Once a person is labeled as the “identified patient,” it is difficult for the clinician to focus in any other direction. The label pulls the energy and focus onto the person in the identified role, and, of course, there is ample energy in the form of psychotic symptoms that the I.P. brings to the mix. The psychotic symptoms are a reality and there is often a history of multiple hospitalizations that have been necessary to keep the symptoms “manageable” for the family.
Clinic and agency policies require continued focus on the I.P., which translates into medication monitoring and management, case management, crisis management, and minimum contact with family members. Family contact can escalate into resentment and hostility toward a family this is trying to be involved and connected to the treatment process. In many instances, an outpatient setting takes on all the characteristics of an inpatient setting. What part does clinic policy and clinical practice (and the thinking and assumptions that drive it) play in promoting entrenched “backward” chronicity?
Does the functioning level of the patient and the clinician have to be doomed to this escalating reciprocal pattern? Even clinicians who try to “think systems” have difficulty in believing that efforts made with parents in managing their own emotional processes will impact on the emotional process and functioning of the I.P. Does such a direction have to be a leap of faith or can it be grounded in solid theoretical principles?
Dr. Bowen’s letter of October 1977 describes his experience with a family over an eighteen-year period of time, with the majority of the contact being with the mother, with the schizophrenic daughter being involved in only a minimum of emotional contact. For the most part, Dr. Bowen’s effort enabled the I.P. to avoid hospitalization.
October 27, 1977
Dear Mr.
Thank you for helping to use the telephone conversation with you in preparing the reports on . It is accurate. I can add a few items. I have seen and her mother regularly but infrequently since January 1960 when Mrs. moved from Iowa to Washington to work for Civil Service. They were referred by M.D., a psychiatrist friend in who had been in charge of treatment for a number of years.
I have spent a good portion of my professional life on schizophrenia and is one of the few with whom I have never been able to make emotional contact. She was quietly silly and sort of hebephrenic in 1960. Over the years the symptoms have shifted a little but she is still fixed in a chronic state, that for most, would require lifelong hospitalization. I consider my 18 years of sessions, mostly with the mother, to have been highly successful. Mrs. has been able to “get off back” and to stop doing the things that agitated and sent her back to an institution. When the environment puts pressure on such as urging her to again work as a nurse, she flowers into “acting out” behavior problem psychosis. Once in the mid 1960s when the mother was sort of anxious about a new job, became symptomatic enough for 2 or 3 years in Western State Hospital. The rest of these 18 years Mrs. has been able to manage at home. She lives her life in the apartment and sort of permits to lead a separate life in the apartment, and it has gone rather well. She has been able to remain calm in the face of psychotic thinking, and to joke a bit with the “voices” and outlandish delusions about money. When Mrs. can joke, the intensity of the delusions subsides, and smiles her silly smile.
I have a dozen or so chronic schizophrenic people, now living fairly comfortable lives at home, who had been institutionalized for years. One had been dropped by his family over 20 year. By calming the family environment, it is possible for these people to live more comfortable lives with their own families than would ever be possible in an institution.
is a low risk for harm to herself and others. About the worst that can happen when she is out alone is bizarre gesturing and psychotic verbalization that disturbs others. Mrs. worked hard to support herself and these 18 years I have known them. I think will have a reasonably comfortable existence as long as her mother lives. After that I see little except that she becomes a permanent resident in a state institution.
Murray Bowen, M.D.