o s i t i v e and negative aspects. The writer f e e l s that i t warrants further study, because the behaviour may suggest the p o s s i b i l i t y of structuring a new type of treatment c l i n i c , which may s t i l l necessitate displacement, but minimise the effects that such displacement has on family members. The suggestion being that there could well be a treatment setting that i s a"" compromise between the day c l i n i c and Crease C l i n i c . 5. The writer has observed i n the analysis of data a chain reaction of threat, stress, adaptation (reaction), threat stress, adaptation repeated i n respect to one role. ^ Other roles may be s i m i l a r l y affected. The evidence seems to suggest that a key r o l e i n the i n d i v i d u a l and s o c i a l role network i s severely threatened, and that the role adaptations and adjustments made i n order to e s t a b l i s h homeostasis, or meet the pressures of the s o c i a l environment, which may include reciprocal's r o l e s , are self-defeating, and only serve to rethreaten the key r o l e , with repercussions for other roles i n an interdependent relationship to the key role. The writer i s not necessarily claiming that such a s i t u a t i o n i s new, however, i t would appear to have s i g -n i f i c a n c e i n the f i e l d s of treatment prevention and analysis. I t would appear to the writer to j u s t i f y some further study. 1 See Chapter IV, Page 91 APPENDIX A Appendix A i s divided into sections A^ and A£. A i shows the Interview Format i n i t * s o r i g i n a l form, phrased i n professional language, and setting out the kinds of questions that would need to be asked of interviewees, to pro-vide a background of information that could be subjected to analysis i n terms of the focus of the thesis. A 2 constitutes of the Interview Format for Patients and Reciprocals as used i n interviews. The introduction remained the same for both patient and family r e c i p r o c a l . APPENDIX A1 - INITIAL INTERVIEW FORMAT MODEL Role What i s your understanding of the term «role»? What were your roles p r i o r to your wife*s/husband«s h o s p i t a l i s a t i o n ? What do you f e e l your wife's/husband's roles were p r i o r to hospita-l i s a t i o n ? What were your family's roles p r i o r to your wife's/husband's hospi-t a l i s a t i o n ? How well do you f e e l you were performing your roles? How well do you f e e l your wife/husband was performing t h e i r role? How well do you f e e l your children were performing t h e i r role? When your wife/husband was hosp i t a l i s e d what happened to your roles? to your children's roles? What sort of compensations or adjustments did you make i n order to contend with roles previously performed by your wife/husband? Were these compensations or adjustments successful, unsuccessful, adequate, inadequate? How long did i t take to e f f e c t the adjustments that were necessary? What would you say i s the role of the h o s p i t a l i n your situation? Does i t meet with your expectations of i t ? What i s the ro l e of the patient? Do you f e e l that your wife knows what her role i s i n hospital? Stress How do you understand the term stress? In terms of your understanding what would no stress, average, severe stress s i g n i f y ? - 109 -Would you consider that your -wife's/husband's h o s p i t a l i s a t i o n was s t r e s s f u l to her/him, to you, to your family? What made i t s t r e s s f u l ? In what way did the stress show i t s e l f i n your s i t u a t i o n , i n your family's situation? Do you f e e l the question of roles caused stress to you, to your family? I f not, what do you f e e l did? How long did you experience.stress? your family experience stress? Why was the h o s p i t a l i s a t i o n factor s t r e s s f u l to you, i f i t was not, what do you think was? What situations related to your wife's/husband's h o s p i t a l i s a t i o n were most s t r e s s f u l to you, your family? What situations a f t e r your wife's/husband's h o s p i t a l i s a t i o n were most s t r e s s f u l to you, your family? Why do you f e e l this way? Do you think your wife/husband i s aware of any of the stresses i n the home, connected with her/his h o s p i t a l i s a t i o n ? I f so, what p a r t i c u l a r stresses? What do you think i s most s t r e s s f u l to your wife/husband? How does this make you f e e l , your family feel? As a resu l t of stress xrfiat changes have taken place i n the home, i n your l i f e , i n your family's l i f e ? How do you f e e l about these changes, your family f e e l , your wife/ husband f e e l , anyone else? APPENDIX A 2 INTERVIEW FORMAT FOR INTERVIEWS WITH PATIENT INTERVIEW FORMAT FOR INTERVIEWS WITH RECIPROCALS Introduction In these interviews we are asking your help and advice i n order to understand a l i t t l e more of what act u a l l y happens to a family when a member i s admitted to a h o s p i t a l . This informa-t i o n we f e e l w i l l help us to appreciate some of the important problems caused by a s i t u a t i o n of t h i s kind. We are presently making a study of the effects that h o s p i t a l i s a t i o n has on a patient, and a patient's family. This study i s important to us because i t can increase our awareness and understanding of the important problems created by a s i t u a t i o n of this kind. The areas that we think you can advise us about, are the ones that deal with the sorts of things you and other members of your family do i n the home, i n the community and s o c i a l l y , and what the things that you do, mean to you and to others. How hospi-t a l i s a t i o n of a member of your family may have affected the things you and others do, and what sort of problems have arisen as a re s u l t . INTERVIEW FORMAT FOR INTERVIEWS WITH PATIENTS 1. Could you describe what sort of things you do i n your home. 2. Could you describe what sort of things you do s o c i a l l y - things you do for entertainment. 3. Could you describe what your husband does, i n the home; s o c i a l l y . 4. Could you also give me a picture of what your children do i n the home; s o c i a l l y . (Give a few leads) 5. What do they not do either i n the home or s o c i a l l y that you would l i k e them to do. 6. In your opinion, what are your feelings about the things you do at home; s o c i a l l y . 7. When you came to Crease C l i n i c what arrangements were made to manage at home. (Explanation. What did your family do i n your absence.) 8. What would you say are your feelings about the things they are doing, (that you did before your h o s p i t a l i s a t i o n ) . 9. What did you f e e l about leaving your family. 10. How did your family f e e l about you leaving them. 11. Could you t e l l me about any r e l a t i v e s that you have who are important to you. 12. What things that you did, do you miss now that you are i n ho s p i t a l . (Things that you did before your h o s p i t a l i s a t i o n that you now miss.) 13. Can you describe your relationship with your wife/husband, and others i n your family. 14. Could you t e l l me how your wife/husband f e l t about you leaving home. 15. Could you t e l l me how other members of your family f e l t when you l e f t home. 16. Can you t e l l me what you f e l t about visiting.arrangements at the h o s p i t a l . - 112 -17. Can you t e l l me how your r e l a t i v e s f e l t about your admission to h o s p i t a l . 18. Can you describe what a patient l i k e yourself does at Crease C l i n i c . 19. How long do you think i t took you to f i t into the c l i n i c program. 20. Can you describe the sort of d i f f i c u l t i e s you experienced adjusting to the c l i n i c program. 21. What feelings do you have about the c l i n i c . 22. What would you say are your feelings about home now that you are away from i t . 23. Have you any thoughts as to what your wife/husband feels about the h o s p i t a l . 24. Could you describe what i n your opinion caused your i l l n e s s . 25. When you were admitted to Crease C l i n i c what word do you consider would describe best the way you f e l t ; your family f e l t . 26. Before your admission and af t e r your admission to Crease C l i n i c what i n your opinion worried you. 27. Can you t e l l me about your friends and how they f e l t about your h o s p i t a l i s a t i o n . 28. Can you t e l l me about your feelings about l i f e ' s situations now that you are i n h o s p i t a l . INTERVIEW FORMAT FOR INTERVIEWS WITH RECIPROCALS So that.we may understand the meanings of words that are sometimes used when we talk about family l i f e , 1. How do you understand the following words: Duty, Job, Resp o n s i b i l i t y , Way of L i f e . 3. Before your wife/husband entered Crease C l i n i c , can you describe the things (a) you did, (b) your family , each member of your family did at home; i n the community; s o c i a l l y . 4. What i s your view about the'things (a) you did (b) they did (this includes h o s p i t a l i s e d patient) at home; i n the community; s o c i a l l y . 5. What i s your view about what happened to the things (a)you did (b) each member of the family did when your wife/husband was admitted to Crease C l i n i c . 6. Can you explain the sort of changes that were necessary i n your way of l i f e , the things you did as a resu l t of your wife/husband's admission to Crease C l i n i c . 7. Can you also explain the sort of changes that were necessary i n your family's (specify each member) way of l i f e , the things they" did as a re s u l t of your wife's/husband's admission to Crease C l i n i c . 8. Can you rate these changes, using the following words. successful unsuccessful adequate inadequate easy d i f f i c u l t they took a short time long time (specify how long) 9 . I f you do not f e e l there were changes, can you explain i n what way you and your family (specify members) were affected as a resu l t of your wife's/husband»s admission to Crease C l i n i c . 10. What do you expect of the h o s p i t a l . 11. Can you explain whether the h o s p i t a l met with your expectations. 12. Could you explain what your wife/husband feels about the ho s p i t a l . Can you rel a t e any examples that would indicate how she/he feels about the c l i n i c . 13. What do you think your c i r c l e of friends f e e l about your wife's/husband's admission to ho s p i t a l . 14. Can you describe things they have done to help, or things they might have done to help. - 114 -Stress 15. When your wife/husband was admitted to ho s p i t a l can you describe what worries you had (a) about your wife/husband (b} about the h o s p i t a l (e) about your home (d) about your s o c i a l l i f e (e) about your family (f) about your friends Are there other things that -were worrying you. 16. I f there were changes can you describe (a) your family's (b) your feelings about them. „ . 17. I f your wife's/husband's admission affected you what were your feelings. 18. What i n your opinion caused the problem that made i t necessary for your wife/husband to be admitted to Crease C l i n i c . 19. Can you explain whether the problems, changes worries started with your wife's/husband's i l l n e s s or h o s p i t a l i s a t i o n . 20. Could you describe what your wife/husband means to (a) you (b) your family (specify members) (c) others i n the family (d) friends, neighbours. 21. Could you describe what situations caused by your wife's/ husband's h o s p i t a l i s a t i o n were the most upsetting to (a) you (b) your family (c) her/him (d) others that are important. 22. What i s (was) your opinion about v i s i t i n g hours, weekend leaves, day p r i v i l e g e s . 23. What are your feelings about your contacts with the h o s p i t a l s t a f f . 24. What are (a) your family:-(specify members) (b) your feelings about your wife's/husbandf.s absence from the home. 25. What do you think"the h o s p i t a l could have done (a) to r e l i e v e your mind (b) to r e l i e v e your wife's/husband's mind about h o s p i t a l i s a t i o n . 26. In your wife's/husband's absence what did you miss about them. 27. What were your feelings about your wife's/husband's admission to Crease C l i n i c . APPENDIX B The following Appendix comprises of Verbatim Responses obtained i n Interviews with Patients and Reciprocals. Paitents are l i s t e d f i r s t , and Reciprocals l a s t . - 116 -Appendix "B" (1) INTERVIEWS WITH PATIENTS  Case #1. Mrs. F. 1. I make the beds; I see that the children get ready for school; on Thursdays and Fridays I do the f l o o r s . I l i v e i n a four bedroom house that i s being rented. 2. I do not have the time and we haven't got the money. Some-times we go to dances and mess dinners. My husband i s a Sgt. i n the Medical Corps. He works regular hours from 8:00 a.m. to 4:00 p.m. I have trouble keeping friends. I v i s i t many of my friends* but no one comes to see us. The reason for t h i s , I think, i s that I keep things to clean. I have two or three friends and with a few of them I play cards.. In- the evening I play Monopoly with my son. I go . to town on Fridays twice a month for groceries. I would l i k e more friends and when I started work I became r e l i g i o u s . No one minded. 3. My husband cleans the garage; he washes the walls and he has a house inspection i n May. It i s conducted by the Medical Corps. Sometimes he helps with supper; waxes the f l o o r s . I have been working as a Nurse Aide for one month from, s i x a.m. to three p.m. The woman up the way looks afte r the youngest c h i l d . Father takes care of the nine year old. He Is also good around the house. My husband i s opposed to me working for fear of mental i l l n e s s . I have had two other breakdowns a f t e r the b i r t h of my children. Most of my husbandTs s o c i a l l i f e i s with me. Occasionally we watch T.V. I do some sewing and I had been coping well u n t i l I l e f t Manitoba. 4. Danny and David make t h e i r own beds. They keep an eye on Dennis, the youngest. They go to swimming classes. They attend cubs and they play with t h e i r friends. We bought them some tr a i n s but they have l o s t i n t e r e s t i n t h e i r t r a i n s . They play ping-pong. Sometimes they help dry dishes and they get paid a quarter a week. Ihey sometimes go to the store. 5. I would l i k e to spend more time with housework. My husband i s more educated than I am and I f e e l that he should help the childr e n with their homework. He also stops me from working at night because he doesn't l i k e me cleaning.. I . f e e l that I am too s t r i c t with the ch i l d r e n and there needs to be more rel a x a t i o n i n the home. - 1 1 7 -6 . I am too hard on the kids and my husband. For instance, when the boys went to a night show recently, I would not have approved of t h i s i f I had been at home. But now I f e e l that the children don't have enough freedom. I wish that I had more time for cooking and spending less time cleaning. 7 . My husband had to take time o f f from work and my mother-in-laxtf from Vancouver i s looking a f t e r the children. It Is working quite well. 8. Everything seems to be a l r i g h t . My mother-in-law t o l d me that she didn't love the c h i l d and I have a bad rel a t i o n s h i p with her. I am s t i l l g r a t e f u l that she i s there but I also have some feelings about her. I was a well fed c h i l d . 9. I c r i e d h a l f the way. I f e l t lonely. I didn't want to leave my family but my mother sent me a t i c k e t . My mother and I are not too close. She drinks and has her own troubles. I went against my w i l l . 10. My.husband was quite hurt. The children keep asking,"Where*s Mommy?" The chi l d r e n know I am i n h o s p i t a l . I get l e t t e r s once a week from my husband. He has also mailed the t r a i n fare but the problem i s that the doctor w i l l not l e t me go home on my own. This has caused a l o t of inconvenience. My husband wants me to come home but said i n a l e t t e r that i f I didn't f e e l wanted and needed, I needn't come back. I think a c t u a l l y that he takes a l o t of things for granted. 11. I hardly ever see them. I have r e l a t i v e s i n Ottawa that I would l i k e to see as I haven't seen them for twelve years. 12. I miss the chi l d r e n and my husband but I am glad to get away from cleaning. I t also bothers me about the condition at home. 13. He's quiet, s i t s down a l o t . He l e t s me v i s i t neighbours a l o t . We are very close and get on well together. I need my husband. I have a good relationship with the children and I also need them. 14. My husband f e l t very hurt because two days before I l e f t I spent i n a hot e l . I f e e l upset that my mother-in-law has not written and I f e e l that she could at least have sent a card. - 118 -15.. It was a l r i g h t with my mother, but I shouldn't have come out here. You wonder why you do c e r t a i n things. Because of my husband's inspection job, I t r i e d to keep up appearances. 16. Generally, I have no v i s i t o r s except my mother on the week-end. I cry when the kids v i s i t the h o s p i t a l and i t makes me sad. 19. I think i t took me a week and a h a l f . I wanted to come to the C l i n i c . I wasn't happy and I knew I needed help and. I wasn't a f r a i d . 20. Coming out in:the morning made me f e e l better. I can get on easy with the s t a f f and I don't mind the C l i n i c at a l l . 21. Treatment i s good. I have l o t s of freedom and ground priviledges but I don't use them. 22. I ' l l have to mend my ways on cooking, keeping myself smart and make things easier at home. I did try to help out with the b i l l s but when things get hard I disappear. My husband fee l s i t was mean. 23. My husband c a l l s i t the mental home and he i s annoyed that they wouldn^t l e t me go home without him. The car i s not i n good shape .so i t i s d i f f i c u l t for him to come down and fetch me. 2h. I t could have been the s t r a i n bf working and I was also worried about leaving home. 2 5 . I f e l t easier - at peace, but I was s t i l l crying and upset. . 26. After admission, I was worried about the kids and getting home. Before admission I worried about my mother and step-father. 28. It's awful hard. It's what you make of i t . I f you can't help yourself no one else w i l l . You've got to motivate yourself to help. I'm happy at home - IV.keep busy. Some-times I'm awfully grouchy and cranky and always harping on something. - 119 -Case #2. Mrs. D. 1. I have a baby seven months, a c h i l d f i v e and a c h i l d age 8, I do housework every day. 2. I used to belong to the Women's Inst i t u t e , a sewing c i r c l e , the P.T.A., a h o r t i c u l t u r a l and alpine Club. I used to attend meetings once a month. We l i v e i n a r u r a l area. I v i s i t neighbours occasionally - once a week. I watch T.V. but not often. I v i s i t with my husband and sometimes I see neighbours i n the evening, once or twice a week. When I became pregnant l a s t year i t stopped me from doing a l l these things. Only i n the l a s t month have I started going out to Chilliwack. 3 . He helps with the dishes. He baby s i t s . He b u i l t us a new house. He makes cement blocks. He reads. He i s a teacher and works from 8 : 0 0 a.m. to 5 : 0 0 p.m. h. One i s at school and the other i s at home. They do not have many friends because of the l o c a t i o n i n which we l i v e but my son has two friends and my daughter has one. Usually the childr e n play with each other and I take my son to the Library and he gets sports at school. 5 . While sick I was d i s s a t i s f i e d with everything. I t was a l l a very tremendous e f f o r t . I went to bed and c r i e d . No one knew that I was sick and I s t i l l went v i s i t i n g . I t i r e d of the baby. Friends came to v i s i t more frequently but i t didn't mean anything. 7. My husband's mother took the baby. My husband looked a f t e r the other two childr e n and during the day the f i v e year old stayed with a neighbour. My husband does a l l the domestic work i n the home. 8 . I'm happy,about the baby but not too happy about my husband looking a f t e r the children. He has a whole day of work and comes home f e e l i n g t i r e d . 9 . I had to leave. I was doing a t e r r i b l e l o t of damage to my husband. I was r e a l l y too sick to worry. 1 1 . A l l my r e l a t i v e s are i n Switzerland. They do not know that I am i n h o s p i t a l . I i . Sunbathing. I enjoyed more freedom. P h y s i c a l l y I am very comfortable. I miss the housework, the children, and I miss my gardening. 1 3 . I have a superb relationship with my husband. We communicate. We are very good mates and friends. We love each other and I am fascinated by my husband. I have a good relationship with the c h i l d r e n and they are very good. - 120 -14. I was a l l broken up. I was close to suicide. I f e l t disturbed. I wanted to cry. He didn't know what to do with me. He t r i e d to spend more time. He did more things for me. He took me out much more. He bought me a second car but I couldn't accept the car or the house that he b u i l t . I now accept them. 15. My son was t e r r i f i e d because his friend's mother is at Centre Lawn and the f r i e n d had been t alking to him. They mind being without a mother and i t i s inconvenient for them. It has more to do with household chores. They l i k e comforts. They wanted to be with father rather than grandmother, who has the baby. 16. Mymother-in-law v i s i t s ; so does my brother-in-law and his vife. 17. I t was a t e r r i b l e shock to my husband's mother. At f i r s t she thought that i t was a t e r r i b l e thing and she talked about me as being the poor so-and-so at Crease. I don't know what other r e l a t i v e s think but I know that my mother suffered i n the way that I'm suffering a l l her l i f e . 19. I f i t t e d i n and had no trouble adapting to the new s i t u a t i o n . 21. I have the f i n e s t regard for the c l i n i c . I have a good re-lationship with the s t a f f and I do not have any contact with the s o c i a l workers. 2 2 . I look forward to going back. Time i s very precious to me. 2 3 . I think he thinks i t i s a wonderful place and he comes to v i s i t and takes me home on week-ends. 24. It had something to do with bodily changes during pregnancy. My behavior changed during t h i s time and I have been depressed ever since. I judge myself so harshly. 2 5 . I do not remember very much about my admission but I was un-happy and I was relieved to be back at Crease C l i n i c . It's a shelter. 2 6 . Before my admission I couldn't enjoy anything. I had no joy -as i f being dead. Even the smallest task seemed l i k e a gigantic e f f o r t . My husband and the family made me tense and I had no i n t e r e s t i n c u l t u r a l goings-on or friends. At the back of my mind there was a dread of d i s a s t e r . A f t e r admission I didn't worry about anything. But the f i r s t time I came to the C l i n i c I worried about treatment. - 121 -27. A l l my friends were surprised but everyone has been very nice to me. 28. I am eager to go home and s t a r t i n again with the family. I f e e l I can give more to the children now that I am cheerful. - 122 -Case # 3 . Mrs. M. 1. Housework - cleaning - washing - cooking food. I care for my son. I went shopping every Friday. , I do no k n i t t i n g or sewing. I read murder books. I have no part i n my husband's a c t i v i t i e s . I do no gardening. 2. I spend a l o t of time with Mrs. M(S). I stayed there on week-ends. In the mornings I had coffee with the neighbours. I watched T.V. i n the evenings, i t stopped me from thinking. I used to s i t i n the corner reading. My husband was involved with son and other things. He worked i n the basement. I played cards on the week-end with Mrs. M(S) and went for drives with her. 3. He eats supper, washes up, makes his own sandwiches, waxes the f l o o r s . When I am away, makes his own food, washes the kitchen f l o o r , cares for my son and plays i n the garden with him. He messes around i n the basement. We are never together. Occasionally he would go for a walk together with the son, v i s i t a fr i e n d , got to a union meeting once a month. He also went to a f i s h and game club once a month. Occasionally he would watch T.V. There was l i t t l e communication between us and when we talked i t ended i n a quarrel. The atmosphere was tense. 4. He plays with toys. He goes to the neighbours. After Christmas he went to Mrs. M(S)s. 5 . I would l i k e my husband to s i t and t a l k to me, give under-standing and comfort. He remains i n the kitchen, reading sexy books. He works for the Burnaby Municipality as a labourer. I am ashamed of him. He i s a d i t c h digger. As for my son, I would l i k e my husband to d i s c i p l i n e him more. 6. I got very bored and b i t t e r . I wanted to go out but couldn't. I went out with Mrs. M(S) but her way of l i f e i s very d i f f e r e n t to mine. I refused to go to my husbandTs club. I didn't l i k e the people. Sometimes I l i k e d the people but couldn't bring myself to go. I do not l i k e housework but s t i l l I had to be tidy and t h i s got on my husband's nerves. I didn't want to go out with my husband because he makes me f e e l embarrassed. 7. We contacted the Welfare i n order to f i n d out whether they could provide a housekeeper but we couldn't pay for the service because of debt so I arranged for neighbours to look aft e r him during the day and my husband p'icked him up at night time. When I came into the h o s p i t a l Mrs. M(S) took the c h i l d back against my wishes. My husband takes care of the house. He i s good at mending and i n a manner he gets a kick out of i t . - 123 -8. I don't mind domestic work. He objected to the care of the c h i l d by the neighbours. He refused to cope with the c h i l d but he takes care of the c h i l d on the week-ends. 9. I was glad to get away from my husband, glad to leave him. I have no f e e l i n g about my son - he gets on my nerves. 10. They haven't said anything and my s i s t e r i s not interested. 11. My sons i n the Navy are important to me and I write to them. 12. I don't miss anything. 13. I do not love my husband and I don't talk to him because i t ends i n a quarrel. He threatens me and thinks that I am crazy. We are distant sexually. We have no sex and before I thought of i t as a duty I had to perform. It seems to be an answer to a l l my husband's problems. We don't do things together. As for my son, I have no patience with him. I didn't want the c h i l d . lh. Don't know. He didn't seem to care. Two days before I l e f t he told me to take a l l the sleeping p i l l s . 15. I do not know. 16. I think they are adequate. I look forward to seeing my husband but i t ends up i n a quarrel. 17. I don't know. 18. I have done more things here than I have ever done - dancing, Recreational Therapy, Occupational Therapy, enjoyed being with g i r l s . I am on i n s u l i n and a member of a group. I watch T.V. 19. A week. 20. At f i r s t I didn't want to mix or go out. 21. It i s very nice. I l i k e i t and I am happier here. 22. I don't want to go back. 23. He told me i n no uncertain terms. He sees i t as an escape f o r me. He thinks that the doctor i s a l l wrong and that I am not sick. He refuses to bring dresses i n for me when I asked him to. 2h. Relationship with my husband. Relationship with Mrs. M(S). I was unhappy. Poor s o c i a l l i f e . Nothing i n common with my husband, except sex. - 124 -25. Escape from my husband. Get away from my family and Mrs. M(S). F e l t awful f i r s t o f f . Mrs. M(S) wanted me to go to a Naturopath. She said I was weak and intervened i n the relationship that I have with the doctor. I was happy. 26. (a) My husband. My son. Mrs. M(S). Poor appetite. Loss of interest, (b) Had no wrries about admission. I am not ashamed of being here. 27. The neighbours thought i t was a good thing and they even told Mrs. M(S) to quit bugging me and she thought that I was running away and even wrote to the doctor to say she could help me. 28. I am happy here. I don't want week-ends. I want to leave my husband and obtain a l e g a l separation. My husband wants our relationship with Mrs. M(S) to continue. He won't understand. I don't know what the future holds. - 1 2 5 -Case # f « Mrs. S. 1 . I l e f t my husband for awhile because he has been a alcoholic since marriage. I went through the Family Court and l o s t my children. At home I do housework. I kept house i n a poor part of town and with l i t t l e money. I do the shopping and cooking and look after the children - clean. I never cared for s o c i a l l i f e . Kept contact with the family i n Vancouver. I enjoyed dancing. I took physical education for s i x months which I enjoyed. I took the boys to the park on week-ends. I .am not interested i n T.V. and sometimes I see the neighbours. 3. My husband i s very handy. He i s a P o l i s h man. He thinks that wives are servants. He i s a great cook and the odd time has made something to eat. He was a v i o l i n i s t but played only four or f i v e times after marriage. The whole block i s f u l l . of alcoholics but he has stopped drinking since he has had a job as a delivery man for a newspaper. He sleeps a l o t . He i s not strong and has had T.B. When he communicates he i s cranky. When' I open my mouth I get scared. h. My sons dry dishes - ti d y up the i r clothes. My husband teaches them carpentry i n the basement. They play with t h e i r friends and one boy i s a Cub. 5. I would l i k e my husband not to drink and to give up his crazy friends i n the block. 6. I am not contented. I hate the way he talks and I am treated as a servant. 7. I am s t i l l worried. My mother and s i s t e r got a lady to do the work i n the house but something happened and she l e f t . I am worried about the children and the fact that the work won't get done. My husband can look aft e r the chi l d r e n i f he doesn't drink. He's very cranky when he's sober. 8. I am very happy they are getting on a l r i g h t . I worried and I t r i e d to go home sooner. That day my husband was very mean. I had the hor r i b l e f e e l i n g I was going to do something insane. I can't remember very much more. 1 0 . The boys were sorry. I don't know what my husband f e e l s about me. 1 1 . My mother and s i s t e r l i v e i n Point Grey. I have a married brother with six children. They are awfully nice. 1 2 . I miss home. I am homesick. I miss the children. I love my children. It was a long time before I had them. - 126 -1 3 . He treats me as a servant. He's cranky. I look after a sick and drunk husband. He shows no kindness, love, a f f e c t i o n . He doesn't know how to treat me. He's not u n f a i t h f u l but he fee l s he buys the groceries and therefore can do anything he wants to. There i s a good relationship with the sons. They know that I am i n ho s p i t a l because I get headaches. 14. I don't know. 1 5 . I don't know how they f e l t . 16. I don't l i k e v i s i t i n g i n a room f u l l of people. I see my sons and I want to go .home today. 17. They were worried and they t r i e d to help with the boys. 18. I r i s e and dress 7*00 a.m. Breakfast, go to Occupation Therapy then lunch. I may sleep and I do k n i t t i n g and sewing. I have tea at 2:00 pm. . Supper at 4:20. The meals are very nice. I watch T.V. and l i s t e n to music and have become intimate with another patient on the ward. 1 9 . I was here three years ago and I just f i t t e d i n but I wanted to go home and gave my notice, but they refrained me and now I am glad. 20. Because I was homesick. I have not adjusted very well. I want to be home with my children. 21. I t was quite wonderful I was gra t e f u l when I came. I needed help. I was not made to f e e l insane. This worried me. I was worried for the children. Today people don't think much of people being i n Grease C l i n i c . 22. I want home more. When I think of my husband I just couldn't have any normal feelings about l i v i n g with men l i k e him. I think of the sun shining tfe©i#itft@) kitchen window and myself s i t t i n g there. 2 3 . He has proved a point - that there i s something wrong with me and not him. He i s pleased I came here. He has v i s i t e d with the boys but I cannot expect too much. Sometimes he can be nice and when he i s I l i k e him. He i s very sensitive about money. 24. Abnormal marriage and the relationships at home. 2 5 . Confused. 2 6 . I f e l t confused. Before coming into the c l i n i c I had the f e e l i n g that I might be doing something insane. After I came to the C l i n i c I was glad to have help. 2 7 . The wives i n the block s t i c k together. They blamed my husband for my h o s p i t a l i z a t i o n . I made some friends at b a l l e t class - 1 2 7 -but my husband stopped me attending. They don't know that I am i n ho s p i t a l . I f e e l much better now. I manage to keep going and thi s i s not bad. My husband getting a job i s the best thing that ever happened and I fin d i t d i f f i c u l t to believe i t . It i s possible that things may be very d i f f e r e n t i n the future. - 128 -Case #5. Mr. B. 1. I help my mother once i n awhile. I wash dishes. 2 . Some bowling. Occasionally I go drinking with my friends. I go to parties quite often. 3. I am separated - I don't know what she does. 4. No response. 5. When I was l i v i n g with my wife she wouldn't cook but she took good care of the children. A l l i n a l l she didn't do very much. She has not been a good wife to me. I am not i n love with her and I would rather not be with her. 6. I f e e l that I did not do the things that I should have done. I treated her roughly and I refused to Sleep with her.-7. I have not had a job for a long time and my wife receives s o c i a l assistance. 8 . I don't care what she does, but i t s funny when she does some-, thing that I don't l i k e , I get mad. 9 . I didn't f e e l anything. 1 0 . My family have no idea but I guess they f e e l sympathetic. I have no v i s i t o r s and I don't want my wife to v i s i t . 1 2 . I miss driving and I miss going out for a beer. I have been i n j a i l before and t h i s place i s somewhat l i k e the j a i l , and I am used to i t . I get a l i t t l e bored. I adjust within a week. At f i r s t t h e c l i n i c program annoyed me but I f e l l i n with the program. 17 . They knew that I am at a mental h o s p i t a l and that i t i s doing some good. The doctor says that I am a hypochondriac. 1 8 . I do recreational therapy i n the morning. S i t out i n the sun. I play pool. I s i t i n , i n the evening and I have been to a dance. I enjoyed i t but I am a l i t t l e shy. It i s hard for me to dance with a g i r l unless I know her. 1 9 . A week. 2 0 . Not any. 2 1 . It i s run l i k e a j a i l . There i s a r e s t r i c t i o n of freedom. At f i r s t I thought i t was a crazy house but I didn't know and I am surprised to see that everyone i s sane. 2 2 . It i s a r e l i e f to leavehome and a r e l i e f to be i n h o s p i t a l but I wish I could get out. - 129 -24. The relationship with my wife,whenever I went near her I got a stomach ache. 25. R e l i e f . 2 6 . Before admission I was worried about getting better. 27. Nothing. 28. There i s no r e a l change. I f e e l a l i t t l e more energetic. - 130 -Case #6. Mr. C. 1. The home served as his business o f f i c e . Many evenings were taken up with bookwork. Wife often helped i n t h i s . Children watch T.V. a great deal of the time. No hobbies - not fond of gardening, etc. 2. S o c i a l l y - ra r e l y went out, but often had friends i n for conversation, a glass of beer, coffee. (Again, much time taken up with business transactions). Plays golf i n summer. 3 . Wife sold r e a l estate the l a s t few years; previous to th a t looked a f t e r the home and some of the bookkeeping connected with the business. Was fond of baking - plays golf i n summer, belongs to a c u r l i n g team i n w i n t e r . 4. Children look after t h e i r own rooms; watch T.V. a great deal of the time. Entire family belonged to a winter club and chi l d r e n went there often for skating and swimming lessons. G i r l s took dancing, piano, singing lessons. Older boy had a large c i r c l e of friends and was out a l o t . Second boy described as "nervous and shy" - spends much time with his dog. Children often went to shows on week-ends. 5. He wishes children were neater - other than that, no complaints. Though the older son led a very active s o c i a l l i f e , he said they had had no worries about him but did wish he would " s e t t l e down" i n school. Feels wife was e n t i t l e d to whatever recreation she wanted as she was often t i e d down with business. Is worried about how both his sons are going to "get along i n the world" as neither are good students. 6. He evidently found t h i s l i f e quite s a t i s f a c t o r y , though he said his wife often got "fed /up" with him working so much. ( A l l this material refers to the time previous to Mr. C s business f a i l u r e . Since moving out to Vancouver those a c t i v i t i e s costing money have been eliminated, and they have few friends out here. The family i s very distressed by thi s and want to move back to Calgary. Mr. C. would have a hard time facing "the embarrassment"). 7. Mrs. C. was working. Gary (oldest son) was looking for a job. They were receiving a compensation cheque. 8. "Not a pleasing thing to think about." Feels i t i s very hard on his wife. Doesn't l i k e to think of his son "'selling shoes". Feels there i s nothing he can do. Is distressed that compensation has stopped because"as long as that was coming through I f e l t they were benefitting i n some way from my work." - 131 -9. He cannot remember much of what went on at the time of admission. He had, "nothing to do with i t . " Misses them badly now - worries about them. 10. "They don't seem to say much". Feels Gary i s more concerned than the other children because he knows more about his father's condition. 11. None p a r t i c u l a r l y . A l i t t l e closer to a s i s t e r i n Calgary than some of the others. She i s dying of cancer. Did not elaborate more here, and I did not f e e l i t was too good an idea to pursue subject as Mr. C. i s i n c l i n e d to be a b i t depressed today. 12. Misses not being able to do anything about looking after his a f f a i r s . 13. "Very good", relationship with wife. "Common knowledge" among th e i r friends that they got along exceptionally well. No serious problems i n any area. Got along well with children, but less patient, more stern than th e i r mother. 14. " I t i s very hard on her". She doesn't say much, but I read be-tween the l i n e s . (Actually, wife told me she was "relieved" to have him admitted he was so depressed). 15. "They didn't think too much about i t . " Elaboration on t h i s i n d i c -ated that he meant they didn't attach much stigma to i t . He had had a very reassuring l e t t e r from another s i s t e r to t h i s e f f e c t . 16. Feels afternoon hours are adequate, but that the evening ones are too short and too early. His wife cannot get here by 7*00 and nothing goes on on the ward from 8:00 to 9*00 anyway. 17. Emphasis always on the "stigma" aspect of being i n a mental h o s p i t a l - emphasizes that his r e l a t i v e s do no look at i t i n t h i s way. 18. Goes to physiotherapy (injured knee) every morning. Attends Mr;' W's group ( r e a l i t y testing - group of men i n t h e i r late twenties and on - discussion on problems they may face returning to commun-i t y ) . Belongs to relaxation group. Goes to Occupational Therapy. Goes swimming every time i t s offered and enjoys i t very much. Eats his meals with a c e r t a i n group a l l the time. Has ground pr i v i l e d g e s . 19. He thinks i t took him a couple of weeks to get used to the program. 20. Being without his family. The thought that he was i n this kind of i n s t i t u t i o n (mental hospital) bothered him. Lack of privacy very much of a sore point. He l i k e s to get away from everything i f he has a migraine. Was i n the Airforce and found lack of privacy there almost unbearable. D i s l i k e s having to ask the nurse to get into his personal belongings, etc. Is very fast i d i o u s and l i k e s to look aft e r his own things. - 132 -21 . He said he thinks we try very hard but can only do so much. 2 2 . Misses home very much - looks forward to returning and to his week-end v i s i t s , though he found himself i r r i t a b l e on l a s t v i s i t . Puts t h i s down to a skin rash he i s suffering from. 2 3 . He thinks his wife f e e l s the same way about the h o s p i t a l as he does, i . e . that they do the i r best to get a person back on h i s feet. Again mentioned that carrying the whole load i s pretty hard for her. 24. Worrying about his unfinished business i n Calgary. 25. Doesn't remember being admitted at a l l . After his f i r s t shock treatment he woke up and r e a l i z e d where he was. In one word he f e l t "bewildered". Could not say how family f e l t - thought the younger children weren't hardly aware of what happened. F e l t oldest son would be worried. Again mentioned stigma aspect; emphasized his family did not f e e l t h i s . 26. F i n a n c i a l d i f f i c u l t i e s - what would happen to family. 27. Only two friends i n Vancouver and they encouraged admission. 2 8 . Sometimes extremely confident that things can be worked out. At others, old fears return, i e . fear of not getting a job, of losing everything that's l e f t . Tends to r e f i g h t the old battles, "only t h i s time I win". In general not overly optomistic, but feels some of i t can be worked out. Trying to decided whether he r e a l l y w i l l be able to face things "head on". (Worker's note - Older (19 yrs) son quit school to get a job to "help out" - was unemployed two months previous to his father's admission and looked af t e r him, i e . cooked lunch for him, etc. Was instrumental i n persuading his father to come here. I talked to the son and he said his father con-t i n u a l l y worried about being a " f a i l u r e as a father". Said he t r i e d to give his father advice, but t h i s only upset him because as son sees i t "I'm his son after a l l , and i t doesn't work for me to tal k to him l i k e that". Mr. C , even now. doesn't l i k e to have his son contribute his whole salar y ) . - 133 -Case #7, Mr. R, - So c i a l Service not active at t h i s point. 1. Presently -unemployed - quit job following troubles - arguments at home - was a barker operator (taking bark o f f logs) - kept a big garden at home - kept 3 milking goats - family f i s h i n g for a past time. 2. Keep within own l i t t l e set of friends - v i s i t with them -s o c i a l conversation - fa m i l y - l i k e feeling. 3. Housework, milking - s o c i a l l y : doesn't belong to any clubs or anything, v i s i t s with neighbours - helped equally with husband i n building the barn - "doesn't shirk from work at a l l . " G i r l - helps with dishes and the housework & helps feed the rabbits -plays with friends, school friends - v i s i t s with them and they with her. "I'm af r a i d I made i t pretty rough on her when I quit., my job". Union. (Wife crossed a department store picket l i n e with woman fr i e n d across the street, despite patient's feelings about i t . ) Boy 8, t r i e s to be h e l p f u l - pretty good with kid - same as older s i s t e r -has friends. Youngest - pre school - "exceptionally sociable, I think he takes a f t e r his mother". Always playing around the barn, looks after his rabbits - asks Dad i f he can help and usually with his Dad. 5. They do everything that they're supposed to - when they're reminded. The Hatter not too often - they're responsible. 6. I don't l i k e to be forced into sociable a c t i v i t i e s , e.g. a v i s i t , I l i k e to do i t as I am ready but I don't mind the wife doing i t , (e.g. union f r i e n d ) . I don't l i k e to get tangled up with neigh-bours; prefer to have a c e r t a i n amount of freedom. 7. "Wife always at home - neighbour across the road (the man) has offered to do the ploughing and take care of the garden and another neighbour with the goats (kids expected and w i l l be sold at auction)". Apart from these developments, no other arrangements. "She was damn glad I was coming." 8. "Carrying on as i f I was there" - very pleased with t h e i r attitude and they seem to want me to stay t i l l I r e a l l y get better - because i t s for t h e i r own.sakes. I'm sorry for the arguments I s t a r t . 9. " F e l t lonesome and sorry not to be there to help them." 10. • "They were shoving me o f f - wanted to see me get better." 1 1 . "My mother i s i n Montreal and most of the family are there. Letters from them are very important to me as far as my outlook on l i f e i s concerned 'cause I know they're r e a l l y sincere and my wife i s r e a l l y sincere too." I guess we argue because we have two d i f f e r e n t points of view. - 13>f -12. Miss a l l the work around the house. Miss the f i s h i n g - quiet and peaceful. 13. Pretty close together (with wife). She's very considerate towards me - puts me more important than the kids: very close to the two boys but kinda hard to get close to the g i r l - she keeps her d i s -tance - because I'm a l i t t l e too s t r i c t with her I think - and maybe also because we're both nervous. 14. Didn't l i k e me leaving home but wanted me to come to get better. She t e l l s me that she misses me at home. 15. "I wouldn't know about that". Commented that the youngest when he came to v i s i t "cried and didn't want me to stay - wanted me to come with him." 16. Pretty good - excellent i n f a c t . 17. My mother phoned from Montreal but I don't know what she said. 18. We look forward to R.T. a l o t , O.T. Enjoy the work - the s o c i a l a c t i v i t i e s on the ward - would do more reading i f lights, were better, e.g. side l i g h t s on wall. 19. Two or three days before I r e a l i z e d what was going on - i . e . the routines - didn't know the purpose u n t i l then. 20. I don't think I had any d i f f i c u l t i e s . 21. S t a f f i s pretty reasonable, very considerate, I noticed that r i g h t away - awful l o t better than St. Mary's i n Montreal - keep us more occupied and don't give us time to fret. I f i t wasn't for the a c t i v i t i e s I think I'd be just as bad as when I f i r s t came i n -nurses occupy you. 22. Appreciate i t a l o t more. Better understanding about my wife -even more sincere than I thought she was. 23. She thinks i t s a r e a l good thing - she was i n s t r u c t i n g me to do everything I was told - to obey the rules - e.g. I was a l i t t l e peeved at not getting week-end leave but she snapped me out of i t . 24. Fear of the future - always a f r a i d of being l a i d o f f and losing the job u n t i l I got so bad I just quit i t - out of the frying pan into the f i r e - used the picket l i n e incident as an excuse to quit. 25. (a) Confident. (b> Relieved. 26. About getting along well with my family, with my wife and kids. 27. They were concerned - neighbours trying to be h e l p f u l . 28. Don't take them as seriously - don't have enough time to s i t and think about them. - 135 -Case #8. Mr. C. 1. I was a machine operator. I did some gardening. Gave some help with domestic chores and I worked i n the basement. 2. I have no s o c i a l l i f e - I watch T.V. . 3 . My wife does most of the d i s c i p l i n i n g i n the house. The children are s p o i l t . My wife shares the domestic duties with my mother who has been a patient at Essondale. My wife has l o t s of friends i n Richmond. She i s very active. She i s r e a l l y a farm g i r l . 4. A l l my children are at school. They do help with domestic chores and they are always out of the house. 5. N i l . Not thought about i t . As long•as I don't get into trouble. 6. I am never s a t i s f i e d . I would l i k e to spend more time with the c h i l d r e n and have more s o c i a l l i f e . I had a l o t of friends i n Richmond once. 7. I used to be i n Shaughnessy Hospital. 8. Yes, s a t i s f i e d . 9. I mind being away from the family. I miss the whole family. . 11. I don't know. 12. I miss working with my tool s . 13. I have a very good relationship with my wife - i t i s good too with the children. 14. I wouldn't say she was much upset. She kept her feelings to her s e l f . 15. They were upset for awhile - no Daddy around. 16. My wife cannot v i s i t . I don't r e a l l y want to see the family as the kids would o n l y worry. 18. I s i t around - relax - walk around and receive p i l l s . 19. I f i t t e d into the C l i n i c 21. I never thought about i t . I don't know why I am here. 24. I had an accident I can't remember about. 25. No memory. - 136 -26. I have no expectations. The h o s p i t a l i s too close to the road. 27. No friends v i s i t but they know I am i n h o s p i t a l . 28. I want to go back to work. I miss work. I am r e s t l e s s to be doing nothing. I have my tools at home. - 137 -Case #9. Mr. E. 1. Upkeep of the home, gardening, I wash dishes once a month. I don't do anything towards the functioning of the house. I am generally the d i s c i p l i n a r i a n i n the family. I spend a l o t of time with the childr e n i n the evening. My wife works i n the evening. I t a l k to the children, play with them and I w i l l clean the c h e s t e r f i e l d and rugs. 2. I generally l i s t e n to records. I do a l o t of reading and a l o t of gardening. .My wife works six nights a week. She has l i t t l e s o c i a l l i f e . She may v i s i t friends on Sundays. In November, December and January we took dancing lessons twice a week. She i s Secretary-Treasurer of the Diabetic Association. She attends two meetings a month i n the evening. We plan our s o c i a l a c t i v i t i e s separately. She does everything - dishes, washing, ironing, cooking. She i s an excellent housewife. She makes the clothes, does the shopping, works at a drive i n two nights i n the week now that I am i n h o s p i t a l . S o c i a l l y , she v i s i t s a l o t on the telephone. She goes to a coffee club i n the afternoon. 4. Nothing. They don't help mother. They have a greatmany friends and go to dance parties except the c h i l d of 8. The other daughter goes to g i r l f r i e n d s ' p a r t i e s . My son i s a Scout and my older daughter a Pioneer. The youngest spends the night with her Dad. 5". Nothing. I would l i k e to v i s i t perhaps a l i t t l e more with my r e l a t i v e s and have more time together with my wife. 6. Bored being alone with the kids. Kids are not suitable f o r adults. I would l i k e to do more dancing, s o c i a l v i s i t i n g , playing bridge, swimming and I need other adult company. I f e e l my r o l e at home i s adequate. At home I am the Court of Last Resort and I f e e l that I am the father i n the house. 7. I phone my wife every day and they put o f f any decisions about money u n t i l they have discussed i t with me. I sign the cheques and i f the c h i l d r e n want to do something they 'phone me at the h o s p i t a l . My wife i s working two nights a week now. I i n s i s t e d on this before leaving for h o s p i t a l . My eldest son looks a f t e r the house and family while mother i s working. My son does a l o t of the gardening for me on my orders. For example, when my wife refused permission f o r my son to take records to school, they had to phone me to gain my consent. 8. Nothing I object to except no s o c i a l l i f e . Now i s the f i r s t time i n twenty years I have been away from home. I didn't discuss my i l l n e s s with my wife because i t went against a l l general p r i n c i p l e s to do so. 1 w i s h e d to discuss i t but i t - 138 -would be to emotional for my wife so I made a l l the arrange-ments before I told her. I f e l t I had to go i f I didn't want my family to break up. I was unhappy about leaving my family because you can't f e e l anything when you leave them. I had to y i e l d to the in e v i t a b l e . I f e l t that the family would manage. 10. Very badly. My son was glad i n a way. He didn't want to see me go. The youngest was heart broken, the middle daugh-ter was not too anxious. A l l the children c r i e d . Before I came to h o s p i t a l i t was a hard ten days. My wife got used to the idea and I f e l t that I couldn't go i n unless my family were adequately provided f o r . We have no savings and no medical plan. I went to S o c i a l Service i n Vancouver and they agreed to help with $140. per month. My wife was allowed to work up to an amount of $170. per month. My boss does not know that I am i n ho s p i t a l but the job i s s t i l l waiting. It mattered l i t t l e one way or another. My family supported me over my decision. I l e f t my wife f e e l i n g that I cared for her and this was a comfort to her. I have a ;" brother and he was told that I was going to h o s p i t a l and that was a l l . We wanted i t kept quiet. 12. I miss a goodnight k i s s , records, s o c i a l l i f e and I would just as soon that people don't see me here because of the attitudes of others. There are a fine bunch of fellows on the ward. I do not miss work. It i s the f i r s t holiday i n 28 years. I f i n d things to do. Lack of freedom doesn't bother me. When I f i r s t came I was worried whether a l l information would be kept c o n f i d e n t i a l . I t bothered me that things might not be c o n f i d e n t i a l . I was upset that they took away my very personal things. 13. Ideal r e l a t i o n s h i p . Close. We are no longer two people, but an extension of each other. This has been a great help to me while i n h o s p i t a l because I f e e l h a l f out there anyway. We discuss things together - except h o s p i t a l i z a t i o n . When my wife comes home at midnight we get together - i t s a r i t u a l . I am an avid reader - interested i n science and history. I have a good rela t i o n s h i p with the children and I have no d i s c i p l i n e problems with them because they know that I mean what I say. 14. I hopal to be out of h o s p i t a l today but i t i s clear that I am not ready to go. I am not emotionally f i t . 15. My parents are i n Alberta and they don't know. 16. Fine. The younger two children don't know that I am i n ho s p i t a l . I go home on the week-ends and they are f i n e . I have my ground p r i v i l e g e s . ' 17. They do not know that I am i n h o s p i t a l . - 139 -18. I am an early r i s e r - I get up at 5*00; I wash; make the bed; p o l i s h the h a l l s and have breakfast. I play cards; I go to R.T.; I swim and go bowling i n the afternoon. In 'the evenings I play pool, bridge and attend dances on Saturday evenings. Personally, I wouldn't i n v i t e my wife and I prefer to keep my wife away from the h o s p i t a l so that I w i l l not depress her. 19. Two days. The environment i s simple, undemanding, and -I f i t i n e a s i l y . I had no problems adjusting. 20. It i s the most marvelous place i n the world. The longer I am here the better. The people are wonderful. It gives you a sense of well being. I expected a great deal more r e s t r i c t i o n . I wasl i l l informed and i t i s clear that the h o s p i t a l needs more p u b l i c i t y . I r e a l i z e that my attitudes were not healthy and that stress made.'me seek help and that t h i s ruled out everything else. I didn't care what people thought. In any case, people's thinking i s out of l i n e and, as I did, thought of the h o s p i t a l as a nut house, but the majority of people here are capable. 22. Home i s the place I would l i k e to be but I am not f i t to be there yet and,I am not anxious to go. 23. The same as mine. This i s the place where help i s . 2k. I s o l a t i o n - the problem I have has been mine for twenty-five years. It i s d i r e c t l y ah ' i n d i v i d u a l problem due to the manner i n which I was brought up and the s o c i a l environment. 25 . A sense of r e l i e f and a foreboding of what was to come i n the way of treatment. 26. Before admission my personal problem worried me and the affects that i t would have on my l i f e . You keep suppressing the problem, and I either had to leave the family or destroy myself. I was worried about the affects that my personal prob-lem would have on the family because the family mean a l o t to me. 27. Some of our friends kicw that I am i n h o s p i t a l but not s p e c i f i c a l l y Grease C l i n i c . 28. I have had my own way i n everything. L i f e never denied me anything. I have done pretty well. We have our own home and we started with mothing. We dress and eat wel l . We go out very l i t t l e and we have an emotional sense of f u l f i l l m e n t . I would l i k e to mention that the f i r s t time I applied f o r ad-mission I was refused and t h i s made me very anxious but l a t e r they accepted me. - 140 -Case #2. Mr.F. 1. Duty means to your wife when you are married. When you were married you swore to love her, take care of her, support her, make sure that she's happy. It has to come from the other side too. To provide a home. Got to be employed - to have steady work and look aft e r finances. Job - thi s means employment. Responsibility -this means face up to things whatever they are and take care of things. Way of l i f e - what you make of l i f e . 3. T e l l Edna the r i g h t way of going about l i f e as I under-stood i t . I f she had li s t e n e d to me there would have been no need for her to come to the h o s p i t a l . I do my own sandwiches, make my own breakfast, take my wife a cup of tea at night. When my wife was at Mrs. M(S)s I made my own supper. Mrs. M(S) was against i t . I washed up the dishes, waxed the f l o o r s , washed the kitchen f l o o r . When I came home from work I spent most of my time with my son. On week-ends I was with him most of the time. She (wife) couHdn't stand him (son) around. In the l a s t four months I couldn't go out. I couldn't go to union meetings and you have to attend one i n three. Some nights I read, watched T.V". I didn't get a chance to s i t down u n t i l 8:00 p.m. when my son went to sleep. I had to keep Edna's p i l l s locked up. My mind i s upset. I would rather stay at home and help her. In any case she did not want me to go out. I have got my own friends and they are constantly giving i n v i t a t i o n s for me to bring Edna along but she doesn't f e e l l i k e i t - she's got nothing else to do and she makes excuses then I have to make excuses to them. It r e a l l y annoys me. In the community I work for the Burnaby municipality. As far as my wife i s concerned, she sat down most of the time. She did some washing, house cleaning, watched T.V., went to Mrs. M(S); she couldn't be bothered with anything. I have been her errand boy. I do i t but I also mind. She won't even walk to the store to get cigarettes. She doesn't say a kind word i n thi s house and i s always ready to jump down my throat. My son wakes up i n the morning; he plays with some toys or some children next door. In the week-ends when he's at'home he i s me a l l the time. 4. I am d e f i n i t e l y not s a t i s f i e d . I have t r i e d to ta l k to her but i t i s no use. We cannot afford to go out - we cannot even cover expenses now. She doesn't do very much at a l l i n the home and I am not s a t i s f i e d . 5. When my wife came to the h o s p i t a l I carried on doing the things I had been doing before and a l i t t l e extra. 6. I look a f t e r the house because I have too. - 141 -8. The changes were not d i f f i c u l t . You manage somehow. It takes up more time thinking about the next day's meals. I f e l t l i k e a frustrated housewife,' thinking about i t a l l day long and what the future holds. Generally I f e l t uncomfortable. 9. I do not f e e l that there were too many changes. 10. I am at wit's end. In a way I hope i t w i l l make a -change but the h o s p i t a l w i l l not be able to change her bitterness. 11. Wo, the h o s p i t a l doesn't seem to have made any difference. 12. She l i k e s i t . She's happy there and. would sooner be there than at home. I do not f e e l S Q good about t h i s and I f e e l h o s t i l e towards the h o s p i t a l and I don't think she should be there and what she says to people at the h o s p i t a l makes me f e e l very bad. Why should I v i s i t ? I t i s not pleasant to v i s i t her because she i s so unpleasant towards me. She i s c e r t a i n l y not eager to get home as any normal person would be. A normal person going into h o s p i t a l would want to get out,but not Edna. I t i s just an escape for her. 13. Wot very much. They cannot understand i t when she's got the security of her home. Mrs. M(S) pleaded with Dr. T. to l e t her f i g h t i t out at home. 14. Without Mrs. M(S), I wouldn't know what to do with my son. I n i t i a l l y she offered to take him but Edna arranged for him to go to some neighbours but this proved to be incon-venient. My.friends have offered to help i n the way of food and I have been out to dinner once or twice. It i s nice to know that they .are there. 15. (a) Worrying where i t was a c t u a l l y going to end also what actual good they could do out there. It i s a problem a person can f i g h t themselves. For instance, Edna wouldn't eat and i s was l a r g e l y because she didn't want to', (b) The h o s p i t a l should administer the reverse treatment - a hard one instead of a soft one - for i t only encourages her to stay there. She's not facing up to the r e s p o n s i b i l i t i e s and she cannot be bothered making fri e n d s . I am scared to bring my friends into the house. I could have l o t s more friends and i t i s natural for anyone to want more friends but i t i s impossible with my wife.(d) My wife talks about me leaving but t h i s i s not l i k e l y because then she would have no support and my son would have no father. I t would be inconvenient without a wife. (d) I do not have any worries about my s o c i a l l i f e . (e) The family do not know that she i s i n h o s p i t a l . (f) Her friends accepted the s i t u a t i o n . They were sur-prised that she went back because eight weeks before she had been doing so well. - 142 -18. My wife says that i t was because Mrs. M(S) was running her l i f e , b u t i n e f f e c t Mrs. M(S) was only trying to put her on the r i g h t path. My wife never keeps her promises and seems to l i k e trouble. Mrs. M(S) helped her to go to a Naturopath and was even paying for i t . Now the doctor wants us to move away from the friends that we have. This makes i t extremely d i f f i c u l t because Mrs. M(S) has been very good for a l l of us. Sometimes.she has taken my wife away on holiday and I have stayed at home. She has looked after my son numerous times. She encouraged my wife to go to Church and we l i k e d Church. My wife developed the idea we were imposing a r e l i g i o u s complex on her. Mrs. M(S) helped my wife j o i n the Ladies Church c i r c l e and she used to attend meetings once per month. There they made bandages and scarves f o r India but she moaned about that. She just couldn't be bothered. She starts something and she never f i n i s h e s i t . 2 0 . (a) I believe my wife can make good and be normal. Some-body has to make her and w i l l not be able to do i t by gentle ways. I am not one to use force but I do think she needs some d i s c i p l i n e . Some nights I was scared to come home because I thought she had done something to harm my son. (d) She puts on a good impression and before Mrs. M(S) met me, I was considered the worst bum i n Van-couver. It Is the same with her other friends and I fear that the same thing i s true with the new neighbours. I know that she t e l l s them that I am t e r r i b l e and frequently runs me down but I have accepted t h i s because what can I do about i t anyway. 2 2 . In some cases, good, because th i s i s the way people w i l l learn to s e t t l e into the community. But f o r others i t i s not r i g h t . V i s i t i n g hours are r e a l l y very adequate and i t depends on the type of treatment that the patient receives. 2 3 . The only contact that I have had with the h o s p i t a l has been with the doctor. I have no bugs myself. The doctor has me as a patient as well and has been acting as go-between every month. He has done something to help but there appears to be no helping my wife. I had no contact with nursing. 25. This i s my wife's t h i r d admission and i t was very much the same old routine. 2 6 . I did not miss very much. Perhaps companionship up to a point. I was glad to be relieved of the stress. 2 7 . I think that my wife has the wrong outlook on l i f e . There i s a goal i f she knows what i t i s but she doesn't want i t . In fact I wonder i f she has any gaals at a l l . She does not have any conception of family r o l e s . She takes no i n t e r e s t . She makes no attempt to do anything at a l l . - 143 -Case #3, Mr. D. 1. " Duty - obligations by law; morals; love; a sense of r i g h t -ousness; family i n society; work. Responsibility - duty. Way of l i f e - I f e e l a l i e n to thi s term because I have never f e l t I have a pattern of l i f e . I t sounds l i k e a pre-chosen path of l i f e . V 2. I helped with the dishes. Most of the time I spent working v on another house. I put my daughter to bed. I d i s c i p l i n e the childr e n when I see the s i t u a t i o n and I do anything that has to be done that I am asked to do. In f a c t , I do a b i t too much to the f r u s t r a t i o n of my wife. I do a l o t of read-ing. S o c i a l l y , not nearly enough. I do not have much s o c i a l l i f e owing to the loc a t i o n i n which we l i v e . I have been working hard on building a house. I v i s i t three or four friends. I do not play any family games and I do not attend Church. As far as the chi l d r e n are concerned, my son goes to school and his a c t i v i t i e s are confined to week-ends. He reads and makes model airoplanes. My f i v e year old daughter plays with cats and the children play together. 4. I have quite enough s o c i a l l i f e . It i s i n f a c t a l i t t l e hard for us to go out. We are s e l f - s u f f i c i e n t and happy to be doing things together. I am s a t i s f i e d with the things I do at home and I am also s a t i s f i e d with the things that the children do. 5. Nothing altered. Things were not so e f f i c i e n t i n cooking and I had to take on e x t r a r o l e s . I did the minimum of everything. I loved the kids more than usual. I did every-thing that had to be done and reserved my strength. Not as much working on the house but I continued s o c i a l l y . • One ch i l d i s staying with my mother and the younger son with a neighbour. 6. When my wife went to h o s p i t a l I had to do some of the things at home. I cooked but my cooking was poor and the chi l d r e n remarked about i t . We enjoyed the meals I cooked by myself. I spent more time with the chi l d r e n talking to them. Consciously i t was an egoyable e f f o r t . 8. Adequate. 9. The children missed t h e i r mother but they are generally con-tent and s o l i d . As for myself, I suffered from boredom and I was making time. It was l o n e l i e r ; there was extra incon-venience as far as domestic chores. There was a f e e l i n g of i n e f f i c i e n c y and I made no attempt to remedy i t . 10. I do not expect anything from the h o s p i t a l but I hope f o r my wife 1s recovery. - Ihh -11 . They have surpassed themselves. She went into the h o s p i t a l sick and scared. The fear died out quickly. The f i r s t time fear didn't mean too much to her. She l i k e d the h o s p i t a l and thinks i t i s t e r r i f i c . "Well I wouldn't be a f r a i d i f you and the kids became insane." 13, Sympathy, understanding and they are very supportive. 1*+. They phoned up and they took the kids out. They sent out i n v i t a t i o n s to meals and they promised to v i s i t when my wife returns from the h o s p i t a l . 1 5 . (a) I was worried that she couldn't be cured and i t was based on my personal ignorance. I worried about our marriage and I had a fear of the unknown, (b) I did not have any worries about the h o s p i t a l - I had complete confidence, (c) I f my wife's h o s p i t a l i z a t i o n was to be long-term, I worried as to how we would get on., (d) I had no worries about my s o c i a l l i f e , (e) Yes, I worried about the e f f e c t s my wife's i l l n e s s would have on the c h i l d and the f a c t that they would be without a mother, (f) I had no worries about friends. 16 . The childr e n joked about the food but they took i t i n t h e i r s t r i d e . They didn't ask too many questions except, "Where i s Mommy?" As f a r as my feelings are concerned, I f e l t ambivalent. I was sorry, worried and scared, yet at the same time I f e l t pleased that I was able to do something to help and that she was a c t u a l l y doing something h e r s e l f i n order to get better. 17. Nothing beyond what I have already said. The news of her h o s p i t a l i z a t i o n was broken to me smoothly. I asked the' doctor i n town and he recommendedvthat she return to Crease C l i n i c . In a sense I see Crease C l i n i c as a poor man's Fl o r i d a and when my wife was-admitted I f e l t a great wave of r e l i e f . I said to myself-"Thank God she's In capable hands". Before she was admitted I f e l t completely helpless. It seems to.be something chemical.and may have something to do with the wind shaking the house. 19'. The problems and worries started with my wife's i l l n e s s 13 months ago. 20. (a) My wife means everything to me and we are very close, (b) She i s very close to the children and a good mother to them and she gets on very well with the children, (c) We have good relationships with the r e l a t i v e s and s i m i l a r ^ we have good relationships with friends. - i45 -2 1 . (a) I was not so upset with my wife's admission but I.was r e a l l y upset to see her so t e r r i f i c a l l y upset at home. (b) It was not r e a l l y a shock to the family. I was honest with the children and they didn't seem to mind too much but I worried about them being without a mother. (c) Fear that she was insane and would remain so. She suggested at one stage that I should leave her and marry' somebody else. At the time I agreed with her and went along with the idea to set her at ease. (d) <My mother was upset a good deal and thi s i s because she does not have an understanding of the modern view of mental i l l n e s s . 2 2 . I think they were excellent and they were much wider than I expected and I didn't f e e l foreign from my wife. 2 3 . Excellent. I found Dr. C. very pleasant and the nursing s t a f f very kind and understanding. 24. (a) I miss her very much. (b) I f e l t less tense and worried when she was admitted to ho s p i t a l but there i s a l i t t l e tension and I s h a l l be worried when she i s out of the h o s p i t a l . The chi l d r e n miss her too and things are less tense at home. We are thiriing very much about her now that she i s i n the h o s p i t a l and i n any case the si t u a t i o n i s r e a l l y out of our hands. 25. (a) Nothing. (b) An unreasonable fear - a f r a i d to go or not to go. 2 6 . Her in t e r e s t and company. I miss her domestic functions. There i s some s l i g h t discomfort and inconvenience. 2 7 . . R e l i e f that she was i n the Crease C l i n i c . I had a fear when my wife was at home. I was nervous and I could do nothing and I f e l t at ease when she was i n the hands of professional people. As f a r as anything else, I f e e l that we have to take what comes and, i f cured, well forget i t . On my wife's f i r s t admission to h o s p i t a l we were a f r a i d to l e t people know because we f e l t that they might not under-stand but now,' on her second admission, the s i t u a t i o n i s much better and we do not have the.same fears. - 146 -Mis. C.H.. Case #6. 1. Duty - o b l i g a t i o n - to work and cooperate i f you expect re-s u l t s . Job - employment. R e s p o n s i b i l i t i e s for family taken care of well. I f e e l that i f a patient i s here i t i s up to the family member to do t h e i r part. Way of l i f e - way of-l i v i n g , every day l i v i n g . 3. At home I do the baking, cleaning, preparation of meals and I play g o l f i n the summer and I c u r l . My husband doesn't care to c u r l . In Calgary my husband operated a business and I did books. We did not have many friends. Now that we are i n Vancouver we only know two couples. Since Sept. I have had no interests - I have curled twice i n Vancouver. My s i s t e r v i s i t s once a month from Seattle. The family are a t e r r i f i c help. They haven't made friends i n Vancouver either, and want to return to Calgary. The children used to take dancing, go swimming, but now we cannot afford i t . The g i r l , , age 12, makes breakfast. Together we watch T.V. more here than at any other time. The ch i l d r e n have no other i n t e r e s t s . The g i r l has recently joined the Explorers, Club. A l l the c h i l d r e n are having d i f f i c u l t y at school. My son i s now working and he took a job because of the trouble he had at school. Their school reports have been pretty bad and t h i s i s evidence that they are having a l o t of • d i f f i c u l t y . We don't go out and since my husband's business • f e l l apart i n Calgary he has had f i n a n c i a l wdrries.- This has affected the children. We have a l l had to give up a l o t and my husband has had to give up. I am dissatisfied. 4. I.am not happy where we are and we have had to give a l l sorts of things up because of lack of money and my husband's i l l n e s s has made things worse. Generally, I f e e l that I am d i s a t i s f i e d . 5. No p a r t i c u l a r changes. 6. H o s p i t a l i z a t i o n meant that my husband was not there to help with the d i s c i p l i n e and care of the family. I had to assume added r e s p o n s i b i l i t y . My son started working and has been working ever since my husband came into the h o s p i t a l . Presently we are receiving no compensation and we are going to have trouble with the rent and food. 7. On my.day o f f I come to the c l i n i c . 8. Changes up to a point have been successful and adequate but also d i f f i c u l t . - 147 -9 . The. children took my husband's i l l n e s s and h o s p i t a l i z a t i o n very well.- They told t h e i r friends and they never kept i t a secret. Because my husband's compensation'has been cut of f , i t c e r t a i n l y creates a problem for the future. 1 0 . The h o s p i t a l has been very good. They have done a l o t f o r him and he i s i n a d i f f e r e n t frame of mind. He came to the h o s p i t a l for treatment and so f a r there have been good r e s u l t s . 1 1 . So f a r we have not had much help. We have had two supportive c a l l s and a s o c i a l worker has looked into d i f f e r e n t things. We didn't expect very much so we are pleased. We talked to other people and they t o l d us how much good i s done at the C l i n i c . My brother-in-law from Seattle, who i s a doctor, helped make my husband's mind up about h o s p i t a l i z a t i o n and also suggested that he see a p s y c h i a t r i s t . He went af t e r t h i s advice from my brother-in-law and my friends talked to him as well. 1 2 . So f a r my husband seems pleased with the r e s u l t s . He t e l l s me that the h o s p i t a l i s comfortable but I think that v i s i t i n g hours are inadequate and badly planned. They i n t e r f e r e with family arrangements. 1 3 . The few friends we have thought that i t was the ri g h t thing to do. They have v i s i t e d us frequently and they have also v i s i t e d my husband and have noticed improvement. 14. The fri e n d s that we have offered to help f i n a n c i a l l y although we have not accepted. However, they have helped with trans-portation and they invited us out. They have been very good to the family and they have also p r o v e d us with food. 1 5 . (a) Before my husband came into the h o s p i t a l I knew that he was t e r r i b l y depressed. He got very thin. I figgered he would get help at the h o s p i t a l and encouraged him to go, but he would not go u n t i l he was assured that we would manage. (b) No worries. (c) I had no worries about the home but did have some worries about finances. (e) The children are not worrying too much and we r e a l l y can-not complain. I think that they are a b i t young to understand. (f) Genuine friends don't look at mental i l l n e s s the wrong way. They have been very understanding and I have had no worries about them. 1 7 . I f e l t kind' of l o s t but then I decided to do things and I became so busy I didn't worry anymore. I missed his presence i n the home but i n any case one has to make the most of i t . - 148 -18. My husband's "illness started with f i n a n c i a l worries, his coming to Vancouver and f i n a l l y unemployment. 19. The problems we have i n the home are connected much more with i l l n e s s . I f he could work;my husband f e l t that he was no good. 20. (a). My husband means a great deal to me. He i s a com-panion, a good provider, a hard worker. He i s kind and understanding. (b) The c h i l d r e n are very fond of him. (c) He gets along with most people. He has a younger • s i s t e r dying of cancer. (d) Most friends seem to l i k e my husband. He doesn't • mix too well and he i s quite hard to get acquainted with. 21. (a) His i l l n e s s was very upsetting. He was so depressed that I could do nothing for him. He was not interested i n anything. He was beginning to be a s t r a i n . I t r i e d to draw him out but t h i s did not seem to help. I thought that i f he was away from home he might f e e l a b i t better. '(b) I l l n e s s - they missed him a great deal, (c) He r e a l i z e d that he was too i l l to work but he also worried that i f he came here he would not come out. He f e l t that he was a f a i l u r e as a husband and a father but I do not think he was a f a i l u r e and that t h i s was due to his mental state. 22. S a t i s f i e d . I have already mentioned what I f e e l about v i s i t i n g hours. 23. The s o c i a l worker has been quite good to us. We have not had too much to do with the s t a f f . 24. I miss him and so do the children. We v i s i t . On the week-ends he sometimes comes home and i f he doesn't then we v i s i t him at the h o s p i t a l . I think the family have accepted his absence. Since my husband has been away, my son has assumed a l o t of extra r e s p o n s i b i l i t y . He checks on the g i r l s to see that t h e i r bedroom i s t i d y . He t r i e s to be bossy and this sometimes leads to c o n f l i c t . 2 5 . When my husband was admitted to h o s p i t a l my son came with him and I think the h o s p i t a l should have explained the s i t u a t i o n to him. My son didn't want to say good-bye to my husband. 2 6 . Companionship. 27. I f e l t i t was a necessity. I had the backing from the whole family. I f e l t that he needed help a long time ago. In Calgary he was worrying about the business. It i s nice out here for patients but i t might be better i f the h o s p i t a l were nearer the community and there would be not quite so much - 149 -rushing. When my husband came into the c l i n i c I f e l t r e l i e f at f i r s t ; then I didn't want to t a l k to anyone and my husband f e l t the same way and each time I have v i s i t e d I notice a great deal of improvement. - 150 -Case #7, Mrs. R. 1. Duty - doing things for one's husband and children - what i s best for the family. Responsibility - duty too. Job -support for the family. Way of l i f e - how you l i v e and think about things. 3. Regular routine - house and family, children. There has been no change except that I have to v i s i t him. I have also had to get better at d r i v i n g . I have had most, of the r e s p o n s i b i l i t y before my husband ac t u a l l y l e f t for the h o s p i t a l . He has been sick a long time. I go shopping once a week and sometimes we go shopping together as a family. Two of the children go to school. My daughter takes piano lessons. The childre n help clear the table and make the bed. The seven year old burns newspapers, feeds the rabbits and picks d i r t o f f the f l o o r . My husband worked at the m i l l and he worked as a barker. He quit i n September, 1 9 6 2 , he haan't worked since. He used to b u i l d a barn and he cleared the brush;for most of the time since September he has sat around doing nothing and walked the f l o o r . S o c i a l l y my husband does nothing. He has nothing to do with any kind of organization. I was interested i n Brownies u n t i l my husband became i l l 'and in s i s t e d that mydaughter quit. When she quit, I stopped going. I took music lessons. I v i s i t e d the neighbours but t h i s a l l stopped l a s t September. A l l winter long I saw nobody. Wow that my husband i s i n h o s p i t a l things are back to normal. He has no friends. S o c i a l l y , the boys have a few friends but the problem i s that my husband would not l e t c e r t a i n people here. I had more friends before Sept. My daughter was not allowed to have any friends. On the other hand the boys were much freer before my husband's i l l n e s s and enjoyed a c e r t a i n amount of freedom when he became i l l . I was pretty s a t i s f i e d with things I did when myhushand didn't object. when my husband became i l l things were pretty awful because he could be dangerous. He argued a l l the time and no matter what subject one took up with him he seemed to want to have a r a d i c a l view. He would go into a depression, have drinks, become v i o l e n t and destroy the house. I have been unhappy for seven years, since the second c h i l d was born. At that time my husband became i l l . He was referred to the doctor but he refused treatment and accused me of wanting to have him committed. I wouldn't know how he did at h i s job but he worked there for six years. My daughter i s mentally retarded due to ray husband's problem. His i l l n e s s does not seem to have effected the boys. When my husband i s i l l he turns on the daughter. 5 . Nothing i s r e a l l y changed. - 1 5 1 -6. Not so f a r . I have started going out more. At f i r s t I was a f r a i d to because I thought my husband would object. Since his h o s p i t a l i z a t i o n I have resumed my s o c i a l r e l a t i o n -ships with people I know i n the community. I get along well with them and sometimes I do some baby s i t t i n g . 7. There have been no changes r e a l l y i n the children}, except they f e l t f reer and have been able to contact t h e i r old friends again. 8. Things have been f a i r l y easy because we have had thi s problem for a' long time. 9. At f i r s t ' I f e l t r e l i e v e d u n t i l a neighbour walked i n drunk and asked me why I had put my husband away. 10. I don't know. The doctor has t o l d me that he can never be cured but he can be kept under control. It i s hard to t a l k to the doctor and I would l i k e to have much more contact with him. I would l i k e my husband to show the daughter more love. I am not asking for miracles. He can have his ideas i f he wants to /but I do not l i k e him to pass them on to the chi l d r e n because they don't see things through h i s eyes. 11. On the Easter week-end the h o s p i t a l allowed my husband to come back,but there was an awful l o t of trouble and he wrote a l l over the walls. As a matter of fa c t , I haven't r e a l l y seen any change inhim. I am not expecting too much.but I think that he should stay i n h o s p i t a l as long as possible. The shock treatment that he i s having bothers me a l i t t l e b i t . I have often suggested that he go to his family as he does not seem to respect me. It would seem that he respects no one. 12. He doesn't f e e l any resentment, but he does d i s l i k e being forced to go to dances. On the week-end he was saying he was going to sign himself out. 1 3 . Most of the friends know and they thought that i t was the best thing. Many of them had a l o t of trouble with him. Friends here are pretty tolerant and i n c l i n e d to regard i t as just another sickness. 14. The friends I know have been a great help to me. They have helped me with the animals and the repairing of an e l e c t r i c switch and a water pump. Some of them babysit when I v i s i t my husband. - 152 -15. (a) I don't know. Not many. (b) He might take a notion I had put him i n and come back and hurt me. He has threatened my l i f e when I asked him to go and see a doctor. (c) I,.have no worries. F i n a n c i a l l y , we do not have money worries because I do receive unemployment cheques quite regularly, and the money i s s u f f i c i e n t . We have our own milk and our own fresh vegetables and we do not have any b i l l s . (d) No. (e) He hasn't been very much of a father to the ch i l d r e n and I don't think they miss him but the l i t t l e one does. I was worried about not being able to ta l k to people. For the f i r s t few weeks I f e l t very lonely and would have l i k e d to have talked to someone. I don't think that i t i s good to t a l k to neighbours. I was lucky becaule I had my s i s t e r come up from Seattle on the day my husband was admitted and spend a couple of hours. I t was good to be able to. t a l k to her. In the future I may have to go out to work. The only trouble i s I am a f r a i d of leaving my husband alone i n the home. He i s not able to look aft e r himself and he would be very much alone a l l day long. In fa c t , he might go back-wards. He cannot cook and he cannot care for himself. 16. Because of the fac t that my husband has been i l l f or a long time there were no r e a l changes. 17. I was happy. It i s the f i r s t time that he has ac t u a l l y ad-mitted that he has a problem. Before he said i t was a l l my imagination. I didn't worry too much about being lonely but I was worried because the goats were due to kid and I wasn't sure how to help them. When he came into h o s p i t a l J f e l t re-lieve d and the tense atmosphere at home dissolved. I had no d i f f i c u l t y accepting my husband's admission and accepted i t without question. Just before my husband came into the ho s p i t a l , things got so bad that I decided to take the children and leave. At this time he was kicking me around. We l e f t and I came back to the house and he was there and he begged me not to leave. I said that I would return to the home i f he would go and see a doctor. He then said that he would t r y and seek admission to Crease C l i n i c . 18. I am not too sure but I do know that my husband had t h i s i l l -ness i n the Army before we were married. 19. It started with husband's i l l n e s s . 20. (a) Hard to say - I am very mixed up and I don't know. (b) He means something to the boys but as far as my daughter i s concerned she would be better o f f with another family. He i s awful to her. (c) The in-laws are not happy. His r e l a t i v e ! m Montreal - 153 -have only met me once and when he was admitted they c a l l e d me up on the telephone. They supported my actions and they seem to know that he i s sick. (d) A l l friends r e a l i z e that he i s mentally i l l . He has caused considerable trouble i n the neighbourhood and people a l l know each other's business and I think that they recognized that he i s not responsible for his actions. My husband doesn't l i k e people. I had to learn to drive and my husband's h o s p i t a l i z a t i o n forced me to do things that I had put o f f for years. It upset me to see him i n the ho s p i t a l but I f e l t that i t was the b-est thing for him. When I v i s i t he concentrates a l l the attention on me and tends to ignore the boys and thi s makes the ch i l d r e n very jealous. My husband cannot do anything alone. He cannot function without me. I f e e l that i t i s unnatural but I have had to get used to i t . He picks on the daughter so much that I have. to. stop him. I think i t i s only the r e s p o n s i b i l i t y of the ch i l d r e n that had made me stay so long. Maybe I love him but I don't know. 'I f e e l very badly about putting the children through t h i s . No one can get close to my daughter now and thi s i s p a r t l y due to my husband's lack of concern and lack of in t e r e s t i n hi s daughter. She l i k e s music and she i s progressing very w e l l . 2 2 . I do not think there i s anything wrong with v i s i t i n g hours but I think that the h o s p i t a l should not l e t him come home too soon. On the long holiday when they l e t him come home he was very disturbed and buried money i n the house. It took a great deal of time and e f f o r t to get the money back again. 2 3 . I would l i k e to ta l k to the doctor more. I seem somehow to get more over the telephone. I have small problems and they mean a l o t to me. I have no contact with the s o c i a l worker but I think that would be a great help. In the f i r s t week I was i n a b i t of a daze and would have l i k e d to ta l k to someone at the h o s p i t a l . 24. I do not think they f e e l very much. In any case I have been both a mother and a father to the children. I keep the children?, my husband i s unable to do t h i s . With a l l the r e s p o n s i b i l i t i e s that I have i n the home and to the children, i t i s sometimes d i f f i c u l t for me to give them my time and I would l i k e my husband to do t h i s . When my husband was at home I didn't burden him with any problems. He didn't seem to be able to be responsible enough to cope with them. There was very l i t t l e communication between us. He would watch T.V. occasionally and spent most of his time walking up and down the f l o o r . 2 5 . I don't expect miracles and I found the booklet that i s given to families when the patient i s admitted to the h o s p i t a l very useful. It has l o t s of answers, sometimes the answers are not applicable when the breadwinner goes and for this reason i t would be nice to talk to somebody at the h o s p i t a l . - 154 -One thing I do miss about my husband and that i s i n r e l a t i o n to the water pump. He seems to be the only one who knows how tp work i t . It revolves around the pump and i f i t doesn't work then everything goes wrong. I f e l t happy. - 155 -Case #8, Mrs. C. 1. Duty - duty towards the family. Look afte r them as well as possible. Job - your being a housewife and looking aft e r "the children. Responsibility - looking a f t e r the family. Way of l i f e - take i t as i t comes. S o c i a l l i f e -< way I l i v e . 3. At home I look after my husband. Seeing that he changes his clothing, washes, r i s e s , see that he goes to bed at the ri g h t time. I take him out to v i s i t his friends but he does not remember them. I do housework, cooking, cleaning, washing, shopping once a week and I go to the centre across the street. I have four childr e n to look aft e r and I supply them with lunches and help them generally. I have a mother-in-law who has returned recently from Crease and try to give her some help. S o c i a l l y , I go bowling i n the evenings once a week. I v i s i t friends. Not many friends v i s i t the home because i t i s rather inconvenient for me to have v i s i t o r s . However, they understand. I sew, I watdh T.V. but not very often. The childr e n have hobbies. They go f i s h i n g and hunting. The second eldest boy plays gol f . A l l the others go to school and the two other boys take turns washing dishes and tidying t h e i r rooms. We have made i t a necessity and i n any case I figure that they should have done i t before., but my mother-in-law interfered and they seem to resent what I was asking them to do,but when I was alone I had no trouble. Generally we have not had to give up anything. We l i v e i n the same house as my mother-in-law but she has her own work to do. I help her. When i t comes .to cooking, we do our-own cooking i n the same kitchen. 4. A few problems. I would l i k e to go out to work but I can't. My mother-in-law cannot take the r e s p o n s i b i l i t y of looking after the home and the children. I cannot bring i n a stranger because i t would upset my mother-in-law as she would think that I did not think she was capable. I am as s a t i s f i e d as can be expected. I do not have very much choice. The c h i l d r e n ob-ject to the lack of money and they had a good deal of money before my husband was i n an accident. They moan a l o t about inconveniences. My mother-in-law favours one of the daughters and t h i s leads to a l o t of jealousy among the children. 5. I had just as much r e s p o n s i b i l i t y , i n f a c t , more, when he was ac t u a l l y home before admission to h o s p i t a l . When he came into h o s p i t a l I f e l t r e l i eved. It was getting hard on my nerves and with my mother-in-law at home I had tocare f o r two of them. 6 . I had a year before my husband came to Crease C l i n i c and things didn't change very fiU'cfe except that I went out more . often as an escape to get somebody to talk to and I f e e l that t h i s was the only thing that kept me going. My - 156 -mother-in-law i s not a person you can tal k to. 7. Most of the changes i n the family have been brought on through lack of money. We have had to learn to adapt ourselves to the small income received from s o c i a l assistance. This means that we have to be more f r u g a l . 8. I would say things have been inadequate but t h i s does not apply to my husband's admission to Crease C l i n i c but rather to his admission to the Vancouver General afte r his accident. We used to go out together to banquets and v i s i t i n g a l o t . 9- I don't think anybody was r e a l l y affected by my husband's admission to the ho s p i t a l . We have had the same thing for ten months. The children are not f u l l y aware of how i l l father r e a l l y i s . They don't understand. He used to get mad at the childrent and say they broke his tools. This made the children very fed up so that they were not too unhappy when he came to the c l i n i c and generally f e l t re-lieve d . 10. I want to see what they can do. I don't hope for very much and I wonder whether they can change him at a l l . 11. He seems to be much quieter. He i s walking without the cane now and this i s a tremendous improvement. Before he seemed to want to use the cane for tri p p i n g other patients. 12. I think my husband feels s a t i s f i e d . He's not worried about coming home and we have put no pressure on the ho s p i t a l to l e t him come home. 13. Any friends of value approved of what I had done and the majority i d e n t i f i e d with me. My mother-in-law objects and t r i e d to prevent my husband from coming to h o s p i t a l . My father-in-law does not object and thought that i t was a good idea. 14. After my husband's admission to Crease friends have not had very much occasion to be of help. Certainly before when he was at Vancouver General they helped with trans-portation. As a r e s u l t of my husband's i l l n e s s I have forced myself to learn to drive a car sometime ago -l a s t December, and this makes things easier on everybody at home. 15. (a) I had worries about the cane that my husband used to walk with. I was worried i n case he would hurt someone. - 157 -15. (c) I could not leave him alone - there was a f l i g h t of s t a i r s to the bedroom and I worried i n case he f e l l down the s t a i r s . I worried about money but I was able to get money from S o c i a l Welfare shortly a f t e r his h o s p i t a l i z a t i o n at Vancouver General. The money i s not r e a l l y s u f f i c i e n t but i t i s something to l i v e on. I cannot say that I am exactly happy and I f e e l that there would be no need to depend on s o c i a l assistance i f I was able to work. The only trouble i s that I have no spe c i a l trade. (d) There were many places we went together and now we cannot go out to v i s i t the people we used to v i s i t before together. 16. I don't think he understood why he was going. 17. Itdidn't a f f e c t my feelings because I f e l t that he got the proper care and attention at the h o s p i t a l . In any case, I had become accustomed to the time when he spent a year i n h o s p i t a l after the accident. In a sense he has not been a husband or a father or a breadwinner to the family. I have been much more of a nurse to him and I have had to watch him constantly. 19. Before Christma's. 20. (a) He means the same to me as he did at the time we got married. (b) I,am sure he means the same to them. (c) He gets fed up that he cannot do things for himself. He i s not f u l l y accepting of his l i m i t a t i o n s and his i n -a b i l i t y to perform i n the way that he did p r i o r to his accident. When he gets upset he blames me sometimes. He t e l l s me to get a divorce and t e l l s me he i s no more good to me. (d) My husband's mother means everything to him i n fac t i t has been one of the causes of family problems. She has never l e t him l i v e a l i f e - interfered constantly with the children and the majority of the times when we wanted to go out she would sulk. My husband gave i n to his mother and I had no choice. I thought of leaving him but the r e s p o n s i b i l i t y of the children stopped me. Now I wish I had taken the chi l d r e n and I might have been farther ahead. The presence of my mother-in-law made me f e e l as i f I was a poor and inadequate wife. She denied my p o s i t i o n as her son's wife. 21 . My mother-in-law caused a rumpus. So that there would be a minimum of trouble I arranged everything before I i n -formed my mother-in-law one h a l f hour before my husband came to the C l i n i c and during that h a l f hour she spoke to , him and caused me very much trouble. She did not seem to accept the f a c t that we could not do anything t o r h l m a t ^ - 158 -2 2 . Week-ends are a l r i g h t providing they are not too long. Last week-end my husband came out. It was a long week-end and he wanted to get back to the h o s p i t a l . There > was a l o t of a c t i v i t y i n the home and he couldn't take i t . 2 3 . Very good. S a t i s f i e d and they have helped with anything that I wanted to know. 2h. This relates much more to the way the family f e l t when my husband f i r s t went into h o s p i t a l over a year ago. At that time the family were quite shocked because they were used to him being around and they missed him very much. I guess they probably s t i l l miss him. 2 5 . I would l i k e to know i f they can do something for him or i f he i s going to be l i k e this a l l his l i f e because i f I know this I can.learn to accept i t . You have to face, facts and thi s helps with the future and w i l l enable me to plan and do something about the insurance claim. 26. M a r i t a l r e l a t i o n s h i p s , but I have had to get used to t h i s and i t i s a long time since we have had any s o c i a l contacts so that most of the time now I go out by myself. He has been an influence i n spite of the fac t that he has not been able to function i n the home. When I started working at Crown Zellerbach at a part time job I f e l t much better. 2 7 . I f e l t i t was the only thing and I have a great deal of respect for Crease C l i n i c . My mother-in-law i s no help and when both she and my husband are at home, i t i s a question of taking care of two mental patients. I f e e l the lack of s u f f i c i e n t education so that I can know what to do with him when he i s going through bad times. I am i n good health. Generally I think the family were quite relieved when father went into the h o s p i t a l . In f a c t , I am quite sure that he was relieved himself. - 159 -Case #9. Mrs. E. I. Duty - something that must be done. Job - necessity -domestic. Responsibility - something you have to under-stand and do - r e s p o n s i b i l i t y of children and marriage. 3 . The same things I've always done - but crankier than usual -working, looking after the kids - everyday l i v i n g . h. Fine - just what I wanted to be doing - I wish we had more money. 5 . The children don't know that my husband i s at Crease C l i n i c . They know that he i s i n h o s p i t a l and we a l l took i t as a matter of course. It had to be. We are doing quite well during his absence, except that I had to do a l l the worrying myself and c o n t r o l l i n g the kids. I think we are managing very well. The kids are not so bad, but one thing I had to do was to get my driver's license - th i s was a necessity. 6. Just being alone - l i v i n g alone and adjusting to my husband's absence. 7. Very few things were changed. We a l l had to take on extra r e s p o n s i b i l i t y and we a l l had to watch the money closer. 8. I think we adjusted adequately - everything f e l l into place. It took some getting used to going to bed alone,.- a long time - about f i v e weeks. 9 . We a l l learned to get along together - the family has always been close. I am not s o c i a l l y i n c l i n e d but what s o c i a l l i f e I have carried on as usual. 1 0 . I didn't expect anything but I hoped that he would be helped to quit his drinking - th i s i s something we were a l l interested i n . I I . I had l i t t l e to do with the h o s p i t a l and only went inside once. A l l that I've heard has been good. I used to meet my husband outside. 1 2 . He has nothing but good to say about the h o s p i t a l . He has told me that i t i s a good place. 1 3 . Very few of our s o c i a l friends know that my husband has been to Crease C l i n i c . Some of them know that he i s i n h o s p i t a l but that i s a l l . We decided to keep i t a secret. lh. No response. 1 5 . (a) I worried about money, being alone and to a c e r t a i n amount, I worried about the children. - 160 -15. (b) I had no worries. (c) Yes, I suppose so - a home needs a man to keep i t going - to f i x windows and water pipes - I had some trouble but I c a l l e d a plumber. (d) I carried on as usual. (e) I knew they would miss him, e s p e c i a l l y the youngest -they adjusted f a i r l y well. (f) No one knew where my husband was - some of them knew that he was i n ho s p i t a l - I hated being caught up with l i e s , but we both agreed to keep i t a secret. 16. The oldest c h i l d took on the responsibility of looking a f t e r the other children. He did thi s quite well - he started, slapping his s i s t e r s around and I had to put a stop to i t . The family missed him. They were anxious and every other day we telephoned the h o s p i t a l . I used to v i s i t three or four times a week. 17. It didn't e f f e c t me a l l that much. 18. Drinking. 19. We knew about my husband's intention of going to the h o s p i t a l a week before hand so what changes we made we did i n that week. It was much better t h i s way,because my husband planned everything before he went to the h o s p i t a l . Instead of working six nights, I worked only two. 20. (a) Everything. (b) Everything. (c) Relatives don't mean that much - i t s nice to have • them around - sometimes not. (d) Most people l i k e my husband. 21. (a) Loneliness - he wasn't at home i n the evenings and when something went wrong i t was upsetting but calm thinking fixed that. (b) The f a c t that he wasn't here, (d) Nothing. (c) He was lonely too, and missed a l l of us. 22. They are a great advantage. My husband had a l o t of freedom which made i t easier. 23. The doctor was very nice and the person at the Information Desk was very h e l p f u l . - 161 -2>+. He decided that he had to go to the h o s p i t a l - we • supported him and did not have too many f e e l i n g s about i t , but we knew we would miss him. 25. Not much - I knew nothing at a l l and i t wouldn't have made i t any easier. 26. We just missed him. It was lonely and I had nobody to go to bed with. 27. He was anxious to go and I knew i t had to be. Most people are very narrow-minded and I was reluctant to t e l l people because they always t a l k about i t . If we had told them I think i t would make a difference be-cause i t gives people something extra to ta l k about. I gave my husband a l l the support and was relieved that he f e l t i t the best thing to go to Crease C l i n i c . We made arrangements for money from the Ci t y S o c i a l Service and th i s has been a great help. The one thing that has been d i f f i c u l t was the f i r s t week-end. Everything was tense and we were a l l glad to see him go back to the ho s p i t a l . He was also glad to return. Perhaps the ho s p i t a l should make some e f f o r t to prepare people for the f i r s t week-end so that they know what to expect. APPENDIX C The following appendix, comprises of three samples of Ward Notes, selected mainly because reference has been made to them elsewhere i n this thesis. They are t y p i c a l examples of the c l i n i c a l notes used and prepared by the p s y c h i a t r i c s t a f f at Crease C l i n i c . Where necessary i d e n t i t i e s have been deleted. The ward notes were consulted as an aid to the analysis of the data obtained i n interviews with patients and t h e i r reciprocals. This was done p a r t l y to prevent the p o s s i b i -l i t y of viewing the cases and material, i n i s o l a t i o n of other s i g n i f i c a n t b i o l o g i c a l and psychological factors. - 163 -WARD NOTES - MRS. S. Previous Admissions to Crease C l i n i c Date of Admission - March 1, 1959. Date of Discharge - A p r i l 24, 1959. Diagnosis: Schisophrenic Reaction - Acute Undifferentiated Result: Improved Date of Admission - November 30, 1958. Date of Discharge - January 20, 1959. Diagnosis: Schisophrenic Reaction - Schizo-affective Result: S l i g h t l y Improved. This patient was admitted to the Crease C l i n i c of Psychological Medicine, Essondale, B.C. on March 28, 1963 from Vancouver, B.C. as a c e r t i f i e d patient. History of Present I l l n e s s : Mrs. S. seperated from her husband six months ago. She says that he i s an a l c o h o l i c and that he i s n ' t but that she drives him to drink. They re-united three months ago because she had no other place to go, not because she wanted to. She came back on h i s condition, that i s to say that she must obey orders, etc. Since the re-union she has been upset and hearing voices. These voices are her mother's, her husband's, and also unknown ones, generally speaking they re-hash old events and give her many orders. She recognises the voices as being hallucinatory phenomena, most of the time. In addition she says that she feels dreadful and would l i k e to be dead except for the children. P r i o r to her admission she claimed that she got some notion that she was hypnotising the children. - 164 -Personal History: This i s adequately documented on the patient's previous f i l e to which the interested reader i s referred. In summary, the patient was born i n Edmonton and moved to Vancouver with her family when she was 8 years of age. She was a very timid apprehensive c h i l d and r e c a l l s being enuretic when away from home v i s i t i n g and said that she wouldn't dare to be at home. She l e f t school i n Grade 12 because no one seemed to care I f she attended or not. She was a very clever student but always very poor s o c i a l l y . A f t e r leaving school she worked i n a department store as a clerk and elevator operator and also forced h e r s e l f to undertake o f f i c e work for awhile. Mrs. S. experienced the monarche at 12 years of age and was ignorant and alarmed thereby. Her periods are regular and untroublesome. She married at 29 years of age a f t e r knowing her husband a short time. Her family objected to i t but she was mad at them because she said " a l l I wanted was my own home." The marriage was never s a t i s f a c t o r y , she says that the husband drank a l l the time and that she i s t e r r i f i e d of him. Her husband i s 45, and i s a driver for ^ j^zY^ but has only been with them for six months. He has never kept a steady job. To spite t h i s they own t h e i r home but t h e i r finances are shaky. There are two children, 8 and 6, both are doing reasonably well but one i s emotionally upset. The patient smokes a package of cigarettes a day but doesn't drink at a l l . She i s a p a r t i c i p a t i n g member of the Catho-l i c Church and gets a good deal from her f a i t h . As to her s o c i a l and recreational l i f e , she says that she could be happy but that her husband won't l e t her, that anything she undertakes he makes - 165 -sneering remarks about and i s very c r i t i c a l . She has been trying to make friends with a neighbour and does some reading, watches t e l e v i s i o n , and also does sewing and homemaking. As to her personality when I inquired about this Mrs. S. said "I love my children I know that" and was not able to elaborate further. Her personality makeup i s pretty obviously schisoid. The patient's father died at 51 a f t e r being paralysed for four years by a stroke. The mother l i v e s i n Vancouver. The patient i s the middle of f i v e c hildren, two boys and three g i r l s . The father was a Spanish Consul i n Vancouver but didn't have a penny. Apparently the parents were very society, money and status conscious. They got on okay together. The children fought a great deal. The father was a very s t r i c t , crude, primitive man. The patient sees her homelife as unhappy and insecure. The younger brother has had a nervous breakdown but was not h o s p i t a l i s e d . The s i b l i n g s are a l l on the West Coast and relationships between them are reasonably good. Mental Status Examination: Mrs. S. i s a slim, sharp featured woman. She shows some a b i l i t y to relate but i s rather vague i n her manner. Her conversation i s coherent and relevant and there i s some schisophrenic blunting of thought. Her r e a l i t y t esting i s impaired at times. Her a f f e c t i s f l a t and a b i t inappro-p r i a t e and she indulges i n tearless crying. She i s hallucinated as already described. Her sensorium i s c l e a r and I would estimate her:: to be of average i n t e l l i g e n c e . She has some i n s i g h t into the fact that she suffers from a severe i l l n e s s , motivation i s d i f f i c u l t ; to assess. - 166 -Diagnosis: Chronic Undifferentiated Schisophrenic Reaction. This would appear to have f l a r e d up i n recent months under the stress of the discordant m a r i t a l relationship. Management: Mrs. S. w i l l be exposed to the therapeutic m i l i e u of the h o s p i t a l and incorporated into i t ' s a c t i v i t i e s pro-gram. She w i l l receive a t a r a c t i c and anti-depressant medications i n conjunction with E.C.T. which has already been started. Nursing attitudes of active f r i e n d l i n e s s and reassurance have been pre-scribed. We w i l l ask S o c i a l Service to have a look at the family s i t u a t i o n , but they have done so i n the past and apparently i t i s pretty hopeless. - 167 -WARD NOTES - MR. CH This patient vas admitted to the Crease C l i n i c of Psychological Medicine, Essondale, B.C. on February 19, 1963 from New Westminster, B.C. as a voluntary patient. West 3: The patient started out by stating that he was j u s t a "hopeless case" that he had wound up here, his wife and family were destitute, had no clothing, "only what I've got with me which won't l a s t more than a few days." At t h i s time i t was noted that the patient was very smartly dressed. The patient had a plumbing business i n Calgary, l o s t i t , and came to New Westminster i n September of 1962. Things have not been going well since then, "only worked a few days". According to the patient's wife the "few days" was a c t u a l l y two to three months. Plans had been worked out for him to work for wages but his health broke down due to h i s worrying and t h i s could not be carried out. The patient has never been so low before and does not know why he should be nox^ . His wife i s working. They have four children which were at home yesterday, but the patient cannot vouch for the i r existence today because he l e f t them destitute. The patient i s now 52, his wife i s 45. They have four children, aged 18, 15, 12, and 9. They have been married for 25 years. The patient stated h i s eldest boy couldn't get started at school again so he had to quit and look for work. For the past 12 years business has been good and kept functioning s t e a d i l y . The patient kept good records but when the economy went downhill and business started going sour, with poor c o l l e c t i o n s etc. the patient became depressed and stopped keeping such good books. The patient feels he i s "not as young as I used - 168 -to be" and had a nervous stomach for years. This "invalided" him out of the R.C.A.F. He has also had migraine for years for which he obtains r e l i e f with medication. He l o s t a l o t of work through the migraine and'it usually occurred at the end of the week. The patient has always been consciencious and set store by r e s p e c t a b i l i t y . He l i k e s his family and himself well dressed and neatly turned out. He keeps hi s h a i r cut short and has i t cut frequently. When business started to go down h i l l the patient borrowed against the children's education p o l i c i e s and l o s t them for which he now has regrets. He says his children are his l i f e , he had set great store by t h e i r future and he has now ruined i t for them. Past History: The patient has one brother and six s i s t e r s . They had been brought up i n a small p r a i r i e town. The patient i s th i r d youngest. Father was a farmer, and ended up as the secretary-treasurer of the municipality. He died i n 1948 at the age of 77. When the patient's family moved into town he was expected to work quite hard and f e l t he was being driven and he resented i t , but he did the work anyway. He appears to have been brought up to be conscientious and worrying. I t i s not easy to say which came f i r s t ; f i n a n c i a l set-backs or his depression, but probably the former which then gained pace as he would not and couldn't cope with i t . The present s i t u a t i o n seems to be that he l e f t Calgary hoping to leave his troubles behind. He owes most of the money to wholesale houses. He has never consulted a lawyer and has rather an ostrich's attitude to the problem with subsequent g u i l t and depression. He l i v e s i n fear of the mail each day (from h i s creditors) and his wife says he doesn't even open i t . Bringing h i s family to B.C. has also gained them nothing, and removed from the family, t h e i r home-roots, Mrs. Ch. has turned to the church for help and support. Mental Status: The patient i s a scrupulously neat and cleanly dressed i n d i v i d u a l . Mood i s one of severe depression and hi s psychomotor a c t i v i t y i s moderately retarded. His speech i s a slow, monotonous r e p i t i o n of hopelessness, and obsessive concern for h i s wardrobe. He asked to be moved to a ward where he could be provided with clothes. His thought content i s r e s t r i c t e d to the above. He denies s u i c i d a l attempts or ruminations. He i s c o r r e c t l y orientated. He has no i n s i g h t and judgement has been quite defec-t i v e , recently and i n the past. Diagnosis: Psychotic Depressive Reaction. He i s con-sidered incapable. Treatment: The patient w i l l be started on a course of E.C.T. DISCHARGE SYNOPSIS - MR. E. Mr. E. i s a 37 year old married man who was admitted under voluntary application because of depression, alcoholism, both secondary to a c o n f l i c t over homosexual impulses. This patient has apparently always had confusion i n sexual i d e n t i f i c a t i o n from e a r l i e s t childhood although the f i r s t overt homosexual experience occurred at the age of 15. Although married at the age of 21 he continued p e r i o d i c a l l y having homo-sexual experiences usually released through excessive consumption of alcohol. The patient, however, only became concerned over these a c t i v i t i e s around f i v e years p r i o r to admission when he began to f e e l that the whole thing would "blow up" and ruin h i s marriage. He states he and his wife have always been very close, she i s t o t a l l y unaware of her husband's homosexual i n c l i n a t i o n s . For these reasons the patient began f e e l i n g more depressed and f i n a l l y sought treatment by his voluntary admission to this c l i n i c . Examination on admission revealed a s l i g h t l y under-nourished, effiminate appearing man of small stature and asthenic b u i l d . On the ward he was very pleasant and cooperative, s o c i a l -ised well with the other patients, slept s a t i s f a c t o r i l y , and was exceedingly active i n a l l our ward a c t i v i t i e s . In the interview he spoke i n a sof t voice, enunciated his words c l e a r l y and gave his history i n a spontaneous, well integrated fashion. Although usually s u p e r f i c i a l l y cheerful, he had, at the time of admission and following an unsatisfactory weekend at home, appeared quite depressed and showing some s u i c i d a l ideas. He has, himself, frequently remarked on h i s lack of self-respect and feelings of g u i l t and remorse over his homosexual a c t i v i t i e s . No evidence, - 171 -over the period of h o s p i t a l i s a t i o n , of thought disorder was e l i c i t e d , and sensorium and memory were clear. For s t a t i s t i c a l purposes th i s patient w i l l be diagnosed as Sociopathic Personality Disorder - Sexual Deviation - Homosexua-l i t y with Depressive Features. On Kinsey's scale he would probably be c l a s s i f i e d as a Grade 3 homosexual. The psychodynamics i n this case are quite c l e a r , there being evidences of some degree of emotional deprivation from infancy and c e r t a i n l y p r a c t i c a l l y no male figures with whom he could i d e n t i f y . He can remember one probably s i g n i f i c a n t incident, shortly a f t e r h i s admission to the convent, when he was f e e l i n g very depressed and rejected and was comforted by an older boy who took him to bed with him. This was obviously concurrence of g r a t i f i c a t i o n of sexual as well as security needs. In treatment the patient was encouraged to p a r t i c i p a t e a c t i v e l y i n the usualy ward, occupational and recreational therapies. We t r i e d b r i e f l y to treat him with a mild t r a n q u i l i z e r which was very soon withdrawn. He was seen i n a number of psychotherapeutic interviews, l a r g e l y on a f a i r l y d i r e c t i v e basis. At the time of discharge he i s c l a s s i f i e d as S l i g h t l y Improved i n as much as the subjective reactions to t h i s c o n f l i c t have improved although the basic c o n f l i c t i s , of course, s t i l l there. He r e a l i z e s , at this point, that rather than t o t a l e l i m i -nation of his homosexual tendencies he can perhaps achieve greater control. He would l i k e to obtain a more s a t i s f y i n g and more finan-c i a l l y rewarding employment so that his wife could quit work and therefore the lonely evenings at home would be avoided which have contributed to the release of t h i s mechanism. In addition to t h i s , - 172 -the patient -will attempt to get into a number of group a c t i v i t i e s , to s a t i s f y this need. He w i l l be continued i n therapy at our A f t e r Care Department with a male therapist. BIBLIOGRAPHY Ackerman, Nathan W. (M.D.) Editor, Exploring the Base for Family Therapy, Family-Service Association of America, New York, 1962 Ackerman, Nathan W. (M.D.), The Psychodynamics of Family L i f e , Basic Books Inc., New York, 1958 Aitken, Conrad, Blue Voyage, Charles Scribner's Sons, New York, 1927 Argyle, Michael, The S c i e n t i f i c Study of S o c i a l Behaviour, Methner & Co. Ltd., London, 1957 Bentner, Kar l R. (M.D.), and Brauch, Russell, "The P s y c h i a t r i s t and the Patient's-Relatives", The Ps y c h i a t r i c Quarterly, January 1959, Volume 33, No. 1 Bernard, J e s s i e , S o c i a l Problems at Midcentury, Holt, Rinehart and Winston, New York, 1957 Boehm, Werner W., "The S o c i a l Casework Method i n S o c i a l Work Education", Council on S o c i a l Work Education, Volume X, New York, 193T~" [ Bowers, Swithern, "The Future of S o c i a l Work", The S o c i a l Worker, January 1960 Coser, Lewis, The Functions of S o c i a l C o n f l i c t , Routledge & Kegan Paul Ltd., London, 1956 ' " Garrett, Annette, Interviewing, It's P r i n c i p l e s and Methods, Family Service Association of America, New York, 1958 Kaplan, Arthur and Wolf, L o i s , "The Role of the Family i n Relationship to the I n s t i t u t i o n a l i s a t i o n of Mental Patients", Mental Hygiene, October 1954, Volume XXXVIII, No. 4. Kogan, Leonard S., Edi t o r , S o c i a l Science Theory & S o c i a l Work  Research, National Association of S o c i a l Workers, New York, June 1959 Leighton, Alexander H., My Name i s Legion, Volume I, Basic Books, New York, 1959 McCann, Charles W., "Soci a l Role Theory and Professional Respon-s i b i l i t y " , The S o c i a l Worker, January 1960 McCoy, Jacqueline, "The Application of the Role Concept to Foster Parenthood", S o c i a l Casework, May 1962, Volume XLIII, No. 5 Merton, Ralph R., "The Focused Interview", American journal of  Sociology, Volume LI, May 1946 - 174 -Merton, Robert K., Social Theory and Social Structure, Revised Edition, The Free Press, Glencoe, I l l i n o i s , 1957 Morris, Pauline, "Some Disturbances of Family Functioning Asso-ciated with Psychiatric Illness", The British Journal of  Medical Psychology, Volume 31, 1958-59-Murphy, Gardiner and Cottell, Elizabeth, The Contributions of Harry Stack Sullivan, Ed. Mullahy, Patrick, Hermitage House, New York, 19 5 Z Nadel, S.F., The Theory of Social Structure, Cohen and West Ltd., London, 1337 " ' Olds, Victoria, "Role Theory and Casework", Social Casework, Volume XLIII, No. 1, January 1962 . J Policy Manual, Provincial Mental Health Services, Provincial Mental Hospital and Crease Clinic. Regensburg, Jeanette, "The Curriculum Study: Implications for the Practice of Social Casework", Social Casework, January 1960 Reusch, Jurgen, Toward a Unified Theory of Human Behaviour, Ed. Grinker, Roy, R. , Basic Books, New York, 1956^  '. Rose, Charles L., "Relatives* Attitudes and Mental Hospitalisation", Mental Hygiene, Ap r i l 1959, Volume 43, No. 2. Sabin, Theodore R., "Role Theory", Handbook of Social Psychology  Volume I Theory,and Method,,Gardiner, Lindzey Ed., Addison Wesley Publishing Co. Inc., Caimbridge.Mass., 1954 Schlesinger, Ernest, Social Casework in the Mental Hospital, Master of Social Work Thesis, University of British Columbia, 1953 S e l l t i z , Claire. Jahoda, Marie. Deutsch, Marbou. Cook, Stuart W., Research Methods i n Social Relations, Henry Holt & Co., 1960 Vesper, Sue, "Casework Aimed at Supporting Marital Role Reversal" Social Casework, June 1962, Volume XLIII, No. 6. Young, Pauline V., Scientific Social Surveys and Research, 3rd Edition, Prentice-Hall, Englewood C l i f f s , N.J., 1956 

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