International Journal of Social

Psychiatry
http://isp.sagepub.com/

The Schizophrenic Patient in the Community and His Effect On the

Household
J. Hoenig and Marian W. Hamilton
Int J Soc Psychiatry 1966 12: 165
DOI: 10.1177/002076406601200301

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 165

THE SCHIZOPHRENIC PATIENT IN THE COMMUNITY

AND HIS EFFECT ON THE HOUSEHOLD
J. HOENIG, READER
AND
MARIAN W. HAMILTON, LECTURER
Department of Psychiatry, University of Manchester
T is now well known that schizophrenics are no longer kept in hospital to any-
where near the same extent as they used to be (Shepherd, 1957, Mandelbrote
etal., 1961, Grad et al., 1963, Hoenig et crl., 1965). Wing et al. (1964) have pointed
out, however, that this may only be achieved at a price: &dquo;the policy of early
...

of
discharge schizophrenic patients is based to a large degree the willingness of
on
relatives to attempt the role of nurse and put up with considerable discomfort and
distress&dquo;. Financial and other difficulties for the family may also be involved.
So far very few have been made to assess the type and
systematic attempts
amount of burden which devolves on the patients’ households. Because of the
extra-mural type of care practised by General Hospital Psychiatric Units in many
parts of the Manchester Region (Smith 1960), an opportunity offered to make such
an assessment.

It is often too readily assumed that what appears to the doctor to be in the
best interest of the patient is also seen by the patient and relatives to be so. We,
therefore, also tried to elicit the subjective attitudes of patients and relatives to
this extra-mural care.

THE COHORT

The policy of the General Hospital Psychiatric Unit has been described by
Smith (1960). We have studied two such Units which aim to render a compre-
hensive service to their respective catchment areas with minimal or no recourse
to the existing, more remote, Mental Hospital (Hoenig et al., 1965a). We took all
schizophrenic patients admitted to these Units for the first time from November
1st, 1958-October 31st, 1959, and April, 1959-March 31st, 1960, respectively.
These patients and their relatives were followed up four years later and were
interviewed at length, wherever practicable. The fate of the patients from the
moment of inception and throughout the four-year period was studied. Details of
the mode of inception, initial disposal and form of treatment have been described
elsewhere, and clinical details of the patients were also given (Hoenig et al., 1965b).
The total cohort numbered 62 patients (47 per cent males, 53 per cent
females). All but four of the group were under 60 years of age. Although this was
the first admission to the Units, 50 per cent had been treated elsewhere in the past.
In 42 per cent the illness had lasted more than two years; only 30 per cent had
been ill for less than six months. Thus, although we were ostensibly dealing with
first admissions, the patients were to a large extent chronic.

During the four-year follow-up period 14 per cent were seen as out-patients
only. Twenty-one per cent spent an aggregate of less than 12 weeks as inpatients
in hospital and another 35 per cent spent between 13 and 42 weeks. Five per cent
spent from one to two years and another five per cent more than two years. These

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166

figures are aggregates and do not represent one consecutive stay but the total
hospital time over the four years. Most of the admissions were to the Units and
sparing use was made of the Mental Hospital. Thus the bulk of the four-year
period was spent in the community. As the morbidity rate was high (Hoenig et al.,
1965b) and in fact did not differ much from the morbidity rate in schizophrenics
of past years who spent most of their time in a mental hospital, one might expect
that the stay at home would have a considerable effect on the patients’ households.

THE BURDEN ON THE HOUSEHOLD

The term &dquo;burden&dquo; calls for care in usage. It may mean totally different things
according to the point of view of the patient and his family or of those outside

TABLE 1
ADVERSE EFFECT ON HOUSEHOLD

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 167

the kin group. A &dquo;burden&dquo; taken on in loving care or from a sense of social obliga-
tion may not be regarded as such and in any case may be preferred to what others,
anxious to help, may visualise as &dquo;relief&dquo;. Our findings brought this out clearly
in respect to the patients’ families.
We devised a means of discriminating between what might be called &dquo;objec-
tive&dquo; and &dquo;subjective&dquo; burden in respect to the families under survey and from
the fact that our findings were very similar in the two Units studied, it would
seem that the method conveys a degree of validity.

Under &dquo;objective&dquo; burden we recorded two types of events; (a) a number of

adverse effects on the household, such as financial loss, effects on health, on chil-
dren and the general disruption of the life of a family member. This is shown in
Table 1.
(b) Any type of abnormal behaviour in the patient which was likely to be dis-
turbing to others. It was assumed that if such behaviour was present more than
occasionally, this would constitute some &dquo;burden&dquo; on the family. The type of
behaviour recorded and the incidence of this can be seen in Table 2.
TABLE 2
OBJECTIVE BURDEN: DISTURBING BEHAVIOUR

It will be appreciated that one family might have to shoulder one or several
of these problems and to a varying degree.

Effects on the Housold

Table 1 shows that 76 per cent of all patients produced some kind of adverse
effect on their households. At first glance this figure seems high, but it must be
remembered that not only constant but periodic effects are included here and the

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168

latter may not have been very frequent during the four-year period. Twenty-four
per cent had either no such burden to carry or only very occasionally.
Taking the different types of effect severally, we find that the highest figure
(42 per cent) appears in the category where there was general disruption of the
life of some member of the family, but in only eight per cent of the cases was this
effect at all marked or prolonged. In 34 per cent there was only a very moderate
degree of disruption.
The next most frequent effect was that of financial loss suffered by the patient
or the family. This applied to 30 per cent of the cases.
Poor health in any member of the household due to the patient’s illness
occurred in 16 per cent. Children suffered separation from one or both parents in
12 per cent. The figure seems large but the separations were in the main tem-
porary. None of the children developed neurotic characteristics although in two
per cent the children showed some distress.
The of the patient influenced the situation to only a relatively slight
sex
extent. As mightbe expected, financial loss is more common amongst the male
patients and where there was separation from children, this was more frequent
among the female patients, but in all the other categories the sex distribution was
fairly equal.
Disturbing behaviour
Sixty per cent of the cases showed some type of disturbing behaviour either
constantly or periodically. Forty per cent, however, never showed any such traits,
or if so, only very occasionally over the four years. Table 2 lists the types of
behaviour recorded. &dquo;Other unusual behaviour’ ’showed the highest incidence. This
included the following categories as far as they are not covered by other headings:
(1) hostile, aggressive, irritable behaviour; (2) behaviour calling for watchfulness;
(3) offensive personal habits; (4) extreme seclusiveness and withdrawal. Forty-one
per cent of the patients came into this group, showing many of these traits con-
stantly or periodically; eight per cent occasionally.
The next highest incidence was found in the group who used odd speech or
expressed unusual ideas, namely 38 per cent. What seemed to be wilfully
unco-operative behaviour appeared in 25 per cent, while 20 per cent of the patients
were thought dangerous to themselves or others. Eighteen per cent were generally
restless, and talkative; 10 per cent were noisy and wandering at night; and 10 per
cent were found unresponsive. A demand for excessive companionship was
recorded in five per cent and nursing care was required for another two per cent.
Hypochondriasis was recorded in three per cent and then only occasionally.
Unacceptable sexual behaviour was not reported at all.
There seems to have been a slight difference as between the two sexes, in
that women showed noisy behaviour and wandering more frequently than men,
whereas more men were dangerous, unresponsive, requiring nursing care or show-
ing traits listed under &dquo;other unusual behaviour&dquo;.
TOTAL &dquo;OBJECTIVE&dquo; BURDEN

Table 3 shows that there were 31 per cent who did not seem to have caused
any of the types of &dquo;burden&dquo; at all, whereas 69 per cent had created difficulties

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 169

for their household. Table 3 does not indicate whether the patients created more
than one difficulty or whether they had done so constantly or periodically. Very
occasional difhculties, however, were not counted under this head.

TABLE 3
TOTAL OBJECTIVE BURDEN ACCORDING TO SEX OF PATIENT

There are no comparable figures, but the &dquo;burden&dquo; would not seem incon-
siderable. There was a slight difference between men and women. Seventy-nine
per cent of all men caused &dquo;burden&dquo; but only 60 per cent of the women. The
difference, however, is not statistically significant.
TABLE 4
TOTAL OBJECTIVE BURDEN ACCORDING TO AGE OF PATIENT

Table 4 shows the age distribution as between the &dquo;Burden&dquo; and &dquo;No Burden&dquo;
group. The ages are by no means equally distributed. The younger the patient,
it appears, the more likely was he or she to cause the household some form of
&dquo;burden&dquo;. In the &dquo;Burden&dquo; group the figure for patients under 29 years of age
was 51 per cent; for those between 30 and 39 years it was 23 per cent, and between
40 and 49 years it was 14 per cent. Patients over 50 years showed seven per cent,
and over 60 years five per cent. In the &dquo;No Burden&dquo; group the age groups are
much more evenly distributed. This high incidence of &dquo;burden&dquo; in the households
of younger patients with a slight predominance of males among them is undoubt-
edly due to the financial loss suffered and is less likely due to clinical factors.
As regards the Civil status of the patients, this does not seem to be relevant
in this context. In both the &dquo;No Burden&dquo; and &dquo;Burden&dquo; group, there were 63 per
cent of single patients. In the &dquo;No Burden&dquo; group there were 26 per cent married,
in the &dquo;Burden&dquo; group 25 per cent married. For the widowed, separated and
divorced group, the figures were 11per cent and 12 per cent respectively.
In view of the findings of Brown et al. (1962) that schizophrenics discharged
from hospital do better in their social adjustment if they live away from their
parents, this aspect was also considered. The patients living with their parents
represented 40 per cent of the &dquo;No Burden&dquo; group and 56 per cent of the &dquo;Burden&dquo;
group; those living with spouse represented 30 per cent and 32 per cent and those
living with sibs 20 per cent and 12 per cent respectively. Only one patient was
living alone. Thus there is a gradient in the direction indicated by Brown et al.
(1962). The numbers are perhaps too small, but as far as they go, statistical tests

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170

show that the differences are insignificant. Our figures, therefore, rather support
those of Waters et al. (1965) and of Kelley (1964) which indicate that the type of
household in which the patient lives does not seem significantly correlated with
successful adjustment.
The same applies to Social Class. The distribution in the &dquo;No Burden&dquo; and
&dquo;Burden&dquo; group seems to be the same, namely Class I and II show 16 per cent
in both groups, Class III shows 37 per cent and 51 per cent respectively, Class IV
shows 11per cent and 14 per cent and Class V 15 per cent and 19 per cent. What-
ever differences there are in these figures, particularly in Social Class III, they are
not statistically significant.
TABLE 5
TOTAL OBJECTIVE BURDEN, ACCORDING TO THE
DURATION OF PATIENT’S ILLNESS

An interesting finding is shown in Table 5. It can be seen that the aggregate

duration of morbidity during the follow-up period only affects the degree of bur-
den if the ill-health exceeds two years. Patients who were ill for less than two
years in all were equally represented in the &dquo;No Burden&dquo; and &dquo;Burden&dquo; group.
The X2 test does not show the difference as significant and it can only be regarded
as a trend.

SUBJECTIVE BURDEN

The subjective aspect of the &dquo;burden&dquo;, namely what the relatives themselves
felt about it, and to what extent they considered they had carried any burden, is
shown in Table 6.

TABLE 6
SUBJECTIVE BURDEN ACCORDING TO THE SEX OF THE PATIENT

There were 43 informants who could give relevant information. Forty per
cent felt they hadcarried no burden at all, 51 per cent considered there had been
some burden, but only nine per cent complained of any severe burden. Table 6
also shows that there was a slight preponderance of &dquo;subjective&dquo; burden in the
households of male patients, but when severe burden was complained of, the sex
of the patient did not seem to affect the position. Some burden: 61 per cent males;

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 171

40 per cent females. Severe burden: nine per cent males; 10 per cent females.
Again, however, the differences do not reach the level of significance.
Patients who created a severe &dquo;subjective&dquo; burden comprise numerically
a very small group; they all fall into the under 49 age group, the majority being
in the under 30 age group. As regards the &dquo;some burden&dquo; group, the gradient is
similar, and so it is with the &dquo;no burden&dquo; group. Neither age nor civil status seem
to correlate with the degree of &dquo;subjective&dquo; burden. The same may be said for
Social Class.

TABLE 7
SUBJECTIVE BURDEN ACCORDING TO THE
DURATION OF THE PATIENT’S ILLNESS

The &dquo;subjective&dquo; burden seems to increase with the aggregate duration of

illness in the four years. All the patients who gave rise to the sense of severe
&dquo;subjective&dquo; burden in their families had been ill for more than an aggregate of
two years, while 50 per cent of those who caused &dquo;Some Burden&dquo; were also in
this category. On the other hand, as many as 36 per cent of the &dquo;no burden&dquo; group
were patients who had been ill for more than two years. The differences seem

quite striking, but as absolute numbers are small they do not reach statistical
significance.
Relationship between &dquo;Objective&dquo; and &dquo;Subjective&dquo; Burden
To make a satisfactory comparison between the separate findings on &dquo;objec-
tive&dquo; and &dquo;subjective&dquo; burden, we had to reduce our final total to the 43 cases
where all the information on both aspects could be elicited.

TABLE 8
TOTAL OBJECTIVE BURDEN. ACCORDING TO THE SUBJECTIVE BURDEN
COMPLAINED OF BY THE FAMILY GROUP OF THE PATIENT

The figures in Table 8 show that the total amount of &dquo;objective&dquo; burden was
considerably greater than the &dquo;subjective&dquo; burden. Thus, although 81 per cent of
the group appeared to carry some form of &dquo;objective&dquo; burden, only nine per cent

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172

complained that the &dquo;subjective&dquo; burden was severe, while 51 per cent had felt
&dquo;some&dquo; burden and 40 per cent considered they had carried none at all. There was
one case where there appeared to have been only occasional &dquo;objective&dquo; burden,

yet some &dquo;subjective&dquo; burden was reported by the family.

If the two types of &dquo;objective&dquo; burden are considered separately in relation
to the degree of severe &dquo;subjective&dquo; stress, we find that the percentages are very
similar indeed. The illness had produced &dquo;objective&dquo; adverse effects on 70 per cent
of the households though only 13 per cent had felt these to be &dquo;severe&dquo;. In the
case of disturbing behaviour on the part of the patient, this had occurred in 67

per cent of the households and 14 per cent had felt a severe burden had been
placed on them. In neither case did the &dquo;objective&dquo; burden offer any consistent
pattern in those cases where severe &dquo;subjective&dquo; distress had been aroused. Each
case could show at least six to ten of the listed items, but so could some of those
where only moderate or no burden had been felt and there was no specific con-
figuration for those with severe &dquo;subjective&dquo; burden. The behaviour that created
severe distress was pre-eminently inability to co-operate, apparent refusal to do
so, odd speech and unusual ideas, and the varied asocial conduct that was covered
by the term &dquo;other unusual behaviour&dquo;; restlessness and danger to self and others
appeared only to a lesser extent. But similar behaviour was also common among
those who created little or no burden to their households.
It isinteresting that disturbing behaviour in the patient correlated to the
same degree with &dquo;Subjective Burden&dquo; as did the various adverse effects. The lat-
ter represent a type of burden which the nonpsychiatric patient or invalid probably
causes for his household just as much as the schizophrenic patient does. The dis-
turbing behaviour, however, is more specific to the psychiatric patient as such
and to the schizophrenic patient in particular. One can thus see that to have a
psychiatric patient in the home is subjectively no more difficult to accept than to
have a physically ill person to be cared for.
It has been shown above that factors such as sex, age, social class civil status
and duration of illness affect both &dquo;objective&dquo; and &dquo;subjective&dquo; burden in similar
fashion. The main point, however, appears to be the actual discrepancy between
the two types of burden, which is often overlooked when the need for services is
under discussion. The issue does not simply depend on the objective criteria of
externally assessed need but on the actual attitudes or the degree of &dquo;need felt&dquo;.
Our findings suggest that the discrepancy found in our cohort between the
60 per cent who admitted to burden of some kind and the 81 per cent who were
deemed to carry one &dquo;objectively&dquo;, provides a useful index of the tolerance
extended to schizophrenics in the community. If we only take into consideration
the 9 per cent &dquo;severe&dquo; burden-which it might be thought legitimate to do-
then the discrepancy between that and 81 per cent becomes really startling, as
shown in Table 9.
Finally, relatives were asked if they felt anything more should have been
done for the patient. Where there was no &dquo;Objective Burden&dquo;, the relatives did
not feel anything more should have been done, which is not surprising. Nor is it
surprising that where &dquo;Objective Burden&dquo; did exist, the relatives felt in 24 per cent
of the cases that something more might well have been done. But it is astonishing
that in 76 per cent of the cases where &dquo;Some Objective Burden&dquo; existed, the rela-
tives definitely stated that they did not feel anything more might have been done.

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 173

TABLE 9
TOTAL OBJECTIVE BURDEN, AGAINST WHETHER THE PATIENT’S RELATIVES
FELT MORE COULD HAVE BEEN DONE BY THE MEDICAL SERVICES

This seems to indicate a rather low expectation of therapeutic possibilities and

social agency help.

DISCUSSION AND CONCLUSIONS

How do these findings compare with observations made elsewhere? One

would like to know how this picture of burden compares with what is found in
a community that is served by a Mental Hospital or a rather more conventional

type of service. Unfortunately, there are no strictly comparable studies, mainly

because the problem is a relatively recent one and reports that have come out
have been published while our own study was under way. The research designs
have not proved to be exactly similar. It is to be hoped that time will provide
more illuminating comparisons arising from work now in progress in this Depart-
ment and from other sources.

There are at least three studies that concern themselves to some extent with
the aspect of household &dquo;burden&dquo; created by schizophrenic patients. These con-
cern short-stay patients (Wing et al., 1964) and long-stay patients (Waters et al.,
1965) discharged from mental hospital in both cases and a group of patients
managed largely in the community, served by a new type of mental hospital ser-
vice, where emphasis is placed on the avoidance of long-term hospitalization.
(Mandelbrote et al., 1961.)
Wing’s study (1964) only extends year and is, therefore, not fully
over one

comparable to ours. Nevertheless, he finds that within the first year 43 per
even
cent of the patients were readmitted because of disturbing behaviour, the most
abnormal of which was described as &dquo;actively deluded&dquo;, which would seem to
parallel our category of &dquo;odd speech and expression of unusual ideas&dquo;. The expres-
sion &dquo;strained relations&dquo; in Wing’s paper suggests that this corresponded to our
&dquo;Subjective Burden&dquo;. Both were felt roughly to the same extent in his and our
group (59 per cent and 60 per cent respectively) but in Wing’s group, unlike to
ours, this led in 43 per cent of the cases to a readmission to mental hospital, though
we are not told whether prolonged hospitalization was involved or not.

Waters et al. (1965), who followed up 42 long-stay male patients for 24-52
months, came closer to our own investigations. The patients were all discharged
from one mental hospital, and had to undergo an intensive rehabilitation pro-
gramme before leaving. This may account for the better results than were achieved

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174

in Wing’s group. Only 29 per cent had been readmitted two years after discharge.
Of the 71 per cent who had not been readmitted, 43 per cent showed moderate
or severe disturbances in social behaviour at home. The particular type of
behaviour is not specified. Nineteen per cent caused a period of severe distress
to their families. This is a considerably higher figure than in our own group, where
only nine per cent created a severe &dquo;Subjective Burden&dquo;-always providing these
items can be seen as comparable.
The impression gleaned from this is that the severe &dquo;Subjective Burden&dquo; felt
by the households of our patients was much less than that felt by households of
patients, long- and short-stay, who had been discharged from mental hospitals.
These findings are all the more interesting as in only 19 per cent of our cases
where there was &dquo;Objective-Burden&dquo; did the relatives or other members of the
household consider that more could have been done for the patients. In 76 per
cent they did not feel that anything further could have been done.

All this would suggest that where a patient, although chronically ill, showing
disturbing behaviour and causing a considerable amount of disruption in the home,
is managed largely in the community rather than in hospital right from the begin-
ning of treatment, this creates a greater degree of household tolerance.
Mandelbrote et al. (1961 b) actually followed up a small group for four
years. Seventy-four patients (69.9 per cent) were still out of hospital at the end of
the follow-up period. The rest (30.1 per cent) had been readmitted, were dead or
could not be contacted.
It is not clear whether the burden recorded is &dquo;objective&dquo; or &dquo;subjective&dquo; in
our sense. Mandelbrote writes &dquo;typical stress situation were those in which the
behaviour of the patient upset his family or prevented them from doing certain
things&dquo;. Again the figures for the patients in this community are similar to ours.
Fifty-five per cent of the families were rated as disturbed in some way.
Asregards more detailed analysis of the type of upset caused, the figures
are not strictly comparable as not all the patients listed in Mandelbrote’s Tables
were followed up for the full four years. &dquo;Objective&dquo; burden in the form of
financial difficulty showed that 40 per cent caused none and 16 per cent caused
some or serious burden. In our group the figure for financial loss was 30
per cent.
This difference is perhaps not as great as would appear because 18 per cent of
his patients could not be maintained in the community at all and stayed in the
Mental Hospital for the full period. If this group is added on, the figure (34 per z

cent) is much closer to ours.

The disturbing behaviour also appears less than in our group. Fifty-six per
cent appeared well and a further 21 per cent showed only slight signs of illness
(71 per cent as compared to 40 per cent in our group); 23 per cent were moderately
or severely ill (compared to our 60 per cent). We must again keep in mind, how-
ever, that in Mandelbrote’s study the worst group (18 per cent) were in fact in
hospital and as such had of course been eliminated.
&dquo;Subjective&dquo; burden in our group is perhaps parallel to Mandelbrote’s &dquo;stress
to family&dquo;. In his study although 55 per cent were reported as disturbed in some
way 54 per cent showed no stress, 38 per cent showed some stress and two per cent

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 175

reported severe stress. Again the figures are better than ours, but the discrepancy
is much less than in the case of &dquo;Objective Burden&dquo;. The figures again illustrate
the difference that exists between &dquo;objective&dquo; and &dquo;subjective&dquo; burden, and point
along the same lines as our own study.
It is undoubtedly hazardous to place too much reliance on these comparisons,
but as far as they go it would seem that a type of extra-mural psychiatric service
which hospitalizes a higher proportion of schizophrenic patients than one which
reduces hospitalization to a minimum creates less &dquo;Objective&dquo; and less &dquo;Subjective
Burden&dquo; on the patient’s household, since the more seriously ill patients are in
hospital.
Factors such as sex, age, social class, civil status and even duration of the
illness only affect the degree of &dquo;Objective Burden&dquo; very slightly. In the case of
the last item, the illness has to be of very long duration indeed before it does so.
The same may be said of the &dquo;Subjective Burden&dquo;. Here again only the aggregate
duration of illness seems to have an aggravating effect.

SUMMARY

1. Sixty-two schizophrenic patients who comprised all 1 st admissions to two

General Hospital Psychiatric Units were followed up for four years. Particu-
lar attention was given to the degree of &dquo;burden&dquo; carried by their households.
2. A method is described of assessing &dquo;Objective&dquo; and &dquo;Subjective&dquo; burden.

3. It is shown that &dquo;objective&dquo; burden is much greater than &dquo;subjective&dquo; burden

reported by the family. The difference can be seen as a measure of tolerance
accorded to the schizophrenic patient.
4. Sex, age, social class or civil status exert little influence; duration of illness
seems to lead to increase of both types of burden.

5. Neither the quantity nor the quality of the &dquo;Objective Burden&dquo; appeared to
affect the &dquo;Subjective Burden&dquo;.
6. Compared with a conventional mental hospital service, the &dquo;objective&dquo; bur-
den in ourcohort seems the same as that in the households of discharged
mental patients. The &dquo;subjective&dquo; burden, however, in our extra-mural ser-
vice appears less, suggesting that extra-mural management increases tolerance
in the community.
7. In a mental hospital service which is largely extra-mural in type, but keeps
the worst cases hospitalized for long periods, &dquo;objective&dquo; and &dquo;subjective&dquo;
burden seem less than in a General Hospital Psychiatric service, which
reduces hospitalization to a minimum.

ACKNOWLEDGMENTS
The Research was carried out with the help of a grant from the Manchester Regional
Hospital Board. The field enquiry was carried out by Miss Nancy D. Young, Psychiatric
Social Worker.
We would like to thank Drs. E. Downham and R. Ferguson and their staff for the
help they extended to us throughout.

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176

BIBLIOGRAPHY
Brown, G. W.; Monck. E.; Carstairs, G. M.; and Wing, J. K.: "influence of family life on
the course of schizophrenic illness." Brit. J. Prev. Soc. Med., 1962. 16. 55- .

Grad, J., and Sainsbury, P.: "Mental illness and the family." Lancet, 1963, i, 544-547.
Hoenig, J., and Hamilton, M. W.: (a) "Extra-mural care of the psychiatric patient." Lancet,
1965; (b) "The schizophrenic patient under new management." Comp. Psychiat., 1965.
Kelley, F. E.: "Relatives’ attitudes and outcome of schizophrenia." Arch. Gen. Psychiat.,
1964, 10, 389-394.
Mandelbrote, B. M., and Folkard, S.: (a) "Some factors related to outcome and social
adjustment in schizophrenia." Act. Psychiat. Scan., 1961, 37, 223-235; (b) "Some prob-
lems and needs of schizophrenics in relation to a developing psychiatric community
service." Comp. Psychiat., 1961, 2, 317-328.
Shepherd, M.: Study of the Major Psychoses in an English County. London, 1957.
A

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