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SOME SOCIAL FACTORS DELAYING- THE DISCHARGE TO RELATIVES OF SELECTED PATIENTS IN A VETERANS ADMINISTRATION NEUROPSYCHIATRIC HOSPITAL
A Thesis Presented to the Faculty of the School of Social Work The University of Southern California
In Partial Fulfillment of the Requirements for the Degree Master in Social Work
fey Morton Robbin June 1950
UMI Number: EP66361
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UMI EP66361 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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0 R erience is his preparation for the impending separation, helping the patient and his family look forward to the discharge from the psychiatric hospital should be a continuous process from the time of admission.5
In this way, the relationship between
® Jack H. Stipe, 11The Veterans Administration Social Service Program,11 Public Welfare, 5:52, March, 1947.
patient and his family is kept active and meaningful and the hospitalization is viewed with the family as an episode after which the patient will be able to rejoin them.^ IV.
SELECTION OF CASES
Study was made of a selected, diagnostically mixed group of patients who, by medical definition, were fit under given conditions to begin trial visits. Selection was made by limiting cases tor 1.
Patients who had remained on the predischarge
ward for one year continuously after attaining maximum hospital benefit. 2.
Patients who had relatives residing in the
area of Los Angeles County. 3.
Patients who were veterans of World War II.
Patients without the diagnosis of alcoholism.
The patients in the ten cases selected were the only ones of the 213 In the predischarge ward who met all of the above criteria.
Four others had been eliminated
either because they were discharged or became acutely ill and were transferred to a closed ward.
6 Kurt Freudenthal, ,fParticipation of the Community Agency in Hospital Discharge Planning,” The Journal of Social Casework. 30:422, December, 1949..
10 Letters7 were sent to the nearest responsible relatives of these ten patients requesting hospital interviews with the social worker.
Three were returned "addressee unknown".
The seven relatives who received letters responded.
number of cases was in this fashion reduced to seven, which provided the basic data for the inquiry♦ V.
COLLECTION OF DATA
In preparation for the interview with the relative, relevant social data about each patient were assembled by the use of a schedule.
Except for the necessary identifying
information, only those items considered significant to the research question were included.
These were as follows:
reason for hospitalization, personal history, family record, family attitudes, military history, present hospital adjustment, trial visit reports, related social service entries, nature of the compensation or pension, and a statement about the visiting record. All of the available medical and social records were used for securing the material considered pertinent to the study.
The medical records included the clinical and
correspondence files and the doctor’s progress notes as kept on the ward. 7 See Appendix. 8
11 The clinical file was reviewed for the reports of neuropsychiatric examinations, psychiatric social histories, and also the continuous record of the nursefs and doctor1s notes describing the patient’s hospitalization* In one case no psychiatric history was obtainable while for others there were no reports from such departments as occupational therapy, educational therapy, or psychology. The correspondence file was used to review the correspondence between relatives and the hospital as it concerned their inquiries into treatment and progress. «
The Claims Pile, an official record of medical and hospital treatment, was found to be helpful for supplementary social history data and military * information. It contained also the claim for disability status, the current disability rating, and the records of military hospitalization* The doctor’s ward notes were helpful for medical impressions of the patient when admitted to the ward and for an ongoing picture of his ward behavior*
also were comments about the visiting relative and the nature of the familial interest* The social service record was a guide to the number and nature of the contacts between the social worker and the family*
It included the trial visit
12 reports, a much needed aid in learning about the relativepatient relationship and the adjustment achieved by the patient in previous trial visits* Finally, the "visitor record", kept by the Hospital Information Desk, was used in determining the identity of the patientsf visitors and the frequency of their visits with the patient*
These records were Incomplete
because on an open ward it is not uncommon for the older residents of the ward to arrange meetings on the grounds with relatives who have not registered*
such a record offered an Indication of the amount of contact with and sustained interest in the patient* VI*
DEFINITIONS OF TERMS
Discharge is leaving the hospital with medical authorization and with the goal of permanent separation. Maximum hospital benefit discharge is a form of discharge given patients who have attained maximum improvement, but in whom some residual disability may persist that cannot be benefited by further hospitalization. Trial visit is a three month’s period during which the patient continues under the supervision of the hospital in the care of the nearest legally responsible relative. The latter Is asked to advise the hospital of any changes
13 in the patient’s condition. Trial visit adjustment report is a written report from the social worker of the regional office which is concerned with the nature of the veteran’s personal adjustment and the casework performed to further it.
is used by the hospital in determining whether the patient is to be discharged or the length of the trial visit extended. heave of absence is any authorized absence of over twenty-four hours to a maximum of fifteen days • Pass is an authorized absence from the hospital of less than twenty-four hours. Elopement is the overstaying of a leave or any unauthorized leave from the hospital. Pens ion is, according to the usage of the term in Federal law, money paid to a veteran by the government for non-service connected disability or disease. Compensation is money paid by the government to a veteran for service connected disability or disease. Competence is the ability of the patient to receive and handle funds.
The recommendation of competent or
14 incompetent is made by a neuropsychiatrist and decided upon by adjudication. Detail is an assignment of work made by the physician primarily for its therapeutic value for the patient. Institutional award is an allowance provided for the needs of the veteran during his hospitalization.
the incompetent veteran who draws compensation and has no legal guardian is eligible for such an award, VII.
PLAN OP THE STUDY
The ward physician was consulted regarding each of the cases studied.
In these consultations the amount
and nature of supervision necessary was described as well as the employability of each patient. The seven relatives, four mothers and three sisters, were interviewed at the hospital within a three-week period during March.
A directed casework interview was
used in order to elicit material for answering the focal questions of the study.
These interviews are described
in Chapter IV. Following the interview with his relative, the patient was seen.
Interviews with patients were brief and
centered around the following four questions:
(1) Did the
patient know why he was here, and did he feel that he had
benefited from treatment?
toward the relative?
Would he leave the hospital
What was his attitude
on the recommendation of the doctor?
What were his
wishes about remaining in or leaving the hospital?
CHAPTER II BACKGROUND DATA:
INTERVIEWS WITH RELATIVES AND PATIENTS
The plan of this chapter Is to present background social data for each of the seven cases studied, followed by an interview with the relative and an interview with the patient.
Since the idea of extramural care for
psychiatric patients is not readily grasped by relatives to whom the patientfs illness may bear mysterious, frightening, or socially unacceptable connotations, much care was taken to emphasize that the purpose of the interview was the hospital*s need to understand the problem from the familyfs point of view rather than to make decisions or to take action on these cases. CASE 1:
Mr. Bishop,^ a thirty-nine-year-old, divorced, American veteran, was voluntarily admitted to the hospital on May 7, 1946 with a diagnosis of encephalopathy, trau matic, chronic, manifested by non-psychotlc reaction, deteriorated type. An encephalogram taken at an Army hospital was reported as showing cortical atrophy believed to be due to a cranial Injury sustained seventeen years earlier. He was returned to the United States and admitted to a veteranfs hospital on July 6, 1943. He was transferred 1 All names and identifying information have been disguised.
17 to another veteranfs hospital on September 17, 1943 from which he was discharged four days later as having received maximum hospital benefit* It was the present medical opinion that his amnesia was undoubtedly on a functional basis, although some of his mental deterioration might have been due to cortical atrophy* Reason for Hospitalization; At the time of his admission he showed a definite memory defect and had a history of becoming lost* He usually knew where he was but not how he got there* His memory for recent events was adequate, but memory for remote events was poor* According to the records, he had ridden a motorcycle over a bomb which exploded. He denied the motorcycle episode but stated that a bomb had exploded and that he had been in a hospital in Casablanca for five days in a state of unconsciousness. He had continued to have amnesia after his return to the United States but improved gradually and in December, 1944 he was able to go to work. He was relieved of his job on April 1, 1946 because of his inability to apply himself at dock loading. Personal History; Patient began school at the age of seven and stopped at the age of fourteen in the eighth grade. He left school to work as helper on a Coca-Cola truck. Other jobs held by him were as messenger for Western Union, soda dispenser in a drug store, and bellhop. He was employed for two years before the war as a truck driver. In he lived His wife A social received in 1938.
1932 he married but did not live with his wife; with his mother and she lived with her mother. divorced him and remarried after eleven months. service exchange clearance showed that he assistance from the State Relief Administration
Military Service; After about two and a half years in the Army, Mr. Bishop was given a Certificate of Disability Discharge on September 17, 1943 with a diagnosis of psychoneurosis, hysteria, amnesic type, severe. Medical records disclosed that from the time of his injury in service until his discharge he was disoriented and showed a marked memory defect. He held a Sergeantfs rating in a Headquarters Company of an Engineers Battalion. Family Record;; The patient was the second of three siblings. His father, a Baptist minister, died when he
18 was seven years of* age* His mother was living and at this time was dependent upon his compensation for support. One brother and one sister were living and well# Present Hospital Ad jus tment: Mr* Bishop had been on the predischarge ward continuously for thirty months without a_ trial visit. From neuropsychiatric examination: "The patient has made a good hospital adjustment and works regularly and well at a kitchen detail* He is, however, childlike in his relationship with other people, and his?memory defect is still obvious• He occasionally loses his way on the grounds of the hospital. He is an extremely cooperative and passive patient whose behavior has been excellent. He has been on many weekend passes with his mother who reports good adjustment under supervision. In summary, this man continues to be socially and.economically incapacitated and needs constant supervision.” t From the doctor*s ward notes:: "Situation unchanged* The mother is extremely protective of„the patient*s disability compensation. Her conversation carries numerous references such as, ’h e ’s a little better in this or that way but of course he Is still 100 per cent disabled.* She now enters to claim his G. I. Insurance Refund. I think this case fears close social,service scrutiny. I think there is a possibility that the mother deliberately infantillzes him for the conscious purpose of maintaining his pension status - not to mention the deeper and underlying motives.” Social Service Record:: 9/12/47 "Mother is convinced that he is not ready to leave the hospital. She doubts whether he will ever be well. It is evident that she has a tremendous need to keep her son’s compensation going as it is her chief means of support. ffWorker expressed sympathy with the mother who has been widowed for a long time and a wage earner for many years. Worker also interpreted patient’s efforts to experiment and explore possibilities for leaving the hospital as healthy signs of his improvement. Worker tried to relieve the mother’s anxiety about losing the pension check. The mother has a tremendous need to insist that the patient, was damaged during the war, and worker made no attempt to shake this conviction."
19 Compensations Patient had been adjudged incompetent by the doctors. He was receiving an Institutional Award of Thirty Dollars a month as a 100 per cent disabled veteran. Mother was swarded $137.50^ a month as his dependent* Visitor Records of once a weefc*
Mother visited the patient on an average
INTERVIEW WITH THE PATIENT»S MOTHER Mrs . Bishop was an elderly woman with dyed hair and a recent permanent wave. She was brash, assertive, and distrustful, and spoke of her son, the patient, in a detached and business-like way. I described the research purpose of the interview, underscoring the confidential nature of the material. We wanted to understand the individual aspects of her son's confinement since the doctors now felt he was medically able to leave the hospital. This introduction was clearly a letdown for her, and she let me know it. The word "benefits*1 in our letter had meant financial benefits to her. She.felt cheated having come under a misapprehension of what was in store for her. She thought the clinical director should be told about it. I said that I thought her error was not an illogical one under the circumstances. I asked whether a doctor or a social worker had ever spoken with her about taking her son home. She denied that anyone had ever suggested the possibility, although she had thought about it many times, but when she spoke with the doctors, they told her he needed continued hospital care. She had not discussed it with the present ward physician since he had been with the ward only a short time (six months). She disliked him. He seemed haughty and superior with her for such a young man. She knew he was the doctor and an educated man, but she had a twelfth grade education herself and was not so downright stupid that she could not understand him. Her contact with social service had been limited to one interview regarding her boy's behavior at home before o
This sum represents a dependency allowance for the mother in addition to a special apportionment out of the veteran's compensation. The exact amount is determined by adjudication.
20 his admission* I asked what she really thought was In the way of his coming home* We thought he could suitably be cared for in his home with supervision from her* She said that she realized that she could take him and had seriously considered it, but she got so darn mad when she read about things in magazines like McCall^ about the brain operations performed in other parts of the country for mental patients resulting in cures* Her boy was so tense and nervous she just thought he had a little pressure somewhere in his brain which could be relieved by brain surgery. I thought she might be referring to an operation known as a prefrontal lobotomy and mentioned that this kind of operation was rarely performed* It was used sometimes with violent and assaultive patients when every other treatment had failed. It was not an operation designed to correct a brain Injury, but simply made the patient more manageable and compliant. I wondered if she were not feeling that the hospital had failed to give her son treatment but could if it tried. She thought this was so because she had not seen one bit of improvement in him since he was admitted in 1946. If the doctors would come right out and say to her that they could not help him, she would feel better than just not v knowing anything. I asked how the patient was at home on weekends • She described how occasionally he would lose his way, If permitted to wander from the house. What bothered her most was that he just sat around and read the comics and then went to sleep. He slept most of the time. She had tried to take him with her to visit friends, but he refused to accompany her. - He didnft seem to care about doing anything. When he got home, he was usually awfully dirty and his clothes smelled. He particularly disliked having her ask him to wash and change into clean clothes* It cut her to the heart seeing him so changed. Having him around was upsetting to her because she was not well by any means. I thought that it would not be an easy thing to be with her son if she were not well and asked about her condition. She sighed deeply and said she didn!t know if I could understand, not being a doctor and all, but one minute her blood pressure was up and then it was down, and she had a floating kidney. Why only four years ago she went through triple major surgery, and she had had minor surgery since* I was sympathetic and wondered if her boy might not share some of the household
21 chores * The doctor had thought he would enjoy light gardening. Mrs. Bishop snorted that there wasnft enough space to stick one single flower. X encouraged her to tell me more about her home. Well, it was a small place, a three-room house in a court with no yard and no garden. She occupied the bedroom and when at home he slept on the couch In the living room. I asked whether his habit of going to bed at an early hour interfered with visits from her friends. She didn!t mind that. She liked to have a friend over now and then but no parties. Her landlord permitted no noise or goings on, nor did he tolerate children for which she didn’t blame him in the least* Her boy simply was not happy at home. He called the hospital his home. She really thought he was contented here with the other boys. He was really interested in the kitchen detail and his typing lessons. Wasn’t he doing his work at the hospital satisfactorily? she asked. I assured her that his adjustment in the hospital had been good but we wanted to help her understand that the hospital was a treatment facility and not a substitute home. Primarily we believed that her son could be helped by living outside of the institution, particularly if he could be given the understanding and patience and attention that she could contribute. Mrs. Bishop beamed. If we only knew how much she did for him at home. She waited on him for everything. Doctor had even told her that she babied him too much. She had always been fond of her boy and admitted without reservation that her life had been invested in him. I said that I thought she had a genuine interest in doing her best for him, evidenced by what she had told me and by the regularity with which she spent weekends with him. I could see that having him with her permanently with his present disability would not be easy; that maybe she should offer him assistance only where he really seemed to need help. Again I stated that I was not trying to help her toward a decision but wanted to know primarily .what was interfering with a plan for discharge. Well if we really wanted to know, she didn’t want to think of him spending the rest of his life here, but she didn’t think we would do what she thought was right. His compensation should be made into a permanent pension because surely we must know that he would never be any different. She was no longer a young woman and couldn’t work although she did operate a lathe during the war even in her poor health. But she wasn’t old enough to get a pension for herself. Frankly she was entirely dependent upon her son’s compensation, though it was little enough.
She Just knew that six months after he was discharged, the doctors would reexamine him and cut their compensation in half* She described the ordeal of obtaining the compensation originally. She wouldn* t want to go through that again. You would have thought that she was “trying to get on the county1* instead of what was coming to them. Her son was entitled to his pension for what he had sacri ficed for every one of us. I told her that the doctors con sidered her son 100 per cent disabled and she might be ex aggerating the dangers of his losing it. Her fear seemed immediate and real. She was now receiving $137.50 and the patient got Thirty Dollars. Her rent was Thirty Dollars a month but she was fairly certain that if the rent controls were lifted, her rent would become Forty or Fifty Dollars per month, and the two of them could not live on the remainder. She said that the patient spent most of his part of the money on her; that he was thoughtful and all he thought about was something for his mother, and she lived for him. She searched for more reasons why she might not be Justified in taking him. Last weekend he was much worse. He suffered from the conviction that he would grow worse as he became older. He had told neighbors in their court that he would kill himself if he thought he wasn* t going to get better or if it wasnrt for his mother needing him. She was also certain that he needed treatment for a severe allergy and had a condition of partial paralysis which caused him to walk stiffly. He had aged twenty-five years in the past seven, and people often mistook him for her husband. She was becoming so upset herself from thinking about him and having him around that her doctor insisted she take, a vacation from him. So four months ago she spent a few weeks with her sister in Austin, Texas. Her daughter in Seattle, hearing that she was about to take a vacation, suggested that she bring the patient and spend some time with them. Mrs. Bishop angrily remarked that her daughter seemed to have missed the main point that she needed to get away from the patient in the interests of her own health. Yes, she had been afraid for a long time that this would happen and we would discharge the patient. She really had never thought that he was a fit subject for discharge, but the doctors might know what they were talking about. She didn*t care to think of him at home
23 sitting with nothing to do. He had no friends. About all he did was go to church regularly. He had never been able to do quiet stuff like weaving rugs or baskets. She thought it would be nerve-wraeking for him at home. Before she took him, she would want two assurances which she knew I could not promisei that his coming home be a trial visit and that his compensation continue. She had been wracking her brain for at least three years over whether to keep him with her. She didn’t know the answer and couldn’t make up her mind. I said that the present interview was not to make her decide but was to increase our understanding of the problem faced by mothers like herself. It was suggested that the social worker attached to her son’s ward would be the proper staff member to talk with if she desired help in deciding what to do. She would like to speak with him if he would help her in making up her mind. She would make an appointment with him next week, she indicated. INTERVIEW WITH THE PATIENT Mrs. Bishop introduced me to her son shortly after our interview. The two of them had been talking over his coming home; he was not in favor of it. The patient, a slow-talking individual with what seemed a permanently sad expression, said that Dr. 0 had told him he could stay on at the hospital until he felt ready to leave, and he did not feel that he was ready. Dr. J was kind of like a daddy to him and he was one of the few people around who really understood him. The doctor knew that he wanted to study typewriter repair work under the GI education bill. The only school where this could be learned was in Idaho. The doctor had told him he wasn’t ready to travel alone. Whenever Dr. J. gave him the word, that would be enough for him. He couldn’t see sitting around the house with nothing to do. He felt that he paid for his keep many times over with his K.P. duties in the kitchen. I agreed that there would have to be careful planning and preparation for the discharge and that his social worker would be agreeable to discussing it should they request his assistance.
24 CASE 2s
Mr. Morgan, a forty-two-year-old, white, divorced, American veteran, was admitted to his hospital directly from a military hospital on April 11, 1946. He was given a Certificate of Disability Discharge for a neuropsychiatric condition. His diagnosis at the time of his admission was a schizophrenic reaction, simple type, mild. Heason for Hospitalization: 1116 patient was admitted to a military hospital at the request of his commanding officer. He wandered away from his job and insisted on wearing T/4 (technician, fourth grade) stripes because he felt this was his proper rank. At the time of his admission to this hospital it was reported that he displayed bizarre behavior and lack of judgment and was somewha t confus ed. He was given a maximum hospital benefit discharge from the hospital two weeks after his admission, only to be readmitted after two months through commitment by the court on the initiative of his mother. Her reason for taking this action was the poor adjustment made by her son. He refused to eat and was seclusive. Personal History: The mother stated that the patientfs birth was normal and that he was a wanted child. The patient gave a vague history of having completed high school and one year at college. He married in 1939 against the wishes of his mother. He and his wife lived with his mother. Three weeks after, the marriage the wife went on a trip with another man and stayed away for weeks. Upon her return she drank constantly and encouraged the patient to drink. The mother believed that the wife was the cause of the patient*s unhappiness. When patient and his wife were separated, the mother said, 111 tried to cheer him up by acting just like a girl friend and going everywhere with him.” Wife divorced the patient in 1940. The marriage lasted,approximately eleven years• The employment history was not clear. It was known only that the patient worked in an aircraft plant before the war. It may also be noted that he received public assistance for an indefinite period before the war.
Family Record; His parents were divorced when the patient was seven years of age- There were three siblings- One brother was deceased; the other was married and had four children. This brother was employed at a flying field in Hevada. Family Attitudes t Mention was made repeatedly in the medical and social records of the unnatural attachment between the patient and his mother. In a pretrial visit report of January 25, 1946, mother stated that the brother was unaware of the patient fs true condition- He did not know that the patient had been committed and believed that he was at this hospital ”for a rest.” Mother tearfully stated that she did not wish anyone to know of his having been in a mental hospital* Military History: Mr. Morgan was Inducted on February 26, 1943, and discharged on April 11, 1945 from an Army hospital. He served as a private in a medical detachment. Records indicated that he had no foreign service, although he himself spoke of having served in Italy. Present Hospital Adjustment: Report of Neuropsychlatric Examination of July 5, 1949: ”The patient returned from his most recent trial visit In.poor contact, retarded, secluslve, and withdrawn. He makes a fairly good adjustment on an open ward where he has been since March 7, 1949. He plays with the orchestra at the hospital and seems to enjoy this. He still appears rather vague, talks in a rather irrelevant manner, is somewhat secluslve, somewhat delusional, but his delusional trends are not marked.” Ward attendant described the patient as normal in behavior and very easily managed on the ward. He would not, however, go for an X-ray or other appointments unless escorted by an attendant. Trial Visit Adjustment: The patient had three trial visits. The first one terminated after he had become Intoxicated several times and been robbed. His mother felt that people in the neighborhood knew his condition and took advantage of him by getting him intoxicated and then robbing him. His last trial visit ended with his return to the hospital on May 24, 1948. Trial Visit Report of 11/25/47: He spent most of his time with his mother. He enjoyed driving the automobile
26 which his mother permitted him to do in the daytime. He took some interest in painting and fixing up the house and spent considerable time practicing his saxophone. He had no friends except those who exploited him when he was drunk* Trial Visit Report of 5/7/48: Veteran showed no progress and was becoming increasingly difficult to handle. He had episodes when he was melancholy and sat for hours at a time without talking* He was suspicious of his mother1s actions and accused her of plotting to return him to the hospital. Several times a month he became extremely irritable, used profane language, and was verbally abusive to his mother. It was believed that she feared he would become physically abusive but was reluctant to admit this fear to the worker. It had been difficult for her to face the decision of returning him to the hospital. Social Service Heport of 9/19/46: "Patient does not have any planned activities and occupies his full time by looking out of the window. At.this interview, mother discussed the possibility of returning him to the hospital. The worker discussed with her many of her feelings about her son, and it became evident that she was resentful towards him because he was punishing her almost constantly while they were living together. She has a martyrlike attitude about the whole situation. She has little or no insight regarding him or her own behavior. K i s
"She concluded that she would not take him home again on trial visit until the doctors thought he was perfectly well and able to go. She said she realized now that it was a mistake to have requested a trial visit for him before the medical staff was certain that he could make a success of it. She felt that no pressure on his part would alter this determination of hers.” Compensation: Patient was incompetent to handle funds. His mother received $137.50 as the dependent mother of a veteran who was rated 100 per cent disabled for a neuropsychiatric service-connected condition. Patient received an Institutional Award of Thirty Dollars monthly, a sum which was kept for him by the, manager of the hospital. Visitor Record: The mother visited once a week during 1949 and through the month of March, 1950. She was the only visitor.
27 INTERVIEW WITH THE PATIENT*S MOTHER Mrs, haired and toward the spoke in a
Morgan was a sedate, elderly woman, whitewell preserved, with a mildly patronizing air interviewer* Throughout the interview she gentle voice, slightly above a whisper*
I gave the purpose for our meeting, underscoring our need for her help and the confidential nature of the material* She said that she was aware that her son's ward was the predischarge ward and that in medical opinion he was well enough to be home* But she realized that it wasn't good for him to stay at .home as he was despondent, apathetic, and spent his time ffmoping about*. She would much rather have him at home if it were possible, but considered that he was not completely well. And if his doctor assured her that her son was well enough to be home with supervision? I asked. She knew he wasn't ready to go because she spent weekends with him and would dread the idea of reexperiencing committing him again. What had been her experience in the past when he had gone on a trial visit with her? She answered that each time he had come home, after a -few days, he would refuse food and sat up all hours reading and smoking cigarettes. She was a very good cook and she put on thirty pounds trying to encourage him to eat. She was In the habit of fixing his breakfast on a tray and bringing it to him in bed. At her age she couldn't sit up with him all night. I proposed she tell me In what way he had been sick at the.time of his original admission. She said surely our records would have all of that. I urged her to tell me about it in her own words. She said that he would walk and walk by the hour and wouldn't talk to her nor eat until he became as thin as a shadow.. He refused to enter a hospital voluntarily and she became afraid of him, having heard stories about acts of unintentional violence about other boys who had come back from the war in mental distress. Had she noticed any improvement in his condition since his admission? She had noted some improvement but his memory seemed very bad. Had she had any contact with the ward physician or social worker recently? Her last meeting with the doctor had been three months- ago at his request. He had given her some test questions and it had taken her one and one half hours to complete the questions.
Her boy, she indicated, was a sort of favorite on every ward he had been on because of his good manners and good nature* Her main hope had been that he would eat and gain weight* He was thin as a shadow. She had been thinking of taking him home for a few months this spring as a kind of vacation* If only he weren’t so terribly thin and would begin to care.about his music again* He seemed so normal here in the hospital and they had such nice weekends together. I asked about her home. She owned a five room house. Patient had his own room and had refused *his mother permission to rent it even though he used it only periodically. * I asked what it was about him when he was ill that she found most difficult to tolerate* She said that he went off on his funny little quirks and found fault with everything she did. It took a lot out of her being with him, never knowing if her suggestion would be right or wrong. I asked for an example. She said that movies were about all there was to do, and she had wanted to see the preview of ’’Stromboli”. He refused to accompany her and gave no sensible reason for not wanting to go. She didn’t know what would have become of him if she hadn’t been the kind of person she was with her understanding of people. She was a trained nurse. Most people could not have put up with what she had. She thought this was due to her nurse’s training. What would he like to do? I asked. She didn’t encourage friends to visit the home nor did she encourage him to contact anyone when he was at home because he was so sensitive about being a patient. If there were people at the house, he would stay outside until they left. She didn’t believe that people had any real understanding of mental illness such as she had from her close experience. She felt that she had done more for her boy than anyone and felt that his condition was deeper than a psychological thing. I wondered what he was like when he was well. She described him as a jolly, amiable, harmonious, witty person who never found fault. Now if she turned on the radio, he turned it off. She couldn’t understand it. They were always such pals when he was an adolescent. She separated from her husband when her son was seven years old. So she was mommy and daddy to him and knew she did a good job. She joined him and his friends in whatever they did. This included hunting, fishing and scouting.
29 He had such a mild disposition, and was so gentlemanly that people were deceived and did not under stand that he was ill* Recently he had begun to talk with her in a simple manner like a child and to buy toys. Last Saturday night he insisted upon buying a mechanical chicken and a chocolate Easter egg. She didnft say a word, but laughed to herself. At Christmas he bought little airplanes. She couldn*t understand why, since he was not,a deprived child, and had as many toys as he pleased. She had tried to tell him that no one could help him until he tried to help himself. She was careful not to cross him. She never argued but tried to help him with suggestions and by being cooperative. They never discussed his illness. He was the kind of person who could not take a drink. One drink seemed ,to poison his whole system. He became tip sy and there was no harmony. He went to his room and blew on his saxophone day and night without playing a note. She used the expression ”mis behaved” and I asked how she meant this. He would sulk, refuse to talk. ”Don*t bother me” was his attitude. There were times when he refused to go.home with her. She felt he didn*t have enough understanding friends outside of the hospital. She thought he would take advantage of anyone who gave him the love and respect she did. She did not consider him an alcoholic, but there was a deficiency in his system which made it poisonous for him. About a year ago, he sent his written application to an institute for training (she could not recall in what), and she kept the reply.from him because the doctor said.he wasnft ready for it. She described him as a person with fluctuating moods, and had feared that he might do away with himself in a fit of depression. INTERVIEW WITH THE PATIENT Mr. Morgan was exceptionally well-groomed and welldressed. He wore a new suede coat and immaculately pressed trousers. A silver cowboy tie clasp held his old fashioned tie. His facial expression was doleful, and he spoke so softly that at times his voice approximated a mumble.
30 I gave a rather careful explanation of my purpose in speaking with him, trying to help him to understand that no action would take place as a result of our discussion. Nevertheless, he was evasive as to whether or not he wanted to be at home. He explained that it was not up to him but depended upon how his mother felt about it. Whatever was convenient for her would suit him. He said that she was a trained nurse and that her work was periodic and it would be inconvenient having him around. She was elderly and overworked and seemed easily provoked, especially by anything he said. Was he satisfied here? I asked. Not exactly, he answered. There were worse .places, but it did become wearisome and boring at times. At home, money was one of the matters that troubled him, as he was receiving Fifty Dollars a month and this was not enough to help his mother pay her bills• Nor did he care about ever taking a trial visit. Trial visits interrupted his work at the hospital. I encouraged him to tell me more about his work here. He was a member of the hospitalfs orchestra. The saxophone was one of the instruments he played at the dances. He also worked at various clean-up details on the grounds. Patient did not regard himself as psychiatrically ill. He said he had gotten everything he came here for. His teeth had been repaired and he had recovered from the flu. He recalled having electric shock treatments, but laughed because it happened by mistake and was rectified several days after he was received on the shock service. Patient hoped some day to be reconciled with his wife and live with her permanently in Texas; CASE 3:
Mr. Gonzales was a thirty-nine-year-old, single, Mexican-American veteran who was admitted to this hospital on July 11, 1944 as a voluntary patient directly from another'Veterans Hospital. His diagnosis was schizophrenic reaction, paranoid type. No psychiatric history had been compiled either by the doctor or the social worker at the time of the present study. The patient had been in the hospital continuously for sixty-eight months without a trial visit.
31 Reason for Hospitalizations While in the service, Mr. Gonzales attempted suicide twice in one day, by taking five strychinine tablets and later stabbing himself in the chest. The reason given for these attempts was that he wasn*t wanted in the pharmacy* He had appeared normal to his officers until the day that he filed an application for a transfer which ho signed as "Acting Commanding Officer". In the military hospital he was secluslve and would sit in his room the entire day staring at the floor. The original diagnosis was psychosis with delusions of grandeur and persecution with suicidal tendencies. He was discharged (C.D.D.) directly to a veterans hospital after two months.in the military hospital. After thirteen months in that veterans hospital he was transferred to this hospital. Personal History: Little was known. Patient completed high sciiool and lacked only twenty units toward attaining a college degree In pharmacy. The draft interrupted his schooling. He had been employed for six years as a clerk In a drug store owned by his brother. He lived in a rented room close to an older sister who cooked for him. Military Service: He enlisted May 12, 1942 and was given a Certificate of Disability Discharge on June 26, 1943.’ His rank at the time of discharge was Technician fifth grade in a medical detachment. Period,of army hospitalization was from May 1, 1943 to June 24, 1943. There was no record of overseas duty or combat. Family He cord: Father and mother were dead. and two brothers were living and well.
Present Hospital Adjustment: This patient had spent twelve continuous months on the predischarge ward. He had made a fairly good adjustment. For a considerable time during his hospitalization here, he was a behavior problem, assaultive, hostile and aggressive; while on pass he would frequently drink, and his deep symptoms would become aggravated. The last such incident occurred in March, 1949. Since that time, he had made a good open ward adjustment. - He was neat and clean, took care of himself well, slept well and had a good appetite, maintaining his weight. He did a great deal of reading in the library and took care of a small detail without prompting on the part of ward attendants. He voluntarily entered into athletic activities with other patients and seemed to adjust well with people. He went on pass with his sister
32 about every other weekend and returned on time, apparently not drinking. Social Service Record: A letter was written to his sister regarding the possibility of a trial visit to her home on December 19, 1947. The sister telephoned her answer* Her response amounted to a refusal. She had had considerable trouble with patient on his Thanksgiving visit. The trip to and from the hospital would have been easier if she had had an automobile but she didn1t own a car. Patient was obstinate, argumentative about, taking correct buses to return here. He insulted passengers on the buses and seemed to be trying to pick fights* While in her home he was constantly asking his sister to provide him with liquor. Sister was married and had three children and did not feel she could meet her responsibility to her family, and care for the patient simultaneously. Patient's two brothers were dismissed as possibili ties for taking care of the patient. One used liquor to ex cess. The other's attitude toward the patient was one of indifference and his wife “who is disagreeable anyway” would never permit patient's presence in her home. Compensation: Patient was adjudged incompetent. As a 100 per cent disabled veteran with a service-connected disa bility he was receiving an Institutional Award of Twenty Dollars a month. There were no dependent relatives. Visitor Records The sister was the only visitor he had had "Suring his hospitalization. She came nineteen times during 1949, and every other week this year. INTERVIEW WITH THE PATIENT'S SISTER Mrs. Rivas, to whom our letter was addressed, was the patient's sister. She was a motherly-appearing woman with a very good natured, ingenuous manner. She was accompanied to the interview by her five-year-old daughter and her brother. They were Mexican Americans and both spoke English brokenly, but seemed able to understand the purpose for the interview and able to give lucid replies to my questions. I gave my reason for writing to the sister as one of wanting to address myself to a member of patient's
33 family who seemed interested in him as she evidently was since she took him, home bi-monthly ♦ Mrs, Rivas assumed the responsibility for handling the discussion while her brother joined in when he disagreed.^- Both of -them evidenced genuine concern and interest in the patient. She did not regard the patient as a psychiatric problem. She saw him as a very childlike person with considerable dependency needs, which she was not able to meet because she had three children aged nine, seven and five. She, her husband and children lived in a onebedroom, three-room house which they rented. She would have been willing to accept the patient were it not for the inadequate living facilities and her inability to give him the required supervision. Another reason advanced by her for not wanting to take him on a permanent basis was her fear that he might make, sexual advances to her three small girls. She wondered if he had been sterilized. Patient played with the children a good deal of the time, and bought them toys and candy, but had never given the family any reason to feel that he was behaving toward them with a sexual motive. Her brother, in a rapid stream of Spanish and then for my benefit in English, explained that .the idea of his brother having such ideas was ridiculous • Sister said that the newspaper stories about sexual deviates had stirred these fears since she did have three little girls and couldn’t watch them every second. I questioned her about patient’s behavior while on pass. She described him as a very quiet person who at times would not eat. His time was spent reading the newspapers, listening to the radio, and playing with the children. She saw him as needing supervision in one respect. He occasionally would drink to excess, but abstained when his sister reprimanded him. She considered him easily managed at home, but stated-that he preferred the hospital by far to living in her home since he enjoyed the dances, television and other recreational opportunities of the hospital. She believed that hospitalization had done a-great deal for-hin^and her solution was to keep him there" indefinitely as an employee. She had not spoken to a doctor for two years nor did she recall any contact with social service. The financial situation for this family seemed adequate. The husband, a cook, earned Twelve Dollars a day. Rent was Twenty-five Dollars monthly. They
34 considered0themselves very poor people in contrast to a third brother, married to an American woman, who owned two drug stores. This brother committed patient originally. He was not at all interested in the patient or in the poorer members of the immediate family. The solution proposed by him and endorsed by the brother in my office was to take the patient to Mexico and consign him to the care of two other sisters who had offered to take him. Mrs• Rivas did not approve of this proposal since the sisters in Mexico have "many, many" children and did not realize the severity of patientfs condition. Mrs. Rivas, still feeling that the present interview had been motivated by our wanting to make another arrangement, suggested that we keep patient a few more months or until he was well enough to travel to Mexico alone or live in a room by himself. Before his admission he lived in a room near UCLA, where he was a third year student in Pharmacy. Both felt that the wealthy brother, who had never visited the patient, was too busy and too indifferent to help out. In their opinion, he disliked them because they were poor and, indeed, no longer cared about 11 Mexican people". The brother who was present today was compelled to tell me that he was unable to take the patient because he was married and had five children. He was convinced that the patient should go to Mexico, and he would escort him there if a choice were forced upon them. Patient had indicated to him that he would be willing to go. He explained that he and his sister had been reared with the patient and felt close to him. They wished to do the best thing for him. INTERVIEW WITH THE PATIENT Mr. Gonzales was a tall, slightly stooped person, who Impressed me as mi id, phlegmatic and trusting. He tended to evade the question of whether he wanted to leave the hospital. He said he was under the orders of the doctor. He would obey the doctor in every way. He would not go against medical advice.
35 Again I asked whether he preferred to stay in the hospital or live outside. He replied that he felt in perfect condition and wanted to be outside, but he wondered if I had checked earefully with the doctor about his readiness to go. I said that 1 had and it now depended upon his having a place to live under the supervision of a relative. He said that he could live with his sister, Mrs. Rivas. They were very close. ”Her house had always been his ,home, and his house had always been hers.” He would like to work again and described his experience as a clerk, soda jerker, and salesman. He had worked in his brother^ drugstore for a while. I mentioned that his other brother had spoken of sending,him to Mexico to a sister living there. This suggestion was not to his liking because Los Angeles had been his home-town for too long. He felt that he had been helped very much by hospitalization. He enumerated some of the treatments he had received: electric shock, hydrotherapy, ultra violet treatment, insulin shock. He was very grateful for having been here but indicated that the hospital could be monotonous, too. He reflected that he had never been on a trial visit. His sister had always told him ffto go by what the doctor says.” This patientrs detail was gardening which he performed several hours each day. Because patient wanted to know how to go about arranging a trial visit plan, he was referred to his social worker. CASE 4:
Mr. Rosen was a twenty-two-year-old, single, Jewish, American-born veteran who was readmitted as a voluntary patient to this hospital on January 17, 1949. He was diagnosed as schizophrenic reaction, paranoid type, chronic, moderate, manifested by delusions of body scheme and history of persecutory ideas. He was discharged from this hospital with maximum hospital benefit on October 27, 1948 following 411 days of hospitalization. During the interim period, he had plastic surgery performed on his eyes and nose by a private physician in California against the recommendations of the psychiatrists of this hospital. A few days later
36 he returned to the parental home in Ohio where he remained until his present readmission. Heason for Hospitalization: The patient was readmitted because his parents were annoyed by him. His complaint at the time of readmission remained unchanged. He was not satisfied with his appeai'ance because his eyes still protruded. He had noticed people watching him and making remarks about him since his operation. He had felt uneasy and nervous at home because of arguments with his parents. At times he blamed his mother for his appearance. Personal History: He attended school to the age of seven teen at which time he was in the eleventh grade. He found sports more interesting than his studies. His grades were average and on the whole he got along adequately with his teachers and fellow students. Prior to service he had worked in the post office for one summer. He was unemployed following his discharge from the Army. He planned to go to a trade school to take up^printing but had taken no active steps in this direction. Military Service: Mr* Hosen was drafted into the Army in February 7, 1946 and was given an Honorable Discharge on July 23, 1947. His entry into the Army followed the cessation of hostilities. Although he_was in Japan for twelve months, he was not exposed to any active combat duties. His grade was private first class in a Head quarters company. He did not enjoy his service while in the United States. flIt was too strict. Overseas it was better. The discipline was relaxed.M Family Record: The patient was the younger of two siblings. The father was about fifty years of age and had been a druggist for twenty years. The patient described him as a mild mannered man who had provided a substantial living for the family. Sister, aged twenty-three had been married for about three years. She lived in Santa Monica and her husband was attending school learning bookkeeping. The patient described his sister as nervous, irritable, and easily excited. His mother was forty-five years of age and was well. Family Attitudes: Father had not resorted to physical discipline 'since the patient was six or seven years of age. Because of long hours at his business, he had found little time to spend with his son.
37 Mother would become provoked when patient would leave his things lying around the house or if he did not respond immediately to any of her requests. The sister was an exceptionally good student and the patient was mediocre; therefore, they kept pushing him all the time. Mother asserted that she might have been at fault by being too protective and not allowing the patient to do more for hims eIf. Sister: During the four months prior to his admission, the patient made his home with his sister and brother-inr law. He said that his sister ”rushed” breakfast and that this haste aggravated his,stomach condition. He had several differences of opinion with her and did not like the way she bossed him around. They complained he played the radio too frequently and stayed in the bathroom for long periods. He felt that they interfered with his business too much. Patient: Following his return from the service, he had a violent attack during which he threatened to kill his mother and to tear his eyes and hair out. Patient was always ashamed of being a Jew. Present Hospital Adjustment: The patient had been on the predischarge ward for fourteen months. He had made an excellent adjustment on the privileged ward and had been attending a detail with the department of physical educa tion. Ho change, however, had occurred in his general mental condition. He planned to have another plastic operation on his face when he left the hospital. He would have liked to look like the movie actor, Burt Lancaster. He felt that people continued to laugh at his appearance, and that was the reason he would have liked to have his face changed. He had little interest in trying to establish a life independent of that of the hospital until he was able to change his face. He blamed his mother for his ”ugly looks” and cursed her, but when he was among other people he,did not express these ideas. Compensation: He was adjudged competent and awarded 100 per cent disability compensation for a service-connected neuropsychiatric condition. In the hospital he received an Institutional Award of Thirty Dollars a month. His parents did not receive any allowance. Visitor Record: His father visited twice in January, 1949 His brother-in-law came three times during 1949. An uncle
38 from Pennsylvania came once in 1949. INTERVIEW WITH THE PATIENT *S MOTHER Mrs. Rosen, patient*s mother,, was a small woman, fashionably dressed, with an imperious manner. She was apparently loath to talk with the interviewer because he was not the doctor. Despite the fact that the appointment had been arranged over the telephone, she had informed the receptionist that her appointment was with Dr. Stanley, Assistant Chief, Professional Services (his signature was on the letter inviting her.to the interview). She was impatient and fretted as I explained the purpose for asking her to talk with me. She said she had come under a different impression. Pur letter (especially the phrase "benefit your son") had suggested to her that perhaps some new medical treatment for the patient was going to be recommended, "like injections or something11. She had been reading about all of the marvelous cures which were being performed in some places. I attempted to explain what we had meant by "benefits" pointing out that her son was one of a selected group of patients who, it was felt, could be benefited by discharge, although we recognized that he was still not well. This mother said she would be real honest with us. She did not have much faith in the "social end of it." She had spoken with a social worker_at the time of her son’s admission when she was desperately in need of advice and was very much disappointed in the help given her. Now she was only interested in what could be done for her son In a medical way. Had she talked with his doctor about his treatment? She admitted that she had not spoken with his doctor for more than a year but wanted - us to know that the family was thoroughly and Intensely interested in him. She felt that the family needed help in understanding him. She and her husband had- read about everything that had been written on mental illness. She said certainly we should know that when there was a sick patient, there was a sick family. But she had found no understanding here and had had to find peace within herself. They had tried the patient at home. He tried and they tried to get along, but they both failed. Yet they loved each other. It was no use. She didn’t want to discuss It. Nevertheless she went on to explain that she and her husband had left their home and business
39 in Pennsylvania to be with the patient* They were buying a home out here at a great sacrifice just so that their son would have some place to spend his weekends* She felt that they did things too fast in the beginning* She wished to try him for visits at home very gradually this time* But she knew that he could not be brought directly home from the hospital. She believed that some day he would be able to live outside but not with them. In her opinion the patient needed a family which was crude, care less, and placid in order to adjust. There would be no one at home who could offer him any supervision* Her husband had been a teacher of chemistry, and a scholar. He was temperamentally different from his son. He was a nervous, hypertensive person and at present was not well enough to work. They were a "worrying family0. She was a very fussy, nervous person who was much more so with the patient. They were ■unhappy living together. She was used to living according to certain standards and had no tolerance for her son*s slovenly, unclean manners. She knew that she shouldn*t be this way but we should know how hard it was to change anyone• In reply to a question from me about her son*s wishes in regard to leaving the hospital, she said that she knew that he was planning to leave sometime, but at present he was quite content here and it was ffhis home0 really. She spoke of how he spent his days here lifting weights in order to build up his body* She snickered at this and said that she was really delighted that he should be interested in anything because anything was better than nothing. When he was home with them, he was unhappy and did nothing except talk about his sicknesses and make them jumpy. As a child, she recalled, he was a little more shy and bashful than most children, but there was no indication of illness. In high school he adhered to the regulations about cleanliness and knew enough to take care of himself. Then during the war he went to Japan and when he returned she felt that he no longer belonged to her, with his phobias and his sloppy ways. Seeing him this way did something to her familyfs pride. She had to give up all her friends. The family suffered very much because of him. One thought something like this could never happen and then it did. He insisted upon having his laundry and dry cleaning taken care of outside of the hospital and would not have it done here. She acceded to his wish because
40 she preferred not to argue with him. She was just getting to the point where she was more normal again and didn’t see any use in taking him if it would upset her and ruin the family way of life. She had felt that she wanted to cope with the problem somehow but it was too big for her. There had been nobody in the hospital to tell her that he was ready to go or she might have tried him sooner* She wished to try him at home gradually and at her own pace. When he told her that he was contented at home and wanted to stay, she would realize he was ready. In this vein, she concluded that he was ,ftheir own but utterly foreign to them.” This mother did not feel that the patient’s compensation had had any influence upon family attitude regarding hospitalization. She would have considered paying something toward a family care home if such a program existed. This really was what they wanted for him a year ago instead of rehospitalization. My offer to refer her to the social worker for further consideration of the problematic aspects of her son’s care here was met by refusal, ’’because there is nothing for us to talk over at this late date.” She knew what she wanted to do and felt that experience had been her teacher. INTERVIEW WITH THE PATIENT Mr. Rosen was a plump youth with moderately prominent eyes but not unpleasant in appearance. His manner was quiet and thoughtful. He told me that he was planning to go home on a trial visit in May and he “hoped* to heck it would work this time.” When I asked him why it had not worked previously, he,answered that his interests and opinions were different from his folks, but he felt they understood him better at present. Living in the hospital hadn’t been easy for him and he would have been happier at home. He had always had a good home and he felt nearly ready to go. I asked whether he thought that he had benefited from hospitalization and from the treatment he had received here. He told me that he had received individual psychotherapy, group therapy, electro-narcosis, and insulin shock treatment, and it was his opinion that not one of these treatments had helped him in the least. He
41 had done a great deal of reading about the shock therapies and did not believe in them. He knew-that among the doctors themselves, there was considerable variance of opinion as to their effectiveness. Before the interview closed, I asked what his trouble mainly had been? He said that an ,fInferiority complex” was his problem. He asked several questions about the, reason for the present study and seemed pleased that there were persons interested in Hxa fellows who have been here a long time.” CASE 5s
Mr. Darrell was a thirty-five-year-old, single, white veteran who was admitted to this hospital with a diagnosis of schizophrenic reaction, paranoid type. He was transferred to this hospital directly from a military hospital and afterwards was committed by his mother. Reason for Hospitalization s. While in military service overseas, he struck the owner of the house in which he was billeted, thinking the man was jealous of him and the man’s wife. He was admitted to a military hospital on June 19, 1944 and shortly afterwards returned to the United States, where he was given a Certificate of Disability Discharge to a veterans hospital. At the time of his admission to the hospital, he was quiet, cooperative and apparently rather indifferent. He complained of a slight lapse of memory. Since being in this hospital he had shown some combative tendencies* Personal History: He began school at about the age of seven and graduated from high school at the age of nineteen. At the age of twelve he carried a paper route after school hours. He paid all of his own expenses during his years in high school. For one and one-half years afterwards he was in the Civilian Conservation Corps. He was never far away from his home, and his family visited him on weekends. For seven years before his entrance into the Army, he was employed, as parts manager for General Motors. His social activities were rather limited because he had to work. When he went to parties, his sisters usually accompanied him.
42 Military Service: He was drafted in August 31, 1942 and discharged October 12, 1944. He was a corporal in an Ordinance Base Depot. He did not seem concerned about entering the Army and always had a very patriotic attitude. He went to England in October, 1943. While on leave he wrote that he had gone to Scotland on a vacation and met a girl to whom he became engaged. Mother thought it possible that he was disappointed in love and that this might account for his lethargy and depression. Family Record: The patient was the second oldest sibling in a family of four. His childhood was not remarkable. He lived with his parents until about 1939 when his parents were separated. Then he lived with his mother and brother. Family Attitudes: The father was described by the patient as a very stern man who was difficult to get along with. Mother said she never allowed him to punish the children because he ”didn’t show good sense”. He was inclined to restrict.the mother’s activities and wanted things to go along in a very routine manner. Mother related the following incident as an example. When patient bought a car which was a Model A Ford, the father would not permit his son to keep this car in the double garage at their home, and patient had to go elsewhere and pay rent for a garage. Following this incident, patient and father were not on speaking terms for a period of time. Present,Hospital Adjustment: This patient had been on the predischarge ward continuously for fifteen months. The most recent entry on the ward doctor’s progress notes was made October 26, 1948. At that time, the patient was described as cooperative and not a behavior problem. Also ’’quite changeable, curses, talks to self.” The patient performed an assignment of work at the hospital theater. He did excellent wood work at occupational therapy under supervision and derived a good deal of satisfaction from a well done completed article. The ward attendant described the patient as ’’way out in left field and not ready for discharge.” Social Service Record: Notation dated 6/11/48 disclosed that the mother was unable to take the patient on an over night pass because her apartment was small and she had no place for him to sleep at night* Trial Visit Adjustment:
The patient was granted a
43 ninety-day trial visit starting 7/13/45 but was readmitted the following month. The reason given for the failure of the visit was that the patient was hallucinating and seemed unable to adjust. The mother was apprehensive at the time she accepted him owing to her feelings about not having a ^man about the house in case of a crisis0. She was also concerned at the time about money for his support as she was not receiving any compensation for him. A third concern was with providing the patient with an activity as he did not care to read much. Compensation; Patient was considered incompetent. He had been awarded 100 per cent disability compensation. He received an Institutional Award of Thirty Dollars monthly, and his mother was given One Hundred Dollars a month as the dependent of a disabled veteran. Visitor Record; Mother came four times during 1949 and twice in 1950. Her last visit was in March. A sister visited once in January, 1949. INTERVIEW WITH THE PATIENT’S MOTHER This mother was an exceedingly docile woman who arrived punctually for her appointment. Her voice was hushed and her manner timid and resigned. I explained that we had written for the purpose of using her help in relation to a study the hospital was engaged in concerning a selected group of patients on her son’s ward. He was a member of this group who, the doctor had felt, could return to their homes with the proper family supervision. We wanted to know how she felt about taking care of him at the present time. We wanted to understand from her point of view what might interfere with his living at home with her. There were others in the hospital like him and we wanted to know why their families could not take care of them at home. Today’s interview would not alter her son’s continued hospitalization as our purpose was to examine the situation rather than to do anything about it at present. I also asked whether our letter requesting her to come had made her curious as to why we had called her in.
44 She said she had not thought one way or the other about it except maybe to wonder if her son was all right. She thought she understood our reasons and wanted to help in any way she could. She was living alone in an apartment house where noise was not tolerated. When Mr. Darrell visited he tended to become quite noisy and she did not care to risk the loss of her small apartment as the rent was only Thirty Dollars a month. There was no yard or space for.him to.use for vocational purposes. A major problem, she saw, was that he had nothing to do when he was at home. At the hospital, he went to .the canteen, and the recreation hall, or observed television. About three years ago — she apologized for not being able to recall the date — she took him on a trial visit. He became so difficult to manage that she had to call the authorities to have him returned after thirty days. At this time she felt compelled to have him committed since he refused to return of his own accord. The commitment proceeding had been a severe trial for her, and the patient had never forgiven her for her part in it. It had put a barrier between them which she was unable to penetrate. Sometimes he refused to talk with her, but if she didn’t visit for a week, he resented that too. Two weeks ago she came bringing cigars and candy; he met her at the gate and after accepting the gifts, bade her go away. I asked about the details of the trial visit which led to his readmission. The main unpleasantness had been his continual irritability with her for what seemed minor reasons * If she mislaid a possession of his or if he thought she had, he became stormy and obscene. He spent his time taking apart her electrical appliances such as her radio and record changer. Her other son, an air corps officer, had advised her to return his brother to the hospital. The patient was easily provoked by trivial matters but always in relation to her. When she questioned attendants about his demeanor at the hospital, they told her he was a model patient. The last time she had him home was on Christmas day. Again he became provoked by trifling matters. He was playing with a typewriter in the house undisturbed by anyone. When he overheard his mother mention that this typewriter was not the one they had owned when he was a child, he became enraged and denied that this could be true* He would have refused his Christmas dinner, but his brother placated him and finally induced him to join the family at their meal. Once again when the time for
45 his return to the hospital arrived, he refused to go* Mrs. Darrell stated that she would love to try him gradually on weekends, or for a period shorter than the ninety day trial visit, but she did.not drive or own an automobile and would not care to escort him back and forth In a public conveyance* She described him as the sweetest person in the world to his mother, so that when he was angry with her, she realized he wasn’t himself. At home he used the bedroom while she slept in the dining room. Her sole income was the One Hundred Dollars a month she received as the dependent mother of a disabled veteran. She denied feeling threatened by the loss or possible diminution of the sum should he come home. If her allowance were to cease, she thought she might seek a job, or if her son could work enough to earn One Hundred Dollars a month, she thought she could manage on that for the two of them by careful budgeting. If in her heart she thought he was ready, she would take him. She felt that he hadn’t had all of the treatment we could offer him. From articles she had been reading, she realized that there were some marvelous treatments which he had not received* He had been given several electric shock treatments, but they didn’t seem to help him. As he objected to these rather strenuously, they were stopped. She saw him as slowly deteriorating rather than improving. In relation to this, she considered that he was not being helped to use the vocational or corrective training which he received pre viously on the closed wards. Before the war he had been employed as the service manager for a General Motors plant. He held this job for eight years. In her opinion he had a ta,lent for electrical appliance and radio repair. I wondered whether she might care to discuss this aspect of his use of the hospital with his social worker. As she wanted to very much, an appointment was arranged for her to talk over this problem with the social worker from her son’s ward. I asked when she had spoken with his doctor last. It had been more than a year ago. She thought that if there had been any good news for her, a letter would have been sent her or an appointment with the doctor arranged for her. She frankly did not want to bother the doctors unless she knew they had something to tell her. She questioned the good of speaking with them unless she observed improvement in his condition.
46 I summarized for her some of the highlights of what she saw as difficult in her son's behavior at home. Correcting me at one point, she said that "belligerent” was a more accurate descriptive word than "irritable” . in referring to her son’s behavior. "His eyes shoot.fire She was. afraid to have him at home. She spoke at one moment of being physically afraid of him, then explained that she mainly feared he might harm himself or get into trouble by injuring her. In a moment of anger, he pushed her downstairs at one time. Stories*she had read in the newspapers had given her the idea that he might do something terrible. She did not mean he was a bad boy, but you heard such terrible things. Yet it was terrible to have him here. She had not gone to sleep one single night without thinking about it. But he did not get enough happiness at home to risk coming back. He just sat and smoked. She was concerned because she seemed to be the only one who bothered him. What she believed really brought on his sickness was the breaking of his engagement to a Scotch girl on the day before VJ day. At the time he went haywire. Three years later, the girl paid him a visit at the hospital, and he was moderately pleased by her visit, but surprisingly indifferent when she departed a month later. A final aspect of his activity which she pointed out as distressing was the ideas he had expressed about taking a trip to their former home in Iowa. He felt he could earn sufficient money making poppies to buy a ticket and a suitcase. He tried to persuade her to buy a new automobile and a television set, and seemed unable to understand the financial impossibility of these plans. She believed that he wanted to be home very much* He blamed her even when It was the fault of the hospital that he could not do the things he wished. She felt he spent money for crazy things. He bought a child’s bank and a correspondence course in piano lessons. She recognized that he was not improving at the hospital and would approve his transfer to a convalescent home for the mentally ill, but could not see how she might control him at home.
47 INTERVIEW WITH THE PATIENT Mr* Darrell was a dignified, moderately corpulent person, business-like at one moment and introspecting the next. He was willing to go home conditionally. First, he wanted a permanent discharge and not ’’one of those three month things”. Second, he wished to be providedwith a work placement in order that he might earn extra money and put his electrical talents to use. He simply could not afford to go home and sit there inactively for another three months. Here at least he was earning a little extra money making poppies• To the question of how he was at this time, he replied that his health was very poor. The hospital was too drafty. We had given him shock treatments and sweat treatments, but these hadnft helped him in the least with his bowels, eyestrain, or sore feet. But he was satisfied because there were people here # 1 0 understood him. Wasn’t he understood at home? I asked. He thought not. Mother was pretty old and didn’t understand her children. She wasn’t much interested in them. They didn’t have much in common together — just eating, sleeping, and an occasional movie. Mother got angry when he went out alone. Patient was very interested in the prospect of employment. He said he was a graduate electrician from Stanton High School, and gave a rapid and lengthy record of past jobs. He had various questions about the possibility of a veterans bonus from the State of California and about his national life insurance dividend. CASE 6:
Mr. Cortez was a forty-six-year-old, white, single, American veteran of Spanish parentage. He was admitted to this hospital on September 7, 1946 with a diagnosis of dementia praecox, paranoid type. His mother was the Petitioner for his commitment. Reason for Hospitalization: On admission, he stated, frPeople think I am not as good as they are, that I am small and not able to do work as they do.” He complained that people were trying to irritate him when they spoke about him. He repeatedly related unpleasant family relations, mostly in-law difficulty. The doctor
48 described him as confused, seclusive, childish, and negative with striking variability of mood* Since his discharge from the Army, he had been tense, very jumpy, and had had considerable abdominal distress* Every little thing seemed to upset him. It had been an effort for him to carry on with a daily routine. Prior to his admission, he had been unable to hold a job and had spent most of his time in the home of his mother by himself. Personal History: The patient was always retarded in his development, according to his brother. He had severe temper tantrums as a child and had been a wproblem” ever since his brother could remember. He did not advance beyond the sixth grade in school. He did not make a good school adjustment and finally dropped out owing to his difficulty in learning. He had worked as a utility repairman and truck driver. The longest job held by him was with a tire company for about two years. Military Service: He enlisted In the Army on January 22, 1941 and was honorably discharged by reason of being over thirty-eight years of age on February 27, 1943. He was a private in a Military Police Detachment. There is no record of overseas duty. He had not made a very good adjustment in the service. Family Record: The patient was the second of eight children. Mis three brothers and four sisters were living* His father, born in Spain, had died in 1937 of pneumonia. Mother was eighty-two^years of age and ill as a result of a heart condition, iter use of English was very limited. Family Attitudes: Prior to his hos'pitalization, the patient had lived with his mother and an older brother. The brother was a truck driver and was absent most of the time so that the patient was alone with his mother. She could not manage him as he was extremely antagonistic toward her. He never actually harmed her but would threaten to do so, and this frightened the mother. She finally decided to have him hospitalized on the advice of the other members of the family. Patient never married and showed no interest in girls, which the brother felt was abnormal. According to the brother, patient had always had a mind like a child. He could not stand to be disagreed with and became antagonistic. He resented anything the family suggested but would do things for outsiders. Mother had had to lock her bedroom several times during the night. The mother feared he might do her physical harm since he told her he hated her.
49 Present Hospital Adjustment: Patient had been adjusting satisfactorily on the predTscharge ward for twenty-two months. He performed satisfactorily as a kitchen worker under the supervision of the staff dietician. Prom the ward doctor1s progress notes: Patient is a simple schizophrenic in good contact, pleasant and cooperative. He expresses no delusions or hallucinations. He is somewhat inappropriate and childish in his emotional reactions. Judgment and insight are impaired. With supervision, he should get? along outside.” Trial Visit Adjustment: Patient was granted a ninety day trial visit in the custody of his mother on December 13, 1946. This visit was extended four times before Mr. Cortez was■readmitted to the hospital. A visit to the home by a member of the social service department revealed that the veteran was seclusive, uninterested, withdrawn, and, in general, behaved like a child. He rarely left the home and was erratic about performing chores, but was cooperative and easily managed by his family. It was felt by the worker that he was making an adjustment on a simple custodial level. The family, in the main, left him to his own devices until he made too many demands on his mother. He liked her to wait on him and refused to eat unless she prepared his plate. On February 12, 1948, it became necessary to return him to the hospital. His mother stated that he would not eat at all unless she insisted. He would go for long periods without talking with anyone. She felt that he had become much more seclusive and withdrawn. As a result of the worry of caring for him, her health was becoming impaired. She asked to have a little rest from the care of the patient, and he was more than willing to return to the hospital. ✓
Pension: Patient’s condition was never adjudged to be service connected. He did, however, receive a nonservice connected stipend of Thirty Dollars monthly. Visitor Record: Sister and mother visited only once in February, 1949, and not at all during 1950.
50 INTERVIEW WITH THE PATIENT rS MOTHER Patientfs mother was a tiny, shriveled woman of eighty-two years, who spoke and understood only a few English words* She was slightly deaf and had no vision in her left eye* She was accompanied by her son, who did all the talking, stopping now and then to assure his mother in Spanish that everything was all right and not to worry* He was very simply dressed and his manner was direct and sympathetic regarding our purpose. He had come directly from his job as mail carrier and brought his mother, despite her Infirmity, upon her insistence. I asked what he thought had been the purpose of our letter* Frankly, neither he nor his mother knew what to think. She felt that her son had been sick and we had called her in to let her know this. I carefully explained what the purpose for the Interview was, stating that the doctor felt that the patient no longer needed acute hospital care* What did they feel stood In the way of his coming hornet The son said that there was nobody at home who could give the patient any supervised care. His mother had been suffering from an acute heart condition for the past two years. She had had several heart attacks in the last year and had been spending most of her time in bed. Each time she seemed to be at the point of death, and the doctor gave up hope for her long ago. They felt she had pulled tjhrough only by some miracle. She visited the doctor three times a week for shots. She got up from her sick bed a month ago. His mother would, despite her condition, have liked to have the patient at home with her, but when he was around, she became awfully ne rvous. The b rothe rs (two) and s is te rs (four) felt it would be best not to take him. His mother had a nervous disposition anyway. At home the patient refused to help with the chores and just dilly-dallied around and his mother couldnft tolerate this. He felt that if his mother could learn to tolerate the patient*s habits of inactivity and let him do as he pleased, he might get along at home. Another brother and his wife lived with the mother in a three bedroom house. This brother was employed as a truck driver and was often absent for two and three days at a time. His wife definitely refused to live with the patient as she feared him. The mother felt that the patient could provide her with his company on lonely evenings•
51 I asked why the patient had been committed originally. Brother said that patient refused to obey his mother and threatened her with a shovel in a moment of anger. Patient insisted upon having everything his own way. They had been afraid of him ever since. They felt that he was not responsible for his actions and might hurt his mother in a fit of anger. Patient appeared very well to them here because of the freedom which was allowed him. They had not visited much recently because of the mother’s illness and need for constant attention. They had taken turns sleeping on a cot beside her bed at night. Although the patient was always glad to see ,fmomj* he really seemed indifferent to their visits. He really seemed to want to escape seeing them and was sometimes’ not around even when he had been informed that they were coming. The patient seemed content with himself and did not mix with the other patients. They had him home for a weekend in January, 1950, and the mother was quite upset by having him about. They felt that he was more content here. He was made unhappy by the tensions of the home. Their mother had always been ambitious and it was hard for her to see her son not doing anything. The brother told me that he was married and had two daughters, and they would not consider taking the patient because they feared his violence. His four sisters were married and three of them had children. The mother interjected at this point, that she would like to try him for a ninety-day trial visit. The brother shook his head at the impracticality of this and explained that his mother felt that she was the only one who had the patient’s interests at heart. She had always felt that he was not ’’right”, and that only she understood him. He wanted me to understand that the entire family had his interests at heart but they knew only too well what taking him would mean. At home the patient didn’t give a darn about his appearance or what the others thought of him. His dentures broke several months ago, and they couldn’t seem to get him to order another pair. Meanwhile, his cheeks had begun to sag, but he didn’t seem to care. The brother said that the hospital had helped his brother a great deal. Patient was at ease here and content in a way that he never was at home. He loved the entertainment that was available here. Brother talked with the doctor about three weeks ago about mother’s wish to take him for a trial visit. The doctor questioned him
52 about the situation at home and recognized the undesirability of discharging him. At the hospital patient was not at all sociable, but was happy with his dishwashing detail. Patient received Thirty Dollars a month in compensation which was held in trust for him at the hospital. The mother had a small income from property which she owned and rented. Brother believed that if the patient had the activity program and entertainment at home plus an attitude of permissiveness which was not possible, he could be satisfied at home. The mother again spoke about wanting to take the patient out for a while on a vacation to a hot springs, when she was feeling a little better. I wondered what the patient was like before the war. I was told that he worked for about two years and seemed perfectly well. When he returned from the service, he was changed and would not associate with people. Mother seemed compelled to keep him busy when he visited her. She had him mow the lawn, take care of small repairs and do plumbing jobs on some of her rentals. Mother said that she might not have been able to provide her sons with an education, but she did teach them to work. Interview concluded with brother saying that they had been very grateful for the care extended the patient by this hospital as patient had been growing worse and they would have had no other place to turn. They felt he belonged here, however, at present, and not at home. INTERVIEW WITH THE PATIENT Mr. Cortez was a small, slender man with a dark complexion who apparently had not shaved for about a week. He had no dentures and as a result tended to lisp when he spoke. He wanted to go home just for the change and to be outside for a little while. On the other hand, he was satisfied here and was willing to remain. I asked how he and his mother got along together. All right, he answered, but he tended to become nervous and say things he didn*t mean. He had been this way since Army
53 maneuvers in 1943 when they went seven days without sleep, f,on the doubleff most of the time. He had learned to relax again by.being here. Patient seemed to believe that he was here for the treatment of his piles by the order of the doctor. S i n c e he had been, here', he had worked as a dishwasner in the hospital kitchen. He thought he might help his mother with the daily repairs and cleanup of the ten houses she owned. CASE 7:
Mr. Vito was a twenty-six-year-old, single, American veteran of Italian parentage who was transferred to this hospital directly from Camarillo State Hospital where he had been committed on May 4, 1944. He was admitted to this hospital on January 1, 1945 with a diagnosis of schizophrenic reaction, mixed type. Reason for Hospitalization: He was arrested by the police for blocking traffic and grimacing at the occupants of cars while attempting to hitchhike. At the time of his commitment to the State Hospital, he showed stereotyped movements of the hands, a fixed expression, and expressed paranoid ideas. Psychological examination revealed a low intelligence. Eight electric shock treatments were administered without benefit. Personal History: The patient was the youngest of ten siblings• Prom about the age of fourteen, he had been thought to be dull mentally. He left school in the eighth grade at the age of sixteen. He held a number of jobs at unskilled labor. His longest period of employment was for eight months in the knitting mills. He had been released from jobs after very short periods owing to his social inadaptability. He had never been socially inclined and did not make friends easily. He had not any heterosexual experiences and had no plans for marriage. Military Service: He was drafted into the Army on February 8, 1943 and was given a Certificate of Disability Discharge on September 11, 1943. He served as a private in an Engineer Light Equipment Company. He had no overseas duty. A military document stated that his
54 character was good but his efficiency unsatisfactory* Family Record: Father and mother were deceased. of their deaths were unknown.
Family Attitudes s Mr. Vito got along with members of his family but did not make friends outside. He enjoyed listening to the radio and attending movies. Relatives stated that they had not observed any symptoms of mental disorder either before or after patient*s Army experience. They had considered him mentally deficient but never ,finsane,f. They wished, however, that treatment could be given to.improve his mentality. Present Hospital Adjustment: He had the assignment of newspaper carrier to patients and hospital personnel which he conducted competently. This detail consisted only of delivery and not the collection and handling of funds for subscriptions. From Report of Neuropsychiatric Examination: MSince his admission to an open privileged ward (fifteen months ago), his behavior seems to have become stabilized at his present level and there have been no marked changes over the past year. He makes an excellent open ward adjustment and is very active and interested in his detail work. Usually he is seclusive but will occasionally exchange a few words with other patients. He follows the general hospital routine without difficulty, and shows no behavior deviations, except when frustrated. Under very slight frustration he becomes extremely irritable and sometimes very profane and abusive. In the protected hospital environment, it is possible for him to adjust; however, it seems obvious that this tremendous irritability would make it impossible for him to make any kind of outside social adjustment except, possibly, at home with maximal supervision by the relatives I* Compensation: Mr. Vito was rated incompetent and received l6b per cent disability compensation for a service-connected condition. At this time neither the patient nor his relatives were receiving any money as he had accumulated the maximum amount of Fifteen Hundred Dollars as a hospitalized veteran. Vlsitor!s Record: Mrs. Logan, the sister of the patient, visited four times during 1949. Her last visit was in December of that year. Patient had no other visitors.
55 Home Via its: Social service records disclosed that this patient had never gone on a trial visit nor had he eloped at any time. Six leaves of absence of varying lengths were noted, but the records did not describe the nature of these visits. INTERVIEW WITH THE PATIENT’S SISTER The appointment for the interview had been made with Mrs. Cole, patient’s sister. She brought her husband and sister, Mrs. Logan. Her husband was needed to drive the automobile, and Mrs. Logan wanted to be included because the patient invariably lived with her whenever he went on a leave of absence. Mrs. Logan stood out as the older and more maternal of the two. She and Mr. Cole shared the role of spokesman in the handling of the discussion. The two sisters were taciturn and slow in responding. They seemed perplexed at first and unable to give themselves freely and voluntarily to the discussion. I explained that their brother was one of a selected group of patients who, the hospital had feltv could manage with supervision outside. I wondered what they had thought we had In mind by our letter. They said they hadn’t known what to think but had wondered what it was all about. Mr. Cole admitted that he had a hunch that the letter was connected with the recent reduction of hospital staff that he had read about in the newspapers. He supposed that with a smaller staff we would have to get rid of a few of the patients. I corrected this mistaken Impression and stressed that no change would result in the patient’s hospital status as a result of today’s Interview. We wanted to understand what had stood in the way of their broth®fe leaving the hospital since the doctor had informed us that he was medically able to go under supervision. Mr. Cole wanted to know what the medical opinion was regarding the patient’s condition, and what sort of supervision the hospital considered would be necessary. After I had answered him, he Indicated that they could not provide any supervision at present. Mrs. Logan was a widow, living with her nineteen-year-old daughter in a rented house. They were being evicted and had to find another home within two weeks • She was dependent upon the small salary earned by her daughter and had to seek employment for herself as the daughter
56 did not earn enough for the two of them. Mr. Cole was employed as a carpenter and his wife also worked. They lived with his *mother whom they described as aged and infirm. A brother, who was divorced, lived in a single room on Mare Island, where he was a fireman for the Naval Station. Prom their experience with the patient on leave, they were positive that he could not manage without having someone, preferably a man, around to watch him and tell him what to do all the time. They visited the patient infrequently. The last visit was in December, 1949. The reason given for not visiting was the fact that they lived far away (about twenty-five miles) and neither sister drove. Mrs. Logan always took the patient with her on any holiday and he seemed to expect this. On his last visit the patient did not talk at all but brooded all the time. He seemed anxious to get back to the hospital and was not relieved until they had driven him through the gate (of the hospital)• The problem in having the patient with them they saw as one,of management and control. He became irritable, restless, and irresponsible, although it was felt that he meant no harm. At home he was untidy and had to be told when to take a.bath. Mrs. Logan had lost her temper with him a number of times because of his untidiness, and because she had to tell him to do every thing. He didnft do anything of his own accord. Mr. Cole added, "He-wants to do what he wants to do." Mrs. Logan offered her opinion that her brother was all right while his mother was alive, but she died when he was ten years old. Both sisters were employed so that he was in his father’s care during adolescence. He quit school upon reaching the sixth grade in order to go to work, but never was able to hold a job for more than a couple of days. The circumstances of the original commitment were described for me at my request. The patient was arrested by the Burbank police in 1945 for creating a disturbance while hitchhiking. He had stopped the traffic in annoyance because no one would give him a ride. He was committed to Camarillo State Hospital, but the family hated having him there with so many "sick people”. They felt he didn’t belong there and were pleased when it was arranged to transfer him to the veterans hospital. Relatives in the East had never been told that patient was in a neuropsychiatric hospital, and the patient himself would become quite angry if
57 anyone ever called him a ”psycho”• The latter remark was contributed by Mr* Cole. They felt that he was extremely immature and more of. a behavior problem than a psychiatric” patient. The sisters had no idea whether or not patient had received any specific treatment here nor did they seem curious. They had never spoken to any professional member of the hospital: social worker, contact man, or doctor. They said that the hospital seemed very big, and it would have been difficult to find a doctor. To them, the patient was unimproved and seemed to be about the same as he was at the time of his admission. Before the patient*s army experience, they had never noticed anything wrong with him but supposed this might have been because they worked long hours and never took the time to notice. They did not know whether he received compensation but supposed he was paid a few dollars every week for delivering papers as this was one of his jobs, and he always seemed to have money to spend for candy. I said that if there were disability compensation it would help defray expenses if he were in their care. Mr. Cole remarked that even if he were receiving compensation, it would cease about six months following the discharge after the Review Board reexamined him. This had happened to other veterans he had known. I said that was something we had no control over. All the patient talked about at home was the shows and entertainment he received here. Mr. Cole thought the patient might be helped by being placed on a ranch with normal people where he could be given light routine tasks to perform* He wanted to know whether the Veterans Administration had any such facility. I said that we did not but wondered whether .-they would approve a plan whereby the patient would live in a boarding home under a person who understood him, since the hospital was working toward the adoption of such a plan for patients who could adjust outside of the hospital with a little help. Mrs. Logan said they would have to think quite a long time about it. They wouldnft want him to be mistreated and at the same time they hated to think that he would have to spend the rest of his life in an institution. They just didn*t want him to be any place where he would be worked to death. I thanked them for coming in for the interview, adding, that we wanted them to feel free to use the social
58 .ervice Oepartment regarding any questions or problems around the patient*s hospitalization. Mrs. Cole wrote our telephone number and asked how an appointment might be made as this could be a possibility in the future. They did not want me to feel that they were not interested in patient or had given him up, but that they had no home for him at the present time. INTERVIEW WITH THE PATIENT Mr. Vito was a swarthy, carelessly attired man who appeared confused and looked away from the interviewer. His speech was garbled and circumstantial. He seemed to have no understanding as to the purpose for the interview but was quite willing to reply to questions. He said without conviction that he would rather be home and working, but that was up to his brother who was his guardian. Five years was too much time to be in one place. He didn*t want to become institutionalized like they said could happen to you if you stayed too long. He didnTt know why he was here. They told him he was nervous and he guessed he was once in a while. A doctor once wanted him to go to the Domiciliary, but he said no. He didn*t want to mix with the old men over there. He wasn*t going to let anyone put anything over on him. He seemed to regard his brother as his closest relative. His brother had promised to take him to San Francisco to live with him some day. His brother had told him, ,fyou donft want to stay out there the rest of your life, ..do you?” He thought that whatever his brother wanted to do was up to him. He spoke indifferently about his sister, Mrs. Logan, saying that she had her troubles since her house was sold. He had been tola that he would spend the Easter holiday with her. He didn*t know whether hospitalization had helped him. Shock treatment had made him as fat as anything. Sister, Mrs. Logan, had told him when he was living with her that he was eating her out of tfhouse and home1*, and if he continued to eat between meals so much, he would have to wear a corset. Hhen asked about his hospital work assignment
59 he explained that he delivered newspapers every day* He received three dollars a week for spending money, but had no idea whether he was receiving any compensation
CHAPTER III ANALYSIS OP INDIVIDUAL CASE FINDINGS Each case was studied individually in order to show as fully as possible the answers to the following seven questicns: 1*
What was the reaction of the relative bo the pur pose of the study and to the word "benefits*1 used in. the letter of request?
Had the relative demonstrated any personal respons ibility for the patient during his hospitalization? (For example, had she taken the patient home on weekend pass, leave of absence, or trial visit?
Had she kept in touch with social service or the doctor?) 3.
What were the elements in the patient’s illness which were unacceptable to the relative?
What attitudes and feelings which interfered with the discharge did the relative display toward the hospital?
What was the nature of the affectional tie which might have been present but was not strong enough or free enough to enable the relative to take the patient?
What were the obstacles in the way of the discharge?
As stated by the relative.
As stated by the patient.
As seen by the researcher.
What possibility was there of eliminating barriers to the movement of the patient from the hospital to his home?
MR. BISHOP What was the reaction of the relative to the purpose.of the study and to the word “benefits!1 used in -the letter of request? Mrs. Bishop was suspicious and distrustful of our motive for discussing this stressful situation with her. She was outspokenly disappointed upon learning that “benefits” did not have any financial implications.
She had come to the
interview with the impression that an increase in her allow ance as a dependent would be the topic of discussion. Had the relative demonstrated any personal responsibility for the patlent during his hospitalization? Yes.
There had been many talks with the doctor about
the veteran*s condition.
It was noted further that Mrs.
Bishop visited the patient approximately once a week. took him on weekend passes occasionally.
But he had never
been taken home for a trial visit during the forty-six months of his confinement, and she let us know with feeling that the veteran was still our responsibility because of the sacrifice he had made for the country during the war. What were the elements in the patient »s illness which,were unacceptable to the relative? She objected to the dependency characteristics of his present behavior.
His slowness, passivity, and lack of
63 initiative were singled out as making him difficult for her to live with*
The personal untidiness of the patient was
also distasteful to her, as well as some of his habits, such as sleeping during part of the day. What attitudes and feelings which,interfered with the discharge did the relative display toward the hospital? She was contemptuous of the doctors and expressed her annoyance with the two doctors who had had direct dealings with the patient. ward physician.
One was his therapist and the other his She was threatened by any therapeutic at
tempt to change his behavior or his hospital status.
expressed opinion was that the patient was growing worse because of lack of interest on the part of the hospital as shown especially in its failure to provide a miraculous cure through brain surgery. What was the nature of the affectional.tie,which,might have been present but was.not strong enough or free enough to enable the relative to take the patient? The mother had little insight into her son’s illness and was intolerant of its manifestations.
nevertheless, a demonstrated attachment between them.
present she was overprotective of him to the point of treating him like a child.
Her concern for her own health
and activities, however, seetned to outweigh any
considerations for the patient. What were the obstacles in the way of discharge? As stated by the relative: (1) She feared that a discharge would disqualify him for continued compensation; (2) she was unable because of poor health to provide adequate supervision; (3) she felt that he was too ill to leave the hospital; (4) she had observed that he was dis satisfied at home; (5) she objected to the fact that the doctor had not expressly informed her that he was ready for a trial visit; (6) she pointed out the patientfs continued need for medical treatment of an allergic condition and a partial paralysis; (7) she was aware that the patient preferred the hospital to his home; (8) she pointed out the lack of an activity for the patient in the home. As stated by the patient:
The patient recognized that
he was not wanted at home and also that his home did not provide any
vocational activity to occupyhim.
willing to leave until
he had improved
He was un
toa point where he
might seek some form of limited employment.
He would not
consider planning for discharge until the medical chief of his ward told him that he had to go. As seen by the researcher:
The attitudes both of the
his mother were in the way
Even if she
could have been given some
assurance that the
compensation would continue, it seemed likely that her
rejection of the patient’s dependency needs and the encroach ment of his habits and the supervisory requirements upon her life would have res tilted in the failure of an attempt by the patient to live at home. Mrs. Bishop was determined to keep her son in the hospital in order to protect the full amount of his compen sation.
She told us unambiguously that she was too ill and
far too old for employment and was dependent solely upon his compensation.
The danger of its loss or reduction seemed
obvious to her if he should leave the hospital. What possibility was there of eliminating barriers to the.. movement of the patient from,the hospital to his home? The Bishop case was an example of the failure of the relative to understand that she and not the hospital was responsible for the patient’s continued care.
It was be
lieved that if some assurance were given her of the patient’s continued compensation she would have been willing to take him for a trial visit. An evaluation of the mother and her home Indicated that neither was suitable for the maintenance needs of the patient.
At sixty Mrs. Bishop was unlikely to modify her
attitudes toward his disability.
Casework in conjunction
with the medical recommendation for discharge might have induced her to take him but would not have been likely to Increase her tolerance to his limitations.
MR* MORGAN What was the reaction of the relative.to the purpose of the study and to the word Pbenefits? used,in.the letter of . request: Although the letter and the word 11benefits11 had given Mrs. Morgan the notion that her son was improved, she seemed quite apprehensive about our purpose in asking for her help. She wished to appear cooperative but disliked talking about her son's- illness and said that we must already have every thing in the records.
Her voice scarcely rose above a
whisper as though she feared detection by an unseen listener. Had the relative demonstrated any personal responsibility for the patient during his hospitalization? . Yes. She had taken the patient home on three trial visits, one in 1946, another in 1947, and a third terminating in May, 1948.
She visited once a week during his hospital
ization, and had taken him home for weekend visits frequently. She had spoken infrequently with the doctor and the social worker of the predischarge ward. What were the elements in the patient1s illness which were unacceptable to the relative? She was unable to bear the indifference of the patient to her cooking.
She was hurt easily by his antipathy toward
her protectiveness as evidenced by the way he found fault
6? with whatever she did for him.
She was especially intoler
ant of his schizophrenic makeup as expressed in withdrawal from friends, relatives and herself, and in despondency and apathy.
Finally, she was resentful of his childish behavior.
He bought toys and spoke like a child.
history of the patient showed a child and an adolescent in whom extreme dependency was bred by the mother.
literal sense, the patient had remained the faithful, de pendent child. ifaat attitudes and feelings which interfered,with the discharge did the relative display toward the hospital? Since the unsuccessful trial visit in May 1948, there had not been any helpful contact between the mother and the physician or any professional member of the hospital.
was left with the understanding that the hospital would reach out to her regarding the readiness of the patient to leave.
c When she was told in the course of this study that
her son was ready to leave, she denied the reliability of the medical recommendation on the strength of her own feel ings about his condition.
Yet she said that she might take
him for another trial visit in May.
The researcher!s im
pression was that she would take him not when he was ready to go but when she was ready to receive him.
What was the nature of the affectional tie which might have been present but was not strong enough or free enough to enable the relative to take the patient? Mrs* Morgan was an exceedingly overprotective mother who wanted the patient with her but could not live with his illness.
Having him in the hospital where they could spend
^nice weekends together11 was the extent of the responsibility she could stand at that time.
Several of her attitudes were
noteworthy: the feeling that she was a martyr to the cause of helping him, that she had tolerated more than ordinary people could, that she alone understood him as a person, and that he would have perished long ago were it not for her sustained interest.
But because of pride and shame she was unwilling
to let anyone else, relative or friend, know of or discuss his disability. What were the obstacles in the way of discharge? As stated by the relative:
(1) She did not consider
him sufficiently improved; (2) she did not feel physically able to provide the patient with the recommended supervision; (3) she feared violence to herself since the patient w.as nnot himself11; (4) she saw no appropriate activity or interests for him in the home. As stated by the patient:
He was diffident over the
question of remaining or going home. decision, was his motherfs to make.
He insisted that the He had no insight into
his condition but seemed to know that going home would not he the most helpful plan.
Paradoxically, he felt able to live
outside the hospital and wanted a full discharge in order to go to Texas to rejoin his former wife, but he was not suf ficiently motivated to do anything about this wish* As seen by the researcher: Again,, this was a mother who was not ready to accept or live with the very limited improvement of the patient.
The home was certainly an in
adequate one emotionally, and the mother was incapable of administering the amount or quality of supervision which would have been desirable* What possibility was there of. eliminatIng,barriers.to the movement of the patient from the hospital to.his home? In the light of our knowledge of the relationship between mother and son it would not have been beneficial for him to return to the parental home.
He would probably have
made an ideal patient for a foster home in the community.
MR. GONZALES What was the reaction of the relative to the purpose.of the study and to the word ubenefits M used in the letter of . request? A certain amount of tenseness and suspicion prevailed in the beginning of the interview because, Mrs* Rivas, the patient’s sister and her brother were convinced that they would be compelled by the authority of the hospital to take the patient home.
They insisted that they had no under
standing of what might have been intended by the word Mbenefitsn. The family was not aware that the patient re ceived compensation for his disability.
They assumed he was
paid for detail work at the hospital as he seemed to‘have money to buy candy for himself and the children.
He did not
recompense his sister in any way for meals while on pass to her home. Had the relative demonstrated any.personal respons.lbili.ty . for the patient during his hospitalization? Yes#
The sister had visited him every other week and
had taken him to her home for weekends.
The patient had never
been on a trial visit or leave of absence during the sixtyeight months of his hospitalization. There had been no relationship between the family and the social service department except in one instance, when an
attempt was made to interest the sister in trying the patient in her home on a trial visit status.
She had not spoken with
a doctor in two years. What were the elements in the patient«a illness which were unacceptable to the relative? There was considerable reluctance on the part of the sister to give him the attention and time he needed since she had three small children.
Thus his dependency needs
would infringe upon her freedom and ability to devote her time to her own family. There was some uncertainty, too, about being able to restrain his drinking.
In addition, she, very much like the
two mothers described earlier, was ill at ease with his silence, apathy, and periodic refusals to eat. Her fear that the patient might make sexual advances toward her children did not appear to be based on any past . episode.
It was not, however, unreasonable for her to be
physically afraid of him since he was touchy and easily provoked and had a history of assaultive behavior with other patients and persons outside the hospital who offended him. Clearly, the sister was insecure in her ability to handle the patient’s hostility. What attitudes and feelings...which interfered with the, discharge did the relative display.toward the hospital?
Interestingly, Mrs .Rivas felt that hospitalization had greatly improved the patient.
Sine© hospital care agreed
with him so well, she saw the solution to his further care as continued hospitalization and, recommended that he he kept as a permanent employee.
The absence of any understanding of the
hospital as a treatment facility rather than a custodial home obstructed her participation in constructive planning for her brother1© care outside the hospital.
What was the nature of the affectional^tie .which,might have been present but was not strong enough or free enough to enable the relative to take the patient?. Before his entry into the army the patient lived alone in a single room.
His sister, to whom he had been closer
than to any other person, seemed to have adopted a mother relationship to him.
While she seemed to have some feeling
of responsibility for him she had lived away from him long enough to have broken the original close family tie. What were the obstacles in the way of. discharge? As stated by the relative: (1) She regarded the patient as a very childlike person with considerable de pendency needs, which she was not able to meet because she had three small children to car© for; (2) her home wa3 too small for another person, as there was only one bedroom for the family of five; (3) she was afraid that the patient might
constitute a danger to her children when she was not present. As stated by the patient; He was agreeable but not eager to leave.
The unusual emphasis he placed upon not
wanting to go without the full consent of the doctors was an indication of the extent of his dependency upon the hospital. As seen by the researcher:
Certainly, the limited
quarters of the sisterfs home in addition to her responsibil ities to her family precluded any planning with her for the adequate care of the patient in her home.
The problem in
this instance was mainly situational, unless the patient im proved to the point where he could live alone again and engage in limited employment.
Such a plan was not now
considered feasible by the ward physician. What possibility was there of eliminating,barriers to the movement of the patlent from the, hospital to his home? Little persuasion would have been needed to induce the sister to assume the burden of her brother’s supervision, but the risk of unbalancing the family unit would not ultimately have benefited either the patient or the family.
patient could advantageously live in a family care home in
MR. ROSEH What was the reaction of the relative to the,purpose,of the study and to the word “benefits11 used in the letter,of request? Mrs. Rosen was less interested in our purpose than in relieving herself of her stored up feelings against the hospital for its failure to alter her son’s personality and to help her.
She was very much disappointed because she had
come under the impression that “benefits*1 meant a new kind of medical procedure for curing her son’s psychiatric complaint. Had the relative demonstrated any personal responsibility for the patient during his hospital iz at ion? Until recently the family home and business had been in Pennsylvania; therefore visits to the patient had been infrequent.
Yet there was a very strong interest in him.
Plastic surgery costing the family more than two thousand dollars was performed on the patient.
The medical cor
respondence file contained numerous letters from the parents to the hospital inquiring about his condition and treatment and asking to be informed when they might take him home as recovered.
The physician discouraged their coming for him
owing to the severe and chronic nature of his sickness.
order to be closer to him and to provide him with a home for his weekends, the family had sold the business and were
■buying a home in this community.
Although numerous contacts
were made with the doctor, few if any were held with the social service department. What were the elements in the patientfs illness which were unacceptable to the relative? The patient *s inability to excel in an intellectual pursuit was regretted by the family, and his excessive, even obsessional interest in sports was found ridiculous and was disparaged rather than accepted as symptomatic of an illness or of an individual difference.
Also there was no acceptance
of personal difference in daily habits, vocational interests, or life goals. What attitudes and feelings which interfered with-the discharge did the relative display toward the hospital? This mother was not interested in seeking help if it would involve change for her.
She, too, had been seeking an
easy solution such as plastic surgery, an injection, or a sympathetic professional person willing to allay her guilt feelings and offer simple, acceptable advice.
She felt that
neither hospitalization nor the concurrent treatments had improved the patient.
It was gratifying to her that, in a
sense, we shared her failure to modify her son1s extreme feelings of inferiority.
When she said the problem had been
too big for her, she was telling us that it was too much for
.And when she said that no one had told her that he
was ready to go, she was pointing to a real deficiency in the program of 11total push”.
For certainly this case was one in
which the coordinated approach of the doctor and the social worker could have hastened and improved upon the trial visit plan which was then anticipated. What was the nature of the affectional tie which might have heen present hut was not strong enough or free enough to enable the relative to take the patient? The family relationship was obviously a close one in which-both the patient and the family had a strong sense of failure.
The mother had deeply ambivalent feelings toward
She loved him but found it impossible to live with
He was her offspring and the product of her upbringing,
but he flwas utterly foreign to her”*
She was repelled by
his aspirations and attitudes, but she could not give him up. Hor would the patient want her to.
He said that he came from
a good home, and he only hoped things would work this next time. The family were willing to spend money for operations, read textbooks about mental illness, and keep in close touch with their son’s doctor.
Indeed, they seemed compelled to
do everything possible for him short of suffering the ignominy and discomfort of actually living with him.
What were the obstacles in the way of discharge? As stated by the relative:
(1) She was unable to
accept the limited improvement or the patient as the best offort of the hospital; (2) she was convinced that she and her husband lacked the understanding and flexibility to deal with the differences in their interests and temperaments and those of the patient; (3) she considered the patient too sick to leave just yet; (4) she objected to his personal untidiness and crude manners; (5) she was resentful of and ■unprepared to assume the responsibility for a dependent adult; (6) no one had told her he was ready to go home; (7) it embarrassed and hurt the family pride to have in the home a member of the family with a psychiatric illness; (8) she considered the patient to be happier in the hospital than he would be at home* As stated by the patient; Until recently he had not considered himself ready for a discharge.
He intimated that
he had not cared to return to his family until they had moved to this community, since he was planning to receive outpatient care at the Mental Hygiene Clinic, Veterans Administration Regional Office. As seen by the researcher:
Social service around
discharge planning was not offered since parents were in another state and the only contact was between the family and medical administration by correspondence.
There were no material reasons why this patient could not he cared for in the home of his parents • Neither parent was employed. income.
They owned their home and had a substantial
The reasons advanced by the mother for not taking
him were real ones for her, involving the attitudes of her-* self and husband toward the patient.
They admittedly found
certain aspects of his personality and behavior intolerable. What possibility was there of eliminating barriers to the movement of the patient from the hospital to his, home? There was little necessity for speculation about this point since preparation was now under way for a trial visit in May, 1950.
In order, however, to insure a successful
extramural adjustment, there should certainly have been care ful pretrial visit preparation at this point for the relative and the patient.
There should also be close follow-
up by the social worker from the Veterans Administration, Regional Office.
MR* DARRELL What was the reaction of the relative to the purpose of the study and to the word >!beneflts!> used in the letter of request? Mrs. Darrell appeared unusually complacent and un touched hy the statement that her son was heing regarded as a possible candidate for a trial visit and gave no outward sign that this news was either threatening or welcome* word ,!benefitsM puzzled her*
The letter itself suggested
the thought that her son might have taken a turn for the worse. Had the relative demonstrated any personal responsibility for the patient during his, hospitalization? There was little clear evidence of this mother*s interest.
Her visits to the hospital had been neither
frequent nor regular.
The patient had not been home for a
weekend since Christmas Day, and the mother had not spoken with the doctor for more than a year.
There was no record
of social service activity other than an inspection of the patient during a therapeutic review staff discussion when it was felt that he had improved markedly in 1947.
one trial visit attempt in 1945 which failed, resulting in the return of the patient after thirty days.
What were the elements in the patient1s illness which were unacceptable to the relative? She was perplexed and did not understand why she especially was able to vex him or incite him to rage over trifling matters.
His tendency to become noisy or to dis
mantle an electric appliance was disturbing for her.
inability to exert any control over his behavior provided a real problem when he was at home*
Even if she were assured
that he was not dangerous, she would have been unable to endure his halluncinatory behavior or the occasional episodes in which he talked to himself. He had adopted an openly rejecting attitude toward her visits to the hospital, and these rebuffs were interpreted rather narrowly by her as meaning that he did not want to see her.
She doubted that he would ever forgive her for commit
ting him; yet she saw him as becoming sicker since if he were 11himself” he would be more understanding of her position. What attitudes and feelings which interfered with the discharge did the relative display toward the hospital? She was in awe of the doctors and reluctant to ap proach them although she was convinced that her son was not receiving treatments that she believed were available. Because the patient had not attended occupational or cor rective therapy since his transfer to the open ward, she
was *under the impression that lie tiad been neglected*
failure to respond to electro-shock treatment puzzled her, and she wanted to request seme other treatment for him such as she had road about in popular journals* In regard to discharge she seemed to feel that it was her option to take him or not to take him rather than an action that was dependent upon the authority of the doctor. What was the nature of the affectional tie which might have been present but was not strong enough or free enough to enable the relative to take the patient? She was more concerned with doing the socially ap proved thing in relation to the patient than in helping him. She had relied heavily upon the advice of her other son regarding the commitment and her responsibility toward the patient.
The chronic and moderately severe nature of his
illness plus the separation from him during the war years and the sixty-four months spent away from her in the hospital had resulted in making the tie between them more tenuous. The early developmental history offered the picture of an overprotective mother, strongly bound to her son. What were the obstacles in the way of discharge? As stated by the relative: (1) She was wholly con vinced that he was not well enough to live at home; (2) she did not feel that her apartment offered adequate living or
sleeping facilities for the two of them; (3) she realized that she was incapable of providing the proper supervision for him; (4) she was very much afraid of his violence and temper; (5) she feared the loss of her apartment as a result of her son’s obstreperousness; (6) there was no activity or vocational outlet for him at home; (7) she regarded the hospital as a home far superior to what she might offer and was certain that he preferred the hospital to living with her* As stated by the patient: Mr. Darrell was frankly unwilling to leave unless given a maximum hospital benefit discharge and provided with a suitable job.
Living with his
mother had no appeal for him whatsoever since she did not ♦
understand him and they had no shared interests. As seen by; the researcher: There might have been reason to believe that the mother was concerned about her son’s continued compensation, although she indicated that she was asked to apply and had not done so automatically. The outstanding problem unquestionably was the inability of the mother to manage or control the patient or to offer him a suitable home in terms of space, activity, and freedom. What possibility was there of eliminating barriers to the movement of the patient from the hospital to his home? This patient would probably have made a suitable ad justment only in a small hospital for chronic schizophrenic patients or a placement where he could work by himself .
83 MR. GORTEZ What wag the reaction of the relative to the purpose of the study and to the word "benefits11 used in the letter of request? Mrs. Cortez remained apart and stoical, as she under stood little of the ensuing discussion.
Her son, who came
as her representative and interpreter, was cooperative, interested, and sympathetic to our purpose.
“benefits" had left them puzzled and concerned rather than with a particular impression as to its meaning.
had given the mother the idea that the patient had been ill, and she considered this our purpose for calling them in. Had the relative demonstrated any personal responsibility for the patient during his hospitalization? The degree of responsibility felt by this mother was difficult to evaluate from hospital visits owing to her long standing Illness and Infirmity.
The five trial visit periods
extending into 1948 seemed to show that the family, and par ticularly the mother, felt some responsibility for the patient.
There had been little or no contact with the
doctor or hospital social service. What were the element s In the patient1s illness which were unacceptable to the relative? The mother mainly opposed the inability of the
patient to hold a job or to do small household chores on a sustained level.
She interpreted his moodiness, seclusiveness,
and dependency as malingering.
His lack of ambition to im
prove himself and his mental slowness were qualities which the entire family found difficult to bear.
He was their one
failure, socially, economically, and vocationally.
He was *
the only member of the family who had not married or founded a life independent of the mother.
It was apparent that it
was the childishness and lack of interest which the family found objectionable rather than the irritability, anger, and occasional threats leveled at them.
They were offended, too,
by his unconcern with his appearance. What attitudes and feelings which interfered with the discharge did the relative display toward the hospital? This family knew the hospital only as an institution which had relieved them of the burden and responsibility for the patient.
They were glad that he was content to remain,
and they initiated as little contact with him or the doctor as possible lest this arrangement, ideal from their point of view, be spoiled.
The attitude of the family was one of not
understanding the purpose of the hospital, but finding their need to be rid of the patient met, they offered gratitude for the care given.
85 What was the nature of the affeotional tie which might have heen present hut was not strong enough or free enough to enable the relative to take the, patient? The mother had been a driving, ambitious, dominating force in the lives of her children.
She had been econom
ically independent of them and had done as she pleased, uninfluenced by them, until recently.
The attachment between
her and the patient was deep, and even though she was in capable of supervising him while she was ill, she proposed to take him on another trial visit.
Her son had to tell us ^no”
for her. What were the obstacles in the way of the dis charge? ,As stated by the relative: (1) There was no one in the home to give him adequate supervision or care owing to the age and the illness of the mother; (2) even when the mother was well, she could not have tolerated his inactivity and dis orderliness; (3) the family was afraid of his violence and did not consider him responsible for his actions; (4) the unity of the family and the health of the mother were dis rupted even when the patient came for a weekend; (5) they felt that he preferred the hospital to his home. As stated by the patient:
He had no particular drive
to leave the hospital but thought it might offer a pleasant change now that he had learned to relax again.
He v/as wil
ling to leave but not to take the initiative for the action.
The patient was a chronic,
long-term schizophrenic, unwanted and feared by his brothers and sisters, who seemed to have little affection for him but maintained a slight interest out of loyalty to their mother. His mother was still devoted to him but had no insight into his limitations.
She had been critically ill and would
never be physically able to take him, and the siblings lacked the motivation to do so. What pos sibility was there of eliminating barriers to the movement of the patient from the hospital to his home? Hone.
His family had neither the understanding nor
the desire to resume the responsibility of his care after a twenty-five month separation from him.
87 MR. VITO What wag the react ion of the.relative.t o the purp osa .of .the study and to the word “benefits“ used in the letter of request? The sisters of the patient, Mrs. Logan and Mrs. Cole, reacted by becoming more tense, not knowing what to say and not wanting to say the wrong thing.
assumed that it was necessary to
be rid of the patient in
view of a reduction in the staff
of the hospital.
They had no idea what was meant by “benefits for the patient“ but did not connect it with money as they evidently were unaware that he received compensation. Had the relative demonstrated any personal .responsibility. for the patient during his hospitalization?There was a remarkable absence of any responsible feeling toward the patient as an ill person.
sixty-three months of hospitalization, neither sister had ever consulted with a professional member of the hospital to inquire about the improvement of the patient or the pos sibility of a release for him.
They had taken him home a
half-dozen times for a few days but visit rather than a trial period
for the purpose of a
The sisters had
no awareness of what treatments he might have received.
What were the elements, in the patient1s iline as which .we re unac cep table to the relative.? They objected to his irritability and restlessness and to what they regarded as irresponsibility*
annoyed with his personal untidiness and stubborness and seemed to be ashamed of him for never having Hgrown upn. What attitudes and feelings which interfered.with the discharge did the relative display toward the hospital?. They considered the hospital too big for them to understand and the doctors too elusive for them to locate* They found the patient unimproved but were indifferent to finding out why or what could be done about it.
ashamed to have a brother in a psychiatric hospital because if anyone knew he was in a neuropsychiatric hospital, they might think he was ^psycho11. What was the nature of the affectional tie which might have been present but was not strong enough or free enough to enable the relative to take the patient? Following the death of his mother, when the patient was ten, the father took over the role of the mother and the sisters were employed.
There seemed to be little feel
ing that he belonged to them since they had not experienced much responsibility for him.
The patient had been closer to
his older brother than to them.
He had been unwanted and
rejected for many years and the long period of hospitalization had increased the feeling of separation. The writer asked at one point how they would feel about having him placed in a home or sanitarium outside of the hospital.
The response was not, ttWe would rather take himw;
hut, **We would not want him any place where he might he worked to death or mistreated, of course'1. What were the obstacles in the way of dis charge? As stated by the relative: (1) There was no one to give him the constant supervision he required; (2) they were not ahle to meet the problem of controlling him; (3) they had no space for him in their homes at that time. As seen by the patient: Patient did not understand why he was in the hospital but offered to go to his sister1s home if he were permitted to work.
He was also willing to live
with his brother in San Francisco. As seen by the researcher:
The situational problems
of home and supervision were the major obstacles,
the fact of being employed, neither sister was in a position to provide the maximal amount of supervision necessary. These reasons in addition to the unwillingness of the family to have him were sufficient to prevent discharge.
What possibility was there of eliminating.barriers to the movement of the patient from the hospital to his home? Hone,
fhis patient had made an excellent adjustment
to the controlled environment of the hospital.
needs could best have been met by a hospital for the chronic, institutionalized patient.
CHAPTER XV SUMMARY OF FACTORS INTERFERING- WITH DISCHARGE OF PATIENTS TO RELATIVES In the preceding chapter each case was presented individually to show which factors were mainly responsible for the prolonged hospitalization of the patient and which ones were incidental factors*
In no case was there a
single cause that could be held entirely responsible* Where there was an acute reality problem, there were accompanying attitudes toward the patient of lack of interest or intolerance, or there were misconceptions regarding the role of the hospital*
situational aspects were so interrelated that it was difficult to ascribe primary importance to either. When a reality problem was presented as a reason \ for inability to take the patient home, one could
justifiably ask why the family had not requested help
\y * \
in meeting it.
These families had feelings about the
patients which got in the way of their dealing with the situational problem*
Nor was it possible in any Instance
to ascribe to lack of interest alone a refusal to assume responsibility for the patient*
Several relatives visited
the patient each week over a period of years.
In fact, there
seemed to have grown up a close family attachment
dependent upon the separation itself. In order to understand the limitations of the information given by the relatives and to form a judgment as to the validity of the findings, it was necessary to examine the responses of the relatives to the stated purpose
of the study.
Did they comprehend its purpose,
and were they able to meet it with genuine feeling and sincerity? In each Instance the relative came with a considerable degree of concern and suspicion about the interview. These feelings were not always manifested on the surface, but had to be met before significant material was forthcoming.
The interviewer had to place particular
emphasis on the confidential nature of the information given.
Of great importance, too, was the assurance given
the relative that the interview would not alter the status of the patient or endanger the position of the relative.
In other words, to be able to speak freely,
they needed to be told that the patient would not be discharged as a consequence of what was disclosed. The reaction of the relative to the word "benefits * in the letter of request was of interest to this study, since she could project onto the word whatever meaning it held for her in relation to the patient.
Bishopfs mother, in Case 1, spontaneously expressed
93 annoyance because the phrase did not mean there was to be an Increase in the amount of compensation*
In Cases 4, 5
and 6, the relatives connected the word with the patientTs illness; Mrs* Rosen, in Case 4, supposed that her consent was needed for a new medical procedure; the relatives in Cases 5 and 6 thought this meant that the patient had become worse.
The relatives in Cases 3 and 7 did not
how they interpreted the reference to "benefits,tf but neither of them knew the nature or amount of the patient’s compensation. Inadequacy of the physical facilities of the home* Inadequate size of the home was given as a leading reason by relatives in three cases (3, 5 and 7).
out that the home did not have the necessary sleeping space for the patient. It was thought by the relatives in six cases (1, 2, 3, 4, 5, and 7) that their homes were deficient In resources for recreation, vocational activity, or social outlets*
This was an incidental consideration for
the most part and yet very much of a problem.
In Case 1
the mother lived in a court where there was no yard, garden, or workshop space.
This situation was made more acute by
the factNthat the patient could not have been allowed to A
leave the house unaccompanied even for an errand to a grocery store*
94 Inability of the relative to provide recommended supervision*
In all of the cases studied the relative
advanced reasons why supervision at home could not be provided*
This consideration was important from the point
of view of hospital responsibility since moderate to extensive supervision was recommended by the physician in every case* In Gases 1 and 2, the mothers stressed their own ill health*
They said that previous experiences with the
patients on weekend visits made them doubt their ability to meet even responsibilities of feeding and observation. Poor health in both of these instances seemed an incidental rather than a major objection. For Mrs. Rivas in Case 3, on the other hand, having a husband and three children to take care of seemed the out standing reality reason.
She also viewed with some trepida
tion the possible problem of her brother's excessive drink ing. . The mothers in Gases 2, 4, and 5 felt that they were persons from whom the patient would not tolerate any form of protection or control*
Between them and
their sons were reciprocal feelings of emotional and social incompatibility.
On the part of each of these
mothers there seemed to be a sense of utter inability ever to accept the patient back into the home.
serene relationship seemed dependent upon living separately, and hospitalization with weekend visits appeared to these mothers to be an ideal arrangement. Only in Case 6 was it completely apparent that the mother was too old and ill to attend to the maintenance requirements of her son. The sister and brother were engaged in full time employment in Case 7.
The other sister, with whom the
patient stayed periodically, was seeking work.
writer felt that other reasons would have been used if the ones above had not been present. The failure of the patient to make a satisfactory adjustment in the home on a weekend, leave of absence, or trail visit provided the relative in every case, except Case 3, with an unpleasant memory of the patient to which referral was made.
Since a trial visit had not been made
by patients in any of these cases for more than a year, the validity of these Judgments as applied to present conditions must be questioned. Unwillingness of the relative to risk loss of com pensation.
The question as to whether a relative might
not be reluctant to take home a patient because of fear that such an action would Jeopardize her income required close scrutiny.
Only the veterans in Cases 1, 2 and 5
had dependent relatives relying upon their compensation# Had these patients left the hospital, their mothers, as dependents, would have continued to receive a small dependency allowance without the apportionment from the compensation (unless a legal guardianship was established); however the full compensation would have been restored to the veteran#
These mothers, as elderly
unemployable women, were very much dependent upon the patients, but only Mrs. Bishop in Case 1 actually said that her income would be endangered if the patient were discharged.
She alone admitted the fear that her son’s
compensation would be diminished or stopped. main reason why she had not taken him home.
This was the It is, of
course, a requirement that a veteran outside of the hospital receiving compensation must be seen periodically by a medical examiner for rating purposes.
In the event
of Improvement or recovery, the rating may be altered and compensation reduced or eliminated.
There was some
question as to whether or not this could be one of the moti vating factors for Mrs. Darrell in Case 5. that it was#
In the other cases, with the exception of
Case 2, the relatives did not know whether or not compensation was being paid# The attitude of the relative toward the patient *s
readiness for discharge*
The relatives in five cases
(1, 2, 4, 5 and 7) responded to the statement that the patient was ready to leave the hospital by denying that he was well enough to do so*
Furthermore, they did not
believe that the patient had changed for the better during the hospitalization*
In the remaining two cases (3 and 6),
where the patient’s lack of readiness was not given as a reason for refusing to take him, the feeling of the relative was that he was apparently well in the institutional setting but would not adjust at home* A most important consideration was also raised in Gases 1 and 4*
These two mothers complained about the
hospital’s failure to inform them earlier of the patient’s readiness for discharge.
Indeed, all of the relatives
reacted with some degree of disbelief when informed that the patient was ready to leave the hospital*
scepticism was not surprising since all of these patients were of the chronic type and had not shown extensive evidence of improvement.
The relatives were, in actuality,
being asked to take home an ill person because the hospital believed that he could adjust outside the institution. The sharing of medical information with relatives regarding the progress of a patient does not occur routinely.
For those relatives who had initiated little
or no contact with the doctor, the news that the patient could go home came suddenly and without adequate preparation.
It has been suggested that a relative may
be rationalizing a rejection when she objects to receiving the patient because she has not previously been told of his readiness to leave the hospital.^
although this study was not concerned with the factor of medical management as an obstacle to discharge planning, it was not possible to overlook it entirely since relatives did direct attention to it. Attitude of the relative toward the patient fs illness.
Oases 2, 4 and 5, illustrate the feelings of
embarrassment and injured pride which are characteristic of relatives for whom psychiatric illness has an aura of social unacceptability.
These three mothers spoke of
not being able to invite anyone over when the patient was at home and even of having lost friends.
mother in Case 5, said that she did not want anyone to know of his having been In a psychiatric hospital. In addition, each relative found objectionable and sometimes unacceptable in the patient certain types of behavior and certain personality traits.
This comment was made to the writer by Mr. Donald Lee, social worker for the predischarge ward at the hospital*
fear of violence in some cases*
The following categories
indicate the chief objections and fears of these relatives: a*
Childishness and dependency in all cases*
Periodic inactivity and indifference in all cases
Personal untidiness in four cases (1, 4, 6, 7)*
Periodic refusal to talk in three cases (3, 5, 7)
Periodic refusal to eat in two cases (2, 3)*
Irritability and touchiness in four cases (2, 4,
5 , 6 )*
of violence in four cases (2, 3, 5, 6)*
Attitude of the patient toward leaving the hospital*
Hot one of the patients in the study group
appeared eager to return to his family*
from his family for more than a year had weakened the nature of the relationship with the relative so that the patient no longer cared to look toward his mother or sister to do anything for him*
All of the patients seemed
to feel that while the hospital was not an ideal place, it was now home* The attitudes of the patients in this study would not, in the main, have prevented their discharge*
of them manifested willingness to leave the hospital uponthe recommendation of the
Even Mr* Bishop
in Case 1 who obviously did not wish to leave, indicated willingness* to go if directed by his doctor*
cases (2, 3, and 7), the patients seemed unmotivated to remain or to go* to the question*
They were passive and indifferent
Mr. Darrell in Case 5 was definitely
unwilling to live at home except on his own unrealistic terms.
The only positive feelings were expressed by
Mr. Bosen in Case 4 and Mr. Cortez in Case 6, both of whom seemed to want to go home. Attitude of the relative toward the hospital. Those relatives who held strongly to the belief that the patient's illness was due to the traumatic experience of the war seemed more inclined to expect the hospital to assume responsibility for indefinite, ongoing care. This was the attitude of the relatives of the three veterans who had been overseas (Cases 1, 4, and 5). The mother in Case 1 explicitly and pointedly disclosed her feelings about the threat of possible discharge when she said that her son sacrificed himself for the government and deserved to be taken care of as long as he was disabled.
In Case 4, the mother felt
personal guilt for her son's, illness, but stressed, too, that something had happened to him in the army that made him impossible to live with.
The mother in Case 5
divided the responsibility for the patient's illness
between his army experience and a disappointing love affair. Also found in Cases 1, 4, and 5, were expressions by the relative that the hospital had not attempted to treat the patient with the most recent medical procedures for the illness but might 11cure” him by such an effort. The mother in Case 1 wondered whether brain surgery might be considered.
In the other two cases, the
relatives were not as specific but f,just knew*1 from articles they had read that something might be done for their sons.
Such unrealistic expectations could have been
dealt with by the doctor and the social worker through a continuing relationship. Of major significance in all cases was a lack of understanding by the relative of the function of the hospital as a treatment facility rather than a custodial home.
Closely connected with this was the absence of
a realization that they might be expected to resume responsibility for the patient who had Improved to a limited degree and might succeed in achieving an extramural adjustment. The five relatives who asserted that the patient was happier in the hospital and preferred it to his home (Cases 1, 3, 4, 6, and 7) offer a particularly striking illustration of what is meant by a relative’s not
understanding the philosophy and purpose of the hospital. Another problem was raised for the mothers in Cases 2 and 5 in which the patient when visiting at home either for a holiday or weekend refused with great obstinacy to return to the hospital.
The mothers of
these two patients dreaded a possible trial visit because if the patient relapsed into more acute illness, there would again be the ordeal of calling the authorities to return him.
CONCLUSIONS It has been stated that an over-extended period of hospitalization is undesirable both from the standpoint of its effect on the patient and as a poor use of hospital facilities.
The Group for the Advancement of Psychiatry has
circumscribed the problem in stating that the hospital is a treatment facility of the community, the goal of which is a return to community living.3* But unless the family is helped to understand its responsibility in the total treat ment program, the likelihood of its gradual separation from the patient is increased, and the rehabilitation of the patient through his family becomes more difficult.
study has revealed that such understanding was very limited in the cases studied. Henry Freeman has divided relatives of psy chiatric patients into three categories*
who seem capable of meeting the patient*s needs; second, those that have problem attitudes but seem capable of modifying them; and third, those who
3* The Psychiatric Social Worker in the Psychiatric Hospital, Group for the Advancement of PsycEiatry, 'Seport No. 2, January, 1948, p. 1.
present rigid and inflexible patterns."
None of the relatives studied in the present paper belonged in the first category*
It would be
difficult to be certain which of them belonged to the second and third categories.
The majority of the
relatives in the study group, however, were too Involved with their own emotional needs and limitations to meet the patient1a post-hospitalization requirements* It may be said that whenever relatives of psychiatric patients present attitudes which are inimical to the patient's welfare but may still be modifiable, the social worker in a neuropsychiatric hospital has a definite responsibility.
It should be
his effort to help such relatives to reach a clearer understanding not only of the patient's problem, but also of their own role in a treatment program. The present study was limited by the number and kind of cases and by the focus upon relative-patient relationships.
Certain other inquiries to further the
knowledge of the problem pf returning patients from the hospital to the community would be valuable.
writer would suggest, for example, a study of the p
Henry Freeman, "Casework with Families of Mental Hospital Patients". Journal of Social Casework, March, 1947, p. 108. .
patient with a relatively short record of hospitalization who presents the problem of placement when ready for discharge*
What are the obstacles to the discharge of
such patients (chronie and non-chronic) before they become institutionalized?
In such a study one might
well examine the problem in terms of the patient, his family, and the contribution of medical management to a social solution*
By the last is meant scrutiny of the
activity of the doctor and the social worker to determine what channels are provided for helping and sharing infor mation with relatives so as to prepare them for and facilitate the patients discharge.
A study of the
casework process in planning for discharge with long and short term contacts with relatives could also offer a fundamental contribution* Finally, a foster home program is needed for the patient without relatives as well as for the patient whose family is unable to offer the recommended supervision or has no tolerance for his illness.
Such patients include
a considerable number of the population of the hospital* An inquiry into which of these would be suitable for foster care and how receptive they would be to such a program would be another project for investigation*
Bartlett, Harriett M., Some Aspects of Social Casework in SL Medical Setting, Chicago: The Committee on Functions, American Association of Medical Social Workers, 1940, 370 pp. Crutcher, Hester B., Foster Home Care for Mental Patients. Hew York: The Commonwealth Fund, l9'44. 199 pp. French, Lois Meredith, Psychiatric Social Work. The Commonwealth Fund, 1944• 344 pp. Peters, Fritz, The World Next Door. Straus, 1949, 369 pp. B.
New York: Farrar
Crutcher, Hester, ”The Role of the Social Worker in Family Care of .Mental Patients, ”Smitfa College Studies in Social Work, 1943-1944, pp. 118-196. , ,fThe Function of the Psychiatric Social Worker In a Mental Hospital”, The News -Let ter, A.A.P.S .W., 12:1, Summer 1942, pp 3-11. DeWitt, Henrietta B., ”The Function of the Social Worker in the Total Treatment Program in a State Mental Hospital”, The American Journal of Psychiatry, 105: October, 1948, pp 2§S-303. Freeman, Henry, ”Casework with Families of Mental Hospital Patients”. Journal of Social Casework, March, 1947, 107-133 ppZ Freudenthal, Kurt, ”Participation of the Community Agency in Hospital Discharge Planning”, The Journal of Social Casework, XXX, December, 1949, pp. 421-1^6 Group for the Advancement of Psychiatry, ”The Psychiatric Social Worker in the Psychiatric Hospital,” Report No. 2, January, 1948,.14 pp.
Newhouse, Edward, "Come Again Another Day11, The New Yorker April 15, 195G, pp 26-32 , ‘ Osborne, Maysie, f,Use of Family Care as a Treatment Procedure with the Mentally 111”, Mental Hygiene, 27: July, 1943, pp. 412-423 , , Stipe, Jack, "Social Service in the Veterans Administration” Journal of Social Casework, February, 1948, pp. 43-48 ______ , "The Veterans Administration Social Service Program”, Public Welfare, 5:3, March, 1947, pp. 50-54 Stone, Anthony R., "The Caseworker’s Contribution to the Social Rehabilitation of an Intellectually Limited Rehospitalized Psychotic Patient”, Journal of Psychiatric Social Work, Winter 195^7 115-122 pp. Worthington, Florence, "Suggested Community Resources for an Extensive Parole.System for Mental Patients in Illinois”, Smith College Studies in Social Work, June, 1933, pp. 265-337 C.
Shea, Margene M., ”An Experiment in Planning for Psychotic Patients at Home”, 1950. 3 pp. (A Study made by the Chief Social Worker, Veterans Administration Hospital, Murfreesboro, Tennessee). D.
Veterans Administration Regulations and Procedures. Procedure in Effecting Discharges of Patients, Par. 6352 March 1, lUl’ 9, 96-4R pp• Veterans Administration Neuropsychiatric Hospital in Los Angeles, California, "Admission and Disposition Sheet, Period Ending 12:01 A.M., April 11, 1950, 1 p. Veterans Administration Standard Medical Administrative Procedures for Veterans Administration Hospitals, June 1, 1947.
Lear _______________ : We wish to spend some time in a discussion with you about your , Mr# , in connection with an intensive study now being conducted by the hospital* Your assistance in this matter is important and should result in benefits for him as well as other patients in the hospital* Please telephone Mr. Bobbin, social worker in this hospital, for your appointment* The interview will last about one hour* His office is located in Building 157, Boom 40, and he may be reached on Monday, Tuesday and Thursday between the hours of 8:00 a.m* and 4s30 p.m* at ARizona 7-6761, Extension 751* He will appreciate hearing from you at your earliest convenience.
Very truly yours,
Assistant Chief, Professional Services Neuropsychiatric Hospital
SCHEDULE IDENTIFYING INFORMATION Name Age Race Nationality Marital Status Admitting Diagnosis Admission Date Committed or Voluntary Admission REASON FOR HOSPITALIZATION Circumstances of the Admission PEESONAL HISTORY Education Marital History Employment MILITARY SERVICE Dates of Service Rank Type of Discharge Overseas - Yes
112 family record
Composition FAMILY ATTITUDES PRESENT HOSPITAL ADJUSTMENT Admission to this Ward Report of Most Recent Neuropsychiatric Examination TRIAL VISIT ADJUSTMENT REVIEW Number of Trial Visits Trial Visit Reports Related Social Service Entries COMPENSATION Degree of Disability Amount to Relative Amount to Patient Competence to Handle Funds VISITOR RECORD
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