UBC Theses and Dissertations

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UBC Theses and Dissertations

The concept of stress in the experience of relatives of Crease Clinic patients : a study of the subjective… Reid, Birnie Ella 1961

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T H E C O N C E P T O F S T R E S S I N T H E E X P E R I E N C E O F R E L A T I V E S O F C R E A S E C L I N I C P A T I E N T S A S t u d y o f t h e S u b j e c t i v e R e s p o n s e s o f R e l a t i v e s t o t h e H o s p i t a l i z a t i o n a n d t h e P o s t H o s p i t a l P e r i o d o f P s y c h i a t r i c P a t i e n t s b y B I R N I E E L L A R E I D T h e s i s S u b m i t t e d i n P a r t i a l F u l f i l m e n t o f t h e R e q u i r e m e n t s f o r t h e D e g r e e o f M A S T E R O F S O C I A L WORK i n t h e S c h o o l o f S o c i a l W o r k A c c e p t e d a s c o n f o r m i n g t o t h e s t a n d a r d r e q u i r e d f o r t h e d e g r e e o f M a s t e r o f S o c i a l W o r k S c h o o l o f S o c i a l W o r k 1 9 6 1 T h e U n i v e r s i t y o f B r i t i s h C o l u m b i a I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r a n a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l m a k e i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s m a y b e g r a n t e d b y t h e H e a d o f my D e p a r t m e n t o r b y h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t b e a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f T h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , V a n c o u v e r 8, C a n a d a . D a t e ~ ^ b ? < s w C , i i i A B S T R A C T P s y c h i a t r i s t s a n d s o c i a l w o r k e r s a r e a w a r e o f t h e e x i s t e n c e o f r e l a t i v e s w h e n a p a t i e n t i s h o s p i t a l i z e d i n a p a y c h i a t r i c t r e a t m e n t c e n t r e . C u r r e n t r e s e a r c h p o i n t s t o t h e i m p o r t a n c e , i n t h e p a t i e n t ' s e n v i r o n m e n t , o f m a n y v a r i a b l e s , a n d a m o n g t h e s e , t h e p r e s e n c e o f r e l a t i v e s w h o i n t e r - a c t w i t h t h e p a t i e n t i s o n e w h i c h m a y h a v e a s i g n i f i c a n t b e a r i n g u p o n t h e o u t c o m e o f t r e a t m e n t . T h i s t h e s i s e x a m i n e s t h e s t r e s s f a c t o r s w h i c h i n f l u e n c e t h e r e l a t i v e s b e h a v i o r t o w a r d t h e p a t i e n t , a s t h e y a r i s e f r o m t h e f a c t o f h o s p i t a l -i z a t i o n a t t h e C r e a s e C l i n i c o f P s y c h o l o g i c a l M e d i c i n e , a n d f r o m t h e s u b s e q u e n t p e r i o d o f p o s t h o s p i t a l a d j u s t m e n t . L i t e r a t u r e o n t h e s u b j e c t o f e n v i r o n m e n t i n r e l a t i o n t o p e r s o n a l i t y h a s b e e n c o n s u l t e d , a n d n i n e f a m i l i e s w e r e s t u d i e d . T h e m a i n t e c h n i q u e e m p l o y e d w a s t h e s t r u c t u r e d r e s e a r c h i n t e r v i e w w i t h t h e r e l a t i v e s . S u p p l e m e n t a r y i n f o r m a t i o n w a s o b t a i n e d f r o m a r e v i e w o f t h e C r e a s e C l i n i c f i l e s o n t h e p a t i e n t s , a n d f r o m d i s c u s s i o n w i t h t h e c a s e -w o r k e r s a n d t h e c a s e w o r k s u p e r v i s o r . T h e i n f o r m a t i o n o b t a i n e d f r o m t h e i n t e r v i e w s c o n c e r n e d t h e r e l a t i v e s ' r e s p o n s e s t o t h e f a c t o f h o s p i t a l i z a t i o n , t o t h e i r u n d e r s t a n d i n g o f m e n t a l i l l n e s s , a n d t o t h e p r a c t i c a l p r o b l e m s a n d e m o t i o n a l s t r e s s e s o f t h e r e h a b i l i t a t i o n p e r i o d . T h e s a m p l e g r o u p w a s d i v i d e d i n t o t w o g r o u p s , w i v e s a n d m o t h e r s , t o e x a m i n e t h e e f f e c t o f f a m i l y s t r u c t u r e i n t h e p a t i e n t ' s p o s t h o s p i t a l e x p e r i e n c e . T h e s a m p l e a l s o c o n t a i n e d a n u m b e r o f c a s e s r e c e i v i n g s o c i a l c a s e w o r k s e r v i c e s , b u t n o c o n c l u s i o n s c o u l d b e r e a c h e d i n r e g a r d t o t h i s v a r i a b l e o w i n g t o t h e d i f f i c u l t y i n p l a c i n g s p e c i f i c r e s e a r c h f o c u s o n t h i s f a c t o r w h i l e e x a m i n i n g t h e s t r e s s a r e a s . T h e s t u d y r e v e a l s t h a t t h e r e l a t i v e s o f m e n t a l l y i l l p a t i e n t s e x p e r i e n c e s t r e s s i n t w o p h a s e s , t h a t o f h o s p i t a l i z a t i o n a n d t h a t o f t h e p o s t h o s p i t a l i z a t i o n p e r i o d . I n t h e f i r s t , s t r e s s e s c e n t r e a r o u n d f e a r o f m e n t a l i l l n e s s , t h e k i n d o f h o s p i t a l r e q u i r e d , a n d t h e r e l a t i v e ' s i s o l a t i o n f r o m t h e t r e a t m e n t p r o g r a m . I n t h e l a t t e r p h a s e , s t r e s s e s o r i g i n a t e i n t w o s o u r c e s , p r a c t i c a l p r o b l e m s s u c h a s e m p l o y -m e n t o r h o u s i n g , a n d t h e r o l e r e l a t i o n s h i p s w i t h t h e p a t i e n t . T h e m o s t f o r c e f u l s t r e s s e s a r e c o n n e c t e d w i t h i n t e r r e l a t i o n -s h i p s , a n d t h e r e a r e d i f f e r e n c e s b e t w e e n t h e g r o u p o f w i v e s a n d t h e g r o u p o f m o t h e r s i n t h i s r e g a r d . T h e r e s u l t s i n d i c a t e a n e e d f o r m o r e f a m i l y o r i e n t e d c a s e w o r k b o t h i n h o s p i t a l a n d c o m m u n i t y . P r e s e n t t r e n d s t o t r e a t t h e p a t i e n t i n t h e c o m m u n i t y f i n d s u p p o r t i n t h e s t u d y . iv A C K N O W L E D G E M E N T S I wish to express my thanks and appreciation to those whose invaluable assistance made t h i s thesis possible. I p a r t i c u l a r l y acknowledge with gratitude the encouragement of Dr. Leonard C. Marsh, and the guidance throughout the organization of the material of Dr. Charles McCann, both of the School of S o c i a l Work, University of B r i t i s h Columbia. To Mr. Eugene Elmore, Supervisor of Crease C l i n i c S o c i a l Service Department, most sincere thanks are due for his constant help and advice during the research. I am gra t e f u l also to the staff members of Crease C l i n i c S o c i a l Service Department for the i r assistance i n the research. i i T A B L E OF C O N T E N T S P a g e C h a p t e r 1 T h e M a t t e r o f M i l i e u ' 1. R e l a t i v e s a s p a r t o f t h e e n v i r o n m e n t ; a s s u m p -t i o n s a n d h y p o t h e s e s o f t h e s t u d y ; t h e t o t a l s i t u a t i o n a n d t h e " b e t a s i t u a t i o n " ; r e l e v a n c e t o s o c i a l w o r k ; s e t t i n g . C h a p t e r I I C a s e S t u d y M e t h o d 20. A d v a n t a g e s a n d l i m i t a t i o n s o f c a s e s t u d y m e t h o d ; s t u d y s a m p l e - c r i t e r i a , v a r i a b l e s , r e p r e s e n t -a t i v e n e s s , l i m i t a t i o n s ; i n t e r v i e w m e t h o d . C h a p t e r I I I S t r e s s e s o f H o s p i t a l a n d P o s t H o s p i t a l P e r i o d s 3 7 . C a s e p r e s e n t a t i o n s : w i v e s ; g e n e r a l i m p r e s s i o n s o f i n t e r v i e w s w i t h w i v e s ; m o t h e r s : g e n e r a l i m p r e s s i o n s o f I n t e r v i e w s w i t h m o t h e r s . S t r e s s e s i n h o s p i t a l p e r i o d ; s t r e s s e s i n p o s t h o s p i t a l p e r i o d . C h a p t e r I V T o w a r d s T r e a t m e n t i n C o m m u n i t y 7 7 . L i m i t a t i o n s o f s a m p l e , a r e a s o f s t r e s s , d i f f e r e n c e s i n w i v e s a n d m o t h e r s . T h e s o c i a l w o r k v a r i a b l e . A r e a s f o r f u r t h e r s t u d y . S u g g e s t i o n s . A p p e n d i c e s : A p p e n d i x A I n t e r v i e w G u i d e 88.' A p p e n d i x B I n t e r v i e w s - T h e C r y f o r H e l p . . . . . . . . 9 3 . A p p e n d i x C B i b l i o g r a p h y 101. C h a r t s C h a r t 1. S t r e s s e s I n H o s p i t a l P e r i o d 63A. C h a r t 2. P r a c t i c a l P r o b l e m s - P o s t H o s p i t a l P e r i o d . . . 66A. C h a r t 3 . R o l e R e l a t i o n s h i p s - P o s t H o s p i t a l P e r i o d . . . 7 '1A. THE CONCEPT O F STRESS IN THE EXPERIENCE OF RELATIVES OF CREASE CLINIC PATIENTS CHAPTER I - THE MATTER OF MILIEU The patient leaving a psychiatric hospital often re-enters the same community"*- from which his i l l n e s s made withdrawal necessary. Relatives may be an important part of the patient's immediate environment i n that community, especially i f they share a home with the patient, or l i v e close to his home. P s y c h i a t r i s t s and s o c i a l workers-^ f r e -quently recognize the presence of r e l a t i v e s , but do they weigh the importance of that presence i n the patient's return to community? Often the attention paid the r e l a t i v e seems to be of s u p e r f i c i a l nature, as when the ps y c h i a t r i s t sees the r e -l a t i v e s once or twice to t e l l them about the patient's i l l -ness, and perhaps to suggest what they "ought" to do to be he l p f u l to the patient, or when the s o c i a l worker sees the re-l a t i v e s only to discover their material resources for helping the patient. In s o c i a l work practice, r e l a t i v e s are often 1 The term "community" i s used throughout t h i s paper to s i g n i f y the environment i n the geographic community to which the patient returns and which i s diff e r e n t from the environ-ment of the "hospital community" i n that i t i s not protective, but instead, requires individuals within i t to function responsibly. 2 The term " r e l a t i v e " i n t h i s paper applies only to those persons i n the family whose day to day l i v i n g i s closely connected with that of the patient. 3 The terms " s o c i a l worker", "worker", and "caseworker" are interchanged throughout t h i s paper and there i s l i t t l e difference i n meaning except that where "caseworker" i s used there i s the implication that the technique of casework i s being s p e c i f i c a l l y employed at the time, whereas " s o c i a l worker" or "worker" implies that the writer i s speaking of the f i e l d generally and of a person p o t e n t i a l l y capable of using any of those techniques - casework, group work, community organization, administration and research - which have been developed i n the profession. 2 categorized as " c o l l a t e r a l " or "resource person", and i t i s the opinion of the writer that labels such as these tend to lead s o c i a l workers away from a consideration of the dynamic role i t may be possible for the r e l a t i v e s to play i n the patient's milieu. Especially during the post hospital period, the configuration of his environment"1- may have a bearing on the patient's adjustment to the community, and i f r e l a t i v e s are a s i g n i f i c a n t feature i n this, configuration i t seems relevant to accord them closer attention. It i s the purpose of t h i s study to review the thinking found i n current l i t e r a t u r e i n regard to the significance of parts of the environment and especially of r e l a t i v e s i n the r e h a b i l i t a t i o n process; to describe, using the case study method, the meaning of the patient' s. h o s p i t a l i z a t i o n and post h o s p i t a l period to the r e l a t i v e s ; and to examine the stresses which affect the r e l a -p t i v e s during the r e h a b i l i t a t i v e phase of treatment. 1 The term "environment" i s used i n t h i s study i n the s o c i o l o g i c a l rather than the b i o l o g i c a l sense, and has a comprehensive intent, to include a l l the physical and emotional elements i n the milieu of the patient. It i s exclusive of any meaning pertaining to the i n t e r n a l functions of personality except as external and i n t e r n a l influences are related, and as t h i s relationship i s discussed i n t h i s paper. 2 In t h i s study the assumption i s made throughout that "treatment" forms a continuum from the i n i t i a l recognition of i l l n e s s by a medical person through post h o s p i t a l adjust-ment i n community. It does not begin and end behind h o s p i t a l doors. 3 It i s an attempt to bring into focus the problems and con-f l i c t s experienced by the r e l a t i v e s at the time of h o s p i t a l -i z a t i o n and when the patient comes home from h o s p i t a l , and to perceive the r e l a t i o n s h i p between these and the behavior the r e l a t i v e displays toward the patient. Assumptions and Hypotheses of the Study In t h i s study i t i s assumed that there i s a corre-l a t i o n between r e l a t i v e ' s behavior or attitudes and the patient's post h o s p i t a l adjustment. This assumption i s based on and substantiated by studies conducted by Howard E. Freeman and Ozzie G. Simmons. In t h e i r paper e n t i t l e d "The S o c i a l Integration of Former Mental Patients"- 1- they emphasize the special significance played by the r e l a t i v e s i n the patient's r e h a b i l i t a t i o n , stating " that the tolerance of deviant behavior on the part of family members Is a key factor affecting the course of post h o s p i t a l experience."2 They found that "... the perception of a person as 'normal' by his family, peers, and occupational associates i s e s s e n t i a l to his integration into k i n , friendship and work groups . n 3 1 Freeman, H.E., and Simmons, 0.3., "The S o c i a l Inte-gration of Former Mental Patients", i n The International  Journal of S o c i a l Psychiatry, Spring, 1959, v o l i v , number 4, The Avenue Publishing Company, 9 Fellows Road, London WW3,England. These authors have published several studies from th e i r research conducted under the aegis of Harvard University, for the Community Health Project, sponsored by the S o c i a l Service program at the Harvard School of Public Health. Another a r t i c l e on t h e i r studies appears i n S o c i a l Forces, Dec, 1958, and presents corollary material. 2 I b i d , page 264 3 I b i d , page 266 4 And they suggest that "... patients who express alienating character-i s t i c s on either the level of abnormal or of work and social performance remain in the community only when there is a high tolerance of deviance on the part of their significant others. 1 , 1 The "significant others" studied by Freeman and Simmons were o relatives of the patients , and they discovered that character-i s t i c s of the relatives, such as "authoritarianism", " r i g i d i t y " , and "frustration" bear a relationship to the social performance of the patient.3 Freeman and Simmons did not examine relatives' reactions and the bases for them, and this is a logical next step. An understanding of the reasons for the individual relative's response to crucial events such as hospitalization and post hospital problems of housing, employment, recreation, etc., should contribute to our knowledge of family l i f e and f a c i l i t a t e professional practice in developing a salubrious atmosphere for the psychiatric patient on his return to community. 1 Ibid 2 This study was conducted amongst wives and mothers of male patients of a psychiatric hospital after the patients had been in the community for one year following discharge from hospital. 3 It was found that patients who ranked low on the authors' social integration scale were li k e l y to have relatives who were "anomic, frustrated, withdrawn, authoritarian, aid r i g i d " , and a table is provided on page 2 6 9 giving numerical weights to these relationships. These are rather vaguely explained figures, "anomia" being assigned . 3 0 , and "ri g i d i t y " , . 15 , with no indication of the extent of the range, but i t is assumed that the figures indicate a positive significance for the effect on performance for a l l the characteristics l i s t e d . 5 In regard to c r u c i a l events, i t i s an hypothesis of t h i s study that the period of h o s p i t a l i z a t i o n and the post ho s p i t a l period represent c r i t i c a l experiences for the r e l a t i v e . Causative relationships between the personalities of the patient and the r e l a t i v e are not studied here, but rather the meaning to the r e l a t i v e s of the c r i s i s experience of h o s p i t a l i z a t i o n and post h o s p i t a l i z a t i o n . (The assumption i s stated above that the r e l a t i v e ' s personality at t h i s time has an impact upon the patient's personality as manifested i n his s o c i a l performance.) Rennie and Woodward state the assumption that " A l l behavior has r e a l and adequate causes. Each person i s what he was born with plus a l l that has happened to him i n his t o t a l experience."'! H o s p i t a l i z a t i o n i s part of " a l l that has happened to" the patient and also the r e l a t i v e , thus affecting not only the patient's personality but also the r e l a t i v e ' s . Kluckhohn and Murray elaborate t h i s thinking: "Personality i s not always 'a whole'; that i s , i t i s seldom perfectly integrated (completely u n i f i e d ) . Since the course of l i f e i s punctuated by countless o c casions when some choice must be made (between al t e r n a t i v e , i f not opposing, needs, goals, goal-objects, concepts, t a c t i c s , or modes of expression), indecisions and c o n f l i c t s are common and f i n a l resolutions of c o n f l i c t s are rare. Consequently, the psychologist i s w e l l advised to include some 1 Rennie, Thomas (M.D.), and Woodward, Luther E. (Phd.), Mental Health In Modern Society, The Commonwealth Fund, 1948. 41 East 57th Ave., New York 22, N.Y., page 197 6 account of his subject's major dilemmas and c o n f l i c t s during c r i t i c a l periods of his l i f e . " 1 The hypothesis i n t h i s study, then, i s that h o s p i t a l i z a t i o n and post h o s p i t a l i z a t i o n are c r i t i c a l periods not only for the patient, but also for the r e l a t i v e . The "dilemmas and problems" which are s t r e s s f u l to the r e l a t i v e during these c r i t i c a l periods are to be examined to ascertain how they affect the personality of the r e l a t i v e , since i t i s assumed that i t In turn affects the performance of the patient. Relation of Study to the "Total S i t u a t i o n " To f u l l y understand one part of a s i t u a t i o n , i t i s h e l p f u l to examine i t s i n t e r r e l a t i o n s with other parts in the " t o t a l s i t u a t i o n " , and to comprehend the s i t u a t i o n i t s e l f as a whole. When the patient leaves h o s p i t a l , he enters a " t o t a l s i t u a t i o n " which i s complex. He must re-orient himself not only to the physical factors of the community, such as where street cars or buses are boarded, and how to locate housing, but also to the human factors. There are various groups of people with whom to greater or lesser degree he must interv-act i f he i s to be a functioning member of society. • Neighbours, employers, f r i e n d s , r e l a t i v e s , club members, etc., are some of the groupings which may combine to make up the patient's environment. The " t o t a l s i t u a t i o n " 1 Kluckhohn, Clyde, and Murray, Henry A., Personality  In Nature. Society, and Culture, Alfred A. Knopf, 1 9 5 6 , New York, page 31 7 of the patient is a synthesis of two components, his own subjective reactions, and the objective elements over which he may have l i t t l e or no control. Lewin's concept of "fields", cited by Kluckhohn and Murray, expresses this idea: "According to Lewin's definition the field at an instant includes both the external situation (say, the smile of a certain acquaintance who wants to borrow money) and the internal situation (say, fatigue and a feeling of depression) and both are within the head of the subject, because for him external reality is what he perceives and apperceives out there, no more, no less. Since this formulation abolishes the important difference between normal verifiable perceptions and apper-ceptions, on the one hand, and illusions and delusions, on the other - not to speak of the many extravagant projections of normal people - i t has seemed advisable to c a l l the external situation as i t actually exists (insofar as this can be . determined by careful inquiry) the alpha situation, and to c a l l the external situation as the subject apperceives i t the beta situation. Although the subject's response to a given situation provides a f a i r l y reliable clue to the nature of the beta situation, the latter should be ascertained, whenever possible, by direct inquiry."1 The "beta" situation in the present study is narrowed to only the activity, within the entire " f i e l d " , of one segment, that occupied by the relatives. Marie Jahoda2 has shown how perception of environmant influences personality and behavior, in her studies in Austria and in Great Britain. Austrian children adapted themselves to an environment of poverty by limiting their powers of 1 Kluckhohn and Murray, ibid, pages 9-10 2 Jahoda, Marie, "Toward a Social Psychology of Mental Health", in Rose, A.M. (ed.) Mental Health and Mental Disorder, ¥.¥. Norton and Co., Inc., New York, 1955, pages 561, 562 8 imagination and restricting ambition in themselves. British school g i r l s traded values of intelligence and industriousness for their opposites when they moved to work in a factory where these values did not represent the accepted h'orm. Jahoda also points out that the inner parts of. personality may be functioning as a well integrated unit, but that conflict between this unit and the outside environment (or the nbeta" situation, the environment as i t is apperceived by the individual) may occur. Jahoda concurs with Kurt Lewin who believes " behavior is always a function both of person-a l i t y and environment, a formulation which encompass the facts regarding changes in later l i f e and Is complementary to, rather than inconsistent with, psychoanalytic theory. It would seem, then, that the answer depends on whether or not the behavioral change persists when the original environmental conditions are restored. A l l through l i f e environment acts as an agency mobilizing select-ively different facets of the personality ........ It is the pressure of the external world that can alternatively favor or reject some personality t r a i t s , for shorter or longer periods. I , J-In the complex environment, many causes of pressure are to be found. Only one aspect of the complex network of potential pressures is to be studied here, and while this may be a limitation to the ultimate value of a study of environment i t is a necessary one for conducting the study since total knowledge may be attained only slowly, and by the piece? meal 1 Jahoda, Marie, ibid, page 5 6 8 9 process. There are times, o f course, when work must be done w i t h i n one segment, and knowledge of that part alone i s u s e f u l then. Relevance to S o c i a l Work and S o c i e t y S o c i e t y b e n e f i t s from the s a t i s f a c t o r y f u n c t i o n i n g o f i t s members, and s o c i a l workers on the p s y c h i a t r i c team are concerned w i t h f a c i l i t a t i n g b e t t e r f u n c t i o n i n g o f persons who have been i n h o s p i t a l f o r treatment o f mental i l l n e s s . As a "secondary g a i n " , the b e t t e r f u n c t i o n i n g of r e l a t i v e s may a l s o r e s u l t , thus i n c r e a s i n g the numbers of i n d i v i d u a l s who are b e t t e r able to c o n t r i b u t e to community l i f e . Increased knowledge of the v a r i o u s aspects of l i f e i s becoming more important i n s o c i a l ' work p r a c t i c e . Gordon Hamilton p r e d i c t s : "The s o c i a l worker of tomorrow can no longer r e s t r i c t h i m s e l f to c o n s i d e r a t i o n of how the c l i e n t f e e l s about h i s s i t u a t i o n - he must be e q u a l l y attuned to the e f f e c t s on the c l i e n t o f e t h n i c , c l a s s , and other s i g n i f i c a n t group determinants of b e h a v i o r . u l S e t t i n g o f the Study Because the h o s p i t a l p e r i o d i s considered to be a s i g n i f i c a n t aspect of the treatment experience f o r both p a t i e n t 1 Hamilton, Gordon, i n P r e f a c e to S t e i n and Cloward (eds) S o c i a l P e r s p e c t i v e s on Behavior, Free Press, Glencoe, I l l i n o i s , 1958 page x i 10 and relatives, i t is necessary to have an understanding of the hospital setting familiar to the patients and relatives among whom this study was conducted. The hospital 1 from which the subjects were selected for the study was Crease Cli n i c , at Essondale, B. C. It is a hospital where prevention of more serious illness through early treatment, is the aim, and therefore patients in early stages of illness often experience their f i r s t hospitalization for a psychiatric illness at Crease Cl i n i c . Crease Clinic is housed in a single building which shares the well kept grounds of the Provincial Mental Hospital, and the c l i n i c i s , in fact, a part of the administrative organ-ization of the larger hospital although i t functions separately as a treatment unit. The buildings of the Provincial Mental Hospital and Crease Clinic together comprise the village of Essondale, which has its own post office. The village is located in a rural area on the Lougheed Highway, about twenty miles from the centre of Vancouver City. The original building was opened in 1934 as a Veteran's Block, and In 1946 work was begun on the additional wings. In 1948, the "Clinics of Psychological Medicine Act" was enacted in British Columbia, and in November, 1949 the building was opened, with the west wing housing wards for I Throughout this study the term "hospital" w i l l refer to Crease Clinic, and is used to differentiate the institution's actual function from confusion with the day centre type of c l i n i c . 11 men, the east wing, wards for women, and the centre section "incorporating the administrative headquarters of the mental Health Services, and the specialized medical departments for investigation, diagnosis, and teaching. "•*-On A p r i l 3 r d , 1950, the f i r s t patients were received into the buil d i n g , and from that date to December, 1950, the building was used as an admitting unit for the P r o v i n c i a l Mental Hospital. On January 1 s t , 1951 the " C l i n i c s of Psychological Medicine Act" was proclaimed e f f e c t i v e , and on that date, the f i r s t patients came to the c l i n i c for whom were intended i t s s p e c i f i c treatment services. Purpose of Crease C l i n i c There are two essential differences between Crease C l i n i c and the P r o v i n c i a l Mental Hospital and these represent a departure from the older procedures for h o s p i t a l i z a t i o n of the mentally i l l . The f i r s t i s that admission may be on a voluntary basis, and the second i s that patients may not be held for longer than four months. Voluntary admission can only be made by those "whose mental condition i s such as to render him competent to make a p p l i c a t i o n " 2 and thus the i l l n e s s cannot have progressed as far as the il l n e s s e s which necessitate l e g a l committal to the P r o v i n c i a l 1 Annual Report of the Mental Health Services Department, 1953, page 18 2 " C l i n i c s of Psychological Medicine Act", section 8, subsection 1 12 M e n t a l H o s p i t a l . T h e a d m i s s i o n s p r o c e d u r e o f G r e a s e C l i n i c h a s o n e o u t s t a n d i n g f e a t u r e . P a t i e n t s a r e a d m i t t e d i n o n e o f t w o w a y s , b y v o l u n t a r y a d m i s s i o n , o r b y c e r t i f i c a t i o n b y t w o p h y s i c i a n s u p o n t h e a p p l i c a t i o n o f a r e l a t i v e o r i n t e r e s t e d p e r s o n t h a t t h e p a t i e n t r e q u i r e s c a r e i n a h o s p i t a l f o r p s y c h i a t r i c i l l -n e s s . N e i t h e r o f t h e s e m e t h o d s r e q u i r e s a l e g a l c o m m i t t a l , w i t h c o n s e q u e n t l o s s o f c i v i l r i g h t s . T h e p a t i e n t t h u s r e m a i n s a m e m b e r o f t h e c o m m u n i t y a t l a r g e w h i l e t e m p o r a r i l y r e m o v e d f r o m i t . H i s r e t e n t i o n o f c o m m u n i t y i d e n t i t y i s a v a l u a b l e a s s e t t o t h e p a t i e n t f o r w h o m t h e t r e a t m e n t g o a l i s r e i n t e g r a t i o n i n t o t h e c o m m u n i t y . T r e a t m e n t a t C r e a s e C l i n i c i s d e s i g n e d t o b e p r e -v e n t i v e , a n d t h e q u e s t i o n m i g h t b e a s k e d " w h a t c o n d i t i o n s a r e t r e a t e d i n p r e v e n t i o n ? " T h e P o l i c y M a n u a l o f t h e P r o v -i n c i a l M e n t a l H e a l t h S e r v i c e s f o r P r o v i n c i a l M e n t a l H o s p i t a l a n d C r e a s e C l i n i c s t a t e s " P e r s o n s w h o a r e c o n s i d e r e d s u i t a b l e f o r a d m i s s i o n a r e t h o s e w h o w i l l r e s p o n d t o t r e a t m e n t i n a p e r i o d l e s s t h a n f o u r . m o n t h s a n d w h o c a n t h e n r e t u r n t o c o m m u n i t y . " 1 I t f u r t h e r s t a t e s t h a t " . . t h e f u n c t i o n o f C r e a s e C l i n i c • i s t o t r e a t a c u t e c a s e s o f m e n t a l a n d e m o t i o n a l d i s o r d e r s . A l t h o u g h t h e m a x i m u m p e r i o d o f t i m e i s f o u r m o n t h s , i t i s t o b e n o t e d t h a t t h e a v e r a g e p e r i o d o f t r e a t m e n t i s a b o u t t w o m o n t h s . " 2 1. P o l i c y M a n u a l , P r o v i n c i a l M e n t a l H e a l t h S e r v i c e s , P r o v i n c i a l M e n t a l H o s p i t a l a n d C r e a s e C l i n i c , p a g e 32 2 I b i d 13 The manual l i s t s the following as types of patients considered 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 psychotics, except those of long standing duration and those demonstrating marked deterioration and having a poor prognosis. 1 1 1 Those cases considered unsuitable for treatment are: "... the long term psychoses and neuroses, and per-sistent behavior disorders, cases of mental deficiency, chronic neurological disorders, senile brain diseases, alcoholism and drug a d d i c t i o n . " 2 From the s t a t i s t i c a l tables of the 1958 Annual Report, i t can be seen that the early states of i l l n e s s treated at Crease C l i n i c cover the entire range of diagnostic cate-gories i n the f i e l d of psychiatry. In the group of patients with psychosis, a l l the schizophrenic disorders are repre-sented, such as hebephrenic, paranoid, l a t e n t , etc., etc.; the manic-depressive reactions are present i n varying types; there are instances of senile psychosis, cerebral psychosis, alcoholic psychosis, anxiety reactions, h y s t e r i c a l reactions, obsessive compulsives, etc. In the group without psychosis, a l l the categories are present, such as disorders of character, behavior and i n t e l l i g e n c e under headings of pathological personality (schizoid, paranoid, inadequate, a n t i s o c i a l , e t c . ) , immature personality (emotional i n s t a b i l i t y , passive dependency), 1 I b i d , page 33 2 Ibid 14 alcoholism, drug addiction, primary childhood behavior disorders, and acute s i t u a t i o n a l maladjustment. To l i s t the entire catalogue would be needlessly space consuming. The examples above s u f f i c e to show that i n a c l i n i c of psjrchological medicine which has as i t s purpose the pre-vention of the more serious forms of the i l l n e s s , a l l types of mental i l l health i n i t s early stages may be found. F a c i l i t i e s of Crease C l i n i c Crease C l i n i c i s equipped with f a c i l i t i e s to meet most standards for psychological hospitals. Dr. Davidson i n the 1951 Annual Report reviewed them: "The C l i n i c i s furnished a t t r a c t i v e l y , providing a comfortable environment for the relaxation and treatment f a c i l i t i e s that the patient receives. Adequate f a c i l i t i e s are provided to renable a thorough diagnosis of a l l medical and psychiatric conditions; these include c l i n i c a l laboratory, X-ray f a c i l i t i e s , neurological consultation services, and complete f a c i l i t i e s for psychological t e s t i n g . Every medical aid also i s provided to enable the best i n psychiatric therapy, including physiotherapy, hydrotherapy, occupational and recreational therapy f a c i l i t i e s , etc. These f a c i l i t i e s are a u x i l i a r y aids and assi s t In the other more s p e c i f i c forms of psychiatric therapy. A l l necessary f a c i l i t i e s , including electroshock, electronarcosis, coma i n s u l i n , etc., are available i n the new C l i n i c . " 1 In addition, there i s a l i b r a r y , amusic therapy department, and a s o c i a l service department. 1 Annual Report of Mental Health Services Department, 19 15 Crease C l i n i c can accomodate 312 patients, and locked doors are kept to a minimum. There i s only one "closed" ward i n each wing, for the segregation of patients who are so seriously disturbed upon f i r s t a r r i v i n g i n hospital that they require special precautions for their own safety, and for the safety and peace of mind of the patients who are somewhat recovered.. S o c i a l Service Department One of the f a c i l i t i e s of Crease C l i n i c i s i t s provision for s o c i a l services. The Crease C l i n i c S o c i a l Service Department has operated as a separate unit since 1952, although i n 1951 the S o c i a l Service Department of P r o v i n c i a l Mental Hospital, o r i g i n a l l y established i n 1930, gave service to Crease C l i n i c patients. There i s a provision for nine s o c i a l workers on the Crease C l i n i c s t a f f , and at the time of the study there were f i v e workers giving service to about f i f t y percent of the patient population. Of the r e f e r r a l s made to the department, adolescent patients, pregnant patients, and patients with young children i n the home are considered to be the most urgent cases. However, marital problems, r e h a b i l i t a t i o n problems and relationship therapy for schizo-phrenic patients seem to occupy most time as the numbers of patients i n the f i r s t group are not so large. Function of the S o c i a l Worker The s o c i a l worker's task i s d i r e c t l y influenced by 16 the unique nature of the i n s t i t u t i o n , which represents the f i r s t focus upon the psychiatric i l l n e s s of the patient out-side of his own home and for twenty-four hours a day. E a r l i e r attention to the i l l n e s s may have been received i n the form of interview therapy on a private basis or i n a general h o s p i t a l , but admission to Crease C l i n i c s i g n i f i e s that the psychiatric i l l n e s s as such has assumed dominance to the point where the patient needs to be segregated for i t s special treatment. This segregation has an impact upon the patient and upon his family, and thus has implications for the act-i v i t i e s of the s o c i a l service department personnel. The worker i n t h i s s i t u a t i o n functions as a member of the treatment team and i s both a therapeutic instrument i n direct work with patient and r e l a t i v e s , and an enabler i n work with others i n the patient's environment both i n the hospital and i n the community. Generally there are three aspects of the ho s p i t a l experience with which the s o c i a l worker deals: admission, treatment, and discharge planning. Ernest Schlesinger i n his thesis on the services given by t h i s department, states that the s o c i a l worker p o t e n t i a l l y i s involved i n every stage of the patient's and family's needs, and divides the needs into six phases; 1 In the Mental Health Services Annual Report of 1953> Dr. Davidson commented " I t i s pleasing also to note the large number of patients who come to the Crease C l i n i c as t h e i r f i r s t psychiatric r e f e r r a l without previous treatment." (page 33) 17 1. Admission services 2. Diagnostic services 3 . Treatment services 4. Pre-convalescent services 5. Convalescent services 6. Family services. It should he made clear that "discharge planning" and "convalescent services" include r e h a b i l i t a t i o n planning and a c t i v i t i e s . Schlesinger says "Treatment, i n t h i s survey, defines the process whereby the patient i s helped to overcome or l i v e with his i l l n e s s . R e h a b i l i t a t i o n , on the other hand, represents a l l the other processes whereby the patient and his family are restored to a more sat i s f a c t o r y adjustment i n t e r n a l l y and to the community. " l The goals of the s o c i a l service department include not only treatment of the patient and r e h a b i l i t a t i o n of patient and family, but also prevention of further mental breakdown. That h o s p i t a l i z a t i o n for mental I l l n e s s i s an event which j.olts r e l a t i v e s was recognized by Schlesinger at the time of his survey i n 1953. He said: "When the patient enters h o s p i t a l , r e l a t i v e s are frequently more 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 may f e e l responsible for the patient's breakdown, and may be affected 1 Schlesinger, Ernest, S o c i a l Casework i n The Mental  Hospital. Master of S o c i a l Work th e s i s . University of B r i t i s h Columbia, 1953, page 2. These d e f i n i t i o n s were u t i l i z e d by the present writer i n conducting t h i s inquiry. 18 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, and may decide to break a l l t i e s with him because they find his bizarre behavior too p a i n f u l to face again. 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. The s o c i a l worker can give r e a l i s t i c assurance and support to the family, and encourage i t to p a r t i c i p a t e a c t i v e l y i n the treatment and r e h a b i l i t a t i o n of the patient. He i s also i n the position to help the family with the material and emotional issues which i t may encounter." 1 Schlesinger found that there has been a move away from the s o c i a l work done i n the beginning of the department's history when services were mostly related to changes i n the external environment. More work i s now done to help the patient i n his relationships with other people, and the l e s s tangible aspects of the worker - c l i e n t relationship require more time than formerly. He stated that " personal d i f f i c u l t i e s (of r e l a t i v e s ) usually cause d i f f i c u l t i e s for the patient upon his discharge from the c l i n i c to his f a m i l y . . " 2 and he l i s t e d the kinds of help a worker might give families as: 1. Support around anxieties related to patient's h o s p i t a l i z a t i o n . 2. Help around the I n a b i l i t y to accept the patiemt's i l l n e s s 3 . Support around s o c i a l problems i n the home 4. Casework services based on emotional needs of the patient's r e l a t i v e s . 1. I b i d , page 9 2 Ibid, page 32 19 The conclusion which Schlesinger reached i n regard to the importance of work with r e l a t i v e s was at that time i unsubstantiated by research, but has since found support i n the studies l i k e the one referred to e a r l i e r , by Freeman •i and Simmons, and i s subscribed to by t h i s writer as the premise from which research starts into the problem of how to create an accepting and h e l p f u l environment for the d i s -charged patient. Schlesinger commented: "Understanding and accepting the patient on the part of the r e l a t i v e s improves the s o c i a l relationships between the patient and his family. It helps the family overcome the i r reluctance to v i s i t the patient and helps them be a constructive force i n the patient's r e h a b i l i t a t i o n . " ! The concern of the present writer i s how understanding and accepting of the patient by the r e l a t i v e s may be promoted through understanding of the r e l a t i v e s responses to the experiences of h o s p i t a l i z a t i o n and r e h a b i l i t a t i o n . 1 Schlesinger, Ernest, i b i d page 32 CHAPTER I I - CASE STUDY METHOD The case study method was employed as the vehicle for conducting t h i s investigation. For the examination of int e r r e l a t i o n s h i p s and subjective material, i t i s the most usable instrument avai l a b l e , especially for the researcher working alone. Though some writers argue about i t s l i m i t -ations and consider that i t should be combined with other methods (such as the survey) when a large study i s being undertaken, most research workers today find i t has peculiar advantages for the limited study i n i t s a b i l i t y to highlight d e t a i l and nuances of experience. Pauline V. Young opens her chapter on the case study method with a quotation from c h a r l e s H. Cooley, who f e l t that: "Case study deepens our perception and gives us a clearer insight into l i f e . " 1 In the opinion of Young, the case study of an i n d i v i d u a l : "Is capable of revealing his inner s t r i v i n g s , his way of l i f e , the motives that drive him."^ and she ci t e s the evaluation by Thomas Znaniecki of case study material as "the perfect type of s o c i o l o g i c a l material" because i t gives: "...(a) more enlightening and fundamentally more r e a l record of personal rexperiences, with a wealth of concrete d e t a i l , v i v i d memories, tension si t u a t i o n s , and multifarious reactions to s o c i a l situations which escape.- the attention of most s k i l l e d investigators using other techniques."-^ 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-Hall Inc., Englewood C l i f f s , N.J. 1956 page 229 2 I b i d , page 231 3 Ibid, page 235 21 The present writer i s of the opinion that the forming and gathering of detailed impressions in t h i s manner leads to the deeper understanding of the i n d i v i d u a l . The impressions gained through intensive study of a small number of cases are the moulds of future knowledge. Myers and Roberts, considering the limited numbers of cases examined i n the case study, sum up the advantages: "The case study method provides a v e r t i c a l view of a small number of cases with a few r e s t r i c t i o n s on the number of t r a i t s studied i n any one case. It i s a 'microscopic 1 approach, permitting a detailed and dynamic study of any part of an individual's l i f e cycle. Since materials are usually collected by free association or c l i n i c a l interviews, they are not limited by pre-arranged plans. The researcher can c o l l e c t a vast amount of unique data on his subjects which he could not obtain by the survey method. C l i n i c a l experience and judgment are used, i n analyzing materials, often providing greater insight than i s possible i n more standard-ized a n a l y t i c a l procedures."! The method Is, of course, limited i n that r e p l i c a t i o n of the study or adding to a certain study, i s d i f f i c u l t , and pre-d i c t i o n may not be possible. Rubinstein and Pa r l o f f have also observed that the variables of the patient's personality and the interviewer's personality may combine to direct p attention away from the research focus. 1 Myers, Jerome K. & Roberts, Bertram H. Family & Class  Dynamics i n Mental I l l n e s s . New York - John Wiley & Sons Ltd., London - Chapman & H a l l Ltd., 1959, page 23. 2 Rubinstein, E . A . & P a r l o f f , M.B. (eds) Research i n  Psychotherapy, Proceedings of a Conference, Washington, D.C, A p r i l 9-12, 1958, National Publishing Co., Washington, D.C., 1959. 22 The writer of the current study, however, is of the opinion that this very i n t e r a c t i o n may be controlled so as to bring forth more findings for research into the nature of being. Young quotes Professor Read Bain who comments that techniques-in case study have improved in recent years so that the method now is "indispensable for therapeutic and administrative purposes". 1 The controlled or structured interview and the analysis and classification of responses into significant categories, has p given the case study technique new value. In the present study, the case method consisted mainly of interviews with relatives. The data was supple-mented, however, by information from the f i l e s about the patient's illness, and where the social worker had been active in the situation, discussion with the worker was held about the patient's progress. Discussion with the supervisor of the social service department was held about the choice of a l l the cases in order to minimize possible danger to the success of the patient's rehabilitation period due to the research interview. 1 Young Op. Cit. page 238 2 The present writer's interest in the interview^as a technique in case study was a determinant in the choice of the case method. 23 The Sample To obtain a group of patients' r e l a t i v e s to i n t e r -view, the patient population was screened according to a set of c r i t e r i a drawn up to l i m i t the group chosen. Included i n the c r i t e r i a were the variables which had been deliberately-singled out for attention. They were the type of family (procreation or orientation) to which the patient returned, and the presence or absence of hospital casework services. A cross section of patients and r e l a t i v e s i n the h o s p i t a l and post hosp i t a l periods i s not contained so that representative-ness cannot be claimed and i s one of the l i m i t a t i o n s to the selection f i n a l l y made. The C r i t e r i a The following c r i t e r i a were used i n selection for the reasons given: I. The patient should have experienced his f i r s t admission to Crease C l i n i c . This test was chosen for the obvious reason that f i r s t admissions would be expected to have an impact upon family d i f f e r e n t from that of readmis.sions, which might have less or greater impact, depending on the circumstances. Also, i n keeping with the preventive aspects of treatment, i t was f e l t that i t would be useful to learn more about the time following f i r s t admissions i n hopes of adding to general knowledge information which might help develop measures preventative of readmission. 24 2. The patient should have remained i n hos p i t a l for at least six weeks. It was f e l t that the time i n hospital should be s u f f i c i e n t to make the separation from community s i g n i f i c a n t both for patient and r e l a t i v e s . 3. The patient should have been i n the community since discharge no longer than six weeks. It was the purpose of the study to examine r e l a t i v e s ' feelings while the r e h a b i l i t a t i o n experience was current, and questions and discussions would have meaning for the r e l a t i v e c l o s e l y related to post hospital problems. 4. The r e l a t i v e should be a wife or mother of the patient. The patient whose mothers were to be interviewed could be either male or female. Female r e l a t i v e s are usually i n the home a larger proportion of the time and thus might be sensitive barometers of the impact on the home of problems at the r e h a b i l i t a t i v e period. It was also f e l t that i t would be interesting to observe whether type of family (procreation or orientation) might make a difference to the r e l a t i v e s ' experience. 5 . The age range of the patients should be between twenty and f o r t y - f i v e . It could be assumed that general problems of s o c i a l adjustment would be simi l a r from a physical stand-po i n t . 6. Casework services should have been provided i n half of the cases. It was hoped to assess the significance of t h i s variable i n the post hosp i t a l s i t u a t i o n by noting differences i n the group receiving services from those not receiving them. 25 7. The families should l i v e i n the lower mainland area, to be accessible for interviews. The Variables Rubinstein and P a r l o f f comment: "Ideally the investigator might wish to comprehend the complex interaction among a l l variables. However, for the p r a c t i c a l purposes of research, each of the variables i s a r b i t r a r i l y separated and studied. The pa r t i c u l a r element that one chooses to work with r e f l e c t s one's own taste and c l i n i c a l judgment.',J-In the community s i t u a t i o n comprising the t o t a l "beta" perception incorporated by the patient into his person-a l i t y adjustment, there are many factors, and i n working with an i n d i v i d u a l i t would be necessary to review a l l of them to discover which were of significance to that i n d i v i d u a l . For study purposes, however, certain of the sections are set apart for separate examination. The presence of r e l a t i v e s i s not a constant factor i n the environment of patients returned to the community but i t i s , rather, a variable one, and i t i s t h i s variable primarily with which t h i s study i s concerned. Two additional variables have been added purposely, and other variables d i f f i c u l t to eliminate are present. The two added are the structure of the family, and casework service. Different kinds of r e l a t i v e s are a variable, and two of these, wives (family of procreation) and mothers (family of 1 Rubinstein & Par l o f f - op c i t page 288 2 6 orientation) were chosen for study. Not a l l patients receive casework services, and thus s o c i a l work also constitutes a variable. The group was therefore structured to contain a number of cases presenting t h i s variable. Other factors which vary from patient to patient are age, and location of home. The l a t t e r may be a s i g n i f i c a n t variable because i n the metropolitan lower mainland area, many more resources are available than i n the outlying places. It i s the opinion of the writer that such a variable does not deter from the value of the study since comparative groups i n r u r a l areas might be studied i n further research. Representativeness Since t h i s was not a random sampling but instead a selected one, no effort was made to assure representative-ness. The selection was made i n accordance with s p e c i f i c c r i t e r i a which had been de l i b e r a t e l y limited so that not a cross section, but one segment of experience would be examined, and so that the impact of certain variables might be assessed. 1 It i s not a t y p i c a l group because no patients from outlying areas could be included, but the group does indicate the trend toward admission i n the early stage of i l l n e s s insofar as the patients were a l l quite young. The sample breaks down roughly 1 Attention was also given in selecting cases to the p o s s i b i l i t y of endangering the patients' progress through research intervention and some cases were discarded on t h i s count, so that the sample i s t r u l y a selected one. 27 into s o c i a l classes of two groups, the working class and the "professional" or middle to upper middle class and may be said to be t y p i c a l of the large majority of patients i n t h i s respect. From the point of view of i l l n e s s e s faced by the i patients or r e l a t i v e s , the sample i s also f a i r l y t y p i c a l . The nine cases i n the sample were characterized as follows: (the l i s t s do not follow the same order, so that the 32 year old patient i s not the patient with a diagnosis of obsessive compulsive neurosis). Age of Patient Diagnosis of Patient 1. 32 1. Obsessive compulsive neurosis 2. 30 2. Schizophrenic Reaction 3 . 27 3 . Neurotic Depressive Reaction 4. 23 4. Psychoneurotic Depressive Reaction 5. 20 5. Anxiety Reaction 6. 26 6. Psychoneurotic Conversion Reaction 7. 31 7. Schizophrenic Reaction -Chronic Undifferentiated Type 8 . 16 8 . Chronic anxieties i n Schizoid type of i n d i v i d u a l 9 . 34- 9 . Chronic Schizophrenic, simple type. S o c i a l l e v e l , According to Occupation and Home Setting 1. Working Class, neat suburban home. 2. Professional c l a s s , select r e s i d e n t i a l area, b e a u t i f u l home. 1 At the beginning of the study period the writer consider-ed examining only r e l a t i v e s of schizophrenic patients, but decided to broaden the focus to include a l l types of mental i l l n e s s because s o c i a l workers i n a psychiatric setting are usually engaged i n helping patients i n a l l diagnostic groups and the post hosp i t a l problem of r e h a b i l i t a t i o n applies to a l l patients. 28 3. Working class family, rented home, run down c i t y neighbourhood. 4. Working class, own home i n r e s i d e n t i a l area. 5. Professional Class, small apartment i n good r e s i d e n t i a l area. 6. Professional Class, a t t r a c t i v e suburban home. 7. Working class, own home near i n d u s t r i a l section of suburb. 8. Working class, small home i n an almost r u r a l part of suburb. 9. Working class, older home i n older part of town near commercial section. Limitations of the Sample The sample i s small i n numbers,1 and i t i s not representative of a l l groups of r e l a t i v e s (e.g. fathers, brothers, husbands, etc. are not included). There was no way of knowing, at the time of sel e c t i o n , whether or not psychiatric help had been received i n the community prior to or following h o s p i t a l i z a t i o n for those patients not receiving s o c i a l service from the ho s p i t a l , and therefore t h i s i s a variable which i s not uniform i n the study. It proved to be impossible to find enough cases receiving s o c i a l casework services from the ho s p i t a l of a similar nature to make exam-inatio n of t h i s variable a useful one i n t h i s study. The study does not speculate on the nature of the families who 1 Of about 70 cases i n hospital during a period which provided the necessary post hosp i t a l experience, only ten could be found to meet the c r i t e r i a . Of these only 5 agreed to par t i c i p a t e , the others either declining or being considered unsuitable for interviewing. The remaining four were selected from ten suggested by S o c i a l Service Department as the only ones of the ten meeting t h i s c r i t e r i a . 2 9 d e c l i n e d t o p a r t i c i p a t e , a n d i t m i g h t h e o f i n t e r e s t t o c o n -j e c t u r e o n t h e s i g n i f i c a n c e o f t h e f a c t t h a t s o m e r e l a t i v e s a g r e e d t o t h e i n t e r v i e w w h i l e o t h e r s d i d n o t . 1 I n o r d e r t o s e l e c t a g r o u p i t p r o v e d n e c e s s a r y t o m o d i f y s o m e o f t h e c r i t e r i a . F o r e x a m p l e , l e n g t h o f s t a y i n h o s p i t a l w a s a d i f f i c u l t c r i t e r i o n t o m e e t , e s p e c i a l l y a s t h e r e s e e m s t o b e a t r e n d t o w a r d e a r l i e r n o t i n g o f i l l n e s s a n d t h e r e f o r e s h o r t e r p e r i o d s i n h o s p i t a l . ( S h o r t e r h o s p i t a l -i z a t i o n m a k e s i t d i f f i c u l t f o r s o c i a l s e r v i c e t o b e p r o v i d e d a l l r e f e r r a l s a n d a d d e d t o t h e d i f f i c u l t y i n s a m p l i n g t h e s o c i a l s e r v i c e v a r i a b l e . ) I t b e c a m e n e c e s s a r y t o u s e s o m e c a s e s w h e r e t h e p a t i e n t s s t a y i n h o s p i t a l w a s l e s s t h a n s i x w e e k s a n d a l s o w h e r e t h e p o s t h o s p i t a l p e r i o d h a d e x t e n d e d p a s t s i x w e e k s . T h e s e p e r i o d s t h e n a r e n o t s t r i c t l y u n i f o r m , a n d s o m e v a r i a t i o n m a y e x i s t a m o n g r e l a t i v e s r e s p o n s e s d u e t o t h e d i f f e r e n c e s i n e x p e r i e n c e i n t e r m s o f t i m e . S u c h v a r i a -t i o n i s n o t a c c o u n t e d f o r i n t h e s t u d y . I t m i g h t b e o f i n t e r e s t t o m e a s u r e t h e i n t e n s i t y o f r e s p o n s e i n r e l a t i o n t o l e n g t h o f t i m e t h e r e h a b i l i t a t i o n p e r i o d h a d e x t e n d e d . T h e w r i t e r s i m p r e s s i o n i n t h e p r e s e n t s t u d y w a s t h a t w h i l e t h e r e l a t i v e s f e e l i n g s w e r e o f a p i q u a n t q u a l i t y a t t h e t i m e o f d i s c h a r g e , t h e y b e c a m e e v e n l e s s e n d u r a b l e a s t i m e w e n t o n . T h e r e w a s n o s e p a r a t i o n i n t o g r o u p s o n t h i s s c o r e , h o w e v e r . 1 I t m i g h t b e s a i d t h a t t h o s e w h o a g r e e d t o t h e i n t e r -v i e w h a d s o m e a w a r e n e s s o f a n e e d f o r h e l p , b u t i t m i g h t a l s o b e s a i d t h a t t h e s e w e r e m o r e a l t r u i s t i c o r c u r i o u s , e t c . a n d s t u d y i n t o t h i s p a r t i c u l a r a s p e c t w o u l d b e n e c e s s a r y t o d e t e r -m i n e i t s s i g n i f i c a n c e . T h e n u m b e r o f r e l a t i v e s r e f u s i n g t o p a r t i c i p a t e i n t h e p r o j e c t w a s s m a l l e r t h a n t h o s e a g r e e i n g . F o u r t e e n w e r e a p p r o a c h e d a n d n i n e r e s p o n d e d p o s i t i v e l y . 30 The Method of the Study To select the cases for study, a memorandum l i s t i n g the c r i t e r i a was circulated amongst members of Crease Clinic Social Service Department and the writer also spoke to the social workers at staff meeting and privately. The cases to be used in the group receiving social casework services were chosen from the names the workers submitted. The group of cases in which no social service was given was selected by proceeding from the f i l e number of each social service case to the next f i l e numbers following i t and apply-ing the c r i t e r i a u n t i l one was found which could be used. In the group receiving social service, the relatives were prepared by a discussion with their own case-worker for the writer's telephone c a l l to arrange an appoint-ment. Letters were sent to the groups of relatives where the social service department had not been active, advising them of the research project and preparing them for a telephone c a l l . The main method of obtaining data was the inter-view, and in research the technique differs slightly from that in the casework service interview. Edna Wasser advises: "It is always the research setting and the research design that determine what the basic role of the caseworker is to be. This role needs to be clearly defined i f his practice is to be consciously and purposefully adapted to the needs of research. 1 1 Wasser, Edna, "The Caseworker as Research Interviewer in Follow-Up Studies" in Social Casework, October 1957 > vol. xxxviii, number 8, page 423 3 1 To help preserve t h i s focus, the interview wars prepared beforehand by constructing a guide with general areas of discussion marked out and types of questions out-l i n e d . (See Appendix "A"). This guide could be used only to focus the Interview and not i n the manner of a survey. 1 The areas around which the interview was constructed were chosen from the problems with which s o c i a l work finds most concern in r e h a b i l i t a t i o n , plus the topic of reaction to h o s p i t a l -i z a t i o n and mental i l l n e s s . The topics of the interview were: 1 . Education or re t r a i n i n g plans of the patient 2. Employment plans or problems of the patient 3 . Housing arrangements of the patient 4. Recreational a c t i v i t i e s of the patient 5 . F i n a n c i a l problems of patient and r e l a t i v e s due to i l l n e s s 6 . The impact of h o s p i t a l i z a t i o n on the r e l a t i v e s 7. The understanding of mental i l l n e s s gained by the r e l a t i v e s The interview was designed around the f i r s t f i v e topics as they seemed to be concerns that might be shared by patient and r e l a t i v e , or which might have a meaning to the r e l a t i v e which could result i n her manifesting attitudes toward the patient which might affect his performance i n these areas. I I t was found that the word "survey" seemed reassuring to the r e l a t i v e s upon opening the interview, whereas the word "research" seemed to put them a l i t t l e on guard before further explanation could ease t h e i r fears. 32 The l a t t e r two topics were intended for examination of the r e l a t i v e s ' personal reactions to c r i s i s . Recording during the interview was done by means of a code card, three by f i v e inches i n siz e , on which the areas of discussion and responses were indicated by abbreviations and symbols, to be marked by the interviewer when the subject was touched upon by the r e l a t i v e . The introductory phase of the interview proved to demand special attention. It was necessary to overcome the r e l a t i v e s ' i n i t i a l reserve, and t h i s was accomplished by explaining the purpose of the v i s i t i n simple terms and making sure the r e l a t i v e understood. A sense of harmony and trust had to be created i n order to free the r e l a t i v e s to display her feelings about her experiences, and the interviewer had to sense the r e l a t i v e s ' mood and adapt the style of discussion to i t . With some r e l a t i v e s , the discussion had to start where the r e l a t i v e f e l t most comfortable, preliminary con-versation leading into such an area. S t r i c t adherence to one topic at a time was often impossible, as the r e l a t i v e s , i n open discussion, often jumped to other subjects, and the . worker followed t h e i r lead as long as focus was maintained. It proved simple enough to bring the informants back to an area, once they had been allowed to discover that they were not being "forced" and that what they contributed seemed to be h e l p f u l . Use of the structured o u t l i n e , of course, was 33 helpful with informants who found open discussion somewhat threatening, or needed help to p a r t i c i p a t e . The end of the interview required special care, because of the tendency for the r e l a t i v e s to discover the possible comforts i n relationship with a person i n whom the "giving" element has not been eliminated i n the interests of research. Edna Wasser comments: "Inevitably there i s a q u a l i t y of giving to the c l i e n t , not i n a service or treatment sense but i n terms of the interviewer's expressed interest and what he reveals of his appreciation and com-prehension. The interviewer t r i e s to make the experience a constructive one for the c l i e n t , and to repair any d i s t r e s s i t may cause. Any such ' s e r v i c e - l i k e ' aspects, however, are subsidiary to the primary research focus."1 I t w i l l be recalled that Rubinstein and Parloff noted the influence of the i n t e r a c t i o n between interviewer and interviewee, and with the basic "giving" attitude of the caseworker, plus the deliberate e f f o r t s mentioned by Wasser, i t i s not possible to prevent the r e l a t i v e s from sensing a new q u a l i t y i n t h i s experience. (See Appendix "B"). For that reason, the writer found i t necessary to weave into the structure of the interview c e r t a i n features to minimize any pain which might occur as a result of withdrawing.3 the comfort of r e l a t i o n s h i p after displaying i t . Especially i n cases where there was an obvious problem, the following measures were observed: 1 Wasser, Edna, Ibid 34 1. Recognition of the problem. 2. Stating that the research worker cannot help with the problem. 3. Giving f a c t u a l information about where to obtain help. 4. Conveying warmth. 5 . Controlling the kind of information the r e l a t i v e might reveal. 6 . Giving the r e l a t i v e a sense of value because of his contribution. 7. Careful closing." 1-In closing the interview, the research focus was stressed, the r e l a t i v e s were thanked for t h e i r help i n terms of future help to others, and were reminded that no further v i s i t would be made. The worker at that point t r i e d to con-vey, through general a t t i t u d e , warmth and appreciation of not only the r e l a t i v e s ' contribution to research, but also of the r e l a t i v e s ' q u a l i t i e s as a person. The structured type of interview, used i n an "open" manner was useful i n several ways. General feelings and attitudes could be noted, s p e c i f i c feelings towards problems could be ascertained, and some of the s p e c i f i c questions brought out material which required interpretation but which was valuable i n that way. For example, the question: "Had you any special hopes for the patient when he came out of hospit a l and how i s t h i s turning out?" 1 This method was composed by Edna Wasser and the seven steps given here were compiled from a review of her method. 35 revealed attitudes of f r u s t r a t i o n , h o s t i l i t y , disappointment or withdrawal from the s i t u a t i o n . There were some questions which might bring f o r t h more response i n a group setting. Few r e l a t i v e s , for instance, could think of what s p e c i f i c questions they had had about mental i l l n e s s i n general. The quality of the one to one r e l a t i o n s h i p , and the fact that i n only one interview only a certain amount of time could be given to developing a r e l a t i o n -ship or to allowing r e f l e c t i v e periods, may have affected the response to t h i s question. (It i s of interest to note that several r e l a t i v e s had read popular a r t i c l e s on the sub-j e c t , but did not raise questions about them, whereas perhaps i n the anonymity and acceptance of a group s i t u a t i o n they might have done so). Most comments about mental i l l n e s s were centered around the pa r t i c u l a r i l l n e s s of the patient and whether or not questions had been s a t i s f a c t o r i l y answered by the h o s p i t a l p s y c h i a t r i s t . The request for "your suggestions" gave opportunity for free expression of attitudes. The ideas ranged from p r a c t i c a l ones such as, "there should be more buses" (there are only two a day at inconvenient hours for v i s i t i n g ) to "sick patients should be segregated from ones l i k e my son". The l a t t e r indicated persevering protective tendencies i n the mother. There i s segregation to a point i n that one ward i s "closed", and patients with severe disturbances remain there u n t i l t h e i r health improves. The several r e l a t i v e s who wanted 36 "desegregation" were speaking of t h i s ward, feel i n g t h e i r patients to be less i l l than the others i n i t . Denial of the i l l n e s s , and, possibly, lack of adjustment to the ho s p i t a l setting were thus indicated. The interview i n the case study method i s time-consuming and often t i r i n g i f the interviewer i s to be al e r t to a l l the nuances of meaning and feeling i n the interchange of conversation, but i t seems to be a device capable of bring ing data to research from the sensitive areas of human experience. CHAPTER I I I - STRESSES OF HOSPITAL AND POST HOSPITAL PERIODS The aim of t h i s study i s to d e s c r i b e the impact of h o s p i t a l i z a t i o n and the post h o s p i t a l p e r i o d upon the r e l a t i v e s of mentally i l l p a t i e n t s and to c o n s i d e r the s t r e s s experienced by the r e l a t i v e s i n the r e h a b i l i t a t i v e phase of treatment. For these purposes, the case study method, u t i l i z i n g mainly the i n t e r v i e w technique, has been employed, and Appendix B g i v e s some examples o f t h i s p rocess. For t h i s chapter, the r e l a t i v e s interviewed have been d i v i d e d i n t o two groups, the group of wives and the group of mothers. The cases i n the group o f wives have been designated by the l e t t e r s A,B,C, and D, and the mothers, by the numbers 1,2, 3,4, and 5. In a l l of the f o l l o w i n g p r e s e n t a t i o n s , the s t a t e -ments are g i v e n as they were r e v e a l e d i n the i n t e r v i e w s i t u a t i o n , and thus represent o b j e c t i v e and s u b j e c t i v e f a c t as experienced by the r e l a t i v e . Where the impressions o f the i n t e r v i e w e r are i n c l u d e d , drawing i n f e r e n c e s from the m a t e r i a l , these are noted i n the record as the o p i n i o n of the worker. The case r e c o r d s are presented i n two groups, f i r s t the group of wives, then the group of mothers, with some g e n e r a l o b s e r v a t i o n s drawn at the end o f each group. The t o t a l group i s then d i s c u s s e d . In each case r e c o r d , the headings of the i n t e r v i e w o u t l i n e are employed to d i v i d e the case m a t e r i a l . The headings " E d u c a t i o n or T r a i n i n g " , "Employment", "Housing", " R e c r e a t i o n " , and "Finances", are used not to i n d i c a t e that d e s c r i p t i v e i n f o r m a t i o n about the a c t u a l s i t u a t i o n f o l l o w s , 38 but information regarding how the r e l a t i v e feels about t h i s aspect of the patient's experience. The heading "Pressures" i s used i n the case studies of the f i r s t group because the wives were able to state where they f e l t s t r a i n , whereas the mothers were not so a r t i c u l a t e . The section under the heading "Assessment" i s the workers interpretation of the material preceding i t . WIVES Case A. "Mrs. W" Mr. W i s a univ e r s i t y trained professional person aged 26 who experienced d i f f i c u l t y i n his f i r s t year after graduation when he was not comfortable with his employer. His b r i e f i l l n e s s consisted of an "Anxiety Reaction" and he was sent by his ps y c h i a t r i s t i n the community to Crease C l i n i c , where he remained only two weeks. He then went into a business on his own and at the time of the interview was just getting i t underway. He continues to see a psyc h i a t r i s t i n the community and s t i l l has periods of tension. He and his young wife of less than two years have a baby, and l i v e i n a small apartment i n a pleasant d i s t r i c t . Mrs. W at f i r s t denied any problems but soon began examining some of her feelings about her experiences. Employment 1 In regard to her husband's employment, Mrs. W displayed some anxiety, which the worker considered j u s t -i f i a b l e under the circumstances, since his new venture was i n i t s beginning stages. She balanced her anxiety with her pleasure i n her husband's improved outlook, however, and she f e l t convinced that t h i s was the right course for her husband to take. She had noticed that he experienced occasional'.;, periods of tension i n r e l a t i o n to his work, and t h i s caused her concern, which she did not wish her husband to perceive. She f e l t that he needed her posi t i v e support and encouragement i n t h i s venture. Mrs. W spoke knowledgably of her husband's I Since the patient had completed his professional t r a i n -ing, education was, not a topic for discussion i n t h i s interview. 39 future prospects i n his job. Housing The small apartment occupied by the family was an at t r a c t i v e one, and Mrs. ¥ enjoyed maintaining a happy atmosphere i n i t . She expressed concern, however, for her husband's response to i t s l i m i t a t i o n s , f e e l i n g that he needed more scope for such a c t i v i t i e s as gardening, carpentering, and general homey '"puttering" as outlet for his pent up energies, and for feelings of accomplishment. Mrs. W hoped they would be able to move to a home of thei r own i n the near future. In the meantime, the worker had the impression that she was making the most of the p o s s i b i l i t i e s i n the i r apartment. Recreation This wife participated f u l l y with her husband i n his s o c i a l l i f e . They enjoy v i s i t i n g and having friends i n . Mrs. W., however, was concerned about whether or not her husband should be encouraged to maintain friendships with one or two patients he had li k e d i n the h o s p i t a l , and who had since v i s i t e d . The patient tended to take on a good deal of r e s p o n s i b i l i t y i n a club he belongs to, and Mrs. ¥ was concerned about t h i s , too. Finances This couple had not experienced severe f i n a n c i a l set back because the patient's period i n hospital had been b r i e f and his previous earnings had been good. Their families had also been able to help. Mrs. ¥, however, expressed fears i n thinking of the p o s s i b i l i t y of future unemployment due to i l l n e s s . She said "I wouldn't know what to do — I panic when I think of i t . " H o spitalizat ion The act of h o s p i t a l i z a t i o n was a shock to Mrs. ¥. Her husband had been seeing a psychia t r i s t in the community for a year, and she had considered that s u f f i c i e n t treatment to insure no further development i n the i l l n e s s . She added that she had thought i f he did need more intensive treatment, i t would take place at the General Hospital. " I t was a blow when Crease C l i n i c was prescribed." When she v i s i t e d the patient, she suffered further shock on discovering locked doors, and the severity of i l l n e s s some of the patients around her husband displayed. She spoke to the hospit a l ps y c h i a t r i s t once, but otherwise developed no f e e l i n g of 40 communication with h o s p i t a l personnel. She had no preparation for the patient's homecoming, and she f e l t he might have benefited from a s l i g h t l y longer stay, "but nobody asked:" She said she did not l i k e to pick f a u l t s , because she f e l t her husband had a c t u a l l y benefited from his experience i n Crease C l i n i c , but she was not well impressed with the physical s e t t i n g . Understanding of I l l n e s s Mrs. W. had never before known anyone with a mental i l l n e s s . She f e l t her questions about i t had not been sa t i s -f a c t o r i l y answered, and she would not turn to magazine a r t i c l e s f e e l i n g that they would not be authoritative, nor help her understand her husband's s p e c i f i c i l l n e s s . She had wondered about her own involvement i n the i l l n e s s and had therefore v i s i t e d her husband's psychia t r i s t i n the community. She had been reassured, but occassionaly wonders about i t now. Pressures Toward the end of the interview Mrs. W. talked about her own feelings of tension and s t r a i n . She said she "could not take" another period of h o s p i t a l i z a t i o n right now. She reviewed the s i t u a t i o n , and f e l t that having had to adjust to marriage, then to motherhood, then to mental i l l n e s s , h o s p i t a l -i z a t i o n , and r e h a b i l i t a t i o n , a l l i n less than two years, had reduced her stamina. Assessment The worker's impression was that h o s p i t a l i z a t i o n was a rude awakening to Mrs. W. regarding mental i l l n e s s . She was unable to u t i l i z e the resources of the hospi t a l and possibly f a i l e d to understand the continuum of treatment, expecting her husband to be "cured" when the hospi t a l door closed behind him. She seemed to suffer feelings of i s o l a t i o n , of being l e f t out of the s i t u a t i o n , i n her comment, "nobody asked me" i n respect to the hospi t a l experience. It seemed to worker as though t h i s r e l a t i v e may have avoided asking probing questions about mental i l l n e s s i n an effo r t to deny i t s existence, or not to face a l l the i m p l i -cations. In her emphasis that mental i l l n e s s carries no stigma, i t seemed that she might be denying her r e a l f eelings. The post hospital period for Mrs. VJ. means watchful-ness on her part not to upset the patient, plus s t r a i n for her a r i s i n g from anxiety over the new employment, the housing l i m i t a t i o n s , fear of the f i n a n c i a l implications of future i l l n e s s , and from her lack of emotional support. The dependency needs of t h i s wife did not seem to be receiving g r a t i f i c a t i o n , and i t was the worker's impression 41 that" her emotional resources were being drained, so that i t was questionable how long she could maintain positive attitudes i f she did not receive s p e c i f i c support for her emotional needs. Case B. "Mrs. X." Mr., X. i s a 34 year old semi-skilled person who was transferred from a l o c a l gaol to Crease C l i n i c owing to the condition of poor amenta! health he seemed to be i n at the time of his offence. He was i n Crease C l i n i c six weeks, diagnosed as "Chronic Anxiety State i n a Schizoid Individual," and upon return to the community has been unable to obtain employment. The family i s composed of the patient, his wife, the i r pre-school son and th e i r infant son. Mrs. X saw the research interview as an avenue to obtaining help, and she presented the s i t u a t i o n c l e a r l y . Employment Mrs. X. seemed to worker to be r e a l i s t i c a l l y anxious about her husband's unemployment. She f e l t her husband was growing increasingly depressed by his b e l i e f that prospective employers look unfavorably on men with gaol and mental health experiences. She said that at f i r s t she had been inclined to dismiss t h i s p o s s i b i l i t y , but now was beginning to share her husband's opinion, although she would not l e t him know i t . She had taken Into consideration the minor economic recession of the country and had t r i e d to help her husband recognize i t as a feature i n his unemployment, but she could not f e e l reassured herself. Education or Training Mrs. X. expressed confidence i n her husband's i n t e l l i g e n c e and s p e c i f i c a b i l i t i e s , and f e l t he lacked educa-t i o n up to his capacity. She f e l t he would benefit from further t r a i n i n g i n his trade, not only because of increased s k i l l s , but also i n increased confidence i n himself and regard for his own worth. She wished that a course of t r a i n i n g could be arranged for him. Housing The two roomed apartment was f e l t by Mrs. X. to be too small for two adults and two children, and said i t pre-sented problems of heating, cleaning and storage, but worker 42 observed that she kept i t i n clean and comfortable order. She said she had suspended any thoughts of moving, knowing they were not f i n a n c i a l l y i n a position to do. She was grateful to "new Canadian" neighbours i n the upstairs apartment who "baby sat" cheerfully and refused payment. Recreation Mrs. X had proved to be resourceful i n finding recreational a c t i v i t i e s she and her husband could share at l i t t l e cost. A community group provided a young adult's program and she and her husband had joined i t . They also spent some evenings v i s i t i n g f r iends. This wife also expressed concern about her husband's continuing friendships made i n h o s p i t a l . In one p a r t i c u l a r friendship she did not know i f i t would be wise to encourage her husband, since the friend might be h e l p f u l to him i n terms of education and employment, or'to discourage him, since the two might emphasize each other's i l l n e s s e s . Finances Although r e a l i s t i c a l l y concerned about the l i m i t -ations of unemployment insurance, Mrs. X stated that she f e l t capable of managing on whatever income was available. She herself would l i k e to work, and had done so for a time but gave i t up because of her husband's i l l n e s s . An evening job which she enjoyed had to be relinquished because her husband became upset caring for the children at night. H o s p i t a l i z a t i o n The events surrounding the patient's h o s p i t a l i z a t i o n a l l came as a shock to Mrs. X, although h o s p i t a l i z a t i o n i t s e l f was seen as a "rescue" from the more damaging incarceration i n gaol. Mr. X had seen a psyc h i a t r i s t i n the community for a time, but had then become unable f i n a n c i a l l y to continue t h i s treatment. When his health seemed to deteriorate, neither he nor his wife could think of any way to obtain the cost of treatment, and they did not know whom to consult about the matter. Mr. X therefore received no treatment, and Mrs. X f e l t that his tension b u i l t up u n t i l i t exploded i n the minor offence which caused his apprehension. Fortunately, Mr. X's former ps y c h i a t r i s t was consulted, and he advised Crease C l i n i c care. Mrs. X v i s i t e d the patient i n h o s p i t a l , but f e l t at a loss i n the setting. She did not know how to communicate with s t a f f , although she very much wished to consult with someone. She had many questions, and a l l were l e f t u n s a t i s f i e d . She f e l t that she was not taken into p a r t i c i p a t i o n i n treatment at a l l , and was l e f t with a helpless f e e l i n g . 43 Understanding .of I l l n e s s Mrs. X v i s i t e d the psych i a t r i s t i n the community whom her husband had seen, and learned that she encourages her husband to "lean" on her "stronger nature". This came as a completely new concept to her, but she said that she could understand i t and note how i t operated i n her re l a t i o n s h i p with her husband. However, she said she now f e l t very con-fused and very much wished for help in modifying her attitudes for her husband's sake. Pressures The strains f e l t by Mrs. X seemed to be caused by: 1. her i n a b i l i t y to sort out the material and emotional problems of herself and her husband, and take steps to solve them. (Her employment could perhaps have been f a c i l i t a t e d had there been someone to help her and her husband to look at the matter.) 2. her confusion about the i l l n e s s and how she should modify her behavior to help her husband. 3. her lack of knowledge of "where to turn". Although Mr. X was on good terms with his probation o f f i c e r , Mrs. X commented "his (probation o f f i c e r ' s ) job i s not a psychiatric one." She said she f e l t d e f i n i t e need for psychiatric consultation. 4. her feelings about family relationships. She remarked that she did not know how long she could go on creating a positive atmosphere for her husband, because she found herself having l i t t l e to give the children, and a c t u a l l y sometimes bursting out i n her f r u s t r a t i o n at them, and she was becoming increasingly alarmed at her own reactions. Assessment This r e l a t i v e seemed to have a good potential for helping her husband but lacked guidance and support. It appeared that Mrs. X would be capable of providing an income but subordinated her desire to do so to the needs of her husband's condition. She was confused and hurt by the hospital's lack of attention to her, and was at a loss as to how she might proceed to f i n d psychiatric help which she f e l t was desperately needed. In t h i s case, the worker f e l t that the r e l a t i v e showed need for emotional support as well as help regarding p r a c t i c a l matters and help i n obtaining information about the i l l n e s s . 44 Case C "Mrs. Y." Mr. Y i s a 32 year old c l e r i c a l worker who dev-eloped excessive fears about germs and about the danger of his bringing disease to his family. He was i n h o s p i t a l six weeks. The family consists of the patient, his wife, t h e i r school age son and t h e i r pre school age son. Mrs. Y's attitude was casual and calm throughout the interview although toward the end of i t she began to express her feelings about the i l l n e s s with more spontaneity. Education or Training Mrs. Y did not respond to discussion i n t h i s area, f e e l i n g her husband was not i n need of any form of t r a i n i n g . Employment Mr. Y had returned to his former job which had been held for him. Mrs. Y commented that while her husband's employer had acted kindly i n t h i s regard, there was l i t t l e reason why he should not, since her husband had been a steady worker for over ten years, never being absent a day. She thought her husband like d his job, and had established a place for himself with the other employees, with whom he engages i n recreational sports. She appreciated the security the job offered, but did not think what i t r e a l l y meant to her husband i n terms of s a t i s f a c t i o n s derived from i t or advancement possible i n i t . Housing There was no question i n t h i s area, since the patient returned to his own home, a modern suburban bungalow. Recreat ion In t h i s area, Mrs. Y stressed that they "just took up where they l e f t o f f " . She noted some improvement, however, i n that her husband resumed an interest i n sports which had lagged just prior to h o s p i t a l i z a t i o n . She noted, too, that friends remained l o y a l , some of them discl o s i n g that they had also had experience with mental i l l n e s s . Ho spit a l i z a t ion The patient was referred by the family doctor to a p s y c h i a t r i s t i n the community just before h o s p i t a l i z a t i o n . Although Mrs. Y at f i r s t seemed to cover her f e e l i n g of shock regarding h o s p i t a l i z a t i o n , she returned to the topic 45 toward the end of the interview, saylng^lt r e a l l y was a blow, actually." At the time of h o s p i t a l i z a t i o n , Mrs. Y knew nothing about Crease C l i n i c , not even where i t was. She f e l t her husband suffered shock at f i r s t , but later.enjoyed the experience. Despite the inconvenience of buses 1, Mrs. Y v i s i t e d her husband almost, every day. She spoke to his psyc h i a t r i s t i n hospi t a l several times, and was very pleased that her husband l i k e d him a great deal whereas he had not been so comfortable with the community psy c h i a t r i s t who recommended h o s p i t a l i z a t i o n . Mrs. Y f e l t that her opinion v/as not considered regarding discharge plans. She telephoned the ps y c h i a t r i s t to discuss whether the patient v/as quite ready for discharge, did not receive a s a t i s f y i n g reply, and then suddenly found the patient at home. Mrs. Y remarked that she had talked with the s o c i a l worker two or three times, but had. not been engaged i n intensive case\^ork. Understanding of I l l n e s s In t h i s area of discussion Mrs. Y showed deeper in t e r e s t . She showed a f a i r l y good grasp of the general o r i g i n s of mental i l l n e s s , and i n the worker's opinion, an i n t e l l e c t u a l capacity to come to grips with the s p e c i f i c terms of her husband's i l l n e s s , i f she could obtain more information. She said she desired information about the " r a r i t y of the i l l n e s s " and i t s implications. She read magazine a r t i c l e s eagerly i n attempts to learn more about mental i l l n e s s . She wondered why r e f e r r a l to Mental Health Centre had not been made rather than to Crease C l i n i c , f e e l i n g her husband was not i l l enough to cease functioning i n the community. Pressures Mrs. Y revealed that she i s sometimes concerned over what might be the effect on her husband i f he or the children developed physical i l l n e s s , and she feel s a l i t t l e tense about things the children do-, such as playing i n the d i r t , for fear they might upset her husband, whom, she suspects, s t i l l harbours some anxieties. She copes with these l i t t l e things on her own, rather than t e l l her husband about them. When he ta l k s over any of his feelings she has learned to respond without haste, but she finds i t a s t r a i n trying to think what she should say. 1 There are only two buses a day, at inconvenient times for v i s i t i n g . 46 Assessment This wife appeared to be a capable person who was consciously t r y i n g to help her husband. She tended to minimize the impact of i l l n e s s , i n her emphasis on "picking up where we l e f t o f f " , and there may be some tendency to withdraw from facing the implications of i l l n e s s . Her r e a l concern about the i l l n e s s seems to underly t h i s a t t i t u d e , however, and given support, she appeared to have good potential for p a r t i c i p a t i n g a c t i v e l y i n treatment. She gave the impression of having been denied a f u l l opportunity to p a r t i c i p a t e . Her willingness to do so would seem apparent from her frequent v i s i t s to hospital and her several t a l k s with the doctor. Despite her comment that they "just picked up where they l e f t o f f " , i t seemed that she needed preparation for his homecoming, and more information and guidance about how to conduct herself and family matters for the sake of the patient. H o s p i t a l i z a t i o n , i t s e l f , she admitted, had been a "shock" to her. Case D. "Mrs. Z" Mr. Z i s a t h i r t y year old labourer whose i l l n e s s became apparent after family relationships became entangled. He was i n hospital for a month, with a diagnosis of "Psychoneurotic Depressive Reaction." The family consists of the patient, his wife, and three children, one school age, two, pre school. Mrs. Z spoke of her experiences and feelings openly. Employment The patient had returned to a former job, but wanted to leave i t and start a business which he could operate from his own home. Mrs. Z concurred with him i n t h i s because he does not l i k e l i v i n g too far away from work to come home at noon for a hot meal. Mrs. Z could also help i n the business, and as she appeared to the worker to be an extremely capable person i t seems quite possible that her share of the work would be large. Mrs. Z spoke of herself as though she were a r e a l part of a team concerning her husband's work and his future prospects i n i t . Education or Training Neither Mrs. nor Mr. Z had given any thought to t h i s matter. 47 Housing Mrs. Z's awareness of her part i n her husband's i l l n e s s was brought out i n discussion of t h i s section. The home i s an old one, i n need of repairs, and Mrs. Z o r d i n a r i l y does a l l the carpentry tasks, but now understands her husband should be allowed to do some of these things, and so she r e f r a i n s from doing them, although they are easy for her to do. She said she f e l t some tension l i v i n g near the c i t y and would l i k e to return to t h e i r property i n the i n t e r i o r of the province, where the countryside Is more to her l i k i n g . Recreation Mrs. Z was concerned about her husband's lack of interest i n s p e c i f i c forms of recreation. She has no form of entertainment by herself, and her husband w i l l not go out anywhere. She had enjoyed sports before marriage, and missed these a c t i v i t i e s . She was concerned by his unwillingness to go out to make friends although he i s disappointed that few friends v i s i t , which he enjoys. .This wife also wonders whether her husband should continue a friendship made i n h o s p i t a l . Finances Despite f i n a n c i a l shortages during the hosp i t a l period, Mrs. Z expressed no concern i n t h i s regard. She was aware that s o c i a l assistance would be available should i l l -ness recur. H o s p i t a l i z a t i o n Mrs. Z f e l t h o s p i t a l i z a t i o n as a shock. Her husband had been seeing a psych i a t r i s t i n the community for a year, but she did not consider him to be i l l . She v i s i t e d regularly while patient was i n h o s p i t a l , and spoke once with the ho s p i t a l p s y c h i a t r i s t , who prepared her for the patient's discharge. She f e l t the hospital period was not long enough and that i t therefore did not have much effect on the patient's condition. She f e l t the doctors did not know enough about the "whole s i t u a t i o n " , by which she meant the s o c i a l entangle-ments which seemed to have precipitated the i l l n e s s l . I These "entanglements" were f u l l y recorded on f i l e , so that i t seems the doctors were well aware of th e i r s i g n i f i -cance. L i t t l e i n terpretation of a he l p f u l nature seems^to have been given - or perhaps to have reached - Mrs. Z. i n t h i s regard, however. 48 Understanding of Il l n e s s Mrs. Z had found p a r t i a l answers to her questions from magazines, friends, s o c i a l workers and doctors. She f e l t she had a good understanding of the effect on the patient of her "mothering" him, but she f e l t s c e p t i c a l about general information she had received pertaining to the o r i g i n s of mental i l l n e s s . Both she and Mr. Z had had a few i n t e r -views with s o c i a l workers following h o s p i t a l i z a t i o n , but f e l t d i s i n c l i n e d to continue them. Pressures Mrs. Z spoke about her attempts not to "mother" her husband, saying that she was beginning to f e e l a s t r a i n i n "always watching myself". Apart from t h i s , she f e l t able to take f i n a n c i a l , employment, recreational and other problems " i n her s t r i d e " despite th e i r inescapable presence. Assessment Mrs. Z i s one of the most unusually capable women to be met with i n the writer's experience. Her re f u s a l to consider her husband i l l prior to h o s p i t a l i z a t i o n , and her scepticism regarding roots of i l l n e s s may be a denial of the i l l n e s s , or perhaps i n d i c a t i v e of a f a i l u r e to f u l l y understand her own "mothering" r o l e , because she appeared to be so s e l f s u f f i c i e n t and genuinely capable that she would not need to be aware of her husband's inadequacies. Having to stop and look for them, and then adjust her behavior accordingly, seems to be some disturbance to her ordinary routine of l i f e . She undertakes to modify her behavior, however, with good w i l l , and with her usual c a p a b i l i t y . She was not unresponsive to interest taken i n her, and encourage-ment given her, and the interviewer f e l t , from Mrs. Z*s excursion into the personal matters of the " s o c i a l intangle-ment", that there were matters she would l i k e to discuss which she had perhaps been coping with herself i n her own sel f s u f f i c i e n t way. This woman would require much deeper diagnostic evaluation to assess her basic needs, yet i t was f e l t that her potential for taking a meaningful part i n her husband's treatment would be enhanced by an agent providing support and interest i n her. Summary of General Observations Made by Worker  In Interviewing Wives This summary draws together the main impressions 49 gained from the interviews with wives, which are to be analyzed after a l l the cases are presented. Since the impressions gained from the two groups of interviews are somewhat d i f f e r e n t , i t seems he l p f u l to summarize them for each group before examining the factors operative i n the f a m i l i e s ' experience. It i s interesting to note that the wives i n person-a l i t y were not unlike the mothers. They seemed to be capable and confident women, although unmet dependency needs, such as i n case A., where the young wife had had too rapid adjust-ments to make and had apparently lacked the emotional support usually received from husbands during these times, could be detected, especially when the interview became a l i t t l e deeper than the research focus of t h i s paper s t r i c t l y per-mitted. While the wives did not express any wish to dominate, i t seemed that th e i r natural capacities might make them seem the dominant figures i n th e i r f a m i l i e s . Since similar impressions were gained from the mothers, i t seems possible that the wives had been placed by t h e i r husbands i n the dual role of wife and mother, with r e s u l t i n g confusion for both patient and wife. The stress occassioned by t h i s r o l e con-fusion w i l l be discussed l a t e r , In the analysis of a l l the interviews. In the interviews, the wives indicated that they had gained some understanding of the matter, but wished to receive more help and guidance i n handling i t . It seemed that to the wives, the i l l n e s s and the post h o s p i t a l experience created a group of completely new 50 feelings which had been foreign to them e a r l i e r . These arose from t h e i r r e a l i z a t i o n of t h e i r husbands' i l l n e s s e s and the sense they had that they could contribute to the recuperation process. They became aware of themselves i n the s i t u a t i o n and developed feelings of anxiety and tension around the i r handling of themselves. They kept these feelings hidden from t h e i r husbands, however, f e a r f u l of disturbing him, and perhaps causing recurrence of the i l l n e s s . These wives seemed to appreciate, and, indeed, almost to ask for support, encouragement, and guidance i n involving them-selves i n a struggle to help the patient win his battle against mental i l l n e s s . The fact of h o s p i t a l i z a t i o n was of great significance to the wives, who had not realized the f u l l extent of the i l l n e s s e s previously. The greatest d i f f i c u l t y for them i n the post hosp i t a l period seemed to be not so much i n the v a r i e t y of material problems facing them as i n the need to evaluate the implications of the i l l n e s s and to modify t h e i r own conduct for the welfare of the patient. Feelings of tension and s t r a i n were general i n t h i s regard. This group of wives a l l made conscious e f f o r t s to be h e l p f u l to th e i r husbands, and i t i s to be noted that only one of the husbands was unemployed. 51 Mothers Case 1. "Mrs. P" The patient i n t h i s family was a twenty-three year old g i r l who was hospitalized for two and a half months for treatment of simple type chronic schizophrenia. The family i s composed of the mother, the patient, her s i s t e r and her two brothers. Mrs. P was a l i t t l e resistant when the writer telephoned to make an appointment,1 and seemed to indicate her mixed feelings toward the patient when she burst out rather t r u c u l e n t l y "well she hasn't got any work yet" but then added, as i f f e e l i n g g u i l t y for complaining, "but she's t r y i n g . " In the interview Mrs. P was not at a l l resistant?, and gave information f r e e l y . Her basic f r u s -t r a t i o n and her attitudes of over-protectiveness and h o s t i l i t y toward the patient could be detected by the worker i n her pattern of comments which resembled the one outlined i n the telephone conversation. Education of Training Mrs. P said she would l i k e her daughter to have a hairdressing course, and the patient herself would l i k e to have a p r a c t i c a l nursing course, but Mrs. P disparaged the patient's a b i l i t y to complete any course, saying she was not strong enough, or clever enough, and never finished anything she started. Employment Mrs. P thought that the patient would f e e l better i f she could contribute to household expenses. As Mrs. P had e a r l i e r complained about not being able to paint the kitchen because of the patient's medical expenses, i t Is worker's opinion that Mrs. P also would have f e l t better If the patient were contributing. Mrs. P was pessimistic about the patient's chances of getting work. Finances The family depended on a DVA pension and the children's earnings, and they had always had d i f f i c u l t y i n making ends meet. The patient contributed nothing, and despite Mrs. P's affirmation that i t wasn't necessary, that • the"others could take care of the patient, i t seemed to worker that the subject was heavily laden with emotional overtones for a l l members of the family. 52 Housing The f a m i l y had adjusted w e l l to the absence o f the p a t i e n t from home du r i n g h o s p i t a l i z a t i o n . The o l d e r son had made h i s own b r e a k f a s t and had done the shopping. He and the daughter had helped with the housework. Upon the p a t i e n t ' s r e t u r n "both are g r a d u a l l y s l i p p i n g i n t o t h e i r o l d ways" while the p a t i e n t resumes these t a s k s . R e c r e a t i o n Mrs. P expressed no i n t e r e s t i n her daughter's r e c r e a t i o n o u t s i d e the home and d i d not encourage the p a t i e n t to b r i n g f r i e n d s home. She d i d show i n t e r e s t i n the p a t i e n t ' s hobbies which could be persued w i t h i n the home, such as embroidery. H o s p i t a l i z a t i o n • I t was a. shock to Mrs. P when the p a t i e n t telephoned home one day to announce that she was i n Crease C l i n i c . The f a m i l y adjusted w e l l , however, to her absence. Mrs. P enjoyed v i s i t i n g the h o s p i t a l because she l i k e s s i c k ' people. She spoke wi t h the doctor and the s o c i a l worker, but d i d not r e c e i v e s p e c i f i c p r e p a r a t i o n f o r the p a t i e n t ' s homecoming. On the p a t i e n t ' s r e t u r n home, Mrs. P n o t i c e d the change her presence made i n t h e i r budget. Understanding of I l l n e s s Mrs. P denied that her daughter s u f f e r e d mental i l l n e s s , and i n s i s t e d that i t was "o n l y an emotional d i s -t urbance". She f e l t the p a t i e n t had learned to t a l k more f r e e l y through her h o s p i t a l experience, and now spoke to the f a m i l y , s u r p r i s i n g them, by r e v e l a t i o n s about how she f e e l s about t h i n g s . Mrs. P f e l t the other c h i l d r e n d i d not accept t h i s very w e l l , and sa i d she h e r s e l f d i d not know how to respond to her daughter, and wondered i f her former hand l i n g had been remiss, although she could not b e l i e v e that i t had been so. Assessment The impact o f the h o s p i t a l period was to l e t the f a m i l y d i s c o v e r that they could manage n i c e l y without p a t i e n t . They d i d not fa c e up to the f a c t o f i l l n e s s , and t h e i r p a r t i c i p a t i o n i n treatment seemed m i n i n i a l , as they could not meet the p a t i e n t ' s new e f f o r t s at changing 53 r e l a t i o n s h i p s . The f i n a n c i a l s i t u a t i o n was perhaps a factor increasing the family's negative attitudes since they seemed to be covering up impatience at her i n a b i l i t y to contribute. The patient was being sustained by the s o c i a l worker, but the family had not yet been reached. This r e l a t i v e seemed to experience f r u s t r a t i o n due to the patient's finances, and showed some h o s t i l i t y i n . r e s i s t i n g the idea that changes were necessary i n family attitudes toward the patient. Overprotectiveness i n the areas of employment and t r a i n i n g seemed to spring from basic feelings of h o s t i l i t y . Case 2 . "Mrs. T" The patient, a 2 7 year old u n i v e r s i t y student suffering a schizophrenic reaction, was hospitalized for four months. The family consisted of the patient, his widowed mother, and a married s i s t e r (not at home;. Mrs. T was reluctant to participate i n research because she wanted to "forget a l l about" her experiences, but decided i n favor of the interview for the sake of helping future patients, and gave material quite frankly. Education or Training Mrs. T expressed lack of confidence i n her son's a b i l i t y to continue his studies, f e e l i n g he had not pro-gressed far enough i n his treatment. Employment Mrs. T seemed to withdraw from t h i s subject, having doubts as to the patient's readiness, and the general a v a i l a b i l i t y of summer work. Housing There was an a i r of di s t r e s s about Mrs. T as she discussed patient's presence i n her home, because she said his evidences of remaining i l l n e s s made her uneasy. It was f e l t by worker that she projected her own r e a l wishes i n saying "He would probably prefer to l i v e elsewhere", i f h is finances permitted. Recreat ion Mrs. T was gratef u l to the patient's friends for 54 their continuing kindly attitudes, hut apart from acquies-ing when he invited someone i n to dinner, she did not participate with him i n any form of recreation. Finances There was no f i n a n c i a l s t r a i n i n t h i s family due to lack of funds, but Mrs. T suffered acutely when creditors telephoned regarding debts the patient had accrued during the onset of i l l n e s s . This was f e l t as a blow to family standing i n the community. Hospitalizat ion This mother was i n favor of h o s p i t a l i z a t i o n and urged i t on the patient, f e e l i n g i t was the only solution to his long standing problems. She v i s i t e d seldom. She took the part of the hos p i t a l on an occasion; when the patient went "AWOL" one day, and she discussed with him his need to accept hosp i t a l rules. She was disappointed when he was discharged, f e e l i n g he needed a longer period of h o s p i t a l -i z a t i o n for complete treatment. She told very few people about his i l l n e s s , and was surprised to learn that the one neighbour i n whom she confided had had experience with mentally i l l r e l a t i v e s . Understanding of I l l n e s s Comprehension of the nature of the i l l n e s s was li m i t e d . She sought answers" to her questions from doctor and s o c i a l worker, but rejected some of th e i r interpretations. She continued to believe that the patient should be able to use his superior i n t e l l i g e n c e to "think his way" out of the i l l n e s s . Assessment Ho s p i t a l i z a t i o n was viewed as the f i n a l p o s s i b i l i t y of "cure" for the patient, and was welcomed probably because i t removed the "cause" of s t r a i n from the home. It also represented a blow to family prestige, and not many acquaint-ances were told of i t . The post h o s p i t a l period, despite some preparation from the s o c i a l worker, seemed to mean only a renewal of tension for Mrs. T., who seemed to withdraw from involvement i n continuing treatment. Family status seemed to be a s i g n i f i c a n t factor here, forming a component of the r e l a t i v e ' s f e e l i n g of comfort, which suffered from the patient's i l l n e s s and his presence i n the home. 55 Case 3 . "Mrs. E" The patient i n t h i s family i s a 3 1 year old man who suffers from a "habit spasm of the choreoathetoid type", and who entered Grease C l i n i c for help with emotional problems, staying for nine weeks. Diagnosis was "Psycho-neurotic Conversion Reaction". The family consists of the patient, his widowed mother, married brothers and s i s t e r s away from home, and the daughter of one of these, being cared for by the patient's mother. Mrs. E re a d i l y assented to an interview from which i t was impossible to exclude the patient. It was of interest to observe the interaction between the mother and son. Education or Training Mrs. E blamed the hospital for not providing a program of t r a i n i n g for the patient. Employment Mrs. E disparaged the patient's chances of getting a job but wished he could find work "with his hands" f e e l i n g that i t would "cure" him. She would not have him help her i n her small business i n which there was such work, however. Housing There were no plans for the patient other than to l i v e at home, but Mrs. E confided (during an absence of the patient from the interview) that she had problems when her daughter, currently receiving treatment i n a mental h o s p i t a l , was home, because the two (son and daughter) "get on ealch other's nerves". The house was very small and i t could be observed i n the interview that tension rose whenever the patient came i n , p a r t l y because there was l i t t l e space for him to move about i n or find privacy i n . Finances This r e l a t i v e had struggled with f i n a n c i a l problems since the husband's death many years e a r l i e r and because of advancing age, found more d i f f i c u l t to carry her re s p o n s i b i l i -t i e s without f e e l i n g "edgy". Recreation Concern was expressed by Mrs. E i n discussing the recreational pursuits of the patient, which consisted of 5 6 quite daring sports. It was observed by the ivorker i n t h i s " j o i n t interview" that the patient resented his mother's att i t u d e . H o s p i t a l i z a t i o n H o s p i t a l i z a t i o n did not distress Mrs. E and she was happy i n the h o s p i t a l s e t t i n g , where she was able to . get along we l l with the other patients. She discussed the patient's i l l n e s s with one of his doctors and f e l t her ideas were given a f a i r hearing, but were not implemented (eg -t r a i n i n g program for the patient) Understanding of I l l n e s s Mrs. E was unable to communicate any understanding of her son's condition. She confided that the patient "gets on my nerves sometimes", but she apparently made no ef f o r t to understand the r e l a t i o n s h i p between herself and the patient. Assessment Ho s p i t a l i z a t i o n seemed a pleasant interlude for t h i s overworked mother, and the post hosp i t a l period a wearisome picking up again of her whole burden. Mrs. E showed l i t t l e understanding of the emotional complications of her son's physical condition and apparently continued i n her l i f e - l o n g r e l a tionship with him, of providing for his needs. There seemed to be a new element following h o s p i t a l i z a t i o n i n that the "holiday" for her had been pleasant and returning to the old problems and tensions-seemed harder because of her age and increasing family and business probelms. Case 4. "Mrs. G" The patient i s a sixteen year old g i r l who experienced a schizophrenic reaction ("Chronic Undifferent-iated Type") and was hospitalized for almost four months. The family was composed of patient, mother, and father. Mrs. G displayed a great deal of h o s t i l i t y i n t h i s interview, but i t was f e l t , after the h o s t i l i t y had been handled by the worker to some degree, that there was, beneath 5 7 i t , a long standing wish for help and a fear of r e j e c t i o n i f i t were revealed (see appendix B). Otherwise i t would be d i f f i c u l t to understand why Mrs. G had eventually agreed to the interview, because she had angrily attacked the method of research. Information was not given d i r e c t l y , and there were many areas t h i s mother refused to discuss, but from her comments on other subjects, her general attitudes could be discerned, although her s p e c i f i c problems could not. Education or Training Mrs. G also blamed the h o s p i t a l for providing no plan of t r a i n i n g for the patient. Employment Mrs. G was angry with the hospital for not following her daughter's problems into the community and thus helping her find work. Recreation The worker f e l t that Mrs. G tended to keep the patient away from groups, i n that she said she arranged out-ings and "projects" for the two of them. Hos p i t a l i z a t i o n This mother v i s i t e d regularly but found no sat-i s f a c t i o n i n t a l k i n g with treatment personnel. She c r i t i -cized the " i s o l a t i o n " of the h o s p i t a l , f e e l i n g that i t could not expect to be e f f e c t i v e i f i t did not keep i n touch with the community aspects of mental i l l n e s s . Understanding of I l l n e s s It could not be observed that t h i s mother had any understanding of the nature of the patient's i l l n e s s and she would say no more than that the h o s p i t a l s t a f f had not given her any h e l p f u l information. Assessment This mother was described i n the f i l e as having paranoic tendencies, and i t i s d i f f i c u l t to assess the v a l i d i t y of some of her statements, such as that the psych-i a t r i s t would not l i s t e n to her. Nevertheless, i t was f e l t that she needed and wanted help. She burst out at the end of the interview - "This may have helped some people — but where does i t leave me? I've s t i l l got a l l my problems". It seemed to the interviewer that there were obvious s o c i a l problems i n t h i s s i t u a t i o n for which r e f e r r a l to s o c i a l service was indicated, and that some of her anger was j u s t -i f i e d . The neriod of h o s p i t a l i z a t i o n was perhaps a period 5 8 i n which t h i s mother t r i e d , i n her warped way, to c a l l for help, and being unheard, she was l e f t embittered i n the post hospital period, fee l i n g i t to be a continuation of the h o s p i t a l 1 s 'neglect". Her p a r t i c i p a t i o n i n t h i s period was more p a r t i c i p a t i o n i n i l l n e s s than i n treatment. Her own deprived l i f e , plus the p r a c t i c a l problems she encountered' and her f a i l u r e to evoke a response i n anyone to herself as a \-7orthwhile person, seemed to have combined to make her involvement after the hos p i t a l period perhaps even more of a negative one than before. Case 5. "Mrs. J." The patient-was a twenty year old un i v e r s i t y student who suffered a "Psychonuerotic Depressive Reaction" and was hospitalized for three weeks. The family consisted of the patient and his mother and father. Mrs. J proved to be an exceptional mother, with responses more l i k e those of the wives than those of the mothers i n t h i s study. She had entered f u l l y into treatment, and she found the research interview an opportunity to test her thinking. Education or Training Mrs. J wished to maintain a helpful and positive attitude to her son's return to University. She cared not so much that he pass his year, as that he find s a t i s f a c t i o n i n his studies and a c t i v i t i e s . Employment Despite the parents' tendency (which they now understood) to protect and indulge the patient, the mother had come to r e a l i z e that the patient needed to develop his independence, and therefore she hoped he would find work for the summer. Housing The parents had discussed with the hospit a l psyc h i a t r i s t the a d v i s a b i l i t y of the patient's returning to the i r home. Although the psychia t r i s t was of the opinion that the patient needed to establish an independent l i f e , i t was decided to l e t him move at his own pace. The patient there-fore returned home, but after a short time decided on his own to move closer to his studies. The parents curbed t h e i r impulses to encourage him to stay home, and, instead, bent t h e i r energies to making the experience a happy one. The res u l t i n g r e l a t i o n s h i p has been pleasant as the patient fee l s free to come home when he wishes but i s learning to l i v e ind e p end ent l y . 59 Finances Again, the patient's need to grow toward inde-pendence was recognized, and the parents thus restrained t h e i r protective attitudes i n the area of finances, l e t t i n g the patient experiment for himself i n the use of limited funds. Recreat ion This mother, l i k e the wives, was concerned about the poor influence of certain friends, and wondered what to do about i t . Mrs. J participated with her son i n f a i r l y -frequent outings. Ho s p i t a l i z a t i o n and Understanding of I l l n e s s Both parents saw the hosp i t a l period,, although i t v/as a d i f f i c u l t event for them to accept at f i r s t , as an opportunity for them to engage;." themselves i n treatment. They v i s i t e d the psychi a t r i s t regularly hut not the patient, who did not wish v i s i t s . They thought through a l l the p s y c h i a t r i s t ' s interpretations, and Mrs. J did not become too threatened by them, but saw her husband's discomfort, and found i t d i f f i c u l t to help him and the son at the same time. At the h o s p i t a l , Mrs. J. was dismayed by the grouping of apparently severely i l l patients with less i l l ones, and she found disagreement i n the opinions of the hospi t a l p s y c h i a t r i s t and t h e i r community psy c h i a t r i s t con-fusing. She f e l t that the patient should have been better prepared to meet negative community attitudes to mental i l l n e s s upon his discharge. Assessment Ho s p i t a l i z a t i o n represented an extension of the community ps y c h i a t r i s t ' s services, and a resource for their deeper involvement i n treatment for these parents. The mother proved most able to adapt her thinking to the t r e a t -ment or i e n t a t i o n , while the father found some ideas a l i t t l e d isturbing. The post hosp i t a l period v/as seen as a contin-uation of treatment, and Mrs. J f e l t her r e s p o n s i b i l i t y to continue testing her own attitudes against the p s y c h i a t r i s t ' s thinking and to change them accordingly. She and Mr. J, who was interviewed on request following Mrs. J's interview, both expressed a need *for support and reassurance as ttfcey/ engaged i n the new experience of helping th e i r son through a d i f f i c u l t period. Because of Mrs. J's diff e r e n t involvement from that of the other mothers, i t i s interesting to speculate on the reasons for her more positive attitudes. Several 60 f a c t o r s s e e m n o t e - w o r t h y . F i r s t , t h e m o t h e r h a d r e a c h e d a n u n u s u a l l y h i g h l e v e l o f e d u c a t i o n a n d w a s m o r e t h a n u s u a l l y i n t e l l i g e n t . S e c o n d , s h e w a s a t t r a c t i v e a n d f a i r l y y o u n g , k e e p i n g h e r a g e w e l l . T h i r d , h e r a g e w a s c o n s i d e r -a b l y l e s s t h a n h e r h u s b a n d ' s ( M r . J . w a s a l s o a h i g h l y e d u c a t e d p e r s o n ) . I t s e e m e d p o s s i b l e t h a t t h e r e l a t i o n -s h i p b e t w e e n m o t h e r a n d s o n r e f l e c t e d u n r e s o l v e d o e d i p a l w i s h e s w h i c h t h e m o t h e r u n c o n s c i o u s l y e n c o u r a g e d s i n c e s h e h a d f o r m e r l y f o u n d s o m e s a t i s f a c t i o n i n s o c i a l a c t i v i t i e s w i t h h e r s o n . ( S h e n o w f e l t h e m i g h t f i n d i t e m b a r r a s s i n g t o b e s e e n w i t h h i s m o t h e r , a n d w a s t h i n k i n g t h r o u g h t h i s a s p e c t o f t h e r e l a t i o n s h i p ) . A l s o o f i m p o r t a n c e i s t h e f a c t t h a t i n t h e f a m i l y t h e r e w e r e n o p r o b l e m s o f h o u s i n g , e m p l o y m e n t , f i n a n c e s , e t c . , t o d i s t r a c t t h e i r e n e r g i e s f r o m c o n c e n t r a t i o n u p o n t h e t r e a t m e n t o f t h e p a t i e n t . S u m m a r y o f G e n e r a l O b s e r v a t i o n s M a d e b y W o r k e r  i n I n t e r v i e w i n g M o t h e r s A s i n t h e c a s e o f t h e g r o u p o f w i v e s , t h e m a i n i m p r e s s i o n s f r o m i n t e r v i e w s w i t h t h e g r o u p o f m o t h e r s a r e d r a w n t o g e t h e r b e f o r e v i e w i n g t h e m a n a l y t i c a l l y . W i t h t h e e x c e p t i o n o f c a s e n u m b e r 5, t h e m o t h e r s s e e m e d t o d i f f e r g r e a t l y f r o m t h e w i v e s i n t h a t t h e y d i d n o t s e e m t o h a v e d e v e l o p e d a w a r e n e s s o f t h e p a r t t h e y p l a y e d i n t h e i l l n e s s o r c o u l d p l a y i n t h e r e h a b i l i t a t i o n p e r i o d . T h e y l a c k e d e n -t h u s i a s m f o r e n t e r i n g i n t o t h e t r e a t m e n t o f t h e p a t i e n t , a n d t h e i r a t t i t u d e s t o w a r d s t h e p a t i e n t s w e r e m a i n l y o f h o s t i l i t y , o v e r p r o t e c t i o n ( s t e m m i n g f r o m g u i l t ) , a n d w i t h d r a w a l . P e s s i m i s m i m b u e d m o s t o f t h e i r r e s p o n s e s w i t h n e g a t i v e t o n e . T h e m o t h e r s s e e m e d t o b e m o r e c o n c e r n e d w i t h p r a c t i c a l p r o b l e m s , a n d w i t h t h e i r o w n f e e l i n g s o f f r u s t r a t i o n a n d d e p r i v a t i o n t h a n w e r e t h e w i v e s , w h o s e c o n c e r n i n r e l a t i o n t o t h e i r o w n f e e l i n g s w a s f o c u s s e d a r o u n d a d j u s t i n g t h e i r a t t i t u d e s f o r t h e p a t i e n t ' s w e l f a r e . 61 The mothers, with the exception of case number 5j referred i n the interviews to areas of d e p r i v a t i o n 1 , such as loss of parents, or husbands, or f i n a n c i a l d i f f i c u l t i e s , they, had suffered i n t h e i r e a r l i e r l i v e s , and found con-tinuing episodes of deprivation, however small, p a i n f u l . For example, i n case number 1, the mother was frustrated i n being unable to paint the kitchen and seemed to f e e l t h i s a painful deprivation. In case number 2, the blow to status was painful when creditors telephoned for the patient. These kinds of problems seem to further deplete the mothers' low reserves of strength and warmth and leave them less able .to create a positive atmosphere for the patient. Discussion In these case- i l l u s t r a t i o n s . ' , the objective r e a l i t y of the "beta s i t u a t i o n " for the patients, as i t involves certain r e l a t i v e s , i s observable. The wives were consciously (and conscientiously) presenting to the patients an appearance of f a i t h and encouragement. Most of the mothers, on the other hand, could not conceal h o s t i l i t y , f r u s t r a t i o n , overprotectiveness, or withdrawal i n t h e i r feelings toward • the patient. To such r e a l i t i e s i n the objective environment must be added the patient's subjective perceptions of them to complete the beta s i t u a t i o n , but from the performance of 1 This was not included i n the interview presentation, since i t was not a standard area for discussion, but came up spontaneously i n some interviews. This may be another area for research to which the interview method might be adapted. It would be of interest to know, for example, i f and how the mothers of schizophrenic patients had experienced deprivation. 62 the patients i n the community, as reported by the r e l a t i v e s interviewed, i t would seem that the objective factors are not too disparate from the patient's subjective perception of them. To b r i e f l y i l l u s t r a t e some of the "objective r e a l i t i e s " viewed i n the r e l a t i v e s , the matter of employment, since i t offers the most obvious area i n which to see per-formance, i s reviewed for each case: Case A: - encouraging attitudes i n the wife, together with anxiety which was being concealed from the patient. Case B : - anxiety present, but the wife made an ef f o r t to que l l her feelings and be encouraging to the patient i n his attempts to find work. Case C: - n e u t r a l i t y of affect seemed the keynote i n r e l a t i o n to the patient's employment, although the wife's appreciation of the security it"' offered perhaps was f e l t p o s i t i v e l y by the patient. Case D: - encouragement and actual help came from t h i s capable wife i n connection with the patient's employment plans. Case I: - f r u s t r a t i o n because the patient could not con-tr i b u t e to household expenses was noted, together with pessimistic attitudes towards the chances of the patient's obtaining work or keeping i t . Case 2: - pessimism again noted, i n the mother's doubt that the patient could perform i n work, or get a job. Case 3: - discouragement, r e j e c t i o n , and f r u s t r a t i o n were discerned i n that the mother did not think the patient could find a job, would not l e t him work with her, and yet wished he had work to "cure" him and to provide income. Case 4: - h o s t i l i t y projected onto the hospit a l by the mother may have been f e l t by the patient as inkiic'itiug Case 5: - the attitude discovered i n t h i s mother was po s i t i v e , being hopeful of the patient's chances of getting work, and supportive of his e f f o r t s . 63 The case i l l u s t r a t i o n s also bring into focus the fact that the objective s i t u a t i o n i s influenced by elements inherent i n the t o t a l s i t u a t i o n which may be viewed as " s t r e s s f u l " . The purpose of t h i s study i s to develop better understanding of the stresses which cause r e l a t i v e s to behave i n certain ways toward the patient, and as a l l of the r e l a t i v e s interviewed gave evidence of experiencing "stress", i t i s th i s element which i s indicated for examination. "Stress" i s a concept recently adapted to the b i o l o g i c a l and s o c i a l sciences. Dr. Hans Selye's theories of stress as i t applies to the human body have led to similar developments i n the thinking about human behavior. Jessie Bernard"*' has studied the phenomenon of stress i n our present day society as i t i s manifested i n the performance of human beings and her formulation i s useful for the present study. She defines a stress s i t u a t i o n as one involving threat, and divides i t into three parts: "(I) the stress f a c t o r , which threatens, (2) the value which i s being threatened (3) the reactions ... to the threat." 2 Although stress may arise within one's own body, or from nature, or from the s o c i a l system, i t i s the l a t t e r only with which t h i s study i s concerned. Bernard states that "a certain amount of threat i s i m p l i c i t i n the very process of s o c i a l i z a t i o n , 'by which the in d i v i d u a l as a b i o l o g i c a l creature with limited endowments i s forced into roles assigned to him by society and pressed into the moid of 1 Bernard, Jessie, S o c i a l Problems at Mid century, The Dryden Press, New York, 1957 2 I b i d , page 70 STRESSES IN HOSPITAL PERIOD Threat Value: Facing Mental I l l n e s s Homeostosis of Family Kind of Hospital Prestige Physical Factors Freedom, Dignity Is o l a t i o n from treatment group p a r t i c i p a t i o n , con-, fidence i n role per-formance. Case A X X X X Case B X X Case C X X X Case D X Case 1 X Case 2 X Case 3 Case 4 X Case 5 X X CHART 1 ON 64 i t s culture.' As a result of the 'inevitable press of standardized s o c i a l i z a t i o n techniques' there i s always a certa i n amount of so-called, 'free f l o a t i n g ' anxiety i n most populations. 1 , 1 This study, then, disregards a l l threat factors except those operating i n the context of society. Bernard notes that "change" i s a threat to s t a b i l i t y and security, and i s f e l t i n r o l e relationships and i n status. The case i l l u s t r a t i o n s corroborate t h i s idea. Bernard also postulates a difference between "objective pro-b a b i l i t y " and "subjective p r o b a b i l i t y " i n stress, and t h i s can also be demonstrated i n the cases studied. Stress reactions of anxiety, h o s t i l i t y , apathy, etc., are also observable. To view the experiences of the r e l a t i v e s studied i n t h i s context, the following analysis i s divided into exami-nations of the threat factors, the value threatened, the influence of the subjective p r o b a b i l i t y of threat, Role Re-l a t i o n s h i p s , and Stress Reactions. It should be noted, however, that, as Bernard states; "This break down i s purely for a n a l y t i c a l purposes; i n r e a l l i f e , stress situations occur as unitary wholes, not as separate elements." 2 Threat Factors and Values It i s f e l t by t h i s writer that threat factors and values are so closely intertwined that a d i s t i n c t separation of them interferes with the meaningful comprehension of the 1 Bernard, i b i d , pages 7 1 - 7 2 2 I b i d , page 7 0 65 stress s i t u a t i o n , and so they are here examined together, rather than i n separate sections. In examination of the case i l l u s t r a t i o n s , the stress s i t u a t i o n for the r e l a t i v e i s divided for study purposes into the h o s p i t a l period and the post hosp i t a l period. In the hospital period, a number of threat factors are observable, with accompanying values being threatened. As an o v e r a l l threat, there exists the fear of change, which endangers the security - or the "homeostasis" - of the family group. The fear of mental i l l n e s s , and facing up to the fact that i t can affect one's own family, are components of t h i s threat. Once the r e l a t i v e has adjusted to t h i s threat, there are threats within the changed s i t u a t i o n : the threat of the kind of h o s p i t a l to which the patient i s sent - a threat to the value of prestige, or status; the threat of physical factors i n the hospital which affect values of freedom and d i g n i t y ; 1 the threat of being isolated from the treatment process, endangering the values associated with p a r t i c i p a t i o n and belonging to a group, and also the value of confidence i n one's role performance. From chart 1, i t can be seen that seven of the r e l a t i v e s were threatened by the necessity of facing mental i l l n e s s as i t was represented by h o s p i t a l i z a t i o n at Crease C l i n i c . Only cases 3 and 4 seemed immune to t h i s threat, 1 Values may relate "to one's s e l f , to one's loved ones, or to one's group, or to a l l three" according to Bernard, i b i d , page 75. 66 p o s s i b l y b e c a u s e o f t h e l o n g s t a n d i n g n a t u r e o f t h e i l l n e s s . Two r e l a t i v e s , i n c a s e s A a n d C , s u f f e r e d t h r e a t s t o p r e s t i g e o r s t a t u s i n t h e k i n d o f h o s p i t a l n e c e s s a r y f o r t h e p a t i e n t . T h e r e l a t i v e s i n c a s e s A a n d 5 w e r e " d i s t r e s s e d " b y t h e l o c k e d d o o r s a n d n o n - s e g r e a t i o n d i a g n o s t i c a l l y o f t h e p a t i e n t s , w h i c h t h r e a t e n e d v a l u e s o f d i g n i t y a n d f r e e d o m . F o u r r e l a t i v e s , i n c a s e s A , B , C , a n d 4 w e r e t h r e a t e n e d b y b e i n g l e f t o u t o f t h e t r e a t m e n t p r o g r a m , a d a n g e r t o t h e i r v a l u e s o f b e l o n g i n g t o t h e g r o u p a n d o f r o l e c o n f i d e n c e . T h e t h r e a t s o r s t r e s s f a c t o r s n o t e d i n t h e c h a r t m a y b e i l l u s t r a t e d b y r e f e r e n c e t o s o m e c a s e e x a m p l e s . C a s e A F a c i n g u p t o t h e i l l n e s s w a s a s t r e s s f a c t o r , o r t h r e a t , f o r M r s . '7 b e c a u s e s h e h a d c o n s i d e r e d h e r h u s b a n d ' s v i s i t s t o t h e c o m m u n i t y p s y c h i a t r i s t s u f f i c i e n t t r e a t m e n t f o r a c o n d i t i o n s h e d i d n o t r e g a r d a s s e r i o u s m e n t a l i l l n e s s . F a c i n g t h e r e a l i t y o f i l l n e s s s i g n i f i e d f o r h e r a s e v e r e s e t b a c k t o t h e s e c u r i t y o r " h o m e o s t a s i s " o f t h e f a m i l y , b e c a u s e t h i s w a s i n t h e p r o c e s s o f d e v e l o p i n g , a n d s h e h a d h a d t o a d j u s t t o s e v e r a l n e w f o r m s o f f a m i l y i n a s h o r t p e r i o d a n d h a d n o t e s t a b l i s h e d a f e e l i n g o f a s e c u r e e s t a b l i s h m e n t w h i c h c o u l d w i t h s t a n d s h o c k s . D e s p i t e M r s . W ' s p r o t e s t a t i o n , i t w a s f e l t t h a t s h e h a d a " h i d d e n " v a l u e o f p r e s t i g e a n d s t a t u s , w h i c h w a s t h r e a t e n e d b y h o s p i t a l i z a t i o n a t C r e a s e C l i n i c b e c a u s e s h e h a d p r e v i o u s l y t h o u g h t o n l y i n t e r m s o f h o s p i t a l -i z a t i o n a t t h e G e n e r a l H o s p i t a l . H e r v a l u e s o f f r e e d o m a n d d i g n i t y w e r e t h r e a t e n e d b y t h e l o c k e d d o o r s o f t h e h o s p i t a l PRACTICAL PROBLEMS - POST HOSPITAL PERIOD STRESSES Education or Training Employment Hous inq Finances Recreation Threat to Opportunity Threat to s e l f image as worthwhile i n d i v i d u a l Threat to security Threat to health Threat to privacy Threat to peace Threat to independence Threat to Status Threat to pleasure Threat to health Case A X X X X Case B X X X X X X Case C Case D X X X X Case 1 X X X Case 2 X X Case 3 X X X X Case 4 X Case 5 X x X X CHART 2 67 and the association of severely i l l patients with less i l l ones, the l a t t e r group, she f e l t , including her husband. A f e e l i n g of i s o l a t i o n was s t r e s s f u l to Mrs. W regarding her lack of communication with treatment s t a f f as indicated i n her comment "nobody asked me", a f a i r l y obvious blow, not only to one's sense of belonging to a group, but also to one's confidence i n the significance of one's r o l e . Case B In t h i s s i t u a t i o n the threat factor of being l e f t out of treatment predominates, complicated by the general f e e l i n g of i s o l a t i o n suffered by Mrs. X i n "not knowing where to turn" for help with p s y c h i a t r i c , and also with s o c i a l problems. Case C Facing the i l l n e s s was a threat which Mrs. Y attempted to avoid. Prestige may have been threatened as she wondered why Mental Health Centre had not been recommend-ed i n preference to Crease C l i n i c . This also may have been part of her avoidance of facing the stress factor of mental i l l n e s s . Case 1 Facing up to mental i l l n e s s threatened the personal security of Mrs. P, who did not wish to admit that her e a r l i e r handling of the patient had been remiss. Case 4 Mrs. G's references to the " i s o l a t i o n " of the hospital led the worker to think she was objecting to her 68 e x p e r i e n c e w i t h t r e a t m e n t s t a f f , w h i c h s h e p e r c e i v e d a s n e g l e c t o r p e r h a p s r e j e c t i o n . S h e s e e m e d t o b e e x t r e m e l y t h r e a t e n e d b y l a c k o f i n c l u s i o n i n t r e a t m e n t a n d b y l a c k o f a t t e n t i o n t o h e r r o l e . i F r o m t h e f o r e g o i n g c a s e i l l u s t r a t i o n s i t a p p e a r s t h a t t h e g r o u p o f w i v e s w a s m o r e s u s c e p t i b l e t o t h e t h r e a t s i n h e r e n t i n h o s p i t a l i z a t i o n t h a n w e r e t h e m o t h e r s , o n t h e w h o l e . I n t h e p o s t h o s p i t a l p e r i o d , t h e t h r e a t s o r s t r e s s f a c t o r s a r e o f a d i f f e r e n t n a t u r e , a n d t h e v a l u e s t h r e a t e n e d s e e m m o r e c o m p l e x . T h e y e x i s t i n t w o . a r e a s , t h a t o f p r a c t i c a l p r o b l e m s , a n d t h a t o f r o l e r e l a t i o n s h i p . C h a r t 2 d i v i d e s t h e p r a c t i c a l a r e a s d i s c u s s e d i n t h e i n t e r v i e w i n t o t h e t w o v a l u e s w h i c h s e e m e d m o s t t h r e a t e n e d . T h u s , t h e p r o b l e m s b r o u g h t b y t h e r e l a t i v e s u n d e r t h e t o p i c " E d u c a t i o n o r T r a i n i n g " r e l a t e t o v a l u e s o f o p p o r t u n i t y , w h i c h o f t e n h a m p e r e d b y l a c k o f e d -u c a t i o n o r t r a i n i n g , a n d o f t h e s e l f i m a g e a s h a v i n g w o r t h b e c a u s e f e e l i n g s o f i n a d e q u a c y o f t e n a r i s e f r o m l a c k o f e d -u c a t i o n . T h r e a t s i n e m p l o y m e n t e n d a n g e r f a m i l y s e c u r i t y , a n d t h e p a t i e n t ' s h e a l t h d u e t o l a c k o f a c h i e v e m e n t o r s a t i s -f a c t i o n i n w o r k . H o u s i n g e n t a i l s t h r e a t s t o p r i v a c y f o r t h e p a t i e n t , o r t h r e a t s t o p e a c e a n d c o m f o r t f e l t b y t h e r e l a t i v e . I n f i n a n c e s , t h r e a t t o i n d e p e n d e n c e i n d i c a t e s t h a t t h e f a m i l y w o u l d h a v e t o b e c o m e d e p e n d e n t u p o n a p u b l i c a g e n c y i f f u n d s w e r e d e p l e t e d , a n d t h r e a t t o s t a t u s i n d i c a t e s t h a t m o n e y i s r e g a r d e d a s o n e o f t h e m a r k s o f s t a n d i n g i n c o m m u n i t y , a n d o f m a i n t a i n i n g o r a d v a n c i n g t o s o c i a l l e v e l s . I n t h e 69 area of recreation, the threat was to the pleasure of the r e l a t i v e , or to the health of the patient. In these dichotomies, i t may he noted that the threats are of two kinds, one, threats to one's s e l f , and the other, threats to the patient as f e l t by the r e l a t i v e . The reason for the dichotomy i s that wives tended to experience stress i n terms of values centered on the patient, while mothers were p r i -marily concerned with personal values. Stresses Felt i n Relation to P r a c t i c a l Problems In the area of education or t r a i n i n g , only four r e l a t i v e s f e l t stress. In case B, the wife f e l t her husband's opportunities were hindered by his lack of t r a i n i n g , and she f e l t t h i s barrier as a threat which she would l i k e removed. She also suffered stress because his lack of t r a i n i n g made him f e e l inadequate. The mother i n case 3 blamed the hospital for not permitting the patient to increase his opportunities through t r a i n i n g , but t h i s threat was probably a side effect of the general stress i n regard to a l l p r a c t i c a l matters with him because they combined to threaten her security and comfort. The same applies i n case 4. The mother i n case 5 reacted only to the possible threat to her son's health i f education f a i l e d to increase his sense of adequacy, thus improving his s e l f image. Employment implies values for six of the r e l a t i v e s . In case A the threat to security i s less than the threat to health, because the family has resources, and the patient 70 would have l i t t l e d i f f i c u l t y i n finding work i n his profession, but i f he f a i l e d to make a success of his private business venture, his wife feared his health would suffer. In case B, the patient was unemployed, and despite the actual danger to their security, the wife did not f e e l i t as such owing to the fact that she f e l t herself capable of finding work and providing an income i f the worst happened.1 She feared that without work, however, her husband would suffer acute loss of s e l f esteem, adversely affecting his mental health. In case D, the wife was concerned for her husband's health i f he did not establish a business he could conduct at home. She disguised her concern i n a physical garb, say-ing he li k e d to be at home to have a hot lunch, but i t seems l i k e l y that she was actually concerned for her husband's sense of adequacy on his present job and feared for his emotional w e l l being i f i t declined. The mother i n case I disguised her concern with family security under the pretext that the patient would f e e l better i f she were working and could con-t r i b u t e to family expenses, but i t was not f e l t that t h i s was a true concern with health, but a stress a r i s i n g from income problems, especially as a change for the worse i n the family budget had been noticed since the patient's return home. In case 3, the mother saw employment as a path to health. Lack 1 See section on "subjective p r o b a b i l i t i e s " , 71 of employment thus threatened the p o s s i b i l i t y of the patient's being "cured". The exceptional mother i n case 5 feared for her son's developing independence i f he f a i l e d i n summer employment, and thus experienced the problem as a threat to his health. Five r e l a t i v e s experienced stress i n regard to housing. In case A, family privacy was highly valued i n order to allow the patient to "putter", which he could not do i n a building owned by someone else. In case B each member of the family lacked privacy i n the t i n y apartment. In cases I , ,2, and 3> the mothers revealed that the presence of the patient was a threat to t h e i r personal comfort, as tension arose when the patient was at home. Fi n a n c i a l problems had s t r e s s f u l meaning for f i v e f a m i l i e s . In cases B and D the wives recognized that cess-ation of income meant dependence on s o c i a l assistance, robhing them of independence. The mothers i n cases 1, 2, and 3 were sensitive regarding threats to status. In case 1, status consisted of the family's attempts to improve the status of the home by improving i t s physical appearance; i n case 2, status meant standing i n the community which the mother f e l t was lowered when tradespeople made ef f o r t s to c o l l e c t payments on the patient's debts; i n case 3 status combined the meanings of case 1 and 2, since lack of income from the patient reduced p o s s i b i l i t i e s of improving the home, and the mother would not l e t the patient earn money i n her own business because her standing,, she f e l t , would suffer from his presence. ROLE RELATIONSHIPS - STRESS IN POST HOSPITAL PERIOD Factor Lack of Knowledqe About I l l n e s s Maintaining S e l f Awareness and Adaptinq I n t e r a c t i o n w i t h P a t i e n t Threat Threat to r o l e performance Threat to S e l f Image and comfort Threat to comfort Case A X Case B X X Case C X Case D X Case 1 X Case 2 X Case 3 X Case 4 X Case 5 X CHART 3 72 In only one family did recreation offer a serious threat. In case D, the wife was unable to pursue recreations by herself, such as sports, which she had previously l i k e d . This did not concern her as much as the threat to her husband's health of his i n a b i l i t y to gather friends;. In cases A, B, and 5, there was some threat f e l t i n regard to the patient's health. In a l l of these three cases, the re-l a t i v e feared that c e r t a i n friendships threatened the patient' health. Role Relationships Any of the countless s o c i a l relationships that ebb and flow around the i n d i v i d u a l can at times upset his personal equilibrium and i n t e n s i f y s t r e s s . " ! In t h i s study, i t appears that s o c i a l relationships form the most serious v a r i e t i e s of stress. The " i n d i v i d u a l i s forced into roles assigned to him by society ..." and threats to the performance of the roles may create great anxiety. In a l l of the interviews, the impression was gained that p r a c t i c a l problems were s t r e s s f u l , but less so than the problems of re l a t i o n s h i p . A difference i n relationship structures was notice-able between the two groups, wives and mothers, and i t was noted that there seemed to be a l i k l i h o o d that the husbands had placed the wives i n dual roles of wife and mother, and confusion, which arises under such circumstances, i s a stress 1 Bernard, i b i d , page 73 7 3 causing anxiety for human beings. It i s akin to fear of the unknown, and i s complicated by the variety of p o s s i b i l -i t i e s for choice, so that the i n d i v i d u a l i s immobilized and cannot select one course of action because of being con-fronted with so many avenues at once. There i s stress then, inherent i n some role relationships where confusion reigns. In t h i s study other threat factors were discerned within the role r e l a t i o n s h i p s . Chart 3 divides the role relationship f i r s t into "Lack of knowledge about i l l n e s s " , which i s a threat i n that i t endangers the adequate performance of a ro l e . It may also add to confusion, i n i t s e l f a stress factor since the lack of knowledge about the i l l n e s s hinders the r e l a t i v e from knowing what kind of a role i s expected of her. The next d i v i s i o n In Chart 3 i s "Maintaining self awareness and adapting". Change of any sort i s a threat, and changing one's self i s perhaps the most anxiety provoking. It i s also a threat to comfort, since alertness i s always required. The r e l a t i v e s who exercised positive attitudes a l l had a need for a stress reducing r e l a t i o n s h i p , i n which they need not fear that t h e i r unguarded reactions might threaten the health of the patient. The f i n a l d i v i s i o n i n Chart 3 i s en t i t l e d "Interaction with patient" and refers to the situations i n which knowledge was not f e l t as a need, and se l f awareness was not present, but the qua l i t y of the relationship with the patient produced tension which threatened the personal I Bernard, i b i d , page 7 3 74 comfort of the r e l a t i v e . In case A, the young wife found the necessity for continual s e l f awareness more than usually threatening not only to her comfort but also to her s e l f image and her r o l e concept, because she had had to adjust rapidly to a series of new r o l e s : wife, mother, "psychiatric nurse"'*. In case B the wife was threatened by lack of knowledge about mental i l l n e s s and desired psychiatric consultation t'o help her learn how to perform for her husband's sake. She also found the necessity to watch her responses to the patient threat-ening because i t drained her energy for f u l f i l l i n g her r o l e as mother. In case C the wife's i n s u f f i c i e n t knowledge about mental i l l n e s s seemed especially threatening. She displayed an eagerness for information which belied her casual approach to the interview. She turned to every source available for answers to her questions about "the r a r i t y of the disease" but found inadequate answers. In case D the necessity to maintain self awareness and adapt her actions to the needs of the patient was s t r e s s f u l because i t was a l i e n to her nature, although she was unusually capable of doing i t . In cases 1, 2, 3 5 and 4, the mothers experienced the patient's return home as repeating the situations which created interpersonal tension. The "exceptional" mother i n case 5 needed support for her comfort diminishing e f f o r t s to consciously avoid enhancing the patient's propensity for i l l n e s s . 7 5 Subjective and Objective P r o b a b i l i t i e s for Stress Bernard points out that there i s a difference between a c t u a r i a l , or objective, p r o b a b i l i t i e s of threat, and subjective p r o b a b i l i t i e s for threat. "Some people, for example, have much higher sub-je c t i v e p r o b a b i l i t i e s for threat than do others. If the a c t u a r i a l p r o b a b i l i t y of contracting some germ disease i s , l e t us say, one i n f i v e , t h e i r subjective p r o b a b i l i t y i s one i n three, or one i n two, or even, i n extreme cases, one i n one. If they hear of a single case of the disease i n the community they behave and make decisions as though they were going to contract i t These people are under much greater stress than others l i v i n g under a c t u a r i a l l y i d e n t i c a l pro-b a b i l i t i e s of t h r e a t . " 1 In the case i l l u s t r a t i o n s , some of the r e l a t i v e s had higher or lower subjective p r o b a b i l i t i e s for threat than others i n certain areas. For instance, i n case B the sub-jec t i v e p r o b a b i l i t y for threat to security a r i s i n g from her husband's inemployment was lower for the wife than i t might have been for the wife i n case A, owing to the fact that she f e l t capable of earning an income on her own i f necessary. The same applies to case D. In case A the higher subjective p r o b a b i l i t y of threat was indicated i n the wife's remark that she would "panic" i f another bout of i l l n e s s disrupted t h e i r l i f e . It seems probable that the subjective p r o b a b i l i t y for threat to status was higher i n the mother i n case 2, for whom telephone c a l l s from creditors were s t r e s s f u l , than i n a l l the other cases, which would probably have varying degrees 1 Bernard, i b i d , page 7 5 76 of subjective p r o b a b i l i t y on t h i s score. The in d i c a t i o n here i s that a device for measuring these subjective prob-a b i l i t i e s for threat i s needed and further research may prove enlightening i n t h i s area. The subjective p r o b a b i l i t i e s i n the area of role relationships requires research i n i t s own r i g h t , as t h i s would seem to be an element i n the objective component of the "beta s i t u a t i o n " with which s o c i a l workers might deal, and prediction of the d i f f e r e n t i a l amounts of stress r e l a t i v e s might expect to f e e l would be h e l p f u l . Stress Reactions From t h i s study i t may be observed that the stress reactions of wives and mothers d i f f e r . The wives become anxious i n r e l a t i o n to the threats they f e l t to t h e i r a b i l i t y to continue showing p o s i t i v e , encouraging attitudes to th e i r husbands. The mothers reacted by f e e l i n g frustrated or hosti or by withdrawing from the s i t u a t i o n . These reactions to stress form an objective r e a l i t y i n the components of the patient's "beta s i t u a t i o n . " , and the reactions themselves perhaps increase anxiety for the r e l a t i v e who may f e e l some-how at odds with society generally for being unable to cope with the s i t u a t i o n . This anxiety produced by stress i n the r e l a t i v e c a l l s for attention from those whose c a l l i n g i t i s to treat mental i l l n e s s i n patients, because of i t s effect upon those patients. CHAPTER IV TOWARD TREATMENT IN THE COMMUNITY In t h i s study, the operation of stress factors upon r e l a t i v e s i s indicated despite the l i m i t a t i o n s of the small sample. Differences i n stress for the two groups, wives and mothers, are observable, but the effect of the s o c i a l work variable could not be measured. The size of the study does not allow conclusive generalizations from i t , such as might be used to make re-commendations regarding l e g i s l a t i o n , but i t does permit speculation on areas where further study seems indicated. The small sample i s a microcosm of the broader group, and i s representative of the larger whole as i s a sample of clot h taken from a large bolt of s t u f f . From t h i s study the implications must be viewed i n r e l a t i o n to the limited sample, but as they form a f a i r l y d i s t i n c t pattern, they may be applied to testing i n larger areas. In summary, the stress factors examined seem to arise i n two areas. The f i r s t cluster of stress factors for the r e l a t i v e occurs with the event of h o s p i t a l i z a t i o n of the patient, and the second, with the discharge of the patient into the community. Stresses occuring in the hos p i t a l period are concerned with facing the fact of mental i l l n e s s , which may threaten family s o l i d a r i t y , security, or prestige; with features of the ho s p i t a l i t s e l f which threaten the r e l a t i v e ' s concepts of freedom and dignity for the patient; and with lack of involvement i n the treatment program which " i s o l a t e s " 78 the r e l a t i v e , again threatening the s o l i d a r i t y of the family. Stresses i n the post hosp i t a l period concern p r a c t i c a l problems and role r e l a t i o n s h i p s , the l a t t e r being found to be the most f o r c e f u l stresses upon the r e l a t i v e s interviewed for t h i s study. Differences i n the group of r e l a t i v e s appears immediately i n the way they are affected by the stress of h o s p i t a l i z a t i o n . To the wives, h o s p i t a l i z a t i o n seemed a sudden and serious proclamation of mental i l l n e s s i n her own family. To the mothers, the absence of the patient i n h o s p i t a l seems to allow a respite from the s t r a i n imposed by the i l l n e s s of the patient when i n the home. There i s a t h i r d d i v i s i o n i n which the r e l a t i v e s see the h o s p i t a l , after re-covering from the i n i t i a l shock of facing the fact of i l l n e s s , as a l o g i c a l step i n treatment, and use i t as such. In t h i s study, the mother i n case number 5 occupied t h i s d i v i s i o n , and i t was f e l t that the wife i n case B would also have done so, had she received guidance and help. Facing i l l n e s s appears to be a major stress i n h o s p i t a l i z a t i o n and wives seem to need support i n accepting i t , while mothers need help to take stock of the s i t u a t i o n and their long standing avoidance of the subject. The t h i r d group also need help of a sustaining and encouraging nature while they work through the treatment implications. Some of the stresses of the h o s p i t a l period seem 79 i n f l u e n t i a l i n creating the atmosphere i n the home when the patient i s discharged. For instance, the r e l a t i v e may f e e l inadequate to cope with the patient because no one discussed the nature of the i l l n e s s with her. It would seem that several measures might reduce the major stress of " i s o l a t i o n " during the ho s p i t a l period and thus create a' more positive threshold for the r e h a b i l i t a t i v e phase of treatment: 1 . Drawing the r e l a t i v e into p a r t i c i p a t i o n with the treatment team i n helping the patient. 2. Giving information about mental i l l n e s s i n general and the patient's i l l n e s s in s p e c i f i c , with help around the r e l a t i v e ' s involvement i n i t . 3. Preparing the r e l a t i v e for the patient's discharge and the problems l i k e l y to occur i n the post hospi t a l period. In the post hospital period stresses arose for these r e l a t i v e s i n the p r a c t i c a l problems of employment, housing, etc., but were outweighed by the impact of the s t r a i n i n relationship with the patient. The wives exper-ienced confusion and anxiety i n becoming aware of t h e i r own role i n the r e l a t i o n s h i p , and of the patient's needs. The mothers became more uncomfortable i n the interaction with the patient from which they had had a respite during h o s p i t a l -i z a t i o n . It appears that these r e l a t i v e s require assistance i n the area of relationship of the kind which may be provided by s o c i a l workers. 80 T h e S o c i a l W o r k V a r i a b l e F r o m t h i s s t u d y i t w a s n o t p o s s i b l e t o o b s e r v e e f f e c t i v e l y t h e o p e r a t i o n o f t h e s o c i a l w o r k v a r i a b l e u p o n t h e s i t u a t i o n . I n f o u r o f t h e c a s e s , t w o w i v e s , ( i n c a s e s C, a n d D) a n d t w o m o t h e r s , ( i n c a s e s 1 a n d 2) s o c i a l w o r k e r s h a d b e e n i n v o l v e d t o s o m e e x t e n t , b u t t h e w o r k h a d b e e n o f v a r y i n g k i n d s a n d i n t e n s i t y . T h e t w o w i v e s h a d s e e n t h e s o c i a l w o r k e r o n t w o o r t h r e e o c c a s s i o n s , b u t n o i n t e n s i v e r e l a t i o n s h i p h a d b e e n e s t a b l i s h e d . I n c a s e s 1 a n d 2, t h e s o c i a l w o r k e r w a s c o n c e r n e d m o s t l y w i t h t h e p a t i e n t , a l t h o u g h p l a n s f o r f u t u r e w o r k i n c l u d e d t h e m o t h e r s . W i t h o n e o f t h e s e p a t i e n t s , i t w a s d o u b t f u l i f a m e a n i n g f u l r e l a t i o n s h i p c o u l d b e e s t a b l i s h e d . T o c o n d u c t a s t u d y o f t h e s o c i a l w o r k v a r i a b l e i t w o u l d b e n e c e s s a r y t o s t a n d a r d i z e t h e f a c t o r s t o b e c o n s i d e r e d s u c h a s t h e k i n d o f w o r k d o n e , a n d t h e i n t e n s i t y a n d l e n g t h o f t h e r e l a t i o n s h i p . I f t h e i n t e r v i e w m e t h o d w e r e u s e d , i t w o u l d b e n e c e s s a r y t o b u i l d i n t o i t s s t r u c t u r e s o m e s p e c i f i c f o c u s o n t h e a r e a o f s o c i a l w o r k , a n d a n u m b e r o f i n f l u e n c e s , s u c h a s t h e r e l a t i v e ' s f e e l i n g s I n t a l k i n g a b o u t a t h i r d p e r s o n , w o u l d h a v e t o b e t a k e n i n t o a c c o u n t . I n t h i s s t u d y , a l l n i n e c a s e s i n d i c a t e d p r o b l e m s o f s o c i a l o r r e l a t i o n s h i p n a t u r e w h i c h s e e m e d t o r e q u i r e a t t e n t i o n , b u t t h e g r o u p i n w h i c h t h e s o c i a l w o r k v a r i a b l e w a s p r e s e n t d i d n o t d i s p l a y a n y s i g n i f i c a n t i m p r o v e m e n t o v e r 81 t h e o t h e r g r o u p , n o d o u b t b e c a u s e o f t h e f a c t o r s l i s t e d a b o v e . O n e e x c e p t i o n d i d e x i s t i n t h a t i n t h e f a m i l y w h e r e t h e w o r k e r h a d a s u s t a i n i n g 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 , ( c a s e 1) t h e p a t i e n t s e e m e d b e t t e r a b l e t o w i t h s t a n d t h e r e s i s t a n c e o f t h e f a m i l y t o w a r d h e r d e v e l o p i n g a b i l i t y t o t a l k a b o u t h e r f e e l i n g s . T h e w o r k e r a t t e m p t e d t o h e l p t h e f a m i l y w i t h t h e l a t t e r p r o b l e m a s t i m e w e n t o n . H o w e v e r , t h i s c a s e p o i n t s u p t h e f u r t h e r n e e d i n e x a m i n a t i o n o f t h e e f f e c t o f t h e s o c i a l w o r k v a r i a b l e f o r a m e a s u r i n g d e v i c e t o d e t e r m i n e t h e a m o u n t o f i n f l u e n c e s o c i a l w o r k h a d i n t h e p a t i e n t ' s p r o g r e s s . F r o m t h i s e x p e r i e n c e , i t s e e s t h a t e x a m i n a t i o n o f t h e v a r i o u s s e c t i o n s o f t h e p a t i e n t ' s e n v i r o n -m e n t s h o u l d p r o c e e d o n e a t a t i m e i n t h e s m a l l s t u d y . A r e a s f o r F u r t h e r S t u d y T h e s t u d y o f t h e m a n y v a r i a b l e s i n t h e " b e t a s i t u a t i o n " a n d t h e w e i g h i n g o f t h e s i g n i f i c a n t f a c t o r s i n t h e t o t a l , g e n e r a l l y r e q u i r e s m o r e s t u d y . O n e o f t h e f i r s t s o c i a l w o r k e r s i n B . C . t o a t t e m p t a c a s e s t u d y o f s o m e o f t h e o b j e c t i v e e l e m e n t s o f t h e " b e t a s i t u a t i o n " w a s M i s s A . K . C a r r o l l , w h o r e f e r r e d t o h e r r e s e a r c h p r o g r a m i n t h e 1958 A n n u a l R e p o r t o f t h e M e n t a l H e a l t h S e r v i c e s . S h e s t u d i e d e i g h t p a t i e n t s w h o h a d r e c e i v e d l o n g t e r m c a r e a n d w e r e d i s -c h a r g e d t o t h e c o m m u n i t y f r o m t h e P r o v i n c i a l M e n t a l H o s p i t a l . T h e p a t i e n t s i n t h i s g r o u p w h o l a t e r r e t u r n e d t o t h e h o s p i t a l h a d e x p e r i e n c e d , d i f f i c u l t y i n t h e c o m m u n i t y i n o n e o r m o r e 82 of the following areas: accomodation, employment, loneliness, recreation, r e s i d u a l i l l n e s s making the patient inaccessible to casework help. From Miss C a r r o l l ' s report i t i s apparent that there are gaps i n community services for these needs. It seems to the present writer that services present i n a community form variables which may influence the t o t a l "beta s i t u a t i o n " of the patient and thus the operation and influence of each service requires study, and the i n t e r r a c t i o n of the services should also be examined. However, i t also seems that the attitudes of the people involved require study, and, too, the way i n which " s i g n i f i c a n t others" may affect the patient's reception of these other parts of the environ-ment such as the services. It would appear that close family members are s i g n i f i c a n t l y i n f l u e n t i a l and that their needs affect the performance of the patient i n regard to community services, so that further study of the needs of r e l a t i v e s i s ind icated. Freeman and Simmons remind us that not only one s i g n i f i c a n t "other" may affect the patient, but that the group close to the patient may be s i g n i f i c a n t i n i t s i n t e r -ract ion: "There i s obviously, a strong p r o b a b i l i t y that prediction could be improved i f the personalities of a l l individuals i n the family were assessed, rather than that of a single member.,|J-1 Freeman, H.E. and Simmons, O.S. "Wives, Mothers, and Former Mental Patients" i n S o c i a l Forces, Dec. 1958, v o l 37, no. 2. Published for the University of North Carolina Press by the Williams & Wilkins Co. page 158 83 This study i s limited i n that i t does not extend beyond one member i n each family, although i n case 5? there was i n d i c a t i o n of the problems of i n t e r a c t i o n when the father was also interviewed, and had somewhat dif f e r e n t per-ceptions of the patient's i l l n e s s than had the wife. In case 3 , there was reference to a s i s t e r with whom in t e r r a c t i o n i n the family was a problem. Nevertheless, as stated e a r l i e r , i t seems a workable approach to begin with one factor at a time. Further research into the significance of family i n t e r a c t i o n , however, seems necessary for f u l l comprehension of the "beta s i t u a t i o n " . From the present study i t appears that r e l a t i v e s often need help to withstand the stresses they experience when a patient i s h o s p i t a l i z e d , and, l a t e r , discharged. Further study seems necessary into the kinds of help they need, for some seem to require intensively supportive help, while others might be able to maintain their roles adequately with only "information giving" kinds of help. Their re-l a t i o n s h i p needs, then, as well as t h e i r observable needs, may require further study. There seems to be evidence that some r e l a t i v e s have experienced deprivation of material goods or' emotional supplies during th e i r e a r l i e r experiences, and studies into the effect of e a r l i e r deprivation upon the "subjective p r o b a b i l i t y of stress" for these people would perhaps be he l p f u l i n better 84 understanding the r e h a b i l i t a t i o n experience of the patient and family. In view of the negative attitudes displayed by four of the f i v e mothers toward the patients, i t would be of interest to study the effect ( i n the family of orientation) upon family i n t e r r e l a t i o n s h i p s of discharging the patient to a foster home rather than to the r e l a t i v e ' s home. Especially where parents remain i n touch with the patient although he i s out of the home, the res u l t i n g i n t e r r e l a t i o n s h i p pattern might offer suggestions for working with r e l a t i v e s toward more successful r e h a b i l i t a t i o n of patients. Suggestions The need for more family oriented casework seems to be indicated from t h i s study. It i s very easy to focus only on the patient i n hospital and forget that his problems have an impact upon his r e l a t i v e s . I t i s , of course, more d i f f i c u l t to work with r e l a t i v e s because the i r needs are hidden and i t takes time and effort to discover the stresses affec t i n g them, and thei r attitudes toward the patient. I t would appear that e f f o r t s should begin i n the hospit a l i t s e l f to "reach" the r e l a t i v e s , and l e t them f e e l a part of the process of treatment.. Although the treatment team may devise ways of draining the r e l a t i v e into p a r t i c i p a t i o n and of helping them to adjust to the hos p i t a l and to the fact of mental i l l n e s s , 85 a consistent pattern does not seem to have developed i n the hospital studied, and perhaps there would be merit i n con-sidering group methods similar to the one described by Jacob Brower and Richard R. Brown i n t h e i r a r t i c l e "The Relatives' Conference i n an 'Isolated' Neuropsychiatric H o s p i t a l . 1 , 1 At the Veterans Administration Hospital, Sheridan, Wyoming, the authors noted: "The t r a g i c fact was that family and patient d r i f t e d i n e v i t a b l y apart. Bonds with the community were cut..." They therefore instigated a two day "conference" of some of the patients' r e l a t i v e s , i n v i t i n g a group of r e l a t i v e s to come to the h o s p i t a l on a given week end for v i s i t s with patients and s t a f f , and for group meetings i n which questions could be asked and discussed. After general group discus-sions they were given the opportunity for i n d i v i d u a l con-sul t a t i o n s . In evaluating the conferences, 97$ of the re-l a t i v e s said they would l i k e to have the conferences con-tinued . Such a project i s a huge undertaking, but perhaps smaller group plans might be arranged as beginning steps i n helping the r e l a t i v e s become a more positive part of the objective component of the patient's "beta s i t u a t i o n " upon 1 Brower, J. & Brown, R.R., "The Relatives' Conference i n an 'Isolated' Neuropsychiatric Hospital" i n Journal of  Psychiatric Casework, Sept. 1955? reprinted by AAPSW, Columbia University Press, New York. 86 discharge. One of the aspects of the Wyoming program which seemed to give i t a broad philosophical base, and which perhaps gave the r e l a t i v e s a feeli n g of contributing such as was noted i n the research interviews for the present study, was the t a l k by a s t a f f psychologist to the r e l a t i v e s "emphasizing that a r e l a t i v e ' s role could be that of ambassador for better understanding i n his community". 1 Although every effort should be made i n the hospital to help the r e l a t i v e i n making adjustment to. h i s s t r e s s f u l s i t u a t i o n , perhaps even e a r l i e r attention to the entire matter i s indicated. Where possible, i t seems that while the patient i s s t i l l i n the community, attention should be given to the t o t a l s i t u a t i o n i n which he finds him-s e l f . In t h i s study, several of the patients had been attend-ing p s y c h i a t r i s t s i n the community before h o s p i t a l i z a t i o n , and three of the wives, and at least one of the mothers, had v i s i t e d the psyc h i a t r i s t once or twice to express t h e i r con-cern about the i l l n e s s . It seems that i t would be h e l p f u l to the patient and his family i f r e f e r r a l to a s o c i a l worker could be made at that point. In t h i s way, the r e l a t i v e could be helped to help the patient, and perhaps h o s p i t a l i z a t i o n might be avoided. If h o s p i t a l i z a t i o n became necessary, the re l a t i v e s could be helped to understand the "continuum" of 1 Brower, & Brown, i b i d , page 216 87 treatment, and the hospital's place i n i t . The need for reaching out to the r e l a t i v e s while the patient i s s t i l l i n the community i s perhaps the most urgent one i n present day treatment of the mentally i l l . Current psychiatric thinking tends towards the b e l i e f that greater numbers, although not a l l , psychiatric patients >may be cared for i n the community. Dr. Gee, i n his introduction to the 1958 Annual Report of the Mental Health Services, had th i s to say: "Certainly there i s no in d i c a t i o n that mental hospitals w i l l be e n t i r e l y unnecessary, but .there i s every i n d i c a t i o n that mental hospitals can be greatly reduced, and further, that the majority of future patients need not go to hospit a l If given early diagnosis and help i n the community." Understanding of the stresses contributing to attitudes of the community members toward the patient may make such "help i n the community" possible. I Mental Health Services Annual Report, 1958, page l ' i APPENDIX A - INTERVIEW GUIDE In preparation for the interview the following subjects were prepared, with the type of information re-quired formed into questions which might or might not be asked, depending upon the i n d i v i d u a l s i t u a t i o n . A r i g i d structure was avoided, and t h i s guide was intended more as a frame of reference than as a questionnaire. Education or Training 1. Has patient resumed school or begun any training? 2. Do you think he/she i s enjoying i t ? 3. Do you think i t w i l l be useful to him? 4. Do there seem to be any problems - d i f f i c u l t i e s for you or him? 5. Do you f e e l very concerned about t h i s ? Employment 4-1. Has patient resumed former job? 2. How do you think he i s getting along? 3. Do you think i t i s a suitable job for him? 4. Would you prefer another job for him? 5. What kind? 6 . Why? 7. Do you know any of the people he works with? 8 . Do you think they are h e l p f u l to him or otherwise? 9. Do you have any hopes for his future i n t h i s job? 89 or B. 1. Is patient looking for a job? 2 . What job would you l i k e him to have? 3 . What do you think his chances are? 4. Why? 5. Do you foresee any d i f f i c u l t i e s ? 6 . How do you think employers w i l l react to him? 7. Do you have any tal k s with patient about employment and how does he seem to react to t h i s conversation? Housing 1. Did patient l i v e here prior to h o s p i t a l i z a t i o n ? 2 . Were any changes necessary such as room? 3 . If patient did not l i v e here previously was there any d i f f i c u l t y i n arranging t h i s ? 4. . Was there a decision to be made about patient coming here? 5. Was the decision d i f f i c u l t to make? 6 . Was i t discussed with the patient? 7. How long did i t take to arri v e at the decision? 8. Were there any disagreements, and to what do you a t t r i b u t e these (patients i l l n e s s , lack of co-operation, r e a l i s t i c problems) 9. Can you remember how you f e l t on the day the patient came home? 1 0 . Are there any d i f f i c u l t i e s because of his being here? 1 1 . Is there any plan which you think -would have been better? 1 2 . Because of his being here do you ever have upset feelings? 9 0 Recreat ion 1. Does patient have any form of recreation - hobby, club, sport? 2. Do you think i t helps him f e e l better? (think he should) 3 . Since coming out of h o s p i t a l has he made any new friends, or renewed any old friends? 4. What i s your opinion of these friends? 5. Do you think they are h e l p f u l or otherwise to him? 6 . Do you think patient i s ready to enjoy friends? 7. Do you go out with patient much or have people i n to v i s i t ? I l l n e s s 1. Have you ever known anyone else who experienced i l l n e s s of t h i s kind? 2. Have you any l a s t i n g impression of your feel i n g about that person? 3 . Most people have one or two special things they would l i k e to know about mental i l l n e s s , such as heredity, danger, etc.,. Did you have any such questions before ho s p i t a l i z a t i o n ? 4. Have you received satisfactory answers during patient's treatment? 5. Can you t e l l me the source of the answers -- Doctor, Magazines, friends? 6 . There are usually a number of people involved i n helping the patient get better. In your personal opinion, were there any of these people who had special significance i n the patient's recovery eg Doctor, others i n h o s p i t a l , family, friends? 7. Have you ever sought, or would l i k e to, professional help? 8 . In helping patient get better i s there anything you think might have been done or anyone who might have added any-thing? 91 9. Had you any special hopes for patient when he came out of hospital? How i s t h i s turning out? 10. Quite often various family members react rather strongly to the patient just home from h o s p i t a l . Have you noticed how other family members feel? 1 1 . What i s your opinion about the way the world at large responds to persons who have had mental i l l n e s s ? 1 2 . What have your experiences been, for instance with neighbours -- how do they seem to f e e l about patient's i l l n e s s ? 1 3 . How do you handle t h i s problem with neighbours — t e l l them about h o s p i t a l , keep patient away from them, etc? F i n a n c i a l Aspects 1. Has the patients i l l n e s s created any f i n a n c i a l d i f f i c u l t y for you? 2 . Have you wondered i f there was any way you could get help with t h i s matter? 3 . Would you l i k e to t a l k i t over with someone, or did you find i t h e l p f u l to do so? 4. Should f i n a n c i a l problems crop up i n future, can you predict what you might do — request help from r e l a t i v e s , suggest s o c i a l agency, or h o s p i t a l worker? Hospital 1. Did you understand hospital's purpose and regulations? 2 . What did you think of patient's experience there? 3 . Did you v i s i t often? 4. How many times did you t a l k to Patient's Doctor? 5. Did you f e e l h o s p i t a l considered your thoughts and feelings? 6. Were you consulted about plans? 7. Were you included i n preparation for patient's coming home? 92 8. H o w s o o n d i d y o u k n o w o f d i s c h a r g e d a t e ? 9. W h a t w a s y o u r i m p r e s s i o n o f t h e h o s p i t a l ? R e l a t i v e ' s S u g g e s t i o n s T h e r e l a t i v e s s h o u l d h e a s k e d i f t h e y w i s h t o m a k e a n y c o m m e n t s o n t h e i r e x p e r i e n c e o r s u g g e s t a n y c h a n g e s t h e y m i g h t h a v e w i s h e d . APPENDIX B THE INTERVIEW — "The Cry For Help." In a l l the interviews an impression gained was that the r e l a t i v e s needed and wanted help. As each i n t e r -view drew to an end, the r e l a t i v e s , r e a l i z i n g the comfort of dropping protective defences, allowed th e i r r e a l feelings to peep through, and thereby revealed a person, b a s i c a l l y frightened, t i r e d , or at a l o s s , t r y i n g bravely to keep up appearances» This tendency of r e l a t i v e s to suddenly discover the comfort of r e l a t i o n s h i p made i t necessary to conduct the research interviews c a r e f u l l y , because, as no further work was to be done with the f a m i l i e s , i t would be cruel to hold out a suggestion of promise and then remove i t e n t i r e l y . By stressing the research focus and explaining how useful the interview would be i n terms of future help to others, the matter was handled sympathetically. Four of the r e l a t i v e s interviewed showed a need for help that was almost i r r e s i s t a b l e . In case B, the wife was able to a r t i c u l a t e her need openly. She said she had agreed to the interview because of her desperation to find some avenue leading to assistance, even though she realized the interview was intended for research. Her obvious need constantly enticed the worker to abandon the research slant and enter into a h e l p f u l r e l a t i o n s h i p . Her need to t a l k made her reveal a great deal of material, much of i t valuable research information, but surrounded by material highly 94 charged with diagnostic and treatment significance. The interviewer was tempted to encourage her out-pouring for the sake of research, but the matter of pro-f e s s i o n a l ethics i s to be considered i n such interviews, and the individual's welfare cannot be subordinated to s c i e n t i f i c i n t e r e s t . The interviewer i s responsible i n the s i t u a t i o n for deciding what material i s to be brought f o r t h . To bring out the necessary research information, while at the same time discouraging some discussion, yet communicating sympathy, warmth and endeavouring to minimize f r u s t r a t i o n , requires professional s k i l l . It v/as found that the interviewees gained a feeli n g of worth by knowing of t h e i r contributions to the future good of society. The end of the interview must be made warBK-.and f i n a l , giving the " c l i e n t " a clear understanding of the nature of the v i s i t . Recaptulation of the research purpose and of the fact that no further v i s i t s would be made, were combined b r i e f l y with gratitude for the individual's help i n research. The steps i n the research interview where r e a l need i s detected are given i n chapter two. Appl i c a t i o n of these i n Case B resulted i n what appeared to be a successful research interview i n that information was obtained, and the " c l i e n t " did not appear to have suffered any loss of d i g n i t y but instead seemed to have gained some value from the exper-ience. 9 5 The interview i n case 4, while not so successful from either the point of view of obtaining research inform-ation or of leaving the interviewee with positive f e e l i n g s , made even greater demands on the interviewer, and was stimu-l a t i n g because of the dynamics involved. It concerned the mother who was thought to have paranoic tendencies. When the research worker, after sending the l e t t e r signed by the Medical Director of Crease C l i n i c explaining the research project, telephoned "Mrs. G" to ask i f she would participate i n the project, and i f so, to arrange an appointment, Mrs. G spoke with an a i r of suspicious ambi-valence. At f i r s t i t seemed that she would not agree to an interview, and the worker, respecting her right of s e l f determination, did not press the matter, but suggested that i t was to be expected that there might be some questions since the l e t t e r did not explain the project f u l l y . Mrs. G grasped t h i s opportunity, and rigourously cross examined the worker about the intent of the research, and about the method. Her remarks were quite threatening, and i t was d i f f i c u l t to remain calm and deal with her points in an accepting and l o g i c a l manner. F i n a l l y , Mrs. G agreed to an interview, but when the worker attempted to make an appointment, Mrs. G refused a l l suggestions u n t i l the worker remembered her need to control and allowed her to set the date, even though she set i t (probably to express h o s t i l i t y and to prove her control) more than two weeks hence. 96 The worker arrived at Mrs. G's home almost pre-c i s e l y at the time arranged. The moment the door opened, however, the worker was thrown into confusion and nervousness for Mrs. G opened the door only p a r t i a l l y at f i r s t and showed no change of f a c i a l expression -when the worker introduced herself. She said nothing, and the worker wondered i f she had.arrived at the wrong house, and nervously asked i f Mrs. G recalled the appointment, and i f so had the worker noted the time c o r r e c t l y . Mrs. G with no change of expression, said "Of course; I'm ready", and, opening the door a l i t t l e wider, moved s l i g h t l y to allow the worker i n . Wordless h o s t i l i t y f i l l e d the room and the worker for quite a few minutes con-sidered giving up t h i s interview. Even after the f i r s t attempts to draw Mrs. G into p a r t i c i p a t i o n , there was a strong temptation to discontinue the effo r t and withdraw, because Mrs. G followed up her suspicious and h o s t i l e greet-ing with a barrage of openly h o s t i l e answers to the worker's comments. The worker began to f e e l extremely insecure, since i n a l l of these interviews the right of the researcher to v i s i t these homes and "pry" into personal matters could be questioned, and could be j u s t i f i e d only by professional concern for improving human welfare generally, a rather flimsy sounding debate when used against such a f o r c e f u l opponent. With the uncanny s e n s i t i v i t y of the emotionally disturbed c h i l d , or the patient i n hos p i t a l for mental 97 i l l n e s s , Mrs. G,sensed t h i s weak point i n the interviewer immediately and her angry questioning of t h i s r i g h t of re-search threw the worker into a near panic. It was a dramatic experience for the worker to ba t t l e with her own c o n f l i c t i n g feelings for few moments. There were two d i s t i n c t currents of thought and fe e l i n g within her. One was of outright fear i n the s i t u a t i o n ; the other, a strange sense that beneath her anger, the woman was hurt, and had a need for help which she dared not admit. Had i t not been for the l a t t e r impres-sion, the worker would have l e f t . Because of i t , however, she resolved her inward c o n f l i c t with the decision to com-municate to Mrs. G the fe e l i n g that she was li k e d and re-spected as a person. With the worker's returning calm and determination not to be upset by h o s t i l i t y , the tid e turned, and although Mrs. G never e n t i r e l y relinquished her a i r of defiance, and of reluctance to help anyone, she did begin to ta l k about the "research project" and how she f e l t about the hos p i t a l . Throughout, she tested the interviewer, who had to be careful to respond without any hint of condescension, r u f f l e d f e e l i n g s , or returning fear, and with constant warmth for Mrs. G as a person. Mrs. G proved to have i n t e l l i g e n c e , although with a bias, and the interviewer eventually found that she could respond with genuine appreciation of some of the things Mrs. G said, and f e l t very g r a t i f i e d when Mrs. G s l i g h t l y smiled once or twice. In t h i s interview the c l i e n t ' s right of s e l f determination had to dominate, and for t h i s 98 reason, many questions could not be discussed because Mrs. G flared up suspiciously when they were approached and refused to consider them a v a l i d part of research. Her attitudes to the topics could be observed e a s i l y , however. Throughout t h i s interview the worker f e l t keenly that Mrs. G. was desirous of attention and help, and t h i s seemed to be borne out when, at the end of the interview, she burst f o r t h a n g r i l y : "Well, i t may help some other people, but where does i t leave me? I'm s t i l l l e f t with a l l my problems I" The vehemence with which she pronounced that she was " s t i l l l e f t " with problems, suggested that she was angry with the worker for showing her some attention, then "re j e c t i n g " her by leaving, with no i n d i c a t i o n of return. The closing v/as not as successfully carried out i n t h i s case as i n others. Nevertheless, the interviewer was delighted when Mrs. G suddenly asked i f she would l i k e a cup of tea before she l e f t , and f e l t a sense of regret that i n a l l the months of the patient's h o s p i t a l i z a t i o n , no one had made any attempt to become acquainted with Mrs. G and to t r y to "reach" her. The implication for research i n t h i s interview i s that a rather different kind of research may be possible i n discerning whether or not c e r t a i n interviewing techniques can be e f f e c t i v e i n bringing service to persons who otherwise tend to be neglected. A uniform diagnostic group would be necessary, however, for such a study. 99 In two other cases, the need for help v/as noted especially. In case number 5? an intangible kind of help was needed. The parents were p a r t i c i p a t i n g f u l l y i n the patient's r e h a b i l i t a t i o n , ^he mother, after a long i n t e r -view, requested that the worker also speak to the father. Both mother and father were giving t h e i r best thought as to how best to help t h e i r son, and they had arrived at sound conclusions. The worker did no more than agree that the effo r t of thinking these matters through and changing one's attitudes accordingly i s a heavy s t r a i n on one, and support them" i n t h e i r v/ay of approaching the problem, at the same time as obtaining research material, but they reacted by saying warmly at the end of the interview, "Thank you so much -you've been such a help to us." They had also been able to verbalize t h e i r need for a sustaining kind of help i n the interview. In case number 3 there were obvious kinds of need. Care of grandchild and the necessity to operate a business requiring much hard work i n order to support her family pre-sented problems for the mother. The presence of the patient during most of the interview made i t impossible to conduct the interview i n the manner i n which i t had been designed, but It was possible to depart from the standard method and combine observational data with verbal. Attitudes could be observed i n action, and here again, i f the s i t u a t i o n could be reproduced i n a number of cases, t h i s might prove to be a valuable method of research. 100 In the interview, both mother and son seemed to desire attention, and besides the help apparently needed with obvious s o c i a l problems, there was f e l t to be need for help through i n d i v i d u a l r e l a t i o n s h i p therapy. The s i t u a t i o n i n t h i s home was a heart-rending one, but the "giving" attitude had to be tempered with respect for the independence of the family group. Their need to be accorded a sense of dignity rose above t h e i r need for help, and the research focus of the interview had to be used i n such a way as to promote i t , because i t would have been possible for the family to f e e l "Oh - you want to find out. what it's l i k e on the other side of the t r a c k s l " Both the mother and the patient seemed to f e e l that they had made a contribution to society, through the research interview and the mother was able to show her need for attention and support after she had been made to f e e l h e l p f u l . BIBLIOGRAPHY Bernard, Jessie, S o c i a l Problems at 1 Mid century, The Dryden Press, New York, 1957 Brower, J . , and Brown, R.R., "The Relative's Conference i n an 'Isolated' Neuropsychiatric Hospital", i n the Journal of Psychiatric Casework, Sept. 1955? reprinted by AAPSW Freeman, H.E., and Simmons, Ozzie S . , : 1. "The So c i a l Integration of Former Mental Patients", i n The  International Journal of So c i a l Psychiatry, Spring, 1959, v o l . i v , number 4. 2. "Wives, Mothers, and Former Mental Patients", i n S o c i a l Forces, D e c, 1958, v o l . 375 number 2 Hamilton, Gordon, "Preface" to Stein and Cloward (eds) Soc i a l Perspectives on Behavior, Free Press, Glencoe, I l l i n o i s , 19F8 Jahoda, Marie, "Toward a So c i a l Psychology of Mental Health", i n Rose, A.M (ed), Mental Health and Mental Disorder, W. W. Norton and Co., Inc., New York, 1955 Kluckhohn, Clyde, and Murray, Henry A . , Personality i n Nature, Society and Culture, Alfred A . Knoff, New York, 1956 Myers, Jerome K and Roberts, Bertam H., Family and Class Dynamics i n Mental I l l n e s s , New York, John Wiley and Sons, London - Chapman & H a i l Ltd., 1959 Rennie, Thomas (MD) and Woodward, Luther E (PHD), Mental  Health i n Modern Society, The Co mmo nw e a 1th Fund, 41, East 57th Ave., New York, 1958 Rubinstein, E.A. and P a r l o f f , M.B. (eds), Research i n Psychotherapy, Proceedings of a conference, Washington, D.C., A p r i l 9-12, 1958, National Publishing Co., Washington, D.C. Schlesinger, Ernest, S o c i a l Casework In The Mental Hospital, Master of S o c i a l Work t h e s i s , University of B r i t i s h Columbia, 1953 Wasser, Edna, "The Caseworker as Research Interviewer i n Follow-Up Studies" i n S o c i a l Casework, Oct. 1957? v o l . x x x v i i i , number 8 102 Young, Pauline V. (PHD), S c i e n t i f i c S o c i a l Surveys And  Research, Prentice and H a l l Inc., Englewood C l i f f s , N .Jo 1956 Annual Reports, Mental Health Services Department, for 1951, 1953, 1958 C l i n i c s of Psychological Medicine Act of B r i t i s h Columbia Po l i c y Manual, P r o v i n c i a l Mental Health Services for P r o v i n c i a l Mental Hospital and Crease C l i n i c 

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