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Fam Proc 1:114-118, 1962

Use of Members of the Family in the Treatment of Schizophrenia

C. F. MIDELFORT, M.D.a
aGundersen Medical Foundation, La Crosse, Wisconsin.

In the fifteen years that the writer has experimented with the use of family therapy, members of the families of patients treated in the La Crosse Lutheran Hospital were used as companions, constant attendants and nurses. The hospital being a general hospital in which there is no special psychiatric facility, the patient and members of the family stayed in a private room on the first floor along with other types of patients. The longest stay in the hospital has been three weeks. During the last eight years the average stay has been from seven to ten days. The cost to the patient is sixteen dollars a day and this includes two dollars a day for the relative who sleeps on a cot and takes his meals with the patient. The care after hospitalization is in the Clinic where patient and relatives are seen once in two weeks for one-half hour to begin with and later on once a month, then once in six months or once a year. Not all continue to come for therapy, but many have been followed for years. The total average cost for the patient, including everything, is about two hundred dollars. Members of the family took part in therapeutic interviews with patient and psychiatrist. Some members of the family, when present, made the patient's illness worse while others seemed to be very helpful. It was easy to tell to which category the relatives belonged because the patient changed noticeably within a day. It did not follow, however, that the relative whose presence increased the patient's illness was a poor companion for the patient. On several occasions a relative might have had to sit outside the patient's room at intervals, but in spite of this the patient improved. Early in the experience with family therapy Insulin was used in doses sufficient to cause sweating, hunger, and slight drowsiness. This was much less of a reaction than that produced by Rennie in his Payne-Whitney experience with sub-coma Insulin. Since the advent of Thorazine, Compazine, etc., Insulin is no longer used. Those with depressive affects have been treated with Tofranil and at times Compazine in addition. Electro-convulsive therapy has not been used in the La Crosse Lutheran Hospital at any time. Some excited and combative patients have had to be referred to a private or public mental hospital but this is not common. During a year, on an average, eighteen patients with schizophrenia are treated in the general hospital with family therapy. The orientation of this family therapy is social and all the various reaction types are considered as family illnesses. When more than one member of a family have been seen as patients during these fifteen years, and this has been the case in over seventy-five families, the similarities in various members of the family are most striking. The tone of voice, words and phrases used, symptoms, gestures, humor, ways of lying on the couch, the diagnostic formulation and responses to therapy have shown so many correlations that it is stated without hesitation that the constellation which we call a mental illness is a group reaction with genetic, social, and cultural factors at work. If the assets in a family's culture, society, and personalities can be mobilized to help understand and relate to the patients in a family, the prognosis is good. The cultural factors have included the family language (Norwegian), the patient's cooking, humor and other values, and these have been used to create a home-like atmosphere of acceptance and understanding. During the last five years the patient's religion has become a more central focus of attention. In the treatment of Norwegian Lutheran patients who in this area of the United States attend church in well over eighty per cent of families, the philosophical and theological position of this denomination (American Lutheran Church) has been made a basis for relationships. The paradox between justification by faith alone and man's being as responsible for himself as possible is maintained. The pastor is included in family therapy to a greater degree and spiritual and psychiatric therapy are administered during an interview with patient and family. The pastor prays, summing up the spiritual aspects of the interview, and the psychiatrist interprets and helps to bring out the assets present in the members of the family. ANOTHER FACTOR THAT has come to the fore in the treatment of schizophrenic reactions is the use of the children of the patients in the hospital care and in therapeutic interviews with patient, relative, and psychiatrist. In paranoid reactions the therapist and patient can relate to each other with security through the children. The patient has success in his role as a parent and the psychiatrist in his understanding of children and their problems. The paranoid difficulties melt away temporarily when adults find a common experience with children in a family-life situation. An example of the pastoral therapy and child therapy used in the treatment of a patient with schizophrenia will be given as an illustration of the combination of these social therapies in a family. A Lutheran pastor's wife, who eight years previously had lost contact with reality and gone "into the pit" without telling her husband anything about it, now was convinced that God was using her thoughts and voice to express His will. Two weeks before admission to the Lutheran Hospital she underwent minor pelvic surgery under local anesthesia. During the

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experience, she felt that God was in the four corners of the room and that she was going to die. Her death was to serve the purpose of bringing her husband and the psychiatrist together to help people in distress. God was using her voice and her life in a meaningful experience for the benefit of her husband who was so busy in his work as minister that he was out of contact with his wife; and for the benefit of the psychiatrist whom she had seen in church at an organ recital a year previously and for whom she had prayed that God might use him for the care of others. The day after admission to the hospital, with the psychiatrist and her husband present she said that, after a common prayer, she would lie down to die. Her husband who had been her companion and nurse, staying with her overnight in the hospital room, told her she was confusing the natural with the supernatural. The psychiatrist said that she had a right to her own opinion but he thought she was mistaken, that it probably meant that she was to die to sin and rise again a new person. After the three in the room recited the Lord's prayer together she lay down in bed and felt numbness in her legs. When this did not progress she sat up, agreed to eat her breakfast and the interview was ended. The next day she informed the psychiatrist that she appreciated his saying that she had a right to her own opinion. God had not been making fun of her. She had misunderstood Him. She was to die to sin and rise again a new person as St. Paul had said. She asked to have her older daughter sleep with her that night that she might be reassured that mother was all right. The daughter's comment the next day was that it was like old times, being tucked in bed by mother. The patient was hospitalized five days and since her discharge she has been seen or has written a few times to tell about her illness and what it meant. Her husband who was much made over by his parents had to be perfect or admit that he was just a human person like others. When he did not behave humanly with her, only being alone with her in the day time once every other week when they went to buy groceries together, she expected him to be perfect. His perfection was in his devotion to his congregation. His lack of human weakness was seen in his being unwilling to take his wife to her family when she was upset and unhappy. WHEN THE PATIENT CANNOT maintain meaningful relationships in all areas of the personality and there is a collapse of a part of the personality, difficulty in choosing between good and evil develops. A young married woman whose husband was in service delivered her first baby in a hospital far from home. She was heavily sedated and thought the obstetrician was the devil. When brought home she entered the General Hospital and was attended by her husband. Both she and he mistook the psychiatrist for their Lutheran pastor on several occasions. The patient was preoccupied with sexual feelings, masturbated openly, and thought of the psychiatrist at such times as the devil. Her husband kept her in control, covering her up when exposed and making her be polite in her talk. On one occasion she grabbed the psychiatrist's hand and asked him to kill her. A little later she said that both she and the psychiatrist had been forgiven their sins by Christ. After a week in the hospital she was seen in the Outpatient Department. The first time she came into the room holding her underwear in her hand. She stated that she was wiser than the psychiatrist and was going to be his friend only, doing God's will. When in church she often twisted the pastor's words so as to give them improper meanings. She thought that many were in church for appearance sake. She herself used to put on make-up because the way she really was had to be hidden from others. Her success as mother and wife continued and she maintained reasonable health. Another young married woman was brought into the Lutheran Hospital by her husband and the pastor who had baptized her baby only the day before. At the baptismal party the patient had been inappropriately dressed and had had too much beer to drink. At home, after the party, she lay in bed, re-experienced childbirth, and was incontinent of feces. She ignored the baby and would not feed it. In the hospital she saw the psychiatrist as the pastor who had brought her in or as an evil person who could read her mind. Her husband served as nurse and companion and forced her to behave herself. She had been an honor student in college and was compelled to quit school when a pregnancy led to marriage. The day of the christening her aunt had committed suicide. One day during the week in the hospital she read a story of a young mother who with her baby was stranded by a mountain snow storm. They were reached by a pastor who enlisted the help of an alcoholic whose vehicle was used. The choice between good and evil, projected onto the psychiatrist in the roles of pastor and rascal, was difficult for her when she failed as a student leader because of the pregnancy and marriage. As she regained her sense of reality through her wifely relationship with her husband in the hospital the danger of the choice between evil and good subsided and she was able to organize herself as a person. She returned to college and graduated with distinction. In the case of both these young mothers the psychiatrist who belonged to the same Lutheran denomination as they did was able to strengthen the influence of good and to encourage the families' return to Christian responsible living. The dependence on God was admitted in their common doctrine of justification by faith, and the responsibility of all in the group for themselves and each other was accepted. The paradox of complete dependence upon both essence as God's relationship with man and on existence as man's responsible relationship with God and others was maintained, and evil and good, God and the devil, were not confused with each other as they had been during the illness.

REFERENCES
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1. 2. 3. 4.

Rosen, John N., Direct Analysis, New York, Grune & Stratton, 1953. Whitaker, C. A. and Malone, T. P., The Roots of Psychotherapy, New York, McGraw, 1953. Whitaker, C. A. (Ed.), Psychotherapy of Chronic Schizophrenic Patients, Boston, Little Brown & Co, 1958. Midelfort, C. F., (1957) The Family in Psychotherapy, New York, McGraw Hill.