Acta psychiat. scand. (1978) 58, 97-1 11 WHO Collaborating Centre for Research and Training in Mental Health (Head: C. A. Ledn), Cali, Colombia, and Battelle Human Affairs Research Centers (Head: J . E. Rasmussen), Seattle, Washington, USA

Who shall be hospitalized? Some social and psychological correlates of alternative dispositions of the mentally ill C. A. L E ~ N AND M. MICKLIN This study conducted in Cali, Colombia, focuses on the question of why persons sharing similar background characteristics and even the same diagnosis often receive varying prescriptive evaluations which lead to alternative types of psychiatric care: hospitalization, outpatient care and no systematic treatment at all. An index group of 70 hospitalized patients is compared with 53 outpatients and 30 “nonpatients” matched for sex, age, marital status, social class and diagnosis. Interviews were conducted with patients, relatives and tho admitting doctors. A selected group of variables representing perceptions, opinions and attitudes of the relatives, subjective evaluations of the patients and perceptions of the admitting physician are examined in terms of their association with the three types of care. It is concluded that interpersonal factors exert a significant influence on the process of assigning cases to alternative types of psychiatric care. Typical profiles for each category are outlined, Key words: Psychiatric hospitalization - interpersonal factors associated with hospitalization - “nonpatients”.

The present paper is the first report of a longitudinal study of factors associated with diverse types of entry into, experience with, and outcomes of a psychiatric care system. The study itself is part of a broader effort to provide a comprehensive picture of mental disorder and its treatment in Cali, a city of more than 1 million inhabitants located in southwestern Colombia. Previous work focused on diverse images of mental illness held by community members as well as various types of health workers (Ledn & Micklin (1971), Micklin & Ledn (1972, 1973, 1975, 1976, 1977a, 1978b), Micklin et al. (1974)), and on the distribution of symptoms of mental disorder and their association with stressful life events and situations (Micklin & Garcis (1974), Gar& (1975), Micklin & Richoun (1976), Micklin & Lebn (1978a)). Results from these studies provide a composite picture of mental illness showing significant cognitive, attitudinal, and behavioral differences between health workers and the public. There are also differences within the two groups according to individual characteristics such as age, sex, education, occupation, tolerance of deviant behavior and prior experience with the mentally ill. I ACTA PSYCH 58:l

98 Several of the overall findings have direct implications for the way in which the psychiatric care system operates in Cali. Mental illness is generally believed to be the result of organic malfunctioning, although expressed through disturbed behavior and psychological processes. Furthermore, there is poor understanding of psychiatric treatment and scanty knowledge about the psychiatric facilities and personnel available in the community. On the other hand, earlier studies of the prevalence of mental disorder (Ledn (1967)) as well as preliminary analysis of the results of a survey on the distribution of psychiatric symptoms (Micklin & Ledn (1978a)) show that mental illness is a fairly common problem for the residents of Cali, especially for females, people with low incomes and low levels of educational attainment, and those whose personal achievement falls below their level of aspiration. These findings point to a definite need for psychiatric services in the community. Nevertheless, it is important to recognize that the public has a poor understanding and conflicting views regarding mental illness and its treatment. Given the aforementioned conditions, it was regarded both as instructive and practically useful to examine how the system of psychiatric care works in this setting. How do people come into psychiatric treatment, what are their experiences and how are they evaluated, and what are the consequences of having been treated? These are the major issues addressed in the larger study, which employs longitudinal observations designed to examine sociocultural and interpersonal influences on the initiation, course, and consequences of alternative forms of dealing with mental disorder. The aim of the present report is to deal with only one aspect of the study, focusing on the elucidation of factors associated with assignment of cases to alternative forms of treatment. It is intended as a first approximation to understanding why persons with similar background characteristics and even the same psychiatric diagnosis often receive varying prescriptive evaluations from both medical experts and laymen, such that some are hospitalized, some are treated as outpatients, and others receive no systematic treatment at all. Evidence suggests that recognition of mental illness is dependent upon such factors as the duration of onset, the degree to which social norms are violated, and the family’s willingness to tolerate the symptoms manifested (Kreisman & Joy (1974)). With regard to this last point, our previous findings show that while there is a relatively low tolerance of deviant behavior in Cali, only a small proportion of the sanctions people would impose on deviants involve psychiatric treatment (Micklin (1977)). In addition, the degree of social rejection of the mentally ill appears to be quite low as measured through a survey of public attitudes toward ex-psychiatric patients (Micklin & Ledn (1973)). Among the several reasons justifying the present research the following are to be emphasized. First, at the time of the study the only alternatives for mentally ill persons in Cali using the public psychiatric facility were either to be hospitalized or treated at the outpatient clinic, with the third option of withdrawing from treatment after an initial contact. In this sense the present study deals with a reality faced by approximately 80 % of the Cali population. Since substantial changes are expected to occur in the foreseeable future through the

99 development of new models of psychiatric care (Ledn & Climent (1976)), there is a need to increase our understanding of the factors involved in the process of assigning cases to diverse types of care, especially when they share similar symptom complexes and background characteristics. Second, this research provides information on beliefs, opinions and attitudes that relatives of the mentally ill have about patients in general and their patient in particular (also see Micklin & Ledn (1977b)). Third, the study contains one category of cases, the “nonpatient”, about which little is known because such persons are typically not identified by researchers. Finally, the study covers a new aspect of psychiatric care for a community in which a number of complementary studies have been conducted. METHODS AND MEASURES Data collection was initiated in 1969. Samples were drawn from three populations: Hospitalized patients: first admissions to the Hospital Psiquiatrico San Isidro, which is the only public psychiatric facility in Cali. Outpatients: persons receiving ambulatory psychiatric treatment at San Isidro’s outpatient clinic who had not fewer than two nor more than five consultations. “Nonpatients”: persons who had sought the services of the hospital (personally or through the intervention of another person) but who after the initial contact had not followed recommendations or attended appointments at the hospital. Using the hospitalized patients as an index group, samples were drawn from the three populations with the aim of matching respondents on five variables that in previous studies had been shown to affect participation in and responses to psychiatric treatment: sex, age category, marital status, social class and diagnosis. Social class was estimated on a four-level continuum (roughly:high, middle, working and low). The diagnosis for patients hospitalized and outpatients was that designated as a first clinical impression by the admitting officer (usually a resident or an intern on call). For nonpatients, the diagnosis was a “best guess” based on available information. For all cases diagnoses were broadly categorized as schizophrenia, neurosis, and “other”. Eligibility requirements included: 1) an age range of 20 through 49 years, and 2) residency within 50 km of Cali for a minimum of 3 months preceding the entrance into the study population. In addition, there was an attempt to obtain an even distribution of males and females in the index group. The study was originally designed to include 70 hospitalized patients, 70 outpatients and 30 matched nonpatients. However, even by extending the data collection period it was not possible to secure the desired number of matches. Complete matching was achieved in 53 of the outpatients and 30 of the nonpatients with respect to the 70 index cases. In addition, data were collected for a number of patients of each type for whom matches were either not available or duplicated, so the total number of cases studied was 175. This report will deal with the 153 cases belonging to a matching pair of 53 cases and a matching triad of 30 cases.

100 Hospitalized patients were entered into the study as soon as they passed the screening criteria. Matches were then sought from the outpatient and nonpatient populations who made new contacts with the hospital over the 14-month duration of the data collection period. For each person included in the study population three interviews were conducted: one with the patient himself, another with an “informant” (that member of the patient’s family who knew the patient best and could most accurately give a perspective on his recent history), and a third with the doctor responsible for admitting hospitalized patients and outpatients. These three sources of information provide a diverse perspective of the “prepatient career” (see Spitzer & Denzin (1968)). Interviews were conducted by only two persons: a project research associate with an M.S. in nursing who interviewed outpatients, nonpatients and all the relatives, and a psychiatric resident who interviewed hospitalized patients and admitting physicians. The focus of these initial interviews was on 1) problems associated with the onset of “disturbed” behavior, especially those involving interpersonal relationships; 2) the sequence of events leading up to initial contact with the hospital; 3) the persons or agencies instrumental in making the original contact with the hospital; and 4) attitudes, opinions and expectations regarding psychiatric treatment and its outcomes. Follow-up interviews were conducted after 18 months. Of the initial 153 cases, a total of 141 relatives and 136 “patients” were reinterviewed, representing a proportion of retrieval of 92 % and 86 %, respectively. Follow-up interviews were designed to provide information regarding events occurring during the 18 months following initial data collection. Attention was focused on 1) changes in psychiatric status over the period; 2) interpersonal relations; 3) performance in work and family roles; 4) attitudinal and motivational changes; and 5 ) reactions to psychiatric care administered during the 18month period. For the purposes of the present paper, a selected group of variables representing perceptions, opinions and attitudes of the informant, subjective experiences of the patient, and perceptions of the admitting physician will be examined in terms of their association with three alternative forms of psychiatric care (hospitalization, outpatient treatment, no treatment). It was assumed that because of extensive matching there was sufficient control for the five criteria variables (sex, age category, marital status, social class and diagnosis). Ordinal or ranked values were obtained for most variables so that a coefficient of association (Kendall’s Tau (TJ, BlaZock (1972)) could be calculated for the relationships under consideration. In the case of nominal values, tests of significance were computed by the chi-square ( ~ 2 )technique with the significance level in both cases set at P 2 0.05. Apart from the five variables which have been shown to be associated with assignment to selected forms of psychiatric care, we wanted to explore more specifically other factors that may influence the initial decisions of the persons involved: the patients, their relatives and the admitting physician. For a preliminary analysis of these influences we selected several groups of variables reflecting: 1) the informant’s observations on the patient and his interpersonal

101

Table 1. Distribution of index cases by selected background variables and type of treatment ~~

Hospitalized Age category* 20-29 30-39 40-49

~

Outpatient

Nonpatient

n

%

n

%

n

%

42 16 12

60 23 17

31 13 9

59 24 17

19 6 5

63 20 17

35 35

50 50

24 29

45 55

15 15

50 50

30 22 9 7 2

43 31 13 10 3

22 20 7 2 2

41

16 10 4 0 0

54

38 13 4 4

10 26 34

14 37 49

7 16 30

13 30 57

1 8 21

3 27 70

37 9 24

53 13 34

24 9 20

45 17 38

12 5 13

40 17 43

70

100

53

100

30

100

Sexb

Male Female Marital statusc

Single Married Consensual union Separated Widowed

33 13 0 0

Perceived social classd

Upper or middle Working Lower Initial diagnosise

Schizophrenic Neurotic Other Total = 0.25, NS. NS. NS. x z = 5.03, NS. x z = 1.71, NS.

a xz

b d e

xz = 0.31, xz = 6.29,

relations; 2) opinions of the informant about the nature and prognosis of the patient’s problems; 3) personal attitudes of the informant toward the mentally ill; 4) subjective evaluations of the patient’s interpersonal relations; 5) subjective evaluations of the patient’s present condition; 6) the presenting problem or stated reason for coming to the hospital; and 7) evaluation by the admitting physician of the patient’s attitudes toward relatives and the doctor, as well as of his own feelings toward the patient. We hypothesize that each of these variables should be significantly associated with the patients’ assignment to one of the three treatment categories: hospitalized, outpatient, or nonpatient. For purposes of calculating measures of association with ranked variables, ranking for type of care is conceived in terms of intensity of care, with the highest rank for the hospitalized group and the lowest for the nonpatients. In summary, a limited number of independent variables will

102 Table 2. Relationships between selected variables and type of care 7.2

Information provided by informant A. Pertaining to the patient Time elapsed since onset of illness Relations with family Fulfillment of family obligations Opinion whether patient is insane Opinion whether patient will improve Opinion whether patient wants treatment Opinion whether other members of patient’s family are mentally ill B. Pertaining to self Acceptance of ex-patient as: Neighbor Workmate Own spouse Spouse of intimate family member Information provided by patient Subjective well-being Self diagnosis of mental illness Perceived need for treatment Perceived need for hospitalization Relations with spousdopposite sex Relations with family

P

0.58 0.02 0.01 -0.26

0.001

-0.17

0.05

0.11

NS

-0.13 -0.16 -0.17 -0.13

0.01 0.004 0.02 0.07

0.16 0.16 0.08 -0.30

0.01 0.03

Information provided by admitting physician Reason for consultation Patient’s attitude toward accompanying relatives Patient’s attitude toward physician Physician’s attitude toward patient

P

16.96 21.24 28.22 16.81

8 8 6

< 0.05 i 0.001 < 0.001

5

0.005

NS 0.002 NS

0.00

df

NS*

0.03

-0.05

x’

NS

< 0.001 NS NS

* NS = not significant. be tested for their association with a dependent variable represented by the initial patient status o r type of care (hospitalized, outpatient, nonpatient).

RESULTS Distribution of cases according to the five matched variables is presented in Table 1. Chi-square tests indicate that none of the five variables shows significant differences among the three types of care. In other words, the three patient groups d o not differ significantly on age, sex, marital status, social class and diagnosis. This finding points to a built-in control for aggregate (population) differences on the five background variables when testing the influence of any of the other independent variables. Table 2 presents a statistical summary of relationships between the independent variables and type of care. The size of

103

the relationship (rC)can be interpreted as an indication of the degree to which predictions of the dependent variable can be improved by knowledge of a given independent variable. Statistical significance simply means that whatever degree of association is evident is not due to chance fluctuations. Information provided by the relative

Time elapsed since the onset of illness shows a high and significant association with type of care (re= 0.58, P < 0.001). Of the cases in the hospitalized category, 63 % had their onset less than 1 month before admission whereas 73 % of outpatients and 70 % of nonpatients had their onset more than 6 months before admission. The evaluation by the informant of interpersonal relations between cases and their relatives shows no significant association with type of care. Relations were rated as “good” for 43 % of the hospitalized, and for 37 % of both the outpatients and the nonpatients. They were rated as “bad” for 23 % of the hospitalized, 34 % of the outpatients and 20 % of the nonpatients. For the remainder of cases, they were rated as “not so good”. Fulfillment of family duties and obligations by the patient as perceived by the informant did not show a significant association either. The proportion of cases rated as “good” was 65 % for the hospitalized, 60 % for the outpatients and 70 % for the nonpatients. The proportions rated as “bad” were 16 %, 17 %, and 26 % respectively. The opinion of the informant as to whether the patient is insane or not shows a significant association with the type of care (re= -0.26, P = 0.002), with 75 % of the hospitalized cases, 47 % of the outpatients and 48 % of the nonpatients being regarded as psychotic by the relative providing the information. The opinion of the informant about whether the patient will improve or not also shows a significant association with the type of care (re= -0.17, P = 0.05). The proportion of affirmative responses is 98 % for the hospitalized, 92 % for the outpatients and 91 % for the nonpatients. The informant’s opinion regarding the patient’s willingness to accept treatment does not show a significant association with type of care. The responses indicating acceptance are 67 % for the hospitalized, 88 % for the outpatients and 59 % for the nonpatients. The existence of any other ill relative in the patients’ families is not significantly associated with type of care. The proportions of affirmative responses are 46 % for the hospitalized, 44 % for the outpatients and 65 % for nonpatients. Each of the relative’s attitudes toward psychiatric ex-patients, with only one exception, show a significant association with the type of care. The majority of respondents show acceptance of the mentally ill but the proportion doing so varies somewhat among the four situations explored. Thus, 93 % of the relatives of hospitalized cases are willing to accept an ex-patient as neighbor as compared with 85 % of the outpatients and 77 % of the nonpatients ( T ~= -0.13, P = 0.01). For acceptance of an ex-patient as workmate, the proportions are 93 %, 83 % and 73 % respectively (re= -0.16, P = 0.004). The proportions accepting an ex-patient as one’s own spouse are 60 %, 41 %, and 43 % (rC= -0.17, P = 0.02). However, for acceptance of an ex-patient as spouse for an intimate

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member of the family, the proportions are 54 % for the hospitalized, 32 % for the outpatients, and 47 % for the nonpatients (rc= -0.13, P = 0.07). Information provided by the patient

In analyzing patients’ own opinions and evaluations, we find that the subjective feeling of well-being (ranked in three categories: well, not so well, and bad) is significantly associated with type of care. The proportion of those who say they feel well is 61 % for the hospitalized, and 40 % for both outpatients and nonpatients ( T ~= 0.16, P = 0.01). The patients’ responses to the question “do you think you are ill” are also significantly associated with the type of care. The proportions who answer “yes” are 57 % for the hospitalized, 70 % for the outpatients and 76 % for the nonpatients (rc= 0.16, P = 0.03). The patients’ opinion regarding whether they need treatment does not show a significant association with type of care. The proportions answering “yes” are 71 % for the hospitalized, 88 % for the outpatients and 74 % for the nonpatients. The assessment of the need for hospitalization made by the patients themselves is significantly associated with type of care. Those answering in the affirmative represent 47 % of the hospitalized and 17 % of both the outpatients and the nonpatients (re= -0.30, P < 0.001). The patients’ evaluation of the quality of their relationship with either spouse or persons of the opposite sex shows no significant association. The question is only applicable to 94 out of 153 cases and the proportion of those identifying the relations as “good” are 50 % for the hospitalized, 68 % for the outpatients and 47 % for the nonpatients. The proportion of cases answering “bad” are 20 %, 16 %, and 12 % respectively. With regard to the quality of interpersonal relations with family members, the evaluations given by the patients show no significant association; 61 % of the hospitalized state that these relations are “good”, as do 74 % of the outpatients and 59 % of the nonpatients. The proportions of those regarding interpersonal relations as “bad” are 11 %, 7 %, and 24 % for the three groups, respectively. Information provided by the admitting physician

These data were collected systematically for hospitalized patients and outpatients only. However, it was possible for all cases to ascertain from the relatives the reasons which prompted them or the cases themselves to seek psychiatric help and this information was also registered in the doctor’s admitting notes as “presenting complaints”. Analysis of a condensed list of these complaints shows them to have a significant association with type of care (xz = 16.96, P < 0.05). A maximum of three main complaints per case were elicited. Aggressivity was stated as one of the main complaints for 17 % of the hospitalized, 7 % of the outpatients, and 12 % of the nonpatients. Anxiety, depression, insomnia, .somatic complaints and related problems were evident for 41 % of the hospitalized, 57 % of the outpatients, and 50 % of the nonpatients. Disordered thought, perceptual disorders, inappropriate behavior and related problems were one of the main complaints for 35 % of the hospitalized, 25 % of the outpatients, and

105 29 % of the nonpatients. Suicidal attempts and thoughts were present in 5 % of the hospitalized cases, less than 2 % of the outpatients and less than 1% of the nonpatients. The admitting physician’s evaluation of the attitude exhibited by the patients toward their relatives at the time of the initial consultation shows a significant association with type of care (x2 = 21.24, P < 0.001). Aggressivity and rejection were perceived in 41 % of the hospitalized and 8 % of the outpatients. Indifference appeared in 19 % of the hospitalized and 42 % of the outpatients. Negativism, suspiciousness and other adverse attitudes were detected in 25 % of the hospitalized and 11 % of the outpatients, whereas collaboration and cordiality were rated as present in 9 % of the hospitalized and 38 % of the outpatients. The attitudes exhibited by the patient toward the doctor at their initial contact show a significant association with the type of care (xz = 28.22, P < 0.001). Aggressivity and rejection were perceived in 22 % of the hospitalized and 4 % of the outpatients. Indifference, suspicion, and negativism taken together amounted to 39 % in the hospitalized and 20 % in the outpatients, whereas cooperation was shown by 18 % of the hospitalized and 62 % of the outpatients. The remaining attitudes were grouped under “others” with a proportion of 21 % for the hospitalized and 13 % for the outpatients. The admitting physician was also requested to evaluate his own predominant feelings toward the patient at the time of their initial contact. These ratings show a significant association with the type of care (x2 = 16.81, P = 0.005). Feelings of rejection were reported for 9 % of the hospitalized and 11 % of the outpatients. Indifference was indicated for 24 % of the hospitalized and 26 % of the outpatients. Desire to help was reported for 13 % of the hospitalized and 32 % of the outpatients. Interest was reported for 16 % of the hospitalized and 7 % of the outpatients; and pity for 29 % of the hospitalized and 6 % of the outpatients. The remainder of these attitudes constitutes a residual category and corresponds to 10 % and 17 % of the two types of care, respectively.

DISCUSSION It appears that the length of time elapsed since the onset of illness is a good indicator of whether or not the patient is a candidate for hospitalization. The shorter the period, the higher the likelihood that a case will be hospitalized. Accordingly, it should be expected that a higher proportion of acute disturbances would be found among hospitalized cases. In order to check this possibility, we calculated the proportion of cases with a (reviewed) diagnosis of acute schizophrenia in each of the categories of type of care and found that out of 40 schizophrenics in the hospitalized group, 21 (52 %) are diagnosed as suffering from either an “acute episode” or “acute undifferentiated type”, whereas in the outpatient group, only four patients (17 %) out of a total of 24 schizophrenics are diagnosed as acute. For the nonpatients, out of a total of 12 schizophrenics, eight were regarded as acute. The difference of proportions between the hospitalized and outpatient groups is significant (xz = 10.97, P = 0.01) and indicates

106

an accumulation of acute cases of schizophrenia among the former group. Indeed, although there are no differences for the generic diagnosis of schizophrenia between the treatment groups, the specific clinical varieties of the disorder may influence the assignment of cases to a given group. In a previous study, it was found that diagnostic subtypes of schizophrenia are an important variable influencing readmissions to the psychiatric hospital (Ledn & Alvarez (1972)). Neither the assessment of the quality of interpersonal relations between cases and their relatives, nor the evaluation by the informant of the fulfillment of the cases’ obligations as family members, showed a significant association with type of care. These findings suggest that the patient’s performance in these areas is not an important criterion influencing the type of treatment received initially, although over a longer period we would expect patients whose behavior is disruptive to be hospitalized more frequently than those who were not so troublesome to their relatives. The significant association between the opinions of the relative, regarding both the mental condition of the patient and his prognosis, and type of care received by the patient, emphasizes the potential influence of family attitudes on the measures taken for handling mental disorders, and on their subsequent course. In this regard, our research may contribute to a neglected area since it has been pointed out that “. .. items directly examining family members’ beliefs about their own deviant family member have rarely been included as part of the research design” (Kreisman & Joy (1974), p. 53). It is probably an attitude of more intense concern and preoccupation with the behavior of the relative regarded as seriously disturbed which prompts relatives to accompany him to the hospital or to bring him there. This interpretation is supported by the fact that for the hospitalized group, 74 % of whose cases were thought to be insane, a relative came with the patient to the initial consultation in 68 of the 70 cases whereas this occurred in only 26 instances for the 53 outpatients. Thus it seems that regarding a relative as insane and taking him or accompanying him to the hospital increases the likelihood that the patient may be hospitalized. Scott (1974) argues that the “. .. unquestioned assumption that patients enter the hospital because they are ill is hardly ever true”, and he even calls it a “myth”. He found that in most cases a family member had decided who was ill before a physician was consulted. Scott also points to Mechanic’s (1962) observation that the person identified as mentally ill is brought into the hospital primarily as a result of lay decisions. In this regard, it has also been suggested that families may exhibit a differential readiness in a “propensity for action” to ascribe a psychiatric label and prescribe treatment for a family member (Spitzer et al. ( 197 1)). The belief expressed by the relative that the patient will improve under psychiatric treatment is associated significantly with type of care and is generally high for all groups. It is also concordant with the belief expressed by 92 % of a sample of the general population of Cali that psychiatrists can help the mentally ill (Ledn & Micklin (1971)). With regard to the psychiatric hospital 90 % of the sample gave a positive evaluation (Micklin & Ledn (1972)).

107

The patients’ willingness to accept psychiatric treatment as evaluated by the informant is not significantly related to type of care, but there is a high proportion of cases (88 %) who are said to accept treatment and are assigned to the outpatient group. In contrast, the higher proportion of cases who are said not to accept treatment is among the nonpatients (41 %). The difference of proportions between the groups is significant (xz = 8.69, P = 0.01). The informant’s opinion as to whether there is another member of the family who is ill shows no significant association with type of care, and the proportions reported for all groups are quite high, averaging 52 %. This finding supports the assertion that several family members are frequently disturbed during a crisis (Scott (1974)). The use of a social distance scale allowed us to ascertain the level of acceptance of the mentally ill in general on the part of the informant. The association with type of care was significant and the level of acceptance generally high regardless of the question asked. These findings correspond closely with those of a previous study of the general population of Cali (Micklin & Ledn (1973)), and indicate a higher level of acceptance of the mentally ill than those found in several similar studies. Perhaps this low level of rejection has to do with the phrasing of the question, which read: “If a person becomes mentally ill (insane) and recovers under treatment at the psychiatric hospital after he (she) leaves the hospital, would you accept him (her) as: 1) a next-door neighbor, 2) workmate, 3) your own spouse, and 4) spouse of an intimate relative?”. Considering the high esteem for psychiatric treatment and for the psychiatric hospital it is understandable that an ex-patient will be well accepted. Incidentally, it is noteworthy that a higher proportion of respondents would accept an ex-patient as their own spouse rather than as spouse of an intimate member of the family. Searching for an explanation of this somewhat paradoxical finding, we discover that all the relatives who responded in this way were spouses of the patients (15 in the hospitalized group, 22 in the outpatients and seven in the nonpatients). They all would be willing to accept an ex-patient as their spouse (an impending fact they will have to confront) but not all of them, it seems, would like an intimate relative to share their predicament. Perhaps another element contributing to this unexpected response pattern was the order in which the questions were placed. The question about accepting the ex-patient as a neighbor was asked first, followed in order by questions regarding the expatient as workmate, own spouse and, finally, spouse of an intimate relative. In other words, some response bias may have been introduced through the ordering of the questions. With regard to the patients’ self-evaluation of their well-being, the high concentration of the “well” answers among the hospitalized appears rather incongruous at first sight, and this result might be attributed to a more pronounced distortion of reality by members of this group. However, there may be an alternative explanation if we postulate that the fact of being admitted to the hospital represents finding refuge from a crisis. As Scott (1974) suggests: “It became clear that most often they [hospitalized patients] wanted refuge, unconditional refuge, on their terms, not ours”. If this is true, then the predominant feeling among

108 members of the hospitalized group should be one of relief for having attained their goal, which may be equated with feeling “well”. The high proportion of those who admitted to being ill among outpatients and nonpatients suggests the presence of better insight in these groups. The need for treatment is predictably acknowledged in a higher proportion of the outpatient group, but the difference of proportions is not statistically significant. Whatever the antecedent events that may have influenced a patient to seek psychiatric help, the final decision as to what type of care should be offered rests with the doctor who examines the case at the initial contact. In order to gain a better understanding of this decision-making process, a number of questions were asked of the admitting physician, reflecting not only clinical matters but also the interpersonal dynamics between patients, their relatives and the doctor himself. Foremost among the elements which may influence the doctor’s decision is the presenting complaint which is, essentially, the reason why the patient comes, or is brought, to the hospital. As indicated by Kreisman & Joy (1974), “it is difficult to know whether family members [respond] to their perception of the severity of symptoms or ... in terms of personal discomfort” (p. 54). Yet, the presenting complaint is a concrete piece of information given to the doctor as a condensed picture of the total situation in the early phase of the initial contact. In our study we find significant differences between the groups with regard to types of complaints, with a preponderance of aggressivity and disordered thought and behavior among the hospitalized and of anxiety, depression, insomnia and somatic complaints among the outpatients and nonpatients. In addition, 5 % of hospitalized cases had attempted or threatened suicide. The nature of these complaints suggests that relatives were responding to both the severity of the symptoms and the personal discomfort they produced. The fact that nearly all cases hospitalized came to the initial contact accompanied by a relative probably helped to emphasize the severity of the case in the eyes of the admitting physician. This finding supports the notion that the family has already made a decision about the type of care needed, prior to bringing the patient to the hospital. The attitudes displayed by the patient toward both the accompanying relatives and the admitting physician, and the feelings experienced by the doctor toward the patient at the time of their initial contact, seem to conform to an intricate pattern in which the question of directionality is extremely difficult to determine. Each of the participants in the interaction could be regarded both as initiator and reactor in the process of generating emotional responses and displaying attitudes. All the sets of attitudes examined were found to be significantly associated with the type of care, indicating their probable influence on the process of assignment of cases to alternative types of care. On the whole, patients who were assigned to hospitalization show higher proportions of negative attitudes such as aggressivity, negativism, and suspiciousness, whereas the reverse is true for those assigned to the outpatient clinic. The self-evaluation of feelings toward the patient made by the admitting physician offers only a limited amount of information as to how these feelings may have influenced his decisions regarding

109

assignment to treatment, except for the cases toward whom he reported feelings of interest or pity, the majority of whom were hospitalized. CONCLUSIONS The findings reported here must be interpreted with caution for two reasons. First, the samples were not randomly selected and thus no valid assumption of representativeness can be made. Therefore, interpretation based upon inferential procedures can be only suggestive. Second, the differences that were found among the groups of hospitalized patients, outpatients and nonpatients on several of the independent variables were examined through bivariate procedures. This form of analysis assumes non-spurious direct effects which should be confirmed through multivariate techniques. The complexity of the interrelation of attitudinal variables also makes the use of such methods highly desirable. Such analyses are now underway and will be reported in future publications. Nevertheless, the analyses performed thus far do suggest some preliminary conclusions. It appears evident that interpersonal factors exert a significant influence on the process of assigning cases to alternative forms of psychiatric care. The opinions and attitudes of relatives seem to play a crucial role in predetermining the type of service to be offered. Several elements contribute to the typical profile of a good candidate for hospitalization. He is a person who developed a mental disorder within the last month, and whose relatives regard him as psychotic, in need of treatment, and decide to bring him to the hospital. The presenting complaint is aggressivity and disordered thought and behavior. The potential patient displays negative attitudes toward relatives and the admitting physician, and is regarded by the latter as a pitiful or interesting case (academically or clinically). The typical outpatient, on the other hand, has been ill for longer than a month and has insight into his illness. His relatives do not regard him as psychotic and do not accompany him to the initial contact. He complains of anxiety, depression, or somatic complaints, and shows mostly positive attitudes toward the physician, from whom he does not evoke any particular feeling. Nonpatients seem to share most of the characteristics of the outpatients, with the exception that the likelihood of presenting schizophrenic symptoms is closer to that of the hospitalized group. The factors influencing their assignment or rather the lack of it can only be elucidated through further probing of the events surrounding their decision to drop out of the psychiatric care system. These findings raise several issues that have not been adequately explored in the psychiatric literature. First, what is the relative importance of family attitudes and disturbed behavior in influencing the physician’s decision regarding assignment of cases to alternative forms of treatment? Second, what is the relative weight given to the family’s opinion as to whether a member is mentally ill as opposed to the member’s judgment about himself? Third, what additional factors, especially those of a nonclinical nature, affect the physician’s decision as to whether or not a person requires hospitalization? Finally, what social and psychological factors are related to decisions to drop out of a treatment program? Answers to these and related questions will contribute to a more rational under-

110 standing of the disposition of cases presented as candidates for psychiatric treat-

ment. ACKNOWLEDGMENTS This research was supported by the Tulane University - Universidad del Valle International Center for Medical Research, Grant AI-10050 from the Institute for Allergy and Infectious Disease and by Research Grant MH 24677 from the Center for Epidemiologic Studies, National Institute of Mental Health, U.S. Public Health Service. Assistance in data collection and analysis was provided by Lida Victoria and William E. Bertrand. An abbreviated version of this paper was presented in a symposium on “Alternatives to Residential Care in Hospital” at the VI World Congress of Psychiatry, Honolulu, Hawaii, 28 August-3 September 1977.

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Cartos A . Ledn, M.D. WHO Collaborating Centre for Research and Training in Mental Health Apartado ACreo No. 1418 Cali Colombia Michael Micklin, Ph.D. Battelle Human Affairs Research Centers P.O. Box 5395 Seattle, Washington 98105 USA