Relatives’ reactions to accepting responsibility for consenting to shock therapy as revealed in social casework interviews

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RELATIVES’ REACTIONS TO ACCEPTING RESPONSIBILITY FOR CONSENTING TO SHOCK THERAPY AS REVEALED IN SOCIAL CASEWORK INTERVIEWS

A Thesis Presented to The Faculty of the Graduate School of Social Work The University of Southern California

In Partial Fulfillment of the Requirements for the Degree Master of Social Ifork

ky John R. Bean June 1950

UMI Number: EP66321

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T h is thesis, w r i t t e n u n d e r the d ir e c t io n o f the c a n d id a te ’s F a c u l t y

C o m m itt e e a n d a p p r o v e d

hy a l l its m e m b e rs, has been p re s e n te d to a n d a c c e p te d by the F a c u l t y o f the G r a d u a t e S c h o o l o f S o c ia 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 ­ q u ire m e n ts f o r the d eg re e o f

MASTER OF SOCIAL WORK

Dean

Date,

r

Thesis o/.—J.OHN..EAYMQED..JBEAN.

Faculty Committee

Chairmfan

TABLE QP CONTENTS CHAPTER

PACE

I. THE PROBLEM

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

1

Purpose of the study............. .

3

Setting

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

Procedure for shock therapy

. . . . . . . .

4 7

Procedure for getting relatives1 consent to treatment...........

9

M e t h o d ...................

11

II. INTERVIEWS WITH THE SIX R E L A T I V E S ...

14

Case 1 - John H auser..............

16

III.

Case 2 - Charles Johnson............... . .

20

Case 3

- Henry R a n d o l p h ................

25

Case 4

- Charles

Henderson.............

32

Case 5

- William

Sanders...............

39

Case 6- Michael F r a n c e ..................

45

FINDINGS OF THE SIX CASE STUDIES.....

51

What were the feelings of the relatives about accepting responsibility for treatment? . . . . . . .

...........

• •

51

. . . . . .

55

Did the feelings of relatives constitute a barrier in the acceptance of responsibility for treatment?

CHAPTER

PACE Did the casework interview enable the relatives to gain sufficient understanding of treatment to allow them to assumeresponsibility? . ........

56

Did the casework interview aid the relatives in lending themselves in a positive way to helping in the over-all planning for thepatient? . . . . IV.

CONCLUSIONS.......................

57 58

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

61

APPENDIX............... ........................

65

CHAPTER I THE PROBLEM Mental illness implies a Breakdown of social relation­ ships; it indicates inadequacy in dealing with one’s self and with the environment,

it is reasonable then to Believe that

when a person Becomes so ill that he must Be cared for in a neuropsychiatric hospital it will not Be he alone, But his whole family who suffer. Mental illness is not easily accepted By the family of the patient for there is little community acceptance of it; the family, as well as the patient, is often stigmatized; more at the point of patient’s admission to a mental hospital than at any other time during the illness. The hospitalization of the patient indicates, most often the recognition on the part of the family that they are unaBle to cope with the problem successfully themselves. Many families expend their entire financial resources in an attempt to treat the patient privately, so great is their dread of the neuropsychiatric hospital and their guilt and fear of placing a family member there.

The family often

views the hospital as the last resource; they have finally

^ Ziskind, Louis, ttThe Caseworker’s Relation to Shock Therapy,11 Journal of Social Casework, 29:391, December, 1948.

had to take the responsibility to place the patient in neuropsychiatric hospital.

They may view this as a part of

their own inadequacy in being unable to aid the patient and guilt and anxiety may arise from the family*s feeling that they may have caused or contributed to the patient*s illness.2 Because family relationships and attitudes of those within the patient!s living situation are significant factors in a patient*s illness, the relative continues to be a part of treatment planned for benefit of the patient.

So that

relatives may better understand their responsibility in treatment it is necessary to provide means through which they recognize their feelings about patient and hospital and learn to help the patient.

They can use an opportunity to

allay anxieties and fears about this unknown process of hospital treatment.

This service is offered by the psychi­

atric social worker of the hospital staff.

Through the

social worker, the relatives can gain understanding of the hospital procedures, the patient*s illness and see their role in relation to treatment of the patient.

Relatives

2

Woodcock, Mary Ellen Hayes, "Case Analysis," Hews Letter of the American Association of Psychiatric Social* Workers, *7:6, Winter, 1941-1942. rz

Hambrecht, Leona, (Lowry, Fern, Editor) Readings in Social Casework, Psychiatric and Social Treatment ihinctions and Correlations. (Hew York School of Social Work, Hew York, Columbia University Press, 1939), p. 291.

3

can ^0 encouraged to participate in treatment plans of the patient directed toward his eventual return to the family and community.

By sharing responsibility with the hospital for

the treatment process at the point of admission it has been shown that they did react more positively to the later responsibility, that of accepting the patient when he is 4 ready for discharge. Purpose of the Study: After patient!s hospitalization is accomplished and routine matters of clothing, funds and other personal items are settled by the family there are more serious responsib­ ilities required of the relative*

One of the first requests

of this nature directed to the relative is the responsibility of consent for a specific form of treatment.

Frequently this,

is a recommendation for shock therapy. Medical staff recommends certain types of shock treat­ ment after a complete psychiatric, physical and social study of an individual before shock treatment of any type is administered*

This is in contrast to all other types of

psychiatric care except surgery.

The fact that consent is

required because of the risk involved may be a basis for the

^ Ryerson, Rowena, nCasework with Schizophrenic Patients Treated with Shock Therapy,n Journal of Social Casework, 6:292, 1945.

4

anxiety the relative feels ahout the role he has heen asked to assume.

The feelings which he has may be related to a

fear of treatment or may be complicated by feelings he enter­ tains for the patient or the hospital. This study arose from an interest in more understanding of what was involved for the relative in consenting to shock treatment.

The research question asked specifically was:

What were the relativefs reactions in consenting to shock therapy as revealed in social casework interviews? Setting: This study was undertaken at the Ueuropsychiatric Hospital, Veterans Administration Center, Los Angeles, Cal­ ifornia.

The Center is under the general administration of

the Veterans Administration, Washington, D. C.

The hospital

was established for the care and treatment of mentally ill veterans who served in the armed forces of the United States. The right of the veteran to receive such treatment is established by law and the veteran whose mental illness is connected with military service receives priority over other veterans (except emergencies), awaiting admission to the hospital. Veterans Administration Hospitals are considered com­ munity facilities, because their goal of treatment is the return of the veteran to the community.

Treatment is a

5

total institutional process directed by psychiatrists in which other professions contribute according to their own skills and patientfs needs.

This results in treatment of the

total person11 by all professions in a team relationship. The neuropsychiatric hospital in which this study was undertaken had a bed capacity of 2109 and a patient popu­ lation of 2076 on May 19, 1950; 340 patients were reported to be on trial visit or leave of absence.5

It is a teaching

institution with resident psychiatrists, psychology internes, dietetic and occupational therapy trainees, and psychiatric social work students. The resident psychiatrists treat the patients under the direction of the staff psychiatrists, the psychology internes contribute to the diagnostic work-up of the patient through their program of testing, the occupational therapy trainees aid the patient in the process of rehabilitation during his hospital stay, the dieticians supervise the daily hospital and special diets menu.

The social work

students use knowledge gained in their concurrent profes­ sional education to help the patient adjust to his living situation within the hospital and to deal with problems in the external environment which may be affecting his ability 5

Admission and Disposition Sheet, Neuropsychiatric Hospital, Veterans Administration Center, Los Angeles, California, May 19, 1950.

6

to adjust to hospital routine.

Families of the patients are

also assisted with problems and anxieties which arise from the patientfs admission to the Hospital and the social worker interprets the routine of the hospital to them.6

a h

0f

these services are directed toward the total treatment of the patient and the effectiveness depends upon the degree of in­ tegration of one to another.

Therefore, this treatment team

has as its purpose the personal, social and vocational rehabilitation of the patient. In May 1950, the staff of the Hospital was made up of twenty-seven full-time psychiatrists, six physicians in other specialties; there were twenty-six resident psychiatrists, six staff psychologists, twenty-three psychology internes, 103 nurses, sixty-five medical rehabilitation and special service workers, 466 attendants and a social work staff con­ sisting of a head social worker, three supervisors, ten psychiatric social workers and five psychiatric social work students, A social worker was assigned to each ward in the Hospital.

Casework service was, therefore, available to all

patients on a selective basis according to the need of the patient and the patientfs ability to use the service.

The

0 Group For the Advancement of Psychiatry, 11The Psychiatric Social Worker in the Psychiatric Hospital,*’ Report #2, January, 1948, p.6.

7

goal of social work was to help the patient make maximum use of hospitalization* Procedure for shock therapy: When a patient entered this Hospital a tentative plan for treatment was made by the doctor who admitted him*

In

the first two weeks of his stay in the Hospital, the patient received a complete physical and neuropsychiatric examina­ tion*

If a patient was considered as a possibility for shock

treatment when admitted, he was presented at a later date to a staff of psychiatrists.

The psychiatrists who made up the

11shock staff11 were those who regularly administered shock treatment.

Also present were the ward nurses and social

worker regularly assigned to the shock therapy ward. 'At the meeting the psychiatrist reviewed the patients recommended for treatment.

They considered the onset of illness,

patientfs history and the patient*s physical condition in determining eligibility for treatment.

After a discussion

of the patient, the chief psychiatrist on this ward decided upon the specific form of shock therapy to be used.

Follow­

ing the meeting, patients approved for treatment were transferred to the shock therapy ward. The plan of management in the Hospital was based upon a realization that the rapidity with which treatment could be inaugurated after admission was a most important factor

8

therapeutically.

The shock therapy ward was geared to make

the patient’s stay in the hospital relatively short.

This

was evident from the fact that patients were selected soon after admission for treatment and therapy was initiated as early as possible. The shock therapy ward, was a separate ward set aside exclusively for patients receiving one of the shock therapies.?. The patients were brought together on this ward for close sup­ ervision before and after treatment.

Diet, exercise and

recreation were regulated to avoid post-treatment complica­ tions.

Recreational, educational and occupational therapy

were available on the ward so that patients could actively use these services and still be under the careful supervision of the ward personnel at all times. This ward differed from others in the Hospital in that elsewhere the services were not available to the patient on his ward; the patient custom­ arily moved from building to building as he used the specialized services set up as part of the total treatment. A regulation of the Veterans Administration was that a relative must consent to the treatment before the Hospital took the responsibility for administering it.

7 Electro shock therapy, instantaneous and glissando types, electronarcosis and insulin coma therapy are the types of treatment given on the ward and referred to as 11shock therapies .n

9

Procedure for getting relatives1 consent, to treatment.: After the patient was assigned to the ward for shock therapy, a form letter was sent to his closest relative by a clerk on this ward.

The letter requested that the relative

sign his consent to the treatment which had been selected and recommended by the Hospital.® The replies to these letters sent by the clerk fell into three groups; those which were answered granting per­ mission, those which denied the permission, and a third, small group in which no reply was received.

The social work­

er assigned to the ward then attempted to contact the relatives in the third group.

If the worker was successful,

he tried to ascertain the relative1s reason for not answering the hospital's. letter and he offered his services to the relative if the relative wished to discuss the matter further. As a result of this procedure, some patients approved for a course of shock therapy by staff waited only a short period before beginning treatment, but others were held over for longer intervals without treatment because the consent letter sent by the Hospital either was not returned promptly or was not returned at all. being held back.

Staff and patient were thus

The patient was not receiving the treatment

® Appendix, Veterans Administration Form, SFFL 18-37

10

recommended for him hut was occupying a bed on the shock therapy ward.

Since the demand for beds often exceeded the

supply on this ward this created an administrative problem* Since the staff was interested in expediting treatment of the patient by securing the consent of the relative who was slow in accepting this responsibility there was an inter­ est in knowing more about the factors which delayed consent* Therefore, this study was undertaken specifically to study relatives1 reactions as they did or did not sign the form letter.

If the relatives1 reactions created barriers to con­

senting to the treatment, it was felt that the relative might be aided by discussing these feelings with a professional member of the staff.

It was not assumed that a social worker

was the only member of staff who could help the relative, but inquiry into the problem faced by the relative at this point might suggest the part that the social worker could play in helping him meet the problem. It seemed that Social Service could make a contribu­ tion to the total treatment by meeting with the relatives at this time.

The use of the interview as a means for beginning

a continuing relationship with the family throughout the patient*s hospitalization might also enable Social Service to establish a method of aiding the family to use help in assuming the eventual responsibility for the patient when he returned to the community.

11

Method: During January 1950 six patients recommended by the physicians for shock treatment were selected from the total group of thirty-nine patients considered.

The criteria

established for the selection of cases were:

first, the

patient had not had shock therapy at a Veterans Administration Hospital, therefore the relative had not had the experience of consenting to shock treatment; and second, that the re­ sponsible relative lived within a reasonable travelling distance from the Hospital.

The six patients selected were

the only ones in the entire group of thirty-nine who satisfied these two criteria.

Of these patients, two had previous

experience with shook treatment given elsewhere, but the six relatives had not had the experience of consenting to it. A letter was sent to the relatives in each of the cases, asking them to telephone Social Service in the Hospital for an appointment.

The letter explained the purpose of the

interview as the need to discuss a particular type of treat­ ment which had been advised for the patient; the type of treatment was not mentioned by name.9

This letter was sent

to five relatives; the sixth relative was approached by the social worker while she was visiting the patient, given the

9 Appendix, Social Service Letter.

12

request for an interview, and an appointment was made for a later date. All relatives readily made appointments for the inter­ view which took place in the Social Service Department of the Hospital, and they lasted for approximately an hour in each instance.

The casework method of interviewing was m ed in

these interviews.

The social worker introduced the purpose

of the interview, explained that a specific form of shock treatment had been recommended by the Hospital for the patient, that the Hospital needed their consent before treat­ ment could he begun.

They were invited to talk about this

request that they make a decial on either to accept or to refuse the Hospital recommendation.^

The social worker

focused upon the relatives1 feelings in accepting the responsibility, attempted to meet the feelings with accept­ ance and understanding, and tried to help the relatives to work through feelings regarding a type of treatment which

0

they often did not understand. 11

10 Hambrecht, Leona, (Lowry, Pern, Editor) Readings in Social Casework, Psychiatric and Soeial Treatment Functions and Correlations. (Hew York School of Social Work, Hew York, Columbia University Press, 1939), p. 289. 11

Ziskind, Louis, ”The Caseworker’s Relation to Shock Therapy,11 Journal of Social Casework, 9:391, December, 1948.^

The interviews with the relatives were conducted to provide an answer to the following four questions: 1.

What were the feelings of relatives about accepting responsibility for treatment?

2.

Did the feelings of relatives constitute a bar­ rier in the acceptance of responsibility for treatment?

3.

Did the casework interview enable the relative to gain sufficient understanding of treatment to allow him to assume responsibility?

4*

Did the case work interview aid the "relative in lending himself in a positive way to helping in the over-all planning for the patient?

14

CHAPTER II INTERVIEWS WITH THE SIX RELATIVES In ©aeh interview the worker discussed the policy of the Veterans Administration, which stated that the relative1s consent was necessary before any shock treatment could he undertaken.

The worker1s discussion of treatment included

only the most general aspects.

The relative was told that

a coma was induced by injections of insulin, and that a convulsion occurred in electro-shock therapy.

It was care­

fully pointed out that there were dangers of fractures in electro-shock, and danger of death in both treatments.

The

danger of death was compared to the danger of death arising from major surgery. When relatives asked if the treatment would cure, they were helped to understand that there was no means by which anyone could foretell the results until the patient had completed a course of treatment. In instances where the rel­ ative asked questions regarding the duration of treatment it was explained that the doctor would determine this as he observed the patients reactions to it.

The worker answered

relatives1 questions regarding pain In treatment or damage to the brain of the patient by stating that it was general medical opinion that neither were observable as a result of treatment•

15

In this study it seemed necessary to help the relative understand treatment by discussing it generally,

This did

not imply the removal of such responsibility from the doctor who treated the patient but was deemed necessary since the relative had an opportunity to talk with the doctor only in isolated instances before he consented to treatment. 12 The interviews from the six cases follow.

i P

The names of persons and places mentioned in the interviews were disguised. M

The recording was done to give the reader a com­ plete picture of the relative!s feelings as revealed in the interviews, thus the worker’s role was not recorded in process.

16

Case 1 John Hauser, age twenty-eight, a World War II veteran, was admitted to the hospital January 18, 1950. His diagnosis at admission was schizophrenic reaction, paranoid type. Patient was first admitted to ttiis hos­ pital in July, 1947, hut remained only two weeks. He then requested a discharge against medical advice. After leaving tiis hospital, he was committed to a state hospital in October, 1947, from which he eloped in December, 1947. Patient had been in the hospital for two weeks previous to the interview. Ho one had visited him. Insulin coma therapy was the treatment recommended. A letter was sent by the social worker to the father of the patient, but no reply was received. Father ar­ rived without an appointment twelve days after the letter was sent. The father opened this interview by stating that he had a difficult time getting to the interview since he lived forty miles from the Hospital.

In response to an explanation

of the purpose of the interview he said he felt Hit was about timeri that his sen received treatment; he had been ill for a long time and had received none. Father then discussed the fact that his son previously had been hospitalized in a state hospital.

Patient was to

have had treatment there, but had eloped before treatment was started.

This occured in 1947, and the family had heard

nothing from or about the patient until they were advised, three weeks ago, of his present hospitalization.

They were

relieved to know that he was again in a hospital so that the treatment previously considered could be given.

17

He was anxious to know more about the treatment now being recommended.

Insulin treatment was briefly discussed.

He wondered ’’just what was wrong” with his son, and seemed dissatisfied with the statement that his son was mentally ill. However, he felt that treatment ’’might enable him to return home and make a new start.”

The father then brought out

more specific questions regarding treatment:

Had this same

treatment been used before on other patients with similar illness?

How would the treatment affect the illness?

about the dangers in treatment?

What

Following a discussion of

these questions, the father decided his son should ’’take his chancel he should take every opportunity to aid himself.” Father had not mentioned the patient*s reaction to the plan of treatment.

To a question he said that when his son

was ”clear” he wanted treatment, but he remembered that there were times when patient did not know what he was doing.

He

then went on to elaborate upon this with detailed descrip­ tions of many incidents In which the patient wrote checks on a non-existent bank account.

He stated that he always paid

these checks and it was not easy! Father said that the patient received a government check recently, which he wanted his father to accept as partial payment for the money spent paying his debts.

He %

then held out the check, which he kept in his hand through­ out the interview, and asked if he could cash it legally.

He

18

was directed to the office of the registrar in the Hospital to accomplish this.

The father then started to leave, saying

he had no more questions.

He offered the consent form, read

it and signed, and commented that it was not hard to understand. Analysis; The father’s real concern seemed to center on the government check which he held in his hand throughout the interview.

He came to the hospital primarily to gain per­

mission to cash it legally, and the discussion of treatment seemed of secondary importance.

Once he received the infor­

mation related to the check he forgot the purpose of the interview, the assumption of responsibility for treatment. Question Is

The father’s feelings, if any, were kept

out of the interview.

His statement that he had difficulty

reaching the Hospital indicated some resistance toward the interview.

He was hostile against the Hospital, and his

utter detachment might indicate the presence of negative feelings toward the patient.

He did not seem at all con­

cerned, as he said that the family had nob seen the patient since his elopement from the state hospital.

He had very

little interest in the patient’s welfare. Question 2:

The father’s feelings did not seem to be

a barrier to acceptance of responsibility.

There seemed to

19

be a lack of feeling for the patient generally. Question 3:

The father did show some willingness to

assume an obligation in relation to patient, as he posed questions concerning treatment.

He wanted to know more about

his son's illness, and was not satisfied only to hear his son described as being ill.

His questions about treatment seemed

to have been answered to his satisfaction, but it was not his understanding of treatment which enabled him to sign the consent form, more probably, it was his feeling that this treatment would cure his son. Question 4: aided by the his son.

It

is doubtful whether the father was

interview to

helpplay a part in treatment of

He took the responsibility which the hospital

asked him to

take, and thereby fulfilled his responsibility

to his son.

He seemed to

feelthat, his responsibility had

ended. Later contact with the father by the social worker assigned to the ward indicated that the father felt his part in the patient 1s illness had ended with the signing of the consent form. the patient.

He would accept no further responsibility for He would not take the patient on pass; he said

he wanted nothing to do with him.

20

Case 2 Charles Johnson, age forty-three, a World War II veteran, was committed to the hospital January 19, 1950. His diagnosis was schizophrenic reaction, mixed type. The patient had been in several mental hospitals, state and Veterans Administration, since his discharge from military service in 1943. Patient had been in this Hospital in November, 1947 but his mother insisted that he leave against medical advice, when the doctors refused to discharge him with maximum hospital benefit. Patient had been in this Hospital for five days at the time of this interview. Electro-shock therapy was the recom­ mended treatment. Mrs. Johnson, mother of the patient, came to the office of the social worker on January 23, 1950 to talk about treatment. Since she had not replied to the letter sent in connection with the study, no appointment had been made for her. When she heard that she could not be seen on that date she stalked from the office. She returned the next day for the Interview. Mrs. Johnson had many mannerisms, tics, and seemed not too well oriented. Mrs. Johnson spoke first about the difficulty she had in getting to the interview because she had to ride busses and streetcars for almost two hours to get to the Hospital, She went on to say that she had just spoken with her son, and that usome thing just had to be done.If She said that, her son still had delusions, and has had them for a long time.

She

thought the whole problem of illness could be attributed to his use of beer and alcohol, and that if the patient could be cured of his need for alcohol, the Illness would disappear. Veterans Administration policy regarding consent for treatment was discussed with Mrs. Johnson, and she inquired about the specific type of treatment, worker said it was

21

electro-shock. this.

She replied quickly that she had heard of

When worker asked if she would like to discuss treat­

ment, she said she did not want to know anything about it, "but she already knew that it hurt the patient.

Mrs. Johnson

was told that the treatment did not give pain to the patient, but she was helped to understand that there were dangers present.

After she had heard this she returned to her con­

viction that treatment should be directed to her son’s use of alcohol.

She wondered if the Hospital could not treat this

first, since it was the cause of his illness. Mrs. Johnson then talked about an earlier experience. Her son had been in a state hospital; electro-shock was pro­ posed as treatment and she had refused to grant permission* She" belie ved prayer was the answer to the problem then; she was a Christian Scientist, too, and this made it impossible for her to agree to the plan of the Hospital.

Now she said

she was not convinced that prayer was the answer. She wanted to know if the treatment would cure the illness.

She did not listen to the discussion of treatment

but interrupted to say that this treatment had to help.

She

felt that she might have waited too long to grant permission. She believed that if her son had had treatment earlier he would now be leading a normal life in the community. Mrs. Johnson then began to discuss her son’s illness, and said that her son had many 11funny” ideas.

She was having

22

difficulty recently convincing her son that he was not a cow­ boy.

She thought he was only playing a joke on her when he

insisted that the house they lived in was a part of a large ranch he owned.

He never would believe her when she told

him it was not.

She thought this was proof that alcohol was

the cause of the illness.

She said once again that if some­

one would talk to her son about his use of alcohol he could then return home, marry and settle down to a normal life. She could not understand why medical staff did not view alcohol as the cause of the illness when she told this. Mrs. Johnson responded to a re-statement of the recom­ mendation of the Hospital by staring at the wall. she asked to see the consent form.

Finally

After she finished

reading it, she asked if the medical staff thought that this would really help her son.

This was discussed again.

Mrs. Johnson then wanted to know what would happen if her son did not want treatment.

She was told that while some

patients resisted treatment, most of them did not.

She said

she had refused to sign her consent the last time because she did not 1hink her son wanted the treatment, and she did not want to sign the form only to find M e r that her son had resisted.

Mrs. Johnson seemed unable to accept the need for

shock therapy; she felt that if the patient wanted it he could ask for it himself.

Finally she said that she guessed

her son had to be pushed into everything.

She thought that

23

sh© was pushing him into treatment, hut she saw this as her chance to do him some good*

She then signed the form.

As

she left, Mrs. Johnson said that someone should examine her son*s teeth.

He needed dental attention and he was not

receiving it. Analysis: Mrs. Johnson seemed unahle to lend herself to partic­ ipate in the interview.

She did not seem able to give up her

own impression of the cause of her son!s illness.

In doing

this she pointed up her own inability to accept or to under­ stand that her son was mentally ill.

She came prepared to

sign the consent form, but she was agreeing to sign only because she felt that it would give her son the help he needed to return to a normal life.

Throughout the interview she

seemed tense and too involved in her own fear of treatment to be able to listen to any explanation of the methods and possible results. Question 1:

Mrs. Johnson’s feelings were centered

around a real fear of treatment.

She did not understand treat­

ment, but could not allow herself to listen to a discussion of it.

She was certain that treatment would hurt her son, but

she felt some guilt that she had not Question 2:

signed consent earlier.

She did not want to grant permission if

the patient did not want treatment.

This pointed up her im­

pression that she was punishing the patient, and also

24

indicated her inability to see the patient as being mentally ill.

Religion also played a part in Mrs. Johnson's reluct­

ance to accept responsibility, but her high hope of treatment, b o m of the feeling that the patient ttmustT, get well, allowed her to sign. Question 3:

Mrs. Johnson was not aided by the inter­

view to understand treatment, discussed at all.

she did not want to hear it

She came with virtually no understanding

of treatment and left the interview with no clear idea of the meaning of it. Question 4:

Mrs. Johnson probably would not be able

to help in planning for the patient.

Her expectations of

treatment were very high and totally unrealistic.

She would

probably participate in actively planning only if immediate improvement on the part of the patient were to take place. Later contacts with the ward social worker indicated that this mother allowed medical staff to treat her son for only a short period of time.

When her son showed no im­

mediate improvement she asked that he be discharged to her on trial visit.

The Hospital granted the request.

25

Case 3 Henry Randolph, a fifty-four year old World War I veteran, was admitted to the Hospital on January 13, I960, His diagnosis was depressive reaction. He Had been in tHe Hospital for a period of two weeks before this inter­ view. Patient Had electro-shock therapy at a state hospital in 1948. He remained in the hospital five months on that occasion. His recent episode had begun about two months before his admission to this Hospital. E3e ctro-shock was the treatment recommended. Mrs. Randolph, wife of the patient, called in answer to the letter from Social Service. She was very fearful of the purpose of the interview, was quite hostile and resisted coming to the Hospital. She wanted to discuss treatment on the telephone, but agreed to come when she understood that this would be impossible. Mrs. Randolph said that it was necessary for her to give up an entire morning at the office where she worked in order to keep this appointment,

she introduced Mr. Barry, a

close friend of the patient, who had accompanied her to the hospital.

She indicated her wish to have him present in any

discussion concerning plans for the patient.

Mrs. Randolph

spoke in a whisper at the beginning of the interview.

As she

discussed her visit with the patient on the past weekend she became more relaxed.

The flow of speech became almost torren­

tial as she continued. Mrs . Randolph said her husband was very frightened because he had heard that he was going to receive treatment. She wanted to know what type of treatment was being consid­ ered for him.

When she heard that electro-shoGk was

recommended she gasped, replied to a question that she was

not afraid of the treatment, but she knew that her husband was.

She stated that she and her husband had “bad luckM with

electro-shock; her husband had already had some experience with it at a state hospital and she said that much of her feeling about treatment arose from that experience. Mrs. Randolph continued by saying that her husband1s last hospitalization had been a “nightmare“; she was aghast at the way the state hospital was managed.

She was very much

surprised to find that no segregation was practiced there. Her husband was forced to live with “raving maniacs.11 She said all of this upset her sd much that she was scarcely able to enter the hospital to visit her husband.

She felt that

her husband had been treated like an “animal11 at the state hospital, and she said that she was never allowed to take part in a treatment plan for her husband.

To a question, she

replied that she would have liked to have been consulted about treatment.

As it was, she felt that she had been forced

to sign a consent form; she welcomed this opportunity to talk about the patient and about treatment with a member of the staff of the Hospital. Mrs. Randolph said that the entire approach of this Hospital was different.

This made her think that her husband

would get well while in this Hospital.

She then said that

her husband looked quite ill now, and she contrasted this with her impression of him when he was at the state hospital*

She

27

repeated that her husband seemed very fearful now.

She

thought he feared the treatment. Mr. Barry then asked if patients routinely were pre­ pared for treatment.

He wanted to know if the doctors

discussed the treatment with each patient.

The worker

described the staff conference, when the patient met with a staff of doctors, and in which there was a discussion of treatment.

Mr. Barry felt that in addition to a general

discussion of the medical recommendation, each patient should be allowed an opportunity to discuss his feeling about treat­ ment with the doctor who was going to administer it.

The

worker agreed to this, and went on to explain that this very process took place after the patient left the staff confer­ ence, and that further help with his fear was provided following his transfer to the shock treatment ward. After discussing patient!s fear of treatment, both the wife and Mr. Barry seemed to grasp the fact that at least a part of this fear was characteristic of the patient»s illness. Mrs. Randolph said her original fear of treatment arose when she visited her husband at the state hospital shortly after his first treatment.

She expected to find him better than

when he entered the hospital.

Instead she felt that the

treatment had made him worse.

He was acting Hcrazy.”

not recognize her immediately and this frightened her.

He did She

only realized new that a memory loss following treatment was

28

not unusual. told her this.

At the state hospital, there was no one who In answer to worker*s question, Mrs. Randolph

said that her husband had taken four treatments at the state hospital*

At this point Mrs. Randolph became very emotional.

She was helped to express her feeling, and she said that she had made a serious mistake when she took her husband out of the state hospital against medical advice*

She took him home

because she felt that he was not being helped. he was being treated like a

She felt that

crazy man.t!

Mr. Barry wanted to know if some sort of a drug could be used to deaden the patient’s reaction to treatment.

He

thought that if this could be done the patient would not know that he was going to receive treatment.

It was explained

that drugs were not used in this Hospital for that purpose, but Mr. Barry still thought something should be done to mit­ igate the patient’s fear of treatment. many treatments were necessary.

He wanted to know how

Worker pointed out that the

effect of treatment would determine this and that it was difficult to gauge the length of time in which treatment would be given.

Mrs. Randolph wondered if a full course of treat­

ment would insure a cure.

She had an adequate intellectual

understanding of the treatment but her hopes for it seemed quite unrealistic, she clung to the expectation that treat­ ment would make him entirely well again. After Mrs. Randolph read the consent form, she handed

29

it to the patient fs friend and he read it slowly.

After he

gave it hack to her she waited a moment, "began to sign it, stopped, and then said rather breathlessly, uthis will just have to help him,w she then signed the consent form. Glancing at her watch she said she had to leave.

She

wanted to use the opportunity, before visiting hours were ‘over, to talk with the ward doctor.

She suddenly recon­

sidered and said that she could not go to the ward.

If

patient saw her there he would know that she had consented to treatment.

He did not want her to consent to treatment

but as long as the Hospital thought it was the wanswer11 she would sign the consent form.

Mrs. Randolph wondered how she

could keep the patient from knowing she had consented to treatment.

Simultaneously she decided that she would have

to tell him nsooner or later.11 As she was leaving the inter­ view she sighed and said that she would not come to the Hospital until patient was better. Analys is: Mrs. Randolph was very fearful of the recommended treatment.

She felt that she was punishing her husband if

she signed the consent for treatment.

She seemed to in­

dicate this rather clearly when she took her husband from the state hospital before treatment was completed.

Mrs.

Randolph*s ability to consider taking responsibility seemed to stem from her high hope of treatment.

She was able to ask

30

questions about the treatment, but they were always geared to an expectation of cure for her husband*

She could only

sign the form upon one basis, that the treatment would cure her husband.

She had strong feelings about deceiving the

patient. Question 1:

Mrs. Randolph seemed uncertain that she

would be able to leave her husband in the Hospital-.

She had

guilt centered around her own inability to allow her husband to be treated earlier, but she felt this only because of her impression, once again, that she really should not have taken her husband from the hospital.

Much of her feeling

seemed to have arisen from her fear of having to admit that her husband was mentally ill. Question 2: gave pain.

Mrs. Randolph feared that the treatment

She regarded assuming the responsibility for

consenting to treatment as being an act against the patient!s wishes.

This posed a barrier to her. Question 3:

The interview did not enable Mrs.

Randolph to gain a real understanding of treatment, but it did clarify her impressions of treatment.

She released con­

siderable feeling in the interview, but her understanding of treatment as a helping process did not allow her to assume responsibility alone.

She felt she deceived her husband, but

signed the consent because the fthospital felt it was the answer.11 -

Question 4:

Mrs, Han&olph was helped, to a limited

degree, to participate in future planning for the patient* She did welcome the opportunity to participate in the inter­ view*

She could have profited by further contact with a

social worker.

Her limited understanding of treatment and

her high expectations of it pointed up the need for further help in those two areas*

32

Case 4 Charles Henderson, a fifty-eight year old World War I veteran, was admitted to the hospital January 17, 1950. His diagnosis at admission was agitated depression. Patient had not been hospitalized previously in a neur­ opsychiatric hospital. His illness began in 1941 when he began to drink heavily and spend lavishly. Patient had been in the hospital eleven days at the time of the interview. Ele ctro-shock therapy was treatment recom­ mended • Patient*s relatives had not brought him to the Hospital at date of admission but his son had visited on the week-end before this interview. Patient had named his daughter, Mrs. Sheehan, as the relative to contact. A letter was sent to her and she telephoned for^an appointment; she seemed very fearful; seemed unable to make any independent decisions; asked worker to set a time for an appointment and finally asked if she might bring her brother to the interview. When she heard that this was possible she said she would have been afraid to come alone. The patient!s son opened the interview by asking if his father had been seen by the social worker since his ad­ mission to the Hospital.

Told that the father had been seen

at a meeting of staff he expressed surprise that mental ill­ ness could effect such great physical changes in the patient. He had not seen his father for six months, prior to the past week, and he ”looked like a different man, he had lost considerable weight.” The daughter asked what treatment was being recom­ mended, and both were concerned when told.

They wondered if

their father was not too emaciated to undergo such a course

33

of treatment.

They both understood that the medical staff

had prescribed the treatment, and accepted this opinion.

The

son and daughter then discussed the effects of treatment; they wanted to know'if this would cure the patient, and they were helped to recognize that this could not be predetermined. Mrs. Sheehan then asked if her father knew that he was going to receive shook therapy.

It was pointed out that the

patient had been presented at a meeting with a staff of doctors who had discussed his illness.

The son then remem­

bered that his father had mentioned the treatment, and had been quite upset because he had been placed on a ward with tfcrazy people.11 The son made his feelings quite clear at this point. He felt that his father had no reason to complain.

He was

certain that this Hospital was going to give his father the best care possible, and he said he was glad that his father was not in a state hospital.

He related the events leading

up to his father1a hospitalization, described the effect upon the family financially and psychologically.

He said his

mother had had a nervous break-down and the family had spent all of their money, had placed him In a private sanitarium and had even sold their home, in an attempt to cure his father. He ended by saying that he was glad that his father was here. The implication was that he felt the father would not bother the fanily any longer.

34 The daughter then mentioned that her father was not brought to the Hospital by a member of the family; she wondered how the Hospital had obtained her name.

It was explained that

the patient had named her when he came to the Hospital.

She

could not understand why he would do this; she never felt close to her father in growing up, in fact she always feared him. The son made it clear that the entire family had feared the father, and he remembered particularly that the father never liked to "be crossed." The daughter then introduced her concerns regarding pos­ sibility of her father1s requesting to leave the hospital against medical -advice. Administrative procedure in such situations was discussed and commitment procedure was explained. The daughter wondered if she would be expected to sign commit­ ment papers, and was relieved to hear that any family member could do this.

Both the son and daughter felt that their

father might want to leave the hospital at any time.

They did

not think he wanted treatment, but they did think he was ill, and they saw a need for it* When the son and daughter did not speak for a few mo­ ments they were asked if there were other questions they wanted to ask or discuss.

They said there were none, but

when the daughter began to read the consent form she suddenly decided to let her brother read it first. and then handed it to his sister.

The son read it

As she read it she glanced

55

repeatedly at her brother and then asked if her brother could sign it*

She said that she was afraid to sign, but her brother

was not afraid of their father. After the consent form was signed by the son, the daughter monopolized the interview.

She wanted to know first

if her father could find out who signed the form; she did not pause as this was answered, but asked if the treatment would give the pefcient pain. She was not satisfied with the answer that the patient could feel no pain because he was unconscious• She insisted that this was no proof of the absence of pain. She moved quickly to the possibility of death arising from the treatment.

The daughter was not stopping to discuss her

questions, but seemed to be clearing her feelings.

She was

next concerned about visits to the patieat; she suspected that if the patient was visited he would attempt to leave the Hospital.

She thought on question that she and her brother

might be able to help their father understand and accept the Hospital, and she could see that the family might be able to use further help in understanding their role in treatment. As the son and daughter prepared to leave they asked questions about the Hospital.

They wondered if it was nec­

essary for their father to be locked with nsick patients.1* They were told that the grouping of patients was for purposes of more efficient treatment; all patients receiving shock therapy were grouped together.

Just before leaving, the son

36

suddenly remembered that he noticed that his father had a soiled bandage on his leg.

He wondered if this could' be ealled

to the attention of the doctor. Analysis: The daughter*s feeling in the interview seemed to be colored by real fear of the patient.

She felt that to sign

the consent would be to incur his wrath and to put herself in danger if and when he did leave the Hospital. the treatment as punishment. the patient.

She visualized

She saw it as possibly killing

Her fear of her father indicated some of her

hostility toward him, and the taking of responsibility posed the possibility of acting out seme of the repressed feeling. She was quite ambivalent; she wanted to help her father but she wanted to punish him, too, perhaps, but still he had named her as the responsible relative and she felt guilty that her feelings had so much of the negative in them. The son’s feelings seemed to center on his hostility toward the father. ever he got.

He felt that his father deserved what­

He did not want the patient to die, possibly,

but he felt the need to punish the patient, for he could not forget the trouble the father had caused the family during the illness.

He accepted responsibility for treatment

readily, perhaps more because of his sister’s request than from his own sense of doing anything for his father.

37

Question 1:

Both the sun and daughter had feelings

about assuming the responsibility# treatment would give pain#

They both feared that the

They wanted to feel this would

cure their father before they could proceed.

Both son and

daughter had difficulty admitting their father was ill. Their demand of treatment was for a cure, and in all of this they were wondering if treatment was really necessary.

The

daughter and son feared that they were "crossing” the patient. Question 2:

The daughter’s feelings about being named

as the "responsible relative" pointed up the meaning the tak­ ing of responsibility had to her. Question 3:

Son and daughterwere helped to

better understanding oftreatment in the

gain a

interview, but it

cannot be said .that this was the means in helping them to assume responsibility.

It was evident that much feeling was

released, and the acceptance of responsibility was made easier once the relatives released it. Question 4:

The interview indicated the need for

future contacts with a social worker.

The son and daughter

realized this need, too. The social worker assigned to this' case reported later that both the son and daughter reacted in a positive way to a relationship. The son was able

to help in planning,

and gradually accepted the fact that his father had been ill for a long period of time before his hospitalization; the

38

daughter was able to express some of her feelings, but she still had much guilt about the hospitalization and treatment.

The son and daughter were able to help the

patient, even though he made little progress in treatment.

39

Case 5 William Sanders, a thirty-four year old World War II veteran was admitted to the hospital December 31, 1949. His diagnosis at admission was, dementia praecox, simple type. This patient had not been hospitalized previously; he had become ill shortly after leaving the military service and had been unable to hold a job for the past year. Patientfs wife had visited each visiting day and had asked the doctor repeatedly to allow her to take the patient home for a weekend. Doc tor felt this was in­ advisable but wife persisted and the patient was allowed to go home the weekend before this interview. Mrs. Sanders was contacted by the social worker on January 17, 1950, immediately after her husband had been recom­ mended for insulin treatment. Both patient and his wife seemed very anxious and confused but Mrs. Sanders agreed to cone for an interview. Mrs. Sanders arrived fifteen minutes early for her appointment.

When she was approached, as she sat in the

reception room, she did not move; her eyes were directed out the window, as if in a dream.

Invited to come to another

room, she did not move; her gaze remained fastened on the window.

Invited a second time, she seemed to wake with a

start.

She rose from her chair very slowly and seemed al­

most to trudge beside the worker to the other room. Mrs. Sanders first seemed quite excited as she said that she heard her husband was going to be sent to a state hospital.

She had reached this conclusion because her husband

told her that he was getting no treatment and this meant that hospital staff had decided they could not help him.

Mrs.

Sanders then heard that treatment was recommended for her

40

husband, and she seemed to be a little tense as she began to speak about her husband’s pass of the past weekend.

She

dwelt at great length upon her husband’s fear of the hospital.

She thought her husband would be more relaxed if

he could stay at home with her; she noticed that he relaxed when he boarded a bus to go home with her.

The pass had not

been too successful according to Mrs. Sanders; her husband hid in the house, refused to let her leave him, and made it very difficult for her. She wanted to talk about the patient’s illness.

She

described her marriage, the plan she and her husband had to build a home, and ended in recounting that her husband had spent all. of his savings in an episode of drinking which lasted over a month.

Mrs. Sanders had hem. at her parents*

home while this had taken place. found her husband very ill. feared everything.

When she returned she

He could not leave the home;

he

She said with some help, that she almost

had to carry her husband wherever they went. every way to help him but she could not.

She tried in

She tried to be

cheerful; she did not want him to know that she felt almost as sick as he did. now.

She said that she was not feeling well

A few days after her husband came to the Hospital she

had an asthmatic attack, and now she found that she was afraid of the dark too.

She thought that if her husband had not come

to the Hospital she might not have been able to carry on.

41

With a sigh she said that it was really a relief to have her husband in a hospital, Mrs. Sanders understood, when discussing the purpose of the interview, that the recommendation had been made that her husband should receive insulin therapy.

Her husband

really did not want treatment, because he feared it would kill him.

She did not know whether it would kill him or not,

but she had talked with her minister and he had explained the treatment quite fully to her. Mrs. Sanders then talked of signing the consent form and related an incident which had happened in the past week. A doctor approached her in the ward and told her that he wanted her to sign a consent form.

She asked what she was

consenting to, and the doctor told her that it was insulin therapy.

She became very frightened for she thought her

husband was being reated for diabetes,

When the doctor

could hot find a consent form she was quite relieved.

Mrs.

Sanders’ mistaken impression of treatment was corrected and she was told that insulin would be used in this instance to treat her husband’s mental illness.

Mrs. Sanders then

mentioned the minister again; she thought if he approved insulin shock, and he did, that it must be all right.

She

asked to see the consent form and as she took it she seemed to lapse once again into a dream.

She finally summoned

strength enough to say weakly, 11You know, I ’m not his legal

42

guardian.*1 Veterans Administration interpretation of legally responsible relative was explained. As she looked at the forn, Mrs, Sanders asked a number of questions regarding treatment.

She wanted to know if the

treatment would cure her husband.

This answered, she said it

would not really have to cure her husband, for he was not ”really insane.11 He could still think; she knew this. When Mrs. Sanders asked if her husband would receive immediate treatment if she signed she seemed to be consider­ ing waiting, possibly to ask someone else’s advice before taking the responsibility.

She was told that the treatment

would begin soon after she signed.

She grew very hostile

momentarily as she discussed her fatherin-law.

She was very

angry because he had not come to the Hospital when her husband was admitted.

She was also quite upset because he told her

not to visit the patient.

She made it very clear that she

intended to continue visiting her husband.

It was her im­

pression that her husband would become sicker if she did not come to see him often.

She then signed the form.

Mrs. Sanders then talked about the cost of transporta­ tion to the Hospital.

She presented a financial problem, and

she was told that a social worker could possibly help with this.

She thought that this was a good idea,

her husband trusted no one but her.

she said that

She could understand how

the social worker might help her to aid her husband in better

43

using the hospital,

Mrs. Sanders asked for an appointment

with a social worker; it was set for late afternoon, and al­ though she realized that it would mean she would arrive at home after dark, she decided to wait to see the worker. Mrs. Sanders continued to talk about her husbandfs fear of the Hospital and the personnel.

She was trying to

leave the interview but could not seem to pull away.

She

talked continuously as she approached and passed through the exit from the building. Analysisi Mrs. Sanders was so confused, so anxious and so fear­ ful of the Hospital that she probably was not really psycho­ logically ready to sign the consent for treatment. Question 1.

Mrs. Sanders had many feelings pertaining

to accepting the responsibility. treatment and of the Hospital.

She was fearful of the She felt some guilt that she

might have been responsible for her husbandfs illness.

She

was afraid that the treatment would hurt him and she did not want to be solely responsible if that happened.

She could; hot

accept the fact that her husband was mentally ill and she was not able to hear much of what was discussed in response to her questions because of her own anxiety.

Her hostility

toward her father-in-law indicated the feeling that she was the nonlytf person who could determine the plan for her husband and she did not want to accept this.

44

Her expectations of treatment were very high and she gained little understanding of the illness or of treatment. Question 2. harrier.

Mrs. Sanders1 feelings did constitute a

She needed reassurance in the interview and needed

more at the conclusion.

She never was able to accept

responsibility herself; she used the ministerfs words as her rationale. Question 3.

Mrs. Sanders was aided in her understand­

ing of the treatment, and she did release feeling which thus enabled her to sign the consent form. Question 4.

She wanted the sort of help she was

receiving in this interview and thought that she could profit by it. Mrs. Sanders reacted positively to the relationship with the social worker on the ward.

She was able to partic­

ipate in planning, and relieved much of her anxiety and seemed to improve both physically and mentally in the weeks which followed.

45

Gas© 6 Michael Prance, a twenty-nine year old veteran of World War II was admitted to the hospital December 27, 1949. Diagnosis at admission was psychoneurosis. The patient had been hospitalized during military service; had seen extensive combat and had only two months previous to this admission left another Veterans Administration Hospital. The patient had entered the Hospital upon the request of his wife. Insulin coma therapy was the recom­ mended treatment. Mrs. Prance, wife of the patient, told the worker in a telephone conversation before the interview that she had to know more aboufe the patient’s condition before she could consider signing the consent for treatment. She said that she received no satisfaction from the staff of the hospital which her husband left recently. They told her he was suicidal but they did not tell her what was wrong with her husband. She said she would like to talk to a social worker but she was not going to sign a consent form. Mrs. Prance arrived looking very tired and tense.

When

this was mentioned she explained that she had been working fourteen hours a day for the past three weeks.

She welcomed

the opportunity to work overtime for she needed additional money now that her husband was in the Hospital. When Mrs. Prance began to discuss her husband’s hospitalization, the purpose of the interview was discussed. Mrs. Prance reacted to the information that insulin treat­ ment was recommended by saying that her husband had a course of insulin therapy in the army and he did. hot think it did him any good.

She understood that this was the recommendation

of the doctors who had examined her husband, and that she could give or withhold her consent for this.

She did not

46

want to sign anything until she talked with her husband; he had planned to talk to the ward doctor about it and she wanted to wait. Mrs. France felt, in addition, that she could not sign the form, for if she did it might ”do something” to her marriage.

She said that her husband!s family might not be at

all pleased if she signed a form consenting to treatment. Mrs. France was content to let her husband decide about it. She did not want to gp against his wishes.

She said, with

considerable emotion, that if she signed the form she would feel guilty, for her husband was not insane; he could think for himself.

He was able to make the choice himself, she

thought, and wanted him to do this.

Mrs. France said that

she was not going to sign until she found out from the doctors what was wrong with her husband.

She was not able

to get an appointment with a doctor at the last hospital. She wanted an appointment to meet with a doctor here.

When

worker told Mrs. France that this could be arranged she sud­ denly became very quiet,

she asked then if dreams were a

sign of insanity; her husband did have nightmares, she said. She was told that dreams did not indicate insanity but sometimes they could be upsetting. Since Mrs.

France had asked no questions about

insulin coma therapy, worker asked if she had any questions about it.

She said that she understood the treatment quite

47

well as her friend was a nurse on an insulin coma therapy ward.

Mrs. Prance said she knew that insulin aided many

patients, hut she reiterated her belief that her husband had not been aided by insulin treatment earlier.

She seemed to

drift into a discussion of treatment against her will.

She

asked if it "damaged11 the patient, and then clarified this by asking if insulin injured the brain.

Worker explained that

no proof of this was found and she continued by saying that she knew her husband needed treatment for it was very im­ portant to their child and his future. Mrs . France thought her husband was afraid of dying while in treatment.

He worried about dying much of the time.

When he was worried she often sat with him, sometimes until four o fclock in the morning and listened while he talked about his war experiences. to help him.

She did this because she wanted

Mrs . France agreed that she could also help her

husband by consenting to the treatment, but she could not do it; she said her husband had left all of the responsibility on her shoulders. Mrs, France was not satisfied with her knowledge of treatment and asked if the patient was left alone \Then in the coma.

She was told that patients were never left alone

while In the room where treatment was given.

She said that

she was not too concerned about this but her husband was. She said again that her husband feared he would die in

48

treatment, but she did not ask if this were a possibility. When she discussed the meeting with a doctor, Mrs. France said she was not certain that her husband would agree to treatment even after talking to a doctor; she repeated her opinion that her husband needed treatment.

As she said this,

she began to discuss the death of her brother; she said.that he died without any sort of treatment but added quickly, lthe died without suffering.”

Mrs. France sat silently for a

moment and then murmured, 11if you* re going to die you just do.” Mrs. France said that what she needed was for someone to convince her husband that the treatment would cure him. The treatment was discussed again and Mrs. France saw it as a beginning at least, adding that her husband would have ntroublen if he did not agree to it, but she could not say what this meant to her. Finally, Mrs. France asked why her husband could not assume the responsibility himself.

She knew that people who

were ill could not always decide for themselves but did not want to discuss this, repeating that she felt that the treatment had not aided her husband earlier.

Mrs. France

said that she was happy because her husband was being treated very well in this Hospital and she was able to say that she hoped her husband would get treatment soon; she hoped that his treatment would be the 11answer.”

She wished that her

49

husband would be able to leave the hospital soon, for she was haying difficulty keeping up the payments on their home. Since Mrs. France wanted to meet the doctor, on the ward it was suggested that an appointment be made with the social worker there; for this was the best way to arrange an appointment with the ward physician.

Mrs. France thought

this was a good plan for she had to know more about her husband *s iline ss. Analysis; Mrs. France was unable to take responsibility in this interview for she had decided that she had to have medical opinion before she could consent to treatment.

She was able

to state quite clearly the difficulties surrounding the acceptance of responsibility for treatment. Question 1.

Mrs. France had considerable feeling

about accepting responsibility, without her husband’s permission.

she did not want to act She was not able to admit

fully that her husband was mentally ill.

She feared that he

would die in treatment, and for this reason she feared the treatment.

She felt quite alone in taking the responsibility

and she felt that treatment was a type of punishment for she feared that it might damage the brain.

Mrs. France had high

hope of treatment and little understanding of her husband’s illness•

Question 2.

Mrs. France seemed to demonstrate very

graphically the difficulty she experienced in considering the acceptance of responsibility.

She said that she would feel

guilty if she signed the form.

She feared the reaction of

her husband*s family.

She repeatedly stated her reasons for

not acting, and so great was the threat to her that she held to her decision even as she said that the patient needed treatment and she hoped he would get it. Question 3.

In this instance Mrs. France left the

interview with some understanding of treatment, but she was not enabled to assume the responsibility. Question 4.

Mrs. France presented a likely subject

for casework help.

It seemed that she might be aided in a

supportive relationship.

She had a real desire to aid her \

husband and it was felt that she could be aided to partici­ pate with the Hospital in planning for the patient. Later the medical staff deferred treatment of this patient.

In this period Mrs France was able to move into a

good relationship with the worker and was able, later, to understand the treatment sufficiently to be able to accept the responsibility for consenting to it.

51

CHAPTER III FINDINGS OF THE SIX CASE STUDIES This study was focused upon the relative; it attempted to explore feelings which he had as he considered taking the responsibility for giving his consent to shock therapy for the patient.

In considering the findings of the study it

must he assumed that many of the relatives* feelings were interdependent, i.e.; that the fear he evidenced of treatment might also indicate his guilt in being the person who was responsible for consenting to it. This chapter will consider the six cases as a group and will show the findings as they relate to the four questions which served as the base of research for the study. What were the feelings of the relatives about accepting respons ibility for treatment? Relatives did have strong feelings and reactions to assuming the responsibility for giving consent to treatment. All the relatives indicated an interest in the plan of treat­ ment when they made appointments for interviews at the Hospital.

Three of the relatives, Mr. Hauser, Mrs. Sheehan,

and Mrs. Randolph discussed treatment fully with the worker, for they were interested in its effect upon the patient as they considered taking responsibility for it.

All of the

relatives indicated some desire to assume responsibility when

52 they used the interview to learn more about treatment, hospit­ al and the condition of the patient*

All of the relatives but

Mrs* France took the responsibility to sign the consent form and in doing this they accepted the responsibility which the Hospital asked them to take. Mrs. France, Mrs. Sabers, Mr. Henderson and Mrs. Sheehan were sufficiently interested in the welfare of the patient to work with the social worker on the shock ward after the study interview.

The concern of Mrs. France, Mrs.

Johnson and Mrs. Randolph for the patient and his welfare had enabled them to bring the patient to the Hospital, despite the fact that they each had had unpleasant experiences with other hospitals in the past.

The relatives voiced many

negative feelings throughout the interview, as well as genu­ ine concern for the patient in all the interview, except Mr. Hauser.

The relatives clearly showed this ambivalence as

they aired their feelings. Some fear of treatment and its outcome was slrown by four of the relatives.

Mrs. Johnson and Mrs. Sheehan both

thought that the treatment caused pain.

Mrs. Sheehan, Mrs.

Sanders and Mrs. France all felt that the treatment might kill the patient. Negative feelings were declared by four relatives toward this Hospital or other hospitals which treated mental patients.

Mr. Hauser felt wit was about time11 his son received

53

treatment.

Mrs. Randolph was dissatisfied with her earlier

experience at a state hospital when her husband had been ill earlier; she felt that treatment had made her husband worse then and she was so upset by her husband’s condition, that • she had taken him from the hospital before treatment was completed.

Mr. Henderson expressed negative feelings toward

state hospitals for the treatment of mental illness by indica­ ting his relief that his father was a patient in a Veterans Administration Neuropsychiatric Hospital.

Mrs. France felt

that she had received little consideration when her husband was hospitalized earlier. ‘Mr. Henderson and Mrs. Johnson both felt the medical care in this Hospital was inadequate. Mrs. Johnson stated that her son had not received necessary dental care and Mr. Henderson noticed a soiled bandage on his father’s leg and he wondered why this was. not changed. Mrs. Sheehan and Mr. Henderson thought their father should not be kept on a locked ward. Feelings of guilt were evident in five interviews. Mrs. Sheehan, Mrs. Sanders, Mrs. Randolph, Mrs. Johnson and Mrs. France all thought that they were being asked to con­ sent to a form of treatment which the patient did not want and four relatives, Mrs. Johnson, Mrs. Randolph, Mrs. Sanders and Mrs, France thought they were partially respons­ ible for the patient’s hospitalization. Financial problems were revealed by Mrs. Randolph,

54

Mrs# Sanders and Mrs. Prance.

They all felt that they would

have difficulty if their husbands remained in the Hospital. This was rather a resistance to treatment in that it implied continued hospitalization. There was no emotional acceptance of the need for treatment in three instances.

Mrs. Sheehan, Mrs. Johnson and

Mrs. Prance all verbalized an intellectual acceptance of the need for treatment but this did not imply their acceptance of a need for treatment. Some hostility against the patient was evident in the interviews with Mr. Hauser and Mr. Henderson.

Mr. Hauserfs

detachment seemed to indicate a rejection of his son and Mr. Henderson stated his hostile feelings quite easily and clearly. The possibility that she might be expected to commit her father to the hospital was cause of real concern for Mrs. Sheehan. The patient’s reaction to the information that they had consented to treatment was feared by Mrs. Randolph and Mrs. Sheehan. The relatives felt treatment was a punishment of the patient in the six interviews.

This feeling was the product

of the feelings which the relative indicated in each inter­ view; these feelings have been discussed above.

55

Did the feelings of relatIves constitute a harrier in the acceptance of responsibility for treatment? • It can be said that feelings did create a barrier in most instances, but not all, to accepting the responsibility. The feelings of four relatives were sufficiently threatening to induce them to resist the interview experience. Mrs* Johnson and Mr* Hauser spoke with indignation, and res­ ignation of the difficulty they had in reaching the Hospital. Mrs. Randolph preferred to discuss treatment on the telephone and Mrs. Sheehan would have not come to the interview had her brother not accompanied her. The relatives displayed feelings in three instances which generally impaired their ability to use the interview to discuss the feelings which they had in relation to treat­ ment.

Mrs. Johnson1s fear of the treatment and the anxiety

centered around taking the responsibility seemed so great that she was unable to participate freely in discussing questions which she had related to the treatment.

Mrs.

Sheehan’s feelings were so threatening to her that she could not sign the consent from but instead delegated the respons­ ibility to her brother.

Mrs . Sanders feelings centered about

the hospitalization of her husband had made her physically ill and her anxiety related to the treatment allowed her only a limited awareness of the responsibility which she assumed when she signed the consent letter.

Mrs. France^ anxieties

56

were so deeply rooted that she could not release enough or her feelings to accept the responsibility for signing* Feelings present but which did not present barriers to the assumption of responsibility were the feelings of hostil­ ity directed by Mr. Hauser and Mr. Henderson against the patient. All of the relatives, save Mr. Hauser, expressed feel­ ing rather freely and they were able to sign the consent form. Signing the consent form in two instances, Hauser and Henderson, seemed to signify a withdrawal of responsibility on the part of the relative and while this was not a barrier in accepting the immediate responsibility, still it might have created barriers in participating in later responsibilities related to the patient and his hospitalization.

Mr. Hauser

felt that he had fulfilled his entire responsibility when he signed the form and Mr. Henderson’s act of signing the form seemed only symbolic of a growing rejection of his father which stemmed from the hostility he aired in the interview. Bid the casework interview enable the relatives to gain sufficient understanding of treatment to allow them to assume responsibility? It can.be said that each of the relatives lacked a relatively complete understanding of treatment and of its goals at the conclusion of the interview.

All of the rel­

atives but Mrs. France were helped to participate only after

57

they had an opportunity to~@xpress some of their feelings about the patient and treatment.

It cannot he assumed, how­

ever, that the signing of consent insured the later participation of the relative in total treatment plans. Did the casework interview aid the relatives in lending themselves in a positive way to helping in the over-all planning for the patient? Mrs. Sheehan, Mrs. Sanders and Mrs. Prance were referred by the interviewer to a regular social worker assigned to the ward; they participated in planning and seemed to profit from the relationship with a social worker.

Mrs. Randolphs

concern seemed to center in the patient and although she might be able to utilize casework help, she was unable to meet with the social worker.

Mr. Hauser seemed to reject his son and

Mrs. Johnson was inaccessible to help; for this reason they were not referred to a social worker during the initial interview.

58

CHAPTER IV COHCLTJSIOUS It was not possible to draw definite conclusions from a study of such a limited number of cases. exploratory study.

This was an

It indicated the need for further exam­

ination of the fears and anxieties of the relatives and the role these feelings play in the acceptance of responsibility for consenting to shock therapy. The relatives1 reactions to consenting to treatment could not be viewed as an isolated reaction but reflected in part the relative’s basic relationship to the patient.

Mr.

Hauser’s feeling of rejection for the patient enabled him to sign the consent for he felt it relieved him of future responsibility.

Mrs. Sheehan and her brother were allowing

the hospital to take the responsibility when they signed the form consenting to treatment.

Mrs. Randolph had a deep

concern for her husband’s welfare and she feared the treat­ ment because he did. Fear of treatment and unreal hope of what the treatment might accomplish seemed to be a general reaction in all interviews, except Mr. Hauser.

In this connection all

relatives indicated that they wanted and needed medical information about treatment.

This seems to reflect a need

for the relative to meet routinely, with a doctor before he Is

59

asked to assume the responsibility Tor consenting to a treat­ ment he fears and does not understand.

The relatives have a

right to he mad© more fully aware of a hospital1s assumption of responsibility in determining need of shock therapy for the patient• The need for a meeting with a social worker early in the patient *s hospitalization also seemed indicated.

The

relatives released much of their feelings and used the inter­ views in such a way that they were able to consider an acceptance of the responsibility which the hospital requested of them.

The interviews also familiarized the relatives with

the hospital setting and offered them a medium of help which they could use if problems which concerned the patient or themselves arose later during the patient*s hospitalization. Since all of the relatives had unreal hope of treat­ ment, this, too, points up the need for a continuing casework relationship.

If the relatives are expected to participate

in discharge plans for the patient, they will need to work through the unreal expectations they hold for the treatment. With the exception of gr, Hauser, the relatives seemed unprepared emotionally to assume the responsibility of consent as being constructive to the patient.

This points up the im­

portance of discussing the signing of the consent form with a representative of the hospital and seems to Indicate that in all cases where it is possible to interview the relative, this

60

method is preferable to sending the form letter to them.

If

the relative is asked to participate in signing the consent to treatment he can feel that he does have a role in controlling what happens to the patient and in doing so he becomes a more vital part of treatment planning. Since the relatives are properly concerned with the fear the patient has of shock therapy it seems that patient should be given opportunity to participate to a greater extent by being helped to resolve, with the more help of the doctor, the fears about treatment.

The relatives may feel freer to

act in most instances if the guilt and anxiety caused by the feeling that they are acting deceitfully is relieved. There appears to be a need for more careful planning in meeting the problems which arise in the treatment of the patient.

Additional help on the part of both medical and

Social Service staffs should be offered to the relatives as they are informed about the recommended therapy.

Service to

relatives at this point in the treatment process can contrib­ ute to continuing participation on their part in future plans for the patient.

BIBLIOGRAPHY

BIBLIOGRAPHY A. BOOKS Bartlett, Harriett M., Some Aspects off Social Casework in A Medical Setting! Chicago: American Association of Medical Social Workers, 1940. 270 pp. French, Lois Meredith, Psychiatric Social Work. Hew York: The Commonwealth Fund”, 1944. S44 pp. Lowry, Fern, Readings in Social Casework. Hew York: Columbia University Press, 1939. 0^9 pp. B.

PERIODICAL ARTICLES

Alexander, G. H., M.D., 9Electric convulsive therapy; com­ parative classification of results determined with and without use of time factor in their evaluation,9 Journal of Hervous and Mental Disease, 102:357, Sept embe r , 1945. — Bellsmith, Ethel B., ttThe Mentally 111 Patient,9 Hews Letter of the American Association of Psychiatric Social Workers, 11:308, July, 1941. ~ Bennett, A. E., M. D. nShock therapies; evaluation,9 Psychiatric Quarterly, 19:465-477, July, 1945. Biddle, Cornelia, 9The Individual in Relation to A Medical Care Program,9 Family 23:104-111, June, 1941. Braatoy, T., M. D., indications for shock treatment in psychiatry,9 American Journal of Psychiatry, 104: 573-575, March, 1948. * Crutcher, Hester, B., 9The Function of a Psychiatric Social Worker in a Mental Hospital,9 Hews Letter of the American Association of Psychiatric Social Workers, 1^:3-11, Summer,T942^ 1 Froeseh, J., M. D., HElectric shock; reaction.9 American Journal of Psychiatry, 102:311-315, Hovember, 1946.

63

Hauser, A., ’’Present status of electric shock therapy,11 Diseases of the Nervous System, 9:55-59, February, 1948. Honsberger, Jeanette Davis, HFamily Casework and Orthopsychi­ atry,” Journal of 0rthops y chiat ry, l4:350-3377 Aprils

m tr

------------

Huston, P. E., ’’Effect of electric shock on mental efficiency,” American Journal of Psychiatry, 104:707-712, May, 1948. Kerman, E. F., M. D., ’’Electroshock; efficiency in preventing or shortening hospitalization,” Journal of Nervous and Mental Diseases, 106:1-10, July,1947. Levinrew, George, E., ’’Shock Therapy,” Hews-Letter of the American Association of PsychiatricSocial Workers ~ 14:84-^, Spring, 19451 Lewis, W.D.C., M. D., nWhat*s what about shock therapy,” Mental Hygiene, 30:177-185, April, 1946. Michaels, Joseph, J., ‘’Psychiatric Implications of Surgery,” Family, 13:363-369, February, 1943. Polatin, Davis, ’’Shock Therapy in Schizophrenia,” Journal of Social Casework, 16:283-289, December, 1945. Pacella, P. L., M. D., ’’Varieties of electrical shock therapy,” Journal of Nervous and Mental Disease, 109: 396-404, M a y , 1949. Ryerson, Rowena, ’’Casework with Schizophrenic Patients Treated with Shock Therapy,” 16:289-296, Journal of Social Casework, December, 1945. Salzman, L., M. D., ’’Shock therapy; evaluation,” American Journal of Psychiatry, 103:669-679, March, 1947. Veit, H., M. D., ’’insulin therapy at Colorado Psychopathic Hospital,” Diseases of the Nervous System, 8:320-323, October, 1947. Woodcock, Mary Ellen Hayes, ’’Case Analysis, News-Letter of the American Association of psychiatric Social Workers,11:5-9, July, 1941.

Ziskind, Louis, ”The Caseworker*s Relation to Shock Therapy, Journal of Social Casework, 29:389-594, December, 1948. C.

PUBLICATIONS OF LEARNED ORGANIZATIONS

Group for‘the Advancement of Psychiatry, ’’Shock Therapy,” No. 1, September, 1947. , ”The Psychiatric Social Worker in the Psychiatric Hospital,” No. 2, January, 1948. ______, ’’Public Psychiatric Hospitals,” No. 5, April, 1948. D.

UNPUBLISHED MATERIAL

Reznick, Samuel, M. D., ’’Shock Treatment.” Lecture given at Brentwood Neuropsychiatric Hospital, October, 19, 1948.

APPEHDIX

Bear

Your ___ , ____________

,wasrecentlyexamined

by medical staff at this hospital and it is felt that a special type of treatment might be beneficial to him at this time. It is the policy of this hospital that treatment be discussed and administered with the consent and cooperation of responsible relatives.

You may have questions regarding

the treatment and I will gladly discuss them with you. I have scheduled an appointment for you at the Hospital Social Service Office for the purpose of securing your consent to this treatment.

Will you call me at your

earliest convenience to complete arrangements for an interview?

I am In my office each Monday afternoon, and all

day Tuesday and Thursday.

Telephone:

ARizona 7-6761,

Extension 751. *

Very truly yours,

veterans

A d m in is t r a t io n i

________ J2E H IEB ________ Wilshire k Sawtelle Boulevards Los Angeles 25, California

Y O U R F IL E R E F E R E N C E :

IN R E P L Y R E F E R T O :

Dear Your who was recently admitted to this hospital, may require treatments of a specific nature ,at a future date. These treatments will consist of insulin therapy or special treatments given wit h an electrical machine such as electric shock or electronarcosis. These treatments have been of much value when given patients in the past. Th e y will not be given to you until after case has been completely studied and until the medical staf'f is of the opinion that they may be of benefit to him. Results obtained at this hospital have been very satisfactory and we feel we have been instrumental in returning many of our patients to civilian life. There is a certain element of risk involved, of course, as in other types of treatments and for this reason we are asking your w ritten consent for this procedure. It is requested that you return this letter as soon as possible in order that all necessary laboratory work, x-rays etc. may be completed at the earliest possible date. Very truly yours

Clinical Director Neuropsychiatric Hospital K n o wing the possible beneficial effects that m a y be obtained from the above mentioned treatments, and realizing that these treatments are not without a certain element of danger to the patient, I hereby give my consent for the administration of the above treatments to the patient. [ S i gnature ) VA For m Sep 19^6

(Relationship!

SFFL

An in q u iry by or concerning a n ex-service m a n or w o m a n sh o u ld , if possible, give v eteran ’s n a m e a n d file n u m b e r, w h eth er C, XC, K, N, or V. If su c h file n u m b e r is u n k n o w n , service or se ria l n u m b e r sh o u ld be given.