The Family, the Patient, and the Psychiatric Hospital: Toward a New Model by articles

źԴóʴìғȊĔ϶ϷǹʁӃðıƼ‫ڷ‬Ɉȶ‫ڷ‬ɧٚɳƽŋɨŻǰǱ‫ڷ‬ 4 К̺֕‫ڷة‬żo ̻(ր ‫ڷ‬ķŉ΂‫ڷڀ‬ʠԵ֖҂À‫ ڷ‬ʟ‫ڷ‬ʡ ‫ڷ‬ Ž ˃ц֗օ΃'‫ ע‬$‫ڷ‬ Ȃ΄§֘‫ ڷڔ‬ȡ ‫ ڷ‬ȑ΅ʵ¶‫ ڷ ¬ ګ‬Ʊ˄ ȃ˅‫ף‬Á‫ ڷ‬ʂΆ‫ڷ ڏ‬ įҔԶ֙Eч‫ڷפ‬Ō ‫ ڷ‬aшֆ‫ت‬Էӥ ‫ڷ‬žЛˆևϚҫ‫ ڷ‬ǝщҬ )‫ ڷ‬İTſ ‫ڷ‬ ǺԸМӦ‫ ڷ‬ǒ ‫ ڷ‬Ȓցւӧ!‫ڕ‬Â‫ ڷ‬Ʋˇ ˈ©Ã‫ڷ‬ʃ ‫ڐ‬Ä‫ڷ‬ ʲ̼̭‫ ږ‬ԹӨ‫ڷ‬ʄˉъө‫ث‬Ժ֚Å‫ڷ‬ɉ ˊӪϽt̮֛ٛϾ µ ‫ڷ‬ʢ ‫ڷ‬

ƀԻȢȣǪʅʆƾϻĚĺ‫ ڷ‬ɴԼ̽֜ōȓ‫ ڷ‬ǫ‫צץ‬ěĜƿ‫ڷק‬ ]ˋӫ‫ ڷ‬Ŏ ‫ڷ‬ŏ Ͽ·֝ ‫ ڷ‬ȷΈ‫ ڷځ‬ʣ ֞҃ ‫ڷ‬f ʤ‫ڷڲ ڷ‬ ¿ĲН5ы֟ֈ̾'‫ר‬Խ ‫ڷ‬ ʶʓ²ǲǳьˌӈ‫ ڷ‬ɩ ‫ڷ‬ŦΉˍ͚֠‫ש‬ҭϛΊ,‫ڷ‬ŧٜľ‫ج‬ٝӬ ‫ڷ‬ȤˎĻŁ‫ڷ ڴ‬ ɔˏٞ=‫ڷ‬ČȄ ‫ڷ‬ǌэӭ҄Æ‫ڷ‬ɕО 79ҕ։ юː V‫ ڷ‬ɖˑ ‫ڷ‬ [΋Գ‫ڷ ^ڷڗ‬Ǔ˒ٟҖ‫ح‬Ç‫[ ڷ‬яЀП ˓Ӯ͛‫ ڷ‬ɗ˔(҅È‫ڷ‬ĝĞĦ ‫ڷ‬ ǻ٠͜ѐ‫خ‬Р‫ڷ‬Ǟ ‫ڷ‬ǔ җ͝É‫ ڷ‬ǟ˕ ёϵ̬‫ڑ‬Ê‫ ڷ‬ȸԾ‫ڷ˖ٷ‬gr ‫ڷ˗ د‬ ɪԿ͞Ό ђ̿‫ڷ‬ǕՀ‫ן‬΍‫ژ‬Ë‫ ڷ‬ȔՁ‫ڷת‬Ő ЁuҘu‫ڷ ׫‬Y˘ҙ } ‫ڷ‬ ȥ˙D¯ ˚‫` ڷ‬ѓ֡҆֊˛¡ ̀҇ ‫ڷ‬ȕՂ‫ڷ׬‬őӯЂϜ Ύ‫ڷ ׭‬Ɓ˜ є³Ď‫ڷ‬ ɫՃ‫ڷڙ‬ʔٓęô‫ *!)( ڷ‬2 6 /1 $ 6 +3 6 ɘΏ֢֣‫ڷښ‬Ɋ‫ْذ‬.v ̯"¢ЃJ‫ ڷ‬əС =˝͟ϝ ֋Т#˞Ì‫ ڷ‬ɚ˟ ‫ڷ‬ ȋ Ӱ͠Մӱ‫ ڷ‬i ‫ڷ‬ɵӉ<® Í‫ ڷ‬ɛ ΐ֤ӊՅ ‫ڷ ر‬ȹ ʥ-‫ڷ‬

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ƂՆȦȧǶʑʇϪϫɋĶń‫ ڷ‬hğĠ‫׎‬ԱŒɦǋ‫ز‬ʈǼƃ‫ڷ‬ƄœɬٔĹ‫ڷ‬ 2iz{ Í.§G W¨ Í)w ± j H¹k Í5hl Í ́ŀУˠѕ¦֌Α֥ē‫ا‬ՇӲ‫ڷ‬ 1Β‫נ‬ˡ֦͡‫ ڷ‬Ũˢ‫ס‬đǵ Ϟ֧ ‫ڷ‬ƅ Ӌӄň'і͢Є͂ ‫ ڷ‬ʷϬ̧‫ڷ ׯ׮‬ ʉФ ӌˣ«‫ ڷ‬ǀ-‫ ڷ‬Ɔ١֨‫س‬ї‫ ڷ װ‬Ƈ ˤ֍ϟҮ‫\ ڷ‬ј ?Î‫ ڷ‬Ⱥ ƈ ‫ڷ‬ 4Ո̰ ‫ڷي׏‬ʗ ‫ ڷ‬ǖ p¨Չ Ï‫ڷ‬ʊƳ‫ ױڂ‬$J‫ڷ‬cͣ ‫ڷ‬ ƴՊ ͤ‫ ڷ‬CFr Í 2˥ӍӎΓ֩‫ ײ‬Δ‫ڛ‬Ð‫ ڷ‬ʸʕ˦‫׳‬ХљħĨЅҚ үҰ ‫ڷ‬ӳ ̓‫ڷ‬ ʘ ұ lӏ‫ڷ‬1 ‫ ڷ‬Ǡ° ‫ش‬Ε¤ ‫ ڷ‬ġĩĪÑ‫ ڷ‬Ŕ ̱٢֒H ֪֓°Ζ ‫ ڷ‬Ȼ c‫ڷ‬ ɭՋqΗ‫ًא‬Ռ‫ ڷ‬b ‫ڷ‬ǽњӐΘ%v‫ڧ‬Ò‫ ڷ‬ɶ˧Ӵ‫ ڷ‬ŕӵ‫ص‬BӶ Ս ‫ ڷ‬ʋΙ‫ڷ ڒ‬ ʹқͥ‫ٸ‬ћ$‫ڷ‬ɷ˨̲‫״‬Ц ӷõ‫ ڷ‬ʙ˩‫׵‬ЧќӸІ֫ ӹ/‫ ڷ‬Ҳҳ Ɖ ‫ڷ‬

Ş ι‫ͱ ̊ړ‬κ‫ڷ־‬ǘå‫̋ڮ‬Ҥ‫ד‬Ѿҥ͌ ‫ڷ‬ɡթ¥‫ڷؾ‬ơзλؕ‫ؿ‬.μֿ,‫ڷ‬Ɇ ‫ڷ‬ʖ ‫ڷ‬ ȯѬ ®ժԙ‫ڷ‬ZEνξ@̶ ̌‫ـ‬G ‫ڷ‬ɻ;֏‫ٺ ٮ‬xͲ̍ ‫ڷ‬Ƣ̎Ҧ | ‫ڷ‬ Ș ‫;׀ڋ‬Ԛ͍ο‫ڷ‬Ǒ ‫ڷ‬Ǚ ͎͏ 9 Би ‫ ڷ‬Һ ի‫ ڷؖ‬şԛВϣһπ‫ڷ ؗ‬ƣ̏ ´ď‫ڷ‬ Ǌ‫ ה‬ρ¬‫ڷف‬Ȱ ‫ ڷ‬ǚ‫ו‬±yԜ̷ςׁГ ‫ڷ‬ŵz‫ق‬йσ‫ڷ ̐ͳؘ‬ȱʹ ‫ڷ‬ ɼτ‫ڣ‬Ӟլ‫ڷ¦ٯ‬1 Í ǥ̑>ҼϤłĵ æ‫ڷ‬Ƥк̒֐z ‫\ڷ‬ѭ> ‫ڷ‬Ƿ‫ ڷ‬ư ‫ڷ‬ ;¼N }cÌÍ,O ¡ ¶ Í0_Èq d½¢ Í `‫ڷ ڤ‬ _ ϥ ‫ڷ‬ɽþ‫ ڷ‬Ǧ̓ԝ‫ל‬ӆҏׂ ‫ڷ‬kѮ ӟ:¯‫ك‬υÿ‫ ڷ‬Ǯ ‫ڷ‬

Vȇ ‫ڷ‬ƥխٰ͙‫ ڷگ‬ǯ‫ڷ‬ҧѯ‫ؙ͘ڰ׃‬Ė‫ڱ‬л̸φׄ~ç‫ڷ‬ʏծ֑͐ҐŇ+‫ ڷ‬ȍè‫ٱ‬Ĥ‫ؚ‬Ā‫ڷ‬ ɢկ٘ٙѰ̔‫ڷ‬ŶϦ Ҩ‫ٌ ڷ‬ҽӠԞχ ‫ ڷ‬ɾٍ ‫ ڷ‬ǧϧҾψԟ̕ ‫ڷ‬Ʀ̖ҩ ϴ ‫ڷ‬

Ŗ lӺ‫ ڷ‬Ƶ ‫ڷ‬4Վ ĢΚӻ̳ ëĐ‫ٴ‬. ‫ڷ‬Ȗ5˂Ҵ٣ ҵ˪K‫ڷ‬Ɗ˫= } *‫ڷ‬ eIm©¥Qª² Í ǡwӼ֬‫ ڷڜ‬ˀ»ˁ ‫ڷڳ‬ũ֭Տ‫׶‬ѝ%Ó‫ڷ‬ʌ٤̈́©Ր ‫ ڷ‬ŗ֮ўĮÔ‫ڷ‬ ǁ٥~ΛӽΜ‫ ڷ‬Ǣö‫ ڷ‬ǍΝџЇΞ ‫׷‬ՑӾ÷‫ ڷ‬Ū֯ՒՓ҈ ‫ڝ‬ӿ ‫ ڷ‬ļ ʦ ‫ڷ‬ 8 fX Í ~ÃxnRgYy³ Í 9ZÄ Í? «s Í @ Í WԀ‫ְ י‬Ο‫ڷڃ‬ɜ ‫ʺڷ‬ҜՔ'ֱѠ‫׸‬Օ@Õ‫ڷ‬Ƌˬӑpֲ ͦЈΠÖ‫ ڷ‬Ȩm‫ڷ ئإ‬ ʚ Ҷѡ˭Ӓ‫ ڷ‬ƌ ‫ ڷ‬ɌϭϮΡԁШmA‫½ڷ ڨض‬ҝѢ ‫ڄ‬ˮ٦҉΢Σ×‫ ڷ‬ʛ ‫ڷ ׹‬

ȀnI‫ ڷ‬Ȏ̗‫ل‬Ŋé‫ڷ‬ɇω‫ڷڌ‬Ǩ̘ʿºϊԠ)‫ڷ‬ƧӡӢ ‫ڷ‬ ȁ̙ӣϋ‫ڷ؛‬Š ‫ ڷ‬ȏԡ<ДмG ‫ ڷ‬eό‫ڷڍ‬Ɏ‫ז‬ҿ͑ %/‫؜‬N‫ ڷ‬a̚ ‫ڷ‬ ɏ ѱ?͵̛‫ ڷ‬d ‫ ڷ‬Ȑ‫ח‬HЕO‫ ڷ‬ƨѲԢ͒#ԣَُ̜‫ م‬ā‫ڷ‬ɐ ‫ڷ‬

ƍՖĽʍɮǬū‫ط‬ʎǭȼƎ‫ ڷ‬ȩԂ‫ב‬ԲģíĳĭŃ‫ڷ׺‬ Ǿ՗ЩīĬ‫ڷ‬ǂ ‫ ڷ‬ŘŅӂ˯ӓ‫׻‬Ø‫ ڷ‬Ǘ˰#ԃΤ‫ٹ׼‬ѻ ΥÙ‫ ڷ‬ǎ ‫ڷ‬ Ə˱‫ ך‬՘‫ڷ׽‬Ɛ ‫ڷ‬ř ͧͅ ^‫ט‬R ‫ڷ‬Ŭ٧ϩϯ̨ ՙÚ‫ ڷ‬Ƚ ʧU‫ڷ‬

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ƶ ‫ ۻ‬ȕՀ§сѪ‫ۻٿ‬Ǝ ‫׫‬ҠͧѫŅ‫ ۻ‬Ʒ ̕ °֏‫ڏڎ‬ϧٌ‫ ڶ‬ӯϨņ‫ ۻ‬ʠ̖ ‫ۻ‬ Ơ ‫׬~ؠ‬Ζ‫ ۻ‬ơ̗ՁΗҡϩ‫׭‬Ę‫ ۻ‬Ƹ̘ԉ͇‫׮‬ҢΘтϪę‫ ۻ‬Ȯ áٍ ‫ۻ‬ ˇʡ ±‫ڀ‬ϫÝ‫ۻ‬ǜ ‫ ۻ‬Ƣ̙‫֐ځׯ‬Ղ ‫ ۻ‬Ǹ̚‫؝‬åӔĚTԊΙě‫ ۻ‬ʢ‫ۻ ڐ‬ Ȃ‫ ڷ‬9‫ۻ‬Ǉ ‫?ͨ\ ۻ‬8ң͵¼ ‫ ۻ‬ƹ֑Ü 7‫ ۻ‬Ǳ̛͈ Иَ ‫ ۻ‬ǩ ̜ ‫ۻ‬ ʣ ֒ӕ̝‫] ۻ‬Ϭؓ՛̞‫ ۻ װ‬ȼϭ‫ ۻۇ‬ʻ֓‫ױ‬Ӏ ‫ ۻ‬j ʼ ‫ۻ‬ ȯ‫ۈ֔] ۻۢ ؕؔڤ‬Ϯ ‫ ۻ‬ƺѬϯ‫ ۻۣڸ‬ƻѭُ̟ϰĜ‫ ۻ‬ĝˈȃΚ ‫ۻ‬

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ƥɆƓɭǘ‫ ۻ‬ɇǧ‫ۻ‬ɈíɮǞǁʗɉɯʇ‫ۻ‬ ɗτ‫ۻۛ>ט‬ǆŔ‫ ۻ‬ʋy6ҾґÁьı‫ٷ‬պԭ ‫ ۻ‬Ǔ˻¯Ӥz‫ ۻ(ػ‬ʌυ‫ۻ ې‬ Ɲ‫ۜ͠י‬φ‫ ۻ‬ʍ Ԁֹ χ‫ٸ‬ջԮ ‫ ۻ‬ɘ 46.ΐГӥֺѡҒ˼Ľ‫ ۻ‬k{ ‫ۻ‬ ə‫͡ؼ ך‬ռ‫כ‬ľşĿ‫˃ ۻ‬ʜ+‫ ۻ‬ʎ սԁÓ‫ؽ‬վÇ ‫ ۻ‬řψ˽‫ ڲ‬Ú‫ٹ‬տ:$‫ ۻ‬ɂ‫ל‬ωл ‫ۻ‬ Ȋր‫ؾ‬ϊֻѢ‫ ۻ‬ɚR‫ ۻ‬ʏ‫ּڠ‬ғԯ ‫ ۻ‬ɿ˾͢‫˿ם‬Ԃϋ԰‫ٺ‬ցĎ‫ ۻ‬ǈ ¯ҔХŎ‫ۻ‬ ȋւѣԱ‫ۻ‬ƈ ‫ۻ‬ʐ‫¿؎ڡ‬ό‫מ‬ŀ‫ ۻ‬ʀrԲ‫ۻ‬Ǥ‫̀ן‬Êͣҕ‫ۻ ֱͲؿ‬Ứ³ҖЦ ‫ۻ‬ ǰ ύ‫ۻ‬ȆŏŐ‫ۻ‬ʚ‫ ـ‬Գ ‫ ۻ‬Ȼώ‫ۻۂ‬Ƀ‫נ‬ӐϏ̂Դ‫ف‬ď‫ ۻ‬ț| ‫ۻ‬ ʨ̃>‫؛‬ϐԵ‫ ۻ‬ʑS‫ ۻ‬ʝ éмѤ̄ % -‫ ۻ ؚ‬ɛփ؏‫ڊ‬ÎӦ ‫ ۻ‬ʞ̅ӧӨͤ‫ڳ‬Ł‫ۻ‬ ư̆өұЧ ‫ۻ‬ ɪքͅϑؐ‫ۻڋ‬ʁł‫ۻ‬ʩ̇8Ӫϒ×‫ٻق‬ϓҗԶ ‫ ۻ‬ʂ̈Է‫ ۻ‬Ǩؑ̉ԸͥҘàͳÏG‫ۻ‬Ʊ̊7©Т‫ۻ‬ Ɖ Α ϔ‫ۻۃ‬p ‫ۻ‬ʪt@‫ك‬Ñ½Ń‫ۻ‬ƊÃÀ‫ ۻ‬Ƌ‫ ס‬օ‫ע‬H‫ ۻ‬ȭ4ͦ ‫ۻ‬ ƞÛ‫̋۝‬՚‫ۻڌ‬h ‫ۻ‬qϕ нϖĐ‫ۻ‬q̌‫ل‬3ҙÅо‫ټ‬ֆ đ‫ ۻ‬ǔ Ǆő‫ۻ‬ oҚΒԹ ۞‫ۻ‬ȜT‫˄ۻ‬ʟϗ‫ף‬ҿԃ ԺC‫ۻ‬ǕϘԻ‫ڴ‬ϙ‫פ‬Ē‫ۻ‬Ʋև"Ï ‫ۻ‬ Ȍֈ‫م‬Ϛֽѥ‫ۻ [ ۻ‬ʫѦϛДӫ‫=ۄ‬ªпѧ‫ٽ‬ē‫ۻ‬ȓ ‫ڕ‬ШҲЕ± Ĕ‫ۻ‬Ƴ̍¹¬ЭV‫ۻ‬ ɫ։͆Ϝؒ‫ۻڍ‬ȝ ‫˅ۻ‬Œʤª"қҜ/Ԅãń‫ۻ‬Ƿ֊‫ڢ‬ä‫ ֋پ‬J‫ۻ‬ʒϝ‫ۻ*ۑ‬

î‫ؗ‬КٞҩΟ ՜‫ۻڅ‬ ȵҪͬ¡̷ ²‫ۻ‬ɰ ‫ۻ‬ʿ̸³Їٟ‫ۻ‬ ǟΠ ۴Ĳ۳‫ ۻ ֪ڪ‬Ǚ؆ҫ‫ۻ ڻ‬ ǳ؇ЈЛ ‫ͭ ۍ‬ѵĭ‫ۻ‬ǂ֫9Ë,‫ ۻ‬ŚӚҬŲŪś‫ۻ‬ ɣ؈Н٫ҭΡԏŊ‫چ‬įǭ‫ۻ‬Ы‫ؘ‬Љ‫ۻڇ‬ ȏЊՔۨ‫ ۻ‬ːťV‫ ۻ‬ȢЋˋĮ 5٠‫ۻ‬ ɤŋɊ ‫ ۻ‬Ʀ֬‫ ۻے‬šŢŧųŴ‫ۻ‬ cs 6 ١I‫ۻ‬ʘЌ‫ۓ‬Ō‫ ۻ‬Ű‫ۻ‬ŭŨũū‫ۻ‬

ʈ‫ڗ‬О؉ ‫ۻ۪؟̿ڈ‬ Ɣ ӵ̹Օ‫ ۻ‬Ƨͮ ыМ ‫ۻ‬ ŬŜ‫ۻ‬Ǡ´‫ ۻ‬ǃ̺Ԑ5Ֆ֭‫ۻ‬Ǯ٢‫̻ׅ‬Я֮ӛ‫ۻ‬ ʙ‫ͯګ‬٣Ò՗ō‫ۻ‬ƕÞҮ‫ۻ ۯ‬ŵŮűţů‫ۻ‬

TABLE OF CONTENTS Statement of Purpose ..................................................... GAP Committees and Membership .................................

v v11

l. Introduction ............................................................... Hospitalization and Family Functioning ........ ..... ..

2. Family Assessment and the Decision about Hospitalization .................. ...... .............. ............ ... .. . The Precipitating Crisis ... .. ................. ..... ..... ......... Patient Management with an Individual Orientation ... ..... ......................... ........... .... ..... . .... Exploring the Family Context ........ ....................... The Approach in Family Assessment ................... Assessment for HospitaliLation .............................. Alternatives to Hospitalization .............................. The Decision to Hospitalize .................. .......... .......

10 11 13 14 l8 22

3. The Hospitalization and Family Intervention .......... Background ............................................................ A Model for Inpatient Family Intervention ......... Inpatient Family Interventions .............................. The Staff and the Family ............. ..................... .... Guidelines for Inpatient Family Intervention ......

23 25 27 30 36 38

9 9

4. Discharge and Aftercare with the Family ................. 41 When the Patient Is Not Defined as Chronic ....... When the Patient Is Defined as Chronic .............. Conclusion ...... ......... .. ..... ...... .... .... ...... ... ... .. .. .... ......

42 5I 62

5. Et.hies in Family-Oriented Treatment .......................

Appendix: Patients, Families and Hospitals: A Guide for Consumers ................................................................ References .. . .. ...... ........ ............................. ... ................. Index ........................................................... .................

69 85 91

xiii

The Family, the Patient, and the Psychiatric Hospital

ting in which the process occurs. The hospital is a more manageable environment in which to influence variables of interpersonal distance and to involve different persons to help effect change. The hospital is not only an important therapeutic adjunct for severely disturbed individuals, but also, and more significantly, a setting in which individuals and families fixed in dysfunctional patterns can begin the process of change. Hospitalization need not be the "end of the road"; rather it can be a "new beginning" for both the patient and the family. Hospitalization can organize major therapeutic interven tions in the family system, in addition to merely bringing temporary relief to a stressed system by offering asylum. The family can provide extensive information, continuity, and support. Maintaining connections between the patient and his or her ecological roots while involving the family in the treatment regimen offers better opportunities for compre hensive therapy and for the management of medication, helps establish a better living environment, and facilitates more effective rehabilitation of the patient. The next three chapters explore family intervention in three stages of the hospitalization process. The problems of including the family (broadly defined to include "significant others" who may not be "blood" relatives) in psychiatric treat ment planning are viewed from the perspective of the pa tient, the family, the provider of service, and the institution-a systems overview. The patient and family are first followed through the process of evaluation and the decision about hospitalization versus alternatives like partial hospitalization (Chapter 2). Then, the characteristics of a family-oriented inpatient treatment program are described (Chapter 3). The final stage consists of the aftercare programs which evolve to make use of the resources of the patient's contexts, in cluding the family (Chapter 4). Throughout the discussions, we contrast an individual treatment perspective with a family orientation in order to illustrate the differences in treatment

Introduction

outcomes an<l costs. In Chapter 5, we explore some of the ethical dilemmas surrounding the choice between a family and an individual approach. Finally, we offer as an appendix a "consumer guide" which may help families as well as hos f pital staf appreciate the family's role in the treatment process and what families can expect from a family-oriented ap proach.

ǁʟǪOʠČƶ ǂ6ˑǫĽˑɦ% ˑD ƷŶƪʸˑŷǃˑ iGčˑ ȽȾ ȿ`RĎǩ6ˑ Y-âďɀɁˑŏȕˑ ɂˎ Hɧ7 Ƣˇ ǬǄˑ ã ǅˑ H ņƲʔĐ äđˑ ɨŞĒˑ åLɃŸWǆˑ Ñ lɩˑ -2ȋIɪ8ƫŹˈ:4źǭǇˑ ǈˑ , ʹˑ ʪ ʺɄ ˑ -ƸēɫŻƹ Ʌpˑ 4ş ˑ Ō+ż ˆoaˑ ȖĔɆǮʕȶøĕ ˑ + ʻˑ ŉŊ Zˑ ʡ 7Ò Ėˑ P5 ȼ Žʢ ɇˑ ɬǯˑ ( ɈȌžɭ¡ ˉ¢ɮſVǉ ˑ ľˑŠ a ɯ; ƣˊ£ )ǰǊˑ Ǳė1ˑ ǲæçlȗqˑ ƀɰˑ ʫJƳ ˑ ɱ¤Ʀ ˑ ȍƬ¥è ˑ "ɉˑ ¦ˑ Ȏ§Ȼʓˑ ǳDˑ9ˑɲ 5+ ɳˑ P¨ǋˑ ʬ éšˑ Ɓ ʣ ƭʤĘɊˑ jŢƂǌMƃSŐˑ ©ÓǴʖɴˑ ª üˑ ɋfƄǍőˑ gG ˑ ŇÐƺƅ ʼˑ «Ɍˑ ˑ ʥƆɵ¬Ʈˑ êǵ ÔǶȘ® Wș ˑ ţ ɍˑë(¯ ɶęȚˑ ʷȏ țĚdˑC°ì ˑ Ŀˑ Ťě1Ĝˑ ōí ǷȜe ˑ

ˑ ˑ {ʽĝ [| O ˑ ÕǸʾˑ )Ɏˑ Ö ȇʗ$ťɷˑ /ˑ ˑ Ğƻ ȝŒ>ǎîʿˑ ^Ȉ.,ˑ ×ˀˑ ±ˑ ŋ KE 4 ˑ Ȟ>Ǐhˑ ²ŀg \ˑ ˑ ˁ.ʘTEɏɸ ȟˑ ýˑ Iɐï ³] ˑ´ˑ ˑ ȠƇňƴ?ˑƈǐˑ ɹŦğˑœ?ǑĠȡµƯˑþƉȢġðɺƊǹǒˑǺŁˑŧƋɑˑ ƼǻɻŨBȺ ˑ ˑ ÿĢȐȣģɒɓ ˑ Ǽʙi ¶ɼ Ĥ ɽˑ Ŏ & Ȥˑ ǽłˑjrʦǾˑØAñ ɔˑ · ɾ¸ɿ ˑƌ ˑ ¹ˑ ʀȥ !ʁ ĥ ʏ ˑ ɕĦbbƍ. ˑ ºǓĀˑ ħù 0Ĩɖˑ ũƎ2ˑ Əǔʂ@S ˑ /ˑ ā0 ʧĩˑ Ɛ3ˑ<8Ȧˑ ƑǕkȉˑ»ˑòǿǖûȸĪʐ īˑÙȧƒĂŔAˑ¼ÚʚʃƽĬǗʑ ˑ ˑ ˂ ʛU ˑ ɗ ǘŕQĭˑ R ʄŪĮ_ˑ ʭƓʅūˑ óŬ\VǙƔôˑ Û½=Ƨˑ ȑ ) ˑ `M2ˑ ŃXȨˑ "ˑ 3ʆZ ǚŖįȩˑ ȒȪİc=ȹƕ kƖȀ sˑ !Ǜăˑ ʇŭ ˑ ʈŮıȫ¾ȓ ˑ Ȭ Ƥˋ@ɘˑ əů ˑ Ɨ3ˑ ˏ úʒ ˑhȊˑ ¿ ǜ}ƨ Ĳȭd ˑ ˑɚʜƵQBǝˑ'ʝɛÜÀǞĄˑÝ^*ǟŗɜˑ'*ɝˑʮƘń ˑ*Ǡ ȁˑ ' ˑĳƾ#Ȯ$ õ˃ˑȷȅȂƿtˑ eʉ9ʊ ǡŘˑ %Á ˑcŰ ˑ&"ɞˑÂřÃƙǢˑÞ <Ȇ Ĵˑʯ ʋűą[Äʰǣuˑ ɟˑʌÅưNƚǤ ˑöȯ:ˌ˄vˑ Æ ĆˑU ɠˑfXˑßĵˑ_÷&ȃ Ȕƛ5Ç ƥˍ ć ˑ ĶʨķȰ ˑʱ##N ˑ!ŅʍĸȱˑŲ ȲˑĈÈʞŚų6ĹYmɡˑʲĺ ĉƜǥśwˑÉˑ,J ƱĻ~Ê$ ˑ ʳȄ ËǦnɢˑ à (ÌʩƝ/]ˑ Kɣˑ ǀ ȳƩļĊˑ á˅ˑ ʴƞ % ȴ ʵ; xˑ ɤƟ Ơ Fyˑ 1ʎÍȵ Fzˑ Î ˑʶ ơTŜLǧŝːˑ ŴC0ˑŵÏǨċɥ ˑ

( ' (# ( # $ ( (% ( !' & ( " # (

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»Ǹ ŞɅ ǌ Á 7 ʩ Ɇńčʩq ȪǞşɇ yʩ #+ʩá 'ʩɫ? ʩ W ʩ Âʩ ʩ $N Y Ɉ" ƥ Gʩ ;ʀ | Ď*ɤʩ ?ʩ &ďĐ ¨ʩ ¼ ǹđʩÃ" ʩ ʩƼɬ cl ʩǍģʩ+J C ʩǟǺ î $ ʩĨÛïɉǎǻȫʩ âǏV ʩÄ ʩãĒʖ ʩɊŅ ʩǠ K Ȭʩ ʗƯ ! ȭʩ 1 ɋʩ jʩ Ǽ ĹɭƙÅǽ)ʘʩ ŠƽV ƚʁ ʩ ʩ -r ʩ š5Ţ ʩ c ɮ ʩ 1 Ȯǡţ C Ť '©ʩ ´ȯʩ Æʩ tN =ťɌ ʩ ä ąʩ ʂ.Ŧ ./)ē¯ʩ ³ǾĔʩ Ç ȕ ʃ 5ʩ ʩ1ǐȰY ƌʣ ɍŧ *ʩ DV^ ƛ åx ʩ Ũ ʩ ʩ ĺ ʄ ʩ z@ ũ ʙ°ʩ ½ ʩ Ū?ʩ ʩ ū {- ȱʩ Ĵƾ# Ɯʩ - ɯ ʩ | ʩ sʩ eaǿ ʩ 7 ƿ ʩ æ ʧ Ɏ4ĕ+±ʩ ¶" ʅÈ Ėʩ (ʚgIŬÉ Ȁ ðʩ r ŭ6 Ȳʩ ʎ Ůñņʩ Ǣ Oȳ ʩ ǀʩ E ʩ òY ó@ǣ ' ʛʩ"0ÊiůƝʜʩ ô ėǤɏʩ ǥË72 n ʩ Ǧ Ű 5[ʩ \ɰUʩ Ǒ Ęʩ ű ʩ W ǒʩFD ɐʩ ĩĪO"hʩ ȁ #ɑư ǁɒʩÌȂ ʩ" H Ȗ" 8ʩɓ ʩ#ʩǧɱç ƍõʩH $ ƞ4Uʝʩ ʩ <ʩ ț ]vʆöʩ ɲ Ǩ 2 ʩ= ʩ ʩG ʇ ǩ ªʩ·- U ʩŇ~ȴǪŲɔ.Ɵȵʩ ǂ ʩǓ ň% ʩ÷ OʏĆ9ćʩ ɳEƠ Fʩĳø ) 6ų9ȶ ʩʐ fŉʩ ȃ9f% A%ʩ Ŵɕ Ʀ ʩɖ ʩ ǫÍȗɥʞʩ + %+ & )+ * &" + *+ èęʩ + #' (+ Îé ʩɗŊĚ ȄʩùȅŵɘěȆŶÏʩ İ ȇʩ_ĈƱŷȷȸŸǔǃʩ _}ĉʩƲÐʟʩ Ź ƎʤkʩÑ kȘ}Òəźʈ ʩ ú Ȉ ʩ Q ʩı ǭ ; 7[ʩ \ɴ ʩ ɚI ʩ Ə ȉʩ ĭÝ ɛ Qʩ ŻǄʩ ŋĜʩ 0û ż ʩ Nʩ 1Ǖȹ 3 Ó wX ʩ ʩ ʩ ŽlMT^ žǖǅʩ !Ĥʩ t ʩ FƧſ<ƀüƁ &«ʩ + s ʩ ǗȊʩ ,Ō9ʩ ,%%,ʩ ʑ!ȋƒ ǆĻʩ ʒƂɜ ʩ ɝō ʩ ĮbƳ4ơʠʩ Ⱥʩ Ôʩ īșɵ, ȌÕɞ Ǉļʩ êɶɟʩ ɷMÖA! Ċ`ëLğʩ `Ț ʩ !:ʩ ɠ ʩƐǘE¡ʩ įb )7ʩþ *mʩ Ɠƃƨ Sʩ×< ʩ ȍ o q?ʩ W4 Ʃʩì ʩ BʩÿɻQ ȎƄ Bʩĝʉ C ɸØ 0ċ¬ʩ ȏʩ<ʩ ʩ aʩ(ƅ-ɹÙ *¢ʩ 4 ʩ ĥʩ ʔ Ƣ "K nʩ ʩ : 3 B Ȼʩ > Ľ Ŏ ʩ : ʩ = (> /ƣ ʩ ɦ 3A ʩ ʩ S Ɔ X Ƈ 'ʩ Ȑʩ . ʩ ʩ Ā) J$# ʩ + ɺPg Zʩ ɡ %ʩā & $ ʩv+ʩ Ǚ ʩ JƔ ƪʡʩ 6 ʩ ȼ ʩ ŏ Ƚ ƈ6DƤʨ Ɖʥ Ɗ ʩ ʩɢŐjʩ & ʢʩ ' ʩ Ħʩ ʊ oʩ {ʩÚʩ ! Ƌʋ ʩ KȑĞýɣ ʩ

The Family, the Patient, and the Psychiatric Hos pital

naturally will be involved in their child's care; usually this will also be true for the parents of a young adult who fails during an effort to live independently. lf the patient is married, the spouse as well as the patient's parents will be included as relevant family members. Ad mission often activates the spouse's loyalty conflicts between the patient and the in-laws. Although very young children of the disturbe<l patient may not need to be included in the initial assessment and decision-making sessions, attention should be given to how they can later become informed par ticipants in what is happening to their parent and what will be happening to them as children of a parent who is mentally ill and hospitalized. What about children? At what age should they be involved in decisions about hospitalization of their parents? Children are entitled to be cared for, but there are many families in which children have long assumed the function of supporting a parent. This is true in single-parent families and in other families where the family hierarchy is diffuse. When the par ent is a chronic relapsing patient, the children usually are very aware of the parent's problems and should be included in the solutions to be implemented. Furthermore, the burden of an ill parent at home may substantially compromise a child's ability to function. For elderly people, their adult chil dren often are the family, obviously to be included in the decision-making process. Other relevant family members will often surface if inqui ry is made about interested family members. It should be stressed that these family members are consulted not to place the burden of responsibility on them for caring for their ill members, but to enlist their help in planning and imple menting the best course for the patient. The evaluating professional should make every effort tu find out who are the important, accessible family members and what is the degree of their availability. This effort is the beginning of a family assessment and will be rewarded amply both in making

Famil y Assessment

� disposition and in implementing it. The assessment of fam ily systems resources is an essential part of the overall assess ment.

THE APPROACH IN FAMILY ASSESSMENT Assessment of the family helps determine which therapeutic option will be best at this time, for this identified patient, in thi, specific context. Such an assessment can occur only when two conditions are fulfilled: 1) The professional person must feel comfortable gaining access to and obtaining the needed family data; and 2) the family and patient must feel some sense of trust in the clinician. Because the family is prominent in his or her thinking, the clinician arranges for at least the primary persons in the family drama to be present face-to-face. The professional person's sensitivity to the context extends also to the physical set�ing. Obviously, a jail holding cell or the ledge of a tall _ bmldmg restricts both family participation as well as the com prehensiveness of professional evaluation. A busy emergency room with multiple interruptions limits both the family's ex perience of respectful contiuuity and the professional's at tention. However, even when a crisis must be addressed in this kind of setting, the presence of family members is none theless essential for an understanding of the emergency. A relationship will he formed with the therapist and a basis established for a more leisurely evaluation in a more suitable setting at a later time. Ideally, the clinician should meet the family in a room sufficiently large to accommodate everyone with a modicum of privacy. There must be enough time for everyone's stories to be heard and considered. The therapist must approach the family members in a way that suggests they are partici pating as colleagues in a problem-solving task, rather than as people being blamed for the problem. Often, however, assessment about psychiatric hospitaliza-

The Family, the Patient, and the Psychiatric Hospital

tion occurs in less than leisurely circumstances such as when there is an abrupt precipitati�g event or emergency. The professional may use phone contact with family members or may have to engage in decision-making processes "under the gun" without sufficient dala about the distressed person's pool of social resources. Police, psychiatric emergency teams, or community-empowered agencies may have to be used to contact disturbed persons in situ; occasionally, the psychialrist makes a home visit. A danger in the assessment process is that the family may focus on the identified patient as the prnblem and may en courage the professional to do so . .Especially in critical cir cumstances, even the systems-oriented professional is not immune from seeking causes or finding fault in order lo understand how a difficult situation came LO be. Family mem bers must be made to feel that they are not being blamed, but are participating together in a problem-solving task. If a symptomatic individual is seen as having a functional disorder, the consultant is prepared to explor� the relevant contextual patterns in both diagnosis and intervention. Even i� the patient has a condition now thought to have a largely f b1olog1cal substrate, such as a psychosis or af ective disorder, it is just as vital for the consulLant to focus on the context of the illness rather than on the "illness" itself. The investigation with the family naturally includes personal and family his tories. It is important, too, to examine the interpersonal as pects of the problems and to identifv the interactional patterns which may have a bearing on cu'rrent difficulties.

ASSESSMENT FOR HOSPITALIZATION The clinician who has a family perspective about treatment will inevitably think about hospitalization in the context of a treatment plan for the entire family. Thus, concerns about the patient's condition will not alone determine the profes sional's decision. Wynne (1982) has detailed the data that

Family Assessment

family therapists need for treatment planning. These data include the presenting problem and its context, the family composition, the family's expectations and wishes, previous attempts to work on the problems and the results of such efforts, the family's resources, and the therapist's ohserva Lions of family lransactions. On the other hand, Fleck (1983) has emphasized the im portance of family leadership, the boundaries between mem bers, the levels and kirnls nr emotion, family affens, 1 he effectiveness of family communication and problem solving, and the developmental stages and goals of r.he family. These differing guides to evaluation suggest the range of data that arc available in family interviews. Family members provide information more freely when they feel the therapist understands an<l appreciates lb�m and is reasonably empathic about their needs. The first rule of assessment, after bringing the family together, is to clearly accepl and label their actions in the current crisis as well intentioned and caring for the idenlified patient. This is a significant part of the joining process which involves personal confirmation and validation, and which underlies most cl' fective therapy. Even when family members are infuriated, hostile, and clearly desirous of getting rid of the patient, it is possible to recognize that these are natural feelings under the circumstances, that symptomatic or ill individuals can be infuriating, and that the intensity of the response reflects involvement and concern for the patient. A second rule in the assessment process is that r.he evaluator is in charge. Each system requires a leader: hierarchy is im portant. Thus, by assuming leadership in Lhis situation and by discovering the natural leadership operations within the family, the professional underscores this important system function. It is important that the therapist ha\·e a clear view about being in cha·rge. Prehospital cvalualions can often threaten t:O get out of hand under the pressures of criticism and unmodulaLcd affect, all of which expresses the urgency

The Family, the Patient, and the Psychiatric Hospital

of the situation. Some clinicians argue that it is important for these feelings to manifest themselves, but we feel that at this stage it is preferable to err on the side of eliciting competent behaviors-that is, all of those coping skills and strengths which are still available, even in this critical situation. Let us look at the previous case example from a family perspective: Case example: Larry and tthel's IH-year-old boy lost control and discharged a .22 rifle in his mother•.� presence. His mother called his fat her, a football coach. The father enlisted the aid of a friend who was a family-oriented psychiatrist. At the psychiatrist's office, the family provided the following infor mation: I) The boy was furious after he had been grounded and his car keys taken away because of two minor car accidents in the preceding week, the last 011e only two days prior to the crisis; 2) The boy stated that he had shot. the .22 rifle at the ceiling. not at hi� mother; �) llis history was one of trying to bully his parents into doing for him ,,,hat he wanted; examples included their giving him an expensive car as soon as he was able to get a license, as well as other items they could barely afford; 4) Although bright, he was doing poorly in school. The psychiau·ist identified a pattern in the family !hat went as follows: The mother would attempt. weakly, to set some limits and resist the boy's demands. The father· would give in to "keep rhe peace," apparenlly afraid that his son would become like those youngsters he coached. Although bright. the boy was doing poorly in school. In the psychiatrist's office, confronted with the combined frustration or his parents, the boy was chastened by the con sequences of his behavior and acknowledged that he found himself in a pickle. He admitted that the scene had gone too far. His mother did not believe that he wanted to kill hei -. She herself appeared depressed, felt isolated and overwhelmed, and did not know how to handle her son. She expressed frustration at not being backed up by her husband. The father recog-11ized that perhaps he had teh too much of the burden of dealing with his son to his wife and that he had tended to get involved only when there was some sort of crisis.

Family Assessment

From this perspective. the therapist. observed sympatheti cally that the boy himself must feel overwhelmed with these kinds of family problems. He noted. further. that neither the boy nor his parents seemed to know how to handle rhe situ ation. He then added that the youngster had successfully brought the problems to the attention of the outside world, perhaps in the hope that the family could, with some help, work it out. \,Vith this definition of the situation, the family could participate without fear or anger in the decision about wher.her ro work on the problem on an outpatient basis or to press for hospitalization. They now dearly saw the family as participating in the pniblem. The family was the "patient." At this point, if the family were feeling r·casonably com fortable that all of the members would he helped in the on going treatment, they might agree to an i11tensive outpatient l,rocrram with the initial ...groals ol' working ' out family . rules and � limits so that nobody would be betrayed or cheated, and eventually the parents could be on the same side. When the evaluatm sympathetically gathers information while concomitantly diffusing the patient's or the family's efforts to attribute blame, the process of evaluation is further facilitated. The more someone hears, "I can appreciate your upset in such circumstances," the more it is likely that rn a_L_ure _ feelings will emerge. When the evaluator goes on to d1ftuse a spedfic or unifocal search for lhe cause of the problem to include the conOuence of many forces involved, this too may help loosen the ties of the participants to a blame-guilt cycle. The "multilateral" position (Boszormenyi-Nagy & Spark, l 973)-i.e. considering each person's pe::r·spective and con tribution- -of the evaluating professional not only promotes the best chance of engaging the members of family, but also provides an opportunity for evaluation of their flexibility and responsiveness. When the fa1 �1ily'� desire to have the symp , tomatic member "put away" 1s retramed as everyone s need for a different kind of space for growth at this time, cautious and curious glances may be exchanged, signaling fa1 :1ily abil _ ity to shift perspectives. On the other hand, the farmly mcm-

The Family, the Patient, and the Psychiatric Hospital

bers and patient may remain affectively and cognitively immobile, unable to consider any alternative possibilities at the moment. In either case, the evaluator has gained impor t.ant information about the family and has set a tone for possible hospitalization that includes the family ,t:s a construc tive force in the ongoing treatment. For example, if the youngster in the aforementioned case is still angry and demanding about the sanctions levied by his parents, while the mother remains overwhelmed, reproach ful of her husband, and says she can't take it any more, and the father persists in defensive helplessness, hospitalization may be chosen as a context to begin the work with the family. Hospitalization would pn)vide a muling-off period, a sense of the critical nature of these events, and a11 opponunity for remoralization.

AlTERNATIVES TO HOSP ITALIZATION When the clinician indudes the family in the prehospitah zation assessment, other factors in the decision on whether or uot to hospitalize will be: l) the family's readiness and skill to care for the patient in a less restrictive setting; and 2) the family's need for relief from the stress of caring for the pa tienl. There are several alternatives to hospitalization in acute family crises that can be consi<lcred if the clinician views individual problems in the context of 011going family living. We will discuss two of the most prominent alternatives -treatment in the home an<l partial hospitalization. In home treatmen1, the disturbed person remains in the home and the family routines are not disrupted by the re moval or a memher. Such a management approach may re quire regular, frequent visits to a treatment facility, home visits by a treatment team, or employment of persons from outside the family for substantial portions of each day. Home treatment services have been successful in a variety

Family Assessment

of settings around the country (Friedman, Becker & Weiner, 1964; Pasamanick et al., 1967; Langsley et al., 1968, [ 969, 1971; Smith et al., I 976; Fenton el al., I 979). In these varied clinical settings, there is a general consensus that at least 60 percent of the patients could be treated in the home and thus avoid hospitalization. Friedman et al. ( I 964) found in their home treatment serv ice that when the patients were evaluated for admission first in the emergency room, it was almost. impossible to maintain the patient outside the hospital. The results were much su pe:1'� or i1 � preventing .hospitaliLation if the evaluation began �•11t1ally m th� home. 1 heir overall conclusion was that early •�tervent1on •� the key _lo successfully maintaining severely disturbed patients outside of the hospital. However, other researchers (Langsley et al., 1969) selected their patients ran domly fro1 �1 those. who were presented to the emergency • :oorn and Jud �ed 1 �1 n�ed o � admiss� on by the emergency _ room psycl11atnst. Workmg with an active home visiting C team ) t }1ey were able to avoid hospitalization and to decrease the amount of time the patient was disabled and unable to work. 1:"he r�sults from treating suicidal and acutely psychotic patients m the home suggest the following: l . ·1 _·he treatment fa�ility must have a team of profes sionals who are onent.ed toward family imervention and who are dedicated to this approa�b. 2. The results were at least as good as and sometimes better than traditional psychiatric hospitalization in short-term follow-up and about the same in longerterm follow-up. f 3. · I"he costs of managing the crisis ef ectivel y out of the hospital are much less than the costs invoi'ved in hos pitalization. It is also quite possible to care for severely disturbed in dividuals in a partial hospital setting either by utilizing· day

The Family, the Patient, ond the Psychiatric Hospital

hospitalization, with the family actively inrnlved in t�e man agement of the patienL <luring the night, o_r �y having the _ patienl in the hospital at night with the family 1m'.olve� w1th _ rhe patient during the day. A careful assessmc_nt_of the tam_tly patterns, sources of strength, and charactenstt�s of the m . dividual patient determines the choice ot the urne mterval for which institutional assistance is more important. The duration of day hospital treatment tends to be longer than that of iupatient settings, but the day treatment group shows a reduced frequency of hospital returns (Wilder et _ al., 1966). There are a number of demonstrations w!th the �1_m ilar conclusions that. partial hospitalization is a viable, effec tive and more economical approach to the treatment of sev�re emotional disorders. However, these exist in few areas of the country. The inpatient hospital is still tl�e most prev alent and available facility for the treatment ot severe emo tional crises. A significant portion of the problem is related to the financial policies of the health care system that reun burses more generously for hospitalization than for 1he less _ _ expensive community-based alternative. It also ,s_ poss1?le tor some professionals to make more mon�y wor�mg with pa tients in the hospital than when engaged m the chffic.ult strug gle to cn:ate and maintain o_utparient care and :5upport options. Third-party payers often arc g-eared to reimburse for full hospitalization, but do not understan? or have the _ facilities to handle either partial care or mrens1ve outpauenr. care to the extent required to support those programs so that they can be successful. . All the community-based programs, whether parual hos pitalization or home treatment, r�quire � great invesllnent _ of time and energy on the part of a dechcated professional and paraprofessional staff. Few su�h programs have been _ maintained and verv little attention 1s currently given to de veloping them des1;ite their effective�css. �ack ?f finan�ial support has been blamed for their d1scont111� auo�. Prof�s sional burnout occurs also. And because there 1s so lmlc sooal

Family Assessment

and financial support for t.hese programs. often they arc not maintained after pilot funding has been spent. Nowadays, as our_ awareness of family relationship re sources increases, the characteristics of the family not only are a m��jor fac1 or in the decision to hospitali£c, but also determine the ultimate effcctivc11ess of the hospitalization as a significant inlervcntion in the pa1iern's difficulties (With ersty, l 977; Gould & Glick, 1977). The important relation ship between the family awl 1.hc hospital in the implementation of a satisfactory program has resulted in the felicitous term ''institutional alliance" (Stewal't, l 98'.2), referring to the mu tual understanding between the family and the hospital staff. l11 some hospitals, the institutional alliance is implemented by developing a contract which serves as a written agreement between hospital staff and the family about the contributions of both sides to the treatment program an<l care needs of the patient (Combrinck-Craham, el al.. l !)82). This contract is initiated at the time of' admissio11 evaluation, then elaborated later ·when both the hospital staff and the family become increasingly familiar with each other. On the other hand, Stewart (1982) describes fom stages in the building of insti tutional alliances, beginning with I he crisis of the patient which brings the family into contact with the hospital, going on to the se/Jaralion which will occu1· when the patient is finally admitted and other family members go home, continuing with the family's rl'i11110/i,emr11t in in-hospital programs, and ending with evaluation, which represents the stage at which the family offers itself for more intensive involvement in the uuuerstanding of the problem and its treatment. 11 is stressed that different families may go through these stages with dif ferent timing. There are at least two kinds of families with whom building the institutional alliance will be particularly difficult-disengaged families, in which individuals feel little connection to each other and may be little affected by the crisis, and families who are characteristically hostile and sus picious of unfamiliar "outsiders'' (Reiss ct al., 1980). Yet there

The Family, the Patient, and the Psychiatric Hospital

.....:

The Hospitalization and Family Intervention

interfering with treatment. Social workers, rather than psy chiatrists, were usually <ldegated the task of dealing with these l'amily-engeudered problems. Prior to the availability of effecrive somatic treatments, hospital stays were much longer and already-fragile family tics were often broken. Even now with shorter stays, public hospitals are often geographically distant from family mem bers, making access difficult. Furthermore, since the hospital 1s associated with much fear and stigma, many families are only too happy to stay away. In the I 970s, hospitals -began to struggle with the newly introduced model of family therapy which suggested that illness was embedded in a family context and often directly responsive to other family members. New social workers were hired to "do family therapy,'' but the rest of the treatment package ,vas unchanged. This ma<le the social worker's job difficult and conveyed a confusing message to the family. This model of hospitalization frequently has the unin tended effect of promoting further hospitalization down the liue. Recent evidence (Mattes et al., 1977a, l 977b) suggests that when a mentally ill individual ts hospitalized for long periods of time (i.e., separated from his or her family and integrated into the hospital environment), a less than optimal copmg pattern begins which sees hospitalization as the so lution to the family problem. This pattern may be repeated each time the individual manifests the same disturbances. A family-oriented hospitalization, on the other hand, views the problem in systemic terms. All persons in the family sys tem are considered (in varying degrees) as interacting with the problem, and hospitalization is geared to supporting fam ily functions (Glick & Kessler, 1980). BACKGROUND In some cultures, families are considered a vital part of the psychiatric hospitalization of any of their members. Because

The Family, the Patient, and the Psychiatric Hospital

of a scarcity of trained professionals and other resources such as food, families are essential to care for the needs of the identified patient. In fact, families often stay with the patient in or near the hospital. The assumption in these other cul f tures reflects dif erent patterns of family care and affirms that the patient is an integral part of the family network. It is unthinkable that the patient would return anvwhere but to the family (Bell & Bell, 1970). Based on this concept, a number of innovative hospital programs in our culture have included more than one family member in the hospitalization. These programs fall into three categories: l) those which attempt to identify the entire fam ily as the patient (Abroms et al., 1971; Bowen, 1966; Com brinck-Graham ct al., 1982); 2 ) those which attempt to use family resources in treatment of a disturbed family member and to change roles and functions in the family during the intensive treatment phase of the hospitalization (Bowen, 1966; Combrinck-Graham et al., 1982; Bhatti et al., 1980; Grunebaum et al., 1982; Grunebaum et al., 1963; Lynch et al., 1975; Main, 1958; Nakhla et al., 1969); 3) those which use the hospital as a laboratory for change in familial rela tionships (Abroms et al., 1971; Bowen, 1966; Combrinck Graham et al., 1982; Bhatti ct al., 1980; Nakhla et al., 1969; Whitaker & Olsen, 1971). A pilot experimental effort to include more than one fam ily member in the hospital was reported from Wisconsin (Abroms et al., 1971; Whitaker & Olsen, 1971). Here, ad mitting more than one family member became the rule. Since it was an adult ward with an already established milieu, family members who had not considered themselves to be patients were quickly socialized as patients by the others in the com munity. Staff members became aware of how they themselves were incorporated into the family triangles, and maneuver ing in these patterns became a conscious part of the treatment experience in the hospital. One program has continued to treat a small number of families (in two apartment inpatient

The Hospitalization and Family Intervention

facilities) (Combrinck-Graham et al., 1982). Another effort involved the hospitalization of infants along with their psy chotic mot.hers as a means of observing and of having the opportunity to foster a better mother-child relationship (Gru nebaum et al., 1963; Grunebaum et al., 1982; Main, 1958). These experiments involved considerable effort, however, and, in most cases, when certain committed staff left the ward, this kind of family intervention was discontinued.

A MODEL FOR INPATIENT FAMILY INTERVENTION Hospitalization should be viewed in most cases as an event in the history of the family, an event that can be devastating or valuable depending upon the skills and orientation of the therapeutic team. When hospitalization is viewed in this way, it becomes central to understand the role of the patient in the family system and to support the family as well as the patient. The hospital becomes an important therapeutic ad junct not only for severely dysfunctional individuals and their families, but also for families who are stuck in modes of relating that appear to interfer� with the development and movement of individual members. For these families, hos pitalization aims to disrupt the family set; this disruption can be used to help the family system to change in more func tional ways. Family-oriented programs can be implemented within ex isting hospital resources, though there is a general trend toward adapting and revising hospital environments to in clude family members in patient care. (This trend is also noted in other specialties, such as "rooming in" in obstetric and pediatric units.) Effective programs involve the staff, from admission clerks on up, in building an alliance with the family. Stewart describes this as "the engagement of the fam ily with the institution in a relationship that achieves mutual understanding and support and establishes clarity, accept ance, and commitment to mutually agreed upon goals for

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The Family, the Patient, and the Psychiatric Hospital

c(iange-orientcd family therapy, is almost always in dassical _ dicated. Even when the family is not available, interested or involved, the designated patient needs to be reconnected to another system.

DISCHARGE AND AFTERCARE WITH THE FAMILY

As we have described, going to a psychiatric hospital for the first time is traumatic, painful, and usually filled with neg ative implications to the patient, the family, and the larger community. :\To less so (but for different reasons) is the event of dischar�e from the hospilal. Patients are often caught up in a system they only dimly understand. They are "processed" and then sent out into the community with great uncertainty about how they can reorganize their lives. This chapter deals ·with the task of including the family in the planning and management of the hospitalized patient's discharge into the community. Involving the family in the patient's posthospital treatment requires little overall change in the health care delivery system, but rather utilizes existing psychiatric institutions without radically redefining illness, treatment, or the social roles of patients, families, and ther apists. Our focus is on urgently needed ways to increase patient functioning and LherapeuLic efficacy, with emphasis on eval uations, comparisons and outcomes. The presentation is di vided into two parts: I) working with the families of psychiatric inpatients who are not defined as chronic, and 2) working with the chronic psychiatric patient. This distinction is made and utilized because individuals, families, and insti tutions recognize the difference and respond quite differ ently to the two conditions. With a first and second psychotic break or inpatient experience, patients and their families 41

The Family, the Patient, and the Psychiatric Hospital

usuallv see the illness as an interruption or their life and expeci'. a return to normality. If third and subsequent hospital admissions occur, there is a slow but dramatic change in the definition of the patient from someone who has an illness to f be treated and cured to someone who is qualitatively dif erent (and by inference inferior) to "normals." This definitional change requires significant alterations in treatment ap proaches.

WHEN THE INPATIENT IS NOT DEFINED AS CHRONIC Most psychiatric patients at first and second admission still have strong family and social ties (Rose, 1959). For such patients, legal, social, and economic forces in American so ciety pressure for rapid discharge. The legal principle of "least restrictive care" dictates one major impetus. Many so cial groups, including those which purport to represent psy chiatric patients' rights, advocate reducing the power of those in posit.ions of social control (i.e., professionals, administra tors). Economically, legislators and third-party payers are in creasingly aware that lengthy hospitalizations threaten their already tenuous cash flow. These varied pressures, in conjunction with advances in treatment, e.g., medications, have resulted in a precipitous drop in hospital stay for psychiatric patients. Hospitalizations which were calculated in months in the 1960s are now re ported in days, with enormous impact on our health care delivery system and on social concepts of mental illness and treatment. The psychiatric system, previously defined as a benevolent controller of social deviance, now has a less pow erful image as only one of many social factors, while the mentally ill are understood as people needing help to estab lish and maintain a clear and socially reinforced role in the community. Traditional psychiatry, with its emphasis on the individual, may not have been the best model for these dramatic changes

Discharge and Aftercare with the Family

in role definition. In the past, the family of the psychiatric patient was often seen primarily as a source of problems rather than as a potential ally. That view, with its implicit elitism, is out of step with current understanding. When pa tients are discharged without an adequate treatment plan t.hat includes the family, they reappear to be processed and discharged again in a never-ending spiral which unfortu nately tends toward chronicity, hopelessness, and increasing isolation from the community. This is the so-called "revolving door" phenomenon (Talbott, 1971). Planning for discharge At first and second admission, most patients have family members concerned about their welfare. Since hospital time is being dramatically reduced, these family members must be involved in discharge planning. Whether in a public or a private setting, psychiatrists, psychologists, and social work ers can interact with the family as partners in rehabilitation. Planning sessions that deal with the needs of the patients and the family alike are essential in promoting the patient's ef fective reentry into the broader sociely. As stated in Chapter 3, the hospit�l with a family orient�tion begins discharge planning on admission. Data from a variety of sources indicate that any kind of severe emotional illness that requires hospitalization can best be treated by including the family in intervention efforts (Goldstein et al., 1978; Anderson et al., 1980; Falloon et al., 198 I). Evidence accumulates that families can be significantly more helpful following discharge when mental health profes sionals provide clear information, take the family's circum stances into account in aftercare planning, and attend to the interface between the identified patient and family members. One stark, simple, and compelling reason for family in volvement is the necessity for patients to continue on med ication (May, 1975). Previously hospitalized patients who

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ć ǉƗġʇ lʇ Ȝ+Œơſʇ ¾ß ɘ ʇ y % ʇ ;¿ HĈ Ȁʇ *Rĉ ʇ aʇ ȝʇ ĤʇȞ, ʇ /4 ʇĥ Ƙ ʇȟ ȁ ʇB1þʇə Ȃɳ ʇ¶, ʇ 2ʇ-2& ʇ ʇCʇİÜ' Ɔ ʇ ʇ& ʇ œ ƙʇà ʇɦĊ< ʇîsre = ʇ ^ Rʇ 9 ʇȠ ʇ 5 [ʇ¹ ʇċɧ ʆ Ƣ ʇ Pʇ Č ÿ ʇɚ ʇ ȡ. ʇŔ! Wŕ # ʇ=Ŗ À I 0Zʇ « ǔ ʇ ' Ľč7Ď ɕʇ ʇ á 4ʇ ǊƇ 01 )ʇ â ʇ ďɨcǕɴƸƣĐʇ ³ ƀŗ1ľʇ ȢŃʇ g ʇ ń@ ï ʇ ʇ ʇ" DƞʇŘ ʇȣ. ʇ ř o£ʇ · ʇ ʇ l ǖf ʇ ɲȤđƤz ʇ ɭŅ .ĢǼʇ ƹ ʇ ƥƺȥʇ Ȧņ ʇ Ň ȃǋHy\ƈ ʄBȧ ʇ ʇ Á ɵʇ ? !Ŀʇ ıĲ ðȨʇIPʇǗ ʇUsʇĀ Pñ- ǘ ʇ Ʀ Ś! ʇ ¬/ Ǚ ʇ Â 1 ʇȄ ƻ ȩʇ7 Ã ʇ ɶʇǚĒĦēǛǜÄƉʇĳǇǝʇJ āśɩ ɛÅ ʇȪ.ĔǞ ǌɷʇ eǈǟʇ ȫ ʇ S $ { ʇ Æ ʇ9 5 ʇ ʇɮ k ʇ n ňƼ(f ʇ z ȬʇŜ ʇ ħ ʇ ʇ Ĩʇ"G ʇE ɖuÇmʇģoĕp ʇN*ʇ#ĩ Ǡ5 ǡ ʇ M ŝƧ ʇ¸ Ėʇd ' Ɗɸʇ ƨFF ȅʇ" ʇƁ O ʇ dʇ bʇ 3 9 ʇ Ȇʇ ƽƩʇƟ$ĂŞòÈȭş ƪʇ ʇŠĪʇ ʇ #Ȯʇ | ʇ ʇ *ĸ 5>ȇʇÉ ʇ ƫ ʇ ė +cǢʇÊ @2! ʇ ʇȯ ʇĴÝ7/ ɹʇã / ʇ 4 ʇ Ȱš Ƭ}ʇ Ȉʇ ;9 țIä Ţȱɺʇĺ ǣʇƠBƂh ŀʇ ȉVw ʇ + Ȳʇ ȳ ʇ& )Y ýËȴţƾ8ʇ ʇ kF! ʇ °8ʇ ăŤȵi 8ʇ ƿʇ %Ę i`Ì ť 8ʇ ʇ Ŧ WŧĄɜÍ ʇ ŉ C ɻ ʇ ȶ. ęʇ Î ʇ & ƭɼʇ Ǥʇ ĵĶ ǥ$ >ʇ ƃH0 ʇ īʇ ÏĬ~ 3ó Ǧ ʇ n ʇ Ðɪ ŨƋ#å ʇ @ʇ v ǧ % ʇ ǽ ɝ ʇ Ě3 ʇ ʇ ɫ Y EÑ J: Ò ʇ Ǩ Cæũƌh ʇ ǩ ʇ ǀ ʇ ĭʇ Ŋbʇ`Oqp ʇ _ŪƍLȷ ʇ ®]%KƎ ʇȸ Ǫ ʇJ=ʇ:Įȹ ʇWěǫ@ʇ, ;*( ʇ vʇ Ǭʇ 4ʇ} ʇ Y N0ʇɯ ʇ Ó ʇç 1ʇ+ǁQǍū> Ŭʅ ʇŭ ʇȊ Ů ʇ ʇ Ôǎ Rʇ Ə Ĝ ʇ º ʇ ʇ ķÞ ʇ '_ ǭ ʇ Ɛ ʇ ʇ :ʇ Ƅʇ ʇ ůƮǓ Ű< ʇ è Sʇ ,Õ ʇ ȋTʇE Ư Ǯư ʇɽ ʇ é:( ʇȺ ʇ;Ö ʇ j ô ǯ ¨ʇ ŋ ʇȻ+ ʇǏ× ű Ʊȼʇ Ȍʇ (ǰŲ Łʇ? ĝʇą] ©ʇ Ō Ƚ- wʇ ʇǂ ʇȍ ʇ ʇ ʇ ʇ ǃ36ªʇ ʇ ʇ Ǳʇ $ʇ ƚMʇ ʇ S ʇ Zʇ » ʇ ʇ Ǆʇ õ ʇ ōʇ ʇ Ⱦ 'ʇ , ȿʇ ǐƑ ! ʇ ǲ ʇê K ʇ' ʇ " ʇ Ć Mʇ ų ʇ"GĞʇ Ȏȏ ʇ ʇȐ ʇ ʇ/% Ǿ T¤ʇ ¼ ɞʇ ʇɗ ʇ6 ʇ ʇ 4Ŏ ʇ &ʇV ) 3ȑɀ ) ʇ Ɂŏ ʇ Ǒ ǳQǅ ʇ Ǵǆëƒ 7Ȓʇ \Ʋ ʇ ʇ ɾ ɟʇ Ĺžɂʇ ʇ ½ ʇ Ŵƛ ʇ ʇ |ʇ " ʇ% 6 ʇ ǵ$ʇ #Ƀʇ Ʉ < ʇ ØǶ$ʇ Ƴ=ʇ Ʌ ʇ Ļ Ɯ ʇ ɠǒʇ ɰL? ʇ 2( ʇ ǿ ŵö ɿʇ ɱLɆ-ʇ - ʇ 2įʇ ʀ ɡʇ Ŷ~Őʇ G qʇ " ʇ ɇ Tʇ m ʇ ì ʇ ŷX ʇ ± ʇ ŸɈ N ʇ O ʇ KƝ ʇ ÙX ʇ ʁ VǷʇ ʇ ƴ ȓʇ ʇ ÷ ø uƷ ¡ʇ ²*ʇ ? ʇ ɉ &ʇ #Ȕ0 Ɋʇ ɋ Ɠ6 ʇ ʇ ʂ (ʇ í ɢɌʇ g ʇ ɣʇ ğ ʇ>tʇ ŹƵȕ Q ¥ʇ ´Úƅaʇ ɤǸ ʇ U Uʇ ǹ ʇ xʇ Ġƶ ʇɍ ʇɎ ʇ ź Ȗ ʇ{ő ʇ xʇɏ ɐʇù Ǻ ʇAtɥ[ʇ

µȗAú j ɑ<Żûʇ Ș ʇ ɬ ʇ D! ʇł D Ɣʃʇ ʇ ʇƕÛșɒʇ§¦ʇA ǻȚ¢ʇ ¯ ʇ ^ ż ʇ ļ ɓ Ž ʇ )ʇ r ʇ Ɩ ü ʇ ɔ Aʇ X ʇ

The Family, the Patient, and the Psychiatric Hospital

become comfortable and sometimes even pleasant. With the increasing emphasis on a variety of treatments, they have also become more complicated, so that the patient and family may have tu deal with a bewildering variety of doctors, nurses, social workers, and aides. When you are feeling worried and upset yourself, this may be very difficult. Certain ways of handling things make things easier. 1) Ask the team which staff person should be your main contact person in the hospital-it's usually either the pa tient's doctor or the social worker. When vou need some thing, call that person first. Find out who 'will be available for phone calls when your contact person is not available and when you're particularly worried. Get to know the team members and make sure they know that you are concerned and involved. As much as possible, try to get your information from only one contact person. Some times keeping notes on your exchanges will be helpful. 2) Appoint one family member as your spokesperson, and avoid having four or five different people call your contact person with the same question. Your spokesperson should do most of the calling and arranging. When there are family meetings or decisions, however, the whole family should be there, not just your spokesperson. 3) If you are getting contradictory information from the aides, the nurses, and the physicians, tell your contact person. If you're unhappy with the treatment your family is getting, talk to that person and ask for an explanation. Don't be afraid to tell him or her if you think something is going wrong. 4) Remember that the staff members are human. Staff mem hers in a hospital are trying their best. They also may feel tired or worried or not sure about how to handle a par ticular situation if they haven't thought it through. They may not be able to get back to you immediately when you want them to. It doesn't mean they're not concerned. You

Appendix

need to find a way to work together with them. They don't want to fight with you anymore r.han you want to fight with them. If you assume that they're trying to help, every one will feel better. 5) What if your judgment conflicts with that of the psychi atrist? Remember that psychiatrists are human beings Loo. They are not always right. Alt.hough they arc experts at handling human problems, you are the expert with your relative. You have lived witb or known this person longer than the team has. You have more information about how he or she behaves and what kinds of things are upsetting. It is sometimes difficult to decide whose _judgment you should trust, particularly if you have a relative whom you're very worried about, or if different family members disagree. What if the doctor, for example, says that the patient needs another two or three weeks in the hospital and you think he or she should go home? Or what if the doct�r thinks that the patient might be ready to go home and you are afraid that he or she still can't function? There are no easy answers here. If you, the patient, and your doctor cannot reach satisfactory agreement, you have the right LO ask for a second opinion or a consul tation. You have the right to ask for information, reading material, and a discussion of all the available data. If the patient is an adult, much of the final decision making will have to be left to the patient and the doctor, but partic ularly if the patient is returning to live with you, you have a great deal of influence over the planning. You are the patient's family. Don't underestimate your importance.

The Family, the Patient, and the Psychiatric Hospital

PART II. WHAT HAPPENS IN A FAMILY MEETING WHO COMES TO THE FAMILY MEETING? Family therapists differ in terms of whom r.hey want to see. lf a married adult patient is admitted, usually the first contact will be with the spouse, and the ther apisl will begin with the coupie together. Ir there are children, the children will need to be discussed. Depending upon their ages, they may or mav not come to the meeting. Whether they come or not, childre� n�ed to know something about what is going on. They are frightened when a parenl is in the hospital, and trying to keep it a secret won't make it any better. Those secrets don't get kept very well. With adoles,cent patients or unmarried adults, usually parents are involved in the meeting, and some times brothers and sisters. Anyone who is living in the house and whose input is important to the family may be invited to the session. If you think there is someone important whom �he therapist doesn't know about, you should suggest bring mg that person. You need to remember this is a chance for you to get. something for yourself. If you've been feeling bad or uncomfortable or guilty, or if there have been stresses in the family you haven't been able r.o cope with, this is the time to get help.

WHAT WILL BE DISCUSSED? Therapists need to know how family members behave with each other, so they sometimes ask family members to talk with each other. Every family has its own pattern and style. The therapist needs to know what the problems are and also how the family functions. Do certain people fight? Do certain people listen to each other? Is someone usually left out of the discussion? The therapist wants all family members to

Appendix

talk about how they see things, because everybody in the family sees things differently. Some therapists want to know about the family's history and some don't. The therapist isn't interested in everyone spending an hour blaming each other and saying hurtful, painful things. The therapist is there to make talking more satisfying, to help people understand each other and figure out how to solve their problems. If there is something that is particularly painful and you don't think you can say it in the first session, then you can wait until another session when you've gotten used to the therapist and the situation. After learning about the family, the therapist will want to offer some practical help. Couple and family sessions are usually direct and to the point. They deal with here-and-now things, rather than with things that happened many years ago. In general, particularly when someone is in the hospital, the therapist will be down-to-earth in dealing with the present crisis and how to handle it best.

WHAT ISSUES WILL THE MEETINGS FOCUS ON? Separateness and closeness between generations It's very difficult to know how much to be involved in a child's life. This is particularly true because children change so rap

idly. Moment-to-moment concern, which is the appropriate

response from a parent for a 2-year-old, is less appropriate for a 6-year-old, and even less appropriate for a 16-year-old. No parent can judge perfectly how "far away" he or she should be at a particular moment. Many families get stuck at transition points. Perhaps the child has moved on to a new stage where more distance is needed, but the parent is still seeing or treating the child as if he or she were younger. For example, a 29-year-old having trouble moving out of the house was living at home with his parents and not working. The family went to a store to buy

The Family, the Patient, and the Psychiatric Hospital

have styles that match. For example, some people find it easy to talk about their feelings, and some people are more re served. When the couple can't learn to deal with each other in a way that allows both to change a little, it can be very difficult.

DOES FAMILY THERAPY CHANGE PEOPLE? Family therapists feel that family members, by changing themselves and the way they interact, can help change each other. That's very different from the concept of blame. Ther apists know that no family member deliberately sets out to hurt someone else. However, that doesn't mean one is be having in the best way one possibly could. The therapist's job is lo open up options-different ways of seeing and behav ing-that will allow the situation to work better. This is a major advantage. If it is only the "patient" who can change, the other family members have to sit around waiting for him or her to decide whether or not to do it. But if you have some measure of control, you can start right away by doing something to change the situation. This is a great relief. Family therapists can help you change by allowing you to talk about your feelings or by suggesting specific changes in behavior that will alter family patterns. For example, if Dad has been sitting on the sidelines not knowing how to help the family, the therapist may plan something specific for Dad and the kids to do.

CONCLUSION When someone in your family has distressing psychiatric symptoms and has to go to the hospital, that is one point in a long process. It started long before the person went to the hospital and the efforts of the family to deal with it will continue long past the hospitalization period. The hospital experience is one small part of the family's experience to-

Appendix

gether. You can make it useful. You can make it count for everybody in the family.

˖ ֋Ρ˗‫@ف‬ӯ‫*ف‬ҒԲ,‫ ف‬Գؑ˘ ֌΢˙‫ؒف‬ғ‫فͪ ך‬ɫ˽‫כ‬Ш‫׎‬ě‫ف‬ɬћ˾‫ ف‬ΣԴ‫ ف‬ɭӰ̏ќ֍ԵS‫ف‬ǆԟԠͺΤ‫̐ײ‬Զ‫ف‬Ҕͅ‫ف‬Ǹ Ѓ‫ف‬ Ʉֆؓ˚ͻΥɮ֎ӱؔ×‫ف‬ŉơØ‫ف‬ŝź¸ őŨũ ‫ف‬ _ɯx ؕÙĜȎĝ‫ ف‬¹ĩ[ƕġE1‫ف‬ț̑ɰ‫׳‬Φѝͫ‫ ف‬F;( b əΟ̒‫ف‬ɚΠ̓Ӳɱӕɪ‫ ف״‬ºǛΧԷ֏кˎ̔˿‫ف‬ɤҕ‫ל‬ўͬ‫) ف‬GL:0 b ȱ ‫ف؃‬ ɥ ӳϹǁ‫˛ ف‬ǹӴɲ؄ĀȀΨ'' ‫ف‬ ȁ9 ͨ&Щ̀L‫ ف‬Ǉ ‫^ ف‬O‫ف» ف‬ĪƢƂƣ/2‫ ف‬ɖͼ ‫ˆ͙ ف‬лΩЄ‫ فؖ‬ɳԸ‫ ف‬Ӗɴԡ‫ ׏‬ӵ‫ف‬o ‫֑ ف̕ ֐ ف‬Cf9 м̖?‫ف͆ فי‬н&џ,ɵv‫ف‬ Ϊ!ЪѠ ԹԺ ‫ف‬ȂҖ։ Ϋ֒ɶw‫ ف‬g3 H<=YA2T^b } AH! u ¼ŪÊÚ‫ف‬WŒƖNœŞĢ ȃҗͭc ‫ؗ‬Û‫ ف‬Ǻ1‫½ ف‬īZ5ĬË ‫ ف‬ɗ ̗‫ ف‬ӗ ϳͮͽ֓‫ ف‬Ҙ͇‫ف‬Ի˜ t‫ظ‬ӎ* Ӷ̘ѡά˝Լ‫ ف‬έѢ‫ ف‬оÁ̙ԭ‫ ֔ ف‬ɷ֕п̚ҏ¡‫ف‬ B @ͯӷɸрԽP‫ف‬Ȅ‫ف‬ҙ֊ή֖ɹЅ‫ف‬ɺѣԩw‫ ف‬I>?ZB3U_b ȸԾ‫;˞ؘ‬ίɻ֗Ӹ‫ؙ‬Ü‫ف‬UUÝ‫ف‬Ȍ‫ם‬І‫ ف ؚ‬ĭƤƃ Vģ¶ǀ ‫ف‬ ȑɼӹ* ЇK‫ف‬a ‫ف¾ف‬4ƥƗĤÌ ‫ ف‬Ǩɽ<ΰЈ‫ف؛‬Կ̛˟ ֘Հ ‫`" ف‬IU ɅԢҚсՁċ‫ ف‬ɍ̜Ә‫א‬TÞ‫ف‬ŊƦū ·Ԯż ‫ف‬ ȒαѤ֙#‫ف‬ȧČ‫ف‬Ǔ3‫ ف‬ĮƧƒƓ/2‫ف‬ȹԣӏˏЉ̝т ‫͚ف‬ӐӺ‫ˌ͡ف‬уβЫϴg ‫׵ف‬Ղ ‫ف‬ә ːx̞ф‫ˇ͛ف‬хγ δgՃ ‫ف‬ɎˠͿε‫ع‬ӑ ΀ӻȺѥζɾ‫ف‬ [89*V4B b b .Ŕ" ‫ ف‬XŬŭNŕŮŽ ‫ف‬ ȓӼ̟pՄцɿѦ#‫ف‬ǜč‫ف‬ǣ ‫ ف‬ȍқ‫؜‬ß‫ف‬ɝ ‫ ف‬ǝQ‫¿ف‬įƨƄş" ‫ف‬Ƿˈzo ‫ف׶‬ӽ̠ՅӚҜ ֈ̡‫֚ف‬ҝ‫ف ΁֛ف‬ч >‫ב‬ʀЊ‫ف‬ηЬ ѧ ՆՇ‫ف‬ Ҟ͈‫ف‬:‫ف‬C !ʁ p‫ ׷‬ƻ‫ ف‬ǈ‫ ف‬İ‫ ׸ ؾ‬f؅‫ف‬ҟ͉‫ف ֜ف‬vϵ, Ӿʂ ‫ױ‬ӿ̢ ‫ ف‬/BJ CvaK# \] b -‫ف‬Ћ‫ف‬ĥF0‫ف‬ XŠāůš Ȝ²ǉˑʃ֝ #‫ ف‬Ȧğ‫ ف‬À‫ف‬ıZƘŋÍĎ‫ ف‬ɞʄЌ‫̣מ‬Ոď‫ف‬Ǥ֞΂θˡՉ ‫ "! ف‬- $h4 Ѝ΃йµ‫ف‬ǩʅшιЎǂ‫ فؿ‬b΄̤Ԥˉ͊ǅκՊ֟ ‫ ف‬ɆҠˢϺ‫ػ‬ ‫׹‬sЭ h ‫ ف‬ǞƼ‫ ف‬Ǌ ӛhѨ‫ف‬ɏ‫؝‬Ջ̥֠щՌ‫ف‬ǔҡO‫ف‬ ȝʆˣӮ‫ ן‬DԀ ‫ _ف‬ȻRà‫ف ف‬Ȟʇ‫ נ]ف‬á‫ف‬ȅ ‫ف‬6Đ‫ف‬-ĲƩžYE ‫ف‬Ǫ;zλ ‫ف؞‬ҢԁͰʈ=μ‫ص‬ʉ ң~‫ف‬Ҥ}‫ف‬ʊ‫ف‬ъ ̦̂ԥҐ‫ف‬ ֡ʋ̧֢‫ ف‬Ս ν :Џ‫ف‬؆ʌ ̃P‫ ف‬%* - + $ - ŰŢţ űŲ4đ‫ف‬ ȟʍы˒ ‫ ف‬ȆS‫ ف‬ɇ ‫ ف ف‬ȶ ϶Ӝ΅ ѩ֣G‫ ف‬ǥ ‫ ف‬Á‫ف‬ĳƪƅƙF ‫ ف‬ɐˤΆξ¢ӔB·Ԃ }οʎ‫ ف ͱס@ ف‬Έ ‫̨؟ ف‬Վ‫ف͋ ف‬ ͜ˊ< iՏQ‫ف‬ȇҥՐ π֤ʏА‫ف‬ʐ؇Б‫ف‬ǕҦь{‫ע‬Ѫρ֥‫فؠ‬ȼև‫˥ز‬Ήςʑ֦ԫ‫س‬0‫ف‬Ōƫ‫ ف‬Â‫ف‬ĴV"G‫ف‬ƚĦųĂƛħſ ‫ف‬ ȠʒѫͲՑВ ‫ء‬I‫ ف‬ǟ ‫ ف‬ǻ ‫ ف‬ǫ' ԯ̩ѬΊʓ͝‫ג‬â‫ ف‬Ȕ$ã‫ ف® ف‬a ˦΋ҧ֧ϻ ä‫ ف‬Ƚ%‫ ف‬ÈņƬƀƭÎ ‫ ف‬ǬҨ yҩ؈ă‫׺̪ف ף‬ʔ ‫ؼ‬ ‫֨ פ‬σҪ ‫ف‬A͌‫ˍ͢ف‬эτГ‫˧فآ‬ԃυՒ Փ‫֩ف‬m̫ ʕӝ‫أ‬1‫ ف‬c>{L2.iRymd V n? w Dot~ 0EM% ƆŴŖ ƇŵƮ ȡʖѭͳДՔ ‫ؤ‬H‫ ف‬ǠR‫ف‬Ǽ å‫ف‬ȕʗӞ ʘѮ ‫ف‬8 ‫ف‬Ȩ3 ‫ف‬Ⱦφ֪֫юʙѯI‫ ف‬ǭ æ‫ف‬ňͣ;˨Ό)֬ϼʚç‫ف‬ȿĒè‫ ف‬ǮЕ я˩~΍ʛ͞‫ד‬é‫ف‬Ȗ J‫ف‬ ‫ف‬7 ‫ف‬ɦ ‫ʹ ץ‬ê‫ف‬ǡ ‫ف‬ÃĵƯƁƜÏē‫ف‬bԄ̬ʜ֭ѐ̭Ѱ֮‫ف‬ҫ͍‫ف‬ǯʝ{χЮϷ̮Օ‫ف‬ψѱ‫ف‬ǖԅωՖϊ՗ ‫ف‬Ȳ ؉‫ف‬ɧҬԆϽǃ‫ف‬ǽԦ‫׮‬Ѳ ‫ف‬ ‫ف‬ɑ ԇʞ ‫ف = ה‬ Ȣʟѳ͵՘Ж ‫إ‬ë‫ ف‬7Ĕ‫ ف‬Ǿ ì‫ ف‬ʠ̄Ķ ֯Ͼʡí‫ ف‬ɀ H‫ف ف‬ǰy)|˪Ѵm ͎ î‫ ف‬ȗ ‫ف‬Äķưƈĸ" ‫ ف‬ǋ԰ϋ̅όѵͶ‫ف‬ԱjѶ ʢЗ‫ف‬ ҭՙ*ύְʣИ‫ ف‬ʤ̆<q՚՛ώ ƽ‫ ف‬ǌ‫͟ ف‬Ӓ' Ү؊Ą‫צ‬ӟ‫ ف‬՜,‫@ ف ئ̇ק‬+M5% Cb J\O!7b ү͏‫ ف‬Qa'"W ` b ĹōƉï‫ ف‬ĺŗƱĻ ļŘ[Ť ‫ف‬ ȣ̯؋Ϗ՝ð‫ ف‬ȩ #‫ ف‬¤ d‫ ׻‬Ԉ՞ñ‫ ف‬ɢ Ɉ ‫ ف‬ǿҰ++ ‫ו‬ò‫ ف‬ɛ ĕ‫ ف¯ ف‬Ɂ ϐ!Я Ӡ՟ó‫ ف‬ɟĖ‫ ف‬Ǎ ‫ ف‬-ĽƲƔ5Ð ‫ف‬ȳ & # - Gx9&5 ), ' ( - :'^ F Nj (eP_ ɒ ՠЙёȤô ‫ف‬ȴ̰،‫ ف‬ɨұԉϿƾ‫ ف‬ǐ ‫װ‬ѷ‫ؽ‬ Ѹ̱ԊĠȪʥ¢̲£ ‫ف‬ ȥ‫ا‬ѹ˫Ύ ‫ف‬ȫ M‫ف‬ɓֱ ϑѺ˓ Ԩͷ0‫ف‬7 õ‫ف‬°‫ف‬ȷѻѼաֲj ̈J‫ف‬Ǘ ‫ف‬ÅľƳƊŶÑ$‫ف‬ǱʦђϒКÖ´‫ف‬Dѽϓֳ‫ف‬ϔѾ‫ˬف;ف‬Ώ ̉ԋ̳>³բ‫ف‬ ӡգ‫˭ب‬ΐϕʧִԌϖˮ‫ف‬ΑҲդӢϗֵʨа3‫ ف‬Q;6O1(W ĿŎƋ ŀŏƴ ‫ف‬ ȬʩϘ ė‫ف‬ɜ2‫ف‬ǲ ‫ف‬ÉŇƺŻƝÒ ‫ف‬ȭҳֶΒ&ԍե‫؍ف‬ϙַn‫˯ف‬Γq ̊ŁĊ˻ѿ‫ف‬r(‫ف‬ʪ‫ ف‬զ‫˰ة‬ΔϚʫ Ԏϛ˱‫ف‬бв էӣ ԏʬЛ ‫ ف‬#D&,X b b ƞYŷąƟťƌ$‫ف‬ Ȑ͠ˋ‫& ז‬ըöȏ ‫ف‬ǎ ÷‫ف‬ɉҴթ̴Ҁ ‫]ف‬TK‫ف ف‬ȘМ ϜҁL‫ف‬8 ‫ف‬ǳ ‫ف‬ÆłƵƍƎ Ó ‫ف‬ǘ)ѓ ʭԐϝժҵ=‫ف‬Ҷ͐ Ε ̋ (Ϟ˲ʮН‫ف‬ k̵ͤͥ˳ָĞϸ‫ (̶׼‬իլ‫ف͑ ف‬¥խΖҷCֹ¦‫̷׽ ف‬ԑծ‫ר‬կ‫§ ف‬ОҸ҂͸¨‫ف‬հֺʯ‫ فت‬Ӥձ‫ ˴ث‬ʰֻԒϟ˵‫) ف‬ղBϠּʱПs‫ض‬ʲֽϡҹ҃Ǆ‫ف‬ `` Ɋ̸ճDг‫ח‬մ‫ ف‬Һ͒‫ ف ف‬řĆ‫ ج‬ʳԓ‫ ف‬ӥһ ‫־‬ΗҼյӦ ֿʴР‫ͦ ف‬ӓСТҽ؎ć‫ש‬ӧ ‫ف‬Sp f)X q@ ȵ҄‫׾‬Ҿє‫* ف‬k7 Ȯ̓ґ‫׀‬ʵУ‫ ف‬4S-$P. b b WƠ5ĈŚƶŦ 9 kնø‫ ف‬6 ù‫ ف‬ɋҿ+̹҅M‫ ^ ف‬ú‫ ف‬ș Ϣ҆û‫ ف‬8 ‫ ف‬Ǵüý‫ ف ف‬ȯϣдеd?þ‫ ف‬Ǣ%‫ ف‬.4ƷƏƐ˔Ô ‫ ف‬Ǚ |ӨʶԔϤ+A>‫ف‬ Ӏ͓‫ׁ ف‬Θ ‫ ف‬eжϥ҇re: ‫ ˼ ͧ ف‬Ϧ‫׿‬l(lշո‫ ف‬Ӂ͔‫©ف‬չnӂԪ ª‫؀ ف‬iŃ‫ـ‬պ‫ת‬ջ‫ « ف‬Ӄ?͹¬‫ ف‬ռ c‫ فح‬өս‫ ˶خ‬ϧ ׂԕϨ˷‫ف‬ Ι Ӫϩ‫ ׃‬t‫ط‬ʷׄϪӄ \‫ف‬ȉȊȋ%‫ف‬ǵ‫ׯ‬ԧ‫ ׅ‬Ԗ‫ف‬ԗ վ‫׫‬з‫ف͕ ف ט‬ʸ‫ف‬śĉ‫ د‬Ԙ‫ف‬ӫӅտ‫ ׆‬ӆր ϫ¡ʹФ‫׬ ؏ !!ͩ ف‬ӬĘ‫ف‬ Tr zl+Y K1b <| s ,l8 Z =l -[ 6R/N] b b ŜƸŸ ŧĨŐ ‫ف‬ ʺ‫ ف ذ‬ɂ ‫ف‬Ɍ ‫ف‬Ǐ ‫ف‬.‫ف‬ńƹƑŹÕę‫ف‬ɔ˸ΚϬ‫ غ‬ӭΛԙ̺҈ϭʻƿ‫ ف‬Ǧ‫؁‬ʼХ‫׭‬ʽ‫ׇ‬ϮӇ҉‫ف‬ӈ͖‫׈ف‬Ԛ̻ʾ‫׉‬ѕ̼Ҋ‫ ف׊‬і̽‫׋‬ΜӉ̌ց ‫ ف‬Eb 6$‫ف‬Ȱ ‫ف‬Ƕԛ̾̿̍їʿ ‫ف‬ȈĚ‫ف‬Țˀ ˁҋ ‫ف‬±‫ف‬Ǒ ‫ف‬ɕ˂̎ӊ˹Ѐ ‫ف‬Çǧ̈́иւ /‫ف‬ǚјҌ Ԝ̀Ν́ҍփϯ‫؂‬ԝ‫ف‬ɘ͗ؐ‫˕׌‬Ӌ Ё ӌ͘‫ف‬Ƀք‫˺ر‬Ξϰ˃‫׍‬Ԭ‫ش‬ÿ‫ ف‬ɠӍЦ ‫ف‬Ņ%‫ ف‬ǒ˄ ϱљ Ԟ͂\‫ ف‬ɣ ϲ˅њօ‫ف ف‬ɩɡuЧЂuҎ

The Family, the Patient, and the Psychiatric Hospital

May, P. R. .I\., & Goldberg, S. C. (1978). l'redi<:tion of schizophrenics' response to pharmacological therap)'· In M. A. Lipton, A. DiMascio, & K. Killam, (Eds.), Pl)'Choph1mnacology: A. Genemtion of Progress. New York: Raven Press. McLean, C., & Grunebaum, 1-1. (1\182). Parent's response to chronically psychotic children. Paper presented at. the American Psychiatric As wciation Annual Meeting-, Toronto. Minkoff, K. (I 979). A map of chronic mental patients. In J. Talbott, (Ed.), The Chronic Mental Patient. Washington, D.C.: American Psychiatric Press, 11-37. Mosher, L. R., & Keirh, S. .J. ( 1979). Research on the psychosocial treatment of schizophrenia: A summary report. American Journal of Psychiatry, 136 (5). 623-63 f. Nakhla, F., Folkart, L., & Wehster, J. (1969). Treatment of families as inpatients. Family Process, 8, 79-96. Pasamanick, B., Scorpitt, F.. & Dinitz, S. (1967). Srhiwphrenics in th1• Corn uiunity: iln Experimental Study in the Prevmtion of Hmj1italimtion. New York: Appleron-Century-Crnfts. Patr.ison, E. :VI. (1973). Social system psychotherapy. . 4.111erica11 journal of PsycholhnafJY, 17, 396-409. Pellegrino, E. (1979). Towa.-cl a reconstruction of medical morality: The primacy of the act of profession anrl the fact of illness. Journal of Mediciue and Philosophy, 4, 32-56. Pepper, B. ( I 980). The young chronic. Pape,· presented at the Annual Institute on Hospital & Community Psychiatry. Reiss, D., Costell, R., Jones, C., & Berkman, II. ( 1980). The family meets the hospital. Archives of General Psychiat1)', 37, 141-154. Rose, C. (1959). Relatives' attitudes and mental hospitalization. Menta.Z HygienP.,43, 194-203. ScheOen, A. (1981). Level, of Schizrrphre-nia. New York: Brunner/Maze!. Scheper-Hughes, N. (1981). Dilemmas in deinstitutionalization: A view from inner-city Boston. Journal of Operational I'sychial'ry, 12 (2), 90-99. Sider, R., & Ckrnents, C. (1!)82). Family or individual therapy: The ethic of modality choice. American journal of Psychia/1)', 139 (11), I 455-1459. Smith, F. A., Fent.on, F. R., Benoit, C., & Barzell, E. ( 1976). Home-care treatment of acutely ill psychiatric patients. Canadian Aychiatric Asso ciationjournal, 21 (5), 269-274. Stewan, R. P. (1982). Building an alliance between the families of patients and the hospital: Model and process. NAPPH.fuurnal, 12, 63-68. Talbott,J. A. (1971 ). Stopping the revolving door: A study of Readmissions to a state hospital. Psychialrir: Qu.arlerly, 48, Summer, 159-168. Talbott, J. A. (1979). Deinstitutionalization: Avoiding the disasters of the past. Hospital & Community P1yrhiah)•, :W (9), 621-624. Tauber, G. (1964). Prevention of post.hospital relapse through treatment ot relatives.journal of Hillside Hospilul, 13, 158-169. Terkelsen, K. (1983). Schizophrenia and the familv: Adverse effects of family therapy. Family Process, June, 191-200.

References

Terkelsen, K. (1984). Reply t.o Grunebaum's commems. Family Process, 23:425-428. Vaughn, C. E., & Leff, J. P. (1!)76). The influence of family and social facto1·s on the course of psychotic illness: A comparison of schizo. phrenia and depressed neurotic patients. British .Journal of Psychiatry, 129, l2!J-11l7 Whitaker, C:. A., & Olsen, E. (197 J). The staff r.earn and the family square off. In G. M. Abroms & N. S. Greenfield (Eds.), The New HosjJital l'.,ychi.atry. New York: Academic Press, 67-81. Wilder, .J. F., Levin, G., & Zwerling, I. (1966). A two-year follow-up eval• uation of acute psychotic patients treated in a clay hospital. American jm,rnal of PsychiahJ, 122, 1095-110 I. With_ersty, D). (1977). Family involvement on a psychiatric inpatient serv ice. Amrncanjournal of l'lychiatry. 134, 93-94. Wynne, L. C. (1982). The family anc� marital therapies. In J. M. Lewis & G. Usdin, (Eds.), Trmt .ment Planning in l'.1yd,iatry. Washington, D.C.: American Psychiatric Press, 227-285.

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The Family, the Patient, and the Psychiatric Hospital: Toward a New Model

Articles inside

A Model for Inpatient Family Intervention

Orientation

l.Introduction .............................................................. . Hospitalization and Family Functioning

When the Patient Is Not Defined as Chronic When the Patient Is Defined as Chronic .............. 5 I

The Approach in Family Assessment

Assessment for HospitaliLation Alternatives to Hospitalization ... .... ......... ... .. .. ....... l