Families of Chronically Mentally Ill Patients: Their Structure, Coping Resources, and Tolerance for Deviant Behavior
Axelrod, Joan, Geismar, Ludwig, Ross, Ruth, Health and Social Work
The movement for deinstitutionalization of mentally ill patients, which began more than 3 1/2 decades ago, has cast the family into a significant role in the long-term management of their chronically mentally ill relatives. The growing recognition that mental disorders are a complex phenomenon with multiple origins rather than the result of the family system gone awry has made it possible to view the family as a partner in the treatment of mentally ill people.
Early writings, going back to the 1920s, emphasized the family's role in the etiology of the disease. Sullivan (1927) saw the cultural distortions provided by the family, primarily the misunderstood or illusory parental attitudes placed on the child through interpersonal dynamics, as being the prime cause of mental illness. By mid-century the focus of research had shifted to interaction within the family system as the root of schizophrenia (Bateson, Jackson, Haley, & Weakland, 1956). Changing views of the family's role in etiology were noted by Hirsch and Leff (1975), who studied more than 200 papers and books and found "no reliable evidence for the concept of the cold, aloof, hostile schizophrenogenic mother"; they also found no supporting evidence for the marital schism and marital skew concept of Lidz, Cornelison, Fleck, and Terry (1957), who attempted to connect severe marital problems to the origins of the child's schizophrenia.
As scientific factors led to a reshaping of research efforts, the behavioral and social sciences, taking note of the advances in biological research, shifted toward a multicausal view of mental illness. The emerging realization that the family per se may make only a minor contribution or none at all to the etiology of the disease led to the development of research on the family's role in patient management. Questions were raised about the consequences of mental illness for the family. How was the family affected by the disease? What were some of the strategies families used for adjusting to their family member's illness, for coping with deviant behavior, and for providing support for the mentally ill individual? The effect of deinstitutionalization put the spotlight on the family's role as caregiver (Hatfield, 1987). Studies like those of Brown and his associates (Brown, Birley, & Wing, 1972; Brown, Monck, Carstairs, & Wing, 1962; Brown & Rutter, 1966) identified the emotional atmosphere of the home as a significant factor in patient relapse. In an extension of Brown et al.'s work, Hahlweg, Feinstein, Muller, and Dose (1989) concluded that family management programs should include education and stress management components with the patient-family group as the focus.
The study reported in this article takes its cue from Terkelsen's (1987) conclusion that little is known about the attitudes and beliefs of families toward their own mentally ill members. Because many families are instrumental in the decisions regarding their ill relative's institutionalization, weekend home visits, release into the community, and care following discharge, it seemed worthwhile to explore the readiness of families to play a role in the care of the patient.
Readiness implies two conditions: (1) being able or in a structural, economic, and social position to take on responsibility for a sick family member and (2) being willing, or psychologically prepared, to shoulder the task of caretaking. The former can be defined objectively in terms of structural and functional family characteristics. The latter is much harder to assess, because the families of mentally ill individuals are exposed to conflicting pressures regarding the care of their ill family member. On the one hand there is the expectation to do the "right thing" and provide the support for a close relative in need. On the other hand there is the personal desire to be free of encumbrances that might overwhelm the family and that could be avoided to the extent that professionals instead of family members care for the patient. …