Home Visits in Child Psychiatry C a r m e l i t a R. Tobias, MD UniversiO' o f Lotdsville
A B S T R A C T : Written from the viewpoint of a Foreign Medical School Graduate, this paper
describes the use of psychiatric home visits in the Philippine Islands and the United States including a general explanation of the prevailing attitudes. Two case histories are u s e d to illustrate the value of h o m e visits in child psychiatry. A single home visit m a y be more revealing as to the cause of the pathology than n u m e r o u s clinic sessions. T h e paper concludes with a brief literature survey followed by a s u m m a r y discussion which p r e s e n t s the author's observations of personal gains derived from h o m e visits.
In my experience as an intern in a foreign setting, I responded to requests for house calls to handle the physical more than the psychiatric problems of patients. The social and family workups were usually done by social workers or public health paramedical workers. Although home visits were emphasized as ways for us to take care of people who could not come to the clinic, we used home visits strictly to treat the physically handicapped, bedridden, and those unable to travel. Therefore, during my internship, I did not experience going to a person's home, asking about their family background, and observing their way of living and interacting with each other.
Informal Survey Not content with my personal experience, I informally surveyed ten psychiatrists from my country. The information obtained revealed that the majority did not engage in psychiatric home visits during their training. Psychiatrists rarely made housecalls because of the scarcity of members of that specialty. For those who worked in the mental health system, which covers a large population located on several islands divided by the sea, Dr. Tobias is A s s i s t a n t Professor, D e p a r t m e n t of Psychiatry and Behavioral Sciences, School of Medicine, University of Louisville, Kentucky; a n d a M e m b e r of the Staff of the Veterans Administration Hospital, Louisville, Kentucky. R e q u e s t s for reprints should be directed to her. Child Psychiatry and Human Development, Vol. 10(2), Winter 1979
0009-398X/79/1600-0077$00.96 @1979Human Sciences Press
77
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home visits were not initiated until the 1960s. T h e y were made primarily during the period of psychiatric assessment and treatment as part of a follow-up scheme rather than for investigative purposes. House visits by a psychiatrist were usually made only for emergencies in which the physician might be n e e d e d to sedate a patient. Attitudes Toward House Visits In my native culture, doctors are so highly regarded by some that having them visit one's home is considered an honor, especially among those persons in the lower socioeconomic status. Prying into the lifestyle of a person and his or her family could be considered as an invasion of their privacy, for they are not accustomed to this mode of outreach. Most likely the physician conducting the house call would be inhibited because this technique has not been introduced during his training and is not congruent with how he sees his role as the medical " m a n . " In point of fact, because of the small size of the dwellings, it would not be difficult to observe the interaction of the families. A typical home for a lower socioeconomic class family has one or two rooms which serve as family room, bedroom, kitchen, and dining area. By contrast, home visits to a family in the upper socioeconomic class are difficult. There are still many inhibitions about giving information freely since their reputations might be jeopardized. In the United States, especially in my psychiatric residency, I discovered that home visitation was emphasized, encouraged, and enforced. In many evaluations and with perhaps a majority of t r e a t m e n t cases, home visits are considered to be a vital part of the helping process. As an FMG, I first reacted to the proposal of home visitation as if it posed a threatening invasion of the family's privacy. I discovered, as a happy surprise, that in the United States the family accepts the idea of the home visit with some enthusiasm.
Home Visits
This paper discusses the first two home visits I made. These were assigned tasks during my child psychiatry rotation. Working in a clinic where 40 percent of the patients were black children and 60 percent came from poverty-sticken families, my supervisor constantly emphasized the importance of home visits. Cases which present with a complaint of the child being hyperactive, showing narrowed attention span, and being out of control give a picture of multiple brain damage or of withdrawal, preoc-
Carme|ita R. Tobias
79
c u p a t i o n , a n d n o n - c o m m u n i c a t i o n . O n e m i g h t c o n c l u d e t h a t the child is autistic. A h o m e visit m a y e n l i g h t e n the p s y c h i a t r i s t as to why the child acts as he does b e c a u s e one m a y see a s i t u a t i o n c o n t r a r y to t h a t d e r i v e d from clinic visits. F a m i l y d y n a m i c s can b e u n d e r s t o o d m o r e readily by o b s e r v i n g them at home.
Case One
Cherri was an 11-year-old, white, female, in the sixth grade, referred to our clinic for emergency evaluation of her school phobia. Born to an unmarried woman, she had been raised in a fatherless household consisting of her mother, grandmother, and herself. The mother was a weJl-groomed, articulate woman who was phobic herself. The maternal grandmother had lived with the mother since the death of her husband which had occurred when Cherri's mother was 15 years old. Cherri and her mother were involved in simultaneous individual therapy and it was during the course of it that a home visit from the child's therapist was suggested. The idea was accepted and a date and time were arranged. The day of the home visit, Cherri became very anxious, experiencing a great deal of concern over the parking difficulties I might encounter. When I arrived, she was standing on the sidewalk, waving her hands and motioning me to a parking space she was guarding. Then she led me up the stairs to her apartment. Her family lived in a downtown area in the oldest section of the city and branded as being a "rough" neighborhood. They dwelt on the third floor of an old, walk-up apartment building. While I was catching my breath, her grandmother greeted me with a warm handshake and the female dog. introduced by Cherry as "Baby," was sniffing around me. At first I felt anxious since this was my first home visit. I did not know what to expect, especially since I had been welcomed by a stranger who might feel that I was "nosing" or spying. Except for the briefing I had read in the section about home visits in a primer [1] written by one of my supervisors, I had no formal information concerning home visits. Although my anxiety level was high, I was able to maintain my composure. This was important because I noticed that everyone else was relaxing too and everything began to be more spontaneous. Cherri informed me that this day was her grandmother's 70th birthday. I complimented her for looking younger and stronger than many 70-year olds. That innaugurated a pleasant conversation which lasted until Cherri's mother arrived. Sensing the relaxed atmosphere, the mother immediately joined us in the conversation about the grandmother and other family members. At that point, the grandmother showed me a picture of her sister celebrating her 25th wedding anniversary the preceding month and proceeded to tell me more about her family of origin. She gave me worthwhile information I had not been able to gather during the clinic evaluation. Cherri too was showing me her own pictures, together with those of her close friends whom she constantly mentioned in her sessions. Both friends were younger than she was. For the first time, Cherri's mother felt able to ask me about myself and my family which she said she had been wanting to do since we had first met. Then Cherri started to show me her toys--mainly dolls. The next extemporaneous thing that I did was to ask her to show me the place
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where she usually played. She took me to a small room near the stairway which held her collection of old and almost threadbare dolls. She also showed me her female bird and female rat. I noticed a prominent absence of any male figure in the whole menagerie. After spending some time playing with her, I asked her to show me her bedroom so that I could become thoroughly familiar with her environment. She took me to a small room in which she shared both room and bed with her mother. The room was too small for an additional bed. The whole room was in severe need of repair--the paint was peeling off the walls and there were holes and cracks in the windows. I now had a glimpse of the reason why, despite my encouragement that she sleep alone, she still slept with her mother. The limited space and the cold that came through the holes in the room were eloquent arguments against some of my "individuation" tactics. Cherri proceeded to give me a "tour" of the rest of the apartment. From that I got an idea of where and how the grandmother fitted into this three-generation household. She slept in a small room near Cherri's play area and occasionally Cherri would sleep with her. During this tour, the mother continually apologized because the house was not tidy. However, I explained that my purpose in coming was only to get a feeling for where and how they lived and to learn more about Cherri's interactions with them. I indicated that tidiness was not my concern. When we reached the kitchen, I noticed that the gas oven was on, being used as a source of heat. At that point, Cherri offered me a piece of the cake that she had baked for her grandmother's birthday. The four of us ate together at the kitchen table. The grandmother showed genuine and obvious pride as she told me that Cherri usually prepared their food because Cherri's mother did not know how to cook! Somewhat embarassed, the mother attempted to rationalize but the "put down" was clear. This trend in the conversation helped me to understand more fully the dynamics of the child's school phobia. Before I left, Cherri showed me the spacious yard in front of the house in which she sometimes played with her friends from across the street. She also pointed out her school a block away and showed me where her mother worked, two blocks away. The places where they all spent the day were so close to each other that it is small wonder that every time Cherri became panicky at school, they came to her "rescue" immediately. When it was time for me to go, her mother wanted to return to work so I offered to drive her, whereupon Cherri anxiously asked if she might ride with us. Driving along, we saw some of her friends and Cherri became very excited, calling and waving to them. T h i s case i l l u s t r a t e s a p o o r l y r e s o l v e d r e l a t i o n s h i p b e t w e e n the child a n d the m o t h e r a n d a s i m i l a r r e l a t i o n s h i p t h a t exists b e t w e e n the m o t h e r a n d the g r a n d m o t h e r . T h e child is p r e c l u d e d f r o m d i r e c t l y e x p r e s s i n g h e r hostile a n d aggressive feelings t o w a r d the m o t h e r which has led to the d e v e l o p m e n t of u n c o n s c i o u s , d e s t r u c t i v e t h i n k i n g a b o u t the m o t h e r as well as the d e v e l o p m e n t of fear for the m o t h e r ' s safety. T h e child also h a d a k e e n c o n f l i c t - i n s p i r e d s e n s e of h e r geographic o r i e n t a t i o n .
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Case Two Shawn was a seven-year-old, while, male, referred to our clinic for hyperactivity, poor academic performance, and lack of concentration. The initial contact revealed his preoccupation with the skeletal and visceral parts of his body. He showed evidence of neologism. His interpersonal relations were defective and his behavior was very inappropriate. He was diagnosed as borderline psychotic, was referred for individual psychotherapy, and received chemotherapy to which he showed some favorable response. Shawn was 20 months younger than his brother. There was a strong sibling rivalry; he always competed for his parent's attention. The mother was an obsessive woman who had been hospitalized one time for depression and anorexia and the father was a rigid man with a paranoid personality. The day of the first visit, the mother called me to tell me she was baking a cake in honor of the occasion. She also mentioned that Shawn had been looking forward to the visit. They lived in a two-story, brick house in an upper-class subdivision. Shawn, his brother, and two of the brother's friends greeted me as I approached the house. His brother immediately invited me to see his rabbit in the backyard but Shawn interrupted and asked me to see his Labrador first. Of course I went with Shawn for I had been forewarned against paying too much attention to his older, rival brother. The "two-month-old" puppy that he always mentioned in our sessions turned out to actually be a nine-month-old dog of average size. When his brother next asked me to see the model car that he had constructed, Shawn held my hands as he adamantly informed his brother, "She is m y guest." Apparently he felt important about my presence so I explained to the brother that I would have to see his model car later since I preferred to spend most of my time with Shawn during this visit. He understood and left to play with his friends outside. Shawn was obviously pleased with this turn of events. Luckily, his parents did not interfere because they had understood the purpose of this visit. Shawn showed me a place in the family room where he usually played with Lego blocks. He then took me to his upstairs bedroom and proudly showed me his drawings that he had made in school--the "slogans" on the table--the stuffed and mounted squirrels and another chest full of toys. The entire house was immaculate. He had a book rack filled mainly with story books and a copy of How Babies are Made. At his insistence, we spent time looking at that book--the visiting doctor hearing his notions and answering his questions. Later he opened his closet, stating boldly that he was no longer afraid of ghosts or skeletons being in there. This was a fear he had mentioned during the early part of therapy. We then proceeded to the basement where he showed me his shell collection and pointed out his brother's pile of car m o d e l s - - a t least a hundred boxes. At this point, Shawn appeared anxious; he indicated that he tended to avoid his brother's belongings. "These are his toys and he gets mad if I touch them." When it came time for coffee, the table was set for four which excluded his brother. I also noticed that Shawn's place mat was entirely different from the others. It was shaped and designed to look like a cat. Throughout the time, the mother constantly corrected Shawn. Later, she tended to dominate the conversation but I handled it by promising that I would set up a time for the parents in the clinic as I would like to spend the remaining time conversing with Shawn. I was well aware of parental complaints that Shawn acted like a three- or four-
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year-old child but now I saw how the family were contributing to his regression. treating him on an infantile level as if he were deficient and immature. When I was ready to leave, Shawn refused to let me go unless I promised to return which I promised to do. I felt I accomplished several things with this visit. First, it developed rapport and trust which had been difficult to establish with Shawn's parents. Second, I became a more authentic image for the entire family. Third, I felt more sensitive to the rigidity of Shawn's environment and I began to feel more secure about the conjectured dynamics of his symptoms.
Literature Review
T h e r e are few published reports of home visits in the child psychiatry literature. Prior to 1956 there was only one report of home visits as part of psychiatric practice [2]. In 1961, however, nine reports appeared and from 1961 to 1966 the n u m b e r doubled. In 1967, Freeman [3] reported that psychiatric home care programs for adults were established at several locations: Boston State Hospital Home T r e a t m e n t Service, the Reception Center in Philadelphia, a county emergency service in Maryland, the Cleveland program for hard-to-reach adults with character disorders and the San Mateo County, California program described by Deutsch and Deutsch. Freeman quotes a 1960 paper by Schwartz et al. which describes a U.C.L.A. Medical Center training program that utilized home visits. Adult patients considered for admission were evaluated by psychiatric residents in their homes. "It is our subjective impression that the home visits have amply justified the extra time required for them from a teaching point of view ''3. Freeman also listed some interesting indications and contraindications for home visits in child psychiatry. He opined that they are best suited for very young and immature children, highly anxious, distorted and unmanageable children, and those with multiple medical and surgical experience for examples. In 1962, Hospital Notre Dame in Montreal was given a grant for the establishment of a psychiatric home care service 4. "This service frequently provides a substitute for hospitalization in the management for both acute and chronic psychiatric states and thereby constitutes an important preventive measure in the field of public health. Even if the initial attitude of the patient is negative, it is possible to gain the cooperation of the family who became a useful ally in the treatment. The cooperation of the patient is not as essential as has been thought. The traditional role of the psychiatrist is reversed by virtue of his attending the patient at home. The active
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participation of social agencies is an integral part of the treatment" I4]. A further review of literature revealed that the first psychiatric home visits in Canada date back to 1958. N. Ronald Aldous ~ reported that the Psychiatric Home Care Service of Montreal General Hospital dealt with a large variety of psychiatric and social problems. He emphasized the involvement of the "adult" children of the patient. He explained the nature of their involvement as a more professional relationship which encouraged children to discuss their relationships with their parents thereby providing a better parent-child relationship. "We try to end each contact in an atmosphere of goodwill but with an absolute minimum of promise and specific arrangements, so that future contact will be as free as possible of feelings of shame and failure" [5]. Marjorie L. Behrens [5] reported successful results from brief home visits, especially in the treatment of lower-class clinic patients. Home visits improved patient-therapist relationships and frequently prevent the need for hospitalization. Bertram S. Brown [7] collected data from psychiatrists about their attitudes toward home visiting. He used the data to categorize the respondents as positive, intermediate, or negative. He also categorized psychitrists' attitudes by the type of practice they engaged in. His analysis revealed that the type of practice played an important role in influencing the attitude toward home visits. Working in black urban ghettos, Chappel and Daniels [8[ found more advantages than disadvantages in home visiting. They reported that it can be effective in bridging the isolation, alienation, and hopelessness found in many ghetto patients. It can enlist important treatment supports from family members and friends not usually encountered in clinic settings. It can be helpful in treating violent or paranoid patients and it also provides an effective non-verbal way of bridging social and cultural gaps which interfere with the development of a treatment relationship between patient and therapists. In cases where only one parent appears at the clinic, home visits offer a convenient way to meet the absent parent. Erik Erikson [9[ always had a meal with the family at their home before engaging in therapy. A good example of his approach to a regressed boy is reported in his book, Childhood and Society. He was able to understand the process of the boy's regression as he observed the child's interaction with his father, during a home visit. Conclusions
Home visits add a new dimension to evaluation and facilitate the establishment of the therapeutic alliance so vital to child psychiatry. They
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t a k e m o r e t i m e t h a n t r a d i t i o n a l office o r clinic m e e t i n g s b u t t h e w e a l t h o f i n f o r m a t i o n t h e y r e v e a l is w o r t h it. In o r d e r to u n d e r s t a n d a child, o n e m u s t l e a r n a b o u t his f a n t a s i e s a n d his milieu. L i k e w i s e , o n e m u s t u n d e r s t a n d his family. T o do this, one m u s t b e c o m e a p a r t i c i p a t i n g o b s e r v e r in t h e household. Visits s h o u l d b e p l a n n e d a n d d i s c u s s e d with t h e p a t i e n t a n d his f a m i l y a t the b e g i n n i n g of t h e r a p y a n d d e p i c t e d as a p a r t of it. O t h e r w i s e , t h e r e is no e s t a b l i s h e d , rigid t e c h n i q u e g o v e r n i n g t h e m . T h e i m p o r t a n t o b j e c t i v e is to p r o m o t e f l e x i b i l i t y a n d a feeling of e a s e l e s t t h e p s y c h i a t r i s t p r o j e c t his own e n x i e t i e s into t h e s i t u a t i o n . T h i s can o n l y b e a t t a i n e d with e x p e r i e n c e a n d c e r t a i n l y s h o u l d b e p a r t of p s y c h i a t r i c t r a i n i n g . I b e l i e v e t h a t f o r e i g n m e d i c a l g r a u d a t e s , in p a r t i c u l a r , c a n d e r i v e m a n y b e n e f i t s f r o m h o m e visits. T h e y give t h e F M G a q u i c k e r view of his p a t i e n t ' s i n t i m a t e s u b c u l t u r e a n d t h e n u m e r o u s b u t d i s t i n c t i v e v a l u e s a t t e n d a n t on h o m e life. T h e y also e n h a n c e t h e F M G ' s e n c u l t u r a t i o n i n t o p s y c h i a t r y as a s p e c i a l t y a n d into t h e U n i t e d S t a t e s as a citizen.
References
1. Adams PL: A Primer of Child Psychotherapy. Boston, Little, Brown, 1974. 2. Chappel JN, Daniels R: Home visiting in a black urban ghetto. Am Jr Psych I26:1455-60, April 1970. 3. Freeman RD: The home visit in child psychiatry; its usefulness in diagnosis and treatment. Jr Am Academy Child Psychiatry 6:276-293, April 1967. 4. Langevin H e t al.: A psychiatric home care program: a report based on three year experience (1962-64). Canada IVied Assoc Jr 94:650-655, March 26, 1966. 5. Aldous NR: The "adult" children of the patient and their invoh,ement in the psychiatric home care program. Laval Medical 38:131-136, January 1967. 6. Behrens MI: Brief home visits by the clinic therapist in the treatment of lower class patients. Am Jr Psych 124:371-375, September 1967. 7. Brown SB: Home visiting by psychiatrist. Arch of Gen Psy 7:98-107, 1962. 8. Chappel JN, Daniels R, et al.: Home visiting, an aid to psychiatric treatment in black urban ghetto. Current Psychiatric Therapies 122:194-201, 1972. 9. Erikson E: Childhood and Society. New York: Norton, 1964.
A B S T R A C T : Written from the viewpoint of a Foreign Medical School Graduate, this paper
describes the use of psychiatric home visits in the Philippine Islands and the United States including a general explanation of the prevailing attitudes. Two case histories are u s e d to illustrate the value of h o m e visits in child psychiatry. A single home visit m a y be more revealing as to the cause of the pathology than n u m e r o u s clinic sessions. T h e paper concludes with a brief literature survey followed by a s u m m a r y discussion which p r e s e n t s the author's observations of personal gains derived from h o m e visits.
In my experience as an intern in a foreign setting, I responded to requests for house calls to handle the physical more than the psychiatric problems of patients. The social and family workups were usually done by social workers or public health paramedical workers. Although home visits were emphasized as ways for us to take care of people who could not come to the clinic, we used home visits strictly to treat the physically handicapped, bedridden, and those unable to travel. Therefore, during my internship, I did not experience going to a person's home, asking about their family background, and observing their way of living and interacting with each other.
Informal Survey Not content with my personal experience, I informally surveyed ten psychiatrists from my country. The information obtained revealed that the majority did not engage in psychiatric home visits during their training. Psychiatrists rarely made housecalls because of the scarcity of members of that specialty. For those who worked in the mental health system, which covers a large population located on several islands divided by the sea, Dr. Tobias is A s s i s t a n t Professor, D e p a r t m e n t of Psychiatry and Behavioral Sciences, School of Medicine, University of Louisville, Kentucky; a n d a M e m b e r of the Staff of the Veterans Administration Hospital, Louisville, Kentucky. R e q u e s t s for reprints should be directed to her. Child Psychiatry and Human Development, Vol. 10(2), Winter 1979
0009-398X/79/1600-0077$00.96 @1979Human Sciences Press
77
78
Child Psychiatry and Human Development
home visits were not initiated until the 1960s. T h e y were made primarily during the period of psychiatric assessment and treatment as part of a follow-up scheme rather than for investigative purposes. House visits by a psychiatrist were usually made only for emergencies in which the physician might be n e e d e d to sedate a patient. Attitudes Toward House Visits In my native culture, doctors are so highly regarded by some that having them visit one's home is considered an honor, especially among those persons in the lower socioeconomic status. Prying into the lifestyle of a person and his or her family could be considered as an invasion of their privacy, for they are not accustomed to this mode of outreach. Most likely the physician conducting the house call would be inhibited because this technique has not been introduced during his training and is not congruent with how he sees his role as the medical " m a n . " In point of fact, because of the small size of the dwellings, it would not be difficult to observe the interaction of the families. A typical home for a lower socioeconomic class family has one or two rooms which serve as family room, bedroom, kitchen, and dining area. By contrast, home visits to a family in the upper socioeconomic class are difficult. There are still many inhibitions about giving information freely since their reputations might be jeopardized. In the United States, especially in my psychiatric residency, I discovered that home visitation was emphasized, encouraged, and enforced. In many evaluations and with perhaps a majority of t r e a t m e n t cases, home visits are considered to be a vital part of the helping process. As an FMG, I first reacted to the proposal of home visitation as if it posed a threatening invasion of the family's privacy. I discovered, as a happy surprise, that in the United States the family accepts the idea of the home visit with some enthusiasm.
Home Visits
This paper discusses the first two home visits I made. These were assigned tasks during my child psychiatry rotation. Working in a clinic where 40 percent of the patients were black children and 60 percent came from poverty-sticken families, my supervisor constantly emphasized the importance of home visits. Cases which present with a complaint of the child being hyperactive, showing narrowed attention span, and being out of control give a picture of multiple brain damage or of withdrawal, preoc-
Carme|ita R. Tobias
79
c u p a t i o n , a n d n o n - c o m m u n i c a t i o n . O n e m i g h t c o n c l u d e t h a t the child is autistic. A h o m e visit m a y e n l i g h t e n the p s y c h i a t r i s t as to why the child acts as he does b e c a u s e one m a y see a s i t u a t i o n c o n t r a r y to t h a t d e r i v e d from clinic visits. F a m i l y d y n a m i c s can b e u n d e r s t o o d m o r e readily by o b s e r v i n g them at home.
Case One
Cherri was an 11-year-old, white, female, in the sixth grade, referred to our clinic for emergency evaluation of her school phobia. Born to an unmarried woman, she had been raised in a fatherless household consisting of her mother, grandmother, and herself. The mother was a weJl-groomed, articulate woman who was phobic herself. The maternal grandmother had lived with the mother since the death of her husband which had occurred when Cherri's mother was 15 years old. Cherri and her mother were involved in simultaneous individual therapy and it was during the course of it that a home visit from the child's therapist was suggested. The idea was accepted and a date and time were arranged. The day of the home visit, Cherri became very anxious, experiencing a great deal of concern over the parking difficulties I might encounter. When I arrived, she was standing on the sidewalk, waving her hands and motioning me to a parking space she was guarding. Then she led me up the stairs to her apartment. Her family lived in a downtown area in the oldest section of the city and branded as being a "rough" neighborhood. They dwelt on the third floor of an old, walk-up apartment building. While I was catching my breath, her grandmother greeted me with a warm handshake and the female dog. introduced by Cherry as "Baby," was sniffing around me. At first I felt anxious since this was my first home visit. I did not know what to expect, especially since I had been welcomed by a stranger who might feel that I was "nosing" or spying. Except for the briefing I had read in the section about home visits in a primer [1] written by one of my supervisors, I had no formal information concerning home visits. Although my anxiety level was high, I was able to maintain my composure. This was important because I noticed that everyone else was relaxing too and everything began to be more spontaneous. Cherri informed me that this day was her grandmother's 70th birthday. I complimented her for looking younger and stronger than many 70-year olds. That innaugurated a pleasant conversation which lasted until Cherri's mother arrived. Sensing the relaxed atmosphere, the mother immediately joined us in the conversation about the grandmother and other family members. At that point, the grandmother showed me a picture of her sister celebrating her 25th wedding anniversary the preceding month and proceeded to tell me more about her family of origin. She gave me worthwhile information I had not been able to gather during the clinic evaluation. Cherri too was showing me her own pictures, together with those of her close friends whom she constantly mentioned in her sessions. Both friends were younger than she was. For the first time, Cherri's mother felt able to ask me about myself and my family which she said she had been wanting to do since we had first met. Then Cherri started to show me her toys--mainly dolls. The next extemporaneous thing that I did was to ask her to show me the place
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where she usually played. She took me to a small room near the stairway which held her collection of old and almost threadbare dolls. She also showed me her female bird and female rat. I noticed a prominent absence of any male figure in the whole menagerie. After spending some time playing with her, I asked her to show me her bedroom so that I could become thoroughly familiar with her environment. She took me to a small room in which she shared both room and bed with her mother. The room was too small for an additional bed. The whole room was in severe need of repair--the paint was peeling off the walls and there were holes and cracks in the windows. I now had a glimpse of the reason why, despite my encouragement that she sleep alone, she still slept with her mother. The limited space and the cold that came through the holes in the room were eloquent arguments against some of my "individuation" tactics. Cherri proceeded to give me a "tour" of the rest of the apartment. From that I got an idea of where and how the grandmother fitted into this three-generation household. She slept in a small room near Cherri's play area and occasionally Cherri would sleep with her. During this tour, the mother continually apologized because the house was not tidy. However, I explained that my purpose in coming was only to get a feeling for where and how they lived and to learn more about Cherri's interactions with them. I indicated that tidiness was not my concern. When we reached the kitchen, I noticed that the gas oven was on, being used as a source of heat. At that point, Cherri offered me a piece of the cake that she had baked for her grandmother's birthday. The four of us ate together at the kitchen table. The grandmother showed genuine and obvious pride as she told me that Cherri usually prepared their food because Cherri's mother did not know how to cook! Somewhat embarassed, the mother attempted to rationalize but the "put down" was clear. This trend in the conversation helped me to understand more fully the dynamics of the child's school phobia. Before I left, Cherri showed me the spacious yard in front of the house in which she sometimes played with her friends from across the street. She also pointed out her school a block away and showed me where her mother worked, two blocks away. The places where they all spent the day were so close to each other that it is small wonder that every time Cherri became panicky at school, they came to her "rescue" immediately. When it was time for me to go, her mother wanted to return to work so I offered to drive her, whereupon Cherri anxiously asked if she might ride with us. Driving along, we saw some of her friends and Cherri became very excited, calling and waving to them. T h i s case i l l u s t r a t e s a p o o r l y r e s o l v e d r e l a t i o n s h i p b e t w e e n the child a n d the m o t h e r a n d a s i m i l a r r e l a t i o n s h i p t h a t exists b e t w e e n the m o t h e r a n d the g r a n d m o t h e r . T h e child is p r e c l u d e d f r o m d i r e c t l y e x p r e s s i n g h e r hostile a n d aggressive feelings t o w a r d the m o t h e r which has led to the d e v e l o p m e n t of u n c o n s c i o u s , d e s t r u c t i v e t h i n k i n g a b o u t the m o t h e r as well as the d e v e l o p m e n t of fear for the m o t h e r ' s safety. T h e child also h a d a k e e n c o n f l i c t - i n s p i r e d s e n s e of h e r geographic o r i e n t a t i o n .
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Case Two Shawn was a seven-year-old, while, male, referred to our clinic for hyperactivity, poor academic performance, and lack of concentration. The initial contact revealed his preoccupation with the skeletal and visceral parts of his body. He showed evidence of neologism. His interpersonal relations were defective and his behavior was very inappropriate. He was diagnosed as borderline psychotic, was referred for individual psychotherapy, and received chemotherapy to which he showed some favorable response. Shawn was 20 months younger than his brother. There was a strong sibling rivalry; he always competed for his parent's attention. The mother was an obsessive woman who had been hospitalized one time for depression and anorexia and the father was a rigid man with a paranoid personality. The day of the first visit, the mother called me to tell me she was baking a cake in honor of the occasion. She also mentioned that Shawn had been looking forward to the visit. They lived in a two-story, brick house in an upper-class subdivision. Shawn, his brother, and two of the brother's friends greeted me as I approached the house. His brother immediately invited me to see his rabbit in the backyard but Shawn interrupted and asked me to see his Labrador first. Of course I went with Shawn for I had been forewarned against paying too much attention to his older, rival brother. The "two-month-old" puppy that he always mentioned in our sessions turned out to actually be a nine-month-old dog of average size. When his brother next asked me to see the model car that he had constructed, Shawn held my hands as he adamantly informed his brother, "She is m y guest." Apparently he felt important about my presence so I explained to the brother that I would have to see his model car later since I preferred to spend most of my time with Shawn during this visit. He understood and left to play with his friends outside. Shawn was obviously pleased with this turn of events. Luckily, his parents did not interfere because they had understood the purpose of this visit. Shawn showed me a place in the family room where he usually played with Lego blocks. He then took me to his upstairs bedroom and proudly showed me his drawings that he had made in school--the "slogans" on the table--the stuffed and mounted squirrels and another chest full of toys. The entire house was immaculate. He had a book rack filled mainly with story books and a copy of How Babies are Made. At his insistence, we spent time looking at that book--the visiting doctor hearing his notions and answering his questions. Later he opened his closet, stating boldly that he was no longer afraid of ghosts or skeletons being in there. This was a fear he had mentioned during the early part of therapy. We then proceeded to the basement where he showed me his shell collection and pointed out his brother's pile of car m o d e l s - - a t least a hundred boxes. At this point, Shawn appeared anxious; he indicated that he tended to avoid his brother's belongings. "These are his toys and he gets mad if I touch them." When it came time for coffee, the table was set for four which excluded his brother. I also noticed that Shawn's place mat was entirely different from the others. It was shaped and designed to look like a cat. Throughout the time, the mother constantly corrected Shawn. Later, she tended to dominate the conversation but I handled it by promising that I would set up a time for the parents in the clinic as I would like to spend the remaining time conversing with Shawn. I was well aware of parental complaints that Shawn acted like a three- or four-
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year-old child but now I saw how the family were contributing to his regression. treating him on an infantile level as if he were deficient and immature. When I was ready to leave, Shawn refused to let me go unless I promised to return which I promised to do. I felt I accomplished several things with this visit. First, it developed rapport and trust which had been difficult to establish with Shawn's parents. Second, I became a more authentic image for the entire family. Third, I felt more sensitive to the rigidity of Shawn's environment and I began to feel more secure about the conjectured dynamics of his symptoms.
Literature Review
T h e r e are few published reports of home visits in the child psychiatry literature. Prior to 1956 there was only one report of home visits as part of psychiatric practice [2]. In 1961, however, nine reports appeared and from 1961 to 1966 the n u m b e r doubled. In 1967, Freeman [3] reported that psychiatric home care programs for adults were established at several locations: Boston State Hospital Home T r e a t m e n t Service, the Reception Center in Philadelphia, a county emergency service in Maryland, the Cleveland program for hard-to-reach adults with character disorders and the San Mateo County, California program described by Deutsch and Deutsch. Freeman quotes a 1960 paper by Schwartz et al. which describes a U.C.L.A. Medical Center training program that utilized home visits. Adult patients considered for admission were evaluated by psychiatric residents in their homes. "It is our subjective impression that the home visits have amply justified the extra time required for them from a teaching point of view ''3. Freeman also listed some interesting indications and contraindications for home visits in child psychiatry. He opined that they are best suited for very young and immature children, highly anxious, distorted and unmanageable children, and those with multiple medical and surgical experience for examples. In 1962, Hospital Notre Dame in Montreal was given a grant for the establishment of a psychiatric home care service 4. "This service frequently provides a substitute for hospitalization in the management for both acute and chronic psychiatric states and thereby constitutes an important preventive measure in the field of public health. Even if the initial attitude of the patient is negative, it is possible to gain the cooperation of the family who became a useful ally in the treatment. The cooperation of the patient is not as essential as has been thought. The traditional role of the psychiatrist is reversed by virtue of his attending the patient at home. The active
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participation of social agencies is an integral part of the treatment" I4]. A further review of literature revealed that the first psychiatric home visits in Canada date back to 1958. N. Ronald Aldous ~ reported that the Psychiatric Home Care Service of Montreal General Hospital dealt with a large variety of psychiatric and social problems. He emphasized the involvement of the "adult" children of the patient. He explained the nature of their involvement as a more professional relationship which encouraged children to discuss their relationships with their parents thereby providing a better parent-child relationship. "We try to end each contact in an atmosphere of goodwill but with an absolute minimum of promise and specific arrangements, so that future contact will be as free as possible of feelings of shame and failure" [5]. Marjorie L. Behrens [5] reported successful results from brief home visits, especially in the treatment of lower-class clinic patients. Home visits improved patient-therapist relationships and frequently prevent the need for hospitalization. Bertram S. Brown [7] collected data from psychiatrists about their attitudes toward home visiting. He used the data to categorize the respondents as positive, intermediate, or negative. He also categorized psychitrists' attitudes by the type of practice they engaged in. His analysis revealed that the type of practice played an important role in influencing the attitude toward home visits. Working in black urban ghettos, Chappel and Daniels [8[ found more advantages than disadvantages in home visiting. They reported that it can be effective in bridging the isolation, alienation, and hopelessness found in many ghetto patients. It can enlist important treatment supports from family members and friends not usually encountered in clinic settings. It can be helpful in treating violent or paranoid patients and it also provides an effective non-verbal way of bridging social and cultural gaps which interfere with the development of a treatment relationship between patient and therapists. In cases where only one parent appears at the clinic, home visits offer a convenient way to meet the absent parent. Erik Erikson [9[ always had a meal with the family at their home before engaging in therapy. A good example of his approach to a regressed boy is reported in his book, Childhood and Society. He was able to understand the process of the boy's regression as he observed the child's interaction with his father, during a home visit. Conclusions
Home visits add a new dimension to evaluation and facilitate the establishment of the therapeutic alliance so vital to child psychiatry. They
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t a k e m o r e t i m e t h a n t r a d i t i o n a l office o r clinic m e e t i n g s b u t t h e w e a l t h o f i n f o r m a t i o n t h e y r e v e a l is w o r t h it. In o r d e r to u n d e r s t a n d a child, o n e m u s t l e a r n a b o u t his f a n t a s i e s a n d his milieu. L i k e w i s e , o n e m u s t u n d e r s t a n d his family. T o do this, one m u s t b e c o m e a p a r t i c i p a t i n g o b s e r v e r in t h e household. Visits s h o u l d b e p l a n n e d a n d d i s c u s s e d with t h e p a t i e n t a n d his f a m i l y a t the b e g i n n i n g of t h e r a p y a n d d e p i c t e d as a p a r t of it. O t h e r w i s e , t h e r e is no e s t a b l i s h e d , rigid t e c h n i q u e g o v e r n i n g t h e m . T h e i m p o r t a n t o b j e c t i v e is to p r o m o t e f l e x i b i l i t y a n d a feeling of e a s e l e s t t h e p s y c h i a t r i s t p r o j e c t his own e n x i e t i e s into t h e s i t u a t i o n . T h i s can o n l y b e a t t a i n e d with e x p e r i e n c e a n d c e r t a i n l y s h o u l d b e p a r t of p s y c h i a t r i c t r a i n i n g . I b e l i e v e t h a t f o r e i g n m e d i c a l g r a u d a t e s , in p a r t i c u l a r , c a n d e r i v e m a n y b e n e f i t s f r o m h o m e visits. T h e y give t h e F M G a q u i c k e r view of his p a t i e n t ' s i n t i m a t e s u b c u l t u r e a n d t h e n u m e r o u s b u t d i s t i n c t i v e v a l u e s a t t e n d a n t on h o m e life. T h e y also e n h a n c e t h e F M G ' s e n c u l t u r a t i o n i n t o p s y c h i a t r y as a s p e c i a l t y a n d into t h e U n i t e d S t a t e s as a citizen.
References
1. Adams PL: A Primer of Child Psychotherapy. Boston, Little, Brown, 1974. 2. Chappel JN, Daniels R: Home visiting in a black urban ghetto. Am Jr Psych I26:1455-60, April 1970. 3. Freeman RD: The home visit in child psychiatry; its usefulness in diagnosis and treatment. Jr Am Academy Child Psychiatry 6:276-293, April 1967. 4. Langevin H e t al.: A psychiatric home care program: a report based on three year experience (1962-64). Canada IVied Assoc Jr 94:650-655, March 26, 1966. 5. Aldous NR: The "adult" children of the patient and their invoh,ement in the psychiatric home care program. Laval Medical 38:131-136, January 1967. 6. Behrens MI: Brief home visits by the clinic therapist in the treatment of lower class patients. Am Jr Psych 124:371-375, September 1967. 7. Brown SB: Home visiting by psychiatrist. Arch of Gen Psy 7:98-107, 1962. 8. Chappel JN, Daniels R, et al.: Home visiting, an aid to psychiatric treatment in black urban ghetto. Current Psychiatric Therapies 122:194-201, 1972. 9. Erikson E: Childhood and Society. New York: Norton, 1964.
