The classless turmoil Cental health workers seem to assume that a middle class family with an ill member is better able to cope in a crisis than the 'disadvantaged problem families' that need much
?f to
their attention. The mother of a schizophrenic expose the fallacy of this assumption.
How
arc
you
friend on the a middle-class mother faced
coping?' inquires
te|ephone, speaking
to a
with the problem of Robert, ln
the house
her
thirty year-old
son,
third relapse of schizophrenia. is something which sounds ^assuring?laconic but brave?'We manage' or well'. In fact she may be in such a c?nfused turmoil of mind, with her judgement and Values so upset, that it would be more truthful to say, *t is hell and we are all in it.' Another mother in the same position said, 'Schizophrenia is infectious'. She was not being unscientific she meant that this disease, with all its attendant Uncertainties of diagnosis, anxieties over treatment and the impact of one divided personality on a family, a trail of alarm, despondency and confusion Which inevitably affected everyone concerned. Every family responsible for the welfare of a member faces tremendous problems. is assumed that a middle-class family commonly ls better equipped to meet them. In fact, in some Aspects, such families may be at a disadvantage. This
suffering a answer expected
Reasonably
^chizophrenic
son
draws
on
her
own
bitter experience
is bccause many workers in the mental health service to find more difficulty in helping them. It is supposed that financial resources, superior education and general know-how of middle-class families will see them through. Social workers seem to feel inhibited in their approach by such assumptions. In fact the need for guidance and advice is universal. The practical issues and decisions to be taken are the same whatever the social status of the family affected. The initial problem lies with the family, the family doctor, and his patient. The patient (the schizophrenic) must be persuaded either to visit the doctor or see him at home. Tension and stress within the family will arise over securing this first step, and time may elapse. Family doctors are not always at their best in these cases. In one such situation the doctor came to the house, had a talk with Robert and then told his parents, 'Well?from what I remember of the little training I had in psychiatric medicine, he is suffering from schizophrenia.' He left after prescribing a sedative, unable or unwilling to answer all the questions that seem
43
appreciate the shock a working class family, he would surely not have denigrated his own knowledge, and at least have attempted to be authoritative and give some guidance to the parents. In another case where the diagnosis had been made earlier, the GP listened sympathetically to the parents' very explicit account (too explicit for his liking) of how their son was behaving and then asked came
to
mind,
not
appearing
to
he had administered. Had it been
him. 'What can be done for him?' asked his parents. 'We feel he should be in hospital.' 'He has agreed to see me weekly,' said the doctor. 'He says he does not want to go into hospital. And I don't feel he is ill enough for me to sign a compulsory order.' During this period Robert made frequent visits to the doctor, and his behaviour at home became increasingly disturbed. Although he refused the tranquilising drugs the doctor offered, he used his social and intellectual resources to persuade the doctor against taking any further action. In the meanwhile he seemed to his parents to be rapidly, and seriously, affected by the progress of the disease. The evidence was all too apparent to the parents, but it was many weeks before the doctor would accept it. The parents were witnessing their son hurl objects from a window, climb high up builder's scaffolding, and have two bad car crashes from crazy driving. They swept up some hundred half-smoked cigarettes which smouldered under his bed, saw him strike innumerable matches against walls in the street, and pay for everything with pound notes without taking change. He would be in bed weeping by day, and walk about the house all night. If Robert had been a member of a working class family the doctor would surely have mentioned the mental health service of the local authority; and, at least, told the parents that they could request a visit from a mental health officer or a psychiatric social worker. Possibly he felt such a suggestion would be unwelcome to middle-class people. He did not suggest any method of obtaining specialist opinion. It was many weeks before he persuaded Robert to see a second doctor, so that the necessary two signatures could be secured for a compulsory order. By this time the situation was so bad that the emergency regulations, by which a certificate can be signed by only one doctor, could have been invoked. But at the time his parents did not know of its existence. It seems that some doctors assume (falsely) that middle-class, professional people can be relied upon to 'know the ropes' and to act intelligently. In fact, under the general strain and a concern not to advertise the fact of schizophrenia in the house, they live in the to see
same
bewildered
turmoil
as
anyone
else.
Taking the situation one stage further, when finally 'a compulsory order committing Robert to hospital was signed by two doctors, it was then given to his parents and they had to make contact with the mental welfare officer. They found the order very uninforma-
tive. It did not state for how long it was valid, or anything about the legal rights of the patient, or how long he was to be detained. The parents subsequently learnt that it was very unusual for the document to be placed in their hands at all. They now had the order and the telephone number of the mental welfare department, but Robert had left home and was wandering from place to place in a manner characteristic of schizophrenia. When his parents were finally able to locate him (a task with which they received no help from the authorities) it was their responsibility to mobilise the services of the mental health department. In the case of a patient who has money and is moving from one authority s area to another, this is not easy. On another occasion when Robert remained at home after a compulsory order had been issued, the situation illustrated the uncertainties of the mental health services in dealing with a middle-class homeWhat the parents needed was authoritative, reassuring action from someone in no way emotionally involvedBut the mental welfare officer, observing the apparent calm and order of the home, the outward display control on the parents' part, adopted a wavering and deferential attitude. He seemed at one point to be falling in with Robert's view that the whole proceedings might be postponed for a few days. WheA Robert had been taken to asked the
?j
officer,
'has
our
hospital, 'Why', department not been helping y?u problem?' Why indeed? Perhaps
before with this some of the answers have been presented above. What are the special problems for middle-claf lS parents when the patient dependant on them discharged from hospital? It is likely that the patient' partly because of this parental support, may be giyerl extended leave after a short period in hospital even 3 though the original compulsory order may run f?r rna> The consultant psychiatrist concerned year. recommend that leave should be spent away fr0lTl Th home and that he should find himself a
job.
parents have a sense of responsibility to him, a t room and can find money for his support. Indeed, patient may have money of his own, in which case n is not eligible for national assistance. Should they help him socially and financially to find a job? Or ar they better advised to stand aside? It is well known that schizophrenics find it e* tremely difficult to cope with the organisation of the lives and the necessary form-filling, interview'
spa^
44
A
of references, tax claims and insurance questions?in fact all the practical problems of rehabilitation. Should the parents help? It seems doubtful whether the social workers have the time for these problems or perhaps it is thought that, in the case of the intelligent and well-educated minority, there should be no difficulty. The Industrial Rehabilitation Units are not of much use to patients with high intelligence, who have had a good education but failed to obtain normal qualifications. There are others, of course, suitably qualified but incapable of pursuing the career for which they are trained. A Disablement Resettlement Officer has particular difficulties with these cases. There seems to be a high incidence of schizo-
obtaining
the young of high intelligence. They may be capable of routine clerical work but, even if they obtain a job, they will not keep it for long. Their intellectual abilities, although clouded by their illness, have not vanished and they are easily bored to the Point of abandoning such work. If schizophrenia has heen the cause of an individual's 'drop out', he may have an in-built resistance to any type of re-training.
phrenia amongst
If rehabilitation presents special problems so does continuity of medical care. Professional families are likely to be mobile. Their members may have attended universities, or worked in jobs all over the country, so that, where there have been recurrent Stacks, a young schizophrenic may have been in four different hospitals in ten years. There are vagrants of aU classes, but living away from home in independence is both financially possible for middle-class
young people and, indeed, encouraged by parents as a sign of initiative. Mental hopsitals tend to admit only, with a view in the average case. improving continuity of care ^uch a policy is clearly against the interests of v'agrant or migrant schizophrenics. There have been
Patients from their catchment
areas
to
instances, in which Robert, having spent a period in hospital, was refused subsequent
j^nhappy helPful
because he was living in another area, found that the hospital was unable to Supply records of his case. The Department of Health admits there are weaknesses in the mental health services. Time may cure these. But can families help themselves? Only if formation is much more easily obtainable than it appears to be at present. They will have to come out ln the that open with their problems and anything SllH remains of the old conspiracy of silence about a patient in their midst must go. Not only onld the individual family face this as a common Problem in which they are all involved, but groups each other mutual support also families
readmission, and it
was
Rental
giving
c?uld be formed.
?f to
their attention. The mother of a schizophrenic expose the fallacy of this assumption.
How
arc
you
friend on the a middle-class mother faced
coping?' inquires
te|ephone, speaking
to a
with the problem of Robert, ln
the house
her
thirty year-old
son,
third relapse of schizophrenia. is something which sounds ^assuring?laconic but brave?'We manage' or well'. In fact she may be in such a c?nfused turmoil of mind, with her judgement and Values so upset, that it would be more truthful to say, *t is hell and we are all in it.' Another mother in the same position said, 'Schizophrenia is infectious'. She was not being unscientific she meant that this disease, with all its attendant Uncertainties of diagnosis, anxieties over treatment and the impact of one divided personality on a family, a trail of alarm, despondency and confusion Which inevitably affected everyone concerned. Every family responsible for the welfare of a member faces tremendous problems. is assumed that a middle-class family commonly ls better equipped to meet them. In fact, in some Aspects, such families may be at a disadvantage. This
suffering a answer expected
Reasonably
^chizophrenic
son
draws
on
her
own
bitter experience
is bccause many workers in the mental health service to find more difficulty in helping them. It is supposed that financial resources, superior education and general know-how of middle-class families will see them through. Social workers seem to feel inhibited in their approach by such assumptions. In fact the need for guidance and advice is universal. The practical issues and decisions to be taken are the same whatever the social status of the family affected. The initial problem lies with the family, the family doctor, and his patient. The patient (the schizophrenic) must be persuaded either to visit the doctor or see him at home. Tension and stress within the family will arise over securing this first step, and time may elapse. Family doctors are not always at their best in these cases. In one such situation the doctor came to the house, had a talk with Robert and then told his parents, 'Well?from what I remember of the little training I had in psychiatric medicine, he is suffering from schizophrenia.' He left after prescribing a sedative, unable or unwilling to answer all the questions that seem
43
appreciate the shock a working class family, he would surely not have denigrated his own knowledge, and at least have attempted to be authoritative and give some guidance to the parents. In another case where the diagnosis had been made earlier, the GP listened sympathetically to the parents' very explicit account (too explicit for his liking) of how their son was behaving and then asked came
to
mind,
not
appearing
to
he had administered. Had it been
him. 'What can be done for him?' asked his parents. 'We feel he should be in hospital.' 'He has agreed to see me weekly,' said the doctor. 'He says he does not want to go into hospital. And I don't feel he is ill enough for me to sign a compulsory order.' During this period Robert made frequent visits to the doctor, and his behaviour at home became increasingly disturbed. Although he refused the tranquilising drugs the doctor offered, he used his social and intellectual resources to persuade the doctor against taking any further action. In the meanwhile he seemed to his parents to be rapidly, and seriously, affected by the progress of the disease. The evidence was all too apparent to the parents, but it was many weeks before the doctor would accept it. The parents were witnessing their son hurl objects from a window, climb high up builder's scaffolding, and have two bad car crashes from crazy driving. They swept up some hundred half-smoked cigarettes which smouldered under his bed, saw him strike innumerable matches against walls in the street, and pay for everything with pound notes without taking change. He would be in bed weeping by day, and walk about the house all night. If Robert had been a member of a working class family the doctor would surely have mentioned the mental health service of the local authority; and, at least, told the parents that they could request a visit from a mental health officer or a psychiatric social worker. Possibly he felt such a suggestion would be unwelcome to middle-class people. He did not suggest any method of obtaining specialist opinion. It was many weeks before he persuaded Robert to see a second doctor, so that the necessary two signatures could be secured for a compulsory order. By this time the situation was so bad that the emergency regulations, by which a certificate can be signed by only one doctor, could have been invoked. But at the time his parents did not know of its existence. It seems that some doctors assume (falsely) that middle-class, professional people can be relied upon to 'know the ropes' and to act intelligently. In fact, under the general strain and a concern not to advertise the fact of schizophrenia in the house, they live in the to see
same
bewildered
turmoil
as
anyone
else.
Taking the situation one stage further, when finally 'a compulsory order committing Robert to hospital was signed by two doctors, it was then given to his parents and they had to make contact with the mental welfare officer. They found the order very uninforma-
tive. It did not state for how long it was valid, or anything about the legal rights of the patient, or how long he was to be detained. The parents subsequently learnt that it was very unusual for the document to be placed in their hands at all. They now had the order and the telephone number of the mental welfare department, but Robert had left home and was wandering from place to place in a manner characteristic of schizophrenia. When his parents were finally able to locate him (a task with which they received no help from the authorities) it was their responsibility to mobilise the services of the mental health department. In the case of a patient who has money and is moving from one authority s area to another, this is not easy. On another occasion when Robert remained at home after a compulsory order had been issued, the situation illustrated the uncertainties of the mental health services in dealing with a middle-class homeWhat the parents needed was authoritative, reassuring action from someone in no way emotionally involvedBut the mental welfare officer, observing the apparent calm and order of the home, the outward display control on the parents' part, adopted a wavering and deferential attitude. He seemed at one point to be falling in with Robert's view that the whole proceedings might be postponed for a few days. WheA Robert had been taken to asked the
?j
officer,
'has
our
hospital, 'Why', department not been helping y?u problem?' Why indeed? Perhaps
before with this some of the answers have been presented above. What are the special problems for middle-claf lS parents when the patient dependant on them discharged from hospital? It is likely that the patient' partly because of this parental support, may be giyerl extended leave after a short period in hospital even 3 though the original compulsory order may run f?r rna> The consultant psychiatrist concerned year. recommend that leave should be spent away fr0lTl Th home and that he should find himself a
job.
parents have a sense of responsibility to him, a t room and can find money for his support. Indeed, patient may have money of his own, in which case n is not eligible for national assistance. Should they help him socially and financially to find a job? Or ar they better advised to stand aside? It is well known that schizophrenics find it e* tremely difficult to cope with the organisation of the lives and the necessary form-filling, interview'
spa^
44
A
of references, tax claims and insurance questions?in fact all the practical problems of rehabilitation. Should the parents help? It seems doubtful whether the social workers have the time for these problems or perhaps it is thought that, in the case of the intelligent and well-educated minority, there should be no difficulty. The Industrial Rehabilitation Units are not of much use to patients with high intelligence, who have had a good education but failed to obtain normal qualifications. There are others, of course, suitably qualified but incapable of pursuing the career for which they are trained. A Disablement Resettlement Officer has particular difficulties with these cases. There seems to be a high incidence of schizo-
obtaining
the young of high intelligence. They may be capable of routine clerical work but, even if they obtain a job, they will not keep it for long. Their intellectual abilities, although clouded by their illness, have not vanished and they are easily bored to the Point of abandoning such work. If schizophrenia has heen the cause of an individual's 'drop out', he may have an in-built resistance to any type of re-training.
phrenia amongst
If rehabilitation presents special problems so does continuity of medical care. Professional families are likely to be mobile. Their members may have attended universities, or worked in jobs all over the country, so that, where there have been recurrent Stacks, a young schizophrenic may have been in four different hospitals in ten years. There are vagrants of aU classes, but living away from home in independence is both financially possible for middle-class
young people and, indeed, encouraged by parents as a sign of initiative. Mental hopsitals tend to admit only, with a view in the average case. improving continuity of care ^uch a policy is clearly against the interests of v'agrant or migrant schizophrenics. There have been
Patients from their catchment
areas
to
instances, in which Robert, having spent a period in hospital, was refused subsequent
j^nhappy helPful
because he was living in another area, found that the hospital was unable to Supply records of his case. The Department of Health admits there are weaknesses in the mental health services. Time may cure these. But can families help themselves? Only if formation is much more easily obtainable than it appears to be at present. They will have to come out ln the that open with their problems and anything SllH remains of the old conspiracy of silence about a patient in their midst must go. Not only onld the individual family face this as a common Problem in which they are all involved, but groups each other mutual support also families
readmission, and it
was
Rental
giving
c?uld be formed.
