A comparative study of referred and self-referred psychotic patients treated in a veterans administration mental hygiene clinic

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A comparative study of referred and self-referred psychotic patients treated in a veterans administration mental hygiene clinic

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A COMPARATIVE STUDY OF REFERRED AND SELF-REFERRED PSYCHOTIC PATIENTS TREATED IN A VETERANS ADMINISTRATION MENTAL HYGIENE CLINIC

A T h e s is P re s e n te d t o th e F a c u lty o f th e School o f S o c ia l Work The U n iv e r s ity o f S outhern C a lif o r n ia

In P a r t i a l F u lf illm e n t o f th e R equirem ents f o r th e Degree M aster o f S o c ia l Work

by E s th e r Ruth M cCladdie Ju n e 1950

UMI Number: EP66349

All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion.

UMI EP66349 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code

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T h i s thesisj w r i t t e n u n d e r the di r e c t io n o f the candidate's F a c u l t y C o m m i t t e e a n d a p p r o v e d by a l l its m e m b e r s , has been p r e s e n t e d to an d a c c e p t e d by the F a c u l t y of the G r a d u a t e S c h o o l of S o c i a l W o r k in p a r t i a l f u l f i l m e n t o f the r e ­ qu ir em e nt s f o r the d e g r e e of

MASTER OF SOCIAL WORK

Dean

Thesis of

ESTHER. RUTH „MCCIADDIE

Faculty Committee

.... Chairman

TABLE OF CONTENTS CHAPTER I.

PAGE

INTRODUCTION..............................

1

V alue o f th e s t u d y ..................................................... The p ro b lem ........................................................ S tatem en t o f th e p r o b l e m ........................................ D e f in itio n o f term s u s e d ..............................

H.

2 2 2 4

P s y c h o a n a l y s i s ..............................................................

4

P s y c h o s is . .......................................................................

4

Psychotherapy..................................................................

5

R e fe rre d p a t i e n t s .........................................................

5

S e l f - r e f e r r e d p a t i e n t s ............................................

5

REVIEW OF THE LITERATURE................................................

6

L i t e r a t u r e on th e use o f a p s y c h o a n a ly tic m ethod i n t r e a t i n g p s y c h o tic p a t i e n t s . . . .

6

L i t e r a t u r e on tre a tm e n t o f p s y c h o tic p a t i e n t s on an o u tp a tie n t b a s i s ...........................

8

Lack o f l i t e r a t u r e on th e f a c t o r o f r e f e r r a l

H I.

and i t s im p lic a tio n f o r tr e a tm e n t ......................

11

THE SETTING OF THE STUDY.................................................

12

The p r o f e s s io n a l s t a f f .................................................

12 •

T ra in in g program o f th e agency

.....................

14

........................................

14

I n ta k e p ro c e d u re . . . . .

Case a ssig n m e n t..............................

14

C o n s u lta tio n s and tre a tm e n t s t a f f m e e tin g s . •

15

ill CHAFFER IV,

V.

Pj&jE

THE METHOD OF STUDY..............................................................

16

S e le c tio n o f tim e s p a n ................................................

16

S e le c tio n o f c a s e s . . . . . . . . . . . . . .

16

D ata sought and re c o rd in g o f in fo rm a tio n

17

•• .

ANALYSIS OF FINDINGS . . ...................................... . . .

.

19

Source o f r e f e r r a l s ..........................

19

Age d i s t r i b u t i o n o f p a t i e n t s ...................................

19

R acial com position o f p a t i e n t s ....................... ... .

20

Sexual d is tr ib u tio n o f p a t ie n t s ...............................

20

R e lig io u s a f f i l i a t i o n s o f p a t i e n t s .......................

20

M a r ita l s t a t u s o f p a t i e n t s ........................................

20

Background fa m ily c o n s t e l l a t i o n ...............................

21

Employment s t a t u s o f p a t i e n t s ........................... .

.

21

E d u c a tio n a l l e v e l o f p a t i e n t s ....................................

22

B ranch o f m i l i t a r y s e r v i c e ........................................

22

M i l i t a r y ran k o f p a t i e n t s . . . * • ......................

22

L ength o f m i l i t a r y s e r v i c e ........................................

23

Combat e x p e r i e n c e s .........................................................

23

Com pensation re c e iv e d by p a t i e n t s . . . . . . .

23

L ength o f tim e span betw een d is c h a rg e from s e r v ic e and c l i n i c c o n t a c t ...................................

24

P re v io u s p s y c h ia tr ic tre a tm e n t re c e iv e d b y p a t i e n t s .............................................................. • P r e s e n tin g problem s o f p a t i e n t s ...............................



25 25

iv CHAPTER

,'

PAGE

D ia g n o s tic c l a s s i f i c a t i o n o f p a t i e n t s . . . . .

26

L ength o f tim e in tr e a tm e n t........................................

26

R eferred p a tie n ts in treatm ent l e s s th e n t e n h o u r s .........................................................

27

S e l f - r e f e r r e d p a t i e n t s in tr e a tm e n t l e s s th a n t e n h o u r s .........................................................

29

R e fe rre d p a t i e n t s in tre a tm e n t t e n h o u rs and o v e r . ..................................

29

S e l f - r e f e r r e d p a t i e n t s in tre a tm e n t t e n h o u rs and o v e r .........................................................

30

E v a lu a tio n o f th e r a p e u tic r e s u l t s by t h e r a p i s t s ......................................................................

31

VI. CONCLUSIONS AND RECOMMENDATIONS.............................

33

C o n c lu sio n s ....................................................

33

Recommendations f o r f u r t h e r stu d y . . . . . . .

37

BIBLIOGRAPHY.......................................................................................

39

APPENDIX

42

.......................................................................

CHAPTER X INTRODUCTION P s y c h ia tr ic and s o c i a l work tre a tm e n t o f th e psycho­ t i c p a t i e n t h a s been expanded d u rin g th e p a s t t e n y e a r s , w ith emphases on b o th th e p o s s i b i l i t i e s and th e l i m i t a t i o n s o f th e p a t i e n t .

A lthough t h e r e i s in c r e a s in g i n t e r e s t , a s

ev id en c ed by grow ing l i t e r a t u r e on th e s u b j e c t , l i t t l e i n ­ v e s t i g a t i o n h as been made i n t o th e a r e a o f s e l f r e f e r r a l and th e im p lic a tio n t h i s f a c t o r h a s in a c c ep tan ce o f and e x p e c ta ­ t i o n from tre a tm e n t o f p s y c h o tic p a t i e n t s .

S in ce many q ues­

t i o n s have been r a i s e d co n c ern in g o u tp a tie n t tre a tm e n t o f th e p s y c h o tic p a t i e n t , i t was f e l t t h a t a stu d y sh o u ld be made w hich w ould fo c u s on th e f a c t o r o f s e l f - r e f e r r a l and i t s m eaning f o r tr e a tm e n t.

P o in ts w hich have been r a is e d in

p s y c h i a t r i c and s o c i a l work l i t e r a t u r e p ro v id e d and stim u ­ l a t e d i n t e r e s t in making a stu d y w hich m ight le a d t o answ ers o r p o in ts o f view on such q u e s tio n s a s th e s e :

Are th e r e

d if f e r e n c e s in e x te r n a l c h a r a c t e r i s t i c s , p r e s e n tin g problem s o r symptoms between th e r e f e r r e d and s e l f - r e f e r r e d p s y c h o tic p a tie n t?

I s th e p s y c h o tic p a t i e n t a b le t o seek tre a tm e n t on

h i s own i n i t i a t i v e ? sh ip ?

Can he s u s t a i n a th e r a p e u tic r e l a t i o n ­

I s s e l f - r e f e r r a l a f a c t o r w hich makes f o r lo n g e r

th e r a p e u tic r e l a t i o n s h i p s and b e t t e r r e s u l t s th a n a r e found in th e r e f e r r e d p a t i e n t ?

Value o f th e s tu d y .

S in ce i t was found t h a t no sueh

s tu d y had been made i n t h i s agency, i t seemed t h a t i n f o r ­ m atio n d e riv e d would be o f v a lu e i n in c r e a s in g th e g e n e ra l knowledge on t h i s d ia g n o s tic g ro u p , p s y c h o tic p a t i e n t s , and s p e c if ic in fo rm a tio n a s t o th e m eaning o r v a lu e o f s e l f ­ r e f e r r a l a s a f a c t o r in tre a tm e n t would be g a in e d . I.

THE PROBLEM

S tatem en t o f th e problem .

I t was th e purpose o f t h i s

s tu d y t o d e te rm in e , th ro u g h an a n a ly s is o f case re c o rd s and s t a t i s t i c a l f i l e c a rd s , i f t h e r e were c e r t a i n d e fin e d c h a r a c t e r i s t i c s i n s e l f - r e f e r r e d p s y c h o tic p a t i e n t s w hich w ere d i f f e r e n t from th o s e o f r e f e r r e d p s y c h o tic p a t i e n t s , and to d eterm in e i f s e l f - r e f e r r a l was a f a c t o r which made f o r lo n g e r use o f and g r e a t e r improvement from tr e a tm e n t. A p i c t u r e o f t h i s d ia g n o s tic group o f p a t i e n t s w as h e lp f u l in u n d e rsta n d in g th e l i m i t a t i o n s and problem s o f tre a tm e n t f o r t h i s g ro u p .

M enninger h as s e t f o r t h th e

p o p u la r d e s c r ip tio n o f a p s y c h o tic p a t i e n t w here he i s seen a s c ra z y , i r r a t i o n a l , u n p r e d ic ta b le and n o t e n t i r e l y r e s ­ p o n s ib le , p o t e n t i a l l y o r a c t u a l l y dangerous to h im s e lf o r h i s com m unity.1

The p s y c h o lo g ic a l p ic t u r e showed t h a t he

* K a rl M enninger, , "D ia g n o sis and T reatm ent o f S c h iz o p h re n ia ," B u lle tin o f th e .M enninger C l i n i c , 2X1 (May, 1948) , p . 1 0 6 ......

3

was: . . . l a r g e l y s u b je c t to th e p r e s s u r e s o f h i s sub­ j e c t i v e n o n -a d ju s te d demands and cannot a c c e p t a r e a l i t y w hich opposes them and f a l s i f i e s th e p ic tu r e o f th e e x te r n a l w o rld w hich h i s s e n s e s and norm al th in k in g o f f e r him ; i t i s e a s i e r f o r him t o r e li n q u i s h h i s con­ t a c t s w ith r e a l i t y th a n to c o n tr o l h i s own em o tio n s, an d , a s a r e s u l t , he s o lv e s h i s in n e r c o n f l i c t s by changing th e p i c t u r e o f r e a l i t y in accordance w ith h i s s u b je c tiv e dem ands.2 A lexander h as s a id t h a t : The p r e c i p i t a t i n g c a u se s o f p sy ch o ses belo n g to ad o le sc e n c e o r a d u lt l i f e . In h i s f l i g h t from th e con­ f l i c t s o f a d u lt l i f e , th e p s y c h o tic r e v e r t s t o a v e ry e a r l y p e r io d when he was n o t y e t a b le t o d is t in g u i s h between p h a n ta s y and r e a l i t y , and i t i s p r e c i s e l y t h i s d ep th o f r e g r e s s io n w hich i s c h a r a c t e r i s t i c o f p sy ­ c h o s e s .3 Froram-Reichman m a in ta in s t h a t i n th e approach t o t h e psycho­ t i c p a t i e n t , i t h o ld s t r u e t h a t th e damage done t o him in e a r l y l i f e can n o t be undone by t h e r a p e u t i c a l l y m an u factu red u n lim ite d ac c e p ta n c e i n l a t e r l i f e b u t o n ly by u n d e rsta n d in g 4 o f and i n s i g h t in t o th e n a tu r e o f th e e a r l y trau m a. A lexander s t a t e s t h a t tre a tm e n t sh o u ld be fo c u se d on s tre n g th e n in g and s u p p o rtin g th e ego t o r e a l i t y r a t h e r th a n t o uncover c o n f l i c t s , remove r e p r e s s io n s o r t o g iv e much

^ F ranz A lex an d er, M.D. . The M edical V alue o f Psycho­ a n a ly s is (Hew York: W• W. N orton and Company, I n c . , 1 9 3 6 ), p p . 116-17. 3 i b i a . . p. 127. F rie d a Fromm-Reiohman, "N otes on th e Development o f T reatm ent o f S c h iz o p h re n ic s by P s y c h o a n a ly tic P s y c h o th e ra p y ,H P s y c h ia tr y . XI (A ugust. 1 9 4 8 ), p . 266.

in s ig h t .5

T hree b a s ie c h a r a c t e r i s t i c s o f th e p s y c h o tic p a t i e n t have been o u tlin e d by L evine a s fo llo w s ; 1.

H is d is tu rb a n c e i s o f a m ajo r p o r tio n o f h i s p e r ­ s o n a lity .

2.

He d i s t o r t s r e a l i t y s e r io u s ly (w ith such pheno­ mena a s h a l l u c i n a t i o n s , o r d e lu s io n s , s e r io u s memory d e f e c ts o r judgment d e f e c ts , o r d i s ­ o rie n ta tio n ).

3.

He f r e q u e n tly h a s l i t t l e o r no in s ig h t in to th e f a c t o f h i s b e in g s i c k . 6 II.

DEFINITION OF TERMS USED

P s y c h o a n a ly s is .

The method o f e l i c i t i n g from n erv o u s

p a t i e n t s an id e a o f t h e i r p a s t em o tio n al e x p e rie n c e s and th e f a c t s o f t h e i r m en tal l i f e , in o rd e r t o d is c o v e r th e me­ chanism by w hich a p a th o lo g ic m e n ta l s t a t e h a s been p ro d u ced , and to f u r n i s h h i n t s f o r p s y c h o th e ra p e u tic p ro c e d u re s. 7 P s y c h o s is .

A d e e p -re a c h in g m en tal d is tu rb a n c e w hich

h a s e i t h e r an o rg a n ic b a s i s from p o is o n s , a lc o h o l, s y p h i l i s , i n j u r i e s to th e b r a in o r abnorm al g ro w th s, o r a f u n c tio n a l 5

A lex an d er, o p . c i t . , p . 117.

6 M aurice L e v in e , M .D ., P sy ch o th erap y in M edical P r a c ti c e (New York: The M acm illan Company, 19 4 2 ), p . 2 u l . 7 W. A. N. B o rlan d , M .B ., The American I l l u s t r a t e d M edical D ic tio n a ry (P h ila d e lp h ia ? W. B. S aunders Company, 1938).

b a s i s w here th e b r a in i s norm al b u t where t h e r e a re em otion a l m a la d ju stm e n ts, b e h a v io r d is o r d e r s and u n s u c c e s s fu l a tte m p ts to so lv e lif e - p r o b le m s . © P sy c h o th e ra p y .

A term used to i n d i c a t e a l l m ethods

o f m en tal t r a i n i n g and m e n ta l h e a lin g d e sig n e d t o r e l i e v e th o s e v ic tim s o f f u n c tio n a l n erv o u s d is tu rb a n c e s and de­ f e c t i v e m en tal c o n tr o l commonly d iag n o sed a s p s y c h o s th e n ia s n e u r a s th e n ia s , h y s t e r i a s and p sy c h o se s; i t in c lu d e s a l l s c i e n t i f i c m ethods o f m en tal m e d ic in e , such a s s u g g e s tio n , 9 d iv e r s io n , re e d u c a tio n and em o tio n al a n a l y s i s . R e fe rre d p a t i e n t s .

T h is term was used t o mean

p a t i e n t s who were a d v ise d o r recommended to th e c l i n i c f o r h e lp w ith t h e i r i l l n e s s and problem s* S e lf - r e f e r r e d p a tie n ts .

T h is term was d e fin e d t©

mean th o s e p a t i e n t s who sought tre a tm e n t on t h e i r own i n i ­ tia tiv e .

8 A rth u r P . Noyes, M .D ., Modern C l i n i c a l P s y c h ia try ( P h ila d e lp h ia : W. B. S aunders Company, 1 9 3 9 ), p . S45. - W illiam S. S a d le r , M .B .. Modern P s y c h ia tr y ( S t . L o u is: The C. W Mosby Company, 1945) , p . 620.

REVIW OF THE LITERATURE Many q u e s tio n s e x i s t i n th e m ed ical p r o f e s s io n con­ c e rn in g th e tre a tm e n t o f p s y c h o tic p a t i e n t s .

T hree o f th e

q u e s tio n s w ere e x p lo re d b r i e f l y in re v ie w in g th e l i t e r a t u r e s in c e th e y were r e l a t e d to t h i s s tu d y . L i t e r a t u r e on th e use o f a p s y c h o a n a ly tic m ethod i n t r e a t i n g p s y c h o tic p a t i e n t s .

The f i r s t q u e s tio n i s con­

c e rn e d w ith th e a d v i s a b i l i t y o f and s u i t a b i l i t y f o r t r e a t ­ ment o f th e p s y c h o tic p a t i e n t by a p s y c h o a n a ly tic m ethod. B eginning w ith Sigmund F reud who r e p e a te d ly s a id t h a t psy­ c h o tic p a t i e n t s w ere n o t s u i t a b l e f o r p s y c h o a n a ly tic th e r a p y , th e o r y .

many p s y c h i a t r i c s have a c c e p te d and fo llo w e d h i s I t was fo u n d , on re v ie w in g p s y c h i a t r i c l i t e r a t u r e ,

t h a t th e m a jo r ity o f w r i t i n g h a s been done on s c h iz o p h re n ic p a t i e n t s s in c e t h i s i l l n e s s i s th e m ost fre q u e n t o f th e m ajo r p sy c h o se s.* ^

A ccording to Fromm-Reichman, th e r e ­

lu c ta n c e t o ap p ly p s y c h o a n a ly tic knowledge and te c h n iq u e t o

P au l F ed ern , M .D ., " P r in c ip le s o f P sy ch o th era p y in L a te n t S c h iz o p h re n ia ," American J o u rn a l o f P sy c h o th e ra p y , I (A p r il, 1 947), p . 129. ^ J* F . Brown, P h .D .. The Psychodynam ics o f Abnormal B ehavior (New York: M cGraw-Hill Book Company, i n c . , 1940), p . 318.

th e p sy ch o ses stem s from F re u d 9s p ap e r on n a r c is s is m whieh im p lie s t h a t th e s c h iz o p h re n ic i s in c a p a b le o f e s ta b l is h i n g 12 a w orking r e l a t i o n s h i p w ith th e p s y c h o a n a ly s t. A more d is tu r b in g th e o r y , w hich i s s u b s t a n ti a t e d , i s t h a t psycho­ a n a l y t i c th e ra p y may p r e c i p i t a t e s c h iz o p h re n ic e p is o d e s in c a s e s where s c h iz o p h re n ia h a s n o t been d iag n o sed and i t i s f o r t h i s re a s o n t h a t m ost a n a ly s ts have a g re e d t h a t th e y found i t n e c e s s a ry t o change t h e i r te c h n iq u e in w orking w ith t h i s group o f p a t i e n t s .

is

L ip to n fo u n d , in re v ie w in g th e w orks o f many psycho­ t h e r a p i s t s who s p e c ia li z e in w orking w ith sc h iz o p h re n ic p a t i e n t s , t h a t in m ost o f th e c a s e s re p o r te d by th e s e t h e r a ­ p i s t s th e p s y c h o th e ra p e u tic in te rv ie w s w ere r e s p o n s ib le f o r im provem ent. 14 He p o in te d o u t, how ever, t h e i r d isag reem en t re g a rd in g th e le n g th o f tim e re q u ir e d f o r tr e a tm e n t, th e m ethods t o be em ployed, th e m a te r ia l w hich i s d is c u s s e d and th e s e t t i n g where tre a tm e n t i s g iv e n .

From th e s e v a r io u s

p o in ts o f view and from th e ac cep tan ce o f p s y c h o tic p a t i e n t s f o r tr e a tm e n t, th e r e seemed to be a movement tow ard a is M Fromm-Beichman, o p . e i t . , p . 263. is

JLLexander, o p. e i t . , p . 113.

Samuel D. L ip to n , M*D., "Some Com parisons o f Psy­ c h o th e ra p e u tic M ethods i n S c h iz o p h re n ia ,19 The P s y c h ia tr ic q u a r t e r l y . XXXII (O cto b er, 1949), p . 705.

d e c is io n t h a t p s y c h o tic p a t i e n t s may d e riv e some b e n e f it from p s y c h o a n a ly tic p sy c h o th e ra p y b u t t h a t th e method o f tre a tm e n t m ust be a l t e r e d a c c o rd in g to th e p a t i e n t 's n eed s and lim ita tio n s * L i t e r a t u r e on tre a tm e n t o f p s y c h o tic p a t i e n t s on an o u tp a tle n t b a s ls *

A second q u e s tio n o f th e m ed ical p r o f e s ­

s io n i s w h eth er p s y c h o th e ra p e u tic tre a tm e n t sh o u ld be g iv e n on an o u tp a tie n t b a s i s .

I f cm a B r i t i s h p o in t o f view ,

A llis o n s t a t e d t h a t " i t i s p ro b a b ly b e s t t o le a v e th e ana­ l y t i c a l tre a tm e n t a t l e a s t o f th e more advanced p s y c h o tic s 15 to th o s e w orking i n i n s t i t u t i o n s . " M enninger e x p re sse d th e o p in io n t h a t : . . . w h ile tre a tm e n t o f s c h iz o p h re n ia o f te n r e q u ir e s i n s t i t u t i o n a l i z a t i o n , more o f te n i t r e q u ir e s f in d in g an environm ent o u ts id e o f an i n s t i t u t i o n and home where th e p a t i e n t can s u c c e s s f u lly ad a p t h i m s e l f .16 Rosen, n o te d f o r h i s d i r e c t work w ith d e t e r io r a te d s c h iz o ­ p h re n ic p a t i e n t s , w h ile o f te n d iv id in g h i s tre a tm e n t betw een i n p a t i e n t and o u t p a t i e n t c a r e , s t a t e d t h a t : The r e s o l u t i o n o f th e p s y c h o s is ta k e s p la c e much more r a p id l y ( in a r e g u la te d environm ent) o u ts id e an i n s t i ­ t u t i o n b ecau se th e amount and c h a r a c te r o f d i s t r a c t i o n s

15 B. Rhodes A llis o n , M .D ., and R. G. Gordon, M .D ., P sy c h o th e ra p y . I t s Uses and L im ita tio n s (London: O xford d i v e r s i t y P r e s s , 19 4 8), p . 9 6 . 16 M enninger, o£. c i t . , p . 106.

9

can be c o m p le te ly c o n tr o lle d .

17

Some c a u tio n i s n ee d ed , how ever, in e v a lu a tin g th e p o s s i­ b i l i t y and s u i t a b i l i t y o f o u t p a ti e n t tre a tm e n t f o r th e sc h iz o p h re n ic p a t i e n t , a c c o rd in g t o Hughes, who f e l t t h a t th e p a t i e n t sh o u ld have p a r t i a l i n s i g h t and m ust n o t be to o 1® u n p re d ic ta b ly a g g r e s s iv e . I t sh o u ld be n o te d t h a t view s so f a r p re s e n te d were th o s e o f m e d ic a l p r a c t i t i o n e r s w hich was u n d e rsta n d a b le s in c e th e b u lk o f p s y c h o a n a ly tic th e ra p y h as been g iv en by m ed ical p e rs o n n e l, and where no n -m ed ical p r a c t i t i o n e r s en­ gage in t h i s p r a c t i c e , th e y a r e o f te n r e s p o n s ib le t o a m ed ical d i r e c t o r .

However, sin c e p s y c h i a t r i c s o c i a l w orkers

a ls o t r e a t th e s e p a t i e n t s in p s y c h ia tr ic c l i n i c ^ , nonm ed ical o p in io n s need to be added to th o s e o f th e m ed ical p r o f e s s io n i n e v a lu a tin g p sy c h o th e ra p y w ith p s y c h o tic p a tie n ts .

P s y c h ia tr ic s o c i a l w orkers R e ic h lin e and S k in n er

i h t h i s agency, The M ental Hygiene C l in ic , i n d is c u s s in g th e r o l e o f th e s o c i a l w orker p o in te d o u t t h a t : The s o c i a l w o rk e r9s background e q u ip s him to work b e t t e r w ith c e r t a i n k in d s o f p a t i e n t s , depending on t h e i r ego s t r u c t u r e s , such a s sim ple am b u lato ry , non­ h a l l u c i n a t i n g s c h iz o p h r e n ic 9s overwhelm ing superego ^ John N. Ho s e n , M .D ., "The T reatm ent o f S chizo­ p h re n ic P sy c h o sis by Dir e c t t e a l y t i c T h e ra p y .99 The Psy­ c h i a t r i c q u a r t e r l y . XXI (Ja n u a ry , 1 9 4 7 ), p . 35. Jo sep h Hughes, M .D ., and B lain e S . M cLaughlin, M .D ., " P s y c h ia tr ic T reatm ent o f th e V eteran O u tp a tie n t," American J o u rn a l o f P s y c h ia tr y , CIV (M arch, 1 9 4 8 ).

10

d is o r d e r s and th e p a s s iv e -d e p e n d e n t.

19

They a ls o p o in te d o u t th e aim o f th e ra p y a s a s s i s t i n g th e p a t i e n t i n g ra p p lin g w ith r e a l i t y r a t h e r th a n t o o b ta in i n ­ s ig h t i n t o u n co n scio u s m o tiv e s. M o th e r such agency, th e B altim o re B eg io n al O ffic e o f V e te ra n s A d m in is tra tio n , h a s f o r o v er two y e a rs used p sy­ c h i a t r i c s o c i a l w o rk ers in g iv in g o u tp a tie n t tre a tm e n t to p s y c h o tic v e te r a n s .

T h e ir f e e l in g i s t h a t r e - h o s p i t a l i z a ­

t i o n f o r th e s e p a t i e n t s h a s been p re v e n te d , a ls o t h a t t h e r e was a g a in in e g o - s tr e n g th o f p a t i e n t s w h ile in such t r e a t ­ m ent.

T h e ir t h e s i s i s t h a t p re v e n tiv e and am bulatory

tre a tm e n t i n o u tp a tie n t m e n ta l hygiene c l i n i c s i s d e s ir a b le f o r p s y c h o tic v e te r a n s from a s o c i a l a s w e ll a s an economic v ie w p o in t.2® A r e c e n t p u b lic a tio n su b m itte d on t h i s q u e s tio n from a p s y c h i a t r i s t and p s y c h ia tr ic s o c i a l w orker s u p p o rts th e th e o r y t h a t "casew ork s e r v ic e s can o n ly be h e lp f u l t o th e am b u lato ry s c h iz o p h re n ic who i s ab l8 to m a in ta in some mar­ g in a l a d ju s tm e n t, and i s n e i t h e r a danger t o h im s e lf o r to

19 jp k iiip b . B e ic h lin e and John S k in n e r, "The Bole o f th e P s y c h ia tr ic S o c ia l Worker in a V ete ran s Adminis­ t r a t i o n M ental H ygiene C l i n i c ," J o u rn a l o f P s y c h ia tr ic S o c ia l Work. XIX (Autumn, 1949) , p . 64. B u rt Nussbaum, M .D ., and S o l C haren, M .A ., "O ut­ p a t i e n t T reatm ent o f P re -P s y c h o tic and P o s t- P s y c h o tic . V e te ra n s in a M ental Hygiene C l i n i c ," The P s y c h ia tr ic Q u a r te r ly . XX ( J u ly , 19 4 8 ), p . 517.

11

th e community.

21

T h is d is c u s s io n p o in te d up m ed ical and

n o n -m ed ical o p in io n s t h a t some p s y c h o tic p a t i e n t s sh o u ld be t r e a t e d on an o u tp a tie n t b a s i s . Lack o f l i t e r a t u r e on th e f a c t o r o f r e f e r r a l and i t s im p lic a tio n f o r tre a tm e n t .

A t h i r d q u e s tio n o f n o t o n ly th e

m e d ic a l p r o fe s s io n b u t a ls o o f th e f i e l d o f s o c ia l w ork, i s w hether th e p e rso n who comes on h i s own i n i t i a t i v e t o t r e a t ­ ment i s d i f f e r e n t from th e r e f e r r e d p e rso n i n h i s d e s ir e and c a p a c ity f o r h e lp and in h i s a b i l i t y t o make more e f f e c t i v e use o f s e r v ic e b ecau se o f t h e f a c t o r o f s e l f - r e f e r r a l .

It

would seem t h a t th e p e rso n who i s s e l f - r e f e r r e d f o r t r e a t ­ ment h as more s tr e n g th and d e s i r e f o r change w hich may make him zoor e A ccepting o f tre a tm e n t th a n th e r e f e r r e d p e rso n and w i l l , t h u s , u s u a lly d e riv e more b e n e f it from th e r e l a t i o n ­ s h ip .

A lthough t h i s i s a co n cep t t h a t i s h e a rd and s t a t e d

in d is c u s s io n , a rev iew o f p s y c h i a tr i c and s o c i a l work l i t e r a t u r e f a i l e d t o d is c l o s e any d e f i n i t i v e sta te m e n t o f t h i s assu m p tio n .

R obert L. S t u b b le f i e l d , M .D ., and A rth u r Mandlebaum, M .S.W ., "Casework T reatm ent w ith th e A m bulatory S ch iz o p h re n ic P a t i e n t , H J o u rn a l o f P s y c h ia tr ic S o c ia l Work . XIX (W in ter, 1 950), p . 92.

CHAPTER I H THE SETTING OF THE STUDY T h is s tu d y was made a t th e M ental H ygiene C lin ic o f th e R eg io n al O f f ic e , V e te ra n s A d m in is tra tio n , Los A n g eles, C a l i f o r n i a , w hich c l i n i c was th e f i r s t o f i t s k in d in t h i s n a t i o n a l o rg a n iz a tio n *

I t opened f o r s e r v ic e in Ju n e , 1945*

T h is agency h a s been d e fin e d a s : « • • an o u tp a tie n t c l i n i c f o r tre a tm e n t o f th e s e rv ic e -c o n n e c te d em o tio n al c a s u a l t i e s o f World War II* I t s p u rp o ses a re t o p ro v id e e a r l y tre a tm e n t w h ile th e r e a r e elem en ts o f a n x ie ty p re s e n t and th e symptoms a re r e v e r s i b l e , and b e f o re th e a n x ie ty becomes to o w e ll c h a n n e liz e d in to som atic symptoms w ith to o much s e ­ condary g a in s and i n t r a e t i b l l l t y , and when p sy ch o th erap y i s l i k e l y to be m ost e f f e c t i v e ; to guide th e se v e re m e n ta lly i l l in to s u it a b le v o c a tio n s and a v o c a tio n s ; and to a l l e v i a t e p r e s s u r e s from t h e i r environm ent and in t h i s way p re v e n t r e p e t i t i v e and p ro lo n g ed h o s p i t a l i ­ z a t i o n s . 22 The g o a l o f th e agency h as been: • * • to a s s i s t th e in d iv id u a l th ro u g h p sy c h o th e ra p y t o make th o s e v o c a tio n a l and en v iro n m en tal m a n ip u la tio n s w hich would h e lp him t o a c h ie v e a d egree o f p e rso n a l* s o c i a l and economic a d ju stm e n ts to th e f u l l e s t c a p a c ity o f h i s ego s t r e n g t h s .23 The p r o f e s s io n a l s ta f f *

At th e tim e th e c a s e s

S . F u tterm an , M.D*, F . J . K irk n e r, and M. M. M eyer, P h .D ., " F i r s t Year A n a ly sis o f V e te ra n s T re a te d in a M ental Hygiene C lin ic o f th e V e te ra n s A d m in is tr a tio n ," American J o u rn a l o f P s y c h ia tr y . CIV (November, 1 9 4 7 ), p . 298. 23 Loo. c i t .

13

s e le c te d f o r t h i s s tu d y w ere a c ti v e , Ja n u a ry 1 , 1948 th ro u g h Septem ber 30, 1949, th e p r o f e s s io n a l s t a f f o f th e c l i n i c was composed o f f iv e f u l l - t i m e and tw elv e p a r t- tim e p sy c h ia ­ t r i s t s , s i x c o n s u ltin g p s y c h i a t r i s t s and p s y c h o a n a ly s ts , f o u r f u l l - t i m e and s i x a tte n d in g p s y c h o lo g is ts , and n in e f u l l - t i m e p s y c h i a t r i c s o c i a l w orkers*

D octor Samuel

P utterm an was th e D ir e c to r o f th e c l i n i c .

Q u a l if i c a ti o n s

f o r t h e p r o f e s s io n a l d i s c i p l i n e v a ry ; how ever, s ta n d a rd s a re s e t by th e V e te ra n s A d m in is tra tio n in acco rd an ce w ith p ro ­ f e s s i o n a l re q u ire m e n ts .

P s y c h i a t r i s t s m ust m eet b a s ic

q u a l i f i c a t i o n s f o r ap p ointm ent a s d o c to rs i n th e departm ent o f m ed icin e and s u rg e ry , m ust be a D iplom ate o f th e American Board o f P s y c h ia tr y and N eurology o r re a d y t o ta k e th e ex a m in atio n , and m ust be e x p e rie n c e d in tre a tm e n t o f th e p sy ch o n eu ro ses and a l l i e d c o n d itio n s and have a w orking knowledge o f modern te c h n iq u e s .

P s y c h o lo g is ts m ust h o ld a

d o c to r a te o f p h ilo so p h y d eg ree in psychology and have had two y e a rs o f c l i n i c a l e x p e rie n c e .

The p s y c h i a t r i c s o c i a l

w orker m ust have had two y e a rs o f g ra d u a te work in an a c c r e d ite d sch o o l and one y e a r 's e x p e rie n c e in a h e a lth o r w e lfa re agency o f a c c e p ta b le s ta n d a r d s .

The S t a f f i s

p s y e h o a n a ly tie a lly o r ie n te d and th e m a jo r ity o f th e members have undergone p e r s o n a l a n a l y s i s , a lth o u g h t h i s i s n o t a re q u irem en t f o r employment*

The method o f tre a tm e n t i s

b r i e f p sy c h o th e ra p y ; p s y c h o a n a ly s is i s n o t p r a c t ic e d becau se

14

o f t h e s t r u c t u r e and f u n c tio n ©f th e agency*

W hile th e

agency h a s been d e fin e d a s a tre a tm e n t c e n te r p r im a r ily , some d ia g n o s tic s e rv ic e i s g iv en and r e f e r r a l s a re made t o h o s p ita ls , p s y c h ia tric c lin ic s o r p riv a te p s y c h ia tr is ts , p u b lic and p r iv a te s o e i a l ag en cies* T ra in in g program o f th e ag en cy * The M ental Hygiene C lin ic a ls o s e rv e s a s a t r a i n i n g c e n te r f o r th e th r e e d i s ­ c i p l i n e s , t r a i n i n g p s y c h i a t r i s t s , psy ch o lo g y t r a i n e e s and s o c i a l work s tu d e n ts .

At th e tim e span s tu d ie d , f o u r r e s i ­

d en t p s y c h i a t r i s t s , s i x psy ch o lo g y t r a i n e e s and f iv e p s y c h i a t r i c s o e i a l work s tu d e n ts w ere i n tr a in in g * In ta k e p ro c e d u re * The a p p lic a n t f o r tre a tm e n t makes an appointm ent f o r an i n i t i a l in te r v ie w w ith th e s o c ia l w orker th ro u g h th e c l i n i c r e c e p t i o n i s t .

He i s th e n seen f o r

one o r more i n i t i a l in te rv ie w s w hich a re used: • • • to se c u re a dynamic h i s t o r y o f th e developm ent o f th e p a t i e n t 9s em o tio n al p ro b lem s, t o e s tim a te h i s a t t i t u d e s tow ard tr e a tm e n t, and t o e v a lu a te h i s s u i t ­ a b i l i t y f o r p s y c h o th e ra p y .24 Case a ssig n m e n t* The in ta k e p ic t u r e i s p re s e n te d t o th e g e n e ra l s t a f f a t a w eekly assignm ent s t a f f where i t i s d is c u s s e d and assignm ent i s made by a p r e s id in g p s y c h i a t r i s t t o a t h e r a p i s t a c c o rd in g t o th e problem s and n eeds o f th e

24 R e ic h lin e and S k in n e r, o £. e i t * , p . 63.

15

p a t i e n t and th e fu n c tio n and s e r v ic e o f th e p r o f e s s io n a l d is c ip lin e . C o n s u lta tio n s and tre a tm e n t s t a f f m e e tin g s .

Con­

s u l t a t i o n s a r e an i n t e g r a l p a r t o f th e c l i n i c a l p ro c e d u re ; each s t a f f member i s e x p e c te d t o use th e s e r v ic e s o f o th e r members o f any d i s c i p l i n e f o r a s s is ta n c e i n d ia g n o s is o r tr e a tm e n t.

T h is i s a ls o a method o f in t e r - e d u c a t i o n a l a c t i ­

v i t y s in c e , in th e s e w orking r e l a t i o n s h i p s , in fo rm a tio n and i n s i g h t i s g ain ed a s t o t h e f u n c tio n , s e r v ic e s and s k i l l s o f each d i s c i p l i n e .

T reatm ent S t a f f m e e tin g s h e ld w eekly are

used a s a mass c o n s u l ta t io n where a c a se i s review ed by a t h e r a p i s t and o p in io n s and recom m endations a re g iv en by th e s t a f f a s t o f u r t h e r tre a tm e n t o r c lo s u re o f th e c a s e .

THE METHOD OF STUDY

S e le c tio n o f tim e sp a n .

The i n i t i a l t a s k was to

d e te rm in e a tim e span to he u se d .

I t seemed d e s ir a b le t o

use a r e c e n t p e r io d inasm uch a s th e r e w ere more s e l f r e f e r r a l s i n t h i s p e rio d th a n in e a r l i e r y e a r s , a c c o rd in g t o c lin ic a l s ta tis tic s .

A p r e lim in a r y check th ro u g h th e s t a ­

t i s t i c a l f i l e o f th e agency r e v e a le d t h a t th e r e w ere a s u f f i c i e n t number o f s e l f - r e f e r r e d p s y c h o tic p a t i e n t s i n th e t o t a l c l i n i c in ta k e o f 1 ,3 6 3 c a s e s i n th e p e r io d , Ja n u a ry 1 , A 1948 th ro u g h Septem ber 30, 1949, to w a rra n t making such a s tu d y .

S in ce th e s tu d y was t o be concerned w ith ca se

m a t e r i a l a s w e ll a s w ith s t a t i s t i c a l d a ta , th e number o f t o t a l e a s e s i n each g ro u p , r e f e r r e d and s e l f - r e f e r r e d , was l i m i t e d to tw e n ty . S e le c tio n o f c a s e s .

O ases f o r th e stu d y were chosen

r o u t i n e l y from th e f i l e c a rd s o f th e p e rio d s e le c te d i f th e y met th e re q u ire m e n ts o f so u rce o f r e f e r r a l and d ia g n o s is o f p s y c h o s is .

T here was an i n t e r e s t in g e tt i n g c a s e s which

s u s ta in e d a tre a tm e n t p e rio d o f te n in te rv ie w s and o v er in o rd e r t h a t th e r e s u l t s o f tre a tm e n t co u ld be b e t t e r e v a lu ­ a te d .

T h is i n t e r e s t was s a c r i f i c e d when i t was found t h a t

a la r g e number o f p s y c h o tic p a t i e n t s , b o th r e f e r r e d and s e l f - r e f e r r e d , came i n f o r a l i m i t e d number o f in te rv ie w s

17

and some n e i t h e r e s t a b l i s h e d a t h e r a p e u tic r e l a t i o n s h i p n o r became engaged i n tre a tm e n t*

I t was found t h a t a t l e a s t

th r e e p a t i e n t s from each group s u s ta in e d a t h e r a p e u t ic r e „ l a t io n s h ip o v er t e n h o u rs w hich en ab led th e w r i t e r to s e l e c t two c a s e s from e a c h group f o r c a se study*

One case

from th e r e f e r r e d g ro u p was s e le c te d w hich showed im prove­ ment i n a p a t i e n t who came to tre a tm e n t f o r o n ly n in e h o u rs and showed im provem ent; th e e a se o f a s e l f - r e f e r r e d p a t i e n t who was in tr e a tm e n t te n h o u rs and im proved was a ls o se ­ l e c t e d f o r study*

A second e a se from each group was se ­

l e c t e d w hich showed unimprovement in p a t i e n t s a f t e r th e y had been i n tre a tm e n t f o r o v e r t h i r t y - f o u r hours* B ata so u g h t and re c o rd in g o f In fo rm a tio n *

B efore

a tte m p tin g a com prehensive ex am in atio n o f th e s t a t i s t i c a l f i l e c a rd s and c a se re c o r d s , a sch ed u le was p re p a re d o f th e fo llo w in g ite m s to be so u g h t: A.

E x te rn a l C h a r a c t e r i s t i c s Age d i s t r i b u t i o n o f p a t i e n t s R a c ia l com position S ex u al d i s t r i b u t i o n R e lig io u s a f f i l i a t i o n s M a r ita l s t a t u s Background fa m ily c o n s t e l l a t i o n Jkaployment s t a t u s E d u c a tio n a l l e v e l

18

B.

M i l i t a r y and P o s t- S e rv ic e E x p e rie n c e s Branch o f m i l i t a r y s e rv ic e M i l i t a r y ran k le n g th o f m i l i t a r y s e rv ic e Combat e x p e rie n c e s Com pensation re c e iv e d P re v io u s p s y c h i a t r i c tre a tm e n t le n g th o f tim e span betw een m i l i t a r y d isc h a rg e and c l i n i c in ta k e

C.

C l i n i c a l T reatm ent and R e s u lts P re s e n tin g problem s o f p a t i e n t s D ia g n o s tic c l a s s i f i c a t i o n le n g th o f tim e in tre a tm e n t E v a lu a tio n o f th e r a p e u tic r e s u l t s

S t a t i s t i c a l c a rd s and c a se h i s t o r i e s were th e n ex­ amined and in fo rm a tio n was re c o rd e d on in d iv id u a l c a rd s f o r each e a s e , l a t e r b ein g tra n s fo rm e d in to t a b l e s f o r each item w hich w ere used f o r a co m p arativ e a n a ly s is o f th e two g ro u p s o f p a tie n ts .

CHAPTER V

ANALYSIS OF FINDINGS i

In a n a ly z in g th e d a ta com piled from th e s t a t i s t i c a l f i l e c a rd s and c a se re c o rd s o f th e two gro u p s o f p s y c h o tic p a t i e n t s , many p a r a l l e l s were found w hich in d ic a te d t h a t th e r e were r e l a t i v e l y few d if f e r e n c e s betw een th e two gro u p s in any o f th e e x t e r n a l c h a r a c t e r i s t i c s s tu d ie d o r from th e r e s u l t s o f tr e a tm e n t. Source o f r e f e r r a l s .

The tw e n ty r e f e r r e d p a t i e n t s

s tu d ie d w ere d i r e c te d t o th e c l i n i c by n in e d i f f e r e n t s o u rc e s .

F i f t e e n p a t i e n t s w ere r e f e r r e d from o th e r d e p a r t­

m ents o f V e te ra n s A d m in is tra tio n ; seven p a t i e n t s b ein g r e ­ f e r r e d by th e R eg io n al O ffic e S o c ia l S e rv ic e D epartm ent, fo u r p a t i e n t s w ere r e f e r r e d from N e u ro p s y c h ia tric H o s p ita ls , two p a t i e n t s w ere r e f e r r e d from th e M ed ical O u tp a tie n t De­ p artm en t o f th e R eg io n al O f f ic e , one p a t i e n t was r e f e r r e d by h i s t r a i n i n g o f f i c e r , and th e o th e r p a t i e n t was r e f e r r e d by th e V o c a tio n a l Guidance D epartm ent o f th e R eg io n al O f f ic e . Two p a t i e n t s w ere r e f e r r e d by th e American Red C ro ss, one p a t i e n t was r e f e r r e d by a p r i v a t e p h y s ic ia n and th e rem ain­ in g p a t i e n t was r e f e r r e d to th e c l i n i c b y ^ h is w ife . Age d i s t r i b u t i o n o f p a t i e n t s .

I t was found t h a t

tw elv e o f th e tw en ty r e f e r r e d p a t i e n t s w ere under t h i r t y -

f i v e y e a rs o f a g e , w h ile f i f t e e n o f th e tw en ty s e l f - r e f e r r e d p a t i e n t s w ere un d er t h i s a g e .

The rem ain in g f i r e s e l f ­

r e f e r r e d p a t i e n t s w ere o r e r t h i r t y - f i r e y e a rs o f a g e , w h ile o n ly two o f th e r e f e r r e d p a t i e n t s w ere o r e r t h i r t y - f i r e , w ith s i x p a t i e n t s u n d er tw e n ty - f ir e y e a rs o f a g e .

I t would

seem t h a t th e s e l f - r e f e r r e d p a t i e n t te n d e d t o he o l d e r th a n th e r e f e r r e d p a t i e n t . B a e ia l co m p o sition o f p a t i e n t s .

No r a c i a l d i f f e r ­

en ces were fo u n d betw een th e two g ro u p s o f p a t i e n t s ; e i g h t ­ een p a t i e n t s in each group w ere w h ite s , w ith one Negro and one M exican p a t i e n t i n th e r e f e r r e d group and two N egroes in th e s e l f - r e f e r r e d g ro u p . S exual d i s t r i b u t i o n o f p a t i e n t s .

There was no d i f ­

fe re n c e i n th e se x u a l d i s t r i b u t i o n i n e i t h e r g ro u p ; each group was composed o f n in e te e n m ales and one fe m a le . R e lig io u s a f f i l i a t i o n s o f p a t i e n t s .

Of th e r e f e r r e d

group o f p a t i e n t s , f i v e w ere C a th o lic s , e ig h t were P ro ­ t e s t a n t s , f o u r w ere Jew ish and th r e e were unknown; i n th e s e l f - r e f e r r e d group f o u r w ere C a th o lic s , n in e , P r o t e s t a n t s , o n e , Jew ish and s i x w ere unknown. M a r ita l s t a t u s o f p a t i e n t s .

There were l i t t l e d i f ­

fe re n c e s i n th e two g roups o f p a t i e n t s i n t h i s a r e a .

Nine

o f each group w ere m a rrie d , one o f each group was d iv o rc e d ;

21

t e n o f th e r e f e r r e d p a t i e n t s were s i n g l e , w h ile e ig h t o f th e s e l f - r e f e r r e d group w ere s i n g l e ; th e rem ain in g s e l f ­ r e f e r r e d p a t i e n t was s e p a ra te d from h i s w if e .

These r e s u l t s

seem to ln d ie a to t h a t m a r i t a l s t a t u s was n o t a s i g n i f i c a n t f a c t o r in e n te r in g tre a tm e n t s in c e th e p ro p o rtio n o f m a rrie d t o s in g le v e te r a n s was alm ost e