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SOME FACTORS IN FAMILY PRESSURE TO REMOVE A PATIENT-RELATIVE FROM A MENTAL HOSPITAL
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 Work
by Nile Donald Poyner June 1950
UMI Number: EP66358
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 EP66358 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 is thesis, w r it t e n u n d e r the d ir e c t io n o f the ca n d id a te ’ s F a c u lt y
C o m m itte e a n d a p p r o v e d
by a l l its m em bers, has been presen ted to a n d accepted by the F a c u lt y o f the G ra d u a te 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 degree o f
MASTER OF SOCIAL WORK
D a t e .. /
F a c u lty Com m ittee
C h airm an
TABLE OF CONTENTS CHAPTER I.
INTRODUCTION TO THE S T U D Y ............ The p r o b l e m ..............
. . . .
. . , .
Statement of the problem . . . . . . . . .
Importance of the study •• • » . . • • • •
Definitions of terms used Factors Family Mental hospital Patient Pressure Relative
) ) ........
) } )
Method and r e s o u r c e s ....................... . The setting . . • • • • • « . . Selection of cases for study Number of cases used
. . . . . . .
. . . . . . . . .
Organization of the remainder of the thesis . II.
7 9 10
Procedure for studying cases Questions to be answered
10 12 13
. . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . .
Case C Case D
. * . . .
iii CHAPTER III.
SUMMARY AND CONCLUSIONS.... ....... . . . . . .
Summary of f i n d i n g s .......................
findings. . . .
Conclusion of the study.• • « . . • • • • .
Implications for the mental hospital . . .
Implications for social work
. . . . . . .
. . . . . .
A P P E N D I X .............................................
CHAPTER I INTRODUCTION TO THE STUDY Hospitalization for the mental patient is considered as only one phase in his treatment.
Ideally he will re
ceive some benefit from hospitalization, and his condition will show some objective improvement.
When his degree of
recovery can be met by the needed degree of acceptance, care, and supervision his family can offer upon return home, he can be released. I.
Statement of the problem.
The family who creates
pressure to remove a patient-relative from a mental hos pital has long been a problem to staff members of these hospitals.
The family may actually jeopardize a patient1s
recovery process because, from the time of admission, they harass the staff to release him, often claiming that he is now well, or that he was never ill, that he is being mistreated and the family can offer better care for him, or that he is needed urgently at home.
Very often the patient
is under undue anxiety because he believes his family is going to have him released any day and there is no use for him to participate further in the hospital phase of his rehabilitation.
2 From the behavior of these families the assumption can be made that for some reason, or many reasons, they are not accepting hospitalization.
The hospital staff can
not always ignore these pleas, promises and demands from the patient1s unhappy family.
Due to overcrowding of the
hospital and the need for bed space, they are tempted,to, and sometimes do, release one of these patients with the frank recognition that the family will probably have to return him shortly. This thesis is an exploratory study into the nature of this family pressure.
A group of cases has been selected
in which family pressure was evident.
They were studied
with this research question in the foreground:
the constellation of factors in family pressure to remove
a patient-relative from a mental hospital before satis factory recovery?
The purpose was to assemble and analyze
some significant data which may be useful to the social worker in a mental hospital as he is able to anticipate and handle these problems. Importance of the study.
Dr. Richardson has devel
oped the concept of the ^family as the unit of illness.”
states, ”The family is the unit of illness because it is the unit of l i v i n g . H e
. . these *intrinsic
1 Henry B. Richardson, Patients Have Families (Hew York: The Commonwealth Fund, 1945}, p. 76.
powers of adjustment1 are characteristic not only of indi viduals but of families,112 The ”family as the unit of recovery” would seem to be a valid concept in reference to the mental patient, since modern psychiatry recognizes the significance of early family relationships in the development of the functional mental disorders.
The importance of this concept is im
plied in the fact that the patient without a family to re ceive him used to stand a lesser chance of being released. Its importance is further implied in the use of the licensed "family care home” for the patient without a family of his own. Thus we need to know more about different types of family relationships to patient and hospital*
We need to
know more aboutr (1) the family who accepts neither the patient nor the hospital, i.e.-, forgets about him; (2) the average family who accepts patient1s illness and the need for hospitalization; and (3) the family who does not accept the hospital and brings pressure to bear upon the hospital to release the patient.
This study is a preliminary one,
concerned with the latter group of families. A study with some bearing on this problem was pre sented in a thesis at Smith College in 1942*
2 Ibid.. p. 63
One of the
4 three primary concerns was the ”reasons that motivate families to remove a patient from a mental hospital against medical advice.n
The material assembled indicated that
families remove patients because of an intellectual mis understanding of mental illness and because they are motiv ated by forces that spring from their own emotional con flicts and relationships to the p a t i e n t . 3 Casework service to relatives of mental hospital patients is now acknowledged as one part of a complete treatment program for the p a t i e n t . 4
The Group for the
Advancement of Psychiatry states that the caseworker, in addition to, or apart from, concrete types of services may help a person ” . . . b) by helping him to understand his situation better; and c) by helping other people signifi cant in his life.”5
other studies have demonstrated that
casework interviews can help to relieve the emotional stress that exists for relatives who bring patients to the mental 3 Helen H. Stamm, MSome Effects of Familial Attitudes Upon later Adjustment of Psychotic Patients Paroled Against Advice.” Smith College Studies in Social Work. XII (Sept. 1941)> 195^937 4 Martha Biehl, wSocial Casework with Relatives of Hospitalized Mental Patients” ^ thesis presented at the University of Southern California, June, 1949) , pp. 46-4?* 3 Group for the Advancement of Bychiatry, ”The Psychiatric Social Worker in the Mental Hospital,” Bulletin of the Menninger Clinic. II, No. 2, (November 194?) pp. 188-89.
Guilt feelings caused by fear of disapproval,
anxiety based on imaginary dangers, and fears based on real danger to the patient could be alleviated ,or dissipated.
addition to relieving immediate emotional stress, intake interviews, such as social history interviews, provide an opportunity to establish a better relationship with the hospital.^ There are many indications that the social service departments of our mental hospitals will be increased and thus will be able to assume broader responsibilities.
writer feels that this problem will be coming more to the attention of the hospital social worker; i.e., in the future, families who are dissatisfied, or unable to accept hospitalization for a relative, will be noted in early con tacts with social service departments where they may be helped to understand the hospital and the patientfs need to be there. II.
DEFINITIONS OF TERMS USED
In this thesis, the following are the definitions of 6 Helen A. Darragh, "The Role of Social Service with the Families of Mental Hospital Patients," Smith College Studies in Social W o r k . XIII (September 1942), 187-88. See also: Biehl, o p * cit. See also: Esther Goodale, "Intake Interviews with Relatives of Psychotic Patients," Smith College Studies in Social W ork. XV (September 1944), 15-51.
Elements that contribute to produce a re
This simple dictionary definition is satisfactory for
this study* Family.
Members of a household, i.e., man, wife, and
children; or a group descended from a common progenitor.' Mental hospital.
An institution for custodial care
and treatment of mental patients, in this study, Norwalk State Hospital; referred to throughout the thesis simply as the "hospital” or as "Norwalk Hospital.” Patient.
A person under medical treatment; as used
in this thesis, a person committed, by one of several methods, to the custody of a mental hospital for care and treatment Pressure.
The act of pressing*
As used here,
family pressure refers to the persistent and continued ef forts on the part of a patient* s family to remove him from the hospital. Relative. Person related by blood, or by marital tie. Thus the title of this thesis refers to the persistent efforts in the form of pleas, requests, demands, promises, of one or more relatives to gain release (discharge or leave of absence) for another relative who is a patient in custody of an institution dedicated to his care.
of such efforts in the selected cases is that the patient
7 was formally considered for the release desired by the family. III. The setting.
METHODS AND RESOURCES This study was conducted at Norwalk
State Hospital, one of the institutions maintained by the state of California, under the Department of Mental Hygiene, for treatment and custodial care of mentally ill persons, alcohol and drug addicts, and sexual psychopaths.
located on the fringes of the Los Angeles Metropolitan area and serves part of the southern California area, mostly Los Angeles and Orange Counties.
The wards in this hospital
are set up on a cottage plan with an average of ninety patients on each ward.
The total patient population of
the hospital averages around 2,500. The medical staff at Norwalk Hospital consists of twelve physicians, two of whom assume the administrative responsibilities.
Direct medical responsibility is dele
gated to the clinical director and the nine remaining physicians who are assigned from two to four wards each, de pending on the ward classification.
The physicians per
form mental and physical examinations, administer electro-shock therapy, prescribe medication and other treatment, and per form individual and group psychotherapy.
An important pro
cedure in this setting is the Mclinic staff,” referred to
8 throughout this thesis as nstaff*”
This staff is a meeting
of the hospital physicians, held two mornings each week, in which patients are considered individually for diagnosis, change in status, consideration of leave of absence, and for discharge.
Permission to conduct this study was ob
tained from the hospital clinical director who conducts these staff meetings. Within the California State Department of Mental Hygiene is the Bureau of Social Wark charged with extramural care, or supervision of patients on leave of absence from the state hospitals.
Social casework service to patients in
or out of the hospital and to their families is the function of the Bureau.
The social service departments within the
hospitals are adjuncts of the Bureau of Social Work, with administrative responsibilities to the hospital superin tendent and to the Bureau.
The activities of the hospital
social service department are largely concerned with:
social histories of patients who live near the hospital in Orange County; (2) written requests to the Bureau for pre-leave investigations of patients1 home situation, family care, and industrial leave placements; (3) casework services to patients in the hospital upon referral by the ward physicians or by staff.
Patients with ground privi
leges may refer themselves to social service for assistance with problems in hospital adjustment, and for leave planning. The hospital department performs no service outside the
9 hospital; work within the community is performed by the Bureau upon specific interagency requests written by the hospital worker. At the time of this study, the social service de partment at Norwalk Hospital consisted cf one full time resident worker, a student supervisor, and three students. Selection of cases for study.
Cases used for this
study are those in which family pressure to have the patient removed was evident.
Thus the following criterion was es
tablished: patients who were presented by their ward phy sicians to the clinic staff for consideration of release, leave, or discharge, not because their progress toward re covery was necessarily satisfactory or hopeful, but primar ily because of pressure from their relatives who wished to remove them from the hospital. staff meetings.
The writer attended the
Cases were tentatively selected on the
basis of comments from the ward physician such as:
patient has not been doing very well but his family is very insistent about taking him home now and I would like to see what the staff1s opinion is"; or "His condition hasn* t improved but his family wants him out -— see me several times with a minister.
theyTve been to
I*m bringing him to
staff at this time because of this letter from attorney X requesting his release. however."
I can’t recommend it at this time,
The patient*s diagnosis, age, sex,
10 decision of the staff were not used in selecting cases since this study is concerned with the family pressure to have them removed regardless of the patient1 s true condition. Final selection of a case was based on the ward physician1s indication of whether the patient1s condition or the family pressure was his reason for presenting him to staff. Number of cases used.
This was not intended to be
a comprehensive statistical study but it was felt that all cases within an arbitrary time period would provide a representative sampling.
Fifteen cases, between October
16, 1949, and December 16, 1949, were tentatively selected; nine of these were discarded because the family pressure was proved not to be the primary reason for their being brought to staff —
that is, although the family pressure
was indicated, the ward physician considered the patient1s recovery was fairly good and he could leave the hospital anyway.
The six cases which remained were all such that
fitted into the established criterion within the two month period. Procedure for studying cases.
To gather material
for these cases, the writer made notes and observations in the clinic staff, read the hospital chart and correspondence file, conducted interviews with the ward physician, and interviewed the family.
Some factual material was drawn
11 from the record.
The ward physicians opinions were given
due consideration in each case. interview with the relatives.
The basic material was the Conclusions made regarding
each case are the writer’s own deductions made from all sources. Interviews with the relatives took place in the fol lowing wayss two families were interviewed while at the hospital for another purpose; two were interviewed in their homes after the patients were home on leave of absence — these interviews were arranged by telephone call to the family, the writer stating that he was a social worker from the hospital and would like to see them to ask some ques tions; in one family the interview took place in the hospital after the relative was asked by letter to come in to see the social worker on the next visit to the hospital to dis cuss why continued hospitalization was necessary for the patient; the remaining relative, an aged mother, was inter viewed in a general hospital where she was recovering from an acute physical illness. In these interviews with members of patients’ families, direct questions were asked only when necessary, although the interviews were focused on these questions, to witr they asked for patient’s release?
Was the patient asking
them to get him out of the hospital?
He anyone at the hos
pital discussed the patient* s condition with them?
12 their plans for the patient?
An attempt was made to draw out
their feelings about the patient and about the hospital, and to see what problems they were facing due to the patient1s absence from the home. Questions to be answered.
I n using the material from
these sources, the writer sought information to answer some questions which would contribute light on the central research questions
What is the constellation of factors in family
pressure to remove a relative from a mental hospital before satisfactory recovery?
Six sub-questions were considered by
the writer to be pertinent to this central question.
studying the six cases, the focus was on these six sub-questions: ( D What is the patient’s family make-up, prior to commitment, and at present?
(2) What seem to be the reasons for wanting
the patient released nowj the obvious, or stated reasons, and any additional reasons revealed in this study?
(3) How well
has patient adjusted to hospital life? Does the pressure, ap parently from the outside, originate partly from the patient? (4) How well does the family seem to understand and accept the patient’s condition?
Has this been discussed with a
member of the hospital staff?
(5) What method has the family
used in working toward the release? Hive they enlisted other professional people as aids?
(6) What plans do the family
have in kind for the patient’s care and treatment, or super vision, outside the hospital?
Are there some obvious hazards
13 in their plans? It was felt that an analysis of these six eases would reveal a common pattern if one exists.
Is there a thread of
similarity running through all these eases?
From the total
picture, it was hoped that some conclusions could he drawn with implications for the practice of the social worker who is working with such problem situations in a mental hospital. IV.
ORGANIZATION OF THE REMAINDER OF THE THESIS
The following chapter consists of case studies of the material from which the conclusions are drawn.
Chapter III are the summary of findings, the conclusions of the study, and the implications for the hospital and for social work.
CHAPTER II CASE STUDIES The cases presented in this chapter contain both factual information about the case and some conclusions re garding them.
They are presented in such a way as to point
up the salient factors with which this inquiry is concerned. The schedule used in analyzing the eases and presenting them is included in the Appendix.
Some factual findings in
the six eases are given-in Table I, also in the Appendix. The names used for these cases are fictitious.
surnames given to the patients coincide with the first six letters of the alphabet for convenient reference.
identifying information has been disguised to prevent posi tive identification of the patient and his family.
GASH, .A Name:
Mrs. Mary Anderson
September 23, 1949
Date presented to staff: Reason:
November 15, 1949
For consideration of leave of absence.
Committed to Norwalk Hospital:
O n petition of her son,
Albert Anderson. Requests for release were presented by patient*s son beginning two weeks after admission.
Mrs. Anderson was divorced in 1932
when she was 4,6 years old, and when Albert, the Anderson* s only child, was 17.
Since then, Mrs. Anderson and her son
have lived together or near each other. went into the service daring the war. a child 2 years old.
Mr. Albert Anderson He is married and has
Since his discharge from the service
four years ago, Mrs. Anderson has lived with her son and his wife, or as near to them as possible.
The whole family had
to move frequently because of Mrs. Anderson1 s difficulties with neighbors and landlords.
At times, due to friction
with her daughter-in-law, Mrs. Anderson would move tempor arily out of her son*s home. Mrs. Anderson has a small, but adequate income from her grandfather*s insurance.
Her son has been supplementing
a disability allowance, for injury in the service, with work as a **bouncer** in a night club two nights per week. Situation at time of commitment.
Patient* s son be
lieved his mother had shown progressive mental symptoms in the past four years. for him to control.
She had become increasingly difficult She believed someone was influencing
her with electric rays, became preoccupied with her digestive system, and allegedly consumed one gallon of mineral oil per week.
O n several occasions, Mrs. Anderson threatened her
daughter-in-law with a knife or an ice pick.
(Case A) led to her son’s decision to sign a petition for her commit ment. Condition at time
Anderson was presented to staff for leave of absence, her condition was reported as essentially unchanged.
not wholehearted agreement but the staff decision was that she might return home if a pre-leave investigation! was satisfactory; she would need twenty-four hour supervision. Patient’s adjustment to hospital.
The record indi
cated a poor adjustment to hospital life for this patient; or rather, a continuation of her inability to get along with other people.
On one occasion she became combative and was
involved in a fight with attendants in the dining room.
entry in the record on 10-16-49 described her as "irritable and quarrelsome at all times; extremely negative, often kicking attendants without warning or reason."
was considered desirable for Mrs. Anderson but was not given because of a condition in her neck and spine. Patient’s part in attempting release.
1 These investigations are carried out by a worker from the Bureau at the request of the staff. Requests for pre-leaves are made through the hospital social service de partment. A thorough study is made of the home situation as to whether this home will fulfill the patient’s needs for understanding and acceptance or in some cases with regard to the amount and kind of supervision patient would have. Find ings in these investigations are returned to the hospital in
17 (Case A) acknowledged that his mother was demanding that he get her out of the hospital.
She did not add to his guilt by blaming
him directly for the commitment; rather, she said that some outside force had influenced him to take this action.
most effective response was obtained by stories to him of being mistreated in the hospital. Relative* s understanding of patient1s condition. Patient1s son gave a vague history of his mother1s having been in two sanitaria about twenty-eight years ago.
to be aware that she had been ill for a number of years and that she was not improved at the present time.
war, he once held a job as a male nurse for a wealthy schizo phrenic patient and therefore had some knowledge of the eare for a mental patient.
The ward physician felt that Mr.
Anderson had a fair understanding of his mother1s illness. He spoke of her ”paranoid condition” and her ” ideas of per secution,” some of which he recognized as such. The writer agrees that Mr. Anderson was aware that his mother was mentally ill; that he had some understanding of her particular illness.
However, his emotional relationship
with his mother prevented him from fully appreciating the nature of the illness.
He failed to see the exaggerated com
plaints against the hospital as symptoms of her illness.
18 (CASE A) had shown him some marks on her neck and to him this was proof that she was being grossly mistreated.
tions of his understanding were indicated' by his unrealistic planning for his mother’s care. Plans for patient’s care outside the hospital. Anderson’s plan for his mother was simple.
He said that his
wife and he had separated and planned to get a divorce; thus there would be no further difficulty there.
He had bought a
trailer house where he and his mother would live alone. Since he worked only two nights per week, he would be able to give patient almost twenty-four hour supervision. A pre-leave investigation report did not confirm Mr. Albert Anderson’s claims. him.
His wife and child were still with
He had bought a second trailer house and parked it
next to the first one; patient would live in the second trailer house.
Mr. Anderson then said that he would either
control patient, or place her in a private hospital.
implied that if his plans did not work out well, his wife could go back to her parents. Relative’s reasons for pressing for release.
Anderson’s ward physician, her son said he wanted his mother released because the changed home situation made it possible for him to care for her.
His wife would no longer be present
(CASE A) to annoy the patient.
He complained, too, that he had been
misinformed, that he would not have had her committed had he not been told at the court hearing that he could remove her any time he chose.
He implied that the trailer house he
now owned would facilitate moving if neighbors became a problem. To the writer, Mr. Anderson expressed fear that his mother would be mistreated and perhaps injured by attendants or by other patients.
He revealed, too, that his mother was
demanding that he take her out of the hospital. seemed to be reacting to a dominant mother.
had been noted by the ward physician, by the writer, and by the social worker who m d e the pre-leave report.
to be suffering guilt for having had his mother committed; for having placed her second to his wife. Relative’s method of working toward release.
from two letters to the hospital, Mr. Anderson’s efforts toward release for his mother were in the form of personal interviews with her ward physicians.
He had not been in
sistent nor demanding; rather he had depended on personal appeal with a convincing distortion of the facts in the case —
and like his mother, Mr. Anderson was convincing. Significant findings.
The principal motivating factor
20 (CASE A) in the pressure for this patient*s release would appear to be the son*s sense of guilt for having initiated his mother*s commitment.
The relationship between patient and
relative seems to be a dominant mother-son relationship. This dominance permitted the patient to demand that the relative seek her release and to get a response to these demands. A release for this patient would accomplish nothing for the relative except perhaps temporary alleviation of the sense of guilt for having had her committed.
permit the patient to regain her position of domination of the relative and his family.
Nothing constructive would
have been accomplished by a release of Mrs. Anderson at the time her son made his appeal.
The reality situation of the
family did not seem to require the patientfs presence; i.e., she would not fulfill a major familial role in terms of responsible activity or financial contribution.
rupting influence on her son*s family has been described. Patient*s needs, as an ill person, would not be met by returning her to a situation so similar to the one pre ceding commitment, wherein patient had become progressively disturbed for the past four years.
The family in this case
did not seem to understand patient*s needs at this time* Implicatifor
Though patient *s son
21 (CASE A) took the initial step in commitment, he obviously needed help in accepting the necessity of hospitalization for his mother.
Thus social casework apparently was indicated from
the beginning of the process of the patient1s commitment and care. Such unmet need of service to the family can block the hospital and nullify its efforts to discharge its function, CASE B Name:
Mr. Donald Baker
Sexual psychopath without psychosis
June 13, 1949
Date presented to staffs Reason:
October 17, 1949
For leave of absence and other considerations.
Committed to Norwalk Hospital:
By the superior court upon
recommendation of the psychiatric advisor to the court. At the court hearing there was opposition to this recommendation, by Mrs, Baker, the patient1s wife, and by other individuals and religious groups apparently enlisted by her.
Continued opposition by Mrs. Baker during the next
four months resulted in this patient*s appearance at staff for consideration of leave. Family situation.
Mr. Baker had been married nine
22 (Case B) years, since age 27. 4*
The Bakers have two sons, aged 7 and
Mr. Baker1s wife is several years his junior, and. Mr.
Baker seems to have held a dominant position In the family due to his wifefs immaturity and inadequacy as a person. Both agreed that their marriage was not a happy one.
cording to Mr. Baker, this was because of his wifefs frigid ity while Mrs. Baker blamed her own ignorance about sex. She complained that her husband was often irritable with her and the children.
She acknowledged, too, that she demanded
material luxuries that were beyond their means.
to commitment the family was supported by Mr. Baker1s income which he earned in the advertising business.
They had been
making payments on a moderately priced home, car, and furn iture . Situation at time of commitment.
Mr. Baker1s dif
ficulty was a pathological urge to see and fondle the gen itals of female children — adulthood.
a difficulty hefd had since
Several times, prior to his arrest, Mr. Baker
had lured a six year old girl in his neighborhood into his garage where he indulged in his abnormal desires.
one of these episodes, the child told her parents, who filed the charges that led to his arrest and eventually to his commitment to Norwalk Hospital.
23 (Case B) Mr. Baker admitted being involved in similar acts in other states on two occasions.
He had escaped prosecution
each time by promising the child's parents that he would move to another state, and by fulfilling this promise.
family knew nothing of this difficulty until his arrest for the most recent episode. Patient's condition at time of staff appearance*
Mr. Baker came to clinic staff, he said he believed he had been cured by religion, prayer, advice, and by forgetting his past troubles*
When asked, he said he did not believe
he should be in a hospital or that he ever should have been. As evidence of his recovery, Mr. Baker stated that he no longer dreamed of little girls. The staff doubted this patient's claims and agreed that his condition was essentially unchanged. denied.
However, though he was considered a poor risk for
psychotherapy, he was referred to the staff psychologist for psychotherapy as a result of staff consideration.
had been one of the requests made by Mrs. Baker for her husband. Patient's adjustment to hospital.
Outwardly M r . Baker
showed a good adjustment to the hospital, though he was resentful about being there.
He was considered a ,fcooperative
24 (Case B) patient,” had ground parole privileges, was well-behaved, and worked under supervision on the hospital farm*
his appearance in staff in October, he received no specific treatment for his condition. Patient1s part in attempting release.
Mr. Baker had
played an active and shrewd role in the pressure for his own release.
Mrs. Baker acknowledged that patient had
coached her and friends of the family in every action they had taken toward his release.
He had written letters for
her to sign and mail to the hospital.
He added to his
wifefs guilt feelings by blaming his difficulty on her frigidity to an extent that she at one time blamed herself almost totally for his condition. Relative1s understanding of patient1s condition.
Baker’s complete lack of understanding of her husband’s con dition was indicated by the fact that she believed she was responsible for the condition.
Since Mr. Baker had been
committed, she had gone to a psychologist for counseling and had gained some intellectual insight into this condition which she then saw as something which started long before she knew him.
She continued to blame herself, however, for
precipitating the recent episode by her lack of sexual knowledge and adjustment in marriage and by her demands for
25 (Case B) material things which drove her husband to overwork himself. Two ward physicians talked with Mrs. Baker but she did not ask for any explanation of her husbandfs condition. Some explanation of the need for hospitalization was given but apparently not accepted. Plans for patient*s care outside hospital.
for Mr. Baker’s care, as Mrs. Baker was able to formulate it, was to reestablish a home with their children.
Baker was to take a job offered him by a religious group; he had had adequate training and experience to earn a living. Psychotherapy would be sought if recommended by the hospital staff. Relative1s reasons for pressing for release.
Baker’s reasons for opposing hospitalization for her hus band changed in nature since his arrest.
After his commit
ment, the Bakers lost their home and furniture.
moved into an apartment for a while and tried.to support herself and the children.
She sought an Aid to Heedy Children
grant but due to a misunderstanding with the public assist ance office, she gave this up and sent the children to her parents in another state —
the latter step partly because
her oldes"t child was subject to ridicule by other children in the neighborhood.
Her initial reason for opposing the
(Case B) commitment to a hospital was to avoid the loss of their home and children* Later, Mrs. Baker was told that her husbandfs con dition was treatable by psychiatry and she was alarmed be cause he was not receiving such treatment in the hospital. She then sought his release so treatment could be assured. To the writer, Mrs. Baker gave these reasons for wanting her husband released£ so that he could have treat ment; to take his place as the family breadwinner; and so they could have their children back and have their home. She believed, too, that his conversion to religion had been an important step toward recovery and that she could now be of help to him. A sense of guilt seems to have been a strong motiva ting force in Mrs. Bakerfs activity.
She believed she had
caused his condition or at least had precipitated its mani festation so that the arrest and subsequent hospitalization occurred. Relative1s method of working toward release.
Baker1s efforts to gain release for her husband were personal interviews with ward physicians and letters to the hospital (which were really written by the patient) .
She enlisted the
aid of the family minister who came to the hospital several times with her.
According to one ward physician, this
27 (Case B) minister was aggressive about the patient’s being released. Pressure was also exerted elsewhere.
The court psychiatric
advisor once wrote the hospital requesting information about Mr. Baker’s condition.
This letter stated that the inform
ation was for the judge who committed Mr. Baker and that the judge was under pressure by members of the community inter ested in Mr. Baker’s release. Significant findings.
The principal motivating
force in the pressure for this patient’s release seemed to stem from the patient’s inability to accept his confinement. His distraught and bewildered wife sought to reestablish her home and family and to regain her source of support by carrying out his instructions toward gaining a release for him.
Due to Mr. Baker’s dominant position in the family, he
was able to activate his wife’s guilt feelings for having caused his condition and thus spur her on to every possible means to gain his release. This family had been disorganized by Mr. Baker’s confinement and he was needed as a responsible member in his own family. needed.
His presence in the family was urgently
However, his release at the time of this study would
probably have meant a hazard to the community and might have brought further difficulties upon the patient and his
28 (Case B) family.
Psychotherapy was included in the plan for his care
outside the hospital, and this need was understood by the family.
Obviously, psychiatric treatment is what this
patient needed most, but in addition to this, he would need a longer period under protective custody, away from society and away from the problems of everyday living and the temptations that were his outlet.
The difficulty here is
that ahy degree of recovery from this condition can hardly he assured as permanent, and a relapse is too much risk for society to take in the light of recent experience with sexual psychopaths. Implications for social work.
Since society demands
that this patient be confined for a long period of time, this was a reality factor which the relative obviously needed help in accepting from the beginning.
help also in making plans for herself and her children during her husband’s absence from the home.
telligence and resourcefulness could have been channelized into a constructive and responsible part in this planning. The relative’s own personal problems precipitated by the hospitalization, i.e., her guilt feelings, was another area indicated for casework service.
Some interagency cooperation
with the public assistance office would also seem to have been indicated.
29 (Case B) The unmet needs for social service to patient1s relatives in this case appear to have prevented the most constructive use of his hospitalization*
The patient’s wife
suffered undue distress, and their children’s normal growth process was unnecessarily disturbed. CASE C Name;
Mrs. Mable Charles
Psychosis with mental deficiency plus syphilis
May 10, 1945
Date presented to staff: Reason:
December 5, 1949
for consideration of leave of absence
Committed to Norwalk Hospital;
Mrs. Haris, were committed
on the same day by the
court on petition of the police chief of their home town. Patient’s mother was released three months later and im mediately began seeking her daughter’s release. Family situation.
Patient* s father died in 1930 and
shortly after this, she and her mother, Mrs. Haris, moved here from another state.
They made their home together
away from any relatives.
is an only
is a vague mention in the history
married for a short time prior to her father’s death.
30 (Case C) Patient and her mother were a source of annoyance to their neighbors.
Allegedly, she was a prostitute and her mother
was her procuress.
They were supported by an Old Age As
sistance grant to the mother; neither of them had any known recent employment.
They had received services from various
social agencies and the health department.
At one time,
the health department had diagnosed the mother as a paretic and the patient as a congenital syphilitic; she had refused treatment. Situation at time of commitment.
This family had an
extensive record with the police department throughout the 1930*s.
Though charges were brought against them several
times, none was ever pressed.
They were often ordered off
the street late at night but continued to be a problem to the police. According to the petition, this family lived in an apartment behind a tailor shop.
Btient and her mother
amused themselves by peeping through a crack in the wall into the men* s dressing room of the tailor shop.
When the pro
prietor boarded up this crack, they became angry and at tempted to burn the place by starting fires on at least three occasions.
This behavior precipitated their commitment
to Norwalk Hospital.
31 (Case C) Patient*s condition at time of staff appearance.
Charles was brought to staff in December, 194&, and at that time a pre-leave investigation was requested.
stated that her mother did not seem to recognize that patient needed supervision and protection nor would she have been capable of giving supervision had she been cogni zant of the need*
Leave of absence was denied in 194^, and
again in December, 1949, because patient!s mental condition was essentially unchanged and her prognosis not hopeful, and because of her mother1s inadequacy to give supervision. Patient* s adjustment to hospital.
Mrs. Charles* hos
pital chart described her as quiet, pleasant, agreeable, cooperative, simple, confused, and delusional. well and did considerable work on the ward. had convulsions —
epileptic or paretic —
She got along
At times she became mildly dis
turbed, talkative, demanding, and difficult.
She had been on
a disturbed ward as a working patient for the past three years.
She was given a course of penicillin shots to stop
the process of the syphilis£ she had not received any other specific treatment. Patient* s part in attempting release.
seemed fairly contented to remain in the hospital.
asked in staff, she said that she would like to go home and
(Case C) take care of her mother.
She seemed to be as well adjusted
to hospital life as her condition would permit.
no evidence that she played any deliberate part in seeking her own release. Relativeys understanding of patient1 s condition.
Haris1 understanding of her daughter^ condition was difficult to evaluate.
When she appeared in staff in 1945, she
acknowledged some awareness that Mrs. Charles was mentally deficient.
One ward physician questioned whether Mrs. Haris
had the ability to understand patientfe condition.
discussed it with her many times. Lack of understanding was expressed to the writer when Mrs. Haris referred to her daughter and other patients as nprisoners.”
She said she believed her daughter was
sent to the hospital for treatment of a ”blood disease” but had been cured and was being held for punishment for having had this disease and partly because the ward attendant did not like her or the patient.
The writer*s impression was .
that Mrs. Haris' complete denial that anything was the matter with her daughter was partly an expression of her own resent ment and frustration with the hospital. Plans for patient's care outside the hospital.
Haris' plan for her daughter's care was simply to return her
33 (Case C) to their former home where they would take care of each other. Relative1s reasons for pressing for release.
Charles1 ward physician, Mrs. Haris said she wanted her daughter released because she was not mentally ill. To the writer, Mrs. Haris expressed these reasons for wanting Mrs. Charles released:
she was not mentally ill;
they wanted to be together and take care of each other; they could return to their home state where the climate was more agreeable to both.
She was also lonesome for her daughter of
whom she spoke lovingly. That Mrs. Haris would return patient to prostitution was suspected by the hospital staff.
This possibility was
expressed to the writer in this way:
Mrs. Haris said that
when her daughter was home, life was so much nicer because they had so many friends.
Mrs. Charles made friends very
easily; lots of men used to visit and bring nice things for both of them.
The writer felt that direct questioning about
the prostitution would elicit only a denial from Mrs. Haris, as she had denied it before. Relative1 s method of working toward release.
Haris* efforts to gain her daughterly release were numerous and varied.
She made many personal visits to ward physicians
34 (Case C) requesting release *
A number of lawyers and public officials
telephoned the hospital in Mrs * Charles* behalf.
wrote the hospital a letter which, however, did not indicate any legal steps were about to be taken.
Other people, who
stated they were friends of the family, also wrote the hos pital regarding release for Mrs. Charles. Mrs. Haris mailed the superintendent what appeared to be petitions signed by friends and acquaintances.
these was a list of names under what might be called a 11character statement,” denying the alleged actions of Mrs. Charlesx the other was a recommendation by the signers that Mrs. Charles be returned to her home which they believed would be a better environment for her.
At Mrs. Haris* re
quest, a public assistance worker wrote the hospital in September, 194$, inquiring about Mrs. Charles* condition and for clues to a possible plan for patient and mother outside the hospital. Significant findings.
Separation of this family left
Mrs. Haris in almost complete emotional and social isolation. She endeavored to reestablish the same pathological relation ship that existed prior to the commitment.
She continued to
live alone in constant hope and anticipation that some day she could effect her daughter's release from the hospital.
35 (Case C) Though patient1s release might have meant fulfillment of the m o t h e r s needs, patient and the community would probably suffer from it.
This release would not improve the reality situation
of the family.
Patient* s needs as a mentally ill person
would not be met in the proposed plan; the relative was un able to provide the kind of supervision patient needed nor did she seem to understand the need for supervision.
doubtful that she has the capacity to understand her daughter*s condition and needs. Implications for social work.
Aside from the broader
implication for more adequate care for the aged, this mother needed help from the time of her own release in accepting continued hospitalization for her daughter and in making the most of her few remaining years.
with the public assistance agency toward a family care plan for Mrs. Haris seems to be indicated; this to fulfill some of the gaps left by her daughter*s absence. Mrs.Charles* condition remains about the same and her prognosis is admittedly poor. However, where such relation ships exist as between this patient and her mother, nothing will be accomplished until provisions are made for some at tention to the patient*s mother.
36 CASE D Name:
Mrs. Helen Davis
Manic-depressive psychosis, manic type
June 17, I94&
Date presented to staff:
December 10, 1949, and again six
weeks later on January 18, 1950 Reason:
for consideration of leave of absence
Committed to Norwalk Hospital:
Patient was committed by the
court on petition of her mother, Mrs. Marks. Requests for release began in January, 1948, If years after commitment.
These requests were presented by the mother.
Family situation. was a child.
Mrs. Davis’ father died when she
Her mother raised her as an only child and
the family moved here from another state in the 1930fs. Patient married Mr. Davis in 1941 when she was 22 years of age.
This marriage lasted about one year.
She lived alone
near her mother for the next two years, and for one year prior to commitment she made her home with her mother.
family was supported by Mrs. Mark’ s earnings and by intermit tent earnings of Mrs. Davis in defense work. Situation at time of commitment.
M r s . Davis had a
history of several arrests for drinking and she acknowledged smoking marijuana.
It was believed she had shown mental
symptoms for a number of years but had had no previous attacks.
37 (Case D) Just prior to commitment, she became dstructive and irration al, cut up her clothing, refused to dress properly, «talked out of her head.11
Recognizing that her daughter was
mentally ill, Mrs. Marks acted upon the advice of friends and filed the petition for commitment to a hospital. PatientTs condition at time of staff appearance. When Mrs. Davis appeared in staff in December, 1949, she showed no insight into her condition —
past or present.
She reported a Ttswimming in her head.”
When asked, she said
she would like to go home but wouldn’t mind staying in the hospital a little longer. Her ward physician did not recommend leave because of continued unpredictable outbursts in Mrs. Davis1 behavior; leave was not granted.
Staff agreed, however, that she
could return home if she could have twenty-four hour super vision by a ”satisfactory, reliable individual — to the mother’s care.”
It was felt that this would dis
courage Mrs. Marks from any further efforts. Mrs. Davis was presented to staff again in January, 1950y. by a different ward physician who also did not recom mend leave.
The staff felt, however, that the mother’s new
plan fulfilled the conditions of their previous decision in December and leave was granted in care of Mrs. Marks.
38 (Case D) Patient1s adjustment to hospital.
Mrs. Davis was
never considered a well adjusted hospital patient.
record contained many "Special Incident Reports" —
concerning fights with other patients.
She was frequently
described by attendants as uncertain, combative, assaultive, and dangerous. used.
Restraints, packs, and seclusion were often
Transfers to different wards were sometimes necessary
to separate her from other patients.
A course of electro-shock
treatments was given Mrs* Davis in 194^*
Another course was
started in December, 1948, but was discontinued in four months (after forty-three treatments) due to family ob jections.
In September, 1949, Mrs. Marks was asked permission
for the hospital to perform a lobotomy on Mrs. Davis; this permission was not given. Patient1s part in attempting release*
behavior, Mrs. Davis seemed to have no objections to her hospitalization.
She did not pester her mother or her ward
physician about it though she did talk to Mrs. Marks about going home when asked about it.
She apparently played no
deliberate part in seeking her own release. Relative* s understanding of the patientys condition. Mrs. Marks seemed to be aware that her daughter was ill, and she seemed to be accepting of this.
Her belief concerning
39 (Case D) the degree of recovery was unrealistic.
When Mrs, Marks saw
patient on week-ends, she behaved very well and this indicated to Mrs* Marks that she had recovered.
One ward physician
saw Mrs. Marks several times and discussed patient1s condition mostly in terms of how she was behaving.
Mrs. Marks saw
changes in her behavior as the influence of religion; thus, religion had improved her mental condition. Plans for patient1s care outside the hospital.
Marks1 original plan was to take patient into her one-room living quarters and supervise her personally.
of the necessity of twenty-four hour supervision, she re turned five weeks later with a new plan.
She had rented a
room in the home of some friends, the Reverend X and his wife.
Twenty-four hour supervision could then be provided
since the landlord and his wife had agreed to share in this responsibility.
They would be supported by her Old Age As
sistance grant and by public assistance to the patient until she was able to work again.
Mrs. Marks felt that the quiet
and peaceful surroundings of this home plus the influence of religion would complete her daughter1s recovery. Relative1s reasons for pressing for release.
Marks’ chief reason for wanting her daughter released seems to be adequately expressed in her own words, "just lonesome
40 (Case D) for my baby —
she’s all I have you know.11
the desire to care for patient personally; which was evidence of her own need again and not lack of confidence in the hospital.
She also indicated that she expected Mrs. Davis
to improve enough to go to work and eventually to take care of her in her few remaining years. These motives were not as selfish as might appear. The writer felt that this mother was sincerely concerned with the patient’s welfare.
Her motives seemed to arise
from her lonesome existence and from her mistaken though sincere belief that patient’s illness was a symptom of not enough religion and that her recovery lay in providing this item. Relative’s method of working toward release.
Marks’ requests for release were by personal interviews with the ward physician and letters to the superintendent written by friends.
When visiting the patient, mother often brought
a minister and other church members with her.
accompanied Mrs. Marks to present her pleas to the doctor and to testify as to her ’’good behavior” during the visit.
Davis was brought to staff in response to a letter from an attorney written at Mrs. Marks’ request, ’’respectfully sug gesting” she be given a trial visit.
41 (Case D) Significant findings*
This mother* s maternal in
stinct seemed to have been reactivated by her only child*s state of dependence and by her own
quests for patient*s release began
very shortly after Mrs.
Marks retired from employment.
Aside from temporarily ful
filling her mother*s needs, this patient*s release will ac complish very little.
Mrs. Davis*presence in the home was
not demanded by the reality of patient’s responsible role or financial contribution. Mrs. Davis* needs for continued treatment or for surgery (the lobotomy) will not be met.
will be provided, however, and she can continue as a chronically ill person for some time. tional treatment is Implications
Her need for addi
by the relative.
for social work.
In this case we
direct blocking of treatment for the patient.
electro-shock and a lobotomy were refused by the family. Social casework service to this mother was indicated at the time of the first requests for release.
nature of this patient’s illness is indicated by the fact that a lobotomy is considered only as a last resort.
absence of this service, a family* s activity has effectively blocked the hospital and nullified its efforts to discharge its function.
42 CASE E Names
Mr. Joseph Edwards
Psychosis with psychopathic personality
Date admitted (returned from leave): Date presented to staff:
October 2., 1949
November 31, 1949, and again
two weeks later on December 14, 1949 Reason:
for consideration of discharge
Committed to Norwalk Hospital:
Originally committed by the
court on petition by his father.
He was released
and was on leave of absence for eight months then returned upon allegations of his second wife. Requests for release were presented by patient1s wife and his brother almost immediately upon his return from leave. Family situation.
Mr. Edwards1 parents live in
another state, and he has several siblings in this vicinity. Mr. Edwards was married at age 23, and two children were born of this marriage.
He was separated from his first
wife for three years prior to commitment and believed she had divorced him in 194?•
Between separation and commit
ment, Mr. Edwards was tied to no particular family unit.
wandered about the state, did not work steadily, and for a period of one year his whereabouts were unknown to his brothers.
Just prior to commitment, he was living alone in
his brother1s home town and was employed by his brother in
43 (Case E) the building trades.
Believing his wife had divorced him, Mr.
Edwards remarried during his leave of absence from the hos pital during 1949* Situation at time of commitment.
The petition stated
Mr. Edwards had drunk to excess for a number of years.
separation from his first wife, he had undergone a person ality change; become irritable, nervous and mean, adopted a superior attitude, believed he knew more than anyone else, and insisted on having his own way.
He had fought with his
brother over money, left home, drunk more than usual, and tended to drift about the state.
When his behavior became
so unusual, his brothers sent for their parents and the father initiated the commitment. Mr. Edwards’ return from leave of absence was pre cipitated when he threatened Mrs. Edwards (the second wife) during a drinking episode.
Mrs. Edwards called the police
for protection and the patient was returned to the hospital. Patient’s condition at time of staff appearance* When Mr. Edwards came to staff on November 31> 1949, he was resentful and hostile.
His ward physician suggested dis
charge, however, because his family was anxious to have him out and, even though he was an alcoholic and there was no indication he would cease drinking, he had apparently recovered
44 (Case E) from his psychosis.
He was not in the hospital on an al
coholic commitment. Discharge was agreed upon provided the wife agreed and a social service report was satisfactory. Mr. Edwardsf case was presented again on December 14, 1949, by a different ward physician, when the social service report was read*
Mrs. Edwards had stated that she wanted
patient released so she could obtain an annulment on the grounds that Mr. Edwards was not divorced from his first wife.
The district attorney had advised her to have nothing
to do with the patient and certainly not to sign his release. She said she wished to have nothing more to do with him and hoped she never saw him again.
She expressed some fear of
her husband, as in the past he had threatened and beaten her. This ward physician felt that not only was there no improvement in the patient1s behavior, but actually he was getting worse;, he was becoming more resentful and belliger ent.
The physician felt that hospitalization was not
benefiting Mr. Edwards and suggested he be discharged F.T. N. B. (further treatment not beneficial).
and his family were obviously troublemakers for the hospital and there was question of what to do with him.
family was demanding his release and were willing to sign
45 (Case E) him out, it was felt that he should be released.
probably continue to have difficulty with the police and would be returned if given leave of absence.
sympathy with the wife and partly as a means of forcing the family to re-commit him on an alcoholic commitment, a dis charge was considered desirable.
Since he. had apparently
recovered from his original psychotic symptoms, he could be discharged as recovered, though his basic difficulties — psychopathic personality and alcoholism — - remained un changed. Patientfs adjustment to the hospital.
M r . Edwards
was never considered a well adjusted hospital patient. escaped once during each period in the hospital,
his first period of confinement, when his parents visited him, he was inclined to be argumentative, abusive, swore at them, and demanded that they get him released.
escape during his second period of confinement, his wife reported he had demanded money from her, threatened to kill her and struck her.
(Mrs. Edwards asked that he not be given
another chance to escape^ however, she continued her requests that he be discharged.)
Hospital rules, especially regarding
smoking in the wards, were persistently broken by Mr. Edwards. Mr. Edwards questioned any treatment that was given
46 (Case E) him*
At one time he complained of pain in his hip*
consulting neuro-surgeon agreed to surgery, hut Mr. Edwards refused at the last minute. P a t i e n t s part in attempting release.
and patientTs brother both acknowledged that patient had brought all the pressure at his disposal to bear upon them toward his own release.
He threatened them and accused them
of not wanting him out of the hospital because they were carrying on an affair while he was confined.
shrewdly with his wife by agreeing to the annulment she de sired, and by promising not to harm her and not to leave the state, if she would continue her efforts to get him dis charged from the hospital. Relative1s understanding of patient1s condition. There was no evidence of any understanding by this family. Mrs. Edwards could interpret her husbandTs distorted person ality only in terms of the danger to herself.
was aware of patient1s alcoholism but did not feel that hospitalization was necessary for this.
He expressed the
notion that if patient were well enough to work, he did not belong in any hospital.
One doctor had tried to discuss the
drinking problem with the family but doubted if they so much as listened.
47 (Case E) Plans for patientfs care outside hospital.
Mr* Edwardsf care outside the hospital were practically non-existent*
When asked, his brother guessed he would take
him into his own home until he found a place to live, and he would put patient to work immediately* Relatives* reasons for pressing for release.
family had talked to several physicians as patient moved from ward to ward; they did not seem to maintain a consistent story.
To one ward physician, Mrs. Edwards had mentioned the
pending annulment, and
the brother merely insisted that
patient did not belong in a hospital. To the writer, patientTs brother said he wanted Mr. Edwards out of the hospital so he could meet his own financial responsibilities.
While Mr. Edwards was on leave of absence,
he had bought some things on installment plan.
return to the hospital, the brother had met these payments and was irritated because he felt a certain obligation to protect patient*s investment. Mrs. Edwards1 reason for wanting patient released (discharged) was to obtain an annulment of their marriage; otherwise, she was not interested in him. Guilt was a motivating factor too.
she had married Mr. Edwards not knowing he was on 11parole*1
48 (Case E) from the hospital.
Once while he was drunk he threatened
her and she called the D. A. or the police; thus he was re— turned.
When interviewed, she felt it was **all a mistake”
and she wanted to right it if patient would agree to sign their annulment.
She had sought his release at first be
cause he had threatened her if she did not do so.
had learned that his divorce was not complete and Mr. Edwards had used this to bargain with her when she asked for an an nulment • Relativest method of working toward release. This family wrote no letters to the hospital but talked with ward physicians during several visits.
Mrs. Edwards brought a
minister with her on two or three occasions.
seemed to be her source of moral support and said very little during these visits.
Patient*s younger brother was the most
persistent and demanding member of the group. Significant findings.
In no other case in this study
were the motivating factors so unsympathetic toward the patient.
These motives seemed to be approximately as the
family stated them, though the writer sensed a slight feeling of obligation toward the patient by his brother.
Fear of the
patient and a desire to complete annulment of the marriage, plus a slight sense of guilt, seemed to be Mrs. Edwards*
49 (Case E) motives* Patient’s release at this time would seem to accom plish nothing constructive for family or patient.
wards still had evidence of psychopathic personality and was considered an alcoholic.
In the past, patient had fought
with his brother and had threatened and beaten his wife — all over the problem of money.
His release would seem
hazardous since his brother was anxious to even a money ob ligation between them. There was no indication that Mr. Edwards’ need for care, supervision, and treatment would be met in the pro posed release, nor that there would even be any understanding of his need. Implications for social work.
Social casework ser
vice would seem to have been indicated for Mrs. Edwards and patient’s brother at the time of their first requests for his release.
They both apparently needed help around their
feelings toward the patient; and in clarification of their understanding of his condition and the function of the hospital. The absence of this service permitted this patient to be released into a situation which appeared unwholesome or even hazardous to him and his family.
50 CASE F Name:
Miss Ann Fenny
Psychosis; syphilis of the central nervous
system, meningo-vascular type; malignant hypertension Date admitted:
October 9, 1949
Date presented to staff: November 21, 1949 Reason: for consideration of leave of absence Committed to Norwalk Hospital:
Miss Fenny was committed by
the court from the county hospital on petition by a staff physician. Requests for her release' were presented by her mother, Mrs. Thompson, beginning three weeks after admission. Family situation.
Miss Fenny was an only child whose
parents were divorced when she was quite young.
raised by the mother who described her to the writer as a ^spoiled child.” was 15 years old. toward Miss Fenny.
Mrs. Thompson remarried when Miss Fenny Hr. Thompson had always been indifferent Patient moved out of her parentsT home
when she was 19 years old and supported herself for the next twelve years; living alone most of the time. married.
She had not
For two years prior to entering the county hos
pital, she had been unemployed due to ill health; she was supported by unemployment insurance, disability benefits and, finally, public assistance.
51 (Case F) Situation at time of commitment. living alone in ill health.
Miss Fenny had been
She was admitted to the county
hospital for a ”heart ailment11 and was later transferred to the psychopathic ward when her physician reported she was ”yelling, screaming, thrashing about, needs restraint, re marks that everyone is against her and is uncooperative.11 Mentally, she was described as 11confused, disoriented, un responsive, depressed, and maintained she was blind.”
Thompson reported that Miss Fenny had been diagnosed ”syphilitic” in 1940> k&d ”some treatment” ; had a ”brain hemorrhage” in 194? &nd bad had hypertension for many months.
PatientTs family did not participate in her commit
ment. Patient1s condition at time of staff appearance>
Fenny was bedridden when her case was considered in staff on November 21, 1949, and could not appear in person.
physician read the ease and recommended leave be granted since the mother was anxious to take her home and had agreed to provide bedside care for her.
PatientTs mental con
dition was about the same though she had become slightly more calm.
In addition, she was in critical physical con
dition because of an enlarged heart. she could not live more than one year.
It was the opinion that Since the mother
52 (Case F) wanted her home and would provide the ambulance to transport her, the decision was to grant patient*s leave to Mrs. Thompson. Patientys adjustment to the hospital. mentally incapacitated. often in the nude.
Miss Fenny was
She tended to wander about the ward,
She was usually quiet but on occasions
became noisy, resistive, and sometimes combative.
and isolation were sometimes necessary in her more agitated episodes.
On one occasion, Miss Fenny became depressed, then
agitated, and threatened suicide.
She was later found with
a sheet tied around her neck. Patient*s part in attempting release.
part in attempting release was effective though not part of a deliberate plan.
Her efforts consisted in simple pleas to
"go home" and complaints that she was not treated well.
mother was reacting to these efforts. RelativeTs understanding of patient* s condition.
ward physician who saw Mrs. Thompson did not think she was fully capable of understanding or appreciating the mental aspects of the illness and that patient should be in a mental hospital.
She was too excited and unreasonable to
discuss anything, according to the doctor.
Mrs. Thompson did
appreciate the serious nature of the physical illness.
53 -(Case F) seemed to be partially incapacitated by her grief over this critical illness*
It was the writerrs impression that Mrs*
Thompson was too overwhelmed by the fatal physical illness to be concerned about the mental illness* Plans for Thompson1s plans
patient*s care outside the hospital, for
to transport patient home.
were to providean ambulance
There she would have twenty-four
bedside care by the mother and a prac
tical nurse, and
the family physician.
attention, when needed, by
It was felt that this simple bedside
care would be sufficient for Miss Fenny until she died. Further psychiatric care did not seem to be indicated since she would not recover from her physical illness.
took no part in this plan and was opposed to it because of the limited finances of the family* Relative*s reasons for pressing for release*
Thompson*s reasons for wanting her daughter released, as exi*
pressed to the physician and to the writer, were that patient was not being treated well and that she would be more com fortable at home.
She wanted to do all she could for patient.
A sense of guilt as a motivating force was revealed in Mrs. Thompson* s comment, *fI guess I*m partly to blame for not raising her up right.
Now I want to make it up to her
54 (Case F) by doing all I can .’1
She acknowledged, too, that she was
moved by her daughter’s pleas to be removed from the hos pital. Relative1s method of working toward release.
Thompson visited patient several times but talked personally with the ward physician only once.
However, she made almost
daily telephone calls to the ward physician and hospital superintendent requesting and demanding that she be allowed to take her daughter home. Significant findings.
This case is similar to the
Davis case^ i.e., the patient’s helplessness has reactivated the mother’s maternal instinct to care for her personally. She was naturally compelled by her grief to do something to relieve her own distress.
She was motivated by guilt for
perhaps having had some part in causing the condition.
she was reacting to patient’s requests. Release of this patient probably afforded more com fort to patient and to relative, though this type of care — financed by going into debt — to Mrs. Thompson.
is incurring heavy expense
The reality situation within the family
did not seem to demand the patient’s presence! i.e, she would not fill a major familial role in responsible activity or financial contribution.
55 (Case F) Miss FennyTs needs as a dying person will be ade quately, or perhaps better met by the family's plan.
physical needs seem to be understood by the family. Implications for social work.
Social casework service
to this family would seem to have been indicated from the time the fatal nature of Miss Fennyfe heart condition was discovered.
Some undue anguish might have been alleviated.
Casework in this instance would be to interpret the function of the mental hospital and examine it as a more realistic alternative to expensive care at home.
CHAPTER III SUMMARY AMD CONCLUSIONS This is a study of six oases in which family pressure was exerted to remove the patient from a mental hospital regardless of the condition making hospitalization advisable These cases were studied and presented to show the consteila tion of factors in this family pressure to remove a patientrelative from a mental hospital. These six cases do not comprise the universe of all such cases.
They are only a few from one hospital.
number is too small to carry statistical weight.
ings here are therefore indicative, not conclusive.
felt, however, that these findings do throw some light on the subject and point to some implications for the mental hospital and social service departments of these hospitals. I.
SUMMARY OF FINDINGS
Seen together, these six cases do show facts which appear to have some significance because they recur, others because they fail to recur. The age of four of these patients, B, B, E, and F,^ was the middle thirties, the period in life when adults ” T In the remainder of this thesis, cases will be re ferred to by the initial of the surname.
57 usually have acquired responsible positions in family groups. Another patient, C, was 52, an age in our society when the individual is still expected to be meeting his own needs and contributing to those of others.
The remaining patient, A,
was 63, approaching but not quite in the era of life when financial self-care is not expected.
Did the familiesf ef
forts at their release mean they needed the patient to return to the responsible role?
Or that they were prepared
to give the older patient the care often needed by the person in his middle sixties? The findings in these few cases warrant a clear nnow to these questions in all except one case.
Of the four
young patients only one, B, was a member of a family unit in which he had filled, and it was hoped he would fill, a responsible role.
His presence and earning power were
needed to reunite a family of father, mother, and two chil dren.
In the other three instances the family unit was, or
would be incomplete.
Mrs. D, age 30, had been divorced, had
lived with her elderly and widowed mother a short time pre ceding commitment, and upon release would return to live with the mother*
Mr. E, age 33, had separated from his wife and
two children, had remarried, and this second marriage was to be dissolved after his release; thus he would be unattached to any family unit, as he was at the time of his commitment. Miss F, age 33, had not married.
She had lived alone prior
5S to commitment, and upon release was to be returned to spend the few remaining months of life in the home of her mother and stepfather.
Of the two older patients, Mrs. C, age 52,
was very much wanted back by her mother in her seventies. Her return would reconstruct their unit but it had been an incomplete, inadequate unit before, and would not be different now| the patient had been and would be the less responsible member of the two.
Mrs. A, age 63, had been living as an
appendage to her married son1s family of a wife and a young son.
Her presence had been a disturbing element in this
Her release was acknowledged as possibly precipi
tating a divorce of the son and his wife.
There was no
evidence that even the patient’s income from annuities was needed or sought in the son’s family unit.
Thus in only one
case of the six did the reality of the patient’s age, family constellation, and responsible role of the patient prove to be a significant factor in the pressure for release. When presented to staff, the first three patients, A, B, and G, were found to be in essentially unchanged con dition and were not released.
Mrs. D, who had at one time
been considered for lobotomy, was found to be improved to such an extent that she could be released under twenty-four hour supervision.
When her mother was able to offer a plan
including this supervision, she was released.
Mr. E was
found to be recovered from psychotic symptoms though his
59 condition of psychopathic personality and alcoholism was not considered as changed or favorable* technical reasons.
He was discharged for
Though Miss F ’s mental condition was es
sentially unchanged, psychiatric care was not a pressing need due to a physical condition which rendered her bedfast. She was given leave to her mother.
Thus the patientTs conS'
dition in all but one of these cases would warrant further hospitalization, continued treatment, or supervision by a capable and understanding person. In half of the cases, A, E, and F, the patient had been in the hospital eight weeks or less at the time he was brought to staff for consideration of release because of family pressure.
Efforts to gain release of these patients
were begun immediately or in the first few weeks, and were of such nature that within four to five weeks the physician made the step to determine whether the hospital could accede to this pressure.
In two instances these were the
relatives who had participated in the patientfs commitment (A), or return from leave of absence (E) .
In B, the pressure
was from a relative who had opposed the commitment and was continuing opposition to patient’s confinement in the hos pital.
In the other two cases the patients had been in the
hospital three and one—half years (D), and four and one-half years (G).
Pressure for their release had been exerted for
two years in the former case, and four years in the latter.
60 Does this mean that some relatives were more effective than others, or that the condition of the patients had changed in the shorter or longer period of hospitalization?
of these patients were in the charge of one particular ward physician for a long period, this seems to suggest that some physicians are more sensitive or responsive to family pressure than others* Four of these six patients had made a poor adjustment to hospital life.
Though Mr. B was not accepting of his
hospitalization, he conformed to hospital rules and out— wardly, at least, made a good adjustment .to ward life*
G was found to be a fairly well adjusted hospital patient; this was probably related to the docility of her level of mental capacity. Three of these patients, A, E, and B (who made an outward show of good adjustment), were found to be playing an active, deliberate and effective part in working toward their own release by demanding that their relatives seek a release for them, and in case B, by coaching the relative in steps to take toward this goal.
These efforts on the
patients1 parts seemed to be effective because of their positions of dominance in the family relationships (though with E, this dominance was based somewhat on fear of the patient).
Miss F fs mother was moved by patient’s simple
pleas to 11go home” ; however these pleas did not seem to be
61 part of a deliberate plan by the patient.
In the two re
maining cases, Mrs. C, who was a fairly well adjusted hos pital patient, and Mrs. D, who was poorly adjusted, the patients seemed to be playing no active part toward their own release.
In these two cases and in F, the pressure
seemed to originate with the relatives who appeared to hold a position of dominance or protectiveness in the family relationship and who apparently hoped to reestablish this relationship upon the patient1s release from the hospital. In all six of these cases at least one ward physician had attempted to discuss the patient’s condition with the relatives one or several times.
When interviewed by the
writer, only two of these families, A and D, could recall anything the physician had told them about the patient’s conditions and only in these two cases did the family recall having specifically asked for such explanation.
Mrs. B had
gone to a psychologist outside the hospital for an explana tion of her husband’s condition and may have gained some by this.
In only one case, A, did the relative seem to have a
fair understanding of the patient’s condition.
others, this understanding seemed to be poor or almost com pletely lacking. Based partly on this lack of understanding, these families seemed to have difficulty in planning adequately for patient’s care after the release they were requesting.
62 Though not necessarily understanding of the patient’s con dition, Mrs* D Ts mother was able to make provisions for twenty-four hour supervision outside the hospital. case F were the plans satisfactory.
This was because, being
bedfast and not expected to live, care for Miss F did not necessarily entail provision for treatment of her mental condition.
In B, an important element, psychotherapy, was
included in the plan; however, this patient obviously needed a longer period of protective custody in addition to adequate treatment.
The plans in case A were unrealistic and unsatis
factory, and in C and E, plans were non-existent. The reasons presented by the relatives for pressing for these patients’ release are summarized as follows: 1.
A desire for patient*s companionship.
B, C, D
Fear of mistreatment or injury to patient.
A desire to give personal care to patient.
Patient not in need of hospitali zation.
Family misinformed about commitment or misunderstood leave status.
A desire for patient and relative to care for each other.
Religion had influenced patient’s recovery.
Patient needed as family breadwinner.
A desire for patient to have treat ment assured.
63 Home situation changed making care of patient possible at home.
To avoid losing home and break-up of family.
5, 7, 10, 13, 14) I and (3) concern for the patient (9, 11)• The pressure for release of these patients, with one exception, D, began a relatively short time after admission. This pressure was exerted by a close blood or marital rela tive, and with one exception, E, by only one relative.
method of bringing pressure upon the hospital was predomin ately in the form of personal interviews with the patient’s ward physician to whom persistent requests and demands for patient’s release were presented.
Letters to the physician
and the hospital superintendent were resorted to in four cases The reasons for wanting the release include most of those presented in the preceding summary of reasons.
The most fre
quent reasons were that patient was not ill (C and E) or had
64 recovered due mostly to the influence of religion (B and D ) ; that patient was being mistreated (A and F) and would or could have better care at home (A, C, D, and F ) ; that patient was needed at home as breadwinner (B), to care for relative (G), or eventually care for relative (D); and that relative desired patient*s companionship (B, C, and D ) . In three cases, B, D, and E, the relatives brought their family minister to the hospital to act as their spokesman or to lend support to the family's pleas for re lease and to testify as to the patient's changed behavior. In C and D, an attorney wrote the hospital in the interest of the family.
Public officials wrote or telephoned to in
quire about the patient in B and C. Significant findings.
A sense of guilt was found to
be a significant motivating force in four of these case studies, A, B, E, and F.
In two of these cases, B and F,
the relatives suffered from guilt feelings for having in some way caused the condition which made hospitalization necessary. Klapman cites another form of guilt reaction which is almost universal among families of mental hospital patients.
guilt is based on fear of disapproval by society for the supposedly dastardly crime of signing the patient into an "insane asylum."
As memory fades regarding the patient's
acute psychotic manifestations prior to commitment, the
65 guilt feelings become more dominant and the relatives are then ready to project these guilt feelings•
Unless a good
rapport has been established with some member of the hospital staff, there are constant and persistent attempts to find displacement objects for this g u i l t s u c h reactions may lead to aggressive behavior in the form of pressure upon the hospital staff to release the patient.
This process would
seem to fit in cases A and E, where the relatives did par ticipate in patientTs commitment (A), or were responsible for patient's return from leave (E). For purposes of analysis it seems valid to consider the eases in two groups; (1) those in which the initiative of the pressure for release stemmed primarily from the patient, and (2) those in which the initiative stemmed from the rela tives.
There was an equal number of cases in each group. In the first group were eases A, B, and E.
cases it was noted that the patient was taking an active, effective, and deliberate part in the pressure which was being exerted upon the hospital by the relative.
same three cases, it was noted that a sense of guilt on the part of the relatives was a strong motivating force in their activity toward gaining a release for the patient.
three patients in this group were found to be poorly adjusted to or not accepting of their hospitalization.
It was noted,
Jacob W. Klapman, Group Psychotherapy. (New York; Grune and Stratton. 1916). p p . 317—IS.
66 too, that in these cases the patient held a position of dominance in the family.
The release of these patients
would mean the reestablishment of a situation very similar to that preceding commitment, and one which was apparently more satisfying to the patient and to his family.
these patients were able to make their own efforts toward release effective, and had themselves brought to the at tention of the staff for formal consideration of release by using their position of dominance in the family and by ag gravating an already existing sense of guilt in a member of the family.
Release of two of these patients, B and E, was
sought by their wives; but in only one instance was it the aim that patient fulfill an important familial role. In the other group of three cases, C, D, and F, the patients were adult females whose release was sought by their mothers.
The initiative of the pressure in these
cases stemmed from the relatives and seemed to have arisen from their own emotional needs, in contrast to the sense of guilt in the first group.
The reasons for wanting patient
released as expressed by the relatives in this group were predominantly a need for the patient1s companionship and a desire to give personal care to the patient.
Only one of
these patients, F, took an active, though not so deliberate, part in working toward her own release.
Only in this same
case was a sense of guilt noted to be a factor on the
67 relative’s part. first group.)
(Thus there is some overlapping with the
Two of the patients in this group, D and F,
were found to he poorly adjusted to the hospital, and C and D were found to be quite aooepting of their hospitalization* In these three cases, in contrast to the first group, the relative seemed to hold a dominant position over the patient or was overprotective of the patient.
The release of these
patients, with one exception, F, would also create a situa tion and family constellation very similar to that preceding commitment.
In none of these was the reality situation a
pressing factor in their being wanted back in the home. II.
The Smith College study cited earlier found that fam ilies would remove patients because of an intellectual mis understanding of mental illness and because they were moti vated by forces that spring from their own emotional con flicts and relationships to the patient*3 The findings in these six cases would tend to confirm this conclusion.
However, the material assembled here would
indicate a reversal and slight alteration in the order of importance of these reasons; that is, these families tried to remove patients from the mental hospital before satis factory recovery primarily because they were moved by their 3 Cf. ante, p.
6$ own emotional needs and conflicts in relation to the patient.
This material would further indicate that because
of these relatives1 emotional needs and conflicts in rela tion to the patient, they were unable to understand or accept even an intellectual explanation of their patientfs condition which made hospitalization advisable. Implications of the study for the mental hospital. Where such relationships exist as within these families, the treatment of the patient without attention to the remainder of the family may result in wasted or nullified effort.
activity of the families studied here seems to have dis tracted valuable time of psychiatric and administrative personnel from their function and, at the same time, the family seems to have gained very little by it.
studies have shown that social casework is a real service to the relatives of mental patients.^*
The social work
profession has the knowledge and skill to aid in dealing with the problem of the family who is not accepting the patient1s hospitalization and would remove him regardless of the condition making this treatment advisable.
4 Martha Biehl, "Social Casework with Relatives of Hospitalized Mental Patients,11 a thesis presented at the University of Southern California, June 1949* tT See alsos Helen A. Darragh, "The Role of Social Service with the Families of Mental Hospital Patients," Smith College Studies in Social Work, XIII (September 1942) pp. 143-49.
assembled here adds to the many indications that the mental hospital would he justified in enlarging its social service staff for this purpose, since the limited time of present social service staffs is taken up by other pressing needs. Implications for social work.
Social service to the
relatives of mental hospital patients is a valid service when it meets any problems related to the patient1s illness, his hospitalization, and his treatment or recovery.
service was seen to be indicated at the time the patient was admitted to the hospital, or at least at the time requests for his release were initially presented.
The purpose of
this service would seem to be to help the relative accept the necessity of a period of hospitalization for the patient by helping him gain a more realistic understanding of the condition and of the function of the hospital.
assembled here indicates that these families would also need some help with their relationships with the patient and with their feelings about the illness.
Reality problems due to
the patient1s absence would be a valid area of service to these relatives.
In two cases in this study, referrals to
other agencies and, perhaps, interagency cooperation seemed to be indicated*
Preparation and planning toward eventual :-3
release and after-care for the patient would be a valid ser vice in any of these cases.
In cases of non-psychotic
70 patients, as Mr. B, the patient*s.intelligence and resource fulness could he enlisted in helping the family meet reality problems due to his absence from the home. This study is not meant to imply that family pressure can or should be eliminated or that the family’s interest is to be discouraged.
Actually, such activity as presented
here is a hopeful indication of a close connection between the family and the patient and his illness.
It is a resource
to be utilized in the patient’s rehabilitation. The teamwork relationship of social worker and psycho therapist, which has proved so successful in child guidance and mental hygiene clinics, would seem equally applicable in the mental hospital.
If these families could be inter
viewed by the social worker upon admission of the patient, the family situation would be known soon enough and well enough to know when there is a disturbance.
As the patient
enters treatment within the hospital, pressure for his re lease could be avoided by early help to relatives who do not understand the illness, treatment, or hospital, until such time as the patient has received maximum benefit from his hospitalization. Recommendation.
Due to limited staffs of many mental
hospitals, the need for social service to these families is largely unmet at the present time.
As the staffs of the
71 social service departments are increased and their functions broadened, service to these families would seem to have some priority* There may be some question as to whether this service should be located in the hospital, or in clinics in the com munity since the hospital is usually so remote from the centers of population*
In the six cases studied, it was
found, with one exception, that the families visited the hospital quite frequently*
Since their problem is centered
in the hospital, they would probably find the most help there.
They would seem to gain the most by a personalized
link with the hospital through a member of the professional staff.
Thus it would appear that the service to these
relatives would be from the social service departments located at the hospital.
It is felt that such service to
patients1 relatives could make hospitalization a more con structive experience for the patient and his family.
B I B L I O G R A P H Y
Bartlett, Harriet M . , Some Aspects of Social Casework in a Medical Setting. Chicago: George Banta Press, 1940, 270 pp. BlehX, Martha, Social Casework with Relatives of Hospitalized Mental Patients. A thesis presented at the University of Southern California, June 1949. 53 pp. Deutsch, Albert, The Mentally 111 in America. New York: Doubleday, Doran & Co., Inc., 193$. 496 pp. Flugel, J. C., The Psycho-Analytic Study of the Family. London: The Hogarth Press, 1939. 359 pp. French, Lois M . , Psychiatric Social W o r k . wealth Fund, 1940. 344 PP* Klapman, Jacob W., Group Psychotherapy. Stratton, 1946.
New York: Common
New York: Grune and
Richardson, Henry B., Patients Have Families. Commonwealth Fund, 1945. 307 pp.
New York: The
Stern, Edith M., Mental Illness: A Guide for the Family. New York: The Commonwealth Fund, 1945. 93 pp. B.
Darragh, Helen A., !!The Role of Social Service with the Families of Mental Hospital Patients,” Smith College Studies in Social Work, XIII (September 1942) > 137-33. Erickson, Melton H., ^Psychological Factors Involved in the Placement of the Mental Patient on Visit and in Family Care,” Menial Hygiene. 2:425-35, H y , 1937. Freeman, Henry, ”Casework with Families of Mental Hospital Patients.” Journal of Social Casework, 23:107-13, March, 1947. Goodale, Esther, ”Intake Interviews with Relatives of Psychotic Patients,” Smith College Studies in Social W o r k , XV (September 1944)? 15-51.
73 Pray, Kenneth, I*. M., WA Restatement of the General Prin ciples of Social Casework Practice,11 Journal of Social Casework, 23:r283~290, October 1947* Stamm, Helen H., f,Some Effects of Familial Attitudes Upon later Adjustment of Psychotic Patients Paroled Against Advice .tTrSmith College Studies in Social Work, XII (September 1941)* 195-96* C.
PUBLICATIONS OF LEARNED ORGANIZATIONS
Bulletin of the Menninger Clinic * "The Psychiatric Social Worker in the Mental Hospital.11 Conclusions and Recom mendations* Report of the Committee on Psychiatric Social Work, Group for the Advancement of Psychiatry, Minneapolis, Minnesota, Vol. II, No. 2, (November, 1947) 138-92. The Cleveland Mental Hygiene Association. 1TThe Mental Hospital of the Future.11 An address given by Dr. Frank F. Tallman, at the annual meeting of the National Committee for Mental Hygiene, New York City, November 8 and 9, 1944-
A P P E N D I X
n SCHEDULE FOR CASE PRESENTATIONS Presenting information a. Name, age, sex, and color b. Diagnosis e. Date admitted d. Date brought to staff; length of period in hospital e. Type of commitment; petition by whom? f. Date pressure started; by whom?
IV. V. VI. VII. VIII. IX.
Family situation (particular emphasis on patient’s family constellation) a. Patient’s marital status b. Relation of patient to other family members c. How patient and family lived Situation at time of commitment a. Symptoms of illness b. Effect on family c. Family action, or lack of action Patient’s condition at time of staff appearance; and staff decision Patient’s adjustment to hospital; and treatment given Patient’s part in attempting release Relatives’ understanding of the patient’s condition; and sources for this conclusion Plans for patient’s care outside hospital Relatives’ sented a. To the b. To the
reason for pressing for release — by the relatives ward physician writer in this study
Relatives’ method of working toward release; and other people involved Significant findings a. Principal motivating factor or factors b. What will release of patient accomplish; for relative? for the patient? for the community? c. Will patient’s release improve reality situation of the family? responsibility? activity? financially?
75 SCHEDULE FOR CASE PRESENTATIONS (continued) d.
Will patientTs needs as an ill person, or as a recovering patient, be: adequately met? better met? or be jeopardized — by the proposed release? Are they understood?
Implications for social work
76 TABLE I SOME FACTUAL FINDINGS IN THE SIX CASES THE SIX CASES
1*J2 L years
Period in hosp. before staff
Period in hosp, before release requested
Relation to pt. of relative seeking release
Who had pt. com mitted; was it same relative seeking release?
Patient1s marital status With whom did patient live before hosp.? With whom he would live if released?
Yes* Yes* Leave Disch.
Mother Mother Wife and Mother bro.
Son and Wife and Mother Mother his fam. own fam.\ Same
Alone Mother and stepfa.
* Mrs. D and Mr. E were released upon a second consideration in staff. ** In this case, release was sought by relative upon whose allegations patient was returned from leave of absence.