A service, a proposal

This work is a vignette of the functioning of the mental health service of the general hospital of La Matanza, and in particular of its proposal of family hospitalisation.

We have built this modest sketch of so rich an experience out of quotations taken from the paper presented at the First Inter-hospital Conference on Systemic Therapy (5, 6 and 7 June 1987), whose authors are D^r Mario Tisminetzky — head of service of the establishment mentioned — and his collaborators, Doctors Gustavo Goldemberg and Silvia Bentolila.

This contribution represents the summary of three years of work in the mental health service of a general hospital which has had, for the past eighteen months, a hospitalisation unit of twelve beds, divided into four rooms of one room each with a bathroom, intended to receive families going through a situation of crisis; that unit is open and connected to the rest of the hospital, with rooms similar to those of the other hospitalisation services.

From the crisis to the hospitalisation of the family

We say that the family system approaches points far from equilibrium, where fluctuations are amplified, and that finally, out of a destructuring, the system settles into a new steady state, into a new situation, with the appearance of a new structure. This process is accompanied by a natural increase in interpersonal tension, which may be experienced as dangerous, since the culture may equate it with illness (order is synonymous with health, and disorder with illness).

Because of this, it is possible that one member of the family group begins to display conduct more and more deviant with respect to the family norm valid until then, which, by feedback, encourages an ever greater deviation. The impossibility of bringing that member back to conduct that is “normal” for the system increases the sense of failure, which is accompanied by fears and anxieties; it is in these conditions that they present at the hospital’s emergency service. During that first contact with the family, the on-call team, made up of physicians and psychologists, seeks to locate what Bateson calls “the pattern which connects”, for all communication requires to be read within a context: depending on how that context is framed for observation, its meaning differs, most often incomprehensible and even “mad”, because there exists a classification of contexts.

The therapeutic team assesses whether it is possible that this family group, after the first interventions, will be able to go on facing that crisis situation with regular sessions in outpatient care, or whether it is preferable, from that field of observation, to try to constitute the therapeutic system on the basis of a family hospitalisation.

We have observed that, as the members of the service came to accept “a change of gaze” upon what is called mental illness — which means a greater epistemological coherence of the therapeutic group —, the proposal of family hospitalisation met with no refusal.

During the first session, the on-call therapists work out the first hypotheses and carry out the interventions needed to begin corroborating them.

We conceptualise hospitalisation as an instrument that operates in several directions at once.

Starting from the medical model, which consists in admitting the one who is called the patient, we posit family hospitalisation as a first attempt to defocus the identified patient and to produce a reading of a family in crisis.

The whole hospitalised family is offered a stay of 48 or 72 hours, with the possibility of a new agreement by mutual consent, which generally does not exceed seven days.

Each morning, the outgoing on-call team informs the incoming team of what has happened during the past twenty-four hours, and likewise passes on news of the hospitalisation to the hospitalisation team; the latter becomes the family’s designated team of therapists, and that family is, so far as possible, not seen in session by the on-call staff. The latter takes part in sessions only from behind the one-way mirror, so as to become acquainted with the family and to learn about the intervention strategies being applied, in order to be able to intervene during their own hours.

This working method has made it possible to improve the learning of the professionals and of the nursing staff, which has resulted in a greater coherence of the care team. Likewise, we have moved from two or three daily sessions to a single one, of two hours at most, which has also made it possible to leave behind the medical model that demanded a rapid solution to the crisis.

What the authors say about it