Schizophrenic Women

Studies in Marital Crisis

Robert D. Towne, Harold Sampson, Sheldon L. Messinger

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780202308166
• eBook ISBN: 9781351306980
• Topic: Politique et relations internationales
• Subtopic: Politique sociale

Schizophrenic Women is a fascinating report on the lives of seventeen families that suffered the experiences associated with the hospitalization of the wife and mother for mental illness. A description and analysis of representative experiences is presented here in an attempt to investigate various key issues--the patterns of family living preceding the crisis leading to medical hospitalization; how the patterns fell apart; how personal and family crises became psychiatric emergencies; how the hospital experiences modified both the immediate crises and the earlier patterns of living--and how durable those changes were once the patients had returned home. The book goes beyond the immediate lives of the women and their families--the authors direct attention to patterns of psychiatric care and to the ways in which such crises as those experienced by these women and their families come to professional attention and are managed. The authors explore how help is found and used and some of the functions hospitalization serves for patients and their families. They point out some of the ways that traditional patterns of psychiatric care limit the power to observe, understand, and effectively influence a pathological course of events. In her new introduction to Schizophrenic Women, Rita J. Simon notes that, "Although the study was conducted in the 1950s, readers will recognize its current relevance and importance for scholars and the lay public interested in the problem of mental illness and intrafamily relationships."

1
The Crisis and Its Context

Concept and Approach

This report describes a critical period in the lives of seventeen married women and their families. Some time during the 1950’s each of these women was admitted as a patient to a California state mental hospital and therein diagnosed as schizophrenic. Their ties to their intimates had become tenuous and fraught with intense, disturbing emotions and fantasies. They were very withdrawn—in most instances confused and delusional, in some instances suffering from terrifying hallucinations. The immediate past and present were frightening, painful, confused, and unreal, and no predictable and tolerable future could be convincingly envisioned. Their everyday world and their customary, implicit scheme of living had shattered.

For some, the episode had occurred suddenly, with well-defined boundaries. For others, the episode had developed so gradually that it would be difficult to say when the person would first have seemed clinically schizophrenic. This was the first state mental hospitalization for each of them, although one woman had been hospitalized in a private sanitarium for a month shortly before entering the state institution and two others had been patients in the psychiatric ward of a county hospital for a few days some time before the present crisis.

The critical period with which we are concerned did not begin with hospitalization, nor did it end with subsequent release. These women had experienced repeated severe difficulties over the years in their marital families. In time, these difficulties became unmanageable for them or their intimates, and the women were removed or removed themselves from the family setting. The hospitalization itself acknowledged and confirmed the collapse of earlier personal and family adaptations. During hospitalization, new personal and family adaptations were tentatively evolved. The period following the young woman’s release from the hospital tested these tentative reorganizations and often further modified them.

The period we shall attempt to describe encompasses a sequence of organization-disorganization-reorganization. We shall trace in some detail the development of the crises which led to the admission of these women to the state mental hospital and, the ways in which these crises were modified during hospitalization and following release. Our broad aim is to describe this extended segment of the careers of these women and their marital families and to understand these careers as shaped by and as parts of family and institutional processes.

Our emphasis on this broad sweep of time and events cuts across traditional patterns of psychiatric care and traditional conceptions which have developed in relation to these patterns. The career of the mental patient and his family has typically come to the attention of treatment personnel during an emergency and then faded when the emergency was in some way resolved. The patterns of living which precede the psychiatric emergency and which follow its immediate resolution have remained for the most part outside of the practitioner’s field of observation. In addition, the professional people who become engaged with the future patient and his family before hospitalization seldom maintain their contact through hospitalization and afterward. Those responsible for hospital care rarely have any professional base in the outside community, and posthospital care, if any, falls to new hands. These compartmentalized arrangements have defined and limited therapeutic perspectives and have tended to segregate our conceptions about, as well as our treatment of, the prehospital, hospital, and posthospital phases of the crisis.

But patterns of treating such psychiatric problems are in great flux, and the trend is toward a more community-oriented management. The large, geographically distant, and administratively unwieldy state mental institution is yielding some of its prospective patients and some of its functions to the local general hospital and the specialized day-care or night-care facility. In these facilities care is provided nearer home, for briefer periods, and with more flexibility. Increasingly, the large mental institution is seeking organizational flexibility, giving explicit attention to the social milieu as a therapeutic (and antitherapeutic) force, and taking steps to reduce barriers between hospital and community. Increased attention is given to early release, aftercare, and also to early identification and treatment of emotional difficulties before they become unmanageable in the community. The concept of continuity of care receives some substance in plans to establish comprehensive mental health centers.¹

These trends give practical point to our concern with describing and conceptualizing a critical period which is not bounded by hospitalization or release. The traditional mental hospital has been, for the most part, a passive recipient of its clients, having only a limited veto power over the entire process whereby a member of the community becomes subject to its care. There has been no question of choosing a time and strategy of intervention in terms of concepts of optimal accessibility to effective help. Usually, indeed, the hospital has been a last resort; thus, hospitalization has taken place when opportunities for intervention were least promising.² After the patient’s release the traditional mental hospital has had very limited scope for therapeutic activity. In this kind of institutional setting, interest in the details of the patient’s extramural career is inevitably somewhat academic. The more earnestly treatment reaches out into the community, the more valuable knowledge of longitudinal patterns becomes. Strategies for earlier detection and intervention require knowledge about the precipitation of crises associated with the high risk of a serious psychiatric outcome, the ways in which such crises are ordinarily contained, and the circumstances under which they tend to become emergencies. We also need to know as much as possible about the determinants of seeking or avoiding professional help in such crises. These kinds of information can permit us to plan how to gear interventions to special opportunities or special risks.

We have considered the posthospital period not alone, as a social transition from one distinctive setting to another, but specifically, as a sequel to the personal and family crisis which resulted in hospitalization. The more usual approach in practice, research, and conceptualization is to emphasize discontinuities rather than continuities between the posthospital and prehospital experience. Because of his recent experience and current status, the patient may encounter such special problems as social stigma or finding himself locked out of former personal and vocational roles. The family, also, may have to accommodate itself to the management of a behaviorally deviant and emotionally disturbed person. In practice, there has been very little continuity of treatment, and the aftercare worker, if there is one, first encounters the patient and family to consult about posthospital issues.

Trends toward earlier prehospital care, briefer hospitalizations, and community hospital settings will inevitably modify the separateness of the posthospital period. The patient and family will experience relative continuity of care instead of a phase of relative isolation followed by a phase of attempted reintegration. The professional worker in comprehensive treatment facilities will have opportunities to observe and deal with the broad sweep of the crisis and its resolution, rather than a discrete phase of it. These changes will, we believe, emphasize the importance of forming a conception of the entire organization-disorganization-reorganization sequence and will stimulate further work using temporal units similar to those we have selected.

We shall not limit our description to the careers of patients alone, but will seriously attempt to characterize family adaptations, family crises, and family as well as personal solutions to crises. In this endeavor, also, our emphasis will tend to cut across many traditional concerns and modes of analysis, but will have particular significance to emerging patterns in the management of mental illness.

The large, geographically distant mental institution not only isolated the patient from his family, but at the same time effectively isolated those who treated him from the family setting in which the crisis arose and to which the patient was likely to return. The mental hospital practitioner met and treated his patients in an insular and semi autonomous province. It was only at the social boundaries of the province—admission, release, and visits—that he was compelled to deal with those who formed the immediate outside community of his patient. This historic pattern is undergoing change in both practice and research, and attention to family processes has become fashionable if not yet traditional. All trends toward an “open” hospital with early and frequent visiting and passes and short hospitalization for only the acute phase, with possible subsequent care, inevitably compel practitioners to become aware of and to relate to the patient’s family. It is therefore predictable that family processes will become a matter of increasingly genuine, practical concern to a great many staff members in mental hospitals over the next years. They will come to require conceptions which link family structure and processes to their own therapeutic and administrative tasks.

There has been a great deal of research on family processes and schizophrenia.³ For the most part, it has been concerned primarily with the parental family and with the early development of those behavior patterns and psychic structures presumed to underlie later manifest illness. The parental family is generally recognized as the strategic site for personality development. Our own emphasis on the contemporary family setting of the chronologically mature individual assumes that it is a strategic site for personality stabilization or decompensation in adult life. This assumption is particularly justifiable for the group of women studied. It was an intended product of our sample selection procedures that all the women were wives and mothers at the time of hospitalization. It was empirically true that none was regularly employed outside the home in the period shortly preceding hospitalization, and it also turned out that very few had ever had significant adult involvements in the occupational sphere. Thus family roles provided their main tie to participation in communal reality and their main immediate source of gratification and threat.

The contemporary marital family might be expected, then, to have importance in the development of the wife’s schizophrenic crisis in two related ways. First, participation in the marital family would press strategic demands, activating earlier developmental conflicts and uncovering earlier developmental defects. Second, the adaptation of the wife to these demands and conflicts would be shaped by the concrete organization of marital family life fashioned from the interlocking anxieties, conflicts, and conditions of intimacy in the family group. Her personal adaptations would be shaped by and be part of a family adaptation. These family adaptations, we assumed, could mitigate or intensify the personal conflicts of the wives. The eventual collapse of her personal adaptation must then be linked in an intrinsic, rather than a merely incidental, way to the collapse of a pre-existing pattern of family adaptation.

The contemporary family situation might also be expected to be of importance in determining when and how treatment was sought and hospitalization utilized. It is known that people who are severely impaired in their functioning or even overtly psychotic may remain in the community for a long time without being identified as psychiatrically ill and without professional treatment.⁴ During this period, the disturbed person maintains some type of accommodative pattern with his immediate personal community. This pattern permits or forces him to remain in the community in spite of his severe difficulties. In the cases studied, as is frequently true, the immediate personal community is the family; thus the family serves as the typical proximate agency of social control and forms a critical boundary between the individual and more formal means of social control. Professional help and intervention become important when and as family mechanisms of control are experienced as inadequate. We thus assumed that a careful investigation of family processes in relation to seeking professional help and deciding to hospitalize the patient would be essential to understanding how a personal or family crisis becomes a psychiatric emergency.

Finally, the contemporary family situation might be expected to be of importance in shaping the resolution of the prehospital crisis. The reorganization of the patient’s shattered scheme of living must include either a repair of disrupted family relationships or the establishment of alternative ties to the community. Any changes in family relationships promoted by the crisis and hospitalization would inevitably influence, as well as be influenced by, the patient’s psychic reorganization. The adjustment tasks and possibilities encountered by the patient after release, as well as his likelihood of remaining in the community, are in part determined by the interpersonal setting to which he returns.⁵

These considerations led us to commit a formidable amount of research time and effort to the study of marital families. We sought as much information as possible about the backgrounds of the husbands as well as of the patients. Ongoing interaction processes were observed and conceptualized, and detailed histories of the marital families were obtained. We tried to learn how professional agents and hospital processes wittingly and unwittingly modified family life.

This report, then, is concerned with various levels of crisis and with relationships between these levels. There is, first, the personal crisis of the patient—the collapse of her defensive and adaptive patterns, resulting in the shattering experience of psychosis, subsequent mental hospitalization, and a partial recovery which may consolidate or decay as she picks up the threads of her life. A second level is that of the family crisis—the failure of those defensive and adaptive arrangements instituted in the marital family to meet requisites of family life and needs of individual participants, resulting in an unmanageable emergency, removal of the wife from the family setting, and then tentative reorganizations which may or may not survive testing by subsequent experiences. Finally, there is the level of the public psychiatric crisis, which arises only as personal distress and deviance is brought to the attention of the wider community and defined as a serious psychiatric problem, thereby invoking new mechanisms of control and new sets of role expectations for family members.

Methods

The decision to follow what would inevitably be a small number of patients and their families over an extended time and to reconstruct for each case the vicissitudes of a crisis was most compatible with a broad, exploratory method of investigation. We could not expect to test previously stated propositions nor to obtain reliable statistics about characteristics of a defined population. We could expect, however, to locate hypothetically important processes and relationships if we exploited the special if restricted virtues of this approach. The particular opportunity afforded by an exploratory study is that of flexibility—data-collection procedures may be modified by new insights or hunches; the research lens may be wide-angle at one moment and adjust for close-ups at the next; and analytic questions and hypotheses may be allowed to develop gradually out of wide experience. We did, in fact, decide at various choice points to pursue an interesting lead or unexpected observation even when this meant that data across cases would not be uniform.

The research team was a specially constituted interdisciplinary group without formal affiliation to any treatment institution. We had no responsibility for administrative or treatment decisions. We worked out an explicit arrangement to obtain information from hospital personnel and other officials while withholding the content of our interviews and observations from them. We observed but did not participate in such decision-making processes as the release conference. We also exercised restraint with patients and their families in directly intervening to offer information, advice, and interpretations. All of our informants were explicitly informed that we were engaged in research, kept our data confidential, and did not contribute to treatment decisions. We held to this definition whatever other role assignments our informants attempted to grant us in fantasy or practice.

This observational role helped us to gain access to kinds of data not ordinarily available to people in other positions in the social system. For example, we regularly obtained information from patients and spouses about postrelease plans which they withheld from hospital personnel because they knew (or supposed) that such information would influence the likelihood of the patients’ release. Thus, the Bakers informed us of divorce plans which were deliberately concealed from the hospital staff. At the same time, our research role prevented us from testing hunches against experience by deliberately intervening in a situation and observing the consequences. Alfred H. Stanton and Morris S. Schwartz have well discussed the advantages of such interventions in distinguishing merely plausible from effective causes of an observed phenomenon.⁶ Further, our research role limited access to certain kinds of data the psychotherapist might obtain in extended contact with patients and spouses. This limitation, however, requires qualification in two important ways.

First, the peculiarities of our role permitted us to maintain contact over a long time with patients and spouses who would have avoided, and did avoid, involvement with treatment personnel. We were thus able to bring into quasi-systematic research observation some of that large group of people who do not appear—except transiently at the height of an emergency—in the office of the physician, psychiatrist, or aftercare social worker. Those who do become involved in a continuing treatment before or after hospitalization are a special and atypical subgroup of the larger population. Second, we explicitly recognized that we could not mai...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Introduction to the AldineTransaction Edition
• Preface
• Dedication
• 1 The Crisis and Its Context
• 2 Mary Yale
• 3 Family Processes
• 4 Kate White
• 5 Becoming a Mental Patient
• 6 Crisis Resolutions
• 7 Conclusion
• Appendix
• Index