Experiential Psychopathology - Dr John Howells

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II - Family Psychology & Family Psychiatry - Diagnosis

Referral

When the organism, the family, dysfunctions, there are repercussions throughout that family. The indicators of dysfunction, symptoms and signs, come to the notice of the family or of others. The awareness of the family, or a part of it, or of an individual varies greatly. In general, paradoxically, the greater the disturbance, the less the insight and the capacity to take action. The link may not be made between the indicator and the emotional state. A physical indicator may be thought to have a physical cause. A behavioural indicator may be thought to be due to some moral deficit. Long drawn-out states of psychopathology may be assumed to be usual. Standards may be low; what are states of ill-health are often widely regarded as being “normal”, i.e. usual. The dictates of relatives, or social position, or lack of finance may make it impossible to seek assistance, hence the need for awareness and then for help from outside.

Usually the whole family is affected. Uncommonly, the whole family will appraise itself and seek assistance. More usually, an outside agency will appraise the family and persuade it to seek assistance as a family. Occasionally, a dyad in the family will seek help either on its own initiative or prompted by others. More often it is the individual who seeks help by his own efforts or encouragement from others. The conditions determining the common presentation of an individual will be discussed later.

Frequently one of the indicators becomes so noticeable to the family or others, or so painful, that it becomes “the last straw” and the final reason for taking action. As will be seen later, this presenting symptom is no more significant than other indicators; it may just be the most noticed, the most painful, the most socially acceptable, the one that offers least embarrassment to the family if discussed with others, or the one that allows an overture for help without final commitment.

Referral agencies can be conveniently divided into medical and social, and the latter into statutory and voluntary bodies. Some of the main medical referral agencies are family doctors, family nurses, polyclinics, hospital departments, industrial medical officers, departments for the care of the handicapped, and school clinics. Some of the main social referral agencies are child-care agencies, workers attached to courts of law, industrial welfare officers, church workers, moral welfare workers, marriage guidance services, housing departments, school welfare officers, the Samaritans, the Salvation Army, and the police.

In some countries medical agencies with associated welfare agencies are ready to offer continuous observation and support of families in what they regard as essentially a medical problem – family psychopathology. Thus whatever the manifestations of dysfunction, they become the main referral channel to the psychiatric service. The continuous medical coverage is given through a family doctor and the continuous welfare coverage either by a home nursing visitor with experience of physical, emotional and social problems, or by an all-purpose social worker with similar experience. These services are supported by specialist medical and social agencies. A vital condition for success is that the workers offering a continuous service should be trained to see the significance of emotional phenomena. The advantage of referral through a medical service is obvious. Family psychiatry teaches the importance of a total somato-psychic approach; much of the symptomatology is physical; continuous support to a family in all its organic and psychic aspects is invaluable.

In the United Kingdom, an appointment is usually sought through the family doctor or personal physician. In an emergency, a family or an individual is accepted at once and the physician responsible for the family is informed. If other agencies, medical or social, become aware of a need for referral, they liaise with the family doctor, who then initiates referral. Experience has shown this to be an indispensable method. It allows of all previous knowledge on the health of the family, physical and emotional, being available. It offers a way whereby, after help from the specialist agency, the family finds itself back with the physician responsible for its continuous care.

The nature of the service given by a department of family psychiatry should in general fall into two categories: (i) A diagnostic appraisal of a family’s problem with a clear-cut opinion on its nature and recommendations for management. In the United Kingdom, the referring family practitioner, for instance, is increasingly being encouraged to ofer help from his own resources. Given the skilled assistance of a health visitor or a social worker, a great deal can be achieved at home level. (ii) Undertaking of management beyond the resources of the referring agency.

Intake Procedure

The appointment is fixed, the letter of invitation is sent, couched in a welcoming vein and accompanied by a brochure on the department and a prepaid postcard for reply; the postcard is received back at the department, finally confirming the appointment. That the postcard is prepaid usually guarantees its return and allows appointments not taken up to be given to others. Rapport begins to be established at this early point of contact.

The family arrives by appointment. They already understand the procedure, as it has been explained in the brochure. The building, including the waiting area, is familiar as they have seen it pictured in the brochure. They are met by the receptionist. This is the first direct staff contact – and therefore important. It sets the tone for all that is to follow. Much goes on in a waiting area. In general, especially for early visits, it is a tense period. It can be relieved by an understanding, helpful, accommodating, receptionist. The décor of the waiting area should be cheerful and a compliment to those who wait. The period of tension can be abbreviated by the interviewer being prompt. Inevitably, from time to time, due to some unexpected demand, a family is forced to wait. When the interviewer meets them, it should be the subject of apology and explanation – as would be expected of a courteous host. Discourtesy, especially unexplained lengthy waiting periods, kill rapport. The receptionist conducts the family, or dyad, or individual to the staff and introduces them. Rapport building continues and the systematic diagnostic procedures have begun.

While the receptionist is usually the first staff contact with a family, it may occasionally be preceded by another staff member – the telephonist – at some routine enquiry before attendance. Departments can fail here. For effective rapport building, the telephonist must be a person of warmth, of infinite patience, and accommodating. New telephonists respond when the importance of their position is explained to them.

Individuals, naturally, concentrate on their own discomfort and tend to seek help themselves; agencies make use of this readiness. Thus a referral service can be based on the individual with intake channels for all age groups – child, adolescent, adult and the aged.

A referral service could also concentrate on relationships – e.g.the marital, parent-child, or sibling-sibling. In practice, the last two are usually associated with a children’s intake channel; it may be useful to establish a marital problems intake channel to gather in marital problems, a common feature of disturbed families.

Establishing an intake channel for the family group is invaluable – with increasing understanding of family psychopathology this will become in time the method of choice; it must never, however, be inferred that only the group as a whole will be accepted by the service.

Intake clinics based on poor physical circumstances are already a feature of countries with well-developed welfare systems. In advanced countries problem or hard-core families find their way to such clinics. If the psychopathological nature of their disability is accepted, in future they will be referred to family group intake channels.

Family-community interaction may break down at many points, engendering problems which require special clinics to cope with them, e.g.delinquency clinics, school refusal clinics, university student clinics, industrial clinics, etc.

Intake channels could also be based on clinical categories. Not only may a family show signs of disruption in any dimension, but it may also present with varying types of psychopathology – psychonosis, psychosomatic symptoms, or delinquency. Thus a service could base its intake channels on clinical categories, instead of on signs of pathology in family dimensions – or on both.

Whatever the family or the agency offers should initially be accepted whether it be an individual member, the whole family, or part of it. The department of family psychiatry can then itself work to achieve the desired aim of involving the whole family.

The Presenting Individual Patient

The family is sick as a whole; yet it rarely presents at a psychiatric service as a complete unit. An individual may be referred as the “presenting” patient, the “proposisitus”, the “indicating” patient, the “identified” patient, or the “manifest” patient. That an individual who is alone, such as a widow, widower, single person, divorcee, student, etc, comes alone is understandable, but what determines that a fragment of the family is sent for treatment rather than the whole? The understanding of the mechanisms concerned with the referral of one member throws light on the correct arrangement of referral agencies and the organisation of the psychiatric service. It exposes important aspects of the psychodynamics of the family. It underlines the central thesis of family psychiatry – that the family is a social unit specially meaningful for psychiatry.

Some of the mechanisms determining the referral of one member of the family will be briefly reviewed.

1.  Organisation of services. Should the psychiatric service in an area be based on adults or children or adolescents, then only that particular age group can find its way to the service, while equally, or more, disturbed members of the family cannot be accepted by the service because they are in a different age group. Thus the shape of the service determines who comes from the family.

Referral agencies tend to have special interests and attract family members falling within their speciality. The family doctor, for instance, concerns himself with individuals with physical problems; this explains why two out of three emotionally ill patients in general practice present with psychosomatic problems. Furthermore, a physical complaint allows the patient to try out the doctor and at the same time hide initial embarrassment. A social agency, specialising in social and welfare problems, sends patients with those problems. Should the school be the referral channel for children, it will give special attention to problems of discipline and scholastic failure. Thus the special interests of an agency determine whom they see and refer to a psychiatric service.

2. The agency and the symptoms. Sometimes the individual or the family tends to produce symptoms which will demand attention by a referral agency. When a medical practitioner, for instance, concentrates exclusively on physical symptoms, his patients, to gain his attention, must have physical symptomatology. Should such symptoms already be present in a family member, he will consult his doctor because of them and will become the family member ascertained. In such a situation there is pressure to produce a physical symptom – and, if possible, one of special interest to the practitioner or the psychiatric service. For example, much attention was given some years ago by the psychiatric service to amnesia; it was held that it was possible for unconscious acts beyond the patient’s control to take place in this state. Many cases of so-called amnesia were reported, but when psychiatric opinion about responsibility in states of amnesia changed, this symptom became less fashionable.

Again, courts of law can be indifferent about psychiatric disorder, but, should someone manifest some sexual anomaly, there may be rapid referral. Their susceptibilities have been provoked.

3. The state of the family dynamics. This varies from moment to moment in the life history of the family, as the following clinical example illustrates: At the conclusion of a brilliant survey of the exclusive treatment of an adolescent patient, who was the son of a widow, a therapist observed that, at the end of the adolescent’s treatment, the widow had become severely depressed, and was now an inmate of a mental hospital. The therapist had supported the son, the dynamics of the family had changed to the mother’s disadvantage, and she had become the propositus.

Thus in families there are “see-saw” movements. The person “down” at a moment in time is likely to become the propositus.

4. Vulnerability of a family member. One family member may be so placed as to be specially vulnerable to stresses within the family. More than this, these family members may have constellations of personality characteristics which make them vulnerable to a particular stress. In addition, ordinal position, sex gender, or age may be important for vulnerability.

A child may be the only child, the first, second, next youngest and youngest. Since the speculation of Adler,1 much attention has been given to the significance of a child’s ordinal position in the family. Generally the studies are contradictory. Although the investigations on ordinal position appear contradictory, when groups are studied, the child’s ordinal position in a particular family may yet be highly significant, but understandable only in that unique set of circumstances.

The sex of a child may lead to vulnerability. In many families there may be a tendency for parents to reject one gender whilst accepting the other. Again, this may only become apparent when evaluated as part of the psychodynamics of a particular family. Sex gender may also be a factor determining the attitudes of siblings.

The age of a family member may be the cause of vulnerability. The writer has observed that in some problem families a mother may pay a child a great deal of attention for the first two years, because of her own needs for an emotional “lollipop”. At the age of two or three, as the child makes demands on the mother, he is rejected and another infant sought; at an early age the child is accepted, later he is rejected. Thus he becomes vulnerable. Similarly, parents talk of difficulties in acceptance of and in relating to their offspring when they are children or adolescents. Old age is anathema to some families.

5. Anniversary reactions. Individuals may not fall ill with equal regularity throughout the year. There are peak periods. For example, Fowler2 reports a higher incidence of suicide amongst the Mormons of Salt Lake City at Christmas; this is probably not unique to Salt Lake City. Not only may there be dates, seasons, months of significance to whole populations, but also to individuals. Furthermore, the individual breakdown may reflect a family’s association with a particular moment in time. The significance of the time may not be apparent to an onlooker, as it has meaning only in terms of the life experience of a particular individual or family. It may relate to a great variety of stresses in the past.

6. Family motivation. The family may make use of an individual family member; it can punish a member by sending him for psychiatric treatment, express guilt through him, and use him in a crisis as a means for getting assistance.

The psychonotic equilibrium of the family can be broken when the adolescent’s behaviour becomes unendurable to himself, the family and/or society. This creates a crisis and then an appeal for help. Suicide or a suicidal gesture by adolescents may also be a cry for help to the family, as these symptoms may be the only symptom-language understandable by their families.

Of the many motivations setting in motion family dynamics, some of the most intriguing are those causing the role of scapegoat give to a family. The member becomes the “butt” for the family. A mother, for example, may imply to her children, “Things go wrong so much because of the feeble father you have”.

7. Communicated symptomatology. Two or more individuals in a family may share common symptomatology to such an extent that they will be referred together to a psychiatric service. The members may be beset by a common stress, as in the case of two elderly sisters who had lived closely together for many years, and who, on hearing that their house was to be sold, walked quietly into the sea, hand in hand, and attempted to drown together. The members of a coalition may borrow symptomatology from one another by imitation or suggestion. A paranoid person can persuade another of a common enemy and draw him into his delusional system. This manifestation is common in psychonotic patients.

8. The demand value of the symptom. From time to time a member of a family will manifest symptoms which are striking, call attention to themselves, or have considerable “nuisance value”. Thus another family member, the family, or a community agency will seek his referral. Some examples of striking symptoms are tics, speech disorders, hysterical symptoms and skin conditions. A child with encopresis, enuresis, or awkward behaviour will quickly come to attention, while an equally disturbed, but apathetic, listless, depressed child may be overlooked.

9. Cultural attitudes. These too, can play a part. In some cultures, the mother is sent as the family representative to clinics, especially with children. In Nigeria, on the other hand, fathers attend with the children. This can lead to undue importance being given to the members of the family seen at clinics. Culture can also affect the demand for a service. It is noticeable in British clinics that American visitors are more ready to make use of psychiatric facilities than the British.

10. Referral as a sign of health. Insight into one’s own emotional state is found to be inversely proportional to the degree of the disturbance. Thus highly disturbed family members avoid, “can see no point in”, or obstruct, referral to psychiatric services. Less disturbed family members, on the other hand, can “see the point” and come as the family’s representatives. Paradoxically, individual psychiatry can lead to a concentration of effort on those members of the family that are least disturbed.

REFERENCES

  1. ADLER, A. (1945). Social Interest. A Challenge to Mankind. Trans. By Linton and Vaughan. London : Faber & Faber.
  2. FOWLER, H.B. (1961). Personal communication.
  3. HOWELLS, J.G. (1962). Family psychiatry and the family doctor. Practionioner, 188, 370.

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