In the early days of civilization and for a very long time afterward, the mentally ill lived at home for the same reasons that everyone else lived at home: there was no place else to live. Certainly there were no institutions in which those so afflicted could be housed together and treated by a staff specially trained and specially committed to their care. But there came a time—in fact, different times in different places— when public note was taken of the neglect with which these unfortunate people were treated within their homes, and consequently facilities were built in which they could live together away from the stresses of life.
Over the course of the last thirty years some compassionate persons have looked into the modern counterparts of these institutions and discovered to their surprise that the mentally ill who live there are still treated with neglect. With the support of many psychiatrists, they have sought to close these institutions and return these patients to their communities and to their families. The fact is, the careless disregard that is usually the lot of those who are chronically and seriously ill mentally does not come from improper living arrangements but from improper care. Nevertheless it is true that there are certain times when a particular patient is better off in a hospital and other times when he is better off at home. Those considerations that are relevant in determining whether to hospitalize someone include the following:
- The potential of a patient to commit suicide or to injure himself in some other way. In general, patients who are actively suicidal should be in the hospital, although it must be noted that patients not infrequently kill themselves even in that relatively protected setting, so that even there they need to be observed closely.
- The potential of a patient to injure others. People have an exaggerated conception of the potential of most psychotic patients to do violence; but some such patients do exist, and they should be admitted to a hospital for their own benefit as well as that of society.
- The response that the patient has already shown to treatment. Hospitalization should be considered for a psychotic person who is unaware that he is sick, who does not cooperate in his treatment, or who has worsened despite treatment. Admission can serve as a signal to him and the people around him that something more needs to be done. Some patients need to be brought into a hospital simply to keep them away from substances of abuse such as alcohol or drugs.
- The patient’s need for treatments or tests that may be undertaken more easily within a hospital. Electric shock treatments, for example, are given more commonly and conveniently to someone as a hospital patient than as an outpatient.
- The physical needs of the patient. Some patients need special diets or special programs of physical rehabilitation that can only be provided in a hospital. Some other patients need extra attention for physical illnesses, which may be both a cause and a consequence of a mental illness.
- The merits of the particular hospital balanced against the alternative, which is usually the patient’s home and family. Some hospitals are so awful — cruel and demeaning — that no one should be admitted to them. Yet some families are just as bad, and no one who is emotionally disturbed should be allowed to remain subject to their influence. Similarly the benefits of a good hospital must be measured against the benefits ofa good family.
Ideally admission into a hospital brings the patient into a therapeutic community, every aspect of which is designed to have a beneficial effect upon him. He is protected from those influences in the outside world that have caused him to become ill. He is offered psychotherapy, individually and in groups; occupational therapy; recreational therapy; work therapy, perhaps; and the therapeutic attention of dozens of trained specialists. He is encouraged to express himself. He participates in decisions concerning his own treatment program. He receives as much medicine as he needs and no more. Although in a protected setting, he exerts himself to the limits of his ability. And so he becomes stronger.
Unfortunately in practice a hospital is a different sort of place. The presence of restraints, locked rooms, and locked wards suggests strongly to the patient that he is locked away not for his own benefit, but for the convenience of society. Upon admission he is cut off not only from the conflicts of ordinary life, but also from its supports. He sees his family infrequently and perhaps not at all. His letters and telephone calls may be limited or monitored. He can perform no real work. And rather than receiving special attention, he is likely to receive no attention at all: he may spend days or weeks with no more contact with staff than a perfunctory greeting in the morning.
The hospital patient is expected to conform to a stereotype of proper behavior that may not resemble at all the behavior of a normal person. He is supposed to be passive, agreeable, and above all quiet. He should not quarrel with staff or take issue with his physician. He should engage fully in the “treatment program,” which means, among other things, confiding his private anxieties and anguish to strangers, some of whom are themselves emotionally disturbed. He is supposed to entertain himself by drawing pictures or watching television—and do these things always in concert with the other patients. He should not try to stay up later than everyone else or read a book when everyone else is taking a walk. Although he may have trouble controlling himself, that ¡s precisely what he must do. He should not cling to the nurses, or violate their sanctuary, the nursing station. Certainly he must not express in action any sexual feelings that he may have.
All behavior of the patient, however reasonable, is likely, if inconvenient to the staff, to be explained as an aspect of deranged thinking. Even the commonplace urge to leave the hospital is interpreted in terms of the patient’s inability to understand his condition or interpret reality. In this regard, a peculiar logic governs clinical decisions: a patient who wants very much to leave the hospital may be presumed to need further treatment, while a patient who wants to stay is presumed to have become too dependent, and is encouraged to leave. Sometimes there is no making sense out of medical judgments.
A twenty-two-year-old man was admitted to a well-known state hospital affiliated with a well-known medical school. The reasons for his admission were somewhat vague: “to give him a chance to pull his life together.” He was told to expect to stay at least six months. Within only a few weeks, however, he found himself bored by the endless routine of hospital life, and he asked to be discharged. That was out of the question, he was told. He was too sick to leave the hospital. He left anyway that afternoon for a beer, returning, though, within the hour. In order to “set limits” for him, the doctors then transferred him to a locked ward. The patient, a vigorous man, responded to this punishment by determining once and for all to leave the hospital, if necessary against medical advice. This time he struck an attendant, took away the man’s keys, and left. The police were called and with their help the patient was forcibly returned to the hospital a few hours later. He was placed in a locked room for the remainder of the day. Over the next month he escaped repeatedly and was recaptured each time until his psychiatrist, in exasperation, warned him that if he escaped one more time, he would not be permitted to reenter the hospital! The patient escaped forthwith and did very well during the next two years with no treatment whatever.
Of course, a mental hospital can be made to approach the ideal somewhat more closely. But even under the best of circumstances, hospitalization cannot by itself be regarded as a definitive solution to anyone’s emotional problems. The less time spent in the hospital, the better. It is only an episode in the long-term course of an illness, and its principal purpose, therefore—besides coping with the acute phase of the illness—is to begin a course of treatment that will continue during the longer and more important period of aftercare.
There are advantages to conducting treatment in the patient’s home when possible, rather than in the hospital or, for that matter, in the psychiatrist’s office. The therapist who sees the patient in his home becomes something more than a functionary of a clinic or a social agency, more even than the knowledgeable but aloof clinical specialist that is the facade of a psychiatrist or a psychologist. He becomes a real person and, to an extent, a guest. The patient, in turn, becomes a friend rather than a supplicant. Consequently, he is more willing to communicate openly.
A home visit, which always takes time, is an unmistakable expression of interest to which the patient and particularly his family invariably respond. Family dynamics may be seen directly in the home instead of merely being inferred. Sometimes, even, the psychological causes of the patient’s emotional disturbance can be seen and sometimes dealt with. Other members of the family who are present can be enlisted into the treatment process, and those who are emotionally disturbed, but not yet labeled as such, can receive special attention. Also the therapist learns by looking around him enough about the actual circumstances of his patient’s life to avoid making recommendations that sound reasonable in theory but could never be implemented, for reasons that are plainly in view. For instance, a mother cannot be encouraged to spend more time by herself when she lives in two rooms with a family of six. A phobic patient cannot be encouraged to walk at night through the streets, if the streets of his neighborhood are very dangerous, and so on.
Many psychotherapists find all sorts of reasons for not visiting a patient at home, but the real reason is that they are uncomfortable outside of the structured confines of their offices.
Nevertheless, it has become conventional practice for psychiatric patients to be seen exclusively in the offices of professionals. (c) Fredric Neuman (excerpted from “Caring: Home Treatment for the Emotionally Disturbed.”)