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Families Facing Hospitalization

Ribeiro Thayana Aparecida de Oliveira, Nobre Thalita Lacerda*

PhD Clinical Psychology – Pontifical Catholic University of São Paulo (PUC/SP). Professor and supervisor at Catholic University of Santos – SP – Brazil and University Paulista – Santos – SP – Brazil

Abstract: This study aims to understand the relationship between the triad: patient-family-staff during the disease process and hospitalization. In view of this, to make the study of a fragment, we used the service provided to a patient on the ward: Clínica Médica II do Hospital Guilherme Álvaro, located in Santos / SP, o Programa de Aprimoramento Profissional. The choice of the topic was given from the difficulty in dialogue between the demands brought by patients and their families by posing as challenge of the important task of facilitating the relationship patient-family-staff, as providing a space for the emotions triggered in this process of struggling for life and give it the freedom of expression and come to be expressed and accepted. From a definition that considers family - closed system of interdependent relationships - is exposed in this work a brief introduction of the concept of family in order to describe the reactions of families most frequently observed in cases of hospitalization. The family can to get to act in pursuit of effective patient recovering, reintegrating them in the family system, paralyzing on the verge of death or diagnosis of the family, and even identifying benefits posed by the disease and mobilizing itself to keep it. Throughout the article are also explored phases faced by family - analogous to the stages experienced by the patient, the range of feelings and emotions that permeate the relations established in this context, to forms of communication and the suffering imposed denouncing through words, gestures, conflicts, silences implicated in the hospitalization process.

Keywords: family, hospitalization, disease, hospital psychology

Received August 05, 2014; Revised August 29, 2014; Accepted October 27, 2014

Citation: Ribeiro Thayana Aparecida de Oliveira, Nobre Thalita Lacerda, Families Facing Hospitalization. American Journal of Applied Psychology, 2 (5A). 17-20. January 2014. doi:10.12691/ajap-2-5A-5

1. Introduction

It is postulated that the family is seen as a family system in which its components are interconnected by means of a relational and emotional web. More than the sum of its elements, the family is subdivided into several smaller systems: individual, parental, fraternal, among others. It is configured it in itself through the relationships which are established, the way they communicate, the activities within and outside the family, as well as exchanges of affection, internalization of social norms and rules and roles established [1].

The different elements mentioned in the previous paragraph perform functions considering the individual needs of protection and autonomy and are governed by explicit or implicit norms created within the family.

In summary, the family provides exchange of affections, structuring lasting relationships and represents a benchmark of support and security.

Camon; Chiattone; Sebastiani, Fongaro, Santos (1996) to better elucidate the concept of family, they use the example of the allegorical image of a balance with various dishes with specific sizes and weights where the position where each plate occupies means a state of equilibration. Which means that, take, add or subtract one of the dishes involves an imbalance in relation to its previous state [1].

This article has focused on the hospital context, considering the moment of hospitalization as a destabilizing factor to the family system (installed by the crisis) and and observing the forms of adaptation in which the elements of the family system while uniqueness, seeking to reorganize, overcome the crisis and return to its status quo (the same state as before) [1].

2. Reaction of Families Facing Hospitalization

2.1. System Mobilizes Itself in an Attempt to Rescue His Former State

In the first case the family system mobilizes with intent to redeem its previous state. It is considered the most frequent reaction where one notices a real quest toward recovery of the patient, reintegrating them in their place and role in the system [1].

Nevertheless, there are cases where the desire to rescue the previous status quo is unattainable and that the family and the patient start to seek a new process of disorganization. Pointing out that a process of initial disorganization is needed to achieve a level of balance again. Such a situation occurs in cases that is found a chronic illness, or when the patient's illness imposes permanent sequel. The new reality imposed upon the family system will make they seek a new identity. The family tends to go through the difficult process of adaptation, however, it is noteworthy that not always simultaneously, which can result in tension and conflict surrounding them [1].

2.2. The System Paralyzes before the Crisis Impact

The family enters in a process immobility. This immobility is directly proportional to the degree of importance imposed by the patient to restore the balance of the system structure and the degree of maturity of this family have as a group. [1]

The authors complement saying:

"The feelings of helplessness, hopelessness, fear, anxiety and threat are frequently observed. The family becomes a burden to the patient, trying to save them, it can omit them and even to the hospital staff its true state in order to get discharged and back to "take care" of theirs. Attitudes of rebelliousness to treatment by the patient can be found in these cases, often accompanied by request to get discharged" [2].

As pointed out by the authors, frightened by the possibility of death of the patient, the family may adopt extreme measures, such as sticking with hospital staff regarding patient discharge, sometimes refusing to listen to his instructions. Not uncommon, using the space to take hospitalization problems to the patient, without considering it in their disease process or treatment. Although, often family members do not have intentionality in their actions. [1]

That said, if the hospital staff, in the other hand, shows itself more authoritarian with the family, it establishes a dodge and avoidance behavior, making the relationship staff-family very conflicting. Insofar as the family awaits the discharge of the patient, they can also develop attitudes as bargain with the staff, making promises and requiring alternative treatments implying miraculous healings. The goal here is to have back the the patient home almost at any cost. [1]

Situations like those described above require greater attention from psychologists, since the proper acceptance of disease as adaptation to new requirements imposed are basic conditions for the hospital staff to develop their job [1].

2.3. The System Identifies Benefits in the Crisis and Mobilizes to Keep It

The third reaction to the hospitalization of a family member when the system identifies benefits in the crisis and mobilizes to keep it.

Family members give the patient the status of illness and it legitimate such a condition as a way to obtain their attention while respond as such. In other words, a new kind of relationship with the ill person is structured. In these cases might have the risk of being urged behaviors chronicity of the disease, regardless of truly chronic condition that occurs. Although the patient is discharged and overcome his illness is maintained the same pattern of relationship, since no longer finds its place in the family as it was before hospitalization. [1]

Similar to the situation described in cases of persons subjected to long, hospitalizations their families are driven to structure a new identity of the family system due to the absence of the patient and after his return the family see themselves impelled again to go through another process disorganization in favor of a new way of living. [1] Remembering that you can also happen that the patient himself take advantage of his condition (all that it provides): special attention given by friends, family, social privileges, among others. Such statements cause in the patient the intimate sense of satisfaction, reducing anxiety and sometimes creating a desire for exploration by affection.

Chiattone (1993) says that:

"If the patient is unable to be your deep desire for pleasant regression justified by illness, aggressive behavior can arise and claims marked by constant dissatisfaction, complaining of everything, determining not infrequently reciprocal aggression team and family" [3].

Elaborated upon the reactions most commonly observed by the family during the hospitalization has been extracted a fragment of a service performed in Hospital Guilherme Álvaro – Clínica Médica II – to elucidate a case of paralysis of the family front the crisis.

3. Reaction of Families Facing Hospitalization

During the Professional Training Program in Health Psychology, was provided assistance the patient M.C, 80 years old, hospitalized in the Hospital Guilherme Álvaro specifically installed in the Clínica Medica II, through the framework of weakness, dehydration and difficulty feeding.

The patient was accompanied only by his daughter, who constantly taking care of her mother. At the time of attendance the woman was hospitalized for less than a month, but had been experiencing some complications in their clinical picture and therefore, the hospital staff still kept under hospitalization regime without predicting discharge.

While Mrs M.C was hospitalized she got a respiratory problem, which drove her daughter to react with quite hopeless because she was not expecting that the mother would remain hospitalized more time and neither would develop other health problems. Talking with the girl I found out that she was an only child and still lived with his mother, both were quite close.

She no longer trusted on the hospital team, checking all dosages of medicines and claimed repeatedly that would take her mother from hospital that week. When the daughter was answered the first time, was desperate, too scared, anxious and scared by the uncertainty of what would happen to the mother. She feared that his mother did not come back to be active, communicative, humorous and autonomous person she was before and also frightened at the idea of losing her.

While we were talking the daughter could only repeat extensively hers dissatisfaction, distrust and outrage regarding the whereabouts of his mother still in hospital. She was convinced that the hospital and all staff were unprepared and unable to provide care for her mother, to her there was no sufficient grounds to substantiate the conduct of keeping his mother hospitalized.

It can be said that this is a case where the child shows difficulties of dealing with the crisis due to the hospitalization of his mother, the changes in the family system and the role that the mother occupied this family system.

As observed, the daughter enters into a process of immobility. Camon; Chiattone; Sebastiani, Fongaro, Santos (1996) indicate that this immobility is directly proportional to the degree of importance that the patient has in maintaining the equilibrium of the family system and in this case, the patient has a major role for the daughter in question. The relationship of emotional dependency on the mother is evident in that disorganized front of his illness [1].

The feelings of helplessness, hopelessness, fear, anxiety, menace are often evidenced.

The mother represents safety, complicity, affection to his daughter and in the possibility of losing it all, the daughter denies any signs that refute the idea of hospital discharge and improvement of the patient, bringing the feeling, even if illusory, to have her mother back . Thus, the daughter starts to require hospital team the discharge of her mother, saying that she will be responsible for their care at home. On this occasion, the daughter has repudiated any consideration of medical staff.

The attitude of bargaining can occur in this case as an attempt to have the patient back home fulfilling their roles. Miraculous cures, promises, alternative treatments are the most common instruments of bargaining and the goal is to have the patient back at almost any cost, even if that cost the patient's life [1].

4. Stage of Facing

It's consensual in the literature that when dealing with the staff-patient relationship-family a range of feelings and emotions are involved. Initially, expressions of shock and disbelief with diagnosis are common, however, is of paramount importance to pay attention to family relationships constructed prior to hospitalization, the psychological structure of its members, the type of disease and prognosis associated with treatment. All these factors imply the way they face the disease [1].

The first reaction to the diagnosis, or even in the early stages of the disease is expressed by a denial, or at least partial denial, this defensive mechanism is used by almost all patients and serves the patient who needs some time to recover from the initial shock. [1] The family also goes through a period of denial and shock and is leading the partial denial of the family to be accepted and understood by health professionals. However, the authors underscore that: “Furthermore, the anxious denial, in general, arising from an abrupt diagnosis, without preparation or lack of internal resources in the family, which determines intense reactions and lack of anxiety or unrealistic optimism and manic reactions, should be a lot of attention by staff, in particular, the psychologist, psychological and psychiatric help may be needed urgently" [4].

Secondly, it is common for families to experience the phase of revolt, voiced by cathartic cry that could may lead to somatic reactions, hostility and rancor usually the one who made the diagnosis or transmitted, the own team of health and even disease . Still, it is possible to observe this stage a fake family adjustment to illness and imminent death of the family, characterized by euphoria, intense hope, mutual aid and solidarity among family and also false optimism to face the possibility of cure. [1] They make unacceptable and incompatible ideas about death and dying, once the illness of the person refers to the finitude itself, making the process even more agonizing illness.

At the time that the patient is undergoing a stage of anger, familiars feel the same emotional reaction. Frequently observes a outbreak of feelings and emotions - envy, resentment, bitterness - that were until then muffled, but that emerge in situations of crisis and imbalance. The helpless family distill their anger members of hospital staff, judging that the care provided to the patient are not adequate, leading them to act in a complaining way [1].

In the course of the hospitalization process, as far as it considers the possibility of non-improvement of the patient, the family is taken by fatigue, hopelessness and stress. This stage, known as Depression is marked by intense fear of death [1].

"The essence of human anguish is the extinction: the fear of death, the destruction of self and body. Man is the only living being who is conscious of his death and finitude, which then causes the anguish of his limitation, unable to do anything against it.” [5].

Regarding the death of the other, there is the fear of abandonment, marked by the absence of the other, lack and separation. It can be inferred that the death of the other is experienced as a living death, or the death of the other refers to the loss of self. In this sense, death is configured as the awareness of finitude own fantasy about when and where to die [6].

Finally, the family they enter the last stage - acceptance - which refers to the step in which the family accept the illness and imminent death of the patient. The last phase, characterized by the acceptance of the family, although expected, is only possible from the inter-relationship between the family, the emotions flow and sharing these feelings and fantasies that permeate this period. [1]

Having said that, it is important to note that as the patient approaches death tends to isolate themselves - a shutdown for acceptance of his own death process - triggering reactions from family from despair to overprotection.

However, the family in an attempt to reverse the sad state of the patient - masking their emotions through false optimism / hope - makes the patient feel more abandoned and least understood in their suffering. Sometimes preventing him from experiencing his last days with authenticity. [1]

The truth is that only those who can overcome their fears and anxieties are able to reach this stage. Similarly, if these troubles could be shared with their families certainly diminish and cause less pain.

5. The Conspiracy of Silence

The following aims conceptualize the called: Conspiracy of silence. It is a very frequent behavior during the process of illness and hospitalization, in which the family and the patient find themselves embroiled in a plot to silence. The patient, doomed to silence, realize in their families their inability to deal with his death, with separation and loss.

The patient's family hides their feelings through smiles and gestures against the inner anguish, these behaviors likely to disappear later as the throbbing pain persists and in silence [7].

This silence is followed by deep anguish and can be felt throughout the hospital, including the family, the patient and hospital staff. Often the complicit silence denotes the inability to tell the other what supposes not want to hear. [8] In other words, the possibility of death of the other enables the family to experience their own physical and emotional vulnerability and silence protects the patient - saving the patient's suffering brought about by the news of the diagnosis and imminent death - and himself, hiding the news and silencing triggered feelings and fears [8].

6. Final Considerations

The research aimed to understand the representation of family and its importance to the balance and organization during the hospitalization process. It was found from this, that hospitalization is experienced by the family as a moment of intense disorganization, causing a change in the dynamics in the family system and creating an emotional and physical fragility of its components.

To this end a literature review was conducted on the theme: families facing the hospitalization, which enabled better understanding of the changes arising in the context studied and forms found by family members to adapt to new demands, the defensive mechanisms and stages traversed during confronting the diagnosis and / or proximity to death.

It was observed during the survey the theoretical dialogue with clinical practice in the hospital context, identifying one of the services performed at the Hospital Guilherme Álvaro - specifically at the Clínica Médica II - the dynamics between the family, the patient and the process of immobility described in this study.

In this perspective, it can be inferred in the care given to the patient M.C., regarding the process of paralysis front hospitalization, is perceived a pattern of relationship between the patient and her daughter who has, as outstanding characteristic, an emotional dependence of her mother, evidenced to the extent that it the daughter disorganized herself against her mother illness and possibility of loss.

In respect of this issue, Camon; Chiattone; Sebastiani, Fongaro, Santos (1996) show that this immobility is directly proportional to the degree of importance that the patient represents to their families and the balance of the system. Still, also contributes to the determination of the equilibrium of the family and the degree of maturity of the family as a group. [1]

Thus, it is understood that the mother figure and the role that it exercises is crucial to the balance of the family system - considering the family system composed only of these two women, mother and daughter. Similarly, it is possible to deduce the inability daughter in dealing with role changes, since the mother is the daughter to safety, complicity, affection.

The reaction stoppage to the crisis made the daughter to adopt an attitude of avoidance and distrust, which led her to believe that all hospital staff was unprepared and unable to provide care to her mother. To the girl, there was insufficient reasons to substantiate the conduct to maintain their hospitalized mother. It was also observed daughter's attempt to convince the hospital staff to give discharge, claiming to have the better treatment conditions at home than in the hospital.

Another important point to consider is the communication established between the family and the patient during this process of struggle for life. Often, communication is configured noisy, alarming, exacerbated, as in the case of patient M.C., other times, reveals and denounces silently, but deafening.

Of all the ways that communication can be present in the hospitalization one thing is clear: it is full of pain and suffering and denounces what words can no longer express.

Acknowledgement

Hospital Guilherme Álvaro - Santos / SP, where I am honored to participate in the Professional Training Program - Psychology and experience with families the relationship with the patient in the hospital context.

References

[1]   | CAMON, Valdemar; CHIATTONE, Heloísa; ET AL. E a psicologia entrou no hospital (...). São Paulo: Pioneira Thompson Learning, 2003.
[2]   | CAMON, Valdemar; CHIATTONE, Heloísa; ET AL. E a psicologia entrou no hospital (...). São Paulo: Pioneira Thompson Learning, 2003: 166.
[3]   | CAMON, Valdemar; CHIATTONE, Heloísa; ET AL. E a psicologia entrou no hospital (...). São Paulo: Pioneira Thompson Learning, 2003: 163.
[4]   | CAMON, Valdemar; CHIATTONE, Heloísa; ET AL. E a psicologia entrou no hospital (...). São Paulo: Pioneira Thompson Learning, 2003: 125.

[5]  
BRÊTAS, José, OLIVEIRA, José. YAMAGUTI, Lie. Reflexões de estudantes de enfermagem sobre morte e o morrer. Revista Escola Enfermagem USP, vol. 40 nº 4, São Paulo, Dec. 2006, 477-783, (479). [online] Available: http://www.scielo.br/scielo.php?pid=S0080-62342006000400005&script=sci_arttext [Accessed Jun, 15 2014]

[6]  
BRÊTAS, José, OLIVEIRA, José. YAMAGUTI, Lie. Reflexões de estudantes de enfermagem sobre morte e o morrer. Revista Escola Enfermagem USP, vol. 40 nº 4, São Paulo, Dec. 2006, 477-783. [online]. Available: http://www.scielo.br/scielo.php?pid=S0080-62342006000400005&script=sci_arttext [Accessed Jun, 15 2014]

[7]   | KLUBER-ROSS, Elisabeth. Sobre Morte e morrer: o que os doentes terminais têm para ensinar a médicos, enfermeiras, religiosos e aos seus próprios parentes. São Paulo: Editora WMF Martins Fontes, 2008.

[8]  
VOLLES, Camila. BUSSOLETTO, Greici, RODACOSK, Giseli. Conspiração do silêncio no ambiente hospitalar: quando o não falar faz barulho. Revista SBPH vol.15 nº 1. Rio de Janeiro, Jun. 2012, 212-231 [online]. Available: http://pepsic.bvsalud.org/scielo.php?pid=S1516-08582012000100012&script=sci_arttext. [Accessed May. 6, 2014].