Abstract
This paper describes the activities of a home treatment program for psychiatric patients. In 1962 the Canadian Mental Health Association, Quebec Division, awarded a grant to the Notre-Dame Hospital for the establishment of a Home-Care Program and Emergency Psychiatric Service. To demonstrate the type of patient admitted to this newly established service and the results obtained, special records were compiled for 69 patients for the purpose of a study. All patients were admitted at random to the investigation and all received thioridazine, the drug employed by the service because of its reported margin of safety. Diagnostically, the patient population can be grouped into four separate categories:
a) Schizophrenic reaction 38 patients
b) Depressive reaction 20 patients
c) Anxiety reaction 6 patients
d) Character disorder 5 patients
Total 69 patients
The dosage range of thioridazine varied from 10 mg. t.i.d. to 200 mg. t.i.d. depending upon the severity of the symptoms with a mean average of 25 to 50 mg. A beneficial effect was noted in 74% of the patients.
The data presented describing the cooperation of the patients and their environment towards treatment of the psychiatric disorder, clearly demonstrate that the treatment prescribed had to overcome many difficulties. Most patients were unco-operative and there was also strong resistance towards the treatment of the patient by his family.
In conclusion, the therapeutic results are gratifying. This is especially so in view of the majority of the patients who were not co-operative or severely ill who would never have obtained a psychiatric consultation were it not for the Home-Care Psychiatric Service. The lack of serious side effects and therapeutic effectiveness of thioridazine observed during this trial contributed to the improvement of the patient population.
Many questions should be raised concerning home treatment or house call by psychiatrists. The experience of the service can be termed a research experiment by only the broadest interpretation. The most important appear evident in our concluding observations:
1) Home treatment could reach a large segment of people who otherwise would not receive treatment and are in need of it.
2) The co-operation and motivation of the patient is not necessarily a pre-requisite for treatment as it was previously believed.
3) The use of auxiliary services, social agencies and drug therapy facilitate the treatment.
4) A better understanding of the institution—the family, will be required in the near future. The meaning of the coined words ‘family crisis’ is still esoteric and should be defined according to scientific measurable standards. The psychiatrist, in order to proceed with the treatment depends on the family and must allow the family to depend on him, with the implication that he must do certain things according to the way of the family. An acute situation resulting either in a psychotic breakdown and/or emergency call must be understood as a communication between the patient and the ‘milieu’. The crisis provoked is a message of the distress of the patient, which means despite the negativistic facade that the patient wished to be helped.
It has also been our experience that the family resorts to the service with the concealed desire to have a witness to their situation. The psychiatrist then becomes the ‘pacifier’ by only his presence, whether he takes a direct active role or not. Repeated crises have appeared to us as a means to solve difficult problems in front of a passive outsider — thus the family dynamics were operative towards seeking a solution and integrative measures. In other words, if an individual demands attention the same can be said for a family, which explains many additional visits required in certain cases. 5) The role and change in the therapist as a result of the home visit will ensue. It is quite clear that the fact of the role reversal, that the patient is the host and the psychiatrist the visitor, unlike the situation in the office, places the onus and burden on the psychiatrist.
The use of manipulation which then becomes a social prescription can be attained if only communication is established between the family and the psychiatrist. In many instances various members of the team are better suited for the initial visit at the onset of treatment be it a nurse, a social worker, or a doctor. The establishment of a therapeutic alliance should be the major objective but additional knowledge must be gained before principles are clearly outlined in this area.