Community Mental Health Journal
Volume 3, Number 2, Summer, 1967
FAMILY STRUCTURE AND CONDITIONS OF HOSPITALIZATION FOR SCHIZOPHRENIA LEO MILLER, Pr~.D.*
This paper raises the question of what social supports might permit the retention of schizophrenic patients in the community. Various types of family structure are examined in relation to the estimated duration of symptoms prior to hospitalization. It was found that the availability of sisters falling within certain ranges of age closeness to the patient is associated with relatively long durations for patients of both sexes. The availability of unemployed mothers and older children also lengthens the duration for female patients. The findings are discussed in the context of social system theory.
The present paper is one of a series dealing with factors of isolation, family structure, and role performance in relation to a group of 85 consecutive new admissions to mental hospital with diagnoses of schizophrenia. Previous reports from this study (Cumming & Miller, 1961; Miller, 1964) and others (Cumming, 1963) have suggested that inadequacy in the performance of certain social roles, particularly those relating to work and marriage, may constitute an important social concomitant of mental illness. Among patients of both sexes in the study group reported on here, hospitalization commonly followed periods of "nervousness," poor marital adjustment, and episodes of deviant behavior. The length of these periods varied considerably from a few days to many years. Male patients frequently had irregular work
histories, while female patients appeared to need assistance in home management and care of young children. Assuming that the maintenance of a deviant or inadequately functioning adult imposes a continuing stress on the family, such evidence raises the question of what social supports might make possible the retention of a member in the community for relatively long periods following the onset of symptoms. In discussing the family and mental disorder, Cumming (1961) distinguishes between socialization studies concerned with the etiology or formation of a predisposition to mental illness and stabilization-control studies concerned with the precipitation of illness, the process of hospitalization, or readjustment following an episode of illness. The question posed above touches upon the stabilization-con-
*Dr. Miller, a social worker, is Research Associate in Social Work, Department of Maternal and Child Health, Harvard School of Public Health. He was formerly Senior Welfare Consultant (Mental Health), Mental Health Research Unit, New York State Department of Mental Hygiene, Syracuse, N.Y. This study was conducted under the auspices of the Mental Health Research Unit with the assistance of its staff. The author is grateful, in particular, to Dr. John Cumming, Director, Dr. Elizabeth Tucker, Dr. Elaine Cumming, Miss Isabel McCaffrey, and Miss Mary Lou Parlagreco for their assistance in the preparation of this report.
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trol function of the family. This in no way involves any depreciation of the many studies based upon the theory that the roots of mental illness lie in defective socialization processes within the family (Spiegel & Bell, 1959). The present concern with the ability of the family to maintain a patient in the community is not meant to imply that delay in hospitalization of a patient clearly showing symptoms of mental illness is good in itself. Such delay may have decided disadvantages for the family, the community, or the individual patient. On the other hand, it is believed that studies concerned with the stabilization and control function of the family may have important implications for preventive or rehabilitative activities both before and after hospitalization. Failure to function adequately in roles prescribed for one's age, sex, and social status concerns not only the family but also the immediate kinship group and the community. At best, the inability or unwillingness of the adult male to maintain his primary occupational role, or of the female to maintain minimal standards of home management, leads to disesteem and loss of status. Failure in these roles may also bring about sanctions from the wider society. To avoid sanctions, some alternative means must be provided for fulfilling not only this type of function but also for resolving the tensions that social life generates and that women customarily watch for and ameliorate. These two types of system functions have been referred to, respectively, as instrumental and socioemotional (Parsons & Bales, 1955). The hypothesis was considered that the combined family system, including both the families of orientation and procreation, could maintain the patient in the community for relatively long periods without hospitalization if these functions were fulfilled by substitutes. Some of the literature on the effect of small group size on inter. action variables seems to have relevance for this hypothesis. For any given nuclear family the addition of other interacting members of the family of orientation will, of course, involve an increase in size of the
family system. Bales and Borgatta (1965) noted that the general result of the increase in size of their experimental groups was that the number of persons who participated at low rates was increased. They also found that increasing size was associated with a decrease in tension. They held that the role requirements for task completion and adequate group maintenance in the bigger groups may be allocated over a larger range of persons, so that there is more likelihood that the necessary roles will be performed by some persons without difficulty. They thought, too, that the larger size group would permit relative anonymity for persons who might be prone to show tension if forced into greater in. volvement. Other recent studies have sug. gested the possibility of association between family setting and relapse rate (Brown, 1959), between expectations of family members and posthospital performance of patients (Freeman & Simmons, 1963), and between the family interaction system and stigma (Cumming & Cumming, 1965). In the present study the decision was made to examine the possible significance of the social roles of family members for the functioning of a family system subject to the stress of maintaining a deviant member in the community. It was recognized that this investigation would be exploratory in nature in view of the relatively small size of the patient population. METHOD The study group of 85 patients reported on here included 44 males and 41 females. All were between 20 and 44 years of age and residents in a threecounty area of upstate New York at the time of admission. Most of the patients were admitted to three state hospitals and one Veterans Administra. tion hospital, located within the area. In addition, a few patients were received into the study from a small private mental hospital, also in the threecounty area, and one or two from state hospitals outside the area. In order to reduce extraneous variance, the study group was limited to native-born white patients who were without known mental defect and had not suffered long-term early separation from both parents. Patients from the Veterans Administration hospital, as might have been expected, were primarily males and comprised about 40 per cent of the males in the study group. The other hospitals, however, furnished a slight excess of females, with the result that the males exceeded
LEO MILLER the females by only a few patients in the total study group. The independent variables in this study include the following: patient's sex, age, and birth order, number and sex of siblings, age of siblings in relation to that of patient, availability of various members of the family of orientation, and presence of spouse, housekeeper, and children aged 12 years or over. The dependent variable is the length of time between the first known appearance of symptoms of illness and hospitalization. This time is referred to as the duration of onset. Data concerning all of these variables were obtained from two primary sources. The first was a home interview with the patient's mother or a sibling, which was made as soon as possible after admission. The second source was the hospital record. In a few cases in which an interview with one of these family members was not possible, information was obtained directly from the patient or a spouse. Supplementary data from local social agencies to whom the patient was known were also sought in a few instances. Operationally, it was intended to investigate various types of family structure in relation to the duration of onset. The estimate of duration was based on reports of frequent or continuous symptoms commonly associated with a diagnosis of schizophrenia, particularly when these were accompanied by marked behavior changes. Judgments of duration were made independently by a psychiatrist and a social worker. While fine judgments as to duration of onset were difficult to make in some instances, most cases fell clearly into one of two groups. These included those whose onset was estimated to have begun two years or more before hospitalization and those whose onset began less than two years before. In the few instances in which there was difficulty in making even this gross judgment, the assignment of the case to one of these two groups was based upon a consensus of the two judges. One patient with a long history of epilepsy and another concerning whom data was insufficient for the purpose were not classified and are omitted from the following discussion. Among the remaining 43 males, 17 had onsets estimated to be less than two years in duration, while the onsets of the other 26 were estimated to have begun two years or more prior to hospitalization. Similarly, 20 females, or exactly half of the 40 female patients who remained, fell into each of the two duration-of-onset groups. The extent to which members of the family of orientation might fulfill instrumental and socioemotional functions in relation to the family system would, of course, depend on their availability and frequency of interaction with the patient's immediate family. Although systematic data concerning the patterns of interaction were not secured, there was information about the availability of members for such interaction. In addition, it was known that most patients in the sample had some type of regular social contact with members of their family of orientation. Approximately two-thirds of both the male and female patients either lived, or
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had regular visiting contact (at least once per month), with one or more of these members. Data concerning the frequency of indirect communications, such as letters and phone calls, were incomplete. However, there was evidence to suggest that contacts of this type may have taken the place of eoresidenee or visiting, particularly for those patients who are geographically removed from their family of orientation. Reference is also made to a previously cited report (Cumming & Miller, 1961) in which it was noted that long-term isolation from all members of the family of orientation was rarely found among hospitalized male schizophrenics. In the latter report it was also pointed out that the duration of symptoms prior to hospitalization might depend, in part, upon the type of treatment facility available to a patient and the ease with which admission can be accomplished. In this respect the Veterans Administration hospital differs from the other hospitals in the study in that it has medical as well as psychiatric wards and does not have the stigma sometimes associated with admission to a large state mental hospital. This is reflected in the fact that, among the male patients, a much higher proportion of those admitted to the Veterans Administration hospital, as compared to those admitted to the other hospitals in the study, had come on their own to seek advice and treatment. The effect of these differences, however, on the duration of onset is not clear. In some instances admission to the psychiatric wards seems to have been hastened, but in others delayed, by prior treatment in medical wards. Unfortunately, the results of the present report are limited by the failure to include data concerning social class and the nature of the patient's symptoms. These two variables have, in fact, been found to be associated (Teele, 1965). There is some indication from data concerning the male patients (Miller, 1964) that the social class level of the families of orientation, as judged by the highest grade completed by either parent, was generally low. It is to he hoped, however, that data concerning these variables would be included in any replication of the present study. ROLES OF FAMILY MEMBERS A s a first step, p a t i e n t s i n e a c h o f t h e t w o o n s e t g r o u p s w e r e c o m p a r e d i n accordance with the availability of various f a m i l y m e m b e r s . P a r e n t s w e r e first c o n sidered. For both male and female patients, however, no differences beyond random variation were found in the proportions of the two onset groups who had either fathers or mothers living at the time of hospitalization. The same was true for those who were themselves residing with a spouse. These findings were consistent with p r e v i o u s r e s u l t s (1961). T h e f a i l u r e t o find d i f f e r e n c e s i n t h e case o f f a t h e r s c o n f i r m e d
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the earlier conclusion that other available sources of financial support had not sufficiently been considered. In the present instance this would apply particularly to male patients and to those females not living with a spouse who might have been expected to contribute to the support of themselves or of their families. Such sources of support included employment, at least of a marginal nature, which some patients maintained up to the time of hospitalization, veterans' pensions, Welfare, and assistance from working mothers or
wives. Attention was given next to siblings of the patient. It seemed possible that the type of system function within the extended family that could be fulfilled by an adult sibling might vary by the latter's sex and, furthermore, that the extent to which a sibling could constitute such a resource might depend on his or her age relative to that of the patient. Accordingly, it was decided to relate duration of onset to the age difference between the patient and closest sibling of each sex by means of a scale of age closeness (or difference). Age closeness was measured in whole number of years by taking the difference between the reported ages of the patient and the relevant sibling. The condition of having no sibling of the relevant sex was counted as the extreme negative position on the scale. It was then found that a sister within certain ranges of age closeness, depending on the sex of the patient, discriminated duration of onset. The range of age closeness for males extended from about two and one-half years' difference between patient and sibling to five and one-half years. The range for females extended from about five and one-half years to ten and one-half. The effect on duration of onset was strongest when the nearest female sibling was less than four years removed in age for male patients and less than seven years removed for female patients. Thus, 5, or 29.4%, of the 17 males with onsets of less than two years had at least one sister less than four years removed, as compared to 18, or 69.2%, of the 26 patients with onsets of two years or over. Similarly, 7, or
35%, of the 20"females with onsets of less than two years had at least one sister less than seven years removed, as compared to 16, or 80%, of the 20 with onsets of two years or over. The differences in these proportions are significant (x 2 = 5.0, P < .05 for males; X2 = 6.3, P < .05 for females). When the above procedure was repeated separately with reference to older sisters only and younger sisters only, similar tendencies were evident, but they did not reach significance. The pattern for sisters, moreover, was not repeated for brothers. No level of age difference for brothers could be found that discriminated duration of onset for either male or female patients. It seems probable that age difference and number of siblings are not independent. The more siblings a patient has, the more likely he is to have at least one who is close in age. Among the male patients the num. her of sisters, like the age difference of the closest, was in fact also found to discriminate duration of onset. This did not, however, hold true for the females. When both factors were combined for males, 10, or 58.8%, of the 17 patients with onsets of less than two years were found to have either no sister at all or just one, and that one four years or more removed in age, as compared to only 3, or 11.5%, of the 26 who had onsets of two years or over (x 2 = 8.9, P < .01). Both those males who were, and were not, living with a spouse contributed to this difference.
The Helping Agent The division of labor within the nuclear family normally imposes certain responsibilities for task performance upon the wifemother. These involve maintaining standards of household order, sanitation, and child care acceptable to the family and community. Even unmarried females are expected to fulfill certain instrumental functions, such as sharing in household tasks or in the care of younger siblings. It seems reasonable to assume that, in most instances, the onset of illness would reduce the female patient's ability to recognize or maintain these standards. If,
LEO MILLER then, she is to remain within the family, it would appear necessary that provision be made, not only for solving the set of socioemotional problems within the family system, but also for fulfilling these instrumental-type functions. Recent literature dealing with the threegeneration kinship unit (Young and Willmott, 1957) suggests that the female adult in the oldest generation (grandmother) frequently has an important role in fulfilling these instrumental functions. When we investigated this among our study group, the data from both the hospital records and interviews showed that unemployed mothers did indeed frequently render assistance to their patient-daughters in the performance of routine household tasks and care of young children prior to hospitalization. Mothers were particularly likely to give this help following childbirth and during other periods of stress or crisis. In one or two instances when help was not available from a mother, a housekeeper seemed to provide a substitute. It is particularly among the families of relatively young wives who become patients that unemployed mothers may be expected to constitute a major resource of this kind. The families of older patients are more likely to include at least one child old enough to assist in the performance of
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necessary household duties and in the care of younger siblings when the wife-mother is incapacitated. Unfortunately, our data did not include systematic information concerning help given by children. Clinical experience and c o m m o n knowledge, however, suggest that those aged 12 years and over can, and frequently do, accept responsibilities in the home during periods of crisis, particularly when these periods are prolonged or recur frequently. In the present study group at least one of these three types of helping agent was available at the time of hospitalization for 27 of the 40 females. Upon further examination it was discovered that only 8, or 29.6%, of the 27 patients with a helping agent available had onsets of less than two years, as compared to 12, or 92.3%, of the 13 who had no access to such help. The difference in these proportions is significant ( x ~ = 11.4, P < .001). As expected, mothers were the agents available for patients under 30 years of age, and children most commonly for those aged 30 years or over. As a next step, the 40 female patients were distributed by combinations of sisters and availability of helping agent in relation to duration of onset. This is shown in Table 1. As can be seen, only 2 of the 17 patients who had both a helping agent and a sister had durations of less than two years, as
TABLE 1 DISTRIBUTIONOF FEMALE PATIENTS BY COMBINATIONSOF AT LEAST ONE SISTER LESS THAN SEVEN YEAES REMOVED AND AVAILABILITYOF HELPING AGENT, MARITAL STATUS AT HOSPITALIZATION, AND DURATION OF ONSET
Combinations of at least one sister less than seven years removed and availability of helping agent 1
Duration of Onset and Marital Status at Hospitalization Not living All Patients Living with Spouse with Spouse Less 2 yrs. Less 2 yrs. Less 2 yrs than or than or than or Tot. 2 yrs. over Tot. 2 yrs. over Tot. 2 yrs. over
Total patients Both agent and sister s Agent only Sister only Neither
40 17 10 6 7
20 2 6 5 7
20 15 4 1 --
28 10 8 5 5
17 2 6 4 5
11 8 2 1 --
12 7 2 1 2
3 --1 2
9 7 2 ---
1 Refers to a mother not obviously ill and residing in the same or adjoining city or township as the patient, the presence of at least one child age 12 years or over and not known to be mentally retarded, or the presence of a housekeeper at the time of hospitalization. x ~ = 14.7, P < .0001 (d.f. = 1) for the difference in the proportions of those with both agent and sister who had onsets of lessthan two years, and all others.
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compared to 18 of the 23 patients who had only one or neither. The difference is highly significant (x 2 = 14.7, P < .0001). Marital status had no effect in relation to this difference. AGE AT HOSPITALIZATION The patient's age at hospitalization must depend on his age at the first appearance of symptoms and on the length of onset. It was expected, therefore, that patients with relatively long onsets would be older at admission than those with shorter onsets. This was, in fact, found to be true for the female patients and also for the 23 male patients who were not living with a spouse. Among the 23 males, 8 were aged 20-24 years at hospitalization. Of the eight, 6 had onsets of less than two years, as compared to only 2 of the 15 aged 25-44 years (P < .01, Fisher's Exact Test). Furthermore, 5 of the 8 were found to have no sister or only one four years or more removed, as compared to only 2 of the 15 aged 25-44 years. This difference, too, is significant (P < .05, Fisher's Exact Test). These observations suggest that susceptible males not living with a spouse who have escaped hospitalization until age 25 are likely to have had onsets of two years or more and to be characterized by a sibship structure that includes at least one sister less than four years removed, or two or more sisters of any age. On the other hand, those hospitalized prior to this age are likely to show briefer onsets, and to have neither the single sister nor the combination of sisters. Among the remaining 20 males who were living with a spouse at hospitalization there were too few (one case) less than 25 years of age for a similar comparison. Although breakdowns at other age levels were attempted, no association could be found between age and duration of onset among this group. On investigating the female patients, it was found that 16, or 80%, of the 20 with onsets of less than two years were under 30 years of age, as compared to only 1, or 5%, of the 20 patients with onsets of two years or over (x ~ = 20, P < .0001). Among
the 17 patients, furthermore, with both a helping agent and a sister less than seven years removed (see Table 1) only 3, or 17.6%, were under 30 years of age, as compared to 14 or 60.9% of the remaining 23 patients (x~= 5.7, P < .05). Both those female patients living and not living with a spouse contributed to this difference, although the former did so much more strongly. This evidence suggests that susceptible females who have escaped hospitalization until age 30 are likely to have had onsets of at least two years and to have available both a helping agent and a sister. Those hospitalized prior to this age, on the other hand, will more probably have shown briefer onsets and not have had available both members of the above combination. DISCUSSION The present observations support the hypothesis suggested at the beginning of this report, namely, that social systems may be able to carry relatively nonproductive members if the necessary functions are being fulfilled. These observations emphasize the possible significance of the roles of certain members of the family of orientation, particularly that of the sister, for maintenance of the patient within the community. The data suggest that sisters may play an in. tegrative and tension-reducing role that permits the family to maintain the patient outside of the hospital. This does not, how. ever, seem to be true for mothers and wives. In the earlier report referred to above (Cumruing & Miller, 1961), it was noted that women closely connected with the prospective patient may, by mediating social interaction for men both in and out of the family, initiate and encourage the activity that keeps the family system intact. It was suggested there, however, that the type of affective obligatory relationship associated with mothers and wives is productive of stress and tension in the male schizophrenic and will tend to increase family tensions. It is possible that such tensions offset the effect of supportive services. The present data suggest that, so far as concerns mothers, this may be true for female as well as male patients. Sisters, furthermore,
LEO MILLER
by providing a more manageable relationship, may possibly neutralize the effect of these tensions for patients of either sex. The present data further emphasize the possible significance, not only of the sister role as such, but of a "peering" effect in relation to age difference between sister and patient. The smaller this difference, the more effective does this role appear to be. Further investigation is needed, not only of this effect, but also of the roles played by other members in maintaining the equilibrium of the family system under conditions of stress. In this connection reference is made to the possible roles of unemployed mothers and children, as noted above in relation to female patients. In the previously cited study, Cumming and Cumming (1965) found that failure of male schizophrenic patients to visit regularly with female kin other than the mother after discharge from hospital was associated with stigma. The present results support their findings. They are also consistent with studies of kinship patterns in America, which have indicated that the sibling bond, usually mediated through women, may be an important source of support to the individual (Cumming & Schneider, 1961). The tenacity of the sibling relationship among older people in certain marital statuses and social situations, as well as the general predominance of women in kinship affairs, has also been noted by Townsend (1957). Various limitations and possible sources of error, of course, exist in relation to the interpretation of the data. It was assumed throughout that interaction is the variable intervening between family structure and length of onset. The findings, however, may also reflect differences in socialization patterns. Sex and age composition, as well as the size, of a patient's sibship must have important consequences for the development of personality. Some of these consequences have been noted by Brim (1962). Another possibility is that differences in delay of hospitalization after the appearance of symptoms are associated with differences in the symptomatology itself, or with the process of hospitalization, as noted above
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in connection with the Veterans Administration hospital. It is, of course, possible that some proportion of the variance that we have attributed to system processes may be accounted for by these factors. We do not know, furthermore, to what extent the interaction factor is itself dependent upon the illness of the patient. For example, it is possible that dependence on the mother is greater among daughters susceptible to illness than among others. If so, susceptible daughters may avoid physical separation from their mothers to a greater extent than would be true of other daughters. Further investigation is needed in regard to all of these factors. This study has emphasized the roles of various family members in connection with the retention of the mental patient in the community. It has been suggested that the roles of these members serve to fulfill func. tions required for the maintenance of the family system. The present data serve also to stress the special pertinence of the family as a system of action for the social control of deviance. REFERENCES BALES, R. F., & BORGATTA,E. F. Size of group as a factor in the interaction profile. In A. P. Hare, E. F. Borgatta, & R. F. Bales (Eds.), Smallgroups, studies in social interaction. New York: Alfred A. Knopf, 1965. Pp. 495-512. Bm~, O. G. Family structure and sex role learning by children: a further analysis of Helen Koch's data. In R. F. Winch, R. McGinnis, & H. R. Barringer (Eds.), Selected studies ia marriage and the family. New York: Holt, Rinehart, & Winston, 1962. Pp. 275-290. BROWN, G. W. Experiences of discharged chronic schizophrenic patients in various types of living groups. Milbank Memorial Fund Quart., 1959, 37, 105-131. CUMMING, ELAINE, & SCHNEIDER, D. M. Sibling solidarity: a property of American kinship. Amer. Anthropologist, 1961, 63, 498-507. CUMMINr J. H. The family and mental disorder: an incomplete essay. Milbank Memorial Fund Quart., 1961, 34, 185-212. CUMMINr J. H. The inadequacy syndrome. Psychiat. Quart., 1963, 37, 723-733. CUMMING,J. H., & CUMMING,ELAINE.On the stigma of mental illness. Commua. meat. Hlth J., 1965, 1, 135-143. CU~mNG, J. H., & Miller, L. Isolation, family structure, and schizophrenia. In Proceedings of the Third World Congress of Psychiatry. Toronto: Univ. of Toronto Press, 1961. Pp. 874-878.
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FREEMAN, H. E., & SIMMONS,O. G. The mental patient comes home. New York: John Wiley & Sons, 1963. MILLER, L. Some social factors associated with hospitalization for schizophrenia. Unpublished doctoral dissertation, Syracuse Univ., 1964. PARSONS,T., & BALES, R. F. Family, socialization and interaction process. Glencoe, IlL: The Free Press, 1955. SPIEGEL, J. P., & BELL, N. W. The family of the
psychiatric patient. In S. Arieti (Ed.), American handbook ofpsychlatry. New York: Basic Books, 1959. Pp. 114-149. TEELE, J. E. Suicidal behavior, assaultiveness, and socialization principles. Soc. Forces, 1965, 43, 510-518. TOWNSEND,P. The family life of old people. London: Routledge & Kegan Paul, 1957. YOUNG,M., & WILLMOTT,P. Family and kinship in East London. Glencoe, Ill.: The Free Press, 1957.
Volume 3, Number 2, Summer, 1967
FAMILY STRUCTURE AND CONDITIONS OF HOSPITALIZATION FOR SCHIZOPHRENIA LEO MILLER, Pr~.D.*
This paper raises the question of what social supports might permit the retention of schizophrenic patients in the community. Various types of family structure are examined in relation to the estimated duration of symptoms prior to hospitalization. It was found that the availability of sisters falling within certain ranges of age closeness to the patient is associated with relatively long durations for patients of both sexes. The availability of unemployed mothers and older children also lengthens the duration for female patients. The findings are discussed in the context of social system theory.
The present paper is one of a series dealing with factors of isolation, family structure, and role performance in relation to a group of 85 consecutive new admissions to mental hospital with diagnoses of schizophrenia. Previous reports from this study (Cumming & Miller, 1961; Miller, 1964) and others (Cumming, 1963) have suggested that inadequacy in the performance of certain social roles, particularly those relating to work and marriage, may constitute an important social concomitant of mental illness. Among patients of both sexes in the study group reported on here, hospitalization commonly followed periods of "nervousness," poor marital adjustment, and episodes of deviant behavior. The length of these periods varied considerably from a few days to many years. Male patients frequently had irregular work
histories, while female patients appeared to need assistance in home management and care of young children. Assuming that the maintenance of a deviant or inadequately functioning adult imposes a continuing stress on the family, such evidence raises the question of what social supports might make possible the retention of a member in the community for relatively long periods following the onset of symptoms. In discussing the family and mental disorder, Cumming (1961) distinguishes between socialization studies concerned with the etiology or formation of a predisposition to mental illness and stabilization-control studies concerned with the precipitation of illness, the process of hospitalization, or readjustment following an episode of illness. The question posed above touches upon the stabilization-con-
*Dr. Miller, a social worker, is Research Associate in Social Work, Department of Maternal and Child Health, Harvard School of Public Health. He was formerly Senior Welfare Consultant (Mental Health), Mental Health Research Unit, New York State Department of Mental Hygiene, Syracuse, N.Y. This study was conducted under the auspices of the Mental Health Research Unit with the assistance of its staff. The author is grateful, in particular, to Dr. John Cumming, Director, Dr. Elizabeth Tucker, Dr. Elaine Cumming, Miss Isabel McCaffrey, and Miss Mary Lou Parlagreco for their assistance in the preparation of this report.
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THE COMMUNITYMENTAL HEALTH JOURNAL
trol function of the family. This in no way involves any depreciation of the many studies based upon the theory that the roots of mental illness lie in defective socialization processes within the family (Spiegel & Bell, 1959). The present concern with the ability of the family to maintain a patient in the community is not meant to imply that delay in hospitalization of a patient clearly showing symptoms of mental illness is good in itself. Such delay may have decided disadvantages for the family, the community, or the individual patient. On the other hand, it is believed that studies concerned with the stabilization and control function of the family may have important implications for preventive or rehabilitative activities both before and after hospitalization. Failure to function adequately in roles prescribed for one's age, sex, and social status concerns not only the family but also the immediate kinship group and the community. At best, the inability or unwillingness of the adult male to maintain his primary occupational role, or of the female to maintain minimal standards of home management, leads to disesteem and loss of status. Failure in these roles may also bring about sanctions from the wider society. To avoid sanctions, some alternative means must be provided for fulfilling not only this type of function but also for resolving the tensions that social life generates and that women customarily watch for and ameliorate. These two types of system functions have been referred to, respectively, as instrumental and socioemotional (Parsons & Bales, 1955). The hypothesis was considered that the combined family system, including both the families of orientation and procreation, could maintain the patient in the community for relatively long periods without hospitalization if these functions were fulfilled by substitutes. Some of the literature on the effect of small group size on inter. action variables seems to have relevance for this hypothesis. For any given nuclear family the addition of other interacting members of the family of orientation will, of course, involve an increase in size of the
family system. Bales and Borgatta (1965) noted that the general result of the increase in size of their experimental groups was that the number of persons who participated at low rates was increased. They also found that increasing size was associated with a decrease in tension. They held that the role requirements for task completion and adequate group maintenance in the bigger groups may be allocated over a larger range of persons, so that there is more likelihood that the necessary roles will be performed by some persons without difficulty. They thought, too, that the larger size group would permit relative anonymity for persons who might be prone to show tension if forced into greater in. volvement. Other recent studies have sug. gested the possibility of association between family setting and relapse rate (Brown, 1959), between expectations of family members and posthospital performance of patients (Freeman & Simmons, 1963), and between the family interaction system and stigma (Cumming & Cumming, 1965). In the present study the decision was made to examine the possible significance of the social roles of family members for the functioning of a family system subject to the stress of maintaining a deviant member in the community. It was recognized that this investigation would be exploratory in nature in view of the relatively small size of the patient population. METHOD The study group of 85 patients reported on here included 44 males and 41 females. All were between 20 and 44 years of age and residents in a threecounty area of upstate New York at the time of admission. Most of the patients were admitted to three state hospitals and one Veterans Administra. tion hospital, located within the area. In addition, a few patients were received into the study from a small private mental hospital, also in the threecounty area, and one or two from state hospitals outside the area. In order to reduce extraneous variance, the study group was limited to native-born white patients who were without known mental defect and had not suffered long-term early separation from both parents. Patients from the Veterans Administration hospital, as might have been expected, were primarily males and comprised about 40 per cent of the males in the study group. The other hospitals, however, furnished a slight excess of females, with the result that the males exceeded
LEO MILLER the females by only a few patients in the total study group. The independent variables in this study include the following: patient's sex, age, and birth order, number and sex of siblings, age of siblings in relation to that of patient, availability of various members of the family of orientation, and presence of spouse, housekeeper, and children aged 12 years or over. The dependent variable is the length of time between the first known appearance of symptoms of illness and hospitalization. This time is referred to as the duration of onset. Data concerning all of these variables were obtained from two primary sources. The first was a home interview with the patient's mother or a sibling, which was made as soon as possible after admission. The second source was the hospital record. In a few cases in which an interview with one of these family members was not possible, information was obtained directly from the patient or a spouse. Supplementary data from local social agencies to whom the patient was known were also sought in a few instances. Operationally, it was intended to investigate various types of family structure in relation to the duration of onset. The estimate of duration was based on reports of frequent or continuous symptoms commonly associated with a diagnosis of schizophrenia, particularly when these were accompanied by marked behavior changes. Judgments of duration were made independently by a psychiatrist and a social worker. While fine judgments as to duration of onset were difficult to make in some instances, most cases fell clearly into one of two groups. These included those whose onset was estimated to have begun two years or more before hospitalization and those whose onset began less than two years before. In the few instances in which there was difficulty in making even this gross judgment, the assignment of the case to one of these two groups was based upon a consensus of the two judges. One patient with a long history of epilepsy and another concerning whom data was insufficient for the purpose were not classified and are omitted from the following discussion. Among the remaining 43 males, 17 had onsets estimated to be less than two years in duration, while the onsets of the other 26 were estimated to have begun two years or more prior to hospitalization. Similarly, 20 females, or exactly half of the 40 female patients who remained, fell into each of the two duration-of-onset groups. The extent to which members of the family of orientation might fulfill instrumental and socioemotional functions in relation to the family system would, of course, depend on their availability and frequency of interaction with the patient's immediate family. Although systematic data concerning the patterns of interaction were not secured, there was information about the availability of members for such interaction. In addition, it was known that most patients in the sample had some type of regular social contact with members of their family of orientation. Approximately two-thirds of both the male and female patients either lived, or
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had regular visiting contact (at least once per month), with one or more of these members. Data concerning the frequency of indirect communications, such as letters and phone calls, were incomplete. However, there was evidence to suggest that contacts of this type may have taken the place of eoresidenee or visiting, particularly for those patients who are geographically removed from their family of orientation. Reference is also made to a previously cited report (Cumming & Miller, 1961) in which it was noted that long-term isolation from all members of the family of orientation was rarely found among hospitalized male schizophrenics. In the latter report it was also pointed out that the duration of symptoms prior to hospitalization might depend, in part, upon the type of treatment facility available to a patient and the ease with which admission can be accomplished. In this respect the Veterans Administration hospital differs from the other hospitals in the study in that it has medical as well as psychiatric wards and does not have the stigma sometimes associated with admission to a large state mental hospital. This is reflected in the fact that, among the male patients, a much higher proportion of those admitted to the Veterans Administration hospital, as compared to those admitted to the other hospitals in the study, had come on their own to seek advice and treatment. The effect of these differences, however, on the duration of onset is not clear. In some instances admission to the psychiatric wards seems to have been hastened, but in others delayed, by prior treatment in medical wards. Unfortunately, the results of the present report are limited by the failure to include data concerning social class and the nature of the patient's symptoms. These two variables have, in fact, been found to be associated (Teele, 1965). There is some indication from data concerning the male patients (Miller, 1964) that the social class level of the families of orientation, as judged by the highest grade completed by either parent, was generally low. It is to he hoped, however, that data concerning these variables would be included in any replication of the present study. ROLES OF FAMILY MEMBERS A s a first step, p a t i e n t s i n e a c h o f t h e t w o o n s e t g r o u p s w e r e c o m p a r e d i n accordance with the availability of various f a m i l y m e m b e r s . P a r e n t s w e r e first c o n sidered. For both male and female patients, however, no differences beyond random variation were found in the proportions of the two onset groups who had either fathers or mothers living at the time of hospitalization. The same was true for those who were themselves residing with a spouse. These findings were consistent with p r e v i o u s r e s u l t s (1961). T h e f a i l u r e t o find d i f f e r e n c e s i n t h e case o f f a t h e r s c o n f i r m e d
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the earlier conclusion that other available sources of financial support had not sufficiently been considered. In the present instance this would apply particularly to male patients and to those females not living with a spouse who might have been expected to contribute to the support of themselves or of their families. Such sources of support included employment, at least of a marginal nature, which some patients maintained up to the time of hospitalization, veterans' pensions, Welfare, and assistance from working mothers or
wives. Attention was given next to siblings of the patient. It seemed possible that the type of system function within the extended family that could be fulfilled by an adult sibling might vary by the latter's sex and, furthermore, that the extent to which a sibling could constitute such a resource might depend on his or her age relative to that of the patient. Accordingly, it was decided to relate duration of onset to the age difference between the patient and closest sibling of each sex by means of a scale of age closeness (or difference). Age closeness was measured in whole number of years by taking the difference between the reported ages of the patient and the relevant sibling. The condition of having no sibling of the relevant sex was counted as the extreme negative position on the scale. It was then found that a sister within certain ranges of age closeness, depending on the sex of the patient, discriminated duration of onset. The range of age closeness for males extended from about two and one-half years' difference between patient and sibling to five and one-half years. The range for females extended from about five and one-half years to ten and one-half. The effect on duration of onset was strongest when the nearest female sibling was less than four years removed in age for male patients and less than seven years removed for female patients. Thus, 5, or 29.4%, of the 17 males with onsets of less than two years had at least one sister less than four years removed, as compared to 18, or 69.2%, of the 26 patients with onsets of two years or over. Similarly, 7, or
35%, of the 20"females with onsets of less than two years had at least one sister less than seven years removed, as compared to 16, or 80%, of the 20 with onsets of two years or over. The differences in these proportions are significant (x 2 = 5.0, P < .05 for males; X2 = 6.3, P < .05 for females). When the above procedure was repeated separately with reference to older sisters only and younger sisters only, similar tendencies were evident, but they did not reach significance. The pattern for sisters, moreover, was not repeated for brothers. No level of age difference for brothers could be found that discriminated duration of onset for either male or female patients. It seems probable that age difference and number of siblings are not independent. The more siblings a patient has, the more likely he is to have at least one who is close in age. Among the male patients the num. her of sisters, like the age difference of the closest, was in fact also found to discriminate duration of onset. This did not, however, hold true for the females. When both factors were combined for males, 10, or 58.8%, of the 17 patients with onsets of less than two years were found to have either no sister at all or just one, and that one four years or more removed in age, as compared to only 3, or 11.5%, of the 26 who had onsets of two years or over (x 2 = 8.9, P < .01). Both those males who were, and were not, living with a spouse contributed to this difference.
The Helping Agent The division of labor within the nuclear family normally imposes certain responsibilities for task performance upon the wifemother. These involve maintaining standards of household order, sanitation, and child care acceptable to the family and community. Even unmarried females are expected to fulfill certain instrumental functions, such as sharing in household tasks or in the care of younger siblings. It seems reasonable to assume that, in most instances, the onset of illness would reduce the female patient's ability to recognize or maintain these standards. If,
LEO MILLER then, she is to remain within the family, it would appear necessary that provision be made, not only for solving the set of socioemotional problems within the family system, but also for fulfilling these instrumental-type functions. Recent literature dealing with the threegeneration kinship unit (Young and Willmott, 1957) suggests that the female adult in the oldest generation (grandmother) frequently has an important role in fulfilling these instrumental functions. When we investigated this among our study group, the data from both the hospital records and interviews showed that unemployed mothers did indeed frequently render assistance to their patient-daughters in the performance of routine household tasks and care of young children prior to hospitalization. Mothers were particularly likely to give this help following childbirth and during other periods of stress or crisis. In one or two instances when help was not available from a mother, a housekeeper seemed to provide a substitute. It is particularly among the families of relatively young wives who become patients that unemployed mothers may be expected to constitute a major resource of this kind. The families of older patients are more likely to include at least one child old enough to assist in the performance of
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necessary household duties and in the care of younger siblings when the wife-mother is incapacitated. Unfortunately, our data did not include systematic information concerning help given by children. Clinical experience and c o m m o n knowledge, however, suggest that those aged 12 years and over can, and frequently do, accept responsibilities in the home during periods of crisis, particularly when these periods are prolonged or recur frequently. In the present study group at least one of these three types of helping agent was available at the time of hospitalization for 27 of the 40 females. Upon further examination it was discovered that only 8, or 29.6%, of the 27 patients with a helping agent available had onsets of less than two years, as compared to 12, or 92.3%, of the 13 who had no access to such help. The difference in these proportions is significant ( x ~ = 11.4, P < .001). As expected, mothers were the agents available for patients under 30 years of age, and children most commonly for those aged 30 years or over. As a next step, the 40 female patients were distributed by combinations of sisters and availability of helping agent in relation to duration of onset. This is shown in Table 1. As can be seen, only 2 of the 17 patients who had both a helping agent and a sister had durations of less than two years, as
TABLE 1 DISTRIBUTIONOF FEMALE PATIENTS BY COMBINATIONSOF AT LEAST ONE SISTER LESS THAN SEVEN YEAES REMOVED AND AVAILABILITYOF HELPING AGENT, MARITAL STATUS AT HOSPITALIZATION, AND DURATION OF ONSET
Combinations of at least one sister less than seven years removed and availability of helping agent 1
Duration of Onset and Marital Status at Hospitalization Not living All Patients Living with Spouse with Spouse Less 2 yrs. Less 2 yrs. Less 2 yrs than or than or than or Tot. 2 yrs. over Tot. 2 yrs. over Tot. 2 yrs. over
Total patients Both agent and sister s Agent only Sister only Neither
40 17 10 6 7
20 2 6 5 7
20 15 4 1 --
28 10 8 5 5
17 2 6 4 5
11 8 2 1 --
12 7 2 1 2
3 --1 2
9 7 2 ---
1 Refers to a mother not obviously ill and residing in the same or adjoining city or township as the patient, the presence of at least one child age 12 years or over and not known to be mentally retarded, or the presence of a housekeeper at the time of hospitalization. x ~ = 14.7, P < .0001 (d.f. = 1) for the difference in the proportions of those with both agent and sister who had onsets of lessthan two years, and all others.
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compared to 18 of the 23 patients who had only one or neither. The difference is highly significant (x 2 = 14.7, P < .0001). Marital status had no effect in relation to this difference. AGE AT HOSPITALIZATION The patient's age at hospitalization must depend on his age at the first appearance of symptoms and on the length of onset. It was expected, therefore, that patients with relatively long onsets would be older at admission than those with shorter onsets. This was, in fact, found to be true for the female patients and also for the 23 male patients who were not living with a spouse. Among the 23 males, 8 were aged 20-24 years at hospitalization. Of the eight, 6 had onsets of less than two years, as compared to only 2 of the 15 aged 25-44 years (P < .01, Fisher's Exact Test). Furthermore, 5 of the 8 were found to have no sister or only one four years or more removed, as compared to only 2 of the 15 aged 25-44 years. This difference, too, is significant (P < .05, Fisher's Exact Test). These observations suggest that susceptible males not living with a spouse who have escaped hospitalization until age 25 are likely to have had onsets of two years or more and to be characterized by a sibship structure that includes at least one sister less than four years removed, or two or more sisters of any age. On the other hand, those hospitalized prior to this age are likely to show briefer onsets, and to have neither the single sister nor the combination of sisters. Among the remaining 20 males who were living with a spouse at hospitalization there were too few (one case) less than 25 years of age for a similar comparison. Although breakdowns at other age levels were attempted, no association could be found between age and duration of onset among this group. On investigating the female patients, it was found that 16, or 80%, of the 20 with onsets of less than two years were under 30 years of age, as compared to only 1, or 5%, of the 20 patients with onsets of two years or over (x ~ = 20, P < .0001). Among
the 17 patients, furthermore, with both a helping agent and a sister less than seven years removed (see Table 1) only 3, or 17.6%, were under 30 years of age, as compared to 14 or 60.9% of the remaining 23 patients (x~= 5.7, P < .05). Both those female patients living and not living with a spouse contributed to this difference, although the former did so much more strongly. This evidence suggests that susceptible females who have escaped hospitalization until age 30 are likely to have had onsets of at least two years and to have available both a helping agent and a sister. Those hospitalized prior to this age, on the other hand, will more probably have shown briefer onsets and not have had available both members of the above combination. DISCUSSION The present observations support the hypothesis suggested at the beginning of this report, namely, that social systems may be able to carry relatively nonproductive members if the necessary functions are being fulfilled. These observations emphasize the possible significance of the roles of certain members of the family of orientation, particularly that of the sister, for maintenance of the patient within the community. The data suggest that sisters may play an in. tegrative and tension-reducing role that permits the family to maintain the patient outside of the hospital. This does not, how. ever, seem to be true for mothers and wives. In the earlier report referred to above (Cumruing & Miller, 1961), it was noted that women closely connected with the prospective patient may, by mediating social interaction for men both in and out of the family, initiate and encourage the activity that keeps the family system intact. It was suggested there, however, that the type of affective obligatory relationship associated with mothers and wives is productive of stress and tension in the male schizophrenic and will tend to increase family tensions. It is possible that such tensions offset the effect of supportive services. The present data suggest that, so far as concerns mothers, this may be true for female as well as male patients. Sisters, furthermore,
LEO MILLER
by providing a more manageable relationship, may possibly neutralize the effect of these tensions for patients of either sex. The present data further emphasize the possible significance, not only of the sister role as such, but of a "peering" effect in relation to age difference between sister and patient. The smaller this difference, the more effective does this role appear to be. Further investigation is needed, not only of this effect, but also of the roles played by other members in maintaining the equilibrium of the family system under conditions of stress. In this connection reference is made to the possible roles of unemployed mothers and children, as noted above in relation to female patients. In the previously cited study, Cumming and Cumming (1965) found that failure of male schizophrenic patients to visit regularly with female kin other than the mother after discharge from hospital was associated with stigma. The present results support their findings. They are also consistent with studies of kinship patterns in America, which have indicated that the sibling bond, usually mediated through women, may be an important source of support to the individual (Cumming & Schneider, 1961). The tenacity of the sibling relationship among older people in certain marital statuses and social situations, as well as the general predominance of women in kinship affairs, has also been noted by Townsend (1957). Various limitations and possible sources of error, of course, exist in relation to the interpretation of the data. It was assumed throughout that interaction is the variable intervening between family structure and length of onset. The findings, however, may also reflect differences in socialization patterns. Sex and age composition, as well as the size, of a patient's sibship must have important consequences for the development of personality. Some of these consequences have been noted by Brim (1962). Another possibility is that differences in delay of hospitalization after the appearance of symptoms are associated with differences in the symptomatology itself, or with the process of hospitalization, as noted above
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in connection with the Veterans Administration hospital. It is, of course, possible that some proportion of the variance that we have attributed to system processes may be accounted for by these factors. We do not know, furthermore, to what extent the interaction factor is itself dependent upon the illness of the patient. For example, it is possible that dependence on the mother is greater among daughters susceptible to illness than among others. If so, susceptible daughters may avoid physical separation from their mothers to a greater extent than would be true of other daughters. Further investigation is needed in regard to all of these factors. This study has emphasized the roles of various family members in connection with the retention of the mental patient in the community. It has been suggested that the roles of these members serve to fulfill func. tions required for the maintenance of the family system. The present data serve also to stress the special pertinence of the family as a system of action for the social control of deviance. REFERENCES BALES, R. F., & BORGATTA,E. F. Size of group as a factor in the interaction profile. In A. P. Hare, E. F. Borgatta, & R. F. Bales (Eds.), Smallgroups, studies in social interaction. New York: Alfred A. Knopf, 1965. Pp. 495-512. Bm~, O. G. Family structure and sex role learning by children: a further analysis of Helen Koch's data. In R. F. Winch, R. McGinnis, & H. R. Barringer (Eds.), Selected studies ia marriage and the family. New York: Holt, Rinehart, & Winston, 1962. Pp. 275-290. BROWN, G. W. Experiences of discharged chronic schizophrenic patients in various types of living groups. Milbank Memorial Fund Quart., 1959, 37, 105-131. CUMMING, ELAINE, & SCHNEIDER, D. M. Sibling solidarity: a property of American kinship. Amer. Anthropologist, 1961, 63, 498-507. CUMMINr J. H. The family and mental disorder: an incomplete essay. Milbank Memorial Fund Quart., 1961, 34, 185-212. CUMMINr J. H. The inadequacy syndrome. Psychiat. Quart., 1963, 37, 723-733. CUMMING,J. H., & CUMMING,ELAINE.On the stigma of mental illness. Commua. meat. Hlth J., 1965, 1, 135-143. CU~mNG, J. H., & Miller, L. Isolation, family structure, and schizophrenia. In Proceedings of the Third World Congress of Psychiatry. Toronto: Univ. of Toronto Press, 1961. Pp. 874-878.
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FREEMAN, H. E., & SIMMONS,O. G. The mental patient comes home. New York: John Wiley & Sons, 1963. MILLER, L. Some social factors associated with hospitalization for schizophrenia. Unpublished doctoral dissertation, Syracuse Univ., 1964. PARSONS,T., & BALES, R. F. Family, socialization and interaction process. Glencoe, IlL: The Free Press, 1955. SPIEGEL, J. P., & BELL, N. W. The family of the
psychiatric patient. In S. Arieti (Ed.), American handbook ofpsychlatry. New York: Basic Books, 1959. Pp. 114-149. TEELE, J. E. Suicidal behavior, assaultiveness, and socialization principles. Soc. Forces, 1965, 43, 510-518. TOWNSEND,P. The family life of old people. London: Routledge & Kegan Paul, 1957. YOUNG,M., & WILLMOTT,P. Family and kinship in East London. Glencoe, Ill.: The Free Press, 1957.
